Tumor Board

2002-69 OPD 91-04-29

Name : 陳OO Chart No. xxxxxxx Age : 66 Sex : M

Diagnosis: 1. NPC, T2N2bM1, stage IVc, s/p C/T with recurrence

2. Colon cancer, operated

1995-4
1995-4~6
1995-6
1995-8~10
1995-10~12
1995-12 / Right neck mass for days
NP Bx (S9503758): NK, differentiated carcinoma
Liver and bone meta: (+)
MEPFL x 3 done
R/T: 2500 cGy of lumbar spine
NP Bx (S9509865): NK, differentiated carcinoma
OPD follow up
CCE x 2 done
R/T: NP: 7000cGy
NP Bx (S9519621): fibrosis

Image study:

91.04.16

Follow-up MRI study of the neck without and with contrast enhancement shows

* somewhat thickening and irregular mucosa of the nasoparhyx at its superior and posterior aspect of the roof more on the right and lateral wall on the right, which is

getting bigger and remarkable as compared with that of prior study of Aug. 9, 2001.

* There reveals equivocal or subtle inferior extent to the prespinal region around C3 on the right.

* No eivdence of LAP is noted, except several nodes noted at the sulingular region. The clius is intact. No evidence of intracranial invasion is noted.

* There reveals perineural spreading and suspicious involvement at the skull base on

the right.

* increasing SI at the mastoids on both sides.

* thickening mucosa of paranasal sinuses.

IMP: NPC, post-R/T, local recurrence at the nasopharynx on the right, susp. skull base involvement on the right.

H&N surgeon1:P’t一開始就是paraaortic和liver都abnormal,spine也abnormal,所以我們spine電2500,想可stablize,也做了induction C/T,後來要看tumor有否消,所以再biopsy,又有,所以在和信電7000(95年時),但是還有residual tumor,就拿Stem cell,之前用cyclophosphamide打,再抽stem cell,抽了兩次stem cell,再high dose C/T with CCE (cyclophosphamide, carboplatin, Epotopside) plus stem cell infusion for 2 courses,效果不錯,之後liver,paraaortic就都沒有了,spine也stable,六年下來,P’t不幸又得到colon cancer,開完刀也沒休息,之後一直都沒問題,三月底時看到右邊怪怪的,而且left aural stuffiness,也給了antibiotic,經驗上覺得general immunity不好,過去的otitis media用augmentin吃都會好,所以仔細看,怪怪的,兩個禮拜後再看,就和P’t說abnormal,就做了MRI。這個地方很難biopsy,我是用endoscope夾,一般夾post. wall夾不到,我是用endoscope夾橫的,一次就夾到了。病理科醫師說片子和以前差不多。So far我們什麼都做了,要討論之後如何治療。右邊耳朵total deaf,左邊有OME

H&N surgeon 2:tumor看來雖不大,可是在Rosenmuller fossa,有點靠近carotid artery,後續該如何治療?

H&N surgeon 3:tumor雖不大,可是沿著Rosenmuller fossa,fascial plane進去,並沒有一個明顯的tumor mass,是infiltrative type,開刀的話旁邊犧牲掉的tissue會很多,而且很靠近carotid artery,所以可以考慮手術以外的方式較好。就算手術後還是要加上R/T

H&N surgeon 2:光手術還是不能解決,手術要達到safe margin不容易。

Oncologist:應該還是以R/T為主,加上radiosensitization,因為induction C/T後又作了high dose C/T,所以tolerance會較差,治療時要小心。

Radiologist:可用IMRT

H&N surgeon 1:我們的IMRT還沒好,和信的也還在調整。是不是3D conformer就可以了?P’t的潛力都用出來了,所以如果要CCRT,希望在台大,我們的medical oncologist比和信好,C/T有用比較好,但是怕太強,怕bone marrow reserve不夠,C/T也可加強local control,如果沒有C/T,電不到6000不能收尾。

Oncologist:bone marrow reserve差了很多,所以作radiosensitization dose可以比較小,還是以cisplatin為主。

Radiologist:IMRT在長庚、中山、澄清醫院有,彰基那個不算是,如果有經驗的話,3D conformer可以取代IMRT,IMRT是把tumor希望電多少,不希望電到的organ設多少,就由電腦設計方向,來達到目的。3D conformer是forward planning,有經驗的物理師也可以達到一樣的程度。

H&N surgeon 2:您覺得我們現在的3D conformer的設計和IMRT差多少?

Radiologist:如果要作在台大也是可以

H&N surgeon 2:所以一個選擇是在台大作3D conformer,一個是作IMRT,。

H&N surgeon 1:如果要CCRT,建議在台大作,如果R/T only,建議到和信或台大。在outcome方面,如果一樣有效,CCRT side effect較多,會吐,因為有cisplatin。也可以看看和信的意見。

Radiologist:cyber knife只有成大有,運作沒多久,明天會到台北來,它是一個機械手臂,基本上是LA,針對tumor作治療,屬於teletherapy。針對小範圍很好。也是一個考慮。台灣只有梁醫師有,台大目前無計畫。

H&N surgeon 1:當初教育部找我審查cyber knife,我是考量成大要在南部生存要有噱頭,才替他背書。效果可以比IMRT多多少是存疑的,目前沒有多少報告。所以如果要CCRT,建議在台大作。

H&N surgeon 2:所以現在就是三種選擇了。