Case Report of Advanced Childhood Nasopharyngeal Carcinoma: Is Radiotherapy Dose Deescalation the Right Way in Good Responders to Induction Chemotherapy

Objectives:. Treatment of childhood NPC similar to adults consists of radiotherapy and chemotherapy, but distant failure is often observed, which led to introducing the induction chemotherapy followed by radiation or chemoradiation. The improved survival rates raised the question of late toxicity. The options for lowering the toxicity rate is the application of advanced radiotherapy techniques like IMRT and VMAT, and deescalation of the radiation dose in good responders and early NPC.Case report: We report a case of13-years old male patient with a high-risk childhood undifferentiated NPC, stage cT4 cN2b M0. He presented with unilateral swallowing at the middle third of left muscle sterenocleidomastoideus, and headache, fever, sore throat and intermittent nasal bleeding for an year. Diagnostic MRI and PET/CT showed good concordance for primary tumor extension and lymph node involvement. Three coursesinduction chemotherapy were applied according to NPC2003-GPOH protocolwith good treatment response. The restaging PET/CT found no distant metastasis. Deescalated protocol of radiotherapy alone was delivered to 50.4 Gy total dose with IGRT, VMAT irradiation technique. At three month PET/CT follow up a solitary bone lesion was detected.Conclusion: The present case proved that in high risk patients more aggressive treatment strategies should be recommended with no omission of concurrent chemotherapy even after full response. Deescalation of radiotherapy dose probably is not appropriate in this group of patients. MRI and PET CT should be used as complementary imaging modalities for early detection of locoregional or distant metastasis

Case Report of Advanced Juvenile Nasopharyngeal Angiofibroma with Cavernous Sinus Involvement: Advantages of Advanced Radiotherapy Thechnique Volumetric Modulated Arc Therapy

Objectives: In very advance unresectable stages Juvenile nasopharyngeal angiofibroma (JNA)radiotherapy is treatment of choice. Usually JNA is in close proximity to different organ at risk, which necessitates accurate and precise radiation delivery. Series reported the application of IMRT (Intensity Modulated Radiotherapy) with good sparing of organ at risk, but the literature search found no report on VMAT (Volumetric Modulated Arc Therapy) treatment in case of JNA.Clinical case: The present publication report for first time a patient irradiated with VMAT and IGRT (Image guided radiotherapy) for JNA. The stage of the tumor based on CT and MRI was IIIB according to Radkovsi with cavernous sinus invasion. Moderate total radiation dose 36 Gy in 1.8 Gy per fraction was delivered. No early and late toxicity was recorded. The patient is followed up every six months and persistent residual tumor on MRI was seen, but no bleeding onphysical exam. At one year follow up this is accepted as good local control.Conclusion: VMAT and IGRT could be safely applied with reduction of the radiation dose at organ of risk. VMAT is promising in the treatment of juvenile angiofibroma with advantages over conventional radiotherapy, but as this is case report of only one patient, further experience with VMAT is needed in JN