Case presentation

History
23 yr old lady presented with complaints of Nasal obstruction since 4months Decreased vision since last 15 days Right sided neck pain for last 15 days

Investigations
Biopsy Bloods NPLScopy Imaging Metastatic workup

MRI findings
Large lobulated T1 hypointense and T2 homogeneously hyperintense nasopharynx, nasal cavity and extending inferiorly into the oropharynx measuring ~6.8x3.5cm The lesion occludes the nasal cavity,causes significant compromise of the nasopharyngeal lumen and partially occludes the oropharyngeal l umen Extent: Superiorly, it extends upto the roof of the ethmoid air cells , floor of the anterior cranial fossa with small extradural component in denting the basifrontal lobes Inferiorly, it extends into the oropharynx predominantly along the right lateral wall with involvement of the tonsillar fossa and indenting the tongue; the lower extent of the lesion is at C3 vertebral level. The uvula is also involved.

 Anteriorly extends into the nasal cavity with involvement nasal turbinates Extension of soft tissue along the walls of the right maxillary s inus is noted. Occlusion of bilateral infundibula with fluid see n in the bilateral maxillary sinuses. The frontal and sphenoeth moid recesses are also occluded resulting in fluid signal within the sinuses; soft tissue thickening along the walls of the sphen oid sinus is also noted Posteriorly, the lesion extends into the prevertebral space with involvement of the prevertebral muscles at C1-3 level, more significant on the right side

 Laterally, the lesion extends into the para pharyngeal space bilaterally right more than left. On the right side, it encases the carotid vessels and indents the deep lobe of the parotid gland. The right masticat or space is involved with involvement of the medial and lateral ptery goids. Extension of soft tissue into the right retromolar trigone regi on is also noted. On the left side, the lesion indents the deep lobe of the parotid ; the carotid vessels lie posterior to the lesion. On the right side, intraorbital extension in the extraconal compartm ent causing displacement of the lateral and inferior recti Posteriorly, extension of soft tissue along the superior orbital fissure and into the cavernous sinus Nodes: Enlarged level 2a and level 1b nodes measuring upto 10 mm on the right side The visualised brain parenchyma is normal.

Chemotherapy

Radiation therapy

Extended radiation treatment fields

Extended radiation treatment fields

IFRT for NHL

IFRT for NHL

INRT
Radiother Oncol. 2013 Oct;109(1):133-9. doi: 10.1016/j.radonc.2013.07.013. Epub 2013 Sep 7. Reduction of the treated volume to involved node radiation therapy as part of combined modality treatment for early stage aggressive non-Hodgkin's lymphoma. Verhappen MH1, Poortmans PM, Raaijmakers E, Raemaekers JM BACKGROUND AND PURPOSE: This retrospective study investigated whether focused involved node radiation therapy (INRT) can safely replace involved field RT (IFRT) in patients with early stage aggressive NHL. PATIENTS AND METHODS: We included 258 patients with stage I/II aggressive NHL who received combined modality treatment (87%) or primary RT alone (13%). RT consisted of a total dose of 30-40 Gy in 15-20 fractions IFRT or INRT. We compared survival, relapse pattern, radiation-related toxicity and quality of life for both RT techniques.

 RESULTS: Type of RT was not related to the outcome in either the uni- or multivariate survival analysis. Relapses developed in 59 of 252 patients (23%) of which 47 (80%) were documented as distant recurrence only. Failure of the INRT technique was noted in one patient. There was no significant difference in acute radiation-related toxicity between RT-groups but IFRT showed a significantly higher incidence of higher grade toxicities. Patients treated with INRT had a significantly better physical functioning and global quality of life compared to the IFRT group. CONCLUSIONS: Given the retrospective nature of this study, no solid conclusions can be drawn. However, in view of the equivalent efficacy and more favorable toxicity profile, the replacement of IFRT by INRT in combination with chemo-(immuno)-therapy looks very attractive for patients with early stage aggressive NHL.

Follow up

Response