Delayed diagnosis of a symptomatic patient with metastatic nasopharyngeal squamous cell carcinoma and a 30-year history of smoking

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BSTRACT

Head and neck malignancies, such as nasopharyngeal carcinoma (NPC), while rare, are prevalent among long-term cigarette smokers. Currently, there are no standardized surveillance algorithms for head and neck cancers (HNCs), unlike the standardized surveillance techniques utilized for lung, breast, or colonic malignancies. This case report highlights a 65-year-old female patient with a robust smoking history (0.50 pack/30 years). She presented with a 5+ year history of dysphagia and a 1+ year history of neck lymphadenopathy and inability to breathe through her right nostril before her ultimate diagnosis of nasopharyngeal squamous cell carcinoma (SCC). After establishing care with her new primary care physician in 2023, she was sent for an ultrasound and computed tomography (CT) of the head and neck for the symptoms mentioned; this revealed a prominent lymph node in the right neck, which CT demonstrated as an opacification of the right nasopharynx, maxilla, and suprahyoid regions. The patient was referred to otolaryngology, where flexible nasal endoscopy demonstrated a large, friable right-sided nasal polyp and irregularities in the right posterior tonsillar arch. Otolaryngology performed fine needle aspiration of the irregularities, revealing CK5 and P63 positive SCC. Subsequent positron emission tomography scan confirmed a large right primary NPC with metastasis to the cervical chain at lymph node levels 2 and 3 and asymmetric metabolic uptake in the right pleural cavity and abnormal uptake in the bilateral palatine tonsils. Magnetic resonance imaging of the face and neck revealed involvement of the right nasopharynx, parapharyngeal space, anteromedial aspect of the right carotid space, and destructive changes of the maxillary sinus, including the right pterygoid plate. Surgical histopathology confirmed non-keratinizing, poorly differentiated SCC positive for CK5, P63, and P16 but negative for ebstein-barr virus immunohistochemistry (EBV IHC) and ebstein-barr virus in-situ hybridization (EBVR ISH). The patient was diagnosed with stage IVA (cT4 N2 M0) NPC and referred to oncology for cisplatin-based chemotherapy and radiation. This case serves to reinforce the necessity for all specialists to maintain a high degree of suspicion for HNC in long-term cigarette smokers based on early symptoms (e.g. dysphagia, nasal obstruction, persistent lymphadenopathy), particularly with NPC due to its surreptitious nature. The standard of care in long-term smokers for lung cancer surveillance involves an annual low-dose chest CT; perhaps this should be augmented by a simultaneous head and neck CT for surveillance of other malignancies known to be associated with similar contributory risk factors.