International Journal of Nasopharyngeal Carcinoma (IJNPC) Vol. 03, No.

01, March, 2021 | 25-27

International Journal of
NASOPHARYNGEAL CARCINOMA
Journal homepage: https://talenta.usu.ac.id/IJNPC

Carboplatin and Docetaxel Chemotherapy in Nasopharyngeal Carcinoma: A Case Report

Denny Satria Utama
Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Sriwijaya University, Palembang, Indonesia

Abstract Article Info

Introduction: Nasopharyngeal Carcinoma (NPC) is a squamous cell malignant tumor that usually occurs Article history:
in the lateral wall of the nasopharynx near the area of the eustachian tube. NPC is often found in southern Received: 28th February 2021
Asia. In head and neck areas, NPC is one of the top five malignant which has the highest frequency Received in revised form: 14th March 2021
tumours in Indonesia. Accepted: 16th March 2021
Case report: We reported a case of a 57-year-old man with complaints of obstruction in both noses,
accompanied by headache. Based on medical history, physical and Radiology examination, we concluded Keywords:
that he was diagnosed with Nasopharyngeal Carcinoma WHO II Stage III (T3N0M0). Histopathology Nasopharyngeal carcinoma, chemotherapy,
revealed a differentiated non keratinizing squamous cell carcinoma in the nasopharynx. Six cycles of carboplatin, docetaxel
carboplatin and docetaxel regimen as an induction chemotherapy were planned for this patient. The patient
*Corresponding author:
then performed a nasoendoscopy followed by nasopharyngeal CT scan evaluation and showed a good
response after Chemotherapy. Address: RSUP Dr. Mohammad Hoesin,
Conclusion: Carboplatin and docetaxel chemotherapy management in this patient was given according Palembang, South Sumatra, 30126, Indonesia
to the management of nasopharyngeal carcinoma and has given a good response to the patient. e-mail: dennyutama77@gmail.com

1. CASE REPORT
A 57-year-old man was referred to RSUP Dr. Mohammad Hoesin
Palembang in September 2020. The patient presented with complaints of
obstruction in both noses (especially in the left nose), headache, nosebleeds,
headache, runny nose with yellowish white discharge, there is no decrease
in smelling, and no lumps on both sides of the neck. The patient also
complained of reduced hearing in the left ear with no history of discharge
from the ear. The complaints have been felt since 5 months ago. He had a
previous history of smoking and drinking alcohol.
On physical examination, the general condition was good. Patient
was full alert, blood pressure was normal at 120/80 mmHg, pulse was 82
x/minute, temperature and breathing within normal limits, and there is no
sign of difficulty in breathing. Neck examination showed no lumps or
enlarged lymph nodes in both necks. No abnormalities were found on ears
and throat examination. Furthermore, the patient underwent an anterior
rhinoscopy, which showed a mass invading both of nasal cavity with lots of
serous secretion. The mass looked brittle and bleeding easily. We performed
a tele nasoendoscopy examination, showing a mass in the nasopharynx that
extends into the right and left nasal cavity. We performed a biopsy in the
nasopharynx.
left sphenoid and ethmoid sinuses, the left sella dorsum and suspiciously
extends to the left cavernous sinus. Abdominal ultrasound examination
showed no visible metastatic nodules. Based on medical history, physical
examination, and radiology imaging, nasopharyngeal carcinoma was
obtained. Histopathology results showed a differentiated non keratinizing
squamous cell carcinoma in the nasopharynx. Patient diagnosed with NPC
WHO II stage III (T3N0M0) and planned 6 cycles of chemotherapy with
carboplatin and docetaxel regimen every 3 weeks per cycles, chemotherapy
starts from October 2020 to February 2021. On February 13th, 2021, during
his last cycles, his blood result showed that he was anemic (Hb 8.6 gr/dl)
and leukopenia (WBC 2890 mcl). Patient administered to the hospital and
we treated the patient with transfusion with 400 cc of PRC and filgrastim
injection. The patient showed response after the treatment and continued
with cycle 6th of chemotherapy. The patient showed good condition after
undergoing chemotherapy and was discharged and prescribed with oral
medicine for home treatment. The patient has been undergoing six cycle of
chemotherapy and showed good condition, despite experiences occasional
nausea and malaise.

Picture 2. The axial and coronal plane nasopharyngeal CT scan on June

Picture 1. Nasoendoscopy of the right and left nasopharynx on September
14th, 2020.
On June 20th, 2020, we performed a radiological CT scan of the
nasopharynx which showed masses in the right and left nasopharynx,
obstructing the rosenmuller fossa and pressing the tubarius torus, the mass
extending to the choana and left nasal cavity, posterolaterally infiltrating the
parapharyngeal space and left masticator space and destructing the left
pterygoid plate. The mass also extends superiorly, destructs the walls of the
20th, 2020 (before chemotherapy).
After the patient had undergone 6 cycles of chemotherapy, the patient
then returned to the ENT outpatient clinic in Dr. Mohammad Hoesin
Hospital in February 2021 for follow-up. Patient had no complaints of nasal
obstruction and nasal bleeding. On physical examination, the patient had no
mass in both nasal cavities, there also no lumps in both sides of neck. The
result of nasoendoscopy showed serous secretions in the nasopharynx with
less masses in the left nasopharyngeal wall.

Copyright © International Journal of Nasopharyngeal Carcinoma Published by Talenta Publisher, ISSN: 2656-9027 e-ISSN: 2656-9035 DOI: 10.32734/ijnpc.v3i01.5725 25
International Journal of Nasopharyngeal Carcinoma (IJNPC) Vol. 03, No. 01, March, 2021 | 25-27
Picture 3. Nasoendoscopy of the right and left nasopharynx on February
23rd, 2021 (post-chemotherapy)
We compared the CT Scan with a contrast of the Nasopharynx result,
performed on June 20th, 2020, to the CT result, performed on February 23rd,
2021 the results showed a mass in the left nasopharynx extending into the
left parapharyngeal space and erosion the left pterygoid plate. We compared
with the previous CT Scan, there is no longer any visible expansion of the
mass to the left nasal cavity, left masticator space, left sphenoidalis and left
ethmoidalis.
Picture 4. The axial and coronal plane nasopharyngeal CT scan on
February 23rd, 2021 (after chemotherapy 6th cycles)
2. DISCUSSION
Nasopharyngeal carcinoma (NPC) is a head and neck malignant tumour
that occurs from nasopharyngeal epithelial cells. In Indonesia, NPC ranks fifth
of all malignancies and ranks first in Ear, Nose, Throat, Head and Neck
Surgery malignancies. The incidence of NPC in Indonesia reaches 6.2 per
100,000 population per year. Nasopharyngeal carcinoma can occur between
the ages of 45-54 years. Nasopharyngeal carcinoma occurs more frequently in
men than women. The clinical symptoms of nasopharyngeal carcinoma are so
varied that an incorrect diagnosis is often made. The most common symptoms
are abnormalities of the neck, ears, nose, and cranial nerves [1-3].
From research data conducted by Masafumi in Japan, for 10 years, NPC
was found in as many as 620 patients with the most at the age of 60-71 years
and occurs more frequently in men than women with a ratio of 4.3:1. In a
study conducted by Kevin, of 101 patients diagnosed with nasopharyngeal
carcinoma, it was found that there were more men than women with a
percentage of 70%. Abdul and Salma analyzed some cases of
nasopharyngeal carcinoma at the Al Nahdha hospital, NPC were found in
men and women with a ratio of 1.4:1 with a percentage of 21% at the age of
20-30 years old and 25% at the age of 50-60 years old. At the ENT clinic of
Mohammad Hoesin Hospital in Palembang from 2017-2018, NPC was
diagnosed and found in 194 new patients [2, 4-6].
The patient was suspected of having nasopharyngeal carcinoma because
the main complaint was nasal obstruction accompanied by nosebleeds.
Physical examination found a mass in the nasopharynx. Computed
tomography with contrast revealed a suspicious impression of
nasopharyngeal carcinoma with extension to the nasal cavity and paranasal
sinuses. The clinical symptoms of nasopharyngeal carcinoma can be divided
into several groups, namely the nasopharynx itself, ear symptoms, eye and
nerve symptoms, and metastases or symptoms in the neck. Nasopharyngeal
symptoms can include mild epistaxis or nasal obstruction. Ear disorders are
an early symptom that arises because the origin of the tumor is close to the
mouth of the eustachian tube (fossa of rosenmuller). Disorders can include
tinnitus, fullness and pain in the ear. Endoscopic examination can provide
information about the location of the tumor on the mucosa but cannot
determine the internal extent so that in this patient a computed tomography
scan (CT scan) is performed [2, 7, 8].
The patient's nasopharyngeal biopsy revealed undifferentiated
nasopharyngeal carcinoma. Undifferentiated carcinoma is the most common
histopathological type of NPC with percentage in endemic areas between
47% and 92% of all cases in endemic areas. In general, studies from non-
endemic areas have always shown that patients with keratinized carcinoma
have a worse prognosis than non-keratinized or undifferentiated carcinomas.
Keratinized squamous cell nasopharyngeal carcinoma has more aggressive
local tumor growth than non-keratinized and undifferentiated squamous cell
carcinoma, in which lymphatic and haematogenous spread of metastases is
more common in this type [9,10].
CT scan of the patient's nasopharynx showed expansion of the tumor
into the paranasal sinus and pharyngeal space, but no expansion to the
cranial or intracranial bases, thus including T3. The patient's lymph nodes
cervical examination did not find a lump so they were grouped into N0.
Chest X-ray examination, abdominal ultrasound showed no sign of
metastasis so that according to the 2018 AJCC classification the patient was
included in stage III (T3N0M0). The patient is able to do light daily work
such as homework so that the patient's performance includes ECOG 1.
The 2021 NCCN guidelines for stage III nasopharyngeal carcinoma
suggest induction of chemotherapy followed by radiotherapy or concurrent
chemotherapy with radiotherapy or radiotherapy not followed by
chemotherapy. For chemotherapy induction, the recommended regimens are
Gemcitabine or cisplatin, docetaxel or cisplatin or 5-FU. A study compared
chemoradiotherapy using cisplatin versus carboplatin and showed that the
3-year life expectancy was the same (78% versus 79%). There is no
consensus regarding the optimal fractionation of the radiation dose when
given with concurrent chemotherapy. This patient underwent concurrent
chemoradiation using carboplatin and docetaxel for 6 cycles [11].
After being diagnosed with NPC stage III (T3N0M0), the patient will
be planned for 6 cycles chemotherapy. This is in accordance with NCCN
2021 recommendations about NPC management. The induction
chemotherapy (ICT) preceded with concurrent chemoradiotherapy (CCRT)
is still controversial and the results are conflicting. Various trials have shown
that ICT followed by CCRT provides results with a manageable toxicity
profile and a positive impact on survival [12]. In case of locally advanced
nasopharyngeal carcinoma (LA-NPC), ICT followed by CCRT can be
considered as one of the standard treatment options for LA-NPC. In some
parts of the world LA-NPC is a relatively common disease with a rather
poor prognosis due to its high metastatic potential. ICT has always been
controversial. Mane et al found that ICT followed by CCRT compared with
CCRT alone in LA-NPC gives a clinical improvement that is significant in
both overall survival and progression‐free survival. A standard option for
patients with LA-NPC should be considered and ICT was one of them [13].
Due to its effectiveness, CCRT followed by adjuvant chemotherapy
(AC) has been recommended by the National Comprehensive Cancer
Network (NCCN) as a clinical standard treatment for LA-NPC [11].
However, Chen et al. reported a clinical trial that the additional AC induced
gastrointestinal toxicities and low patient compliance (63%). ICT is used
before radiotherapy, it's less toxic, improves tumour shrinkage, and leads to
early eradication of micrometastases[14]. The 2021 NCCN guidelines
recommends ICT+CCRT from category III to IIA as one of the most
appropriate treatments for LA-NPC superior than CCRT (IIB) and
equivalent to CCRT+AC (IIA) [11].
In this patient, we selected carboplatin and docetaxel as the
chemotherapy regimens. Research conducted by Liao et al. (2019) states
that CCRT with low-dose docetaxel is an effective therapy for locally
advanced NPC. For patients with low pretreatment EBV DNA levels,
docetaxel improves a survival benefit mainly by control of regional lymph
node metastases [15].
Even though cisplatin has a side effect that can make patients feel
nausea, vomiting, gives ototoxicity, neurotoxicity and nephrotoxicity,
cisplatin is still an accepted regimen and there is only 63% and 55% of
patients completed concurrent and adjuvant chemotherapy. Carboplatin has
become an interest due to its lower side effects, especially gastrointestinal
and nephrogenic side effects. Because of the tolerable toxicity of
carboplatin, patient can be treated as an outpatient. administration, thus
reducing hospitalization, make it less cost for the treatment and less
workload for medical personnel. Eisenberger implied that when given
concurrently with radiation in locally advanced head and neck cancers, 100
mg/m2/week of carboplatin was well tolerated [16].
Chitaparanux et al. found that carboplatin based regimen is better in
tolerability compared to the cisplatin regimen. Moreover, the treatment
efficacy of carboplatin is not different from the standard regimen in the
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International Journal of Nasopharyngeal Carcinoma (IJNPC) Vol. 03, No. 01, March, 2021 | 25-27

treatment of locoregional advanced stage NPC [16]. The cisplatin group is
more toxic for renal, has a side effect of leukopenia and anemia, but in the
carboplatin group, it's more in thrombocytopenia as a side effect. The 3-year
disease free survival rates were higher for the cisplatin group than the
carboplatin group. The 3-year overall survival rates were 77.7% for cisplatin
group and 79.2% for carboplatin groups. Carboplatin showed similar
efficacy with cisplatin and have a better tolerability and could be used as an
alternative regimen [17].
From this case, the results of nasopharyngeal CT scan after
chemoradiotherapy revealed mass in the left nasopharynx extending into the
left parapharyngeal space and erosion of the left pterygoid plate. Compared to
the CT scan on June 20th, 2020, there is no longer any visible expansion of the
mass to the left nasal cavity, left masticator space, left sphenoidalis and left
ethmoidalis. The patient experiences a good response. Assessment of the
results of treatment with chemotherapy, either alone or in combination with
surgery or radiotherapy, is usually done after 3-4 weeks. Complete response is
said when all tumors disappear for a period of at least 4 weeks. Head and neck
CT scan are diagnostic modalities for follow-up after NPC therapy. The
sensitivity and specificity of CT scan after treatment were 67% and 32%.
Imaging to assess recurrence is performed in between 6 months [12].
Picture 5. NCCN Guidelines Version 1.2021 Cancer of the Nasopharynx [11].
3. CONCLUSION
Chemotherapy management in this patient is similar to the
management of nasopharyngeal carcinoma and has given a good response
to the patient. One of the standard treatment options for LA-NPC is to add
IC to CCRT for NPC therapy. Carboplatin and docetaxel could be used as
an alternative regimen and showed a similar efficacy with other
chemotherapy regimens and have a better tolerability.
[9] Chua ML, Wee JT, Hui EP, Chan AT. Nasopharyngeal carcinoma. The
Lancet. 2016 Mar 5;387(10022):1012-24. DOI:
https://doi.org/10.1016/S0140-6736(15)00055-0
[10] Ch Chen YP, Chan AT, Le QT, Blanchard P, Sun Y, Ma J.
Nasopharyngeal carcinoma. The Lancet. 2019 Jul 6;394(10192):64-
80. DOI: https://doi.org/10.1016/S0140-6736(19)30956-0
[11] David G, Sharon S, Douglas A. National Comprehensive Cancer
Network (NCCN) Guidelines Head and Neck Cancers Versions 1.
2021. P 37-42
[12] Bhattacharyya T, Babu G, Kainickal CT. Current role of chemotherapy
in nonmetastatic nasopharyngeal cancer. Journal of oncology. 2018
Oct 1;2018.. DOI. https://doi.org/10.1155/2018/3725837
[13] Mané M, Benkhaled S, Dragan T, Paesmans M, Beauvois S, Lalami Y,
Szturz P, Gaye PM, Vermorken JB, Van Gestel D. Meta‐Analysis on
Induction Chemotherapy in Locally Advanced Nasopharyngeal
Carcinoma. The oncologist. 2021 Jan;26(1):e130-41.. DOI:
https://doi.org/10.1002/ONCO.13520. Epub 2020 Oct 1
[14] Xu C, Zhang S, Li WF, Chen L, Mao YP, Guo Y, Liu Q, Ma J, Tang
LL. Selection and validation of induction chemotherapy beneficiaries
among patients with T3N0, T3N1, T4N0 nasopharyngeal carcinoma
using Epstein-Barr virus DNA: a joint analysis of real-world and
clinical trial data. Frontiers in oncology. 2019 Nov 29;9:1343. DOI:
https://doi.org/10.3389/fonc.2019.01343. eCollection 2019.
[15] Liao JF, Zhang Q, Du XJ, Lan M, Liu S, Xia YF, Cai XY, Luo W.
Concurrent chemoradiotherapy with weekly docetaxel versus
cisplatin in the treatment of locoregionally advanced
nasopharyngeal carcinoma: a propensity score‐matched analysis.
Cancer Communications. 2019 Dec;39(1):1-1. DOI:
https://doi.org/10.1186/s40880-019-0380-x
[16] Chitapanarux I, Lorvidhaya V, Kamnerdsupaphon P, Sumitsawan Y,
Tharavichitkul E, Sukthomya V, Ford J. Chemoradiation comparing
cisplatin versus carboplatin in locally advanced nasopharyngeal
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https://doi.org/10.1016/j.ejca.2007.03.022
[17] Ngaimphaiboon N, Dechaphunkul A, Danchaivijitr P, Jiratrachu R,
Dechaphunkul T, Sookthon C, Jiarpinitnun C, Paoin C,
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