nasopharyngeal carcinoma ( npc ) is an endemic disease within specific regions in the world .
the highest incidence is found among southern chinese people , especially those of cantonese origin , whereas among caucasians from north american and other western countries it is sporadic .
radiation therapy ( rt ) , alone or combined with chemotherapy , is a paramount approach as initial treatment option for npc .
distant metastasis , however , remains one of the major problems after radical treatment in patients with locally advanced disease .
we report a case of a 68-year - old patient with advanced npc who developed intrathoracic endotracheal metastasis after rt .
we believe this to be the first reported case of intrathoracic endotracheal metastasis in an npc patient .
a 68-year - old man presented at our in - patient department on september 21 , 2004 , with a 3-month history of headache and hearing loss .
computed tomography ( ct ) revealed a nasopharyngeal mass extending into the left parapharyngeal space , left carotid sheath , and skull base .
an enlarged cervical lymph node , about 2  2 cm , was found in the left level ii .
pathology showed nasopharyngeal undifferentiated nonkeratinizing carcinoma . according to the 2002 american joint committee on cancer staging system ,
the patient received an initial dose of 66 gy by conventional rt and a boost dose of 10 gy by three - dimensional conformal radiation therapy ( 3d - crt ) to the primary site .
prophylactic radiation was given to his bilateral neck with doses of 63.3 gy to the upper neck and 50 gy to the lower neck .
however , 2 months later , a metastatic nodule about 1.5  1.1 cm was found in the left lower lobe of the lung .
he received 4 cycles of chemotherapy with vinorelbine and cisplatin , 2 cycles of chemotherapy with docetaxel and cisplatin , and a 3d - crt dose of 66 gy to the nodule in 33 fractions over 6.5 weeks .
thirty - four months after the initial rt , the patient presented with a cough and hemoptysis .
ct showed the presence of an enlarged lymph node measuring approximately 1.5  1.5 cm in the para - aortic arch .
2 ) . immunohistochemical analysis found ck ( + + ) , ck7 ( - ) , ck20 ( - ) , ttf-1 ( - ) , and eber ( + + + ) , confirming the tumor 's nasopharyngeal origin .
he was treated with conventional rt with anterior - posterior / posterior - anterior fields to 40 gy to his mediastinum .
the patient tolerated the treatment well with no significant acute side effects and no treatment interruption .
he died of nonmalignant disease with no signs of tumor recurrence in august 2008 , 2 years after treatment completion .
metastatic tracheal tumors are extremely rare ; they usually arise from direct invasion by neighboring primary lesions such as carcinomas of the bronchus , larynx , thyroid , or mid - esophagus .
similarly , tracheal metastasis from a very distant site has also been poorly documented and the upper trachea is the most frequently involved site . to the best of our knowledge , there is no report on intrathoracic endotracheal metastasis with nasopharyngeal origin .
distant metastasis after treatment is the main problem in npc patients with advanced disease . in a large cohort study by lee et al .
, 2,687 consecutive patients were irradiated with 6-mv photons , and the median total dose was 66 gy .
after a median follow - up of 3.4 years , 732 patients ( 27% ) were found with progressive disease , 16% of whom had distant failure  a predominant pattern of treatment failure . however , the specific sites of distant failure in that study were not given .
yi et al .   found the bone to be the most common site of distant metastasis , followed by the liver and the lung .
the patient we presented here developed solitary metastasis both in the lung and in the para - aortic arch prior to the presence of an intrathoracic endotracheal lesion .
it is not certain whether the secondary tracheal tumor is the consequence of the lung metastasis .
anatomically , lung malignancies may spread to the mediastinum and result in mediastinal lymph node involvement through intrapulmonary and hilar lymphatic drainage .
the enlarged tracheal nodule in this patient was not likely to be caused by direct invasion of the mediastinal lymph nodes since they were separated anatomically .
the presence of endophytic tumor growth and the intact outer layer of the trachea found on ct images suggest that it was most likely a separate metastatic deposit .
hemoptysis with coughing is the most common symptom in patients with endotracheal or endobronchial metastasis , with an incidence of 41 - 62% .
although ct provides valuable information about the tumor location and its effect on the distal lung parenchyma , lymph node status and other metastatic lesions , and helps us to plan further management , bronchoscopy remains the gold standard for quickly establishing the diagnosis and management [ 8 , 9 ] .
the appropriate management of patients with endotracheal metastases depends on tumor stage , tumor location , histopathology , patient 's performance , and coexisting disease(s ) .
since these patients usually present with advanced disease , surgery should not be routinely performed unless the patient is in an emergency situation that needs prompt symptom relief .
bronchoscopic treatment can be considered as an alternative to surgery to avoid excessive morbidity and mortality associated with the procedure . however ,
if the treatment is not emergent , other modalities such as brachytherapy , external beam radiotherapy and chemotherapy can be considered . in our case ,
long - term complete tumor control was achieved by conventional rt plus 3d - crt , suggesting external beam rt may be an appropriate management approach to achieve long - term tumor control for this disease .
 intrathoracic endotracheal metastasis from a very distant site is extremely rare . 
 we report the first case of such a disease in a 68-year - old man with nasopharyngeal carcinoma who presented with a cough and hemoptysis 34 months after finishing radiotherapy . prior to tracheal metastasis 
 , he developed a solitary metastasis in the lung and underwent chemotherapy followed by radiotherapy . 
 computed tomography showed the presence of an enlarged lymph node in the para - aortic arch . 
 fiberoptic bronchoscopy revealed an endotracheal tumor 1 cm above the carina . 
 histological and immunohistochemical analyses confirmed its nasopharyngeal origin . 
 he was treated with conventional radiotherapy and three - dimensional conformal radiotherapy ; complete tumor remission was achieved . 
 he died of nonmalignant disease with no signs of tumor recurrence 2 years after treatment completion . 
 radiotherapy may be an appropriate management approach to achieve long - term tumor control for this disease . 
Introduction
Case Report
Discussion