Aims: To describe personalised treatment sequencing, multi-disciplinary decision-making, and clinical outcomes in a patient diagnosed with Epstein-Barr Virus (EBV)-positive oligometastatic nasopharyngeal carcinoma (NPC) treated with chemo-immunotherapy, consolidation radiotherapy and maintenance toripalimab, considering access, tolerability and quality of life.
Methods: A 45-year-old man presented with a12-month history of a right-sided neck mass and low-grade haemoptysis. PET‑CT demonstrated a 31x24mm nasopharyngeal mass (standardised uptake value [SUV] 18.9), bilateral retropharyngeal and cervical nodal disease, and a metabolically-avid left sacral metastasis. Biopsy confirmed poorly differentiated EBV-positive NPC.
Treatment planning incorporated multidisciplinary review and shared decision-making with the patient. Gemcitabine and cisplatin plus penpulimab (compassionate supply) was initiated, transitioning to toripalimab once accessible. Treatment was complicated by grade 3 gemcitabine‑related hepatotoxicity and cisplatin‑related tinnitus. Serial PET‑CT and plasma EBV DNA monitoring informed subsequent treatment decisions.
Following six cycles of chemo‑immunotherapy, the patient received consolidation radiotherapy to the primary site, regional lymph nodes and sacral metastasis.
Maintenance toripalimab continued after radiotherapy for two years.
Results: After three cycles, PET-CT demonstrated a partial metabolic response at the primary site (SUV 6.8) and complete metabolic response (CMR) in the left retropharyngeal node. After six cycles, further metabolic response was observed, including CMR in bilateral retropharyngeal and right cervical nodes and a reduction in sacral SUVmax from 11.2 to 2.0.
EBV viral load fell from 3,457 IU/mL at baseline to undetectable levels by November 2025 and remained undetectable. Post‑radiotherapy PET‑CT (April 2026) demonstrated CMR. At July 2026 follow-up, the patient remained on maintenance toripalimab, with no immune-related‑adverse events, mild cisplatin‑associated tinnitus, and stable grade 1 hepatotoxicity.
Conclusions: This case illustrates the feasibility of an individualised multimodal approach incorporating chemotherapy, PD-1 inhibitor and consolidation radiotherapy in EBV‑positive oligometastatic NPC. EBV DNA and PET-CT imaging guided treatment decisions. Flexible access pathways supported continuity of PD-1-directed therapy and timely delivery of treatment.