Treatment of locally recurrent carcinoma of the nasopharynx

A proposed modification of the Ho stage-classification for nasopharyngeal carcinoma

Based on the clinical data of a retrospective study of 659 NPC patients with routine computed tomography of the nasopharyngeal region, a refinement of Ho's stage-classification for NPC is proposed with reduction in the number of overall stages without sacrificing the accuracy in predicting prognosis in the short term. Classifying the cervical lymph nodal metastasis into supraclavicular (Ho's N3) and above supraclavicular (Ho's N1 + N2) and the nasopharyngeal primary into early (Ho's T1 + T2n + T20) and advanced (Ho's T2p + T3 + T3p) forms the conceptual backbone of the present proposed modification of the original Ho stage-classification. Power in predicting the occurrence of distant metastases and the local failures has been enhanced by the proposed T-stage and N-stage re-grouping. Retrospective comparison between Ho's and the UICC stage-classifications showed a more even patients number distribution among the overall stages and a greater power in predicting NPC prognosis for the former. Prospective studies to compare the value of the different stage-classifications are required for recommendation of a single classification for general acceptance to facilitate comparison of treatment results between centres.

Nasopharyngeal carcinoma in young patients

Seventy-one Chinese patients ranging in age from 9 to 20 years who had histologically verified nasopharyngeal carcinoma were reviewed. The presenting symptoms were often multiple, comprising nasal (77.5%) and ear (73.2%) symptoms, headache (60.6%), and neck swelling (63.4%). The median duration of these symptoms was 2 to 3 months, and 90.1% of the patients were Stage III or IV at presentation. All patients were treated primarily by radiotherapy. Forty-four of the 71 patients died of the disease; the median time to death was 18 months. Nasopharyngeal carcinoma in the young patients in Hong Kong does not appear to be different from that of the adult population in Hong Kong in terms of histology, pattern of relapse, and survival. Compared with the adult patients, however, the current series of young patients presented with more advanced-staged disease. The incidence of nasopharyngeal carcinoma in Hong Kong was compared with Chinese populations in other parts of the world, and the general pattern was comparable. The only postadolescent peak was found in the Chinese population of San Francisco.

High-dose boost irradiation techniques for carcinoma of the nasopharynx

Irregularly shaped tumors of the nasopharynx require the capacity to design flexible and reproducible treatment plans for high-dose boost irradiation. We use a variety of external beam techniques which may be combined with an afterloading intracavitary implant. Careful planning of such treatment is crucial and requires an accurate assessment of tumor volume and regional anatomy as defined by lateral simulator films, computed tomography, and magnetic resonance imaging scans. External beam irradiation is performed using a variety of arc rotations or fixed-beam cross-fire techniques in order to maximize the dose to an irregular tumor volume while minimizing irradiation of sensitive neighboring structures. Intracavitary implantation is achieved by constructing a mold of the nasopharynx with a silastic polymer and fitting it with hollow plastic catheters for afterloading with iridium-192.

High activity iodine 125 endocurietherapy for recurrent skull base tumors

Experience with endocurietherapy of skull base tumors is reviewed. We present our cases of recurrent pituitary hemangiopericytoma, radiation-induced recurrent meningioma, recurrent clival chordoma, recurrent nasopharyngeal cancer involving the cavernous sinus, and recurrent parotid carcinoma of the skull base which were all successfully retreated with high-activity 125iodine (I-125) permanent implantation.

Progressive development of radiation damage in mouse kidneys and the consequences for reirradiation tolerance

The aim of this study was to investigate the influence of protracted overall treatment times on the development and repair of renal irradiation injury in mice. Functional kidney damage was measured, from the proportion of 51CrEDTA remaining in the plasma at 30 min after injection of the tracer. Damage was assessed at monthly intervals for up to 14 months after two equal doses of X-rays given in 1 day, 1 month or 6 months. There was no difference between the time of onset or rate of development of damage after two fractions in 1 day or 1 month, but there was a time lag of 7-15 weeks (depending on dose) before the development of damage after 2F given in 6 months. After this time lag the rate of progression of damage was the same for 2F/6 months as for 2F in the shorter intervals. There was therefore no indication of any increase in total tolerated dose for the kidney when the treatment time was protracted, although the time scales for onset of this damage differed. Tolerance of mouse kidneys to reirradiation at 6 months after single doses of 6-12 Gy was also assessed. All of the previously irradiated animals developed a more severe renal impairment after reirradiation than did the age-matched control mice. The most severe damage occurred in mice which received the highest initial radiation doses, but doses of only 6 Gy were sufficient to markedly reduce the tolerance to reirradiation. It was concluded from these studies that no additional dose-sparing (tissue recovery) took place in the kidneys during a 6-month interval. This was true even when the initial radiation dose alone was insufficient to cause measurable renal dysfunction.

Reirradiation of head and neck cancers. Presentation of 35 cases treated at the Gustave Roussy Institute

Thirty-five patients with head and neck carcinoma who were treated with a second course of radiotherapy for relapse or second malignancy at the Gustave Roussy Institute between 1973 and 1981 were studied. Immediate tolerance for total doses greater than 80 Gy was good but 37% of patients suffered from delayed necrosis or bleeding. Thirty-seven per cent of lesions were locally controlled at 3 months and 97% of patients showed a subjective improvement to reirradiation. Local control was obtained in 53% of patients aged between 40 and 60 as compared to 19% in other age groups, and was obtained in 55% of patients who were irradiated a second time with a dose greater than 60 Gy as compared to 8% for doses less than 60 Gy. Complications following treatment are related to failure to achieve local control and area of second treatment fields greater than 70 cm2. Survival was worse for those patients having an interval less than 12 months between the two courses of irradiation and those in whom local control was not achieved.

Irradiation of nasopharyngeal carcinoma: correlations with treatment factors and stage

Eighty patients with nasopharyngeal carcinoma were treated with radiotherapy in the Radiation Center at the University of Louisville from January 1955 to December 1980. Among the patients were 70 whites, nine blacks and one Chinese; their ages ranged from eight to 82 years. There was a 40% recurrence rate within the nasopharynx, and a 29% recurrence rate within neck nodes. The five year survival and relapse-free survival rates of the entire group were 36 and 33%, respectively. Forty-nine patients died of cancer, four patients died of intercurrent disease and eight patients were lost to follow-up. Nineteen patients are alive and free of disease. Factors considered in this study included tumor and nodal status, the presence of cranial neuropathy, the size and area irradiated, and dose delivered. Primary site relapse was not demonstrated to be dependent on T group or nodal status, but was likely to be related to inadequacy of original treatment volume and dose. A higher survival was noted with our lymphoepithelioma category (p = .056).

Nasopharyngeal carcinoma in Taiwan. Clinical manifestations and results of therapy

A retrospective study was performed on 966 patients with histologically verified nasopharyngeal carcinomas. The follow-up rate was 93.6% over a minimum period of five years. The actuarial and relapse-free survivals were 82% and 49% at one year, 64% and 43% at two years, 43% and 33% at five years, and 36% and 22% at ten years, respectively. None of the patients with distant metastases when initially evaluated survived more than four years following the initiation of radiotherapy and chemotherapy. After the initial radiotherapy was completed, 200 (22.2%) of 900 patients had distant metastases, bone metastases being the most frequent; and 226 (25.1%) patients had locoregional recurrence. There is no statistical correlation found between locoregional recurrence and distant metastases. In patients without recurrence, the rate of subsequent distant metastases is found to be much more heavily influenced by the initial N stage (trend X2 P less than 0.001) than the initial T-stage (trend X2 0.05 greater than P greater than 0.02). Of patients with metastases, the survival time of those with liver metastases was found to be the shortest, 5.4 +/- 0.5 months (mean +/- SEM). Since three quarters of both distant metastases and recurrence developed within two years of the initial radiotherapy, it is highly recommended for patients to be examined monthly during this period. Aggressive retreatment may lead to palliation should recurrence and/or distant metastases be found. Adjuvant chemotherapy is recommended to the patients with T4, N2 or N3 disease following completion of the initial radiotherapy.

Radiation therapy of recurrent nasopharyngeal carcinoma. Report on 219 patients

Recurrent nasopharyngeal carcinoma (NPC), if left untreated, has a 5-year survival of less than one per cent. In contrast, the overall 5-year survival in a treated series of patients was 18 per cent. Excluding those with distant metastases at the beginning of the retreatment, the 5-year survival was 23 per cent. If the recurrence was limited to the neck, a 5-year survival of 34 per cent was obtained and if it was confined to the nasopharynx the 5-year survival was 25 per cent. High doses (about 60 Gy), using multiple narrow beams, carefully directed, were required. For recurrences in the neck, lymph node dissection supplemented by a lower radiation dose should be considered. Surgery was sometimes the only possible method for cure, when recurrence occurred in the neck nodes. Recurrences in the neck, especially when repeatedly appearing, most often were combined with a local recurrence in the nasopharynx.

Nasopharyngeal carcinoma--a retrospective review of patients less than thirty years of age: a report of Children's Cancer Study Group

Data from 119 patients with nasopharyngeal carcinoma who were under 30 years of age were retrospectively analyzed by the investigators of the Children's Cancer Study Group. The overall five-year survival and relapse-free survival rates from diagnosis were 51 and 36%, respectively. When the tumor was confined to the nasopharynx (1 + T2, 41 patients), the five-year survival was 75%. No significant correlation was found between survival or local recurrence and the radiation dose to the primary site. The five-year survival from relapse was 37% for 21 reirradiated patients with local and/or regional relapse compared with 11% for 45 patients with other forms of relapse. It is concluded that the optimal radiation dose for tumor eradication in young patients is now known.

The reirradiation of recurrences of head and neck cancer

The clinical results of reirradiation with 60Co of recurrences of head and neck cancer in 20 patients are presented. Fourteen patients, i.e. 70%, survived three years after reirradiation and ten patients, i.e. 50%, were symptom-free. Necrosis developed in four patients (20%). Reirradiation seems to be valuable and a relatively safe treatment of patients with inoperable recurrences of head and neck cancer.