High-dose-rate brachytherapy as part of a multidisciplinary treatment of nasopharyngeal lymphoepithelioma in childhood

Locoregionally advanced nasopharyngeal carcinoma in childhood and adolescence: Analysis of 95 patients treated with combined chemotherapy and intensity-modulated radiotherapy

BACKGROUND

The purpose of this study was to evaluate the treatment outcomes and toxicities of intensity-modulated radiation therapy (IMRT) for children and adolescents with locoregionally advanced nasopharyngeal carcinoma (NPC).

METHODS

Ninety-five patients of <25 years old in locoregionally advanced NPC (stage III-IVB) were analyzed. All were given neoadjuvant chemotherapy followed by IMRT with or without concurrent chemotherapy/adjuvant chemotherapy.

RESULTS

The 4-year overall survival (OS), locoregional relapse-free survival, progression-free survival (PFS), and distant metastasis-free survival (DMFS) were 90.8%, 94.9%, 79.1%, and 84.0%, respectively. N classification was the only significant predicting factor for OS, PFS, and DMFS, with the p value of .017, .015, and 0.054, respectively. The main long-term complications were xerostomia, hearing impairment, and neck fibrosis.

CONCLUSION

Neoadjuvant chemotherapy followed by IMRT with or without concurrent/adjuvant chemotherapy produced a superb treatment outcome in children and adolescents with stage III to IVB disease. Distant metastasis was the main failure. More effective treatment strategies are urgently needed to further improve the long-term survival. © 2015 Wiley Periodicals, Inc. Head Neck 38: E665-E672, 2016.

Long-term Outcomes Following Radiotherapy for Adolescent Patients With Nonmetastatic WHO Type III Nasopharyngeal Carcinoma

OBJECTIVES

To report long-term results of primary radiotherapy for nasopharyngeal cancer (NPC) presenting in the adolescent group.

METHODS

Ten adolescent patients with World Health Organization (WHO) type III NPC were treated with primary radiotherapy at our institution between 1969 and 2007. Median age was 16.5 years (range, 11 to 21). Median radiotherapy dose to the primary target volume was 67.5 Gy (range, 60 to 74.8). The bilateral neck received 51.1 Gy (range, 50 to 60 Gy). Five patients were treated with once-daily radiotherapy and 5 received twice-daily radiotherapy. Three patients received neoadjuvant cisplatin and 5FU, and 1 patient received adjuvant maintenance cisplatin and 5FU.

RESULTS

Median follow-up time was 9.5 years (range, 1.94 to 34.74). Fifteen-year overall survival, cause-specific survival, and progression-free survival rates were all 70%. Fifteen-year local and regional control rates were 100% and 90%. One patient recurred regionally and distantly simultaneously, and 2 patients developed distant metastases alone. All 3 died of their disease within 3 years. One patient died from multiple radiation-induced secondary meningiomas 34 years after radiotherapy. Five patients developed hypothyroidism, 3 developed sensorineural hearing loss, and 4 developed dental complications. The overall rates of CTCAE grade 3, 4, and 5 toxicity were 40%, 10%, and 10%, respectively. Despite high-radiation doses to the skull base, none of the patients in this study developed grade 3+ cognitive or vision toxicity.

CONCLUSIONS

Radiotherapy achieves excellent local control in adolescent patients with unresectable WHO type III NPC. Our data support current protocols to systematically tailor treatment volumes and deescalate radiation doses to reduce treatment toxicity.

Prognostic factors and long-term outcomes of childhood nasopharyngeal carcinoma

BACKGROUND

The authors studied the survival and long-term morbidities of children with nasopharyngeal carcinoma (NPC).

METHODS

This was a retrospective review of children with NPC who were treated at St. Jude Children's Research Hospital between 1961 and 2004. Prognostic factors and long term effects of therapy were analyzed.

RESULTS

Fifty-nine patients (median age, 14.1 years) were identified. Most were male (66.1%) and black (54.2%) and had lymphoepithelioma (93.2%). Thirty-five patients had stage IV disease (59.3%), 20 patients had stage III disease (33.9%), and 4 patients had stage II disease (6.8%). All patients received radiotherapy (RT) to the primary tumor, and most received cervical RT (98.3%) and chemotherapy (88.1%). The 15-year survival and event-free survival (EFS) rates were 67.2% ± 7.5% and 63.5% ± 7.8%, respectively. Five patients (8.5%) developed subsequent malignancies 8.6 to 27 years after NPC diagnosis. EFS was improved in patients who were diagnosed after 1980 (74.8% ± 10% vs 45.5% ± 10.1%; P = .031), in patients who had stage III disease compared with patients who had stage IV disease (79.3% ± 9.6% vs 56.2% ± 11.8%; P = .049), in patients who received cisplatin (81% ± 10.7% vs 45.8% ± 9.7%; P = .013), and in patients who received ≥ 50 grays of RT (71.4% ± 9.3% vs 43.8% ± 11.6%; P = .048). White patients had higher distant failure rates than black patients (41.7% ± 10.4% vs 15.6 ± 6.5%; P = .045). The 15-year cumulative incidence (CI) of any morbidity was 83.7% ± 5.4%, the CI of sensorineural hearing loss was 52.9% ± 6.7%, the CI of primary hypothyroidism was 42.7% ± 6.6%, and the CI of growth hormone deficiency (GHD) was 14.1% ± 4.7%. Dose-response relations were observed between the RT dose and primary hypothyroidism and GHD.

CONCLUSIONS

The outcome of children with NPC improved over the past 4 decades with the use of cisplatin-based chemotherapy and higher RT doses. However, many survivors had long-term treatment-related morbidities.

Treatment results of 165 pediatric patients with non-metastatic nasopharyngeal carcinoma: a Rare Cancer Network study

PURPOSE

This Rare Cancer Network (RCN) study was performed in pediatric nasopharyngeal carcinoma (PNPC) patients to evaluate the optimal dose of radiotherapy and to determine prognostic factors.

PATIENTS AND METHODS

The study included 165 patients with the diagnosis of PNPC treated between 1978 and 2003. The median age was 14 years. There were 3 (1.8%) patients with stage I, 1 (0.6%) with IIA, 10 (6.1%) with IIB, 60 (36.4%) with III, 44 (26.7%) with IVA, and 47 (29%) with IVB disease. While 21 (12.7%) patients were treated with radiotherapy (RT) alone, 144 (87.3%) received chemotherapy and RT. The median follow-up time was 48 months.

RESULTS

The actuarial 5-year overall survival (OS) was 77.4% (95% CI: 70.06-84.72), whereas the actuarial 5-year disease-free survival (DFS) rate was 68.8% (95% CI: 61.33-76.31). In multivariate analysis, unfavorable factors were age >14 years for LRC (p=0.04); male gender for DMFS (p=0.03); T3/T4 disease for LRFS (p=0.01); and N3 disease for DFS (p=0.002) and OS (p=0.002); EBRT dose of less than 66 Gy for LRFS (p=0.02) and LRRFS (p=0.0028); and patients treated with RT alone for LRFS (p=0.0001), LRRFS (p=0.007) and DFS (p=0.02).

CONCLUSION

Our results support the current practice of using combined radiation and chemotherapy for optimal treatment of NPC. However, research should be encouraged in an attempt to reduce the potential for long-term sequelae in pediatric patients given their relatively favorable prognosis and potential for longevity.

Use of brachytherapy in children with cancer: the search for an uncomplicated cure

Brachytherapy is a sophisticated radiation method in which radioisotopes are placed inside or at a short distance from the tumour. The volume of tissue that receives the prescribed dose of radiotherapy is therefore fairly small compared with that used in standard radiotherapy techniques. In paediatric oncology, this method of radiation delivery can have a favourable effect on several undesirable long-term side-effects that sometimes develop in children who receive radiotherapy, such as growth retardation and development of second primary tumours. Here, we describe the rationale for use of brachytherapy in children with cancer, the methods of the different brachytherapy techniques available, and the results obtained with several brachytherapy regimens in expert institutions throughout the world.