Treatment outcome for synchronous locoregional failures of nasopharyngeal carcinoma

Efficacy of salvage surgery versus re-irradiation for isolated regional lymph node recurrence in patients with nasopharyngeal carcinoma

BACKGROUND

To compare the clinical characteristics and prognoses of patients with isolated regional lymph node recurrent nasopharyngeal carcinoma (irrNPC) who underwent surgery or re-irradiation treatment.

METHODS

We retrospectively reviewed 124 irrNPC patients who underwent initial radiotherapy between January 2010 and December 2020. The staging of regional lymph node recurrence was as follows: 75.8% for rN1, 14.5% for rN2, and 9.7% for rN3. Fifty-five patients underwent regional lymph node surgery (Surgery group), and sixty-nine patients received salvage radiotherapy with or without chemotherapy (Re-irradiation group). The survival rate was compared using Kaplan‒Meier analysis and evaluated by the log-rank test. Cox proportional hazard models were used to analyze prognostic factors.

RESULTS

The median follow-up time was 70 months, the 5-year overall survival (OS) was 74%, and the median survival time was 60.8 months. There were no significant differences in 5-year OS (75.6% vs. 72.4%, P = 0.973), regional recurrence-free survival (RRFS, 62.7% vs. 71.1%, P = 0.330) or distant metastasis-free survival (DMFS, 4.2% vs.78.7%, P = 0.677) between the Surgery group and Re-irradiation group. Multivariate analysis revealed age at recurrence, radiologic extra-nodal extension (rENE) status, and recurrent lymph node (rN) classification as independent prognostic factors for OS. The rENE status was an independent prognostic factor for DMFS. Subgroup analysis of the Surgery group revealed that the rN3 classification was an adverse prognostic factor for OS. Age at recurrence ≥ 50 years, GTV-N dose, and induction chemotherapy were found to be independent prognostic factors for OS, RRFS, and DMFS, respectively, in the Re-irradiation group.

CONCLUSIONS

For NPC patients with isolated regional lymph node recurrence after initial radiotherapy, those who underwent surgery had survival prognosis similar to those who underwent re-radiotherapy with or without chemotherapy. A prospective study is needed to validate these findings.

Retreatment of Recurrent or Second Primary Head and Neck Cancer After Prior Radiation: Executive Summary of the American Radium Society® (ARS) Appropriate Use Criteria (AUC): Expert Panel on Radiation Oncology - Head and Neck Cancer

BACKGROUND

Re-treatment of recurrent or second primary head and neck cancers occurring in a previously irradiated field is complex. Few guidelines exist to support practice.

METHODS

We performed an updated literature search of peer-reviewed journals in a systematic fashion. Search terms, key questions, and associated clinical case variants were formed by panel consensus. The literature search informed the committee during a blinded vote on the appropriateness of treatment options via the modified Delphi method.

RESULTS

The final number of citations retained for review was 274. These informed five key questions, which focused on patient selection, adjuvant re-irradiation, definitive re-irradiation, stereotactic body radiation (SBRT), and re-irradiation to treat non-squamous cancer. Results of the consensus voting are presented along with discussion of the most current evidence.

CONCLUSIONS

This provides updated evidence-based recommendations and guidelines for the re-treatment of recurrent or second primary cancer of the head and neck.

Deciphering nasopharyngeal carcinoma pathogenesis via proteomics

Introduction: Nasopharyngeal carcinoma (NPC) is a distinct head and neck squamous cell carcinoma in its etiological association of Epstein-Barr virus (EBV) infection, hidden anatomical location, remarkable racial and geographical distribution, and high incidence of locoregional recurrence or metastasis. Thanks to the advancements in proteomics in recent decades, more understanding of the disease etiology, carcinogenesis, and progression has been gained, potentially deciphering the molecular characteristics of the malignancy. Areas covered: In this review, we provide an overview of the proteomic aberrations that are likely involved or drive NPC development and progression, focusing on the contributions of major EBV-encoded factors, intercommunication with environment, protein features of high metastasis and therapy resistance, and protein-protein interactions that allow NPC cells to evade immune recognition and elimination. Finally, multistep carcinogenesis and subtypes of NPC from a proteomic perspective are inquired. Expert commentary: Proteomic studies have covered various aspects involved in NPC pathogenesis, yet much remains to be uncovered. Coherent study designs, optimal conditions for obtaining high-quality data, and compelling interpretation are critical in ensuring the emergence of good science out of NPC proteomics. NPC proteogenomics and proteoform analysis are two promising fields to promote the application of the proteomic findings from bench to bedside.

Progression of understanding for the role of Epstein-Barr virus and management of nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is very common in southern China and Southeast Asia. In regions where NPC is endemic, undifferentiated subtypes constitute most cases and are invariably associated with Epstein-Barr virus (EBV) infection, whereas the differentiated subtype is more common in other parts of the world. Undifferentiated NPC is a unique malignancy with regard to its epidemiology, etiology, and clinical presentation. Clinically, NPC is highly invasive and metastatic, but sensitive to both chemotherapy and radiotherapy (RT). Overall prognosis has dramatically improved over the past three decades because of advances in management, including the improvement of RT technology, the broader application of chemotherapy, and more accurate disease staging. Despite the excellent local control with modern RT, distant failure remains a challenging problem. Advances in molecular technology have helped to elucidate the molecular pathogenesis of NPC. This article reviews the contribution of EBV gene products to NPC pathogenesis and the current management of NPC.

CT-guided 125I brachytherapy for locally recurrent nasopharyngeal carcinoma

Purpose: The study evaluated the feasibility, clinical effectiveness, and quality of life of computed tomography (CT)-guided 125I brachytherapy for locally recurrent nasopharyngeal carcinoma (NPC). Methods: We recruited 81 patients diagnosed with locally recurrent NPC after previous radiotherapy with or without chemotherapy. Thirty-nine patients received 125I brachytherapy (group A) and 42 received re-irradiation (IMRT, group B). The evaluated outcomes were local control, complications, and quality of life. Cox proportional hazards regression analysis was used to compare local tumor progression-free survival (LTPFS) and overall survival (OS) in the two treatment groups. Results: The median follow-up was 30 months (range, 5-68 months), median LTPFS was 21 in group A and 17 months in group B. The 1-, 2-, and 3-year OS in group A were 84.6%, 51.3%, 30.7%, and 85.7%, 50.0%, and 32.6% in group B. In group A, 10/39 patients (25.6%) experienced at least one ≥grade III complication; no grade V complications occurred. In group B, 28/42 (66.7%) experienced at least one ≥grade III complication and 6/42 (14.3%) died of severe grade V complications. No significant between-group difference existed in the Quality of Life score on the EORTC QLQ-H&N35 questionnaire before treatment. In group A, quality of life was significantly improved after treatment; but did not improve, or even deteriorated in group B. Conclusions: 125I brachytherapy was a feasible, safe, and effective treatment for locally recurrent NPC. 125I brachytherapy significantly reduced complications caused by re-irradiation and improved patients' quality of life.

Nasopharyngeal carcinoma: United Kingdom National Multidisciplinary Guidelines

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. Although much commoner in the eastern hemisphere, with an age-standardised incidence rate of 0.39 per 100 000 population, cancers of the nasopharynx form one of the rarer subsites in the head and neck.1 This paper provides recommendations on the work up and management of nasopharyngeal cancer based on the existing evidence base for this condition. Recommendations • Patients with nasopharyngeal carcinoma (NPC) should be assessed with rigid and fibre-optic nasendoscopy. (R) • Nasopharyngeal biopsies should be preferably carried out endoscopically. (R) • Multislice computed tomographic (CT) scan of head, neck and chest should be carried out in all patients and magnetic resonance imaging (MRI) where appropriate to optimise staging. (R) • Radiotherapy (RT) is the mainstay for the radical treatment for NPC. (R) • Concurrent chemoradiotherapy offers significant improvement in overall survival in stage III and IV diseases. (R) • Surgery should only be used to obtain tissue for diagnosis and to deal with otitis media with effusion. (R) • Radiation therapy is the treatment of choice for stage I and II disease. (R) • Intensity modulated radiation therapy techniques should be employed. (R) • Concurrent chemotherapy with radiation therapy is the treatment of choice for stage III and IV disease. (R) • Patients with NPC should be followed-up and assessed with rigid and/or fibre-optic nasendoscopy. (G) • Positron emission tomography-computed tomography (PET-CT), CT or MRI scan should be carried out at three months from completion of treatment to assess response. (R) • Multislice CT scan of head, neck and chest should be carried out in all patients and MRI scan whenever possible and specially in advanced cases with suspected recurrence. (R) • Surgery in form of nasopharyngectomy should be considered as a first line treatment of residual or recurrent disease at the primary site. (R) • Neck dissection remains the treatment of choice for residual or metastatic neck disease whenever possible. (R) • Re-irradiation should be considered as a second line of treatment in recurrent disease. (R).

Recurrent nasopharyngeal carcinoma: a clinical dilemma and challenge

Recurrent nasopharyngeal carcinoma, which represents a small proportion of head-and-neck cancers, has a unique set of patho-clinical characteristics. The management of recurrent nasopharyngeal carcinoma remains a challenging clinical problem. Traditional treatments offer limited local control and survival benefits; more seriously, they frequently induce severe late complications. Recently, novel treatment techniques and strategies-including precision radiotherapy, endoscopic surgery or transoral robotic resection, third-generation chemotherapy regimens, and targeted therapies and immunotherapy-have provided new hope for patients with recurrent nasopharyngeal carcinoma. Some of these patients can potentially be cured with modern treatments. However, a lack of adequate evidence makes it difficult for clinicians to apply these powerful techniques and strategies. Individualized management guidelines, full evaluation of quality of life in these patients, and a further understanding of the mechanisms underlying recurrence are future directions for research into recurrent nasopharyngeal carcinoma.

Quality of life of patients after salvage nasopharyngectomy for recurrent nasopharyngeal carcinoma

BACKGROUND

The objective of this study was to examine the quality of life (QOL) of patients who underwent salvage nasopharyngectomy for residual or recurrent nasopharyngeal carcinoma and to justify the value of the procedure.

METHODS

A self-reported, health-related QOL questionnaire was used to assess the QOL of patients after salvage nasopharyngectomy. The effects of potential complications after surgery also were evaluated.

RESULTS

Between 2003 and 2011, 185 patients underwent salvage nasopharyngectomy using the maxillary swing approach. Curative resection was achieved in 80% of patients. There were no significant changes in mean global health system scores after surgery, except after palliative resection requiring postoperative adjuvant chemoradiation. Social functioning scores were the lowest of the 5 functioning scales in all patient groups. Palatal fistula significantly affected social eating and weight loss, and osteoradionecrosis caused more pain and nasal discharge, severely affecting the social life of patients.

CONCLUSIONS

The QOL of patients after maxillary swing salvage nasopharyngectomy was good. The current results indicated that attention must be paid to the factors that adversely affect QOL after surgery, such as palliative resection, and complications like trismus, palatal fistula and osteoradionecrosis.

Current understanding and management of nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is a kind of rare head and neck cancer in Japan. However, NPC has some unique features. It is one of the most popular cancers in southern China, Southeast Asia, the Arctic, and the middle East/north Africa. This distinctive racial, ethnical, and geographic predisposition to NPC implies that both genetic susceptibility and environmental factors contribute to the development of this tumor. NPC is an Epstein-Barr virus - associated tumor. Consistent elevation of EBV antibody titers is a well-established risk factor of development of NPC. Not only pathophysiological relationship, but also molecular mechanism of EBV-mediated carcinogenesis has been enthusiastically investigated. LMP1, an EBV primary oncogene, upregulates each step of metastasis, and contribute to highly metastatic feature of NPC. A tumor suppressor gene p53 is mostly intact and overexpressed in NPC whereas expression of p16, a cyclin-dependent kinase inhibitory protein, is downregulated in 2/3 of NPC. Intention modulated radiotherapy (IMRT) is now getting prevalent for the treatment of NPC because of complicated structure and location of nasopharynx. A good therapeutic result can be achieved by distributing a high dose to the tumor while keeping down normal tissue complications by reducing radiation dose to normal tissues. Chemotherapy is important to control distant metastasis of chemoradiosensitive NPC, and thus, should play an important role. However, most effective combination of anti-tumor drugs, protocol of chemoradiotherapy has not well-established. Finally, molecular targeting therapy, including targeting EBV gene product, has been developing and on the way to the clinical use.

Recurrent nasopharyngeal carcinoma: current management approaches

OBJECTIVES

Providing the primary recurrence is localized, salvage treatment is possible for nasopharyngeal carcinoma (NPC). This is a review of the experience of retreatment of this malignancy highlighting the roles of surgery and repeat radiotherapy.

METHODS

The Tumor Registry of the Prince of Wales Cancer Centre was audited for patients with an initial diagnosis of squamous/nonsquamous cell NPC who had primary treatment with radiotherapy, and now presented for retreatment. Features relating to patient, disease and treatment factors were evaluated. The primary end point was subsequent local control, and secondary endpoints were overall and cancer-specific survival.

RESULTS

Over a 30-year period 39 patients were eligible, with 25 receiving both primary and retreatment at Prince of Wales Hospital. There were 25 males and 14 females with a median age of 50 years. Thirty-six patients had radiotherapy, 4 had stereotactic radiosurgery, 5 had brachytherapy, and the remainder had external treatment. Surgery was performed in 10 patients, of whom 3 had this as the only retreatment modality. Radiotherapy doses for retreatment ranged from 15 Gy (stereotactic radiosurgery) to 71.28 Gy (mean fractionated dose). Local control was achieved in 16 patients giving an overall rate of 41.0%, and the 5-year overall survival rate was 33.3%. Treatment modality was a significant prognostic factor for local control (P < 0.001) and cancer-specific survival (P < 0.05).

CONCLUSION

The presence of local recurrence after definitive treatment of NPC may still be salvageable. The best outcomes with reirradiation occur in the context of limited volume recurrence and a disease-free interval greater than 18 months.

Current management strategy of nasopharyngeal carcinoma

Nasopharyngeal carcinoma is an unique head and neck cancer. It is common among the southern Chinese and is closely associated with the Epstein Barr virus (EBV). To diagnose the disease in its early stage is infrequent as the symptoms are usually trivial and patients only present in late stages. Testing the blood for elevated EBV DNA has now become a screening test for the high risk group of patients, aiming to diagnose the disease in its early stages. Imaging studies, positron emission tomography scans in addition to clinical examination provide information on the extent of the disease. The confirmation of the disease still depends on endoscopic examination and biopsy. Radiotherapy with or without chemotherapy has been the primary treatment modality. The application of intensity modulated radiotherapy and the use of concomitant chemoradiation have improved the control of nasopharyngeal carcinoma together with the reduction of long term side effects. The early detection of residual or recurrence tumor in the neck or at the primary site has allowed delivery of salvage treatment. The choice of the optimal surgical salvage, either for neck disease or primary tumor depends on the extent of the residual or recurrent disease. The outcome of these patients have improved with the application of the appropriate surgical salvage.

The cost-utility analysis of 18-fluoro-2-deoxyglucose positron emission tomography in the diagnosis of recurrent nasopharyngeal carcinoma

RATIONALE AND OBJECTIVES

18-Fluoro-2-deoxyglucose (18F-FDG) positron emission tomography (PET) is effective but costly in the early detection of recurrence for nasopharyngeal carcinoma (NPC) in patients after treatment. In this study, we developed a decision tree model to analyze the cost utility of 18F-FDG PET in detecting loco-regional recurrences for NPC patients after therapy.

MATERIALS AND METHODS

The analysis for cost utility is based on the decision-tree model for three different strategies: 1) magnetic resonance imaging (MRI)-only, 2) PET-only, and 3) MRI-PET (performing PET if MRI result is uncertain). Sensitivity analyses have been performed to examine changes in the cost ratio of PET/MRI and the probability of uncertain MRI.

RESULTS

After inputting the data for utilities and life expectancies into the decision tree model, the quality-adjusted life expectancies turn out to be 16.16 quality-adjusted life-years (QALYs) for strategy 1, 16.70 QALYs for strategy 2, and 17.35 QALYs for strategy 3. The additional cost per additional QALYs for strategy 3 relative to strategy 1 is calculated to be US $462. Strategy 3 dominates over strategy 2 because strategy 3 costs less and yields more QALYs than strategy 2. If the cost ratio of PET/MRI is less than 1.85 or the probability of uncertain MRI is greater than 73%, then the PET-only strategy becomes more cost-effective than the MRI-PET strategy.

CONCLUSION

Our analysis shows that the MRI-PET strategy is the most cost-effective for now. It is likely the PET-only strategy will become the most cost-effective for recurrent NPC in patients in the near future as the cost of PET has decreased in a faster rate than the cost of MRI.

Treatment of locally recurrent Epstein-Barr virus-associated nasopharyngeal carcinoma using the anti-viral agent cidofovir

Nasopharyngeal carcinoma (NPC) is an Epstein-Barr virus (EBV) associated malignant tumor. Recently, cidofovir, an anti-viral drug which is an acyclic nucleoside analogue, has been reported to have an anti-tumor potential. Two patients with NPC, who had previously received multi-round therapy, were treated with cidofovir. Cidofovir was topically injected in and around the tumor once every 3 weeks (originally 75 mg/ml sulution, diluted to 15 mg/ml just before injection, 37.5 mg of cidofovir at a time). Tumor growth was suppressed for several months around the injection site in each patient. EBV-encoded RNAs in situ hybridization revealed the reduction of the tumor cell population; however, the EBER expression was still maintained in the NPC tumor cells. Although the anti-tumor mechanism remains unclear, these results suggest that cidofovir is actually an effective and safe agent for the treatment of NPC.

Detection of local failures after management of nasopharyngeal carcinoma: a prospective, controlled trial

OBJECTIVES

To conduct a prospective study (1) to evaluate and compare the efficacies of nasopharyngeal endoscopy and computed tomography in the diagnosis of local failure of external beam radiotherapy for nasopharyngeal carcinoma, and (2) to assess whether multiple endoscopic nasopharyngeal biopsies are superior to a single, targeted biopsy, for the same purpose.

METHODS

Forty-six patients who had been treated with external beam radiotherapy for primary nasopharyngeal carcinoma were enrolled in the study. For every patient recruited, computed tomography, rigid nasopharyngeal endoscopy and nasopharyngeal biopsies were performed 12 weeks after radiotherapy.

RESULTS

Twelve weeks after treatment, six patients (13 per cent) had evident disease on histological examination of biopsies. Nasopharyngeal endoscopy showed a sensitivity, specificity, positive predictive value and negative predictive value of 66.6, 95, 66.6 and 95 per cent, respectively. There was statistically significant agreement between the endoscopic findings and the histological findings (Kappa reliability coefficient = 0.617, p < 0.01). Computed tomography showed a sensitivity, specificity, positive predictive value and negative predictive value of 50, 45, 12 and 85.7 per cent, respectively. There was no statistically significant agreement between the computed tomography findings and the histological findings (Kappa reliability coefficient = 0.021, p > 0.05). A targeted, single biopsy performed under endoscopic control demonstrated excellent sensitivity, specificity, positive predictive value and negative predictive value, being 83.3, 100, 100 and 97.5 per cent, respectively. The Kappa test showed a very statistically significant agreement between the histological findings for the single and the multiple endoscopic biopsies (Kappa reliability coefficient = 0.897, p < 0.001).

CONCLUSIONS

Rigid nasopharyngeal endoscopy should be considered the primary follow-up tool after radiotherapy treatment of nasopharyngeal carcinoma, with computed tomography being reserved for patients with histological or symptomatic indications. Routine postnasal biopsies are not necessary, given the excellent specificity and negative predictive value of rigid nasopharyngeal endoscopy. Single, targeted endoscopic biopsy provides an excellent alternative to the usual multiple biopsies. In addition, it reduces cost, time, morbidity and patient discomfort.

Survival outcome of patients with nasopharyngeal carcinoma with first local failure: a study by the Hong Kong Nasopharyngeal Carcinoma Study Group

BACKGROUND

The purpose of this article is to report the overall survival (OS) outcome of patients with nasopharyngeal carcinoma (NPC) with local failure who received salvage treatment and to identify prognostic factors for OS.

METHODS

Between January 1996 and December 2000, 2915 patients received primary radiotherapy (RT) with or without chemotherapy for nonmetastatic NPC. At a median follow-up of 3.1 years, 319 patients had developed local failure as the first failure, with or without synchronous regional/distant failure. OS was calculated from the start of primary RT. Univariate and multivariate analyses were performed to identify prognostic factors for OS in patients with isolated local failure.

RESULTS

The T classification distribution of the local failure (rT classification) was as follows: 68 (21%) rT1 to T2a, 92 (29%) rT2b, 82 (26%) rT3, and 77 (24%) rT4. The rT classification was the same as the initial T classification in 82% of patients. Two hundred seventy-five patients (86%) had isolated local failure, and 232 (84%) of them did not have any distant metastasis or regional failure develop during follow-up. Salvage treatment was given to 200 patients (73%) with isolated local failure. One hundred fifty-nine patients (80%) received reirradiation (108 external beam RT [EBRT], 44 brachytherapy, and seven EBRT plus brachytherapy), 22 patients (11%) underwent nasopharyngectomy with or without postoperative RT, and 19 patients (9%) were treated with chemotherapy alone. Four patients died of RT complications, and one died of chemotherapy toxicity in the absence of active NPC. The 3-year actuarial OS for patients with isolated local failure was 74%. On multivariate analysis, advanced initial T classification (hazard ratio [HR], 1.44; p = .0006) and the use of salvage treatment (HR, 0.54; p = .0038) were independent prognostic factors. For the subgroups of patients who had the same recurrent and initial T classification, salvage treatment was associated with improved OS only in the subgroup with T1 to T2 local failure (n = 127; p = 0.0446), but not in the subgroups with T3 (n = 48) or T4 (n = 54) disease.

CONCLUSIONS

Most patients with first local failure have localized disease. Salvage treatment is feasible in most of the patients with clinically isolated local failure. Patients who had early initial T classification have a more favorable prognosis. Subgroup analysis suggests that salvage treatment only prolongs survival in patients with T1 to T2 recurrent disease.

Nasopharyngeal carcinoma

Incidence of nasopharyngeal carcinoma has remained high in endemic regions. Diagnosing the disease in the early stages requires a high index of clinical acumen and, although most cross-sectional imaging investigations show the tumour with precision, confirmation is dependent on histology. Epstein-Barr virus (EBV)-encoded RNA signal is present in all nasopharyngeal carcinoma cells, and early diagnosis of the disease is possible through the detection of raised antibodies against EBV. The quantity of EBV DNA detected in blood indicates the stage and prognosis of the disease. Radiotherapy with concomitant chemotherapy has increased survival, and improved techniques (such as intensity-modulated radiotherapy), early detection of recurrence, and application of appropriate surgical salvage procedures have contributed to improved therapeutic results. Screening of high-risk individuals in endemic regions together with developments in gene therapy and immunotherapy might further improve outcome.