Carcinoma of the nasopharynx: analysis of treatment results in 167 consecutively admitted patients

[Contribution of concomitant radiochemotherapy in the management of undifferentiated carcinoma of the nasopharynx in adults]

L'objectif de l'étude et d'Analyser les caractéristiques épidémiologiques, cliniques, thérapeutiques et évolutives du carcinome indifférencié du nasopharynx de l'adulte. Il s'agit d'une étude cohorte rétrospective portant sur 163 patients âgés de 17 ans et plus, traités pour un carcinome indifférencié du nasopharynx non métastatique. L'âge moyen des patients était de 46,5ans, avec un sexe-ratio de 1,7. 35,57% des patients étaient atteints de tumeurs localement évoluées (T3-T4) et 52,27% avec une atteinte ganglionnaire régionale avancée (N2-N3). Sur le plan thérapeutique une chimiothérapie neoadjuvante a été réalisée chez 77% des patients et 93,8% des patients ont bénéficié d'une radio-chimiothérapie concomitante. Après un recul moyen de 40,8 mois la survie globale était de 92,9% et la survie sans récidive (SSR) était de 78,9%. L'analyse de la survie sans récidive SSR en fonction des différents facteurs pronostiques a montré une différence statistiquement significative pour l'atteint ganglionnaire avec des taux de SSR à trois ans de 88%, 82,6%, 80,8% et 61,5% en cas de tumeur classée N0, N1, N2 et N3 respectivement (p = 0,02). Le cancer du nasopharynx est une maladie complexe, mais des progrès ont été accomplis grâce à des percées en radiothérapie et en biologie moléculaire. La radio-chimiothérapie concomitante représente le standard thérapeutique des stades cliniques supérieur ou égal à T2, ou supérieur ou égal à N1. Les techniques innovantes d'irradiation semblent prometteuses et pourraient pallier aux problèmes de toxicité tardive tout en assurant un excellent taux de contrôle local.

Improved survival of head and neck cancer patients in Greenland

Previously, head and neck cancer (HNC) patients in Greenland have had significant diagnostic delay and poor survival rates. From 2005-2009 several initiatives have been made to ensure faster diagnosis and better survival. The aim of this study was to compare the prognosis before and after these initiatives were introduced.

All Greenlandic patients diagnosed with HNC between 2005 and 2012 were included. Data were retrieved from medical records and national databases and compared with the period 1994-2003.

A total of 98 patients were identified. Diagnostic delay was significantly lower compared to the period 1994–2004 (p=0.048). The 3-year overall survival was 56% for all HNC and 47% for nasopharyngeal carcinomas. We found that patients with HNC between 1994 and 2003 had a higher risk of death from all reasons compared with the period 2005–2012 (HR 2.17; CI 1.46–3.23) after adjustments for stage and diagnostic delay.

Patients with head HNC in Greenland from 2005-2012 were diagnosed earlier and had a better overall survival compared to the period 1994–2003. The change in survival is more likely to be due to improvement in treatment rather than the initiated interventions. Although survival has improved in Greenland, demographic problems and lack of specialists remain a challenge.

Planned Gamma Knife Boost After Chemoradiotherapy for Selected Sinonasal and Nasopharyngeal Cancers

OBJECTIVE

To determine the feasibility of a Gamma Knife boost after intensity-modulated radiation therapy in combination with multimodal therapy in patients with nasopharyngeal carcinoma and sinonasal malignancies with skull base or cavernous sinus involvement.

METHODS

Nine patients were treated with intensity-modulated radiation therapy followed by a Gamma Knife boost. In one case Gamma Knife was given as salvage treatment after resection. Five patients had sinonasal malignancies and 4 had nasopharyngeal carcinoma. The mean radiation therapy dose was 64.3 Gy (range, 54-70 Gy) at 2 Gy per fraction. The median interval from completion of radiation therapy to Gamma Knife boost was 2.2 months (range, 1-4 months). The most common indication for Gamma Knife boost was involvement of the cavernous sinus, which was identified in 7 patients. The median margin Gamma Knife dose delivered was 13 Gy (range, 12-20 Gy), with median prescription isodose of 50%.

RESULTS

All patients tolerated the procedure well, with minimal toxicity. Local control rates were achieved in all patients and no acute grade 3-5 toxicity was observed. One patient experienced late grade 4 toxicity, which was potentially attributable to treatment. Distant failure occurred in 3 patients (1 patient with nasopharyngeal carcinoma and 2 patients with sinonasal malignancies).

CONCLUSIONS

Planned Gamma Knife boost followed intensity-modulated radiation therapy is feasible, safe, and provides excellent local control in patients with sinonasal malignancies and nasopharyngeal carcinoma, particularly in cases with cavernous sinus involvement. Further follow-up will be necessary to determine the long-term effectiveness and complication profile.

Late Visual and Auditory Toxicity of Radiotherapy for Nasopharyngeal Carcinoma

Aims and Background

Classical irradiation of carcinoma of the nasopharynx involves large fields and high doses; therefore, significant late toxicity and late side effects are to be expected. Given the fact that nasopharyngeal carcinoma (NPC) is a relatively radiosensitive disease and a significant proportion of patients are long-term survivors, late visual and auditory complications of treatment are of utmost concern for patients and radiation oncologists. The aim of this study was to evaluate the long-term visual and auditory toxicity in patients treated with radiotherapy for NPC.

Methods and Study Design

Forty-three long-term survivors (including 11 children), following definitive radiotherapy for NPC, underwent a thorough visual and auditory evaluation 2–22 years after their treatment. Ophthalmological examination consisted of anamnesis of dry eye syndrome and visual acuity, visual acuity testing, slit-lamp examination, Schirmer test, fundus examination, and intraocular pressure measurement, as well as fluorescein angiography in patients with pathological vascular findings in the fundus examination. Audiological evaluation included anamnesis of hearing loss, tinnitus or vertigo, examination of the ears and nasopharynx, audiogram, and tympanogram.

Results

Radiation retinopathy was found in 16% of patients by fundus examination, with one patient (2.3%) developing blindness. Severe dry eye syndrome was present in 26%. Fifty-six percent had some degree of hearing impairment, with 74% showing severe sensorineural hearing loss. Fifty-eight percent of patients reported tinnitus and 26% reported suffering from dizziness. Radiation retinopathy as well as all manifestations of auditory toxicity were found to bear a direct correlation with dose per fraction.

Conclusions

Unless there is tumor involvement, the orbital contents should be completely excluded from the target volume. Auditory toxicity is significant when treating NPC with two-dimensional techniques.

Nasopharyngeal carcinoma

Nasopharyngeal carcinoma is uncommon in the United States, with only 0.2 to 0.5 cases per 100,00 people; this is in contrast to southern China and Hong Kong, where the incidence is 25 to 50 per 100,000 people. There is a potential link between Epstein-Barr virus and the development of nasopharyngeal carcinoma. Radiotherapy alone as a single modality leads to similar 10-year survival rates in United States, Denmark, and Hong Kong (34%, 37%, and 43%, respectively). Multiple studies have shown an advantage to concurrent chemoradiation in the treatment of advanced disease. Radiation therapy remains the mainstay of salvage therapy, and modern techniques have allowed clinicians to achieve adequate local control without excessive toxicity.

Expression of Epstein-Barr virus-encoded latent membrane protein (LMP-1), p16 and p53 proteins in nonendemic nasopharyngeal carcinoma (NPC): a clinicopathological study

BACKGROUND AND AIMS

Although the latent membrane protein type 1 (LMP1) is frequently expressed in Epstein-Barr virus (EBV) malignancies, its contribution to the pathogenesis of nasopharyngeal carcinoma (NPC) is not fully defined. LMP1 functions as a viral mimic of the TNFR family member engaging a number of signaling pathways that induce morphological and phenotypic alterations. This study aimed to investigate the LMP1 expression and EBV infection in relation to clinical outcome and survival in a series of Mexican NPC patients. We also studied expression of p16 and p53 proteins.

METHODS

We analyzed in 25 tumor specimens the expression of LMP1, p16 and p53 by immunohistochemistry (IHC) and EBV presence by IHC/in situ hybridization. Differences in clinical outcome and survival in relation to protein expression were correlated through χ(2) statistics and Kaplan-Meier survival curves.

RESULTS

Our results showed a rate of 92% (23/25) of EBV infection. The expressions of LMP-1, p16 and p53 proteins were 40.0, 44.0 and 40.0%, respectively. LMP-1 immunoexpression was more common in older patients (>50 vs. <50 years old, p = 0.02) and with parapharyngeal space invasion (p = 0.02). The presence of metastatic disease at diagnosis (p = 0.03), distant recurrence disease (p = 0.006) and shorter distance recurrence-free survival (p = 0.05) was associated with lack of p16.

CONCLUSIONS

In our series, EBV infection rates are particularly high for nonendemic NPC, although without a statistically significant difference in overall survival, LMP1 and p16 expression was correlated with poorer clinical prognosis. Probably, LMP1 and p16 detection identify a worse clinical prognosis in NPC patient subgroup.

Haplotype-dependent HLA susceptibility to nasopharyngeal carcinoma in a Southern Chinese population

We have conducted a comprehensive case-control study of a nasopharyngeal carcinoma (NPC) population cohort from Guangxi Province of Southern China, a region with one of the highest NPC incidences on record. A total of 1407 individuals including NPC patients, healthy controls, and their adult children were examined for the human leukocyte antigen (HLA) association, which is so far the largest NPC cohort reported for such studies. Stratified analysis performed in this study clearly demonstrated that while NPC protection is associated with independent HLA alleles, most NPC susceptibility is strictly associated with HLA haplotypes. Our study also detected for the first time that A(*)0206, a unique A2 subtype to South and Southeast Asia is also associated with a high risk for NPC. HLA-A(*)0206, HLA-B(*)3802 alleles plus the A(*)0207-B(*)4601 and A(*)3303-B(*)5801 haplotypes conferred high risk for NPC showing a combined odds ratio (OR) of 2.6 (P<0.0001). HLA alleles that associate with low risk for NPC include HLA-A(*)1101, B(*)27, and B(*)55 with a combined OR of 0.42 (P<0.0001). The overall high frequency of NPC-susceptible HLA factors in the Guangxi population is likely to have contributed to the high-NPC incidence in this region.

Genetic factors leading to chronic Epstein-Barr virus infection and nasopharyngeal carcinoma in South East China: study design, methods and feasibility

Nasopharyngeal carcinoma (NPC) is a complex disease caused by a combination of Epstein-Barr virus chronic infection, the environment and host genes in a multi-step process of carcinogenesis. The identity of genetic factors involved in the development of chronic Epstein-Barr virus infection and NPC remains elusive, however. Here, we describe a two-phase, population-based, case-control study of Han Chinese from Guangxi province, where the NPC incidence rate rises to a high of 25-50 per 100,000 individuals. Phase I, powered to detect single gene associations, enrolled 984 subjects to determine feasibility, to develop infrastructure and logistics and to determine error rates in sample handling. A microsatellite screen of Phase I study participants, genotyped for 319 alleles from 34 microsatellites spanning an 18-megabase region of chromosome 4 (4p15.1-q12), previously implicated by a linkage analysis of familial NPC, found 14 alleles marginally associated with developing NPC or chronic immunoglobulin A production (p = 0.001-0.03). These associations lost significance after applying a correction for multiple tests. Although the present results await confirmation, the Phase II study population has tripled patient enrolment and has included environmental covariates, offering the potential to validate this and other genomic regions that influence the onset of NPC.

Experience in fractionated stereotactic body radiation therapy boost for newly diagnosed nasopharyngeal carcinoma

PURPOSE

Radiotherapy is the most effective treatment for nasopharyngeal carcinoma (NPC). The aim of this study is to evaluate the efficacy and toxicity of fractionated stereotactic body radiation therapy (SBRT) boost for NPC.

METHODS AND MATERIALS

Sixty-four patients with newly diagnosed, nonmetastatic NPC were treated with conventional radiotherapy 64.8-68.4 Gy followed by fractionated SBRT boost 12-15 Gy between January 2002 and July 2004. Most patients (72%) presented with Stage III-IV disease. Fifty-two patients also received cisplatin-based concurrent (38) or neoadjuvant (14) chemotherapy. The major endpoints were local control, overall survival, and complications.

RESULTS

All patients finished the planned dose of radiotherapy. After a median follow-up of 31 months (range, 22-54), 15 patients developed tumor recurrences--3 in the nasopharynx, 4 in the neck, 5 in distant sites, 1 in both nasopharynx and neck, 2 in the neck and a distant site. The 3-year actuarial rate of local control was 93.1%, regional control 91.4%, freedom from distant metastasis 90.3%, and overall survival 84.9%, respectively. There were no Grade 4 acute or chronic radiation-related complications.

CONCLUSIONS

Fractionated SBRT boost for NPC is technically feasible and provides good local control without any severe complications.

Nasopharyngeal intracavitary brachytherapy: the controversy of T2b disease

BACKGROUND

Locally persistent nasopharyngeal carcinoma (NPC) carries an increased risk of local failure if additional treatment is not given. It has been shown that intracavitary brachytherapy is effective in the treatment of patients with T1 and T2a NPC, although its role in the treatment of T2b disease had remained uncertain. The objectives of the current study were to evaluate the outcomes of patients with T2b, locally persistent NPC who were treated with high-dose-rate (HDR) intracavitary brachytherapy and to explore whether routine brachytherapy boost could improve the local control of patients who had T2b NPC at initial diagnosis.

METHODS

Thirty-four patients with locally persistent NPC who were treated during 1992-2000 with HDR intracavitary brachytherapy were analyzed retrospectively. All patients had T2b disease at initial diagnosis. They were treated with HDR intracavitary brachytherapy at doses of 22.5-24.0 grays (Gy) in 3 weekly sessions. To compare the efficacy of brachytherapy, another 403 consecutive patients with nonmetastatic T2b NPC who were treated with curative intent by external radiotherapy (ERT) during the same period were evaluated.

RESULTS

An improvement in the 5-year actuarial local failure-free survival rate (brachytherapy group vs. ERT group: 96.9% vs. 81.5%; P = 0.024), the disease-specific survival rate (84.5% vs. 68.1%; P = 0.021), and the overall survival rate (78.3% vs. 63.1%; P = 0.034) was demonstrated in the group that had locally persistent NPC who were salvaged with brachytherapy. In assessing local control, the addition of brachytherapy was just short of statistical significance on multivariate analysis (P = 0.054). The complication rates were comparable between the brachytherapy group and the ERT group.

CONCLUSIONS

The results suggested that patients with T2b NPC who have locally persistent disease can be salvaged effectively with brachytherapy. Their local control was even better than that achieved by patients who had clinical remission of local disease at the completion of ERT. Furthermore, it is possible that routine brachytherapy boost, after the completion of ERT, may improve local control in patients who have T2b disease at initial diagnosis. However, its exact benefit can be elucidated only by prospective, randomized studies.

Treatment results of 1070 patients with nasopharyngeal carcinoma: an analysis of survival and failure patterns

BACKGROUND

The aim of this analysis was to evaluate the outcomes of patients with nasopharyngeal carcinoma (NPC) treated primarily by external beam irradiation (ERT) and to explore for possible ways to improve the treatment results.

METHODS

One thousand seventy patients with nonmetastatic NPC treated from 1990 to 1998 were retrospectively analyzed. The distribution according to the Union Internationale Contre le Cancer (UICC) (1997 edition) staging system at initial diagnosis was as follows: stage I, n = 113; stage IIA, n = 38; stage IIB, n = 360; stage III, n = 306; stage IVA, n = 136; stage IVB, n = 117; T1, n = 284; T2a, n = 88; T2b, n = 398; T3, n = 149; T4, n = 151; N0, n = 321; N1, n = 393; N2, n = 238; N3a, n = 29; N3b, n = 89. Two hundred eight patients were given neoadjuvant chemotherapy. Ninety-seven patients were diagnosed with locally persistent disease and were salvaged with high dose rate intracavitary brachytherapy. Multivariate analysis was performed with the Cox regression proportional hazards model.

RESULTS

The 5-year actuarial local failure-free survival, regional failure-free survival, distant metastasis-free survival, progression-free survival, cancer-specific survival, and overall survival rates were 80.9%, 93.3%, 77.2%, 62.7%, 71.4%, and 66.5%, respectively. Isolated distant metastasis occurred in 191 patients (18%). The distributions were as follow: stage I, 2.1% (two of 95); stage IIA, 5.7% (two of 35); stage IIB, 14.9% (45 of 302); stage III, 26.4% (62 of 235); stage IVA, 40% (40 of 100); stage IVB, 47.1% (40 of 85). Results of the multivariate analysis of various clinical endpoints were discussed. By studying these failure patterns, it is hoped that we could refine future treatments according to the failure patterns of patients with different risks of locoregional and distant failure.

CONCLUSIONS

The 18% incidence of isolated distant metastasis is too high to be ignored. Maximizing the local control and minimizing the risk of distant metastasis and late complications should be the key objectives in designing future clinical trials.

[Assessment of the prognostic capacity improvement of the 5th edition of the TNM in patients with nasopharyngeal carcinoma]

OBJECTIVE

Evaluate the changes included in the 5th edition of the TNM classification in patients with nasopharyngeal carcinoma.

PATIENTS AND METHODS

Retrospective study of 103 patients with nasopharyngeal carcinoma treated with radical intention in our centre from 1985 to 1997. A reclassification according to the criteria defined in the 5th edition of the TNM was carried out. The loco-regional control and survival obtained when patients were classified with the 4th and 5th editions of the TNM were compared.

RESULTS

The use of the 5th edition of the TNM led to a decrease in local category (T) and stage grouping, improving the prognostic capacity in local control and survival. The changes included in the 5th edition of the TNM did not modify the regional classification in a essential way.

CONCLUSIONS

The changes included in the 5th edition of the TNM improved the classification of patients with nasopharyngeal carcinoma.

Nasopharyngeal carcinomas: an update

Among the group of head and neck cancers, nasopharyngeal carcinomas (NPC) represent a distinct entity in terms of their epidemiology, clinical presentation, biological markers, carcinogenic risk factors, prognostic factors, treatment and outcome. Undifferentiated NPC (UCNT), the most frequent histological type, is endemic in certain regions, especially in South East Asia. The disease has also been associated with the presence of the Epstein-Barr Virus (EBV). Although NPC is a radiosensitive and chemosensitive tumour, a substantial number of patients develop local recurrence or distant metastases. For patients with locoregional advanced disease, it is well known that conventional radiotherapy is insufficient in terms of both the local control rates and distant metastases. New techniques of radiation and new combined radiotherapy and chemotherapy modalities have been evaluated in numerous clinical trials in recent years. The purpose of this article is to review the current knowledge in terms of the epidemiology, biology, prognosis, management and outcome of patients with NPC.

Design of a prognostic index score for metastatic nasopharyngeal carcinoma

The survival outcome of patients with systemic cancer differs significantly between individuals even within the same tumour type. We set out to illustrate this by analysing the factors determining survival in patients with metastatic disease from nasopharyngeal carcinoma (NPC) and to design a scoring system based on these prognostic factors. Patients referred between January 1994 and December 1999 were retrospectively analysed. Factors analysed included patient (age group, gender, performance status (BS) at diagnosis of metastases), disease (number of metastatic sites, specific metastatic sites, disease-free interval (DFI), metastases at presentation, presence of locoregional recurrence), and laboratory factors (leucocyte count, haemoglobin level, albumin level). Univariate and multivariable analyses were performed using the Cox proportion hazards model. A numerical score was derived from the regression coefficients of each independent prognostic variable. The prognostic index score (PIS) of each patient was calculated by totalling up the scores of each independent variable. Independently significant, negative prognostic factors were liver metastasis, lung metastasis, anaemia, poor PS, distant metastasis at initial diagnosis, and a DFI of <6 months. Three prognostic groups based on the PIS were obtained: (i) good risk (PIS=0-6); (ii) intermediate risk (7-10); (iii) poor risk (>or=11). The median survivals for these groups were 19.5, 10, and 5.8, months, respectively, (log rank test: P<0.0001). The variable prognosis of patients with disseminated NPC can be assessed by using easily available clinical information (patient, disease and laboratory factors). The PIS system will need to be validated on prospectively collected data of another cohort of patients.

Loss of cyclin D1 and p16 expression correlates with local recurrence in nasopharyngeal carcinoma following radiotherapy

BACKGROUND

The cyclin D1/p16/Rb pathway plays a critical role in tumorigenesis and each component of this pathway may be affected in various malignancies. The purpose of this study was to investigate the expression and prognostic significance of these proteins in nasopharyngeal carcinoma (NPC).

PATIENTS AND METHODS

Sixty-five patients undergoing radiotherapy for NPC were analyzed. The expression of cyclin D1, p16 and pRb was evaluated with immunohistochemical analysis of archived pretreatment tumor materials and expression of these proteins was correlated with clinicopathological parameters.

RESULTS

Positive expression of cyclin D1 was observed in 43 of 65 NPCs (66%). p16 and pRb inactivation was identified in 42 of 65 (65%) and four of 65 (6%) tumors, respectively. All but seven tumors (58 of 65, 89%) contained at least one alternation in the cyclin D1/p16/Rb pathway. Loss of cyclin D1 as well as p16 was closely related to local recurrence after radiotherapy for NPC (P = 0.015 and 0.047). No association between pRb expression and clinicopathological outcome was apparent.

CONCLUSIONS

The study's results suggest that the cyclin D1/p16/Rb pathway plays an important role in NPC tumorigenesis. We also find that cyclin D1 and p16 protein levels in NPC may be of use clinically as a predictor of local tumor control.

Salvage radiation therapy for locally recurrent nasopharyngeal carcinoma

PURPOSE

To study the treatment outcome in patients with locally recurrent nasopharyngeal carcinoma (NPC) and to explore whether a combination of high-dose-rate (HDR) intracavitary brachytherapy and external beam radiation therapy (ERT) could improve the therapeutic ratio.

METHODS AND MATERIALS

Ninety-one patients with nonmetastatic locally recurrent NPC who were treated with curative intent during the years 1990-1999 were retrospectively analyzed. Eighty-two patients had histologically proven carcinoma. The remaining 9 had clinical and imaging features suggestive of local recurrence. The Ho's T-stage distribution at recurrence (rT) was as follows: rT1-37, rT2-14, rT3-40. Total equivalent dose (TED) was calculated by the linear-quadratic formula without a time factor correction. For those treated by combined-modality treatment (CMT), the TED was taken as the summation of the equivalent dose by ERT and the absolute dose delivered to floor of the sphenoid by brachytherapy. Eight patients were treated solely with brachytherapy, all receiving 24-45 Gy in 3-10 sessions. Forty-one patients were treated with ERT alone receiving a median TED of 57.3 Gy (range, 49.8-62.5 Gy). Forty-two patients were treated by CMT with a median equivalent dose of 50 Gy (range, 40-60 Gy) given by ERT and 14.8 Gy by brachytherapy (range, 3-29.6 Gy). Multivariate analyses were performed using the Cox regression proportional hazards model.

RESULTS

The 5-year actuarial overall survival rate, disease specific survival rate and local failure-free survival (LFFS) rate for the whole group were 30%, 33. 3% and 37.8%, respectively. The 3-year LFFS rates of rT1, rT2, and rT3 diseases were 64%, 61.5%, and 18.4%, respectively (p = 0.001). Of the 8 patients treated with brachytherapy alone, 4 failed locally. Further analyses were concentrated on the ERT (41 patients) and CMT (42 patients) groups. The 3-year LFFS rates of rT1, rT2, and rT3 diseases were 66.7%, 66.7%, and 18.4%, respectively (p = 0.0008). Better local control for patients who received a TED of 60 Gy or greater was shown. The corresponding 3-year LFFS rates were 29% and 60% (p = 0.0004). Subgroup analysis on the ERT and CMT groups showed a 3-year LFFS rate of 33.5% and 57% (p = 0.003). ERT group had an excess of patients with rT3 disease. Further analysis was performed on the rT1-2 patients showing a trend toward improvement in local control in favor of the CMT group (3-year LFFS rates: CMT, 71.7%; ERT, 54%; p = 0.13). Multivariate analyses showed that rT stage (p = 0.002) and TED (p = 0.01; HR, 0.93; 95% confidence interval, 0.88-0. 98) remained significant. The 5-year major and central nervous system (CNS) complication-free rates were 26.7% and 47.8%. The following factors were found to be significant on univariate analyses for both complications in the ERT and CMT groups: (1) Modality of treatment: more complications with ERT group; and (2) rT stage. Multivariate analyses showed that the rT stage was significant for predicting the occurrence of major (p = 0.004) and CNS complications (p = 0.04).

CONCLUSION

For rT1-2 local recurrences, CMT with at least 60 Gy TED is recommended. The high incidence of major late complications is of serious concern. Ways of improving the local control of Ho's rT3 disease and reducing the risk of late complications should be explored.

Salvage brachytherapy for patients with locally persistent nasopharyngeal carcinoma

PURPOSE

Locally persistent nasopharyngeal carcinoma (NPC) carries an increased risk of local failure if additional treatment is not given. This study was conducted to evaluate the outcomes of patients with locally persistent NPC as treated by high-dose-rate (HDR) intracavitary brachytherapy, and to explore whether routine brachytherapy boost could improve the local control.

METHODS AND MATERIALS

Eighty-seven patients with locally persistent NPC treated during 1990-1998 with HDR intracavitary brachytherapy were retrospectively analyzed. Fibreoptic nasopharyngoscopy was performed 3-6 weeks after completion of the primary external radiation therapy (ERT). Biopsies were only taken from suspicious areas. Those with complete regression of local disease were put on observation. Eighty-seven patients were shown to have persistent viable disease at a median time of 6 weeks post-RT. The distribution according to Ho's staging system at initial diagnosis was as follows: Stage I-8, II-33, III-41, IV-5; T1-19, T2-48, T3-20; N0-32, N1-22, N2-28, N3-5. CT scan for restaging was not performed after the documentation of persistent disease. Our policy was to treat all patients with persistent disease with brachytherapy irrespective of the extent of disease just prior to brachytherapy. They were treated with HDR intracavitary brachytherapy, with either cobalt sources or an iridium source, giving 22.5-24 Gy in 3 weekly sessions in all but 4 patients. This dose was prescribed at a distance of 1.5 cm from the center of the surface as defined by the sources in the first six patients and subsequently reduced to 1 cm for the others. Twelve patients were treated with neoadjuvant chemotherapy. To compare the efficacy of brachytherapy, another 383 consecutive nonmetastatic patients, treated with curative intent by ERT, during the years 1990-1993, were evaluated. Multivariate analysis was performed using the Cox regression proportional hazards model.

RESULTS

The 5-year actuarial local failure-free survival (LFFS) rates and disease-specific survival rates for the brachytherapy group and ERT group were 85% and 76.6% (p = 0.15), and 72% and 67.8% (p = 0.2), respectively. The corresponding 5-year actuarial LFFS rates for T1, T2, and T3 disease were 94.7%, 88.2%, 67.4%, and 84.1%, 79.8%, 62.6%. In assessing the local control, only the T staging was significant on multivariate analysis (p = 0.0004). Other parameters such as age, sex, and persistence of disease (giving brachytherapy) were all nonsignificant. Complications were comparable between the two groups. In the persistent group, the local failure rates of the patients treated with and without neoadjuvant chemotherapy were 17% (2/12) and 13% (10/75) respectively. When analyzed according to different brachytherapy sources, the 5-year LFFS rates of the T1, T2, and T3 patients treated with iridium and cobalt sources were 100% vs. 85.7 (p = 0.19), 93.6% vs. 70% (p = 0.04), and 67.7% vs. 60% (p = 0.72). The difference was statistically significant for the T2 groups. When early T-stage (T1 and T2) patients were grouped together for analysis, the iridium group again showed a statistically significant improvement in 5-year LFFS rate when it was compared with the cobalt group (95.3% vs. 76.5%, p = 0.03) and the ERT alone group (95.3% vs. 81.5%, p = 0.03). The improvement of local control is attributed to a higher nasopharyngeal mucosal dose that is achieved by using small-size flexible applicators with an iridium source. It is interesting to note that the 5-year LFFS rates for the ERT alone group (T1: 84.1%, T2: 79.8%, T3: 62.6%) are comparable to the corresponding rates of the cobalt group. This information supports our speculation that an adequate booster treatment could compensate for inadequate primary treatment. The prognosis of patients with locally recurrent NPC is grave. Maximizing the local control is therefore crucial for the survival of the patients. (ABSTRACT TRUNCATED)

Locally advanced nasopharyngeal cancer: long-term outcomes of radiation therapy

PURPOSE

To investigate the clinical manifestations and treatment outcomes in patients with stage T4M0 nasopharyngeal carcinoma.

MATERIALS AND METHODS

Findings in 179 patients (age range, 13-78 years) with American Joint Committee on Cancer stage T4M0 nasopharyngeal carcinoma treated from January 1983 to February 1992 with a minimum follow-up of at least 5 years were reviewed. Of the 179 patients, 166 (92.7%) had World Health Organization type II or III disease. Forty-one patients (22.9%) had no lymph nodal involvement; 138 patients (77.1%) had metastatic nodal involvement in the neck. All patients underwent radiation therapy; 39 patients also received different forms of chemotherapy. The radiation therapy doses were usually 70-74 Gy administered to the primary tumor over 7 or 8 weeks, 70-74 Gy to the neck region in patients with nodal involvement, or 50-60 Gy administered to the neck region over 5 or 6 weeks in patients without neck nodal involvement.

RESULTS

In 100 patients, radiation therapy failed in the primary tumor alone (n = 28), neck nodes alone (n = 5), and distant metastases alone (n = 43) or at a combination of sites (n = 24). The cumulative failure rates for the primary tumor, neck metastases, and distant metastases were 25.1% (n = 45), 14.0% (n = 25), and 33.0% (n = 59), respectively. The 5-year primary disease-free, distant disease-free, and overall survival rates were 68.7%, 56.5%, and 28.6%, respectively. Results of salvage treatment for relapse were unsatisfactory.

CONCLUSION

In about three-tenths of patients, T4M0 nasopharyngeal carcinoma can be cured with conventional high-dose radiation therapy.

Carcinoma of the nasopharynx treated by radiotherapy alone: determinants of distant metastasis and survival

PURPOSE

This retrospective study was conducted to identify the prognostic factors for distant metastasis and survival in a population of 378 patients with nasopharyngeal carcinomas treated by radiation therapy alone.

MATERIALS AND METHODS

All patients were treated at the University of Texas M.D. Anderson Cancer Center between 1954 and 1992, following a consistent dose and volume prescription policy. There were 286 males and 92 females. The median age was 52 years (range: 16-86 years). The majority of the patients were white Caucasians (282 patients,75%). Tumors were classified as squamous cell carcinomas (193; 51%), lymphoepitheliomas (154; 41%), or unclassified carcinomas (31, 8%). Three fourths of the patients presented with AJCC Stage IV disease (T4, N0-3, 118 patients; T1-3, N2-3 164 patients). The treatment techniques included opposed lateral fields with or without an anteroposterior or an anterior oblique pairs for dose supplementation to the primary site. Average total doses per T-stage ranged between 60.2 and 72.0 Gy. Median follow-up time was 10 years (range 0.3 to 28.6 years).

RESULTS

A total of 103 patients (27%) developed distant metastases at a median time of 8 months (range: 1-90 months). Actuarial rates for distant metastasis were 30%, 32%, 32% at 5, 10, and 20 years, respectively. Actuarial rates for disease specific survival at the same time points were 53%, 45%, and 39% with 184 patients (49%) dying of their nasopharyngeal cancer. Advanced T-stage, N-stage, and non-lymphoepithelioma histology were independent adverse prognostic factors for disease specific survival. Advanced N-stage and low neck disease were independent adverse prognostic factors for distant metastasis with a very high rate of distant metastases for those patients who presented with both adverse factors (relative risk 7.86). On average, patients with distant metastasis lived 5 months after they were diagnosed with metastatic disease (range: 0-172 months), although four patients (4%) survived more than 5 years after diagnosis.

CONCLUSIONS

This study demonstrates good long term survival rates after definitive radiotherapy for patients with nasopharyngeal carcinomas. Patients with advanced and lower neck disease have the highest risk of developing distant failures. Such patients can be considered the reference risk group to test the value of adjunctive chemotherapy.

Carcinoma of the nasopharynx treated by radiotherapy alone: determinants of local and regional control

PURPOSE

This retrospective study was conducted to review the results of treatment and to identify prognostic factors for local and regional control in a population of 378 patients with nasopharyngeal carcinomas treated in a single institution by radiation therapy alone.

METHODS AND MATERIAL

All patients were treated at The University of Texas M. D. Anderson Cancer Center between 1954 and 1992 following a consistent treatment philosophy but with evolving technique. There were 286 males and 92 females with a median age of 52 years (range: 16-86 years). The majority of the patients were Caucasian (282 patients, 75%). Thirty-two patients (8%) had one or more cranial nerve deficits. Three-fourths of the patients presented with AJCC Stage IV disease (T4, N0-3, 118 patients; T1-3, N2-3 164 patients). Histologically, 193 tumors (51%) were squamous cell carcinomas, 154 (41%) lymphoepitheliomas, and 31 (8%) unclassified carcinomas. Average total dose varied with T-stage and ranged from 60.2 to 72.0 Gy. Median follow-up time was 10 years.

RESULTS

For the entire population the 5-, 10-, and 20-year actuarial survival rates were 48, 34, and 18%, respectively, with 184 patients (49%) dying of nasopharyngeal cancer. Actuarial control rates at 5, 10, and 20 years were 71, 66, and 66% for the primary site and 84, 83, and 83% for the neck. A total of 100 patients (26%) had local failures and 51 patients (13%) had regional failures with a median time to recurrence of 8.2 months and 13 months, respectively. Advanced T-stage, squamous histology, and presence of cranial nerve deficits were poor prognostic factors for local control in both univariate and multivariate analyses. N-stage and tumor histology were significant factors for neck control. Treatment year, total dose within the ranges used, and duration of treatment did not have any significant effect on local or regional control. The actuarial incidence of Grade 3-5 late complications was 16, 19, and 29% at 5, 10, and 20 years, respectively. Twelve patients (3%) died of treatment-related complications; all but one fatal complication occurred before 1971 and the other in 1976.

CONCLUSIONS

This study shows very good long-term local and regional control rates for nasopharyngeal carcinomas after definitive radiotherapy and establishes a benchmark for newer treatment strategies. Improvements in treatment technique over the years have dramatically reduced the frequency of severe late complications. Patients with advanced stage tumors and differentiated squamous histology have a relatively poor prognosis when treated with conventional radiotherapy and are candidates for dose escalation or combined modality studies.

Malignant nasopharyngeal tumours in Iceland

From 1965 to 1990, 46 cases of malignant nasopharyngeal tumours were diagnosed in Iceland. The incidence rate is as low as in other Western countries, 0.6/100,000 per year. Histo-pathological diagnosis were as follows: Undifferentiated carcinoma 45%; squamous cell carcinoma 30%; non-keratinizing carcinoma 7%; and plasmacytoma 9%; lymphoma 7%; rhabdomyosarcoma 2%. Four per cent were diagnosed at stage I, 13% at stage II, 29% at stage III and 54% at stage IV. The overall crude survival at 10 years from diagnosis was 28.3%. The following factors were found to have a prognostic value: Stage of disease, size of tumour (T-classification) and age at diagnosis. Nodal stage (N-classification) alone and sex were not found to be prognostic factors. There was no difference in survival among the different WHO types of cancer. Patients with carcinoma were all treated with radiotherapy. The survival of those who received more than 60 Gy was better than of those who received 60 Gy or less (p = 0.04).

Prognostic factors of locoregionally recurrent nasopharyngeal carcinoma--a retrospective review of 182 cases

Locoregional relapse is the major cause of failure of nasopharyngeal carcinoma (NPC) after radical radiation therapy. The prognosis of such patients is dismal, and the factors related to the outcome are not well identified. Between January 1983 and December 1989, 1,168 new patients with biopsy-proven NPC were seen at this hospital. Eight hundred and eighty-three of these patients were treated uniformly with radical external irradiation and intracavitary treatment with or without chemotherapy. The clinical courses, retreatment outcomes, and prognostic factors for locoregional relapse and subsequent distant metastasis were analyzed. During the follow-up period of 3-10 years or until death, 182 patients (20.6%) developed locoregional relapses without distant metastasis initially. T stage and age were significant prognostic factors for locoregional recurrence. In contrast, histopathologic subtype, N stage, sex, and systemic chemotherapy were not. There were 36 patients (19.8%) who developed subsequent distant metastasis with or without retreatment. The median time from locoregional relapses to distant metastasis was 6 months in this study, and bone was the most frequent and the earliest site of distant metastasis. The N stage at diagnosis, the initial disease-free interval, the presence of neck nodal disease at relapse, and age were the significant factors for predicting the subsequent distant metastasis in locoregionally recurrent NPC patients. We recommend that additional systemic chemotherapy should be considered for retreatment of locoregional relapsed NPC, not only for enhancement of local control but also for eradicating microscopic metastasis as anticipated.

DNA ploidy in nonmelanoma skin cancer

BACKGROUND

Patients with head and neck squamous cell carcinoma die of locoregional recurrence and those with basal cell carcinoma suffer cosmetic and functional changes from its treatment. Prognostic factors are based upon tumor characteristics and host factors. Flow cytometry can assist with prognostic characterization of nonmelanoma skin cancer.

METHODS

Specimens from 40 sequential patients with head and neck nonmelanoma skin cancers were prospectively obtained at the time of surgery. The patients were followed for four years for local recurrence and metastasis to regional lymph nodes. Samples were prepared from frozen specimens using a modification of the Vindelov procedure.

RESULTS

DNA aneuploidy or tetraploidy and histology of well differentiated squamous cell carcinoma were significantly associated with metastasis to regional lymph nodes. Direct extension of tumor below the adipose tissue was associated with an S-phase greater than 4.1 and a proliferative fraction greater than 5.5. No tumors recurred at the site of surgical resection.

CONCLUSIONS

The measurement of DNA ploidy of well differentiated squamous cell carcinoma, and proliferative capacity or S-phase of both basal cell and squamous cell carcinomas assists in predicting the biologic proclivity for locoregional invasion or metastasis of nonmelanoma skin cancer. Identification of aggressive tumors at the time of surgery may offer the opportunity for prevention of lethal metastasis by using adjunctive therapy.

High dose rate intracavitary brachytherapy in the treatment of nasopharyngeal carcinoma

A retrospective study on 61 patients, with local persistent or recurrent nasopharyngeal carcinoma (NPC), treated during 1990-1992 with high dose rate intracavitary brachytherapy alone or combined with external irradiation, is presented. All 39 patients with persistent disease were treated solely with brachytherapy. The actuarial 3-year local failure-free survival (LFFS) rates of the persistent and recurrent groups were 82% and 45% respectively. The corresponding disease specific survival rates were 82% and 62%. Fifteen patients with recurrence received the combined modality treatment and their 3-year LFFS rate was 65%. Three out of 7 patients treated by brachytherapy could be controlled locally. The total dose given to the floor of sphenoid was an important predictor of local control. Of the 23 patients with persistent disease treated with < 17.5 Gy to this area, 6 failed locally as opposed to none of the 16 patients receiving a higher dose (p = 0.031). For those with recurrence treated by the combined modality, none of the 7 patients given >/= 57.5 Gy recurred while 5 local failures were observed among those receiving a smaller dose (p = 0.041). The general implications of these results for the treatment of NPC recurrence are discussed.

Head and neck cancer

This synthesis of the literature on radiotherapy for head and neck cancer is based on 424 scientific articles, including 3 meta-analyses, 38 randomized studies, 45 prospective studies, and 246 retrospective studies. These studies involve 79174 patients. The literature review shows that radiotherapy, either alone or in combination with surgery, plays an essential role in treating head and neck cancers. When tumors are localized, many tumor patients can be cured by radiotherapy alone and thereby maintain full organ function (1, 2). Current technical advancements in radiotherapy offer the potential for better local tumor control with lower morbidity (3). This, however, will require more sophisticated dose planning resources. To further improve treatment results for advanced tumors, other fractionation schedules, mainly hyperfractionation, should be introduced (5). This mainly increases the demands on staff resources for radiotherapy. The combination of radiotherapy and chemotherapy should be subjected to further controlled studies involving a sufficiently large number of patients (4, 5). Interstitial treatment (in the hands of experienced radiotherapists) yields good results for selected cancers. The method should be more generally accessible in Sweden. Intraoperative radiotherapy should be targeted for further study and development.

Impact of changes in the treatment of nasopharyngeal carcinoma: an experience of 30 years

Two hundred and twenty-eight patients with nasopharyngeal carcinoma were treated in a single institution in a 31-year period. Overall survival (OS), disease-free survival (DFS), and complete response (CR) rates were analyzed. In addition, survival and control rates from 1960 to 1975 and from 1976 to 1991 were evaluated. In the latter group, a comparative study was performed between patients treated with neoadjuvant chemotherapy (NCT) before radiotherapy (RT) (45) and patients treated with radiotherapy alone (45). OS at 5 and 10 years were 42 and 34%, and DFS rates were 35 and 30%, respectively. CR was achieved in 184 patients (81%). Tumor progression and survival were strongly associated with T-category. Use of fashioned blocks, age and T-category were the most important factors influencing survival in a multivariate analysis. In the patients treated with NCT, rates of CR and OS were not significantly different when compared with the concurrent RT alone group. Ninety-nine patients had recurrence (54%) and 58 received rescue treatment. Modern radiotherapy techniques have greatly assisted in the improvement of tumor control rates. Chemotherapy must be further evaluated and new treatments for relapsed patients are needed.

Undifferentiated nasopharyngeal cancer (UCNT): current diagnostic and therapeutic aspects

Undifferentiated carcinoma of the nasopharynx (UCNT) is a particular head and neck epidermoid lineage tumor related to the Epstein Barr Virus (EBV). It has geographically selective endemic epidemiologic features, without relation to external carcinogens. Its systemic agressiveness is the source of most disease-related demises, because radiotherapy achieves excellent local control and a significant percentage of cure in patients with exclusive locoregional disease. Difference in the staying systems currently in use, the recent changes in imaging and radiotherapy technology, and the lack of distinction between UCNT and squamous cell carcinoma (SCC) of the nasopharynx in Western literature reports make for some difficulty in therapeutic results evaluation when analyzing available literature. Its chemosensitivity is a relatively recent acknowledged fact, and its use in metastatic patients results in a high percentage of objective responses, many of long duration. Neoadjuvant cisplatin-based chemotherapy seems to be of benefit, but outstanding controversies in this regard will be soon answered through ongoing phase III trials. After a review of the current literature of all the above-mentioned aspects of this fascinating nosologic entity, our own experience, both in metastatic and locoregional disease patients is analyzed.