Nasopharyngeal carcinoma: results of treatment over a 27 year period, 1950 through 1977

Transpalatal insertion of radioactive gold grain for the treatment of persistent and recurrent nasopharyngeal carcinoma

PURPOSE

To evaluate the efficacy of radioactive gold grain implant via the split palate approach in the control of locally recurrent or persistent nasopharyngeal carcinoma.

METHODS AND MATERIAL

Forty-three patients, 10 for persistent NPC, 28 for first relapse in the nasopharynx, and five for second relapse in the nasopharynx, were treated. The diameter of the tumors at the time of gold grain implant ranged from 0.5 to 5 cm, the number of gold grains inserted varied from 4 to 14, the median number was seven.

RESULTS

There was no significant difference in the control of the primary tumor for persistent disease (80% at 5 years), first relapse (61% at 5 years) and second relapse (80% at 3 years), p = 0.8845. The difference in survival between the three subgroups of patients, however, was highly significant (p = 0.0040). Thirty patients had CT evaluation before gold grain implant and the tumor was found confined to the nasopharynx in 21, in the remaining nine patients erosion of the sphenoid sinus or other parts of the base of skull was noted. The difference in the control between those patients with tumors confined to the nasopharynx and those patients with extranasopharyngeal extension of tumor almost reached statistical significance (81% and 44% respectively at 5 years, p = 0.0554). For the six patients who developed local recurrence after gold grain implant and were evaluable for the pattern of failure, the recurrent tumors were considered originating from another region of the nasopharynx in four, and in-field failure in the other two cases.

CONCLUSION

Radioactive gold grain implant as salvage treatment provides satisfactory control of persistent and recurrent nasopharyngeal carcinoma. The local control was better when the tumor was localized to the nasopharynx, thus underlines the importance of close follow-up for early recognition of relapse and persistent tumor. However, such patients still suffered from high incidence of regional and distant failure, the pathophysiology and management of which require further investigation.

Transmandibular transpterygoid approach to the nasopharynx, parapharyngeal space, and skull base

The nasopharynx, upper part of the parapharyngeal space, and skull base are relatively inaccessible to the surgeon without major postoperative complications. Operative fields reached by conventional approaches through the palate and maxillary sinus are too limited and narrow to remove extensive tumors. The authors applied a transmandibular transpterygoid approach for the removal of five residual nasopharyngeal carcinomas (NPCs) after full doses of irradiation, one pleomorphic adenoma of the nasopharynx, and one large parapharyngeal schwannoma extending into the jugular foramen. This approach offers a wide operative field so that large blood vessels and cranial nerves can be managed easily. All tumors were successfully resected. Two patients with benign neoplasma had uneventful recoveries after treatment. Of five patients with NPC, two are alive with no evidence of disease for 68 months and 50 months, respectively, while two died of metastases to the liver and bones. The other patient is alive with metastases in the lungs. No tumor recurred in the local primary site, however. Since the number of NPC cases is small, the usefulness of surgical removal of the postirradiation residual NPC is not clear. Our experience proved that the transmandibular transpterygoid approach is a practical method in the treatment of neoplastic lesions in the nasopharynx, parapharyngeal space, and skull base.

Nasopharyngeal carcinoma in children--a retrospective review and demonstration of Epstein-Barr viral genomes in tumor cell cytoplasm: a report of the Pediatric Oncology Group

Twenty-seven nasopharyngeal carcinomas were entered in the Pediatric Oncology Group Rare Tumor Registry from 1973 to 1988 (15 males, 12 females; 10 white, 15 black, two unknown; aged 8 to 17 years). Eight tumors were non-keratinizing carcinomas (World Health Organization 2) and 19 were undifferentiated (World Health Organization 3). The overall 3-year survival rate was 70% (SE 11%). Nine children developed distant metastases and two were salvaged. We found that localized tumor (P = .02) and black race (P = .05) were associated with a better outcome. In situ hybridization using a biotinylated probe demonstrated Epstein-Barr virus DNA in the cytoplasm of the neoplastic epithelial cells in nine of 11 tumors examined, firmly establishing the presence of Epstein-Barr virus within the malignant cells of nasopharyngeal carcinomas of both World Health Organization 2 and World Health Organization 3 histology, rather than in the surrounding lymphocytes.

Carcinoma of the nasopharynx. The significance of lymphocytic infiltration

From 1974 to 1985, 76 patients with nasopharyngeal carcinoma (NPC) received irradiation with curative intent and 14 with palliative intent in our department. Of the 76 patients, 59 presented with UICC stage IV. The 5-year actuarial survival rate was 41% and the relapse-free survival rate (RFS) 45%. The slides were reviewed according to the World Health Organization (WHO) histologic classification, also taking into account the degree of lymphocytic infiltration according to its Cologne modification. Undifferentiated carcinoma and non-keratinizing carcinoma had similar 5-year RFS (47 and 44% respectively). Patients with major lymphocytic infiltration in the tumor presented with younger median age, with smaller primary tumors and with more advanced neck disease than the other patients. There was, however, no obvious association between the degree of lymphatic infiltration in the tumor and the prognosis. Patients with major lymphocytic infiltration had a 5-year RFS of 44%, versus 49% for patients without such infiltration.

Management of local residual primary lesion of nasopharyngeal carcinoma (NPC): are higher doses beneficial?

One hundred and eighty-two nasopharyngeal carcinoma (NPC) patients, treated from March 1958 through 1978, received 70 Gy or more and were left with gross residual lesion in the nasopharynx, were retrospectively analyzed. Ninety-two patients were given a boost by reduced portals to a total of 90-120 Gy (boost group) whereas for the other non-randomized 90 patients, the treatment was stopped at 70 Gy (observation group). The local recurrence, distant metastasis and 5-year survival rates of the two groups are: 35% (32/92) vs. 58% (52/90), 20% (18/92) vs. 43% (39/90), and 54% (50/92) vs. 21% (19/90), respectively. The benefit of boost is more apparent in patients with T1-2 than T3-4 lesions (p less than 0.001), at increased risk of radiation encephalo-myelitis from 5.5% to 17%. The authors believe that boost be given to patients with early Stage T or small residual lesion at the primary site of NPC.

Carcinoma of the nasopharynx--comparison of the UICC and Ho clinical staging systems

From 1974 to 1985 definitive radiation therapy was performed in 76 patients with nasopharyngeal carcinoma (NPC). Of the 76 patients 59 presented UICC stage IV and 13 UICC stage III. The distribution of the stages was more homogeneous for the Ho system: Ho I, n = 4; II, n = 21; III, n = 16; IV, n = 32; V, n = 3. Radiotherapy followed the guidelines of the M.D. Anderson Hospital in Houston. A median dose of 68 Gy was given to the primary and of 66 Gy to the neck nodes, independent of the histologic subtype. The 5-year actuarial survival rate was 41% and the disease specific relapse-free survival (r.f.s.) 45%. Analysis according to the UICC classification and Ho's classification showed obvious deficiencies in both staging systems, but did not result in major prognostic differences. The freedom from local relapses correlated (P less than 0.05) with the T categories of the UICC at presentation (75% in T1 vs 45% in T4) and the freedom from distant metastases was significantly influenced by the cervical status (fixed cervical lymph nodes (UICC N3) vs, e.g., UICC N2: 51% vs 90%; P less than 0.05). In case of supraclavicular lymph nodes (Ho IV; Kyoto C) the freedom of distant metastases was lower than in case of upper cervical lymph nodes (58% and 79%, respectively; P = 0.3).

Patterns of failure in nasopharyngeal cancer treated with megavoltage irradiation

From 1976 to 1982, 78 patients with nasopharyngeal cancer (NPC) were treated with definitive megavoltage irradiation in accordance with a uniform protocol. The results of treatment were analyzed and prognostic factors reviewed. The incidence of primary failures was directly related to the extent of nasopharyngeal disease, since the relapse rate was 11% in T1T2 patients compared with 37.5% in T3T4 patients. Similarly, failure in the neck correlated with the N stage, being negligible for N0 and N1, while 35.7% for N3. The presence of bulky cervical nodes was associated with a higher risk for metastases: hematogenous dissemination occurred in 50% of N3B patients. The histology pattern seemed to significantly affect the ultimate outcome of patients with NPC, since disease-free survival was 65.5% in patients with a diagnosis of undifferentiated carcinoma (UC) and 23.8% in patients with squamous cell carcinoma (SC). The major cause of poor survival in this latter patient group was not only a higher recurrence rate of both primary and nodal disease but a greater incidence of distant metastases as well.

Improved survival in carcinoma of the nasopharynx

Between 1970 and 1980, we treated 107 previously untreated patients with biopsy-proven carcinoma of the nasopharynx by megavoltage external radiation therapy to the primary site, base of the skull, and both sides of the neck. Eighty-seven percent of the patients had stage IV disease (American Joint Committee 1980), 53% had T4 primaries, and 73% had palpable cervical metastases. The histology was anaplastic or poorly differentiated carcinoma in 81%. The observed 5-year survival rate was 35% for the patients treated between 1970 and 1976, and increased to 72% for those treated between 1977 and 1980 (P less than 0.01). The two patient populations were similar except that the dose of irradiation (median and modal) to the primary site was 6,000 rad during 1970-1976 and 7,000 rad during 1977-1980. The survival rate was not significantly influenced by age, sex, birthplace, histology, or stage. These data suggest that a relatively high cure rate might be possible in carcinoma of the nasopharynx, even though most patients present with locally advanced disease. The patterns of relapse are discussed.