Synchronous radiotherapy and chemotherapy in the treatment of nasopharyngeal carcinoma

Effect of Early Nutrition Intervention on Advanced Nasopharyngeal Carcinoma Patients Receiving Chemoradiotherapy

Background: Patients with nasopharyngeal carcinoma (NPC) frequently developed the problem of malnutrition at the time of diagnosis. Chemoradiotherapy (CRT) can even worsen the situation. Therefore, nutritional intervention should be applied to prevent CRT-associated weight loss and interruption of CRT. However, it is still controversial if early nutritional intervention is beneficial to NPC patients with CRT. This study is to investigate the influence of early nutritional intervention on advanced NPC patients with CRT by evaluating the nutritional status and CRT treatment tolerance. Methods: A cohort of 78 stage III-IV nasopharyngeal carcinoma patients was divided into early (n=46) and late (n=32) nutrition intervention groups. The early group of patients received nutritional support at the beginning of CRT, whereas the late group received such a support until development of the side effects, like 50% required oral dietary intake or >10% weight loss. The data were collected and statistically analyzed. Results: There was no significant difference in baseline clinical characteristics between these two groups, suggesting that no selection bias occurred. Both groups of patients had weight loss at the end of CRT and 3 months thereafter. However, at the later time point, the early group started to regain their weight, while the late group continued to lose weight. At both time points, the early group had a lower percentage of weight loss than the late group. Similar results were also obtained for BMI, albumin, and pre-albumin levels (All p<0.05). Besides, the early group showed a lower rate of advanced mucositis, a lower percentage of patients with more than 3 days RT breaks, fewer days of RT delayed for toxicity, and a lower percentage of patients with unplanned hospitalizations (All p<0.05). A linear correlation was also found between the percentage of weight loss and the number of days of RT delayed. Conclusion: Early nutritional intervention provides beneficial outcomes to NPC patients by maintaining their nutritional status and enhancing CRT treatment tolerance. Our results also indicated early nutrition intervention may reduce the hospital cost and improve patients' life quality.

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.

Treatment results and late complications of 556 patients with locally advanced nasopharyngeal carcinoma treated with radiotherapy alone

The aim of this study was to investigate the outcome in 556 patients with locally advanced nasopharyngeal carcinomas treated by radiation therapy alone. We observed 556 patients with stage T3-4 and N0-3 carcinoma who were treated by conventional radiotherapy alone between January and December 1999. The total dose delivered to the nasopharynx was 66-80 Gy over 6.5-8 weeks and to the neck lymph nodes 60-70 Gy over 6-7 weeks. The 5-year actuarial overall survival rate (OS) reached 66.41%. The OS was higher among stage T3 patients than among stage T4 patients (69.12% vs 58.96%, p = 0.0359). Among patients with stage N0, N1, N2 and N3 disease, the OS was 73.98%, 65.96%, 57.58% and 29.39%, respectively (p = 0.0009). Differences in disease-free survival, locoregional control rate and metastasis-free survival rate among each N stage were statistically significant, although this was not true of differences between stage T3 and T4 disease. Multivariate analysis showed that gender, age, T stage and N stage were significant prognostic factors for 5-year overall survival, disease-free survival, locoregional control and metastasis-free survival. We found that N stage is the dominant prognostic indicator for patients with locally advanced nasopharyngeal carcinoma receiving conventional radiation therapy alone, and that T stage was only a secondary correlative factor.

[Treatment of nasopharyngeal cancer: literature review]

The conventional radiotherapy and the associated treatments improved the prognostic of nasopharyngeal cancer. A better selection of the patients who must have a more aggressive treatment also probably contributed to this improvement. Even if a relation could be found between the locoregional relapse rate and the distant relapse rate, these two events remain often independent. It results from it that the improvement of local control rate necessarily does not result in a better control of the disease. The patients with a locally advanced tumor, with or not an invasion of the base of the skull and/or neurological symptoms, must have an aggressive locally treatment. This probably includes the increase in dose delivered to the tumor via a more conformational radiotherapy, a brachytherapy, radiotherapy in stereotaxic conditions or other techniques. Dose within the tumor must be at least 70 Gy and the prophylactic nodal dose, at least 50 Gy. CT scan and MRI are essential for delineating the volumes of interest. The protocols of hyperfractionated radiotherapy did not give convincing results. Association with chemotherapy allowed, on the other hand, an improvement of the prognostic locally advanced cancers. Neoadjuvant or adjuvant chemotherapy was largely used to attempt to limit the risks of systemic dissemination, but an improvement of results was not clearly demonstrated. An improvement of the rates of survival and control of the disease, on the other hand, was observed in a certain number of studies with the chemoradiotherapy. In the event of locoregional relapse, an aggressive attitude can allow the control of the disease in the absence of systemic dissemination. Salvage treatments are, however, disappointing for when distant relapse occurs which suggests a difference in chemosensitivity between primary tumor and metastasis.

Nasopharyngeal carcinoma treated with external radiotherapy, brachytherapy, and concurrent/adjuvant chemotherapy

The standard treatment for advanced nasopharyngeal carcinoma (NPC) has become external beam radiation therapy (EBXRT) 70 Gy/7 weeks + 3 cycles of concurrent cisplatin followed by 2 to 3 cycles of adjuvant cisplatin/5-fluorouracil (5-FU). Some reports suggest that the addition of low-dose rate brachytherapy to EBXRT also improves local control. To our knowledge, this is the first report of the "triple" combination of EBXRT, brachytherapy, and concurrent/adjuvant chemotherapy. Eleven patients treated from 1992 to 1998 were evaluated. All patients had stage III/IV (excluding T4 lesions) NPC. Treatment consisted of EBXRT (64-70 Gy/7 weeks), followed by a brachytherapy boost (6-15 Gy delivered 0.5 cm deep to the mucosa). Chemotherapy consisted of concurrent cisplatin (100 mg/m2) and post-XRT adjuvant cisplatin (80 mg/m2) and 5-FU (1,000 mg/m2/day x 4 days) for 2 cycles. All 11 patients were evaluable. The average age was 44 years, and median follow-up was 38 months (range: 23-82 months). Median EBXRT dose was 66 Gy, and median brachytherapy dose was 9 Gy (median total dose: 75 Gy). All patients obtained primary tumor complete response (CR). Two patients required post-XRT neck dissection to achieve regional CR. To date, 10 patients are alive with no evidence of disease. The 3-year actuarial survival is 100%. One patient died at 82 months of a late distant recurrence (at 37 months post-XRT). No patient has had a local or neck failure. Chemoradiation plus brachytherapy offers encouraging survival and local-regional control. Further study of this regimen as an alternative or adjunct to intensity-modulated EBXRT is warranted.

Nasopharyngeal carcinomas: analysis of patient, tumor and treatment characteristics determining outcome

PURPOSE

The present study reviews the experience in treatment of 447 patients with nasopharyngeal carcinomas, analyzing patient, tumor and treatment characteristics determining outcome.

MATERIALS AND METHODS

There were 322 males and 125 females, their ages ranging from 7 to 85 years (median, 45 years). Two-hundred and seventy-two patients had World Health Organization (WHO) type 3 carcinomas, 123 patients had T4 tumors and 320 patients had metastatic cervical lymph nodes. Three-hundred and eight patients were treated with radiation therapy alone and 139 patients with chemotherapy in combination with radiation therapy. Cumulative radiation dose to primary tumor ranged from 50 to 76Gy (median, 70Gy) and radiation dose to metastatic cervical lymph nodes ranged from 46 to 74Gy (median, 66Gy).

RESULTS

Follow-up ranged from 0.1 to 19.5 years (mean, 7.6 years). Local complete response was achieved in 357 patients. In multivariate analysis, T-classification, cumulative radiation dose to primary tumor and treatment with chemotherapy in combination with radiation therapy predicted local response. Nodal complete response was achieved in 272 patients. In multivariate analysis, N-classification and radiation dose to metastatic cervical lymph nodes predicted nodal response. Local failure was observed in 70 patients, nodal failure in 35 patients and systemic failure in 114 patients. Overall survival, disease-free survival and disease-specific survival were 33, 32 and 37%, respectively, at 10 years. In multivariate analysis, age, T-classification, N-classification, radiation dose and treatment with chemotherapy in combination with radiation therapy predicted overall survival whereas T-classification, N-classification, radiation dose and treatment with chemotherapy in combination with radiation therapy predicted both disease-free survival and disease-specific survival.

CONCLUSIONS

Radiation therapy alone appears to be an adequate and viable treatment for patients with early-stage nasopharyngeal carcinomas, whereas treatment with chemotherapy in combination with radiation therapy appears to improve outcome for patients with advanced-stage nasopharyngeal carcinomas.

Radiation therapy and concurrent cisplatin in management of locoregionally advanced nasopharyngeal carcinomas

Radiation therapy in combination with chemotherapy in the management of locoregionally advanced nasopharyngeal carcinomas is evaluated in an attempt to improve locoregional response, reduce locoregional failure and reduce systemic failure. The current study was designed to investigate radiation therapy and concurrent cisplatin in this context. From 1992 through 1997, 70 patients with locoregionally advanced nasopharyngeal carcinomas were treated with radiation therapy and concurrent cisplatin. External beam radiation dose was 60 Gy for T1, T2 and T3 tumors, 70 Gy for T4 tumors and 70 Gy for metastatic cervical lymph nodes. An intracavitary brachytherapy boost (10 Gy) was applied for T1, T2 and T3 tumors. Cisplatin (30 mg/m2) was administered weekly during external beam radiation therapy. Locoregional complete response was achieved in 63 patients, locoregional failure was observed in 4 patients and systemic failure was observed in 15. N-stage predicted systemic failure. Overall survival, locoregional failure-free survival and systemic failure-free survival were 63%, 79% and 75%, respectively, at three years. Grade 3 acute skin toxicity was observed in 2 patients, Grade 3 acute mucous membrane toxicity was observed in 6 and Grade 3 acute hematological toxicity was observed in 2 patients. Despite improved locoregional response, reduced locoregional failure and improved survival with radiation therapy and concurrent cisplatin, systemic failure remains prevalent for locoregionally advanced nasopharyngeal carcinomas.

Combined radiotherapy and chemotherapy for nasopharyngeal carcinoma

Among squamous cell carcinomas of the head and neck, nasopharyngeal carcinoma is probably the most radiosensitive and chemosensitive. It also has the highest incidence of distant metastasis. This article reviews the results of randomized trials of combined chemotherapy and radiotherapy for nasopharyngeal carcinoma to date. Induction chemotherapy with bleomycin, epirubicin, and cisplatin was shown to increase disease-free survival but not overall survival in a trial by the International Nasopharyngeal Cancer Study Group. Concurrent radiotherapy and cisplatin followed by adjuvant cisplatin and 5-fluorouracil infusion significantly decreased local, nodal, and distant failures and increased progression-free and overall survival in the Head and Neck Intergroup Trial. The toxicity of combined chemotherapy and radiotherapy, however, primarily acute toxicity, was significantly greater than that of radiotherapy alone. Further clinical trials using novel drugs, altered fractionation radiotherapy and chemotherapy dose schedules, new radiotherapy techniques, and other treatment modifiers are needed to further improve the therapeutic ratio.

Nasopharyngeal Carcinoma: Evidence for Improved Survival with Combined Chemoradiation

Radiation therapy has been the traditional treatment for nasopharyngeal carcinoma. Patients with advanced disease have a higher rate of locoregional as well as distant metastases, which has warranted the addition of chemotherapy in an attempt to improve survival. This retrospective study was designed to determine the absolute survival of patients with nasopharyngeal cancer treated with radiation alone, compared to that of patients receiving concurrent chemoradiation. Between December 1975 and December 1993 eight patients were treated with radiotherapy alone and 14 patients were treated with concurrent chemoradiation using 5-fluorouracil and cisplatin. Analysis of Kaplan-Meier cumulative absolute survival plots revealed that patients receiving chemoradiation survived longer than those receiving radiation alone (p=0.0321). Patients with lymphoepithelioma, as opposed to squamous cell carcinoma, and patients younger than 30 years were also found to have longer survival, although these differences were not statistically significant (p=0.0913 and p=0.04044, respectively).

The role of chemotherapy in the management of nasopharyngeal carcinoma

BACKGROUND

Nasopharyngeal carcinoma (NPC) is a radiosensitive tumor for which there is a high local control rate after radical radiotherapy (RT). However, for patients with locoregionally advanced disease, the rate of distant metastasis is high and the 5-year overall survival rate is poor.

METHODS

A review of retrospective and prospective clinical studies was performed to assess the role of chemotherapy in three settings: metastatic disease; neoadjuvant and/or adjuvant; and concurrent chemotherapy with radiotherapy.

RESULTS

Cisplatin-based combination chemotherapy results in a high response rate in patients with metastatic NPC, and a subgroup may achieve long term disease free survival. The use of neoadjuvant and adjuvant chemotherapy to treat locoregionally advanced disease has resulted in consistently high response rates, but no randomized trial to date has demonstrated an improvement in overall survival. A recent Head and Neck Intergroup study randomized patients in the United States to receive concurrent chemotherapy (cisplatin) and radiotherapy or radiotherapy only. Although this approach demonstrated significant benefit in overall survival favoring the use of concurrent chemotherapy and radiotherapy, its applicability in geographic areas of high NPC incidence remains to be proven.

CONCLUSIONS

NPC is a chemosensitive tumor, and patients with metastatic disease have a high response rate. Further prospective studies will define the standard approach to treating locoregionally advanced NPC, which is likely to incorporate into the primary treatment some form of systemic chemotherapy.

Pilot study of concurrent chemotherapy and radiotherapy for stage IV nasopharyngeal cancer

Nasopharyngeal carcinoma (NPC) is a more radio- and chemosensitive tumor than all other head and neck cancers. Between September 1991 and December 1992, a total of 19 patients (13 men and six women; median age, 44 years) with AJCC stage IV NPC were entered into a pilot study of concurrent chemoradiotherapy. Pathology showed either poorly differentiated epidermoid carcinoma or undifferentiated carcinoma. Radiotherapy was delivered using a telecobalt unit and 10-MV x-rays and by conventional fractionation (1.8-2.0 Gy/fraction, 5 fractions/week). The total doses delivered were 70-75 Gy to the primary tumor and neck positive region, and 50-55 Gy to the neck negative area. Chemotherapy with cisplatin (10 mg/m2/day, days 1-5) and 5-fluorouracil (500 mg/m2/day, continuously infused for 5 days) was administered concurrently during weeks 1 and 5 of radiotherapy. The major toxicities were mucositis (42% had grade III and 58% grade II) and leukopenia (nadir white blood cells <3,000/mm3 in eight of 19). Although four patients required a delay in their second cycle of concurrent chemotherapy or had their radiotherapy interrupted for 1 week, all 19 patients completed the planned treatment and achieved a 100% complete response rate. After a median follow-up period of 42 months, one patient suffered from neck recurrence plus distant metastasis, and three patients developed distant metastases alone. The 3-year overall and disease-free survival rates are 89.5% and 83.3%, respectively. Our data indicated that concurrent chemoradiotherapy for advanced NPC is both feasible and effective, with acceptable toxicities. A phase III randomized trial to compare the efficacy of concurrent chemoradiotherapy and radiotherapy alone deserves to be studied further.

Does induction chemotherapy have a role in the management of nasopharyngeal carcinoma? Results of treatment in the era of computerized tomography

PURPOSE

To assess the outcomes of patients with nasopharyngeal carcinoma (NPC) whose treatment was determined by computerized tomography (CT) and/or magnetic resonance imaging staging and to analyze the impact of induction chemotherapy and accelerated fractionated radiotherapy.

METHODS AND MATERIALS

The analysis is based on 122 of 143 previously untreated patients with NPC treated with radiation therapy at The University of Texas M. D. Anderson Cancer Center between 1983 and 1992. Excluded were 4 patients treated with palliative intent, 4 children, 12 patients not staged with CT, and 1 patient who died of a cerebrovascular accident prior to completion of treatment. The stage distribution was as follows: AJCC Stage I-2, Stage II-7, Stage III-12, Stage IV-101; Tl-15, T2-33, T3-22, T4-52; N0-32, N1-10, N2-47, N3-32, Nx-1. Fifty-nine (48%) patients had squamous cell carcinoma; 63 (52%) had lymphoepitheliomas, undifferentiated NPC or poorly differentiated carcinoma, NOS (UNPC). Sixty-seven patients (65 with Stage IV disease) received induction chemotherapy. Fifty-eight patients (24 of whom had induction chemotherapy) were treated with the concomitant boost fractionation schedule. The median follow-up for surviving patients was 57 months.

RESULTS

The overall actuarial 2- and 5-year survival rates were 78 and 68%, respectively. Forty-nine patients (40%) had disease recurrence. Thirty-three (27%) had local regional failures; 19 at the primary site only, 8 in the neck and 6 in both. Local failure occurred in 31% of patients staged T4 compared to 13% of T1-T3 (p = 0.007). Sixteen patients failed at distant sites alone. Among Stage IV patients the 5-year actuarial rates for patients who did and did not receive induction chemotherapy were as follows: overall survival: 68 vs. 56% (p = 0.02), freedom from relapse: 64 vs. 37% (p = 0.01), and local control: 86 vs. 56% (p = 0.009). The actuarial 5-year distant failure rate in patients with UNPC who were treated with induction chemotherapy and controlled in the primary and neck was 13%. In patients who did not receive chemotherapy, the actuarial 5-year local control rates for patients treated with concomitant boost or conventional fractionation were 66 and 67%, respectively.

CONCLUSIONS

While not providing conclusive evidence, this single institution experience suggests that neoadjuvant chemotherapy for Stage IV NPC patients improves both survival and disease control. Recurrence within the irradiated volume was the most prevalent mode of failure and future studies will evaluate regimens to enhance local regional control.

Partially hyperfractionated accelerated radiotherapy and concurrent chemotherapy for advanced nasopharyngeal carcinoma

PURPOSE

A newly designed concomitant chemoradiotherapy was undertaken to assess the feasibility and efficacy for advanced nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

Sixty-three patients with biopsy-proven NPC were entered in this Phase II trial from March 1992 to November 1993. Most patients present with Stage IV disease (93.4%) and poorly differentiated epidermoid carcinoma or undifferentiated carcinoma were the major pathologic type. Radiotherapy was delivered using a telecobalt unit and 10 MV x-rays and by altered fractionation (72-74 Gy/45 fractions/6 weeks). Chemotherapy with cisplatin 75 mg/m2, 2 h infusion at day 1, followed by 5-FU 400 mg/m2/day, continously infused for 4 days was given concurrently during the first and fifth weeks of radiotherapy.

RESULTS

The major toxicity was mucositis (61% belong to Grade 3, 31% to Grade 2). Weight loss, leucopenia, and skin reaction were frequently encountered. Three patients withdrew from treatment at 15, 25, and 55.5 Gy, three patients interrupted the radiotherapy for 1-4.5 weeks, and two patients refused the second cycle of concomitant chemotherapy due to toxicities. The initial tumor response showed 100% overall response rate, with 90.5% complete response. After a median follow-up time of 38 months, five patients failed at the primary and/or neck (four recurrent and one persistent), and 14 patients developed distant metastases alone. The 3-year primary disease-free, regional disease-free, distant disease-free, and overall survival rates are 89.1, 92.8, 74.3, and 73.6%, respectively. The late complication rate is acceptable so far.

CONCLUSIONS

Our data indicates that concurrent chemoradiotherapy for advanced NPC is both feasible and effective, with acceptable toxicities. Distant metastases are the major site of treatment failure. Postradiation adjuvant chemotherapy to eradicate subclinical distant metastasis should be further studied.

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.

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.