Salvage surgery for recurrent primary nasopharyngeal carcinoma

Clinical outcomes of carbon-ion radiotherapy for patients with locoregionally recurrent nasopharyngeal carcinoma

BACKGROUND

Reirradiation for locoregionally recurrent nasopharyngeal carcinoma (LR-NPC) after high-dose radiotherapy (RT) is challenging and usually is associated with poor survival and severe toxicities. Because of its physical and biological advantages over photon-beam RT, carbon-ion RT (CIRT) could be a potential treatment option for patients with LR-NPC.

METHODS

Patients with LR-NPC who underwent salvage therapy using CIRT at the Shanghai Proton and Heavy Ion Center between May 2015 and June 2019 were analyzed. CIRT doses were 50 to 69 gray equivalent (GyE) (2.0-3.0 GyE per fraction). Overall survival (OS), local control, regional control, distant control, and acute and late toxicities were analyzed. Univariable and multivariable analyses of OS and local control were performed using the Cox regression model.

RESULTS

Among the 206 patients included, 139 patients (67.5%) had recurrent American Joint Committee on Cancer stage III or stage IV disease. With a median follow-up of 22.8 months, the 2-year OS, local control, regional control, and distant control rates were 83.7%, 58.0%, 87.3%, and 94.7%, respectively. Multivariable analysis revealed that older age (P = .017) was predictive of worse OS, whereas a larger tumor volume (P = .049) and a lower biological equivalent dose (P = .029) were associated with inferior local control. No patient developed an acute toxicity of ≥grade 3 during CIRT. Severe (≥grade 3) late toxicities included temporal lobe necrosis (0.97%), cranial neuropathy (0.49%), hearing loss (1.46%), xerostomia (0.49%), and mucosal necrosis (16.02%) (toxicities were graded using the Radiation Therapy Oncology Group and European Organization for Research and Treatment of Cancer criteria).

CONCLUSIONS

Salvage treatment using CIRT is efficacious for patients with LR-NPC and its toxicities are acceptable. CIRT may improve the survival and toxicity profiles substantially for patients with LR-NPC compared with the reported results after photon-based intensity-modulated RT.

Quality of Life Following Salvage Endoscopic Nasopharyngectomy in Patients With Recurrent Nasopharyngeal Carcinoma: A Prospective Study

Background: This study aimed to assess the effect of endoscopic nasopharyngectomy in patients with recurrent nasopharyngeal carcinoma (NPC) on site-specific and sinonasal-related quality of life (QoL) before and after surgery using validated instruments. Methods: Consecutive adult patients with recurrent NPC, who were treated via salvage endoscopic nasopharyngectomy, were prospectively enrolled at a single institution from January 2018 to December 2019. Each patient completed the Anterior Skull Base Questionnaire (ASBQ) and the 22-Item Sino-Nasal Outcome Test (SNOT-22) preoperatively, and then at regular intervals after surgery to assess their perceived QoL. Results: Forty patients fulfilled the inclusion criteria. The median follow-up was 12 months (range, 2-24 months). Overall scores on the ASBQ and SNOT-22 at 3 or 12 weeks after surgery decreased significantly compared with before surgery (p < 0.05). At 6 months and 1 year postoperatively, there was no significant difference from the preoperative score. Subtotal resection was associated with worse overall ASBQ scores at 6 months and 1 year after endoscopic nasopharyngectomy (p < 0.05). Worse QoL was also associated with advanced T stage (rT3 and rT4) and pathological World Health Organization type III. Sex, age (<50 years), tumor necrosis, lymph node metastasis, and use of a nasoseptal flap approach did not impact postoperative QoL. Conclusions: Site-specific and sinonasal-related QoL, measured using validated tools, demonstrated an overall maintenance of postoperative compared with preoperative QoL. Endoscopic endonasal resection is a valuable management choice in patients with recurrent NPC. In addition, subtotal resection was an important factor that negatively influenced postoperative QoL; as such, gross-total resection should be attempted in all patients to optimize QoL after surgery.

Local and Lymph Node Relapse of Nasopharyngeal Carcinoma: A Single-Center Experience

OBJECTIVES

The study aimed to investigate the epidemiological and clinical characteristics as well as the therapeutic results in patients with locoregional (LR) relapse after treatment of nasopharyngeal carcinoma (NPC).

METHODS

We retrospectively reviewed the medical records of patients with local and/or regional recurrent NPC over 13 years (2003-2015).

RESULTS

Twenty-five patients were treated for local or/and local-regional recurrence of NPC. The rate of LR relapse was 7.2%. The mean age of the patients was 46 ± 13.9 years. The median time to relapse was 25 months. The recurrence was nasopharyngeal in 17 patients, nasopharyngeal and neck lymph nodes in 7 patients, and neck lymph nodes in 1 patient. Fifteen relapsed patients had a locally advanced disease (rT3-rT4). Patients who had initially T1 or T2 tumor had a locally advanced relapsed disease (rT3rT4) in 27.3% and patients whose disease was initially classified as T3 or T4 had a locally advanced relapsed disease (rT3T4) in 85.7% (P = .005, Fisher test). Twelve patients had chemotherapy after relapse. Chemotherapy was followed by concurrent chemoradiotherapy in 3 patients and by radiotherapy (RT) in 4 patients. Nine patients had concurrent chemoradiotherapy and 1 patient had exclusive RT. The overall survival (OS) at 1 year, 3 years, and 5 years was, respectively, 58%, 18%, and 10%. The OS was significantly higher in patients with good performance status at the time of relapse (World Health Organization = 1; P = .01) and in patients with late relapse (after 2 years; P = .03).

CONCLUSIONS

Locoregional relapse rate in our study was 7.2%. Locoregional reirradiation was the mainstay treatment modality in relapsed NPC. Relapsed NPC had a poor prognosis with a 5-year survival rate of 18%. The OS was significantly higher in patients with good performance status and in patients with late relapse (after 2 years).

Long-term survival and late complications of intensity-modulated radiotherapy for recurrent nasopharyngeal carcinoma

BACKGROUND

To evaluate the effectiveness and toxicities of intensity-modulated radiotherapy (IMRT) for locally recurrent nasopharyngeal carcinoma (NPC).

METHODS

One hundred and eighty-four previously irradiated NPC patients with recurrent disease and re-irradiated by IMRT between February 2005 to May 2013 had been reviewed. The disease was re-staged I in 33, II in 27, III in 70 and IV in 54 patients. Seventy-five percent of the patients received cisplatin-based chemotherapy.

RESULTS

The median survival time was 33 months. The 3-year actuarial rates of local recurrence-free survival (LRFS), distant metastases-free survival (DMFS), and overall survival (OS) rates were 85.1, 91.1, and 46.0%, respectively. About 53% of the patients experienced Grade 3-4 late toxicities. Forty-four patients died of massive hemorrhage of the nasopharynx caused by radiation induced mucosal necrosis. Multivariate analysis indicated that chemotherapy and time interval between initial radiotherapy and re-irradiation were independent predictors for DMFS.

CONCLUSION

IMRT is an effective method for patients with locally recurrent NPC. Massive hemorrhage of the nasopharynx is the major sever late complication and also the leading cause of death. Early recurrence is negative factor for DMFS. Combination of chemotherapy can improve DMFS, but not for OS. Optimal salvage treatment strategies focusing on improvement of survival and minimization of late toxicities are warranted.

Establishment of prognostic factors in recurrent nasopharyngeal carcinoma patients who received salvage intensity-modulated radiotherapy: A meta-analysis

Local recurrence remains a major cause of therapeutic failure in patients with nasopharyngeal carcinoma (NPC) and the effective treatment of recurrent NPC (r-NPC) is still a challenge. Intensity-modulated radiotherapy (IMRT) is considered as a favorable technique in the management of r-NPC, especially for extensive lesions. However, local r-NPC is a highly heterogeneous disease and the survival outcome following salvage IMRT varies. Furthermore, due to varied samples and therapeutic protocols, no consensus has been reached in the establishment of prognostic values. Hence, we used Medline and Embase electronic databases to conducted a meta-analysis to generate the best estimation of the prognostic factors in local r-NPC following salvage IMRT. Finally, a total of 783 patients in seven studies were enrolled. Overall, the pooled HR for OS of recurrent T stage and recurrent tumor volume was 1.77 (95% CI = 1.15-2.39) and 2.12 (95% CI = 1.42-2.82), without any heterogeneity. In addition, despite a significant association was observed in the pooled HR of significant compliance for OS, however, significant heterogeneity was also observed (I² = 76.6%, p = 0.039). Furthermore, no significant association was observed among the pooled HRs for OS in terms of age, gender, recurrent time interval, synchronous nodal recurrence, chemotherapy and total re-irradiation dose. Therefore, the present meta-analysis demonstrated that recurrent T stage and tumor volume may serve as the prognostic factors for OS in patients with r-NPC who received salvage IMRT. The other factors such as age, gender, and optimal re-irradiation dose warranted further investigation.

Radiotherapy-induced anti-tumor immune response and immune-related adverse events in a case of recurrent nasopharyngeal carcinoma undergoing anti-PD-1 immunotherapy

BACKGROUND

Treatment of recurrent nasopharyngeal carcinoma is a challenging clinical problem. We report the case of a 46 year old male showing excellent response and signs of immunostimulation following re-re-irradiation for recurrent nasopharyngeal carcinoma under systemic treatment with pembrolizumab.

CASE PRESENTATION

Patient was first diagnosed with locoregionally advanced, non-keratinizing nasopharyngeal carcinoma in 2010. After achieving complete remission following induction chemotherapy and concurrent curative chemoradiation, the patient subsequently developed distant and locoregionally recurrent disease. He received various treatments (neck dissection, radiotherapy to a bony metastasis, palliative chemotherapy, stereotactic re-irradiation of local recurrence) before initiation of anti- PD-1 immunotherapy with pembrolizumab in January of 2016. Following marked local progression 6 months thereafter, we performed re-re-irradiation of the recurrent tumor after careful evaluation and treatment planning. While treatment was well tolerated, the patient subsequently developed marked clinical and radiological signs of immunostimulation with mucosal irritation and swelling of lacrimal and salivary glands as described in the report. Immunotherapy with pembrolizumab was reinitiated, with re- staging showing excellent response with regression of all tumorous lesions. At the time of this report, following near complete recovery of inflammatory symptoms, the patient remains in excellent condition and free from recurrence under treatment with pembrolizumab.

CONCLUSIONS

To our knowledge, we report the first observation of a combined effect of immunotherapy and radiotherapy in a patient with recurrent nasopharyngeal carcinoma. Demonstrating distinct signs of immunostimulation as well as excellent tumor response in a heavily pretreated patient progressing under anti-PD-1 immunotherapy, the case adds to the rising paradigm of an immunostimulatory effect of radiotherapy in patients undergoing treatment with immune checkpoint inhibitors.

The challenge in treating locally recurrent T3-4 nasopharyngeal carcinoma: the survival benefit and severe late toxicities of re-irradiation with intensity-modulated radiotherapy

Background

Effective treatments for patients with advanced locally recurrent nasopharyngeal carcinoma (NPC) are limited. This investigation was to determine the potential benefits from re-irradiation by intensity-modulated radiotherapy (IMRT) on survival and the effects of severe late toxicities.

Methods

A retrospective study was conducted in 245 patients diagnosed with locally recurrent T3–T4 NPC who had undergone re-irradiation with IMRT. Follow-up data was colleted and factors associated with survival and severe late toxicities were analyzed.

Results

The 5-year local-regional failure-free survival, distant failure-free survival and overall survival rates were 60.9%, 78.3% and 27.5%, respectively. The presence of severe late complications, recurrent T4 disease and gross tumor volume >30 cm³ were associated with poor survival. The incidences of mucosal necrosis, temporal lobe necrosis, cranial neuropathy and trismus were 22.0%, 14.6%, 27.0% and 14.6% respectively. Conclusions: Re-irradiation with IMRT is an effective choice in patients with locally recurrent T3–T4 NPC. However, the survival benefits can be partly offset by severe late complications and optimum treatments in these patients remain a challenge.

Benefits of local tumor excision and pharyngectomy on the survival of nasopharyngeal carcinoma patients: a retrospective observational study based on SEER database

BACKGROUND

There is ongoing debate about surgery of primary site in nasopharyngeal carcinoma patients.

METHODS

3919 patients with nasopharyngeal carcinoma identified in the SEER registry between 2004 and 2013. The benefit of surgery of primary nasopharynx tumor site on overall and cancer-specific survival was assessed by risk-adjusted multivariate Cox proportional hazard regression and propensity score matching modeling.

RESULTS

Surgery was marginally associated with better overall survival (hazard ratio (HR) = 0.816, 95% CI 0.656-1.015, p = 0.07) and cancer-specific survival (HR = 0.749, 95% CI 0.552-1.018, p = 0.06) in the propensity score model. Among 398 cases who underwent primary site surgery, 282 (70.85%) received local tumor excision and 79 (20.31%) received pharyngectomy. Local tumor excision and pharyngectomy had almost the same effect on survival in propensity score matching analysis. The benefit was significant in subgroups of white, age <60 year, and patients with T3, N1, M0, AJCC stage III, or moderately differentiated tumors. Further survival analysis showed surgery to promote survival in both radiotherapy and non-radiotherapy patients.

CONCLUSION

This is the first population-based analysis using propensity score model to provide evidence of a positive impact of surgery on survival in nasopharyngeal carcinoma. Moreover, surgery demonstrated the significant benefit in subgroups of patients with specific clinical characteristics.

Neoadjuvant and Concurrent Chemotherapy Have Varied Impacts on the Prognosis of Patients with the Ascending and Descending Types of Nasopharyngeal Carcinoma Treated with Intensity-Modulated Radiotherapy

Purpose

To compare the outcomes of patients with ascending type (T4&N0-1) and descending type (T1-2&N3) of nasopharyngeal carcinoma (NPC) treated with concurrent chemoradiotherapy (CCRT), neoadjuvant chemotherapy (NACT) + intensity-modulated radiotherapy (RT) or NACT + CCRT.

Methods

Retrospective analysis of 839 patients with ascending or descending types of NPC treated at a single institution between October 2009 to February 2012. CCRT was delivered to 236 patients, NACT + RT to 302 patients, and NACT + CCRT to 301 patients.

Results

The 4-year overall survival rate, distant metastasis-free survival rate, local relapse-free survival rate, nodal relapse-free survival rate, loco-regional relapse-free survival rate, and progression free survival rate were 75.2% and 73.4% (P = 0.114), 85.7% and 74.1% (P = 0.008), 88.8% and 97.1% (P = 0.013), 96.9% and 94.1% (P = 0.122), 86.9% and 91.2% (P = 0.384), 73.7% and 66.2% (P = 0.063) in ascending type and descending type. Subgroup analyses indicated that NACT + RT significantly improved distant metastasis-free survival rate and progression-free survival rate when compared with CCRT in the ascending type, and there were no significant differences between the survival curves of NACT +RT and NACT + CCRT. For descending type, there were no significant differences among the survival curves of NACT +RT, CCRT, and NACT + CCRT groups, and the survival benefit mainly came from CCRT.

Conclusions

Compared with NACT + CCRT or CCRT, NACT + RT may be a reasonable approach for ascending type. Although concurrent chemotherapy was effective in descending type, NACT + CCRT may be a more appropriate strategy for descending type.

A triplet chemotherapy regimen of cisplatin, fluorouracil and paclitaxel for locoregionally recurrent nasopharyngeal carcinoma cases contraindicated for re-irradiation/surgery

OBJECTIVE

Salvage treatment for locoregionally recurrent nasopharyngeal carcinoma remains a significant challenge. The present study was conducted to evaluate the efficacy, toxicity and prognostic factors of a triplet chemotherapy regimen involving cisplatin, fluorouracil and paclitaxel (TPF) for locoregionally recurrent nasopharyngeal carcinoma (NPC) cases contraindicated for re-irradiation/surgery.

METHODS

Patients with locoregionally recurrent NPC unsuitable for re-irradiation/surgery were treated with TPF therapy. The chemotherapy drugs were administered as follows: 135 mg/m(2) paclitaxel on day 1, 25 mg/m(2)/day cisplatin on days 1-3, followed by continuously infused intravenous fluorouracil for 120 h at a variable dosage from 600 to 800 mg/m(2)/day, depending on prior radiation.

RESULTS

Twenty-seven patients were enrolled. The overall response was 66.7%. The median progression-free survival (PFS) and overall survival (OS) were 8.5 and 27.2 months, respectively. Toxicity was mild to moderate. Neutropenia and leukopenia were the primary grade 3-4 chemotherapy toxicities. 6 patients who regained the potential for re-radiotherapy or surgery showed significantly better outcomes than those treated with chemotherapy alone (median PFS: 20.8 vs. 7.1 months, P = 0.005; median OS: 54.2 vs. 20.6 months, P = 0.021).

CONCLUSION

TPF triplet chemotherapy showed a high response rate for locoregionally recurrent NPC with an acceptable toxicity profile.

Long-term survival and late complications in intensity-modulated radiotherapy of locally recurrent T1 to T2 nasopharyngeal carcinoma

BACKGROUND

We investigated the feasibility of reirradiation with intensity-modulated radiotherapy (IMRT) for recurrent T1 to T2 nasopharyngeal carcinoma (NPC) by assessing long-term survival and late complication rates.

METHODS

Sixty patients who had been previously irradiated were diagnosed with locally recurrent T1 to T2 NPC and underwent reirradiation with IMRT. Severe radiation toxicities were assessed.

RESULTS

The median follow-up time was 40.0 months. The 5-year local failure-free survival (LFFS), distant failure-free survival (DFFS), and overall survival (OS) rates were 85.7%, 96.1%, and 67.2%, respectively. Independent prognostic factors included primary gross tumor volume >20 cm and the presence of significant complications. The most common severe complications were headache (31.6%), mucosal necrosis (30.0%), cranial neuropathy (25.0%), and temporal lobe necrosis (21.6%). Thirty-nine patients (65.0%) developed at least one severe complication and 18 patients died as a result.

CONCLUSION

Excellent disease control can be achieved by reirradiation with IMRT for recurrent T1 to T2 NPC. However, the main challenge remains severe late complications.

The role of Epstein-Barr virus-encoded microRNA BART7 status of resection margins in the prediction of local recurrence after salvage nasopharyngectomy for recurrent nasopharyngeal carcinoma

BACKGROUND

Local recurrence is the major cause of treatment failure in patients who undergo surgical salvage of recurrent nasopharyngeal carcinoma (NPC) after radiotherapy. The authors investigated the role of Epstein-Barr virus (EBV)-encoded Bam HI-A rightward transcript 7 microRNA (BART7) status in resection margins in the identification of a subgroup of patients who may benefit from adjuvant reradiation after surgery.

METHODS

One hundred two consecutive patients who had histologically clear resection margins after undergoing nasopharyngectomy for recurrent NPC were studied. The status of EBV microRNA BART7 in resection margins was investigated and correlated with the pattern of subsequent disease recurrence.

RESULTS

After a median follow-up of 64 months, 20 patients (19.6%) developed local recurrence after surgery despite histologically uninvolved margins. The risk of local recurrence in patients with histologically close (<5 mm) and clear (≥5 mm) margins was 31.6% and 12.5%, respectively. In patients with clear histologic margins, those with margins that were positive for EBV microRNA BART7 has a significantly higher chance of developing local tumor recurrence (P = .016) than those with negative molecular margins. The difference was not significant when the histologic clearance at the resection margins was <5 mm.

CONCLUSIONS

Tissue EBV microRNA BART7 is useful for identifying a subgroup of patients with histologically clear margins who are at increased risk of subsequent local tumor recurrence. Postoperative adjuvant treatment is warranted for these patients.

Salvage treatment for locally recurrent nasopharyngeal carcinoma (NPC)

BACKGROUND

It is important to determine the outcomes of retreatment in patients with locally recurrent nasopharyngeal carcinoma.

METHODS

We reviewed the records of patients treated for local recurrence at Stanford and Shantou Universities. The end points were local relapse-free survival (LRFS) and overall survival after retreatment.

RESULTS

Fifty-six patients from Stanford and 98 from Shantou qualified. For the Stanford patients, 33 had surgery alone (S group), 12 had surgery plus radiotherapy±chemotherapy (CMT group), and 22 had radiotherapy±chemotherapy (RT Stanford group). All Shantou patients received radiotherapy±chemotherapy (RT Shantou group). The 5-year LRFS rates were: 57% for S group, 25% for CMT group, 53% for RT Stanford group, and 41% for RT Shantou group (P>0.05) for rT1-2 tumors; they were 29% for S group, 25% for CMT group, 39% for RT Stanford group, and 9% for RT Shantou group for rT3-4 tumors (P>0.05). For RT patients, 5-year overall survival rates were 49% for Stanford and 25% for Shantou patients (P=0.026).

CONCLUSIONS

Similar and durable LRFS rates were attained for both S and RT groups when stratified by rT-stage.

Effect of total dose and fraction size on survival of patients with locally recurrent nasopharyngeal carcinoma treated with intensity-modulated radiotherapy: a phase 2, single-center, randomized controlled trial

BACKGROUND

The optimal model of total dose and fraction size for patients with locally recurrent nasopharyngeal carcinoma treated with intensity-modulated radiotherapy (IMRT) remains unclear. The authors designed a randomized phase 2 clinical trial to investigate the efficacy of 2 different models, with the objective of determining an optimal model.

METHODS

Between January 2003 and December 2007, a total of 117 patients with locally recurrent nonmetastatic nasopharyngeal carcinoma were randomized to 2 different models of total dose and fraction size: group A (59 patients) received 60 gray in 27 fractions and group B (58 patients) received 68 gray in 34 fractions. Both groups received 5 daily fractions per week. All patients received IMRT alone.

RESULTS

The median follow-up was 25.0 months. The 5-year overall survival in group A was higher than that in group B (44.2% vs 30.3%; P =.06), and the local failure-free survival in group A was slightly lower than that in group B (63.7% vs 71.0%; P =.41). Severe late complications were the main cause of death. The incidences of mucosal necrosis and massive hemorrhage in patients in group B were significantly higher than those among patients in group A at 50.8% versus 28.8% (P =.02) and 31.0% versus 18.6% (P =.12), respectively. Tumor volume (P<.01) and model of total dose and fraction size (P =.03) were found to be significant factors for mucosal necrosis and massive hemorrhage.

CONCLUSIONS

Appropriately decreasing the total dose and increasing the fraction size can achieve local control similar to that achieved with a higher dose after IMRT; furthermore, it can improve overall survival by significantly reducing the incidence of severe late complications including mucosal necrosis and massive hemorrhage.

Multivariate analysis of prognostic factors for salvage nasopharyngectomy via the maxillary swing approach

BACKGROUND

The purpose of this study was to investigate the prognostic factors for salvage nasopharyngectomy.

METHODS

A retrospective review was conducted on maxillary swing nasopharyngectomy performed between 1998 and 2010. Univariate and multivariate analyses identified prognostic factors affecting actuarial local tumor control and overall survival.

RESULTS

The median follow-up duration was 52 months. Among the 268 patients, 79.1% had clear resection margins. The 5-year actuarial local tumor control and overall survival was 74% and 62.1%, respectively. On multivariate analysis, tumor size, resection margin status, and gross tumor in the sphenoid sinus were independent prognostic factors for local tumor control. For overall survival, resection margin status, synchronous cervical nodal recurrence, and cavernous sinus invasion had a negative influence on overall survival after surgery.

CONCLUSION

Extent of nasopharyngectomy should be tailored to the individual tumor to achieve clear resection margins. Cavernous sinus invasion is associated with poor survival outcome, and detailed counseling and meticulous surgical planning is crucial in such circumstances.

Radiation-induced squamous cell carcinoma of the nasopharynx after radiotherapy for nasopharyngeal carcinoma

BACKGROUND

The purpose of this study was to investigate the treatment outcome of radiation-induced squamous cell carcinoma (SCC) of the nasopharynx after radiotherapy (RT) for nasopharyngeal carcinoma (NPC).

METHODS

We conducted a retrospective review of patients who underwent radiation therapy for NPC, which resulted in radiation-induced SCC of the nasopharynx.

RESULTS

Between 1998 and 2011, 24 patients had radiation-induced SCC of the nasopharynx. The median age of diagnosis was 68.2 years. The majority of patients (66.7%) presented with early-stage NPC initially, and they were treated with RT alone (n = 18) or concurrent chemoradiation (n = 6). The mean latency period for the second malignancy was 10.5 years. All the patients were treated with maxillary-swing nasopharyngectomy. Clear resection margin was achieved in 66.7%, and 75% of those with involved margin received adjuvant RT. The mean follow-up duration was 48.2 months. The overall 5-year actuarial local tumor control was 56% and the overall 5-year disease-free survival was 38%.

CONCLUSION

Radiation-induced SCC of the nasopharynx is rare after RT for NPC. The prognosis remained poor despite aggressive surgery and adjuvant RT.

Prognostic model for survival of local recurrent nasopharyngeal carcinoma with intensity-modulated radiotherapy

Background:

Intensity-modulated radiotherapy (IMRT) is the main salvage treatment for advanced locally recurrent nasopharyngeal carcinoma (NPC); however, survival outcomes vary. We aimed to construct a prognostic-score model to identify patients who could benefit from salvage IMRT.

Methods:

This retrospective study involved 251 patients with locally recurrent NPC. The following parameters were analysed following IMRT: patient performance status, age, gender, late complications, T-stage of recurrence, synchronous nodal recurrence, primary gross tumour volume (GTV-nx), disease-free interval, re-irradiation dose and chemotherapy. The model was based on the hazard ratio coefficients of six significantly negative prognostic factors for survival.

Results:

Significantly negative prognostic factors included Karnofsky Performance Status ⩽70, age >50 years, late complications, recurrent T_3–4 stage, synchronous nodal recurrence and GTV-nx >30 cm³. Three subgroups were defined according to model scores: low risk (0–4), intermediate risk (5–8) and high risk (9–15). The 5-year overall survival rates were 64.3%, 32.2% and 7.7%, respectively. The main cause of death was radiation-induced complications.

Conclusion:

The prognostic-score model demonstrated that re-irradiation with IMRT is suitable for low-risk and intermediate-risk patients but may be unsuitable for high-risk patients. Further research into the protection of critical adjacent organs to reduce late complications in these patients is warranted.

Stenting of the eustachian tube to prevent otitis media with effusion after maxillary swing approach nasopharyngectomy

OBJECTIVES/HYPOTHESIS

Our previous report recommended that the management of ipsilateral otitis media with effusion (OME) after maxillary swing nasopharyngectomy was observation. The idea of introducing a stent into the eustachian tube (ET) at the nasopharyngeal side after nasopharyngectomy may prevent postoperative OME. The purpose of this study was to examine the feasibility of intraoperative ET stenting and the efficacy of preventing ipsilateral OME formation.

STUDY DESIGN

Prospective cohort study.

METHODS

From 2009 to 2011, 28 patients with nasopharyngectomy via the maxillary swing approach were recruited. Patients with curative resection were recruited (n = 21). ET stenting was performed intraoperatively using a 16-gauge Angiocath (BD Medical Systems, Franklin Lakes, NJ) with dimensions of 1.7 mm × 30 mm. The stent stays inplace indefinitely. The otologic status was evaluated using otoscopy, pure-tone audiogram, and tympanogram at 3 months, 6 months, and 1 year after the surgery. The outcomes were analyzed and compared with historical control.

RESULTS

There were 9 (43%) patients with no OME at 6 months after surgery, and 15 (71%) patients had no OME at 1 year postoperatively. The results were statistically significant (P < .0001) when compared with our historical control of no ET stenting. There was no incidence of adverse effects of the stenting, such as acute otitis media, dislodgement of the stent, otalgia, and nasal pain.

CONCLUSIONS

ET stenting was feasible after nasopharyngectomy. ET stenting prevented a significant number of patients from suffering from ipsilateral OME and alleviated the symptoms of unilateral aural fullness and unilateral conductive hearing impairment up to at least 1 year after the surgery. ET stenting is recommended in all patients after maxillary swing nasopharyngectomy.

Endoscopic Endonasal Nasopharyngectomy in Selected Cancers

Objective

To describe the different surgical techniques for nasopharyngeal endoscopic resection (NER) and to support the efficacy of the endoscopic endonasal approach in the management of selected primary and locally recurrent nasopharyngeal tumors (NPTs).

Study Design

Case series with chart review.

Setting

Patients affected by NPTs who underwent NER from 1997 to 2011 at two Italian referral centers.

Subjects and Methods

NER was tailored to the NPT extension and classified as follows: type 1 NER, resection of the posterior nasopharyngeal wall; type 2 NER, resection superiorly extended to the sphenoid; type 3 NER, trans-pterygoid approach to the postero-lateral nasopharynx with removal of pterygoid plates and Eustachian tube, under control of parapharyngeal-petrous-cavernous segments of the internal carotid artery.

Results

Thirty-six consecutive patients with primary (9 cases) or locally recurrent (27 cases) NPTs were enrolled. The lesions were staged as follows: stage I, 16 (44.4%); stage II, 3 (8.4%); stage III, 15 (41.6%); and stage IVA, 2 (5.6%). Type 1 NER was performed in 6 cases, type 2 NER in 12, type 3 NER in 16, and bilateral-extended type 3 NER in 2. No perioperative mortality or major complications were observed. Postoperatively, 11 patients received intensity-modulated radiotherapy, with or without chemotherapy. Follow-up ranged from 2 to 173 months (mean: 38 months). Five years overall, disease-specific, and disease-free survivals were 75.1% ± 9.13%, 80.9% ± 7.79%, and 58.1% ± 14.8%, respectively.

Conclusion

NER is a feasible and minimally invasive surgical approach for the management of selected primary and locally recurrent NPTs. Our preliminary outcomes are promising, with local control rates comparable to those of conventional procedures. Larger case series and longer follow-up are needed to validate the reproducibility and efficacy of the technique.

Long-term treatment outcome of recurrent nasopharyngeal carcinoma treated with salvage intensity modulated radiotherapy

PURPOSE

To evaluate the long-term treatment outcome in patients with recurrent nasopharyngeal carcinoma (NPC) treated with salvage intensity modulated radiotherapy (IMRT).

MATERIALS AND METHODS

One hundred and fifty one previously irradiation NPC patients with recurrent disease and re-irradiated by IMRT between 2001 and 2006 had been reviewed. The disease was re-stage I in 7, re-stage II in 21, re-stage III in 50 and re-stage IV in 73. Thirty-seven patients received concurrent chemotherapy, 39 had induction chemotherapy and 75 had radiotherapy alone.

RESULTS

All patients completed the planned IMRT. The median volume of the recurrent gross target volume of nasopharynx (rGTVnx) was 42.2 cm(3) (range 1.5-146.3 cm(3)). The median mean re-irradiation dose to the rGTVnx was 70.4Gy (range 62.1-77.6Gy). The median follow-up time after re-irradiation was 40.0 months (range 1.9-116.9 month). The 5-year local control rate (LCR) and overall survival rate (OS) for re-stage I, II, III, IV were 80.0%, 85.0%, 80.0%, 78.7% and 71.4%, 62.9%, 35.5%, 30.2%, respectively. Multivariate analysis indicated that rT classification (hazard ratio (HR), 2.02; 95%confidence interval (CI), 1.03-3.97; P=0.04) and the volume of rGTVnx (HR, 2.05; 95%CI, 1.31-3.22; P<0.01) were independent predictors for OS. Patients (39.0%) with re-stage III or IV disease experienced Grade 3 or 4 late toxicities.

CONCLUSION

Re-irradiation by IMRT for recurrent NPC resulted in encouraging local control. The clinical outcome for patients with early re-stage diseases was satisfactory. Further investigations, focus on optimising radiation dose and establishing effective treatment strategies, are warranted for advanced recurrent disease in order to improve overall survival and minimise late toxicity.

Endoscopic nasopharyngectomy and its role in managing locally recurrent nasopharyngeal carcinoma

Local recurrence after primary radiation of nasopharyngeal carcinoma (NPC) remains an important cause of morbidity and mortality. Salvage treatment using reirradiation or surgery has been shown to improve survival over nontreatment. Surgery is traditionally performed using an open approach. Advances in endoscopic approaches for resection of paranasal sinus tumors have been extended to NPC. This article reviews the treatment options, in particular the role of endoscopic nasopharyngectomy in the management of recurrent NPC. The endoscopic anatomy, surgical principles, and published results on endoscopic nasopharyngectomy are presented. Short-term outcomes for early-stage recurrences are promising but long-term follow-up is needed.

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.

Intensity-modulated radiation therapy in the salvage of locally recurrent nasopharyngeal carcinoma

PURPOSE

Local recurrences of nasopharyngeal carcinoma (NPC) may be salvaged by reirradiation with conventional techniques, but with significant morbidity. Intensity-modulated radiation therapy (IMRT) may improve the therapeutic ratio by reducing doses to normal tissue. The aim of this study was to address the efficacy and toxicity profile of IMRT for a cohort of patients with locally recurrent NPC.

METHODS AND MATERIALS

Between August 2003 and June 2009, 70 patients with radiologic or pathologically proven locally recurrent NPC were treated with IMRT. The median time to recurrence was 30 months after the completion of conventional radiation to definitive dose. Fifty-seven percent of the tumors were classified asrT3-4. The minimum planned doses were 59.4 to 60 Gy in 1.8- to 2-Gy fractions per day to the gross disease with margins, with or without chemotherapy.

RESULTS

The median dose to the recurrent tumor was 70 Gy (range, 50-77.4 Gy). Sixty-five patients received the planned radiation therapy; 5 patients received between 50 and 60 Gy because of acute side effects. With a median follow-up time of 25 months, the rates of 2-year locoregional recurrence-free survival, disease-free survival, and overall survival were 65.8%, 65.8%, and 67.4%, respectively. Moderate to severe late toxicities were noted in 25 patients (35.7%). Eleven patients (15.7%) had posterior nasal space ulceration, 17 (24.3%) experienced cranial nerve palsies, 12 (17.1%) had trismus, and 12 (17.1%) experienced deafness. Extended disease-free interval (relative risk 2.049) and advanced T classification (relative risk 3.895) at presentation were adverse prognostic factors.

CONCLUSION

Reirradiation with IMRT provides reasonable long-term control in patients with locally recurrent NPC.

Prediction of surgical outcome using plasma Epstein-Barr virus dna and (18)F-FDG PET-CT scan in recurrent nasopharyngeal carcinoma

BACKGROUND

This study was carried out to determine the role of plasma Epstein-Barr virus (pEBV)-DNA and positron-emission tomography (PET)-CT scan in predicting the outcome of nasopharyngectomy and cervical lymphadenectomy for recurrent nasopharyngeal carcinoma (NPC).

METHODS

Between 2007 and 2009, we recruited patients who had local or regional recurrent NPC after radiotherapy. The relationship between preoperative pEBV-DNA level, maximal standard uptake value (SUVmax), and surgical outcome was analyzed.

RESULTS

Forty-two patients had local tumor recurrence. Their median pEBV-DNA level and SUVmax were 348 copies and 4.7, respectively. Both values were significantly lower than those with palliative nasopharyngectomy. Twenty-two patients had regional failure. Their mean pEBV-DNA level and tumor SUVmax were 626 copies and 7.6, respectively. The metastatic lymph nodes with extracapsular spread had a significantly higher mean SUVmax.

CONCLUSIONS

Preoperative pEBV-DNA and PET-CT predict the surgical outcome of nasopharyngectomy for recurrent NPC. Similarly, PET-CT scan predicts the presence of extracapsular spread of metastatic lymph nodes. These patients may warrant further postoperative adjuvant therapy.

Current treatment options for recurrent nasopharyngeal cancer

Loco-regional control rate of nasopharyngeal carcinoma (NPC) has improved significantly in the past decade. However, local recurrence still represents a major cause of mortality and morbidity in advanced stages, and management of local failure remains a challenging issue in NPC. The best salvage treatment for local recurrent NPC remains to be determined. The options include brachytherapy, external radiotherapy, stereotactic radiosurgery, and nasopharyngectomy, either alone or in different combinations. In this article we will discuss the different options for salvage of locally recurrent NPC. Retreatment of locally recurrent NPC using radiotherapy, alone or in combination with other treatment modalities, as well as surgery, can result in long-term local control and survival in a substantial proportion of patients. For small-volume recurrent tumors (T1–T2) treated with external radiotherapy, brachytherapy or stereotactic radiosurgery, comparable results to those obtained with surgery have been reported. In contrast, treatment results of advanced-stage locally recurrent NPC are generally more satisfactory with surgery (with or without postoperative radiotherapy) than with reirradiation.

Comparison of single versus fractionated dose of stereotactic radiotherapy for salvaging local failures of nasopharyngeal carcinoma: a matched-cohort analysis

BACKGROUND

Local failure is an important cause of morbidity and mortality in nasopharyngeal carcinoma (NPC). Although surgery or brachytherapy may be feasible in selected cases, most patients with local failure require external beam re-irradiation. Stereotactic radiation using single or multiple fractions have been employed in re-irradiation of NPC, but the optimal fractionation scheme and dose are not clear.

METHODS

Records of 125 NPC patients who received salvage stereotactic radiation were reviewed. A matched-pair design was used to select patients with similar prognostic factors who received stereotactic re-irradiation using single fraction (SRS) or multiple fractions (SRM). Eighty-six patients were selected with equal number in SRS and SRM groups. All patients were individually matched for failure type (persistent or recurrent), rT stage (rT1-2 or rT3-4), and tumor volume (< or = 5 cc, >5-10 cc, or >10 cc). Median dose was 12.5 Gy in single fraction by SRS, and 34 Gy in 2-6 fractions by SRM.

RESULTS

Local control rate was better in SRM group although overall survival rates were similar. One- and 3-year local failure-free rates were 70% and 51% in SRS group compared with 91% and 83% in SRM group (p = 0.003). One- and 3-year overall survival rates were 98% and 66% in SRS group compared with 78% and 61% in SRM group (p = 0.31). The differences in local control were mainly observed in recurrent or rT2-4 disease. Incidence of severe late complications was 33% in SRS group vs. 21% in SRM group, including brain necrosis (16% vs. 12%) and hemorrhage (5% vs. 2%).

CONCLUSION

Our study showed that SRM was superior to SRS in salvaging local failures of NPC, especially in the treatment of recurrent and rT2-4 disease. In patient with local failure of NPC suitable for stereotactic re-irradiation, use of fractionated treatment is preferred.

Validation of a prognostic scoring system for locally recurrent nasopharyngeal carcinoma treated by stereotactic radiosurgery

Background

Selection of patients with local failure of nasopharyngeal carcinoma (NPC) for appropriate type of salvage treatment can be difficult due to the lack of data on comparative efficacy of different salvage treatments. The purpose of the present study was to validate a previously published prognostic scoring system for local failures of NPC treated by radiosurgery based on reported results in the literature.

Methods

A literature search yielded 3 published reports on the use of radiosurgery as salvage treatment of NPC that contained sufficient clinical information for validation of the scoring system. Prognostic scores of 18 patients from these reports were calculated and actuarial survival rates were estimated and compared to the original cohort used to design the prognostic scoring system. The area under the receiver operating characteristic curve was also determined and compared between the current and original patient groups.

Results

The calculated prognostic scores ranged from 0.32 to 1.21, with 15 patients assigned to the poor prognostic group and 3 to the intermediate prognostic group. The actuarial 3-year survival rates in the intermediate and poor prognostic groups were 67% and 0%, respectively. These results were comparable to the observed 3-year survival rates of 74% and 23% in the intermediate and poor prognostic group in the original reports. The area under the receiver operating characteristic curve for the current patient group was 0.846 which was similar to 0.841 in the original group.

Conclusion

The previously published prognostic scoring system demonstrated good prediction of treatment outcome after radiosurgery in a small group of NPC patients with poor prognosis. Prospective study to validate the scoring system is currently being carried out in our institution.

Endoscopic nasopharyngectomy for locally recurrent nasopharyngeal carcinoma

OBJECTIVES

Nasopharyngectomy is the primary treatment for locally recurrent nasopharyngeal carcinoma (rNPC). However, oncological nasopharyngectomy is difficult to achieve, even using extranasal surgical approaches, with potential risks of severe functional disabilities and serious complications. This report introduces an innovative, minimally invasive, oncological, endoscopic nasopharyngectomy.

METHODS

Between October 2004 and January 2008, 37 rNPC patients received endoscopic nasopharyngectomy, with 17, 4, 14, and 2 cases of rT1N0M0, rT2aN0M0, rT2bN0M0, and rT3N0M0, respectively. Tumors in all patients were confined to the nasopharyngeal cavity, postnaris, nasal septum, superficial parapharyngeal space, or the base of the sphenoid sinus. Nasopharyngeal malignancies and adequate surgical margin (>0.5-1.0 cm) were required for continuous en bloc resection.

RESULTS

Among the 37 endoscopic nasopharyngectomies, 35 achieved en bloc tumor resection with negative surgical margins. In the remaining two cases, the tumors were dissected into small blocks, and one had positive surgical margins. No patient received postoperative radiotherapy and no severe complication was observed. During the 6-45 months of follow-up (median, 24 months), five patients experienced in situ residual or recurrence with 1 submaxillary lymphatic metastasis. One patient developed distant metastases and died, one died of intracranial infection, and one died of another cancer. The 2-year overall survival rate, local relapse-free survival rate, and progression-free survival rate were 84.2%, 86.3%, and 82.6%, respectively.

CONCLUSIONS

Appropriate endoscopic nasopharyngectomy is a minimally invasive, safe, and promising surgical modality for the en bloc excision of rNPCs with encouraging short-term outcome. Long-term patient follow-up is ongoing.

Endoscopic microwave coagulation therapy for early recurrent T1 nasopharyngeal carcinoma

The result of reirradiation in recurrent T1 (rT1) nasopharyngeal carcinoma (NPC) is unsatisfactory. We sought to study the efficacy and complications of endoscopic microwave coagulation therapy (MCT) in salvaging rT1 NPC after primary radiotherapy. Between August 1994 and April 2005, 55 patients with rT1 NPC were treated with endoscopic MCT. With a median follow-up of 102.1 months, 52 of 55 patients are still alive. Five patients had local failure after retreatment. The overall survival and local progression-free survival were 100% (95% CI, 99.4% to 100%) and 94.5% (95% CI, 94.1% to 94.9%) at 2 years, respectively, and 93.6% (95% CI, 93.5% to 94.4%) and 90.7% (95% CI, 90.2% to 91.2%) at 5 years. The common complications of endoscopic MCT were mild postoperative pain and headache. Nasopharyngeal necrosis was transient in one patient and subsided in 1 month. Endoscopic MCT achieved significant survival and tumour control without severe complications in selective rT1 NPC.

Chemoradiotherapy for locally recurrent nasopharyngeal carcinoma: treatment outcome and prognostic factors

OBJECTIVE

To evaluate the treatment outcome of patients with locally recurrent nasopharyngeal carcinoma (NPC) treated with re-irradiation and chemotherapy.

METHODS

Between 1991 and 2004, 36 patients with locally recurrent NPC received re-irradiation and chemotherapy. The median re-irradiation dose was 37.9 Gy; the median total dose of prior irradiation and re-irradiation was 104.4 Gy. The outcome is studied retrospectively and also evaluated the prognostic factors and toxicities.

RESULTS

With a median follow-up of 40 months, 3-year overall survival (OS) was 58.3% and 3-year progression-free survival (PFS) was 25.0%. Patients aged <50 and of early stage at recurrence had a significantly better OS and PFS. Over Grade 3 of late toxicities were seen in patients received a total dose of >110 Gy.

CONCLUSIONS

Age and stage at recurrence were identified as prognostic factors for OS and PFS. Patients received external beam radiation therapy at a total dose of more than 110 Gy should be careful for severe late toxicities, and it is thought to be the optimal dose for recurrent tumor.

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.

An uncommon presentation of orbital apex syndrome

BACKGROUND

Bilateral total ophthalmoplegia secondary to a malignancy or infection of the cavernous sinus and orbital apex is an unusual presentation. Bilateral ophthalmoplegia as the initial sign of this type of rhinocerebral pathology is also uncommon.

CASE REPORT

A 34-year old Haitian woman presented with bilateral vision loss, ptosis, total ophthalmoplegia, and ocular pain. A physical and neurologic examination, laboratory analysis, chest x-rays, and neurologic imaging studies were requested. Cranial and facial computed tomography (CT) scans showed swelling of the soft tissues proximal to the sphenoid extending into the dorsal sella and prepontine cistern, obliteration of the nasopharyngeal reflection, opacification of the ethmoid and sphenoid sinus, bony destruction of the mid-skull base, and bilateral lymphadenopathy of the neck. Magnetic resonance imaging (MRI) showed the presence of a soft tissue mass causing destruction of the skull base. Involvement of the clivus, cavernous sinuses, and sella with nasopharynx extension was observed. Hypodense centers within nasopharyngeal tissues suggested the presence of necrosis. Differential diagnosis included nasopaharyngeal carcinoma, lymphoma, or an infectious process. The patient did not consent to a biopsy and refused treatment.

CONCLUSION

This presentation is a medical emergency. A combination of surgical, medical, or radiological intervention may be required to manage rhino-cerebral diseases responsible for orbital apex syndrome. Despite advances in neurologic imaging, histologic examination of tissue obtained from a biopsy may ultimately be necessary to obtain a precise diagnosis.

Minimally Invasive Endoscopic Nasopharyngectomy in the Treatment of Recurrent T1-2a Nasopharyngeal Carcinoma

OBJECTIVE

To study the efficacy of endoscopic nasopharyngectomy in salvaging recurrent T1 to 2a nasopharyngeal carcinoma (NPC).

STUDY DESIGN

An investigation of the outcome of endoscopic nasopharyngectomy.

METHODS

Six nasopharyngectomies for patients presenting with locally recurrent T1 to 2a NPC were performed exclusively by way of endoscopic resection by a single surgeon (m.-k.c.) during the period 2001 to 2005. All patients were operated on with curative intent without postoperative radiotherapy.

RESULTS

All six operations were successfully performed endoscopically, and no conversions to conventional open resection were necessary. Of the patients who underwent endoscopic excision, three of them had rT1 disease, and the others had rT2a disease. No surgical specimens had microscopic invasion of the resection margins. No complications associated with the operation occurred. The patients were followed up for 16 to 59 (average, 29) months. One local recurrence was noted in this series to date, and the patient was treated with intensity-modulated radiotherapy and chemotherapy.

CONCLUSIONS

Exclusively endoscopic nasopharyngectomy is a feasible method for treatment of locally recurrent T1- to 2a-staged NPC.

Predictive factors of tumor control and survival after radiosurgery for local failures of nasopharyngeal carcinoma

BACKGROUND

Stereotactic radiosurgery has been employed as a salvage treatment of local failures of nasopharyngeal carcinoma (NPC). To identify patients that would benefit from radiosurgery, we reviewed our data with emphasis on factors that predicted treatment outcome.

PATIENTS AND METHODS

A total of 48 patients with local failures of NPC were treated by stereotactic radiosurgery between March 1996 and February 2005. Radiosurgery was administered using a modified linear accelerator with single or multiple isocenters to deliver a median dose of 12.5 Gy to the target periphery. Median follow-up was 54 months.

RESULTS

Five-year local failure-free probability after radiosurgery was 47.2% and 5-year overall survival rate was 46.9%. Neuroendocrine complications occurred in 27% of patients but there were no treatment-related deaths. Time interval from primary radiotherapy, retreatment T stage, prior local failures and tumor volume were significant predictive factors of local control and/or survival whereas age was of marginal significance in predicting survival. A radiosurgery prognostic scoring system was designed based on these predictive factors. Five-year local failure-free probabilities in patients with good, intermediate and poor prognostic scores were 100%, 42.5%, and 9.6%. The corresponding five-year overall survival rates were 100%, 51.1%, and 0%.

CONCLUSION

Important factors that predicted tumor control and survival after radiosurgery were identified. Patients with good prognostic score should be treated by radiosurgery in view of the excellent results. Patients with intermediate prognostic score may also be treated by radiosurgery but those with poor prognostic score should receive other salvage treatments.

Induction chemotherapy with cisplatin and gemcitabine followed by reirradiation for locally recurrent nasopharyngeal carcinoma

OBJECTIVES

Patients with advanced local recurrence of nasopharyngeal carcinoma (NPC) have a poor prognosis. Retreatment by external radiotherapy is frequently the only option but results are usually poor. This study was conducted to evaluate the benefits of adding induction chemotherapy with cisplatin and gemcitabine before reirradiation for locally recurrent NPC.

METHODS

Twenty patients with locally recurrent NPC not amenable to brachytherapy or surgery were enrolled between September 2001 and October 2003. The T stage distribution at recurrence was 5% rT2, 30% rT3, and 65% rT4. Induction chemotherapy consisted of cisplatin 40 mg/m2 and gemcitabine 1.25 g/m days 1 and 8 for 3 times per week for 3 cycles, followed by reirradiation using intensity-modulated radiotherapy.

RESULTS

A total of 58 chemotherapy cycles were administered to patients and most received 3 cycles. Hematological toxicities were mild, with grade 3 and 4 neutropenia in 55% and 5% of patients, respectively, and grade 3 thrombocytopenia in 5%. After chemotherapy, 15 patients achieved partial response (75%). Seventeen patients received external reirradiation and one had radiosurgery after chemotherapy. Severe acute radiation toxicities were uncommon. After a median follow-up of 14.5 months, 55% of patients had locoregional progression and 45% had died. The 1-year locoregional progression-free, local progression-free, and overall survival rates were 63%, 68%, and 80%, respectively. In patients with external reirradiation, the 1-year local progression-free and overall survival rates were 75% and 88%. Patients with rT2-3 stage had significantly better 1-year local control rates than those with rT4 stage (100% versus 52%).

CONCLUSIONS

The combination cisplatin and gemcitabine is active and well-tolerated in locally recurrent NPC. The current approach of using induction chemotherapy before reirradiation may improve the outcome of patients with advanced local recurrence and merits further investigation.

Reirradiation of nasopharyngeal carcinoma withintensity-modulated radiotherapy

BACKGROUND AND PURPOSE

To evaluate the treatment outcome in patients with locally recurrent nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiation therapy (IMRT).

MATERIALS AND METHODS

Between October 2001 and May 2004, 31 patients with locally recurrent NPC received re-irradiation using IMRT. The rT classification distribution was 3 for rT1, 5 for rT2, 9 for rT3, and 14 for r T4. Median time from first course of radiotherapy to re-irradiation was 51 months. IMRT was performed using step-and-shoot method with nine 4-6 MV photon fields and median prescribed dose was 54 Gy (range: 50-60 Gy). Additional treatments included cisplatin-based induction chemotherapy in 68% and radiosurgery boost with a single dose which ranged from 8.5 to 12.5 Gy in 32%. Median follow-up time was 11 months.

RESULTS

After re irradiation, 58% of patients had complete regression of primary tumor. One-year loco-regional progression-free, distant metastasis-free and overall survival rates were 56, 90, and 63%, respectively. Significantly better 1-year local progression-free rate was observed in rT1-3 than r T4 tumor (100 vs. 35%). Grade 3 late toxicities, mostly ototoxicity/cranial neuropathy, occurred in six patients (19%). One-year actuarial rates of late toxicities were 70% for all grades and 25% for Grade 3.

CONCLUSION

Our preliminary results showed that good control of rT1-3 NPC can be achieved using IMRT with a dose between 50 and 60 Gy, whereas the outcome for r T4 tumor remained poor. Late toxicities were common but incidence of severe toxicities was relatively low.

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.

Treatment outcome for synchronous locoregional failures of nasopharyngeal carcinoma

BACKGROUND

To review the outcome and evaluate the prognostic factors in the treatment of synchronous locoregional failures of nasopharyngeal carcinoma (NPC).

METHODS

We reviewed the records of 43 patients with synchronous locoregional failures of NPC who received salvage treatment or chemotherapy between November 1986 and January 2001. The recurrent disease was stage II in 61%, stage III in 30%, and stage IV in 9%. The local disease was rT1-2 in 67% and rT3-4 in 33%, and the regional disease was rN1 in 91% and rN2 in 9%. Persistent disease, defined as failures within 4 months of completion of primary radiotherapy, occurred in 53.5% and recurrent disease in 46.5%. Seventeen patients received surgery for regional and/or local failures with or without combined radiotherapy (ST group), 14 patients received reirradiation to both local and regional disease (RT group), and 12 patients received palliative chemotherapy only (CT group). The median follow-up was 18 months (range, 4-153) and for the surviving patients it was 29 months (range, 6-153).

RESULTS

The 3-year relapse-free survival (RFS) rate and disease-specific survival (DSS) rate after salvage treatment or chemotherapy were 17% and 38%, respectively. The 3-year RFS rates in stage II, III, and IV disease were 25%, 8%, and 0%, respectively. The corresponding 3-year DSS rates were 43%, 28%, and 38%. The 3-year RFS rates in the ST, RT, and CT group were 39%, 7%, and 0%, respectively. The corresponding 3-year DSS rates were 55%, 25%, and 25%. Patients whose local disease was treated by surgical resection had a 3-year local control rate of 71% compared with 38% by reirradiation using brachytherapy or external radiotherapy. For regional disease, the 3-year nodal control rate after radical neck dissection was 65% compared with 24% by reirradiation. Further locoregional failure represents the major failure pattern, and the proportion of patients who had further local, regional, and both locoregional failures were 16%, 9%, and 53%, respectively. Distant metastasis occurred in 30% of patients, and only 5% had isolated distant metastasis in the absence of locoregional failures. On multivariate analysis, treatment by reirradiation or chemotherapy alone and rN2 disease were independent factors that predicted poor survival, whereas treatment by reirradiation or chemotherapy alone was the only independent factor that predicted further relapse or failure.

CONCLUSIONS

Proper selection of patients for aggressive salvage treatment and individualization of treatment are important in managing patients with synchronous locoregional failures of NPC. A significant proportion of patients with early stage locoregional failures can still achieve long-term disease control and survival after aggressive salvage treatment using surgery with or without combined radiotherapy. In patients with more advanced disease, treatment by reirradiation alone or palliative chemotherapy is largely ineffective and is associated with a poor outcome.

Linear accelerator-based stereotactic radiosurgery for limited, locally persistent, and recurrent nasopharyngeal carcinoma: efficacy and complications

PURPOSE

To evaluate the efficacy and complication of linear accelerator-based stereotactic radiosurgery (SRS) when used as salvage treatment for early-stage persistent and recurrent nasopharyngeal carcinoma (NPC) after primary radiotherapy (RT).

MATERIALS AND METHODS

Between March 1998 and June 2001, 18 patients (15 men and 3 women; median age 46 years, range 32-84) with locally persistent or recurrent NPC confined to the nasopharynx (rT1) or with limited extension to the nasal fossa or parapharyngeal space (rT2) were treated by SRS. Thirteen patients had rT1 disease and 5 had rT2 disease. Most patients had disease not amenable to surgery or brachytherapy. All patients had undergone previous radical RT. Persistent disease was defined as tumor relapse within 4 months of completion of primary RT, and recurrence as tumor relapse beyond 4 months. Seven patients were treated for persistent disease, eight for a first recurrence, and three for a second recurrence. SRS was performed using multiple noncoplanar arcs of photons delivered to the target volume, which was defined by axial CT at a 3 mm thickness, supplemented by MRI in selected patients (67%). The median target volume was 5.3 cm(3) (range 2.2-16.9). The median SRS dose was 12.5 Gy (range 11-14) delivered to the 80% isodose line. All patients underwent serial nasopharyngoscopy and imaging after SRS. The median follow-up was 26 months (range 11-48).

RESULTS

After SRS, 16 (89%) of 18 patients had complete regression of tumor as assessed by nasopharyngoscopy and biopsy. Four patients with an initial complete response to SRS subsequently developed local relapse again, with one recurrence developing outside the target volume 8 months after SRS and three within the target volume at 6-26 months after SRS. Two patients with local disease controlled by SRS developed relapse in other sites (neck node and liver metastases). The actuarial 2-year local control rate after SRS was 72%. Patients treated for persistent disease had a better local control rate (100%; 7 of 7) than those treated for recurrent disease (46%; 5 of 11). Patients with rT1 disease also had a better outcome after SRS compared with those with rT2 disease, with a control rate of 77% (10 of 13) for rT1 disease and 40% (2 of 5) for rT2 disease. Treatments were well tolerated, with no acute side effects. One patient had radiologic evidence of temporal lobe necrosis, although the right temporal lobe had already received a high dose during prior RT. That patient also developed additional local recurrence and liver metastases and died. The actuarial 2-year survival rate was 86%.

CONCLUSIONS

Our preliminary results indicate that SRS is an effective treatment modality for persistent and recurrent early-stage NPC, with early control rates comparable to other salvage treatments such as brachytherapy and nasopharyngectomy. A modest SRS dose at 12.5 Gy also appears to be effective and is associated with minimal morbidities. More clinical experience and longer follow-up are needed to validate our results and to address fully the role of SRS in salvaging local failures of NPC.