Nasopharyngeal carcinoma

The Prognostic Value of Treatment-Related Lymphopenia in Nasopharyngeal Carcinoma Patients

Purpose

This study was conducted to evaluate the prognostic value of treatment-related lymphopenia in patients with nasopharyngeal carcinoma (NPC).

Materials and Methods

A total of 413 consecutive stage II-IVb NPC patients treated with concurrent chemoradiotherapy (CCRT) were enrolled. The overall survival (OS), progression-free survival (PFS), and distant metastasis-free survival (DMFS) were calculated with the Kaplan-Meier method, and differences were compared using the log-rank test.

Results

A minimum (mini)–absolute lymphocyte counts (ALC) of < 390 cells/μL or ALC after 3 months of CCRT (post3m-ALC) < 705 cells/μL was significantly associated with worse outcome than mini-ALC ≥ 390 cells/μL (OS, p=0.002; PFS, p=0.005; DMFS, p=0.004) or post3m-ALC ≥ 705 cells/μL (OS, p < 0.001; PFS, p < 0.001; DMFS, p=0.001). Patients with lymphopenia (mini-ALC < 390 cells/μL and post3m-ALC < 705 cells/μL) had a worse prognosis than those without lymphopenia (mini-ALC ≥ 390 cells/μL and post3m-ALC ≥ 705 cells/μL) (OS, p < 0.001; PFS, p < 0.001; DMFS, p < 0.001). Multivariate analysis revealed that post3m-ALC was an independent prognostic factor for OS (hazard ratio [HR], 1.76; 95% confidence interval [CI], 1.12 to 2.78; p=0.015), PFS (HR, 1.86; 95% CI, 1.23 to 2.82; p=0.003), and DMFS (HR, 1.87; 95% CI, 1.13 to 3.08; p=0.014). Multivariate analysis also revealed that patients with lymphopenia had a high risk of death (HR, 3.79; 95% CI, 1.75 to 8.19; p=0.001), disease progression (HR, 2.93; 95% CI, 1.59 to 5.41; p=0.001), and distant metastasis (HR, 3.89; 95% CI, 1.67 to 9.10; p=0.002). Multivariate analysis performed with time dependent Cox regression demonstrated ALC was an independent prognostic factor for OS (HR, 0.995; 95% CI, 0.991 to 0.999; p=0.025) and PFS (HR, 0.993; 95% CI, 0.988 to 0.998; p=0.006).

Conclusion

Treatment-related lymphopenia was a poor prognostic factor in NPC patients.

Mate-Pair Sequencing as a Powerful Clinical Tool for the Characterization of Cancers with a DNA Viral Etiology

DNA viruses are known to be associated with a variety of different cancers. Human papillomaviruses (HPV) are a family of viruses and several of its sub-types are classified as high-risk HPVs as they are found to be associated with the development of a number of different cancers. Almost all cervical cancers appear to be driven by HPV infection and HPV is also found in most cancers of the anus and at least half the cancers of the vulva, penis and vagina, and increasingly found in one sub-type of head and neck cancers namely oropharyngeal squamous cell carcinoma. Our understanding of HPVs role in cancer development comes from extensive studies done on cervical cancer and it has just been assumed that HPV plays an identical role in the development of all other cancers arising in the presence of HPV sequences, although this has not been proven. Most invasive cervical cancers have the HPV genome integrated into one or more sites within the human genome. One powerful tool to examine all the sites of HPV integration in a cancer but that also provides a comprehensive view of genomic alterations in that cancer is the use of next generation sequencing of mate-pair libraries produced from the DNA isolated. We will describe how this powerful technology can provide important information about the genomic organization within an individual cancer genome, and how this has demonstrated that HPVs role in oropharyngeal squamous cell carcinoma is distinct from that in cervical cancer. We will also describe why the sequencing of mate-pair libraries could be a powerful clinical tool for the management of patients with a DNA viral etiology and how this could quickly transform the care of these patients.

Dermatomyositis and nasopharyngeal carcinoma

A nasopharyngeal carcinoma was diagnosed in a 37-year-old man with a two year history of dermatomyositis. The physical and laboratory examinations excluded further medical problems. To our knowledge, this is the first case of dermatomyositis associated with nasopharyngeal carcinoma in a white Israeli Jewish patient.

Doses to radiation sensitive organs and structures located outside the radiotherapeutic target volume for four treatment situations

This study documents dosage to radiation sensitive organs/structures located outside the radiotherapeutic target volume for four treatment situations: (a) head and neck, (b) brain (pituitary and temporal lobe), (c) breast and (d) pelvis. Clinically relevant treatment fields were simulated on a tissue-equivalent anthropomorphic phantom and subsequently irradiated with Cobalt-60 gamma rays, 6- and 18-MV x-ray beams. Thermoluminescent dosimeters and diodes were used to measure absorbed dose. The head and neck treatment resulted in significant doses of radiation to the lens and thyroid gland. The total treatment lens dose (300-400 cGy) could be cataractogenic while measured thyroid doses (1000-8000 cGy) have the potential of causing chemical hypothyroidism, thyroid neoplasms, Graves' disease and hyperparathyroidism. Total treatment retinal (400-700cGy) and pituitary (460-1000 cGy) doses are below that considered capable of producing chronic disease. The pituitary treatment studied consisted of various size parallel opposed lateral and vertex fields (4 x 4 through 8 x 8 cm). The lens dose (40-200 cGy) with all field sizes is below those of clinical concern. Parotid doses (130-1200 cGy) and thyroid doses (350-600 cGy) are in a range where temporary xerostomia (parotid) and thyroid neoplasia development are a reasonable possibility. The retinal dose (4000 cGy) from the largest field size (8 x 8 cm2) is in the range where retinopathy has been reported. The left temporal lobe treatment also used parallel opposed lateral and vertex fields (7 x 7 and 10 x 10 cm). Doses to the pituitary gland (5200-6200 cGy), both parotids (200-6900 cGy), left lens (200-300 cGy) and left retina (1700-4500 cGy) are capable of causing significant future clinical problems. Right-sided structures received insignificant doses. Secondary malignancies could result from measured total treatment thyroid doses (670-980 cGy). Analysis of three breast/chest wall and regional nodal irradiation techniques demonstrated a 25-50% decrease in secondary lung dose with use of independent collimation compared to use of custom alloy blocking material. However, it is unlikely that a reduction in secondary dose of this magnitude would reduce the risk of treatment sequellae. In four-field "box" pelvic irradiation, secondary testes dose may result in temporary (clamshell shield) or permanent azoospermia, but is unlikely to impair androgen production.

The efficacy of fiberoptic endoscopic examination and biopsy in the detection of early nasopharyngeal carcinoma

Fiberoptic endoscopic examination and biopsy of the nasopharynx was done in 130 patients as a prospective study. They all had elevated titers of antibodies against the viral capsid antigen of Epstein-Barr virus but no symptoms or signs of nasopharyngeal carcinoma. Each underwent a biopsy from six fixed sites in the nasopharynx. Of the 780 biopsy specimens taken from seven patients, 11 showed the presence of nasopharyngeal carcinoma. Techniques to improve the yields of such biopsies with fiberoptic endoscopy are discussed. The presence of tumor was unrelated to the macroscopic endoscopic findings. The highest incidence of subclinical tumor is in the pharyngeal recess.

Clinical evaluation of nasopharyngeal carcinoma in Jordan

Thirty-three cases of nasopharyngeal carcinoma are reported. This is the first report of this condition from Jordan. Age, sex, early presentation and metastases are discussed. Bimodal distribution of age showed two peaks between 16-20 and 41-45 years. The disease was more common in males. Lymph node enlargement was the most common presentation, and bone metastases were the most frequent.

[Bilateral abducens nerve palsy in nasopharyngeal carcinoma]

We report a case of bilateral abducens palsy as initial finding in nasopharyngeal carcinoma. Possible mode of involvement is discussed. Only one case has been reported in the past.

Detection of subclinical nasopharyngeal carcinoma by fibreoptic endoscopy and multiple biopsy

Of 6054 people who had high titres of antibodies against the viral capsid antigen of Epstein-Barr virus but no symptoms or signs of nasopharyngeal carcinoma as assessed by conventional methods, 130 were randomly recruited and examined by fibreoptic endoscopy and biopsy of several sites of the nasopharynx. 7 cases of nasopharyngeal carcinoma were detected. The tumours were largely confined to the pharyngeal recess, which suggests that it is the area of the nasopharynx most prone to the development of the tumour. Tumour was found in both recesses in 1 subject, who also had evidence of transition from severe epithelial dysplasia to carcinoma in a sample from the left roof, which suggests that the disease was multifocal in origin. This study showed that endoscopy and biopsy of several sites of the nasopharynx are more effective than the conventional approach in the detection of subclinical nasopharyngeal carcinoma among seropositive individuals at high risk of the disorder.

Spindle cell carcinoma of the nasopharynx

A case of spindle cell carcinoma of the nasopharynx is reported and its current management is reviewed. Surgical excision of the nasopharyngeal tumour may be the treatment of choice in some cases.

Nasopharyngeal carcinoma in Taiwan. Clinical manifestations and results of therapy

A retrospective study was performed on 966 patients with histologically verified nasopharyngeal carcinomas. The follow-up rate was 93.6% over a minimum period of five years. The actuarial and relapse-free survivals were 82% and 49% at one year, 64% and 43% at two years, 43% and 33% at five years, and 36% and 22% at ten years, respectively. None of the patients with distant metastases when initially evaluated survived more than four years following the initiation of radiotherapy and chemotherapy. After the initial radiotherapy was completed, 200 (22.2%) of 900 patients had distant metastases, bone metastases being the most frequent; and 226 (25.1%) patients had locoregional recurrence. There is no statistical correlation found between locoregional recurrence and distant metastases. In patients without recurrence, the rate of subsequent distant metastases is found to be much more heavily influenced by the initial N stage (trend X2 P less than 0.001) than the initial T-stage (trend X2 0.05 greater than P greater than 0.02). Of patients with metastases, the survival time of those with liver metastases was found to be the shortest, 5.4 +/- 0.5 months (mean +/- SEM). Since three quarters of both distant metastases and recurrence developed within two years of the initial radiotherapy, it is highly recommended for patients to be examined monthly during this period. Aggressive retreatment may lead to palliation should recurrence and/or distant metastases be found. Adjuvant chemotherapy is recommended to the patients with T4, N2 or N3 disease following completion of the initial radiotherapy.

Hypothalamic, pituitary and thyroid dysfunction after radiotherapy to the head and neck

One hundred-ten patients who had nasopharyngeal cancer and paranasal sinus tumors and were free of the primary disease were studied one to 26 years following radiotherapy. There were 70 males and 40 females ranging in age from 4 to 75 years, with a mean age of 36.5 years. During therapy both the hypothalamus and the anterior pituitary gland were in the field of irradiation. The radiation dose to the hypothalamus and the anterior pituitary gland was estimated to be 400 to 7500 rad with a median dose of 5618 rad to the anterior pituitary gland and a median dose of 5000 rad to the hypothalamus. We found evidence of endocrine deficiencies in 91 of the 110 patients studied. Seventy-six patients showed evidence of one or more hypothalamic lesions and 43 patients showed evidence of primary pituitary deficiency. Forty of the 66 patients who received radiotherapy to the neck for treatment or prevention of lymph node metastasis showed evidence of primary hypothyroidism. The range of the dose to the thyroid area was 3000 to 8800 rad with a median of 5000 rad. One young adult woman who developed galactorrhea and amenorrhea 2 years following radiotherapy showed a high serum prolactin level, but had normal anterior pituitary function and sella turcica. She regained her menses and had a normal pregnancy and delivery following bromocriptine therapy. These results indicate that endocrine deficiencies after radiotherapy for tumors of the head and neck are common and should be detected early and treated. Long-term follow-up of these patients is indicated since complications may appear after the completion of radiotherapy.

Head and neck carcinoma in patients under 40 years of age

From 1965-1978 over 2,700 patients were admitted to the Massachusetts Eye and Ear Infirmary or the Massachusetts General Hospital with carcinoma of the oropharynx, larynx or nasopharynx; only 36 of these patients were less than 40 years of age. Twelve patients had oropharyngeal carcinoma, 13 patients had laryngeal or hypopharyngeal carcinoma, and 11 patients had nasopharyngeal carcinoma. Analysis of these patients indicates an increased incidence of head and neck cancer in younger females. In patients less than age 31 there was no significant social history which contributed to early onset of disease. The younger patients with nasopharyngeal carcinoma survived longer than patients of all ages with comparable neoplasms. The survival of patients with oropharyngeal, laryngeal and hypopharyngeal carcinoma is comparable to survival in patients of all ages with similar lesions.

Carcinoma of the nasopharynx: results of radiation therapy

Of a series of 186 patients with nasopharyngeal neoplasm 138 cases were treated with curative irradiation between 1959 and 1978. All cases were reviewed and retrospectively classified according to the TNM system. The 5-year crude survival rate was 39.5 per cent. A better prognosis was found for women and for younger age groups. The degree of neck node involvement had more prognostic value than the extent of the primary tumor. The causes of failure were analyzed. In 35 cases distant metastases were observed.

Unresponsive unilateral serous otitis: harbinger of malignancy?

In adults with persistent (three to five weeks' duration) or recurrent serous otitis media, the possibility of an underlying malignancy in the nasopharynx should be considered. Alertness to this and other clues, such as atypical facial pain, will result in appropriate investigation and earlier diagnosis and treatment.

Polypoid sinusitis mimicking orbital malignancy

A 15-year-old boy developed a rapidly progressive exophthalmos of 6 mm within two months. Radiologic evidence showed bony erosion, a palpable firm mass in the right upper eyelid, and mass blocking the right nares. This tumor was found to be polypoid sinusitis emanating through the lamina papyracea.

The epidemiology of oral cavity, pharyngeal and esophageal cancer outside of North America and Western Europe

Geographical variations in the incidence of oral cavity, pharyngeal, and esophageal cancer were studied, with special reference to rates in countries outside of the United States and Western Europe. Although reporting techniques differ greatly and comparisons must be made with caution, significant variations are evident. Tracing such differences often reveals possible etiologic factor for these forms of cancer. The roles are discussed of known environmental carcinogens, such as N-nitroso compounds, polycyclic aromatic hydrocarbons, and such cultural habits as smoking or chewing tobacco, excessive consumption of alcoholic beverages, as well as other possible factors in the etiology of these cancer types.