Nasopharyngeal carcinoma: a medical oncology viewpoint. The Gustave Roussy experience

Rendering Inuit cancer "visible": Geography, pathology, and nosology in Arctic cancer research

In August of 1977, Australian pathologist David W. Buntine delivered a presentation at the Annual Meeting of the Royal College of Pathologists of Australia in Melbourne, Victoria. In this presentation, he used the diagnostic category of "Eskimoma," to describe a unique set of salivary gland tumors he had observed over the past five years within Winnipeg's Health Sciences Center. Only found amongst Inuit patients, these tumors were said to have unique histological, clinical, and epidemiological features and were unlike any other disease category that had ever been encountered before. To understand where this nosological category came from, and its long-term impact, this paper traces the historical trajectory of the "Eskimoma." In addition to discussing the methods and infrastructures that were essential to making the idea of Inuit cancer "visible," to the pathologist, the epidemiologist, and to society at large, this paper discusses how Inuit tissue samples obtained, stored, and analyzed in Winnipeg, Manitoba, came to be codified into a new, racially based disease category - one that has guided Canadian and international understandings of circumpolar cancer trends and shaped northern healthcare service delivery for the past sixty years.

Tailoring distant metastatic imaging for patients with clinically localized undifferentiated nasopharyngeal carcinoma

PURPOSE

The 2000 practice guidelines of the National Comprehensive Cancer Network recommend World Health Organization Type 2-3 nasopharyngeal carcinoma (NPC) be staged for distant disease using chest X-ray and bone scan. Our aim was to evaluate these modalities plus liver ultrasonography for American Joint Committee on Cancer/International Union Against Cancer 1997 clinical Stage I-IVB NPC.

METHODS AND MATERIALS

Between February 1999 and May 2002, all patients with clinical (examination plus CT/MRI of head and neck) Stage I-IVB undifferentiated NPC were prospectively evaluated for distant disease with chest X-ray, liver ultrasonography, and bone scan. Suspicious lesions underwent confirmatory investigation, and patients were reevaluated at 4 months.

RESULTS

In the 139 patients evaluated, the positive yield was 3.6% and prevalence was 5.8% (0.7% lung, 2.2% skeletal, and 2.9% liver metastases). The prevalence increased by N stage (p = 0.004) and overall stage (p = 0.05). Compared with N3 disease (odds ratio 1.0), the odds of metastases for N0, N1, and N2 disease was 0, 0.12, and 0.33, respectively. The positive yield was 0%, 1.8%, 4.8%, and 14.3% for N0, N1, N2, and N3 disease, respectively.

CONCLUSION

This is the first study to evaluate the use of distant staging investigations for American Joint Committee on Cancer/International Union Against Cancer 1997 staged NPC. We recommend alterations to the 2000 National Comprehensive Cancer Network guidelines as follows: high-risk (N3) disease should be fully staged with chest X-ray, bone scan, and liver ultrasonography; intermediate risk (N1 and N2) disease may be staged using all three modalities on an institutional basis. No evidence supports distant imaging for low-risk (N0 or Stage I) disease.

Nasopharyngeal carcinoma

Nasopharyngeal carcinoma represents a morphologic spectrum of neoplasms localized to the nasopharynx and arising from nasopharyngeal epithelium. Nasopharyngeal carcinomas have rather unique clinical, epidemiologic, pathologic, and biologic features. The morphologic spectrum of nasopharyngeal carcinoma includes keratinizing, nonkeratinizing, and undifferentiated subtypes. The separation of these morphologic types is not an academic exercise, but has practical importance relative to differential diagnosis, management, and prognosis. A similar morphologic classification applies to carcinomas arising in the palatine tonsils and the base of tongue. The nasopharynx, palatine tonsils, and base of tongue are collectively designated as Waldeyer's tonsillar tissues. Awareness of the morphologic spectrum of Waldeyer's ring carcinomas may assist in suggesting the primary tumor site in the face of an occult metastatic carcinoma to cervical neck lymph nodes.

Phase II trial combining mitomycin with 5-fluorouracil, epirubicin, and cisplatin in recurrent and metastatic undifferentiated carcinoma of nasopharyngeal type

BACKGROUND

This phase-II study was conducted to investigate the potential benefit from the addition of mitomycin to a conventional anthracycline-cisplatin- and 5-fluorouracil-based chemotherapy for recurrent and metastatic undifferentiated carcinoma of nasopharyngeal type (UCNT).

PATIENTS AND METHODS

Between July 1989 and December 1991, 44 consecutive patients (M/F 36/8; median age: 45, range 20-72; performance status (PS) 0: 20 patients, PS 1: 14 patients, PS 2: 10 patients) with recurrent or metastatic UCNT were entered in this study after complete clinical, biological, and radiological pre-therapeutic work-ups. Chemotherapy (FMEP regimen) consisted of 800 mg/m2/day 5-fluorouracil in continuous infusion from day 1 to day 4 combined with 70 mg/m2 epirubicin, 10 mg/m2 mitomycin, and 100 mg/m2 cisplatin on day 1, every four weeks for six cycles. Mitomycin was delivered in cycles 1, 3, and 5 only. Eleven patients had isolated loco-regional recurrences, 12 patients had local recurrences associated with distant metastasis, and 21 patients had metastasis only. Toxicity and response were evaluated according to WHO criteria.

TOXICITY

Grade 3-4 neutropenia was observed in 122 of 212 evaluable cycles (57%) and 39 of 44 patients (89%); febrile neutropenia occurred in 16 patients (36%) and 24 cycles (11.3%). Grade 3-4 thrombocytopenia was observed in 27 patients (61%) and 45 cycles (21%), including 27 of 45 cycles (60%) with mitomycin. Grade 3 anemia was noted in 18 patients (40%) and 23 cycles (11%), including 18 of 23 cycles (78%) with mitomycin. Grade 3-4 mucositis occurred in 25 cycles (11%) and 14 patients (32%), mainly in those previously treated with radiation therapy in the head and neck area. There were four treatment-related deaths (9%); three of them neutropenia-related, and one of cardiac toxicity.

RESPONSE

Forty-four patients were evaluable for response: There were 23 of 44 objective responses (52%), including six complete responses (13%), and 17 partial responses (38%). Additional radiotherapy was given to 13 patients after documentation of response: Nasopharyngeal tumor + cervical nodes (eight patients) and/or on bone metastasis sites (five patients); mediastinal lymph nodes (one patient). At a median follow-up of 87 months (range 71-100), five patients are alive and in continuous complete remission. The median survival time was 14 months and the median time to progression nine months.

CONCLUSION

The regimen under study is active in recurrent/metastatic UCNT, but associated with excessive toxicity.

Nasopharyngeal carcinoma in childhood and adolescence

BACKGROUND

This study reviews the authors' experience from 1979 through 1996 in the management and outcome of 56 patients with nasopharyngeal carcinoma who were under 20 years of age.

PROCEDURE

There were 33 males and 23 females, their ages ranging from 7 to 19 years (median: 16 years). Forty patients had World Health Organization type III carcinomas, 16 had T4 tumors, 41 had metastatic cervical lymph nodes, and 50 were at stage III or stage IV. Thirty-two patients were treated with radiation therapy alone and 24 with the addition of chemotherapy. Cumulative radiation dose to the primary tumor ranged from 18 to 70 Gy (median: 66 Gy) and radiation dose to metastatic cervical lymph nodes ranged from 18 to 70 Gy (median: 66 Gy).

RESULTS

Follow-up ranged from 0.1 to 16.8 years (mean: 9 years). Locoregional tumoral complete response was achieved in 49 patients. Locoregional tumoral failure was observed in 12 patients and systemic failure in 11. Overall, locoregional failure-free, metastases-free, and disease-free survival rates at 5 years were 49%, 62%, 79%, and 47%, respectively, for the entire group of patients, 42%, 61%, 72%, and 42%, respectively, for patients treated with radiation therapy alone, and 58%, 63%, 87%, and 54%, respectively, for patients treated with the addition of chemotherapy. Advanced T-stage and lower radiation doses worsened locoregional failure-free survival, whereas advanced N-stage and exclusion of chemotherapy worsened metastases-free survival.

CONCLUSIONS

In children and adolescents with nasopharyngeal carcinoma, radiation therapy alone results in an improved locoregional tumoral response rate and a reduced locoregional tumoral failure rate at higher radiation doses, while the addition of chemotherapy results in a reduced systemic failure rate.

Medical oncology in the management of head and neck cancers

General approaches and therapeutic goals of medical oncology for head and neck cancer are presented. The effectiveness of chemotherapy for the treatment of different stages of head and neck cancer in specific anatomic sites is discussed, as well as complications associated with chemotherapy, and approaches to the prevention and management of these stages. Systemic side effects that may occur with specific therapeutic agents are presented in a tabular format. Future directions and evolving approaches to head and neck cancer therapy are summarized.

Interferons and other cytokines in head and neck cancer

The use of cytokines in head and neck cancer is increasingly under investigation. Clinical trials have tested the interferons, interleukin-2 and other cytokines as single agents and in various combinations. The addition of interferon to the cisplatin and 5-fluorouracil (5-FU) regimens (with and without leucovorin) has been explored. A randomized international trial comparing cisplatin and 5-FU with cisplatin, 5-FU and interferon-alpha 2b is in progress.

The effect of loco-regional control on distant metastatic dissemination in carcinoma of the nasopharynx: an analysis of 1301 patients

PURPOSE

This study evaluated the effect of loco-regional control on incidence of distant metastases in patients with nasopharyngeal carcinoma.

METHODS AND MATERIALS

Retrospective analysis was performed on 1301 patients with nasopharyngeal carcinoma treated from 1976-1989 in our hospital. The effect of different prognostic indicators on distant metastases free survival (DMFS) was analyzed, including T stage, N stage, sex, and loco-regional control. The significance of loco-regional control in distant metastatic dissemination was further studied with period and subgroup analysis. Cox regression was performed to identify the independent prognostic variables.

RESULTS

Patients with loco-regional relapse had significantly higher distant metastases rate than patients with loco-regional control (time-adjusted distant metastases rate at 5 years was 40.7% vs. 29.4%, p = 0.0012). By period analysis, the effect of loco-regional control on distant metastases was found to be significant in the first 2 years from diagnosis. Subgroup analysis showed that loco-regional relapse was associated with significantly higher distant metastases rate in patients with T1, N0, and N1 disease (p = 0.001, 0.001, 0.0226, respectively). The Cox regression model also confirmed loco-regional control as an independent prognostic indicator of distant metastases (p = 0.0001) besides T stage (p = 0.0006) and N stage (p = 0.0001).

CONCLUSION

Loco-regional relapse is a significant risk factor for development of distant metastases. Further effort should be made to improve loco-regional control and to eradicate distant metastases.

Epirubicin. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic use in cancer chemotherapy

Epirubicin is the 4' epimer of the anthracycline antibiotic doxorubicin, and has been used alone or in combination with other cytotoxic agents in the treatment of a variety of malignancies. Comparative and noncomparative clinical trials have demonstrated that regimens containing conventional doses of epirubicin achieved equivalent objective response rates and overall median survival as similar doxorubicin-containing regimens in the treatment of advanced and early breast cancer, non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), non-Hodgkin's lymphoma, ovarian cancer, gastric cancer and nonresectable primary hepatocellular carcinoma. Recently, dose-intensive regimens of epirubicin have achieved high response rates in a number of malignancies including early and advanced breast cancer and lung cancer. The major acute dose-limiting toxicity of anthracyclines is myelosuppression. In vitro and clinical studies have shown that, at equimolar doses, epirubicin is less myelotoxic than doxorubicin. The lower haematological toxicity of epirubicin, as well as the recent introduction of supportive measures such as colony-stimulating factors, has allowed dose-intensification of epirubicin-containing regimens, which is particularly significant because of the definite dose-response relationship of anthracyclines. Cardiotoxicity, which is manifested clinically as irreversible congestive heart failure and/or cardiomyopathy, is the most important chronic cumulative dose-limiting toxicity of anthracyclines. Epirubicin has a lower propensity to produce cardiotoxic effects than doxorubicin, and its recommended maximum cumulative dose is almost double that of doxorubicin, thus allowing for more treatment cycles and/or higher doses of epirubicin. In summary, dose-intensive epirubicin-containing regimens, which are feasible due to its lower myelosuppression and cardiotoxicity, have produced high response rates in early breast cancer, a potentially curable malignancy, as well as advanced breast, and lung cancers. Furthermore, there is evidence to suggest that improved response rates can improve quality of life in some clinical settings, but whether this leads to prolonged survival has not yet been determined. Recently implemented supportive measures such as colony-stimulating factors, prophylactic antimicrobials and peripheral blood stem cell support may help achieve other potential advantages of dose-intensive epirubicin-containing regimens such as reductions in morbidity and length of hospital admissions.

Phase II trial of recombinant interferon gamma in refractory undifferentiated carcinoma of the nasopharynx

The presence of Epstein-Barr virus (EBV) genomes in the DNA of tumor cells of undifferentiated carcinoma of nasopharyngeal type (UCNT), associated with significant lymphocytic infiltration of tumor led to therapeutic trials with interferon (IFN) because of its antiviral, antiproliferative, and immunomodulatory properties. Fourteen patients with histologically proven UCNT (2 had locoregional disease alone and 12 metastatic disease) who were refractory to conventional chemotherapy, were treated with IFN gamma 20 x 10(6) U twice a week. Treatment was well tolerated. No objective response were achieved in the 13 evaluated patients, and all patients progressed after a median treatment duration of 10 weeks (6-32). IFN gamma seems unable to induce antitumor activity alone in such heavily pretreated patients. Its possible place in the management of UCNT is probably earlier in the natural history of this disease.

Results of chemotherapy plus external reirradiation in the treatment of locally advanced recurrences of nasopharyngeal carcinoma

Between 1982 and 1991, 16 patients with recurrent cancer of the nasopharynx were treated with chemotherapy (CT) and radiotherapy (RT). All patients had received prior RT (45-69, 30 Gy). According to rTNM there were three rT2, one rT3 and 12 rT4. 5 patients were N1. Reirradiation (12-46 Gy, mean: 28) started 3-4 weeks after CT (2-6 cycles of different combinations), but 2 cases involved concomitant therapy. Out of 16 patients 7 had complete response (CR) (43.7%), 7 partial response and 2 no response. Statistically significant prognostic factors for obtaining CR were time of relapse and response to initial CT. Median duration of CR was 22+ months (9-64+). Failures at primary site occurred in 3 patients, 2/2 of those receiving CT without platinum compounds and 1/5 of other ones, with statistically significant difference in local recurrence free-survival between the two groups. Two- and 3-year actuarial overall survival were 28% and 10%. Rates of disease-free survival were 17% and 8%, respectively. The acute toxicity was generally mild. No central nervous system damage or radiation-induced myelitis were observed in survivors.