Combined treatment in carcinoma of the nasopharynx

Treatment results of alternating chemoradiotherapy for nasopharyngeal cancer using cisplatin and 5-fluorouracil – A phase II study

The present study was conducted to evaluate the therapeutic results of alternating chemoradiotherapy for locally advanced nasopharyngeal cancer. The subjects were 87 patients with stage II-IVB nasopharyngeal cancer. Alternating chemoradiotherapy was performed; initially, chemotherapy was administered, and then radiotherapy (wide field), chemotherapy, radiotherapy (shrinking field), and chemotherapy were alternately performed. For chemotherapy, 5-FU at a dose of 800 mg/m2/24 h was intravenously administered for 5 days (days 1-5), and CDDP at a dose of 50 mg/m2/24h for 2 days was administered on day 6 and 7. The scheduled courses of alternating chemoradiotherapy were completed in 70 (80%) of 87 patients. Although 1 patient developed a transient neurological disturbance induced by hyper-ammonemia by metabolism of 5-FU, no severe adverse effects were noted in any other patients. In these 87 patients, the overall 5-year survival rate was 83% (95% confidence interval: 74-92%), and the progression free survival rate was 75% (95% CI: 66-85%). This method of alternating chemoradiotherapy yielded higher or at least similar survival rates and lower toxicities than concurrent chemoradiotherapy, and is worth trying in a randomized controlled study to compare with concurrent chemoradiotherapy.

[Accelerated hyperfractionated radiotherapy with concurrent chemotherapy in locally advanced nasopharyngeal carcinomas]

BACKGROUND

The excellent results yielded by hyperfractionated and accelerated radiotherapy associated with concurrent chemotherapy in locally advanced oropharyngeal and hypopharyngeal carcinomas led to investigation of this therapeutic regimen in nasopharyngeal carcinomas also.

METHODS

Thirty-five patients with stage III and IV nasopharyngeal carcinomas received accelerated hyperfractionated radiotherapy with concurrent chemotherapy (5-FU, mitomycin C + leucovorin). In the first 3 weeks of treatment five 2-Gy doses per week were delivered to the primary tumour and regional lymph nodes. The fractionation was then accelerated, with 1.4 Gy given twice daily until a total dose of 72 Gy had been administered.

RESULTS

The overall objective response rate was 100%. The median follow-up period was 71 months. Salvage surgery of the lymph nodes was performed in 10 patients, revealing vital tumour tissue in 6 of these. The actuarial 5-year local control rate was 64% (95%CI: 47-81%), while overall actuarial survival at 5 years was 70% (95%CI: 53-86%).

CONCLUSION

Hyperfractionated accelerated radiotherapy with concurrent chemotherapy is effective and feasible in locally advanced nasopharyngeal carcinoma.

Carcinoma of the nasopharynx: analysis of treatment results in 91 patients

The outcome of 91 patients (69 males, 22 females; age range 16-82 years) with nasopharyngeal carcinoma treated in our hospital between 1971 and 1999 was evaluated. Factors that appeared to influence prognosis were assessed using the Kaplan-Meier method. The cause-specific cumulative 5-year survival rate for the entire study population was 61.2%. The 1997 International Union Against Cancer classification was used for disease staging. The 5-year survival rates were as follows: 66.7% (n = 3) for Stage I; 100% (n = 2) for Stage IIA; 90.9% (n = 11) for Stage IIB; 78.8% (n = 25) for Stage III; 53.0% (n = 29) for Stage IVA; 37.5% (n = 16) for Stage IVB; and 20.0% (n = 5) for Stage IVC. The disease-free cumulative 3-year survival rates of the patients classified based on initial therapy were as follows: radiation alone, 50.0% (n = 28); combined radiotherapy and chemotherapy that included an undefined anti-cancer drug, 67.2% (n = 39); combined radiotherapy and chemotherapy that included carboplatin (CBDCA), 92.3% (n = 19). These results showed a statistically significant difference (p = 0.043; log-rank test). Stage IVC patients were excluded from the analysis. We conclude that combined therapy, including chemotherapy with CBDCA, is necessary for the treatment of nasopharyngeal carcinoma. In terms of radiation therapy, a field covering the bilateral cervical regions seemed to produce favorable results, even if cervical node metastasis was not confirmed by palpation at the first hospital visit. Key words: carboplatin, chemotherapy,

[Treatment of nasopharyngeal cancer: literature review]

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Nasopharyngeal Carcinoma: Evidence for Improved Survival with Combined Chemoradiation

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

The role of chemotherapy in the management of nasopharyngeal carcinoma

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Carcinoma of the nasopharynx treated by radiotherapy alone: determinants of distant metastasis and survival

PURPOSE

This retrospective study was conducted to identify the prognostic factors for distant metastasis and survival in a population of 378 patients with nasopharyngeal carcinomas treated by radiation therapy alone.

MATERIALS AND METHODS

All patients were treated at the University of Texas M.D. Anderson Cancer Center between 1954 and 1992, following a consistent dose and volume prescription policy. There were 286 males and 92 females. The median age was 52 years (range: 16-86 years). The majority of the patients were white Caucasians (282 patients,75%). Tumors were classified as squamous cell carcinomas (193; 51%), lymphoepitheliomas (154; 41%), or unclassified carcinomas (31, 8%). Three fourths of the patients presented with AJCC Stage IV disease (T4, N0-3, 118 patients; T1-3, N2-3 164 patients). The treatment techniques included opposed lateral fields with or without an anteroposterior or an anterior oblique pairs for dose supplementation to the primary site. Average total doses per T-stage ranged between 60.2 and 72.0 Gy. Median follow-up time was 10 years (range 0.3 to 28.6 years).

RESULTS

A total of 103 patients (27%) developed distant metastases at a median time of 8 months (range: 1-90 months). Actuarial rates for distant metastasis were 30%, 32%, 32% at 5, 10, and 20 years, respectively. Actuarial rates for disease specific survival at the same time points were 53%, 45%, and 39% with 184 patients (49%) dying of their nasopharyngeal cancer. Advanced T-stage, N-stage, and non-lymphoepithelioma histology were independent adverse prognostic factors for disease specific survival. Advanced N-stage and low neck disease were independent adverse prognostic factors for distant metastasis with a very high rate of distant metastases for those patients who presented with both adverse factors (relative risk 7.86). On average, patients with distant metastasis lived 5 months after they were diagnosed with metastatic disease (range: 0-172 months), although four patients (4%) survived more than 5 years after diagnosis.

CONCLUSIONS

This study demonstrates good long term survival rates after definitive radiotherapy for patients with nasopharyngeal carcinomas. Patients with advanced and lower neck disease have the highest risk of developing distant failures. Such patients can be considered the reference risk group to test the value of adjunctive chemotherapy.

Induction chemotherapy followed by radiotherapy versus radiotherapy alone in patients with advanced nasopharyngeal carcinoma: results of a matched cohort study

BACKGROUND

Prospective randomized and retrospective studies on adjunctive chemotherapy in patients with advanced locoregional nasopharyngeal carcinoma have yielded conflicting results and the role of chemotherapy in this disease had not been clearly defined. The authors report the results of a single institution, matched cohort study comparing a group of 61 patients with advanced stage nasopharyngeal carcinoma treated with induction chemotherapy followed by radiation therapy with a matched group treated with radiotherapy alone.

METHODS

Between 1985 and 1992, 61 patients with advanced locoregional nasopharyngeal carcinoma received induction chemotherapy (cisplatin, 100 mg/m2 on Day 1 and 5-fluorouracil [5-FU], 1000 mg/m2, on Days 1-5) for 3 cycles followed by definitive radiation therapy (CT/RT group). This group was matched with a group of 61 patients from a population of 378 patients who received radiation therapy alone (RT group). Matching characteristics were T classification, N classification, histology, and level of cervical lymph node metastases. These characteristics were found to be significant determinants of distant metastasis (DM) and/or survival in a multivariate analysis that was performed in the entire radiotherapy group. Radiation therapy consisted of 66-72 gray in 6.5 to 7 weeks in both groups. Fifty-nine patients (97%) in both groups had Stage IV disease. Fifteen patients (25%) in both groups had lower cervical lymph node metastases. The tumor histologic types also had similar distribution in both groups. Median follow-up time among surviving patients of the CT/RT group was 4.9 years (range, 1.3-9.8 years).

RESULTS

The 5-year cumulative incidence of DM was 19 +/- 5% for the CT/RT group and 34 +/- 6% for the RT alone group (P = 0.019; log rank test). This reduction in distant failure was more prominent in patients with intermediate (N2-N3 disease; upper or midcervical lymph nodes), or high risk (N2-N3 disease; lower cervical lymph nodes) of DM. This reduction in DM translated into improvement in disease free survival (DFS) and overall survival (OS). The 5-year actuarial DFS rates were 64 +/- 6% for the CT/RT group compared with 42 +/- 7% for the RT group (P = 0.015). The 5-year actuarial OS rates were 69 +/- 6% (CT/RT group) and 48 +/- 7% (RT group), respectively (P = 0.012). The incidence of locoregional failure was slightly lower in the CT/RT group, but this difference did not reach statistical significance. There was no significant difference in the incidence and severity of acute mucositis between the two groups during radiotherapy. The 5-year cumulative incidence of Grade 3 or higher late complications was also similar in both groups (5 +/- 3% in the CT/RT group and 8 +/- 3% in the RT group; P = 0.721).

CONCLUSIONS

This matched cohort study provides additional evidence that induction cisplatin-5-FU chemotherapy prior to definitive radiation improves freedom from distant metastasis, DFS, and OS for patients with locoregional Stage IV nasopharyngeal carcinoma without increasing treatment-related morbidity.

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

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

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Partially hyperfractionated accelerated radiotherapy and concurrent chemotherapy for advanced nasopharyngeal carcinoma

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Iatrogenic Pneumocephalus in a Man with Undifferentiated Nasopharyngeal Carcinoma. A Case Report

A case of pneumocephalus in a 45-year-old male with undifferentiated rhinopharyngeal carcinoma is described. The patient was initially subjected to radiotherapy and then to transmaxillary resection and a second course of stereotactic radiotherapy for recurrent disease. Lastly, the patient was treated with chemotherapy because of local-regional disease progression. After two cycles of cisplatin, adriablastine and bleomycin, the patient suddenly entered in coma. Cerebral CT scan evidenced the presence of air in the frontal and lateral cornua, in the subarachnoid space of the base cisternae extending to the 7th cervical vertebra. After 8 months of a clinical stationary condition, the patient died. The various treatments used are critically reviewed, and modern therapeutic approaches for the neoplasm and the toxicity involved are discussed. We conclude that in nasopharyngeal carcinoma, for patients who relapse after radiotherapy, successive local-regional therapies (surgery, re-irradation) should be carefully evaluated to avoid demolishing treatments, which are burdened with severe side effects that might influence the quality of life with only slight improvement of overall survival. Furthermore, the presence of persistant aqueous rhinorrhea in these patients should be carefully evaluated, because it could be an early symptom of a cerebrospinal fluid leak.

Undifferentiated nasopharyngeal cancer (UCNT): current diagnostic and therapeutic aspects

Undifferentiated carcinoma of the nasopharynx (UCNT) is a particular head and neck epidermoid lineage tumor related to the Epstein Barr Virus (EBV). It has geographically selective endemic epidemiologic features, without relation to external carcinogens. Its systemic agressiveness is the source of most disease-related demises, because radiotherapy achieves excellent local control and a significant percentage of cure in patients with exclusive locoregional disease. Difference in the staying systems currently in use, the recent changes in imaging and radiotherapy technology, and the lack of distinction between UCNT and squamous cell carcinoma (SCC) of the nasopharynx in Western literature reports make for some difficulty in therapeutic results evaluation when analyzing available literature. Its chemosensitivity is a relatively recent acknowledged fact, and its use in metastatic patients results in a high percentage of objective responses, many of long duration. Neoadjuvant cisplatin-based chemotherapy seems to be of benefit, but outstanding controversies in this regard will be soon answered through ongoing phase III trials. After a review of the current literature of all the above-mentioned aspects of this fascinating nosologic entity, our own experience, both in metastatic and locoregional disease patients is analyzed.

Synchronous radiotherapy and chemotherapy in the treatment of nasopharyngeal carcinoma

PURPOSE

Because of the high rates of local tumor control obtained by combining moderate doses of external beam radiotherapy and synchronous 5-fluorouracil/mitomycin C chemotherapy in the treatment of squamous and basiloid cancers of the anal canal, we chose to investigate this regimen for nasopharyngeal cancer which shows significant local and distant failure rates after treatment with radiotherapy alone.

METHODS AND MATERIALS

Between 1983 and 1990, 43 patients with previously untreated squamous cell and undifferentiated nasopharyngeal cancer, without evidence of distant metastases at diagnosis were treated with radical radiotherapy and concurrent chemotherapy using mitomycin C (10 mg/m2 i.v. day 1 of radiotherapy) and 5-fluorouracil (1000 mg/m2 continuous i.v. infusion days 1-4 of radiotherapy and repeated at least 28 days later). Ninety-one percent of cases had Stage IV tumors and 93% had clinically involved regional lymph nodes.

RESULTS

Actuarial rates of survival, local control, regional nodal control and distant metastases at 5 years were 37%, 71%, 94%, and 53%. Grade 3 or 4 skin and mucosal reactions occurred in 30% and 34% of patients, respectively. Only one patient developed greater than Grade 2 myelosuppression and he died of overwhelming sepsis. A second patient died of malnutrition 4 months after treatment giving a 5% incidence of treatment-related mortality. Nine percent of patients developed significant late complications of treatment.

CONCLUSION

Despite the morbidity observed, the treatment outcome is not obviously superior to that reported for radiotherapy as a single modality of treatment.

Nasopharyngeal carcinoma: local control by megavoltage irradiation

This is a retrospective analysis of the long-term local control in 4128 patients with non-disseminated nasopharyngeal carcinoma treated solely by megavoltage irradiation during the years 1976-1985. The T-stage distribution according to Ho's classification was T1 37%, T2 14% and T3 49%. Different fractionation schedules had been employed at different periods, and the median dose to the primary target was equivalent to 65 Gy by time dose fractionation calculation. In 8% (344) of patients the tumour failed to regress completely after the basic course, but 89% (148/167) of those suitable for salvage with additional irradiation eventually attained complete local remission. The cumulative incidence of local failure was 24% (5% persistence, 19% recurrence). The 10-year actuarial local failure-free survival was 67%. While patients with T2 and T3a tumours achieved local control comparable to T1, those with T3c-d had the poorest control (with highest incidence of persistence and advanced recurrence). T-stage adjusted analyses suggested a significant trend of dose-response: the odds ratios for local failure were 1.16 and 1.86, respectively, when patients given 60-63 Gy and 55-59 Gy were compared with those given 64 Gy or above (p value = 0.0018). Patients treated during 1981-1985 achieved higher local failure-free survival than those treated during 1976-1980 (75% versus 70% at 5 years, p value = 0.0013). The possible attributes are studied, and ways for future optimization of treatment discussed.

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.

Carcinoma of the nasopharynx: analysis of treatment results in 167 consecutively admitted patients

Radiotherapy with curative intent was administered to 159 of 167 consecutively admitted patients with nasopharyngeal carcinoma. The classification (UICC 1982) gave the staging: stage I 8%, stage II 2%, stage III 28%, and stage IV 61%. The actuarial local tumor control was 54% and correlated to the T-classification. Primary control of neck nodes was 67% but was not correlated to the N-classes. Distant failure occurred in 20% of the patients; this was correlated to the N-classification. The 10-year actuarially corrected survival rate was 37% (stage I+II 60%, stage III 49%, stage IV 27%). Late reactions were seen in 69%, and most patients had mild to moderate xerostomia. Men with high hemoglobin had a better prognosis than men with values in the lower part of the normal range. It is concluded that primary control in the T- and N-positions is the parameter most crucial to success.

Alternating chemo-radiotherapy with cisplatin and 5-fluorouracil plus bleomycin by continuous infusion for locally advanced undifferentiated carcinoma nasopharyngeal type

More than 80% of undifferentiated carcinoma nasopharyngeal type patients with N3 disease (AJC-UICC 1987) will die with or from distant metastases within 3 years after the first symptom. From February 1986 to November 1987 30 consecutive patients with very advanced local disease were entered in a programme with chemotherapy-radiotherapy (CT-RT) alternation after a thorough work-up to eliminate the possibility of distant metastases.

PROTOCOL

two cycles of cisplatin 100 mg/m2 day 1, bleomycin 15 mg intravenously day 1 and 16 mg/m2 per day by continuous infusion days 1-5; 5-fluorouracil (5-FU) 650 mg/m2 per day by continuous infusion days 1-5 4 weeks apart. This was followed by two series of high-energy radiotherapy, 35 Gy/3.5 weeks, with a third chemotherapy cycle in between. 27 men and 3 women were treated, the median age was 37 years (range 17-71) and the mean WHO performance status was 1 (range 0-3). TNM classification: 15 T4, 9 T3, 6 T2, 28 N3 and 2 N2c. 18 patients had nodes larger than 8 cm and 24 had bulky bilateral cervical nodes. Toxicity for this protocol was moderate, nausea and vomiting being the main side-effects. Results after two CT cycles were 3 complete responses (CR; 10%), 22 partial responses (PR; 73%), 2 disease stabilizations, 2 progressions, and 1 patient inevaluable. Of the 30 patients, 27 patients completed the CT-RT protocol, 2 patients died before radiotherapy and 1 refused treatment after 2 days on protocol. 25 patients were in CR 3 months after the end of radiotherapy. As of August 1991, with a median follow-up of 55 months (range 43-63), there are 17 patients alive, 2 of them with active disease and 15 are NED (2 after salvage therapy).