Phase II study of neoadjuvant carboplatin and paclitaxel followed by radiotherapy and concurrent cisplatin in patients with locoregionally advanced nasopharyngeal carcinoma: therapeutic monitoring with plasma Epstein-Barr virus DNA

PURPOSE

To assess the efficacy of neoadjuvant paclitaxel and carboplatin (TC) followed by concurrent cisplatin and radiotherapy (RT) in patients with locoregionally advanced nasopharyngeal carcinoma (NPC) and to monitor treatment response with plasma Epstein-Barr virus (EBV) DNA.

PATIENTS AND METHODS

Thirty-one patients with International Union Against Cancer stages III and IV undifferentiated NPC had two cycles of paclitaxel (70 mg/m2 on days 1, 8, and 15) and carboplatin (area under the curve 6 mg/mL/min on day 1) on a 3-weekly cycle, followed by 6 to 8 weeks of cisplatin (40 mg/m2 weekly) and RT at 66 Gy in 2-Gy fractions. Plasma EBV DNA was measured serially using the real-time quantitative polymerase chain reaction method. Results All patients completed planned treatment. Response to neoadjuvant TC was as follows: 12 patients (39%) achieved partial response (PR) and 18 achieved (58%) complete response (CR) in regional nodes; five patients (16%) achieved PR and no patients achieved CR in nasopharynx. At 6 weeks after RT, one patient (3%) achieved PR and 30 patients (97%) achieved CR in regional nodes, and 31 patients (100%) achieved CR in nasopharynx; 29 patients (93%) had EBV DNA level of less than 500 copies/mL. Neoadjuvant TC was well tolerated, and the most common acute toxicity of cisplatin plus RT was grade 3 mucositis (55%). At median follow-up of 33.7 months (range, 7 to 39.3 months), six distant and three locoregional failures occurred. Plasma EBV DNA level increased significantly in eight of nine patients who experienced treatment failure but did not increase in those who did not. The 2-year overall and progression-free survival rates were 91.8% and 78.5%, respectively. CONCLUSION This strategy was feasible and resulted in excellent local tumor control. Serial plasma EBV DNA provides a noninvasive method of monitoring response in NPC.

Nutritional Consequences of Radiotherapy in Nasopharynx Cancer Patients

Nasopharynx cancer (NPC) occurs frequently in southern China. Radiotherapy (RT) is the standard treatment for this cancer, and weight loss is commonly observed during and for a prolonged period after RT. The determinants of this phenomenon are not well known. The nutritional status of 38 NPC patients was assessed serially before and for a 6-mo period after RT. Body weight, body composition (by dual X-ray absorptiometry), basal metabolic rate (BMR, by indirect calorimetry), and calorie intake (by 3-day dietary record) were documented at pre-RT (T0), end-RT (T1), 2 mo post-end-RT (T2), and 6 mo post-end-RT (T3). The BMI at end-RT was 21.5 +- 3.7 kg/m2 (range = 13.7-27.9 kg/m2) and was significantly lower than that at pre-RT (P < 0.001). Body weight at T1-T3 was significantly lower than that at T0 (P < 0.001). Mean percentage weight loss was 10.8% at end-RT. Fifty-five percent of patients (20 of 30) had 10% weight loss by the end of RT. BMR corrected for body weight did not change significantly among the four time points, but BMRs corrected for lean body mass at T2 and T3 were significantly lower than that at T0 (P < 0.01). Patients' calorie intake generally declined from T0 to T1 (from 1,857 P < 411 kcal to 11,68 +- 549 kcal, P < 0.001) and then increased from T1 to T3. The calorie intakes at T2 and T3 were not significantly different from that at T0 but were significantly higher than that at T1. Patients were in negative energy balance before, during, and up until 6 mo after RT. The recovery in body weight lagged behind the recovery of dietary intake. Eighty-two percent of NPC patients had significant weight loss and was in negative energy balance at the end of RT, which persisted for at least 6 mo. This finding suggests that there is room for improvement in the nutritional status of patients with NPC treated with RT.

Staging of Nasopharyngeal Carcinoma: Suggestions for Improving the Current UICC/AJCC Staging System11Presented in part at the 4th International UICC Symposium on Nasopharyngeal Carcinoma, Hong Kong, February 2003

AIMS

To evaluate the current UICC/AJCC Staging System for nasopharyngeal carcinoma and to search for ways of improving the system.

MATERIALS AND METHODS

This is a retrospective analysis of 2687 consecutive patients treated in five public centres in Hong Kong during the period 1996-2000. All patients were staged by computed tomography, magnetic resonance imaging, or both. The prognostic significance of the current stage assignment on various aspects of tumour control was evaluated.

RESULTS

T-category, N-category and stage-group were all significant prognostic factors for major end points (P < 0.01). However, the distinction of prognosis between Stage I and II was insignificant (5-year cancer-specific survival being 92% vs 95%; P = 0.13). Multivariate analyses (corrected for age and sex) revealed lack of significance between T2a and T1 in hazards of local and distant failures, N3a and N2 in distant failure and subgroups of T1-2N0 in cancer-specific deaths. Corresponding down-staging of T2a to T1, N3a to N2, and subgroup T2N0 to stage I, resulted in more even and orderly increase in the hazard ratio of cancer-specific deaths (from 1 for stage I to 1.98 for II, 3.5 for III, 6.08 for IVA and 8.62 for IVB), better hazard consistency among subgroups of the same stage and more balanced stage distribution.

CONCLUSIONS

The current UICC/AJCC Staging System could be further improved by the modifications suggested; validation of the current proposal by external data is urgently awaited.

In vivo proton MR spectroscopy of primary and nodal nasopharyngeal carcinoma

BACKGROUND AND PURPOSE

The aim of this study was to determine the feasibility of performing in vivo proton ((1)H) MR spectroscopy of nasopharyngeal carcinoma (NPC) and to document the (1)H spectrum of this cancer.

METHODS

Twenty-seven patients with NPC lesions >1 cm(3) underwent localized (1)H MR spectroscopy performed at 1.5 T. Water-suppressed spectra from both primary tumors (nine cases) and metastatic nodes (18 cases) were obtained at TE 136 and 272. Spectra were analyzed in the time domain by using a nonlinear least squares fitting algorithm with incorporation of previous knowledge. Choline (Cho)/creatine (Cr) ratios for primary NPC and metastatic nodes were calculated and compared. Spectra from normal neck muscle of five volunteers were acquired as control data.

RESULTS

(1)H MR spectroscopy was successfully obtained in seven (78%) of nine primary tumors and 16 (89%) of 18 metastatic nodes. Intense lipid signals in the range of 0.89 to 2.02 ppm were observed in 95% of spectra at TE 136 and 91% of spectra at TE 272. At TE 136, Cho/Cr for metastatic nodes (5.3 +/- 1.6) was significantly higher than the ratio for primary (2.6 +/- 0.5) NPC lesions (P =.02). Cho/Cr ratios for NPC lesions were higher than those for normal neck muscles, for which values ranged from 0 to 0.97 and 0 to 1.1 at TE 136 and 272, respectively.

CONCLUSION

(1)H MR spectroscopy is a feasible technique for the evaluation of NPC tumors >1 cm(3). Cho/Cr ratios for the lesions were high compared with those for normal neck muscle.

Cerebral blood flow measurement by color velocity imaging in radiation-induced carotid stenosis

OBJECTIVE

To show whether there is any association between the development of neurologic symptoms and the total cerebral blood flow volume documented by color velocity imaging in patients with carotid stenosis that develops after radiotherapy.

METHODS

Twenty-three patients with nasopharyngeal carcinoma (4 female and 19 male; age range, 39-69 years; mean age, 55.6 years) and major extracranial carotid stenosis underwent color velocity imaging. In this group, 8 patients had symptoms of a stroke or transient ischemic attack, and the other 15 patients were asymptomatic. The color velocity imaging results in the symptomatic group were then compared with those in the asymptomatic group.

RESULTS

The cerebral blood flow in the symptomatic group was significantly lower than that in the asymptomatic group (224.1 +/- 89.0 versus 532.5 +/- 89.0 mL/min; P = .001).

CONCLUSIONS

Cerebral blood flow as measured by color velocity imaging was lower in the symptomatic group. There is an association between the development of neurologic symptoms and blood flow volume.

Measuring postirradiation subcutaneous soft-tissue fibrosis: state-of-the-art and future directions

Clinician-based rating scales and quantitative instruments used to quantify the severity of soft-tissue fibrosis were reviewed to determine if they were reliable and valid measures for clinical and research use. Existing clinician-based measures, the Medical Research Council (MRC) and European Organization for Research and Treatment of Cancer/Radiation Therapy Oncology Group (EORTC/RTOG), have preliminary testing of reliability and validity such that they provided a basis for the development of a revised measure. The revised measure, designed for use in National Cancer Institute-Common Toxicity Criteria for Adverse Events v3.0, evaluates subcutaneous and deep-tissue fibrosis separately and each is graded on a 5-point scale. The revised measure needs to be tested for reliability and validity, and it is recommended that it be used in concert with the MRC and/or EORTC/RTOG scales until such evidence is available and its utility can be determined. Quantitative measures, although attractive from a research perspective, will have limited clinical and multisite utility because of the apparatus required and the associated costs. Finally, a framework for evaluating fibrosis and the consequences of fibrosis is presented.

Progress of memory function after radiation therapy in patients with nasopharyngeal carcinoma

The authors evaluated the late neurocognitive profile and progress of memory functions in 60 patients with primary nasopharyngeal carcinoma who had been treated with radiation therapy for more than 2 years. Forty had imaging evidence of temporal lobe injury (TLI-positive), and 20 did not (TLI-negative). The patients and 19 healthy control subjects, matched with the patients for age and educational level, underwent extensive memory assessments. Seventeen patients (10 TLI-positive, 7 TLI-negative) were reassessed after an average of 28 months for progress of memory functions. The patient groups performed significantly worse on most memory tests compared with the normal subjects. Patients with memory complaints had lower scores for verbal memory than those without such complaints. The TLI-positive and TLI-negative groups did not differ significantly from each other in cognitive performance. At follow-up, visual memory performance had deteriorated, while verbal memory remained more stable.

Sonographic characterisation of radiation-induced carotid artery stenosis

BACKGROUND AND PURPOSE

To study the distribution, extent and sonographic characterisation of radiation-induced carotid artery stenosis in nasopharyngeal carcinoma (NPC) patients.

METHODS

The distribution of plaques, the extent of stenosis, and the sonographic characterisation of the plaque at maximum stenosis were recorded in 71 NPC patients. The results were compared with the ultrasound results of a control group of 142 patients presenting with symptoms of cerebrovascular disease or carotid bruit.

RESULTS

NPC patients had a higher incidence of carotid stenosis (77 vs. 50.7%). The common carotid arteries were most commonly affected by radiation-induced stenosis (93/142 vs. 37/284 in the control group), whereas the carotid bulb was the most commonly affected (56/284) site in the control group. Significantly more NPC patients had moderate-to-severe stenosis (21/71 vs. 27/142). Analysis of the sonographic appearance of radiation-induced and atherosclerotic plaques showed more diffuse involvement in the post-radiation group. Non-calcified plaques and intraplaque hypoechoic foci were also more frequent in the post-radiation group.

CONCLUSIONS

Radiation-induced carotid stenosis is more diffuse in distribution, is associated with more severe luminal stenosis and has different sonographic plaque characterisation compared with carotid stenosis without radiation exposure.

In vivo diagnosis of persistent and recurrent nasopharyngeal carcinoma by contact endoscopy

OBJECTIVE

To evaluate the potential use of contact endoscopy for the diagnosis of persistent and recurrent nasopharyngeal carcinoma in postirradiated patients.

STUDY DESIGN

Prospective study to examine 64 consecutive patients who have been irradiated for nasopharyngeal carcinoma in a clinic setting using contact rhinoscopes (Karl Storz, Tuttlingen, Germany [7215 AA, 0 degrees, and 7215 BA, 30 degrees; 23 cm long. 4 mm in diameter]).

METHODS

The superficial cells of the posterior walls of the nasopharynx were stained with 1% methylene blue and examined with contact rhinoscopes with the patient under local anesthesia at high magnifications (x60 and x150). Biopsy of the areas under examination was performed. The contact endoscopic images were analyzed and correlated with the corresponding histological sections of the biopsy tissues.

RESULTS

Contact endoscopy was performed in 64 patients (54 men; mean age, 42 y) with the use of local anesthesia. Four patterns of contact endoscopic findings were identified: squamous metaplasia (43 cases), postirradiation atypia (10), granulation tissue (6), and malignancy (5). In the last group, the nasopharynx appeared normal in two patients (40%). The findings of contact endoscopy correlated well with the histological findings (kappa reliability coefficient = 0.847; P <.001; diagnostic accuracy, 92.1%). For prediction of persistent and recurrent disease, the sensitivity and specificity of endoscopic findings were both 100%.

CONCLUSION

Contact endoscopy is an accurate, reliable office-based procedure that allows for in vivo and in situ diagnosis of persistent and recurrent nasopharyngeal carcinoma in postirradiated patients.

Differential expression of the suppressor PML and Ki-67 identifies three subtypes of human nasopharyngeal carcinoma

The promyelocytic leukaemia (PML) gene, which encodes a transformation and growth suppressor, was found to regulate transcription and apoptosis. PML was first identified at the chromosomal translocation break-points t(15;17) of acute promyelocytic leukaemia and the gene product may mediate cell-cycle control and apoptosis. PML was found to interact with the co-transactivator CREB binding protein (CBP) and the apoptotic-modulator Bax. To determine if PML, CBP and Bax may be involved in solid tumours, such as the nasopharyngeal carcinoma (NPC), a rare neoplasia that is prevalent in Southern China, the expression of these proteins and the proliferation marker Ki-67 was analysed by immunohistochemical staining. Expression of PML in the PML-oncogenic domain (POD) or nuclear bodies in most NPC was inversely correlated with the expression of Ki-67. In addition, based on PML expression patterns in NPC three subtypes could be identified, namely, Subtype-1, with strong PML expression in POD structures and with low Ki-67 staining; Subtype-2, where PML was expressed in a homogeneously diffused pattern, but with a low intensity in the tumour cells; while Ki-67 was expressed in a moderate number of cells and Subtype-3, where the majority of tumour cells were PML-negative, while a considerable number of tumour cells were strongly labelled with Ki-67. Furthermore, CBP was present in most of the NPC cells with moderate-strong nuclear staining, while the expression in non-tumour cells were relatively weak. However, there was no direct correlation between PML and CBP expression in the NPC examined. In addition, there was low or no expression of Bax in the NP and NPC. This is, to our knowledge, the first report describing PML and CBP expression in NPC and our data strongly suggests that PML and CBP, but not Bax, may play a role in the transformed phenotypes of NPC.

The clinical efficacy of neoadjuvant chemotherapy in squamous esophageal cancer: a prospective nonrandomized study of pulse and continuous-infusion regimens with Cisplatin and 5-Fluorouracil

BACKGROUND

We evaluated cisplatin and 5-fluorouracil as preoperative adjuvant chemotherapy for patients with locally advanced squamous esophageal cancer and compared two different infusion regimens. The outcomes were also compared with those of our historical control patients treated by surgery alone.

METHODS

From 1991 to 1997, 83 consecutive esophageal cancer patients underwent surgical exploration after completion of two cycles of cisplatin and 5-fluorouracil chemotherapy regimens, either in pulse or in continuous infusion cycles. Outcomes were compared with those of 76 historical control patients. Both groups were comparable in demographic characteristics and tumor stages. The resection rates, operative morbidity, mortality, and survival rates were compared.

RESULTS

Partial response was achieved in 50% of patients who received chemotherapy. There was no chemotherapy-related mortality. The resection, morbidity, and mortality rates and median survival between the surgery-alone group and the chemotherapy group were 71.1% vs. 82%, 51% vs. 55%, and 4% vs. 10.8%, 12.0 vs. 13.5 months, respectively (P >.05). There was also no statistically significant difference between the two regimens.

CONCLUSIONS

Preoperative adjuvant chemotherapy with cisplatin and 5-fluorouracil infusion, in pulse or continuous regimens, followed by surgery for squamous esophageal cancer patients had no added benefit in the overall survival.

Carotid intima-media thickness in patients with head and neck irradiation for the treatment of nasopharyngeal carcinoma

AIM

Intima-media thickness (IMT) has been shown to be useful in the evaluation and monitoring of carotid artery atherosclerosis in patients at risk of cardiovascular events. In this study, we aimed to examine the IMT in patients with nasopharyngeal carcinoma (NPC) who received irradiation to the carotid arteries during radiotherapy, and compared them with a control group.

MATERIALS AND METHODS

Fifty-one NPC patients (aged between 39 and 69 years) and a group of 51 age-and sex-matched controls were studied by ultrasound. The IMT at the far wall of the common carotid artery was measured three times and the average value taken in each subject. The IMT of both groups were compared. Risk factors for IMT thickness, including hypertension, smoking, hyperglycaemia, hypercholesterolaemia, history of cerebrovascular accidents and cardiovascular disease, were also studied.

RESULTS

The mean carotid IMT of patients in the NPC group (2.2+/-1.5 mm) was statistically greater than that in normal controls (0.7+/-0.15 mm) (P < 0.05). There was no statistically significant difference between the IMT in the right and left common carotid arteries within each group of patients.

CONCLUSION

The findings suggest that patients with irradiation have increased arterial IMT. As they are asymptomatic the clinical relevance is not clear.

Factors affecting risk of symptomatic temporal lobe necrosis: significance of fractional dose and treatment time

PURPOSE

To study the factors affecting the risk of symptomatic temporal lobe necrosis after different fractionation schedules.

METHODS AND MATERIALS

One thousand thirty-two patients with T1-2 nasopharyngeal carcinoma treated with radical radiotherapy in Hong Kong during 1990-1995 were studied. They were treated at four different centers with similar techniques but different fractionation schedules: 984 patients were given 1 fraction daily throughout (q.d.), and 48 patients were irradiated twice daily (b.i.d.) for part of the course. The median total dose was 62.5 Gy (range 50.4-71.2), dose per fraction was 2.5 Gy (range 1.6-4.2), and overall treatment time (OTT) was 44 days (range 29-70). In addition, 500 patients received supplementary doses for parapharyngeal extension, 113 received booster doses by brachytherapy, and 114 received sequential chemotherapy using cisplatin-based regimes.

RESULTS

Altogether, 24 patients developed symptomatic temporal lobe necrosis: 18 from the q.d. group and 6 from the b.i.d. group. The 5-year actuarial incidence ranged from 0% (after 66 Gy in 33 fractions within 44 days) to 14% (after 71.2 Gy in 40 fractions within 35 days). Multivariate analyses showed that the risk was significantly affected by the fractional effect of the product of total dose and dose per fraction (hazard ratio [HR] = 1.04, 95% confidence interval [CI] 1.02-1.05), OTT (HR 0.88, 95% CI 0.80-0.97), and b.i.d. scheduling (HR 13, 95% CI 3-54). Repeating the analyses for patients treated with the q.d. schedules confirmed the independent significance of OTT in addition to the product of total dose and dose per fraction.

CONCLUSION

The tentative results suggest that in addition to fractional dose, the OTT also had significant impact on the risk of temporal lobe necrosis, and b.i.d. scheduling increased the hazard further.

Concurrent chemotherapy-radiotherapy compared with radiotherapy alone in locoregionally advanced nasopharyngeal carcinoma: progression-free survival analysis of a phase III randomized trial

PURPOSE

Nasopharyngeal carcinoma (NPC) is highly sensitive to both radiotherapy (RT) and chemotherapy. This randomized phase III trial compared concurrent cisplatin-RT (CRT) with RT alone in patients with locoregionally advanced NPC.

PATIENTS AND METHODS

Patients with Ho's N2 or N3 stage or N1 stage with nodal size > or = 4 cm were randomized to receive cisplatin 40 mg/m(2) weekly up to 8 weeks concurrently with radical RT (CRT) or RT alone. The primary end point was progression-free survival (PFS).

RESULTS

Three hundred fifty eligible patients were randomized. Baseline patient characteristics were comparable in both arms. There were significantly more toxicities, including mucositis, myelosuppression, and weight loss in the CRT arm. There were no treatment-related deaths in the CRT arm, and one patient died during treatment in the RT-alone arm. At a median follow-up of 2.71 years, the 2-year PFS was 76% in the CRT arm and 69% in the RT-alone arm (P =.10) with a hazards ratio of 1.367 (95% confidence interval [CI], 0.93 to 2.00). The treatment effect had a significant covariate interaction with tumor stage, and a subgroup analysis demonstrated a highly significant difference in favor of the CRT arm in Ho's stage T3 (P =.0075) with a hazards ratio of 2.328 (95% CI, 1.26 to 4.28). For T3 stage, the time to first distant failure was statistically significantly different in favor of the CRT arm (P =.016).

CONCLUSION

Concurrent CRT is well tolerated in patients with advanced NPC in endemic areas. Although PFS was not significantly different between the concurrent CRT arm and the RT-alone arm in the overall comparison, PFS was significantly prolonged in patients with advanced tumor and node stages.

Influence of staging thoracic computed tomography on radiation therapy planning for esophageal carcinoma

Radiation therapy with concurrent chemotherapy is frequently used as definitive treatment for esophageal carcinoma. Although thoracic computed tomography (CT) is widely used in staging esophageal carcinoma, its application to radiation therapy planning has been regarded as optional rather than mandatory. Conventional radiation therapy planning is esophagogram-based rather than CT-based. The treatment port is generated by adding 5 cm to the proximal and distal margins of the tumor-involved segment as seen on esophagogram performed in the treatment position. Historically, a maximum port length of 15 cm was recommended to avoid excessive treatment morbidity. The authors examined the limitations of such a planning protocol by projecting conventional treatment ports onto the thoracic CT of 75 consecutive newly diagnosed cases of nondisseminated esophageal squamous cell carcinoma. The authors assessed the adequacy of coverage of the primary tumor and metastatic nodes, with respect to data from thoracic CT and neck ultrasonography. It was found that up to 38% of T2-T3 tumors and 30% of short-length (< or =5 cm) tumors had metastatic nodes outside the port. The addition of neck ultrasonography led to identification of an additional 5% of patients with nonpalpable nodes outside the port. It is concluded that the frequency of inadequate tumor coverage using an esophagogram-based planning protocol, with a maximum port length of 15 cm, is unacceptably high. Thoracic CT should be a mandatory rather than optional imaging investigation in guiding radiation therapy planning for esophageal cancer.

Incidence of carotid stenosis in nasopharyngeal carcinoma patients after radiotherapy

BACKGROUND

Radiation-induced carotid stenosis in patients with head and neck tumors can cause significant mortality and morbidity. This study examined the incidence of stenosis in the extracranial carotid arteries of nasopharyngeal carcinoma patients after radiotherapy.

METHODS

The extracranial carotid arteries of 71 (53 male and 18 female; mean age of 53.6 years) postradiation patients with nasopharyngeal carcinoma were examined with color Doppler ultrasound. The distribution of the arterial stenosis and the degree of stenosis were documented. The results were compared with the control group, which comprised 51 newly diagnosed nasopharyngeal carcinoma patients (35 male and 16 female, mean age of 48.8 years) before radiotherapy. Incidences of risk factors for arterial stenosis such as hypertension, smoking, and hypercholesterolemia also were studied in these two groups.

RESULTS

There was no significant difference in the incidence of risk factors between the two groups. Arterial stenosis was, however, more common in the postradiation group than the preradiation group (56 of 71 vs. 11 of 51). The common/internal carotid arteries (CCA/ICA) were most commonly involved (55 of 71 vs. 11 of 51; P < 0.01), followed by the external carotid artery (ECA) (32 of 71 vs. 1 of 51; P < 0.01) and vertebral artery (VA; 5 of 71 vs. 0; P = 0.069). Significant stenosis (> 50% reduction of luminal diameter) was only found in the postradiation group (21 of 71 in CCA/ICA, 11 of 71 in ECA, 4 of 71 in VA).

CONCLUSIONS

This study showed that radiation could cause significant carotid stenosis. Ultrasound examinations for these patients therefore are necessary for early detection and possible intervention of this late radiation-induced complication.

Clinically underdetected asymptomatic and symptomatic carotid stenosis as a late complication of radiotherapy in Chinese nasopharyngeal carcinoma patients

BACKGROUND

Carotid artery stenosis is a late complication of radiotherapy to the neck region. This complication has, however, a significant impact with increased risk of stroke causing mortality and morbidity. Clinicians' awareness of this complication and early detection is therefore important.

METHODS

Eighty patients with nasopharyngeal carcinoma (NPC) who had received radiotherapy were recruited for color Doppler ultrasonography of the carotid arteries. fifty-eight patients with newly diagnosed NPC who had never received any radiotherapy were recruited as controls. All patients with significant carotid stenosis were referred to the neurology clinic for further assessment.

RESULTS

Twenty-four patients were found to have more than 50% diameter reduction in the extracranial carotid artery. Clinical assessment by a neurologist showed 9 of 24 patients had a history of transient ischemic attack, amaurosis fugax, or stroke. Seven of these patients had clinically detectable neck bruit.

CONCLUSIONS

Clinicians attending to patients after radiotherapy for head and neck cancers should be aware of this long-term complication of radiotherapy. A detailed clinical history and incorporation of auscultation of carotid arteries in routine follow-up of postradiotherapy patients are recommended.

In vivo diagnosis of nasopharyngeal carcinoma using contact rhinoscopy

OBJECTIVES

To evaluate the potential use of contact endoscopy for the diagnosis of nasopharyngeal carcinoma (NPC).

STUDY DESIGN

Prospective study to examine the nasopharynx of 30 patients with nasopharyngeal carcinoma and 18 subjects with normal nasopharynx in a clinic setting using contact rhinoscopes (Karl Storz, Tuttlingen, Germany, 7215 AA, 00 and 7215 BA, 300; 23 cm long; 4 mm in diameter).

METHODS

The superficial cells of the normal nasopharynx and the nasopharyngeal tumors were stained with 1% methylene blue and examined with contact rhinoscopes at high magnifications (x 60 and x 150). The areas under examination were then biopsied. The contact endoscopic images were compared with the corresponding hematoxylin and eosin-stained histologic sections of the biopsied tissues.

RESULTS

Sixty-six procedures were performed in 48 patients. The images of normal pseudostratified ciliated epithelium and squamous epithelium were readily recognized by contact endoscopy in all subjects with normal nasopharynx (10 men and 8 women; mean age, 51.9 y). Twenty-six of 30 patients with NPC (86.6%; 18 men and 8 women; mean age, 50.6 y) were successfully examined by contact endoscopy under local anesthesia. In these 26 patients, two patterns of malignant cells were identified with contact endoscopy. The patterns of contact endoscopic images corresponded well with the histologic findings.

CONCLUSION

Contact endoscopy is an accurate and reliable office-based procedure, which allows for in-vivo diagnosis of nasopharyngeal carcinoma.

Paranasopharyngeal space involvement in nasopharyngeal cancer: detection by CT and MRI

Paranasopharyngeal tumour extension (PTE) from nasopharyngeal carcinoma (NPC) is staged in its own subgroup in the American Joint Committee on Cancer classification. Most large clinical trials use computed tomography (CT) to stage PTE, but diagnosis relies on indirect signs of tumour invasion such as asymmetry of the parapharyngeal fat. Magnetic resonance imaging (MRI) has the advantage of directly revealing PTE because of its ability to depict the complex anatomical structures that form the boundary of the nasopharynx. The aim of this study was to compare CT and MRI in the identification of PTE and to determine whether the imaging modality used influenced staging of the disease. The MRI and CT scans of 78 patients (156 parapharyngeal regions) with NPC were assessed for PTE. On MRI, PTE was considered to be positive when there was tumour invasion through the complex anatomical structures of the nasopharyngeal wall. When using CT, it was considered positive when there was: (1) distortion of the parapharyngeal fat plane; or (2) extension beyond a line drawn from the medial pterygoid plate to the lateral aspect of the carotid artery. CT scanning and MRI were compared. PTE was judged to be present in 28 of 78 (36%) patients by MRI and in 41 of 78 (53%) scanning by CT when using criterion 1 or 2. An analysis of the discordant findings revealed that MRI was positive in three sides of the nasopharynx in early tumour extension through the pharyngobasilar fascia but not identified with CT by using criterion 1 or 2. MRI was negative in 20 and 21 sides of the nasopharynx that were judged to be positive on CT by using criterion 1 and 2 respectively. In these patients MRI revealed that the positive CT scan was caused by a large tumour compressing but not invading the parapharyngeal fat space, a metastatic lateral retropharyngeal node, or a combination of the two. The imaging modality used for staging NPC has an impact on the staging of PTE. CT scanning suggested the presence of PTE more frequently than MRI because of its inability to distinguish the primary tumour from lateral retropharyngeal nodes, and direct tumour invasion of the parapharyngeal region from tumour compression. The imaging modality and criteria used for staging PTE should be taken into consideration when assessing the results of clinical studies.

Molecular prognostication of nasopharyngeal carcinoma by quantitative analysis of circulating Epstein-Barr virus DNA

We investigated the prognostic implication of pretreatment plasma/serum EBV DNA concentration, as measured by real-time quantitative PCR, in nasopharyngeal carcinoma (NPC). In 91 prospectively recruited NPC patients, those with recurrence or metastasis within the first year after treatment had a higher median plasma EBV DNA concentration than those without events (41,756 copies/ml versus 5,807 copies/ml; P < 0.001, Mann-Whitney rank-sum test). In multivariate logistic regression analysis, plasma EBV DNA was an independent prognostic indicator for early clinical events [relative risk = 3.8 (95% confidence interval, 1.6-9.2 for each 10-fold increase in plasma EBV DNA concentration; P = 0.003)]. In a second cohort of 139 NPC patients followed-up for a median period of 2,027 days (interquartile range, 597-2,335 days), serum EBV DNA was found to be a significant variable associated with NPC-related death in multivariate Cox's regression analysis [relative risk = 1.6 (95% confidence interval, 1.1-2.1 for each 10-fold increase in serum EBV DNA concentration; P = 0.007)]. The quantitation of circulating EBV DNA may thus allow improved prognostication of NPC.

Final report of a randomized trial on altered-fractionated radiotherapy in nasopharyngeal carcinoma prematurely terminated by significant increase in neurologic complications

PURPOSE

The aim of the present study was to compare the survival, local control and complications of conventional/accelerated-hyperfractionated radiotherapy and conventional radiotherapy in nonmetastatic nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

From February 1993 to October 1995, 159 patients with newly diagnosed nonmetastatic (M0) NPC with N0 or 4 cm or less N1 disease (Ho's N-stage classification, 1978) were randomized to receive either conventional radiotherapy (Arm I, n = 82) or conventional/accelerated-hyperfractionated radiotherapy (Arm II, n = 77). Stratification was according to the T stage. The biologic effective dose (10 Grays) to the primary and the upper cervical lymphatics were 75.0 and 73.1 for Arm I and 84.4 and 77.2 for Arm II, respectively.

RESULTS

With comparable distribution among the T stages between the two arms, the free from local failure rate at 5 years after radiotherapy was not significantly different between the two arms (85.3%; 95% confidence interval, 77.2-93.4% for Arm I; and 88.9%; 95% confidence interval, 81.7-96.2% for Arm II). The two arms were also comparable in overall survival, relapse-free survival, and rates of distant metastasis and regional relapse. Conventional/accelerated-hyperfractionated radiotherapy was associated with significantly increased radiation-induced damage to the central nervous system (including temporal lobe, cranial nerves, optic nerve/chiasma, and brainstem/spinal cord) in Arm II. Although insignificant, radiation-induced cranial nerve(s) palsy (typically involving VIII-XII), trismus, neck soft tissue fibrosis, and hypopituiturism and hypothyroidism occurred more often in Arm II. In addition, the complications occurred at significantly shorter intervals after radiotherapy in Arm II.

CONCLUSION

Accelerated hyperfractionation when used in conjunction with a two-dimensional radiotherapy planning technique, in this case the Ho's technique, resulted in increased radiation damage to the central nervous system without significant improvement in efficacy.

Prognostic significance of argyrophilic nucleolar organizer regions in nasopharyngeal carcinoma

Increased expression of argyrophilic nucleolar organizer regions (AgNORs) has been identified in certain malignant tumors including nasopharyngeal carcinoma (NPC). However, its prognostic significance in NPC is uncertain and remains to be evaluated. To address this we silver-stained 63 paraffin sections of NPC cases, and examined the correlation between AgNOR count and area, calculated by the CAS 200 image analysis system, and tumor behavior, locoregional control, and survival of patients. The mean AgNOR count and area were 1.62 +/- 0.31 and 3.98 +/- 11.4 microm2, respectively. The AgNOR area was positively associated with T stage (r = 0.26, P = 0.04). The Mann-Whitney test confirmed no significant difference in AgNOR area and count between patients with different outcomes. Multivariate analysis using the Cox proportional hazard model showed neither AgNOR count nor area to be significant predictors of actuarial survival or disease-free survival. It is concluded that AgNOR does not have an independent and significant prognostic value in NPC. AgNOR expression may be merely a reflection of malignant phenotype as well as cellular activity but not necessarily the ultimate behavior of the tumor.

Middle ear effusions after radiotherapy: correlation with pre-radiotherapy nasopharyngeal tumor patterns

OBJECTIVE

The purpose of this study was to assess whether pretreatment tumor patterns of nasopharyngeal carcinoma (NPC) can predict the status of the middle ear after radiation treatment.

MATERIALS AND METHODS

Pretreatment and follow-up magnetic resonance imaging (MRI) was performed in 32 patients (64 ears) who had radiation therapy for NPC. For the purpose of analysis, the ears were placed into their pre-radiation therapy tumor pattern groups and the presence of middle ear effusion (MEE) with regard to eustachian tube (ET) invasion or displacement was identified.

RESULTS

MEEs were present in 31 (48.4%) ears after radiation therapy. All of the MEEs that resolved were in the preradiation therapy groups where tumor invasion of the eustachian tube was present irrespective of the amount of ET displacement. There was, however, no significant difference for resolved MEEs between ears with ET invasion or displacement (p = 0.32 and p = 0.71, respectively, Fisher's exact test). The MEEs occurred with significantly greater frequency in ears with minor ET displacement than in those with major ET displacement (p = 0.013, Fisher's exact test) as well as in previously normal ears compared with other groups (p = 0.008, Mann-Whitney U test).

CONCLUSION

A pre-radiation therapy NPC tumor pattern was not found that clearly predicted the outcome of MEE after radiation treatment. The findings, however, suggest that approximately one third of MEEs in patients with invasion of ET or paratubal structures, irrespective of the amount of ET displacement, resolve after therapy. The MEEs that were present in ears with ET displacement and no invasion did not resolve despite reversal of the displacement after treatment, which suggests that ET position plays a less important role than invasion in the resolution of MEE. It is, however, difficult to be certain, because ears with invasion were invariably associated with ET displacement, and the contribution of radiation therapy to the development of MEE further complicates the issue.

Improved local control for early T-stage nasopharyngeal carcinoma--a tale of two hospitals

PURPOSE

To study the efficacy of intracavitary brachytherapy (ICT) in early T-stage nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

All early T-stage (T1 and T2 nasal cavity tumour) NPC treated with a curative intent up to 1996 were analyzed (n=743), 163 from the Prince of Wales Hospital (PWH) and 25 from Tuen Mun Hospital (TMH) were given ICT after radical external radiotherapy (ERT; group A). They were compared with 555 patients treated with ERT alone (group B). The radiotherapy techniques were identical between the two hospitals. The ERT delivered the tumoricidal dose (uncorrected biological equivalent dose (BED)-10, > or = 75 Gy) to the primary tumour, and this did not differ in technique or dosage between the two groups. The ICT delivered a dose of 18-24 Gy in three fractions over 15 days to a point 1 cm perpendicular to the midpoint of the plane of the sources.

RESULTS

The local failure was significantly less (crude rates, 6.9 vs. 13.0%; 5-year actuarial rates, 5.8 vs. 11.7%) and the disease-specific mortality was significantly lower (crude rates, 13.8 vs. 18.9%; 5-year actuarial rates, 12.2 vs. 15.2%) in group A compared with group B. ICT was the only significant independent prognostic factor predictive of fewer local failures. When ICT was excluded from the Cox regression model, the total physical dose or the total BED-10 uncorrected for tumour repopulation became significant in predicting the ultimate local failure rate. The two groups were comparable in the rate of the chronic radiation complications. A significant dose-tumour-control relationship existed, plotting the local failure as a function of the total physical dose or the total BED.

CONCLUSIONS

Supplementing ERT, which delivered the tumoricidal dose (uncorrected BED-10, > or = 75 Gy), with ICT significantly enhanced ultimate local control in early T-stage (T1/T2 nasal infiltration) NPC. A significant dose-tumour-control relationship exists above the conventional tumoricidal dose level.

Serum fatty acid, lipid profile and dietary intake of Hong Kong Chinese omnivores and vegetarians

OBJECTIVE

To examine the serum fatty acid and lipid profiles and dietary intake of Hong Kong Chinese omnivores and vegetarians with respect to cardiovascular health.

DESIGN

Random population survey stratified by age and sex.

SUBJECTS

One-hundred and ninety-four omnivore subjects (81 men, 113 women) age 25-70 y, and 60 ovo-lacto-vegetarian adults (15 men, 45 women) age 30-55 y.

MEASUREMENTS

Nutrient quantitation was by a food frequency method. Serum fatty acids were analysed by gas chromatography, and serum lipid by standard laboratory methods.

RESULTS

Compared with omnivores, vegetarians had higher serum concentrations of polyunsaturated (PUFA) and monosaturated fatty acids (MUFA), and lower saturated fatty acids (SFA), long chain omega-3 and trans fatty acids (TFA). They also had lower serum cholesterol and higher apoA-1 concentrations, but the LDL/HDL ratio was not different. The ratio of polyunsaturated to saturated fatty acids intake was higher in vegetarians. Compared with results from populations with higher incidences of coronary heart disease, while lower myristic and palmitic acid concentrations and higher eicosapentaneoic (EPA) and docosahexanoic acid (DHA) may partly account for the difference in incidence, linoleic acid concentration was higher. Although the Chinese vegetarian diet may be beneficial for heart health in that antioxidant and fibre intakes are higher and saturated fat lower, the low EPA and DHA due to omission from dietary source and suppressed formation by high linoleic acid level, and the presence of TFA in the diet, may exert an opposite effect.

CONCLUSION

There are some favourable features in the serum fatty acid profile in the Hong Kong Chinese population with respect to cardiovascular health, but the consumption of TFA is of concern. The Chinese vegetarian diet also contains some adverse features.