Enhanced control by radiotherapy of cervical lymph node metastases arising from nasopharyngeal carcinoma compared with nodal metastases from other head and neck squamous cell carcinomas

Initial Experience of Intentional Internal High-Dose Policy Volumetric Modulated Arc Therapy of Neck Lymph Node Metastases ≥ 2 cm in Patients With Head and Neck Squamous Cell Carcinoma

Background and Purpose

Most locoregional recurrences after definitive radiotherapy for head and neck squamous cell carcinoma (HNSCC) develop "in-field." Dose escalation while sparing organs at risk can be a good solution for improving local control without increasing adverse effects. This study investigated the safety and effectiveness of volumetric modulated arc therapy (VMAT) using intentionally internal high-dose policy (IIHDP) to treat neck lymph node metastases (NLNM) ≥ 2 cm in HNSCC patients.

Materials and Methods

We analyzed 71 NLNM from 51 HNSCC patients who had received definitive radiotherapy to treat NLNM ≥ 2 cm using the VMAT technique in our institution between February 2017 and August 2019. Thirty-seven NLNM from 25 patients were treated using IIHDP VMAT (group A), and 34 NLNM from 27 patients were treated with homogeneous-dose distribution policy (HDDP) VMAT (group B). One patient with three NLNM had one lymph node assigned to group A and the other two to group B. Adverse events and local recurrence-free survival (LRFS) was compared between the two groups.

Results

In the median follow-up period of 527 days, there were no significant differences between the groups in terms of dermatitis or mucositis ≥ grade 2/3, but LRFS was significantly longer in group A (p = 0.007). In the Cox regression analysis after adjustment for the propensity score, group A also showed an apparently superior LFRS.

Conclusion

Our initial experience of IIHDP VMAT suggested that IIHDP VMAT to treat HNSCC neck lymph node metastases measuring ≥ 2 cm was feasible and possibly led to better local control than HDDP VMAT.

Aggressive Surgical Resection of Enormous Cervical Metastasis from Nasopharyngeal Carcinoma

While nasopharyngeal carcinoma (NPC) commonly presents lymphoid metastases, the enormous cervical metastasis causing dysphagia and limitation of neck motion is not a familiar symptom for most of NPC cases. We report a 23-year-old male with undifferentiated carcinoma of the nasopharynx, stage III (T3N2M0), who had undergone aggressive surgical resection of bilateral huge cervical mass first followed by concurrent chemo-radiotherapy with cisplatin-based regimens. The postoperative clinical course was uneventful and follow-up, 2 years later, revealed no recurrence of primary lesion and neck metastases. We recommend that aggressive surgical resection may be considered when NPC patients significantly suffer clinical symptoms from a huge cervical metastasis.

10-Year Results of Therapeutic Ratio by Intensity-Modulated Radiotherapy Versus Two-Dimensional Radiotherapy in Patients with Nasopharyngeal Carcinoma

BACKGROUND

The purpose of this study was to verify 10-year results of survival and late toxicities and assess the ultimate therapeutic ratio of intensity-modulated radiotherapy (IMRT) versus two-dimensional radiotherapy (2DRT) in patients with nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

We retrospectively reviewed the data from 1,276 patients with nonmetastatic NPC who received IMRT or 2DRT from January 2003 to December 2006.

RESULTS

Of the 1,276 patients, 512 were treated with IMRT and 764 with 2DRT. Median follow-up was 115 months. At 10 years, the IMRT group demonstrated significantly better results than the 2DRT group in local failure-free survival (L-FFS; 90% vs. 84%; hazard ratio [HR], 0.57, 95% confidence interval [CI], 0.40-0.81; p = .001), failure-free survival (FFS; 69% vs. 58%; HR, 0.69, 95% CI, 0.57-0.83; p < .001), and overall survival (OS; 75% vs. 63%; HR, 0.62, 95% CI, 0.51-0.77; p < .001). Subgroup multivariate analyses showed that radiotherapeutic technique (IMRT vs. 2DRT) remained an independent prognostic factor for L-FFS in the T1 subgroup (HR, 0.30; 95% CI, 0.11-0.80; p = .02); for FFS in the stage II subgroup (HR, 0.42; 95% CI, 0.24-0.73; p = .002); and for OS in the stage I (HR, 0.20; 95% CI, 0.04-0.96; p = .04), stage II (HR, 0.39; 95% CI, 0.21-0.75; p = .004), and stage IVA-B (HR, 0.74, 95% CI, 0.56-0.98; p = .04) subgroups. The incidence of grade 3-4 temporal lobe necrosis, cranial neuropathy, eye damage, ear damage, neck soft tissue damage, trismus, and dry mouth was significantly lower in the IMRT group than in the 2DRT group.

CONCLUSION

IMRT demonstrated an improved ultimate therapeutic ratio compared with 2DRT in patients with NPC after a 10-year follow-up, with significant improvement of L-FFS, FFS, and OS and decrease in most late toxicities.

IMPLICATIONS FOR PRACTICE

The ultimate therapeutic ratio of intensity-modulated radiotherapy versus two-dimensional radiotherapy in patients with nasopharyngeal carcinoma is unclear. In this retrospective study of 1,276 patients with nonmetastatic nasopharyngeal carcinoma with a follow-up of 115 months, intensity-modulated radiotherapy demonstrated an improved ultimate therapeutic ratio compared with two-dimensional radiotherapy, with significant improvement of local failure-free survival, failure-free survival, and overall survival and decrease in most late toxicities and noncancer deaths. However, distant control remains insufficient with this treatment modality.

Treatment for retropharyngeal metastatic undifferentiated squamous cell carcinoma from an unknown primary site: results of a prospective study with irradiation to nasopharyngeal mucosa plus bilateral neck

Background and Objective

To evaluate treatment outcomes for patients with retropharyngeal metastatic undifferentiated squamous cell carcinoma (SCC) from an unknown primary site.

Methods

From January 2005 to January 2015, patients who presented with enlarged retropharyngeal nodes underwent transoral sonography-guided fine-needle aspiration to confirm histology. Those with metastatic undifferentiated SCC with unknown primary tumors were treated with radical radiotherapy to nasopharyngeal mucosa plus bilateral neck. Chemotherapy was administered for patients staged N2-3. Endpoints included metastatic nodes control, the appearance of primary tumor, overall survival and treatment-related toxicities.

Results

A total of 49 patients were recruited into this study. Retropharyngeal and cervical nodal disease was controlled in 96% of all patients. The incidence of occult primary cancer appearance was 8%. No primary cancer other than of the nasopharynx was detected during the course of follow-up. Ten patients developed distant metastases. The 5-year overall survival, progression-free survival, regional relapse free survival, distant metastasis free survival were 79.6%, 61.1%, 83.4%, 73.8%, respectively. Common late adverse effects included xerostomia (57%) and hearing impairment (35%).

Conclusion

Radical radiotherapy to both the nasopharynx and bilateral neck can achieve excellent outcome with mild toxicities for patients with retropharyngeal metastatic undifferentiated squamous cell carcinoma from an unknown primary site.

An elective radiation dose of 46 Gy is feasible in nasopharyngeal carcinoma treated by intensity-modulated radiotherapy: A long-term follow-up result

The purpose of this study is to compare the treatment outcome of different radiation doses of elective neck irradiation (ENI) in nasopharyngeal carcinoma (NPC) patients treated with intensity-modulated radiotherapy (IMRT).In total, 504 patients with nondisseminated NPC who underwent magnetic resonance imaging before radical IMRT between 2000 and 2008 were retrospectively reviewed. The patients were classified into 2 groups based on the ENI dose: low ENI when the ENI dose was 46 Gy (n = 446) and high ENI when the ENI doses were 50 to 60 Gy (n = 58). All the patients in both the groups received a median dose of 72 Gy to the gross tumor and involved nodes. The fraction size was 2 Gy per fraction. Matching was performed between low ENI and high ENI in a 2:1 ratio, and the matching criteria were N-stage, T-stage, treatment modality, pathology classification, sex, and age.The median follow-up for all patients was 63.5 months. In all patients, the 5-year progression-free survival (PFS), local control (LC), regional control (RC), distant metastasis-free survival (DMFS), overall survival (OS), and cancer-specific survival (CSS) for low ENI and high ENI patients were 69.0% and 63.2% (P = 0.331), 89.0% and 83.9% (P = 0.235), 90.1% and 85.2% (P = 0.246), 86.8% and 76.6% (P = 0.056), 77.5% and 80.8% (P = 0.926), and 84.4% and 82.5% (P = 0.237), respectively. In the matched-pair analysis, the 5-year PFS, LC, RC, DMFS, OS, and CSS for matched low ENI and high ENI patients were 74.1% and 63.2% (P = 0.134), 92.0% and 83.9% (P = 0.152), 90.1% and 85.2% (P = 0.356), 86.2% and 76.6% (P = 0.125), 87.0% and 80.8% (P = 0.102), and 88.6% and 82.5% (P = 0.080), respectively. In the multivariable analysis for all patients, the ENI group was not a significant factor for PFS, LC, RC, DMFS, OS, and CSS.A low ENI dose of 46 Gy in 23 fractions is feasible in NPC patients treated with IMRT, and this concept should be validated in the prospective studies.

The diagnostic value of 1.5-T diffusion-weighted MR imaging in detecting 5 to 10 mm metastatic cervical lymph nodes of nasopharyngeal carcinoma

The aim of the study was to prospectively assess the diagnostic accuracy of 1.5 T diffusion-weighted imaging (DWI) for 5 to 10 mm metastatic cervical lymph nodes of patients with nasopharyngeal carcinoma (NPC). All patients with histopathologically confirmed NPC underwent DWI with 2 b values of 0 and 800 s/mm were enrolled. The shortest axial diameter and mean apparent diffusion coefficient (ADC) value were recorded when lymph nodes with a shortest axial diameter from 5 to 10 mm were measured. The correlation between the pathological diagnoses and mean ADC values in the benign and metastatic lymph nodes were compared using the Z test. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic performance of DWI. Three hundred fourteen nodes of 52 patients with NPC consisted of 46.5% (146/314) metastatic lymph nodes and 53.5% (168/314) benign lymph nodes. The mean ADC value (×10 mm/s) of benign lymph nodes was (1.110 ± 0.202), which was significantly higher than that of metastatic nodes (0.878 ± 0.159) (P < 0.05). The sensitivity, specificity, positive predictive value, and negative predictive value, accuracy for differentiating metastatic from benign lymph nodes using a cutoff ADC value of 0.924 × 10 mm/s was 83.56%, 82.74%, 80.79%, 85.28%, and 82.80%, respectively. The area under the ROC curve was 0.851 (95% confidence intervals: 0.807-0.889). This study demonstrated that DWI is helpful in detecting 5 to 10 mm metastatic lymph nodes of patients with NPC.

Functional characterization of TRPM7 in nasopharyngeal carcinoma and its knockdown effects on tumorigenesis

The aim of this study was to evaluate the association of functional expression of TRPM7 with nasopharyngeal carcinoma (NPC) growth. We examined the correlation of TRPM7 expression with cell growth and proliferation, cell cycle, and apoptosis in vitro in NPC cell lines and NPC tumorigenesis in mice by conducting experiments in mice and by further analyzing the tumor volume and growth. We further explored to see whether there is any positive correlation with the TRPM7 knockdown in NPC cells with their sensitivity to radiation. We found that the functional expression of TRPM7 in nasopharyngeal carcinoma is a critical requirement for physiological processes such as cell cycle, resistance to apoptosis, and cell proliferation. TRPM7 knockdown also enhanced sensitivity to radiotherapy of nasopharyngeal carcinoma. Moreover, we identified TRPM7 as a novel potential regulator of cell proliferation in NPC, through signal transducer and activator of transcription 3 (STAT3)-mediated signaling pathway and other anti-apoptotic factors. TRPM7 and STAT3 activation might be critical for the growth of NPC cells and could be an effective target for treatment of nasopharyngeal carcinoma.

3D-CT implanted interstitial brachytherapy for T2b nasopharyngeal carcinoma

Background

To compare the results of external beam radiotherapy in combination with 3D- computed tomography (CT)-implanted interstitial high dose rate brachytherapy (ERT/3D-HDR-BT) versus conventional external beam radiotherapy (ERT) for the treatment of stage T2b nasopharyngeal carcinoma (NPC).

Methods

Forty NPC patients diagnosed with stage T2b NPC were treated with ERT/3D-HDR-BT under local anesthesia. These patients received a mean dose of 60 Gy, followed by 12-20 Gy administered by 3D-HDR-BT. Another 101 patients diagnosed with non-metastatic T2b NPC received a mean dose of 68 Gy by ERT alone during the same period.

Results

Patients treated with ERT/3D-HDR-BT versus ERT alone exhibited an improvement in their 5-y local failure-free survival rate (97.5% vs. 80.2%, P = 0.012) and disease-free survival rate (92.5% vs. 73.3%, P = 0.014). Using multivariate analysis, administration of 3D-HDR-BT was found to be favorable for local control (P = 0.046) and was statistically significant for disease-free survival (P = 0.021). The incidence rate of acute and chronic complications between the two groups was also compared.

Conclusions

It is possible that the treatment modality enhances local control due to improved conformal dose distributions and the escalated radiation dose applied.

Clinical outcome following radiotherapy and planned neck dissection in N+ head and neck cancer patients

CONCLUSIONS

This study confirms earlier findings that patients with viable tumour cells in the neck after external beam radiotherapy (EBRT) have a poor prognosis. The study also indicates that neck dissection (ND) does not change the prognosis for patients with a complete clinical response in the neck. At the moment our guidelines concerning this matter are being reviewed.

OBJECTIVES

The protocol at our institution stipulates a planned ND in patients with metastasis in the neck after EBRT regardless of the response in the neck. As the necessity for a planned ND has not been clarified we wanted to evaluate our results.

PATIENTS AND METHODS

Patients diagnosed from 1998 to 2002 with metastasis in the neck who received EBRT were evaluated for histopathological findings and clinical outcome.

RESULTS

A total of 156 patients were included. Overall survival was 62% and disease-specific survival was 76%. There was a complete response (CR) in the neck in 63 patients (40%); among these 15 had viable tumour cells in the neck. In patients not achieving CR, 40% (37/93) had viable tumour cells left in the neck. Patients with viable tumour cells in the neck after EBRT had disease-specific survival of 48% compared with 90% among patients without viable tumour cells.

Nasopharyngeal carcinoma--review of the molecular mechanisms of tumorigenesis

Nasopharyngeal carcinoma (NPC) is a head and neck cancer rare throughout most of the world but common in certain geographic areas, such as southern Asia. While environmental factors and genetic susceptibility play important roles in NPC pathogenesis, the Epstein-Barr virus in particular has been implicated in the molecular abnormalities leading to NPC. There is upregulation of cellular proliferation pathways such as the Akt pathway, mitogen-activated protein kinases, and the Wnt pathway. Cell adhesion is compromised due to abnormal E-cadherin and beta-catenin function. Aberrations in cell cycle are due to dysregulation of factors such as p16, cyclin D1, and cyclin E. Anti-apoptotic mechanisms are also upregulated. There are multiple abnormalities unique to NPC that are potential targets for novel treatments.

Recurrence potential of diffuse-type giant cell tumor in the foot: radiologic and pathologic features

BACKGROUND

Aggressive musculoskeletal tumors in the foot, such as diffuse-type giant cell tumors or extra-abdominal desmoid tumors, are difficult to treat because the foot does not have enough soft tissue to allow wide tumor resection. We reviewed the clinical behavior of diffuse-type giant cell tumor in the foot and evaluated the recurrence potential of these tumors from radiologic and pathologic perspectives.

METHODS

Six patients with a mean age of 37.6 years were included in this study. Radiologic studies, including sonography, computed tomography (CT), magnetic resonance imaging (MRI), and bone and gallium citrate scintigraphy, were obtained followed by surgical treatment and histologic evaluation of the tumor.

RESULTS

Recurrence occurred in three patients. Although CT and MRI findings were similar in the recurrent and nonrecurrent tumors, marked differences were found between the two by scintigraphy; positive radiotracer uptake to the affected foot with gallium citrate scintigraphy was noted only in recurrent tumors, although positive accumulation was seen in all patients with bone scintigraphy. Histologically, the necrotic area and mitotic activity were more apparent in recurrent than in the nonrecurrent tumors, and tumor cell dyscohesion was noted in the former, (the intercellular space was increased).

CONCLUSIONS

Repeated recurrence with tumor invasion into tarsal bone resulted in breakage of the tarsal arch that supports the body's weight. Amputation would be necessary for patients in whom the disease had progressed to obtain local cure and relief of pain. In the present study, we found two features of the recurrence potential of diffuse-type giant cell tumors: sparse cell to cell contact on pathologic examination and positive accumulation in the tumor on gallium citrate scintigraphy. We concluded that giant cell tumors with these two features have a strong potential for local recurrence, and thus require intensive followup.

Timing of Chemoradiotherapy and Patient Selection for Locally Advanced Nasopharyngeal Carcinoma

AIMS

Predictors of outcome after radiotherapy alone for nasopharyngeal carcinoma (NPC) are now available from several retrospective studies. On the basis of these, it is theoretically possible to separate patients at risk of local failure from patients at risk of distant metastases (DM). According to classical principles of chemoradiotherapy timing, patients at risk of local failure would benefit mostly from concomitant chemoradiotherapy, whereas patients at risk distantly would benefit from sequential combinations.

MATERIALS AND METHODS

We reviewed the literature on combined chemoradiotherapy treatment for nasopharyngeal carcinoma to assess whether timing of combined treatment matches pattern of failure.

RESULTS

Available data show a significant overlap of activity, sequential treatments reducing local failure and concomitant treatments reducing DM. Therefore, in the individual patient, the strict adoption of traditional risk profiles in therapeutic decision-making may not fully exploit all the potential therapeutic effects derived from the maximal association of both sequential and concomitant therapies.

CONCLUSION

Whether such combination is clinically worthwhile in every patient with locoregionally advanced nasopharyngeal carcinoma needs prospective validation, because of the high toxicity of this modality.

Cervical nodal metastases from occult primary: undifferentiated carcinoma versus squamous cell carcinoma

PURPOSE/OBJECTIVE

Controversy exists regarding the management of cervical lymph node metastases from occult primary. Oncologists face a major challenge in adopting an optimal approach. This study attempted to compare the clinical course of two different histologic findings of this disease entity.

MATERIALS AND METHODS

A retrospective analysis was performed for all patients referred to our institution between 1988 and 1998 with cervical lymph node metastases from an unknown primary. Case records of consecutive unselected patients with histologically confirmed carcinoma in cervical lymph nodes were reviewed. Those with histologic findings other than squamous cell carcinoma (SCC) or undifferentiated carcinoma (UDC) and lymphadenopathies at the supraclavicular fossa alone or below the clavicles at the time of diagnosis were excluded. There were 45 patients identified with a mean follow-up of 36 months (range, 4-110 months). Thirty-seven were men and eight were women. The mean age was 57 (range, 29-91). There were 32 patients with SCC and 13 patients with UDC. Treatment modality included surgery (S) alone in 1 patient (2%), radiotherapy (RT) alone in 24 patients (53%), and combined modality in 20 patients (45%). (Twelve patients (27%) had combined S and RT, 8 patients (18%) had combined chemotherapy and RT.) Twenty-eight patients (62%) were treated with radical intent. For those patients treated by radical RT, the RT field covered both sides of the neck and the potential mucosal primary (PMP) sites, including the entire pharyngeal axis. The median radiation doses to the lymph nodes and the PMP were 65 Gy (range, 60-70 Gy) and 60 Gy (range, 40-70 Gy), respectively.

RESULTS

At the time of analysis, ultimate control of disease above the clavicles according to N stage, treatment intent, and histologic type was as follows: N1s, 7 of 7 (100%); N2s, 15 of 26 (58%); N3s, 1 of 12 (8%); radical intent, 19 of 28 (68%); palliative intent, 3 of 17 (18%); UDC, 11 of 13 (85%); SCC,11 of 32 (34%). Eleven patients remained alive and disease free, with a median follow-up of 79 months (range, 27-110 months). The 5-year disease-specific survival (DSS) for the radical treatment group and the palliative treatment group were 67% and 18%, respectively (p =.0011). Significant difference in 5-year DSS was observed among the different N groups: 100% for N1s, 55% for N2s, and 0% for N3s, respectively (p =.0001). There was also a significant difference in the 5-year DSS between UDC and SCC: 81% for UDC vs 34% for SCC (p =.01). No significant difference in the 5-year DSS was observed on the basis of treatment modality in the radically treated group: 63% for RT alone vs 75% for S + RT (p =.711).

CONCLUSIONS

UDC histologic findings in our series are associated with better locoregional control and DSS than SCC. Our results in local control, emergence of primary tumor, and DSS are comparable with other published data. However, disease control of advanced nodal stage remains poor; more aggressive treatment approaches, like the use of concurrent chemoradiation or altered fractionation scheme, should be explored.

Implications of quantitative tumor and nodal regression rates for nasopharyngeal carcinomas after 45 Gy of radiotherapy

PURPOSE

To quantitatively investigate the clinical implications of tumor regression rate (TRR-45) and nodal regression rate (NRR-45) of nasopharyngeal carcinomas (NPC) after receiving 45 Gy of radiotherapy (RT). The values, predictive values, and associated factors of TRR-45 and NRR-45 in NPC are analyzed.

METHODS AND MATERIALS

One hundred one patients with newly diagnosed NPC and who were curatively treated by RT alone were included in the study. Tumor volume and nodal volume before treatment and after 45 Gy were obtained from computed tomographic (CT) scans performed at those times and calculated with the assistance of a computer-based imaging analyzing system. TRR-45 (NRR-45) was defined as the ratio of reduced tumor (nodal) volume after 45 Gy to the initial tumor (nodal) volume. TRR-45 (NRR-45) values were stratified into three groups of slow (below 50%), moderate (between 50% and 75%), and rapid (above 75%) change. After conventional RT with 45 Gy, conformal RT for primary tumors was boosted to 70.2-72 Gy for T1-2 tumors, and 75.6-81 Gy for T3-T4 tumors. RT for residual neck masses was boosted by electron beam to 61-75 Gy.

RESULTS

The mean value of TRR-45 for all patients was lower than that of NRR-45 for the 78 patients with metastatic neck nodes (70% +/- 4.8% vs. 81% +/- 5%, p = 0.003). The 3-year actuarial neck control rate was better than the primary tumor control rate with statistical significance (98% vs. 85%, p = 0.009). No significant statistical differences concerning local control probability, nodal control probability, or survival rate were found among patients with slow, moderate, or rapid TRR-45 or NRR-45. T-stage was the only significant prognostic factor for locoregional control after multivariate analysis. Tumor volume and T-stage were found to have a statistically significant negative correlation with TRR-45. No associated factor was found to be significantly correlated with NRR-45.

CONCLUSION

Slow regression rates of the primary tumor or neck nodes in NPC after receiving 45 Gy of irradiation do not mean ultimately poor radiocurability, but may merely imply slow clearance of the cells damaged during irradiation. The different radiobiological behaviors of the regression rates during treatment, ultimate control probabilities, or associated factors for regression rates of NPC between primary tumors and neck nodes need to be further investigated.

Nasopharyngeal carcinoma: clinical assessment and review of 176 cases

OBJECTIVE

The objective of this study was to delineate salient disease characteristics and to determine factors associated with survival in a series of patients with nasopharyngeal carcinoma (NPC).

STUDY DESIGN

To address our research objective, we used a retrospective cohort study design and a sample of patients who presented for evaluation and management of NPC. Demographic data, medical history, radiographic findings, staging, and histology were recorded. Treatment and follow-up information were ascertained. Survival data and descriptive statistics were calculated. Multivariate analyses identified risk factors associated with survival rates for all World Health Organization (WHO) types.

RESULTS

The sample comprised 123 men and 53 women (n = 176) of which 70% were white and 23% were Asian. A neck mass was the initial symptom in 49% of patients. In 99% of cases, radiation therapy was the primary treatment mode. WHO types 1 and 3 were most common. Overall 5-year disease-free survival rate was 45.5%. Age, use of tobacco or ethanol, and number of presenting symptoms were statistically associated with decreased survival rate in WHO 1 (squamous cell) tumors. Male gender and total number of presenting symptoms were associated with decreased survival rate for WHO 2 and 3 (nonkeratinizing or undifferentiated) tumors.

CONCLUSIONS

Being attuned to the presenting signs of NPC may lead to a more expedient diagnosis. The differing risk factors associated with WHO 1 tumors become clear in this predominantly white population.