Nasopharyngeal carcinoma in children under 15 years of age: a retrospective review of 65 patients

Pediatric Nasopharyngeal Cancer: Case Report and Review of the Literature

Pediatric nasopharyngeal carcinoma, also referred to as cavum carcinoma, is a rare pediatric disease with an infrequent incidence rate. We present the case of a pediatric patient with nasopharyngeal cancer who received an adult schedule of concomitant chemotherapy and conformal radiotherapy with a brachytherapy boost. Adult protocols with high radiotherapy doses are not commonly used in pediatric patients due to the high comorbidity associated with this practice. In this case, the patient displayed excellent overall survival, a longer disease-free period, and fewer side effects and comorbidities, even in the absence of interferon therapy, which is not easily available in low-income countries. In addition, this case shows that conformal radiotherapy and brachytherapy are options that can be used to escalate the radiotherapy dose and decrease side effects.

A 12-year-old female pediatric patient presented to our outpatient clinic with an eight-month history of moderate-to-severe otalgia, intermittent hyaline rhinorrhea, asthenia, adynamia, nasal congestion, epistaxis in the previous months, and local pruritus. Upon physical examination, a 60x60 mm mass was detected at level II of the neck, and a biopsy of the lesion confirmed a histopathological diagnosis of undifferentiated carcinoma compatible with nasopharyngeal carcinoma. The patient was considered to have clinical Stage III cancer, and she received an adult Al-Sarraf protocol with chemoradiotherapy and an intracavitary brachytherapy boost. The patient had a complete response, and she remains without local or distance relapse.

Treating pediatric nasopharyngeal carcinoma patients with the Al-Sarraf protocol could be a feasible modality, as observed in this clinical case, despite the elevated cost of using interferon-beta in low-income countries when using more advanced radiotherapy techniques such as conformal radiotherapy and now, modulated intensity radiotherapy. It should be noted that brachytherapy boosts should be used with caution in pediatric patients; the potential side effects should be weighed against improved local control.

Magnetic Resonance Imaging Findings in Childhood Period Nasopharynx Cancer

Background

Nasopharyngeal carcinoma is a rarely seen tumor in childhood. It is mostly detected late as the clinical features are similar to other childhood tumors which affect the nasopharynx and adenoidal hypertrophy. Therefore, the radiological features of childhood tumors of the nasopharynx must be well known. The aim of this study was to investigate the contribution of MR imaging features of childhood nasopharynx cancer.

Material/Methods

The study included 10 nasopharyngeal carcinoma patients under the age of 18 years who presented at hospital between February 2008 and March 2014 and who had tissue diagnosis and MRI of the nasopharynx region. The MRI scans were evaluated by two radiologists. Loco-regional spread, asymmetry, signal intensity of the tumors, and lymph nodes were evaluated.

Results

In all the patients there was a mass which narrowed the nasopharynx. In all cases, unilateral mastoid opacification was observed. In 9 cases (90%), parapharyngeal extension was found. In 8 cases (80%), the mass showed an extension into the nasal cavity or oropharynx. In 5 cases (50%), there was an involvement of the skull base. In 3 patients (30%), an extension to the masticator space and pterygopalatine fossa was found. There were enlarged cervical lymph nodes bilaterally in 10 cases (100%). In 4 cases (40%), a lateral retropharyngeal lymph node was detected.

Conclusions

Childhood nasopharyngeal cancers are often diagnosed at an advanced stage. MR imaging can be helpful in diagnosis and differential diagnosis of childhood nasopharynx cancer from other diseases of the nasopharynx.

Nasopharyngeal carcinoma in children and adolescents - a single institution experience of 158 patients

Background

To evaluate the clinical features, treatment results, prognostic factors and late toxicities of nasopharyngeal carcinoma in children and adolescents.

Methods

Between January 1990 and January 2011, 158 NPC patients younger than 20 years old were treated in our institution, and the patient’s clinical characteristics, treatment modalities, outcomes and prognostic factors were retrospectively analyzed.

Results

There were 9 (5.7%) patients in stage II, 60 (38.0%) in stage III and 89 (56.3%) in stage IV according to the UICC2002 staging system. Neck mass (32.3%), headache (21.5%) and nasal obstruction (15.2%) were the most common chief complaints. With a median follow-up time of 62.5 months (range 2.0-225.0 months), the 5-year overall survival (OS) rate, local-regional control (LRC) rate and distant metastasis-free survival (DMFS) rate were 82.6%, 94.9% and 76.4%, respectively. There were 43 (27.2%) patients failed during the follow up, with seven local-regional recurrences and 38 distant metastases. In univariate analysis, the 5-year OS of T4 and T1-3 were 75% and 87.9%, p = 0.01, stage IV and stage II-III were 77.1% and 90%, p = 0.04, respectively. In multivariate analysis, T4 (p = 0.02) and stage IV (p = 0.04) were the independent adverse prognostic factors for OS. Significant reduction in trismus (27.3% v 3.6%, p = 0.03) and G2 xerostomia (37.9% v 10.3%, p = 0.02) was observed in patients treated by IMRT.

Conclusions

Most childhood and adolescence nasopharyngeal carcinoma patients were locally advanced diseases at first diagnosed. The treatment results of radiotherapy, with or without chemotherapy, are excellent in our institution. Reducing distant metastasis with new strategies and late toxicities with intensity-modulated radiotherapy are the future directions for the treatment of adolescent nasopharyngeal carcinoma.

Pediatric parapharyngeal lesions: criteria for malignancy

INTRODUCTION

Parapharyngeal space (PPS) pediatric lesions represent a heterogeneous group of uncommon neoplasms of both benign and malignant nature. These tumors tend to be locally advanced by the time they are diagnosed; consequently, an early presumptive diagnosis of malignancy is of utmost importance.

OBJECTIVE

To highlight the occurrence of malignant PPS tumors in pediatric population, to determine their incidence and to describe probable warning clues for diagnosis.

PATIENTS AND METHODS

The charts of 23 pediatric patients with PPS swellings were retrospectively reviewed to analyze clinical and pathologic data. We describe possible criteria to suspect malignancy by clinical and radiological examination.

RESULTS

Twenty-three patients presented with neoplastic lesions in the PPS, benign tumors in 43.5% and malignant in 56.5%. Malignancy was suspected in 13 cases according to combined clinical and radiological criteria: a painless intraoral and neck swelling in children below one year old, presentation with cranial nerve palsy, nasopharyngeal mucosal or sub-mucosal irregular lesion, the presence of multiple lymph nodes with no evidence of infection, and adjacent bony skull base destruction with intracranial extension.

CONCLUSION

Occurrence of malignancy in PPS tumors in the pediatric population is not uncommon. Clinicians should deliberately look for associated secondary signs that predict malignancy. The surgeon must understand the pathological spectrum of tumors of this space and the proper use of imaging studies to make a preoperative diagnosis. This allows for planning of a sound surgical approach and a proper preoperative counseling.

[Is there any difference in therapeutic results of nasopharyngeal carcinoma between adults and children?]

PURPOSE

To compare therapeutic results of nasopharyngeal carcinoma between adults and children.

PATIENTS AND METHODS

Three hundred and seventy seven patients with nasopharyngeal carcinoma received a radiotherapy between 1993 and 2007. Sixty-nine of them were 20years old or less. Two hundred and sixty eight patients received a chemotherapy (neoadjuvant or concomitant).

RESULTS

Overall survival and disease-free survival at 5 years were 67 % and 59.4 % in all patients, respectively. Overall survival rates at 5 years in children and adults were 66 % and 64 %, respectively (P=0.17), disease-free survival rates at 5 years were 66 % and 57 %, respectively (P=0.17). Local failures occurred more frequently in adults than in children (1.4 % versus 14 %). However, metastatic events were frequently seen in children. Late toxicities were important in children, xerostomia was the most common one.

CONCLUSION

Despite locally advanced disease in children, therapeutic results were better than in adults but not statistically significant. The use of treatment combination (chemotherapy and radiotherapy) in juvenile nasopharyngeal carcinoma may explain our findings.

Nasopharyngeal carcinoma in children and adolescents in an endemic area: a report of 185 cases

BACKGROUND

This study aimed to demonstrate the clinical and therapeutic features of nasopharyngeal carcinoma (NPC) in children and adolescents in Southern China, an endemic area.

PATIENTS AND METHODS

A total of 185 newly diagnosed NPC patients younger than 21 years old in the Sun Yat-sen University Cancer Center from 1993 to 2011 were retrospectively analyzed. Overall survival (OS) rate estimates and Kaplan-Meier survival curves were calculated. Cox proportional hazard ratios (HRs) were used to identify independent prognostic factors for survival. Chi-square test was used to compare the incidence of sequelae and the stage distribution between different subgroups.

RESULTS

Most patients were male (71.4%). The main presenting symptoms were neck mass (44.9%), tinnitus/hearing loss (36.2%), bloody nasal discharge (22.7%), headache (22.2%), and nasal obstruction (20.0%). Stage I, II, III, and IV patients accounted for 1.1%, 8.1%, 43.8%, and 47.0%, respectively, of the total number of patients included in the study. All patients were treated by radiotherapy: 39 Gy-84 Gy to primary tumors (median, 68 Gy) and 36 Gy-74 Gy to cervical lymph nodes (median, 60 Gy); 84.3% of the patients were treated by chemotherapy either. The complete response rate was 94.1%. The 5-, 10-, and 15-year survival rates were 78% ± 4%, 70% ± 5%, and 66% ± 6%, respectively. Tumor node metastasis (TNM) stage was the statistically significant predictor of distal metastasis and OS. Distal metastasis was the major pattern of treatment failure. The main long-term complications of therapy were xerostomia (47.0%), hearing loss (28.1%), neck fibrosis (24.3%), trismus (12.4%), glossolalia (7.0%), and radiation encephalopathy (5.4%). The incidences of these morbidities were significantly higher in the high radiation dose (more than the median) group than in the low radiation dose group (less than or equal to the median), while no differences in survival were observed.

CONCLUSIONS

In spite of the majority of patients diagnosed at the advanced stage, children and adolescents with NPC had excellent survival except metastatic disease. The TNM stage was the most relevant prognostic factor. A higher radiation dose (>68 Gy) could not improve survival but could increase long-term morbidities.

PET/CT for staging and follow-up of pediatric nasopharyngeal carcinoma

PURPOSE

While FDG PET/CT for the evaluation of nasopharyngeal carcinoma (NPC) in adult patients has documented advantages and disadvantages compared with conventional imaging, to our knowledge, no studies of FDG PET/CT for the evaluation of NPC in pediatric patients have been performed. In this investigation, we studied the utility of FDG PET/CT in children with NPC.

METHODS

The study group comprised 18 children with biopsy-proven NPC who underwent FDG PET/CT and MRI (total 38 pairs of images). All baseline and follow-up FDG PET/CT and MRI studies were independently reviewed for restaging of disease.

RESULTS

The concordance between FDG PET/CT and MRI in T, N, and overall staging was 29%, 64%, and 43%, respectively. Compared with MRI, FDG PET/CT yielded lower T and overall staging and showed less cervical and retropharyngeal lymphadenopathy. The concordance between follow-up FDG PET/CT and MRI was 79% overall and 100% 9 months after therapy. In patients who achieved complete remission, FDG PET/CT showed disease clearance 3-6 months earlier than MRI. There were no false-positive or false-negative FDG PET/CT scans during follow-up.

CONCLUSION

FDG PET/CT may underestimate tumor extent and regional lymphadenopathy compared with MRI at the time of diagnosis, but it helps to detect metastases and clarify ambiguous findings. FDG PET/CT is sensitive and specific for follow-up and enables earlier determination of disease remission. FDG PET/CT is a valuable imaging modality for the evaluation and monitoring of NPC in pediatric patients.

[Undifferentiated nasopharyngeal carcinoma in adolescent and children]

Malignant tumours with nasopharyngeal primary location are relatively rare in children. One of the most frequent paediatric neoplasms in this region is the undifferentiated nasopharyngeal carcinoma tumour (UCNT). These tumours are usually revealed by nasal obstruction, headache or cervical nodal involvement. The nasopharyngeal mass can be discovered during an ear-nose and throat examination and confirmed after medical imaging investigation. Diagnostic is obtained by nasopharyngeal mass or cervical nodal biopsy. This tumor has a high chemo and radio-sensibility in children. Irradiation of the cavum and the nodes areas remains as the reference treatment of this disease. Most paediatric protocols add chemotherapy to radiotherapy. The value of concomitant or adjuvant chemotherapy is still debated in paediatric population. It was shown that the T and N staging at diagnosis determined by the classification TNM is a major prognostic factor. Due to the importance of the loco-regional sequelae after irradiation and the satisfactory global prognosis, the actual trend is a decrease in the total dose of irradiation delivered, particularly for patient with a good response to first chemotherapy. This article sheds light on the particularities of UCNT in paediatric patients.

Prognostic factors and long-term outcomes of childhood nasopharyngeal carcinoma

BACKGROUND

The authors studied the survival and long-term morbidities of children with nasopharyngeal carcinoma (NPC).

METHODS

This was a retrospective review of children with NPC who were treated at St. Jude Children's Research Hospital between 1961 and 2004. Prognostic factors and long term effects of therapy were analyzed.

RESULTS

Fifty-nine patients (median age, 14.1 years) were identified. Most were male (66.1%) and black (54.2%) and had lymphoepithelioma (93.2%). Thirty-five patients had stage IV disease (59.3%), 20 patients had stage III disease (33.9%), and 4 patients had stage II disease (6.8%). All patients received radiotherapy (RT) to the primary tumor, and most received cervical RT (98.3%) and chemotherapy (88.1%). The 15-year survival and event-free survival (EFS) rates were 67.2% ± 7.5% and 63.5% ± 7.8%, respectively. Five patients (8.5%) developed subsequent malignancies 8.6 to 27 years after NPC diagnosis. EFS was improved in patients who were diagnosed after 1980 (74.8% ± 10% vs 45.5% ± 10.1%; P = .031), in patients who had stage III disease compared with patients who had stage IV disease (79.3% ± 9.6% vs 56.2% ± 11.8%; P = .049), in patients who received cisplatin (81% ± 10.7% vs 45.8% ± 9.7%; P = .013), and in patients who received ≥ 50 grays of RT (71.4% ± 9.3% vs 43.8% ± 11.6%; P = .048). White patients had higher distant failure rates than black patients (41.7% ± 10.4% vs 15.6 ± 6.5%; P = .045). The 15-year cumulative incidence (CI) of any morbidity was 83.7% ± 5.4%, the CI of sensorineural hearing loss was 52.9% ± 6.7%, the CI of primary hypothyroidism was 42.7% ± 6.6%, and the CI of growth hormone deficiency (GHD) was 14.1% ± 4.7%. Dose-response relations were observed between the RT dose and primary hypothyroidism and GHD.

CONCLUSIONS

The outcome of children with NPC improved over the past 4 decades with the use of cisplatin-based chemotherapy and higher RT doses. However, many survivors had long-term treatment-related morbidities.

[Juvenile nasopharyngeal carcinoma: anatomoclinic, biologic, therapeutic and evolutive aspects]

Nasopharyngeal carcinoma (NPC) represents one of the most frequent epithelial tumours of the child in intermediate risk regions. In the Maghreb, it represents the first cancer of teenagers of 15-20 years old. The Epstein Barr virus (EBV) is the most important etiologic factor. Its role in the pathogeneses of NPC has been confirmed by several studies. Young NPCs are characterized by a low rate of EBV antibodies and a high level of LMP1 cell expression than in adult's NPC. The undifferentiated carcinoma nasopharyngeal type (UCNT) represents the most frequent histological type. Immunohistochemical analyses of North Africa early onset NPC is characterized by a weak expression of bcl-2 and p53 and a strong expression of LMP1 and c-kit what makes them different from the adult's NPC. Clinically, cervical node involvement is constantly present. Juvenile NPC is characterized by a very important locoregional extension as well as a high rate of distant metastases. More than 15% of patients had metastases at diagnosis. Radiotherapy is still the standard therapy of NPC. Only some retrospectives studies have been published to determine the benefit, the type and the timing of the chemotherapy in the treatment of juvenile NPC. Metastatic relapses constitute the main cause of death at these young patients. An improvement of the prognosis can be waited with concomitant chemotherapy and intensity modulated radiotherapy. However, randomized multi institutional studies are necessary to standardize the treatment of the NPC in childhood.

Comparison of treatment results between adult and juvenile nasopharyngeal carcinoma

PURPOSE

Nasopharyngeal carcinoma (NPC) has a bimodal age distribution. In contrast to the adult variant, little is known about the juvenile form. This study examined the treatment results between adult (aNPC) and juvenile NPC (jNPC) patients for future treatment considerations in jNPC.

METHODS AND MATERIALS

The jNPC population included 53 patients treated at two institutions between 1972 and 2004. The aNPC population included 84 patients treated at one institution. The patients had received a median dose of 66 Gy of external beam radiotherapy and 72% underwent chemotherapy. The mean follow-up for surviving patients was 12.6 years for jNPC and 6.6 years for aNPC.

RESULTS

The jNPC patients presented with more advance stages than did the aNPC patients (92% vs. 67% Stage III-IV, p = .006). However, jNPC patients had significantly better overall survival (OS) than did aNPC patients. The 5-year OS rate was 71% for jNPC and 58% for aNPC (p = .03). The jNPC group also demonstrated a trend for greater relapse-free survival than the aNPC group (5-year relapse-free survival rate, 69% vs. 49%; p = .056). The pattern of failure analysis revealed that the jNPC patients had greater locoregional control and freedom from metastasis but the differences were not statistically significant. Univariate analysis for OS revealed that age group, nodal classification, and chemotherapy use were significant prognostic factors. Age group remained significant for OS on multivariate analysis, after adjusting for N classification and treatment.

CONCLUSION

Despite more advance stage at presentation, jNPC patients had better survival than did aNPC patients. Future treatment strategies should take into consideration the long-term complications in these young patients.

Nasopharyngeal carcinoma in adolescents: a retrospective review of 42 patients

The aim of the present study was to evaluate the characteristics and outcome of adolescent patients with nasopharyngeal carcinoma (NPC) disease. The study concerned 46 pediatric NPC patients treated during the period 1999-2002 at the National Institute of Oncology, Rabat. The median age of the patients was 16 years. The male/female ratio was 2.8/1. Histologically, all patients had undifferentiated carcinoma. A total of 93% presented nodal metastasis. Four (9%) had distant metastasis. All patients received neoadjuvant multiagent chemotherapy containing cisplatin, followed by radiotherapy. Kaplan-Meier curves were used to evaluate prognostic factors. The log-rank test was used to evaluate the differences between the groups. While none of the patients had locoregional failure, nine patients (29%) developed distant metastasis. The disease-free survival and overall survival (OS) rate for the entire group were 73 and 41%, respectively. Responders to chemotherapy had superior OS (P < 0.001). We suggest that combined modality management using multi-agent chemotherapy and RT as an effective treatment of NPC disease which will achieve satisfactory locoregional control and OS of NPC pediatric patients. Response to chemotherapy was an important prognostic factor.

Radiation and chemotherapy combination for nasopharyngeal carcinoma in children: Radiotherapy dose adaptation after chemotherapy response to minimize late effects

OBJECTIVES

To retrospectively report the clinical and therapeutic features of children with nasopharyngeal carcinoma (NPC) treated by chemotherapy and doses adapted of radiotherapy.

PATIENTS AND METHODS

From 1978 to 2005, 34 children were treated for NPC. All histologic and/or cytologic samples and CT scans were reviewed. Cervical nodal irradiation was reduced (<50 Gy) in the case of a good response to chemotherapy (>/=90% of initial tumor volume).

RESULTS

Thirty-two children had metastatic cervical nodes and one child had systemic metastases at diagnosis. All children had AJJC-TNM Stage IV. Thirty-one children received neoadjuvant chemotherapy with various regimens. The overall chemotherapy response rate was 78%. Fifteen patients had cervical nodal irradiation dose reduced: Median 47 Gy (range: 45-50). Nasopharyngeal radiotherapy was delivered at a dose of 59.4 Gy (range: 45-66). Local and distant failure rates were 10% and 18%, respectively. The 5-year overall survival was 73 +/- 8% and the event-free survival (EFS) was 75 +/- 8%.

CONCLUSIONS

The overall prognosis was not influenced by TNM status, dose of local radiotherapy delivered or response to initial chemotherapy, but EFS was better in patients with a good response to chemotherapy. The cervical local failure rate was low despite radiotherapy dose reduction in the case of a good response to neoadjuvant chemotherapy. We also propose a reduction of nasopharyngeal radiation (</=50 Gy) in the case of good response to initial chemotherapy.

Analyses of the prognostic significance of the Epstein-Barr virus transactivator ZEBRA protein and diagnostic value of its two synthetic peptides in nasopharyngeal carcinoma

BACKGROUND

Although numerous serological studies have determined the diagnostic and prognostic values of Epstein-Barr virus (EBV) antibodies in adult patients with nasopharyngeal carcinoma (NPC), little data about the anti-EBV immune response in children with NPC is available.

OBJECTIVES

To examine the diagnostic value of IgG antibodies against BamHI Z Epstein-Barr replication activator (ZEBRA) protein and two related synthetic peptides (Zp125 and Zp130). To compare the prognostic value of IgA antibodies against early antigens (EA) and viral capsid antigen (VCA), and IgG antibodies against ZEBRA protein, of Moroccan children treated for NPC with their prognostic value for young and adult NPC patients.

STUDY DESIGN

Sera were collected from 255 newly diagnosed Moroccan NPC patients and 226 healthy donors. IgA antibody against VCA and EA was measured by immunofluorescence assays. IgG antibody against ZEBRA, Zp125, and Zp130 was measured by ELISA.

RESULTS

No significant difference in the detection of IgG-Zp125 and Zp130 antibodies was observed in children with NPC. IgG-Zp130 were detected less frequently than IgG-Zp125 in young and adult patients, as compared to children. High specificity of IgG-Zp125 and -Zp130 antibodies was found in the three age groups. A decrease in IgG-ZEBRA was observed in patients with NPC in clinical remission, whereas patients with NPC who died or developed metastases maintained or had an increase in these titers.

CONCLUSION

IgG-ZEBRA is a better diagnostic and post-therapeutic prognostic marker in children with NPC, who showed very low titers of IgA -VCA and -EA.

The efficiency of different chemoradiotherapy regimens in patients with paediatric nasopharynx cancer: review of 46 cases

The purpose of this study was to evaluate the role of combined modality treatment in patients with paediatric nasopharynx cancer (NPC). Forty-six patients with paediatric NPC were retrospectively analysed. Forty-four of 46 patients received combined modality treatment. Five-year overall survival and progression-free survivals were 70% and 72% for the whole group, and only three of 46 patients had loco-regional relapse. Complete remission was obtained in 18 of 45 patients (40%), and the overall survival (94% vs. 62% and 19%, p = 0.0009) and disease-free survivals (93% vs. 70% and 16%, p = 0.0002) were significantly better in complete responders when compared with the patients who had partial response or stable disease. The 5-year overall survival and disease-free survivals of the patients who received neoadjuvant chemotherapy (CT) and radiotherapy (RT) followed by CT were superior to the other groups (77% and 80%, respectively). The number of total CT cycles (p = 0.0001), nodal stage (p = 0.05) and treatment response (p = 0.0009) were significant prognostic factors for overall survival. The treatment type (p = 0.02), the number of total CT cycles (p = 0.0006), nodal stage (p = 0.05) and treatment response (p = 0.0002) were found as significant prognostic factors for disease-free survival. The survival of patients receiving six or more CT cycles was also significantly better than that of patients receiving less than six cycles (p = 0.0001). In patients with locally advanced paediatric NPC, CT should be added to RT to improve outcome. However, a standard protocol is yet to be identified, and further studies evaluating the addition of interferon or immunotherapy to CT and RT shall be performed.

Treatment results of 165 pediatric patients with non-metastatic nasopharyngeal carcinoma: a Rare Cancer Network study

PURPOSE

This Rare Cancer Network (RCN) study was performed in pediatric nasopharyngeal carcinoma (PNPC) patients to evaluate the optimal dose of radiotherapy and to determine prognostic factors.

PATIENTS AND METHODS

The study included 165 patients with the diagnosis of PNPC treated between 1978 and 2003. The median age was 14 years. There were 3 (1.8%) patients with stage I, 1 (0.6%) with IIA, 10 (6.1%) with IIB, 60 (36.4%) with III, 44 (26.7%) with IVA, and 47 (29%) with IVB disease. While 21 (12.7%) patients were treated with radiotherapy (RT) alone, 144 (87.3%) received chemotherapy and RT. The median follow-up time was 48 months.

RESULTS

The actuarial 5-year overall survival (OS) was 77.4% (95% CI: 70.06-84.72), whereas the actuarial 5-year disease-free survival (DFS) rate was 68.8% (95% CI: 61.33-76.31). In multivariate analysis, unfavorable factors were age >14 years for LRC (p=0.04); male gender for DMFS (p=0.03); T3/T4 disease for LRFS (p=0.01); and N3 disease for DFS (p=0.002) and OS (p=0.002); EBRT dose of less than 66 Gy for LRFS (p=0.02) and LRRFS (p=0.0028); and patients treated with RT alone for LRFS (p=0.0001), LRRFS (p=0.007) and DFS (p=0.02).

CONCLUSION

Our results support the current practice of using combined radiation and chemotherapy for optimal treatment of NPC. However, research should be encouraged in an attempt to reduce the potential for long-term sequelae in pediatric patients given their relatively favorable prognosis and potential for longevity.

Treatment results of 84 patients with nasopharyngeal carcinoma in childhood

BACKGROUND

To evaluate the clinical characteristics, treatment regimens, survival, and late complications in patients with nasopharyngeal carcinoma.

PROCEDURE

Eighty-four patients diagnosed with nasopharyngeal carcinoma between 1972 and 2002 were retrospectively evaluated. Tumor status, lymph node involvement, metastasis, and stage were assessed according to the TNM classification. All patients were treated with radiotherapy and chemotherapy. Chemotherapeutic regimens involved cyclophosphamide from 1972 to 1982, vincristine + cyclophosphamide + epirubicine and actinomycin-D protocol from 1982 to 1999 and cisplatin + methotrexate + 5-fluorouracil with leucovorine rescue after 1999. Mean and median values were used for the demographic characteristics. Kaplan-Meier survival curves were used for survival analysis. The patient groups were compared in terms of survival duration using a log-rank test.

RESULTS

There were 51 males and 33 females with a median age of 13 years (7-17) at diagnosis. At the time of diagnosis, 78.5% of the patients were at advanced stage (stages III and IV). Overall and event-free survival rates were 56.3% and 50.1%, respectively. Survival was inversely affected by advanced nodal status (P = 0.01). The survival rates (80%) were found higher with cisplatin + methotrexate + 5-fluorouracil + leucovorine rescue regimen. The most frequent late complications after therapy were hypothyroidism (9.5%), dental caries (7.1%), and trismus (7.1%).

CONCLUSION

The cisplatin-based regimen was the best chemotherapeutic regimen. Less toxic regimens with better survival rates should be investigated in patients with nasopharyngeal carcinoma.

Nasopharyngeal carcinoma in the pediatric age group: the northern Israel (Rambam) medical center experience, 1989-2004

Nasopharyngeal carcinoma (NPC) is rare in children, accounting for less than 1% of all malignancies. Radiation therapy has been the mainstay of treatment of many years, but to improve survival, the use of chemotherapy has been advocated. This is a retrospective analysis of 13 patients less than 20 years of age treated for NPC the Rambam Medical Center during 1989 to 2004. Eight boys and five girls with a median age of 14.5 years (range 10-19) were included. Median follow up (including patients who died) was 6.15 years (range 1-15 years). Duration of symptoms was 1 to 24 months (median 5 months). Of the 13 patients, one patient had stage I, 6 had stage III, 5 had stage IV-A, and 1 had stage IV-B disease. Ten patients (77%) had undifferentiated carcinoma (WHO type III) and three patients (23%) had nonkeratinizing carcinoma (WHO type II). Most of the children received two or three courses of neoadjuvant multiagent chemotherapy consisting of cisplatin and 5-FU, followed by radiotherapy with doses in excess of 60 Gy. One child received concomitant chemoradiation. Ten of the 13 patients (77%) are alive without disease 6 years after diagnosis (range 1-15 years). One patient developed local and distant metastases 1 year after diagnosis and is currently receiving combined radiochemotherapy. Two patients died. Overall survival was 84%; event-free survival was 77%. Nine patients (69%) developed moderate to severe long-term complications. Pediatric NPC is curable by combined radiation and chemotherapy, with doses of radiation in excess of 60 Gy. Long-term follow-up is important for early detection of second malignancies as well as for radiation-induced endocrinologic deficiencies and other normal tissue complications.

Pediatric nasopharyngeal carcinoma: better prognosis and increased c-Kit expression as compared to adults

INTRODUCTION

Nasopharyngeal carcinoma (NPC) in children is distinguishable from the adult form by its close association with Epstein-Barr virus (EBV) infection, a higher rate of undifferentiated histology, and a greater incidence of advanced locoregional disease.

PATIENTS AND METHODS

Sixteen NPC patients, < or =20 years of age were identified from our 1976-2001 tumor registry records. Clinical stage, treatment, recurrence, and survival were evaluated. Sections were stained by immunohistochemistry for p53, Bcl-2, Ki67, and c-Kit and by in situ hybridization for EBER. Obtained data were compared to 32 adult patients. All patients had undifferentiated or non-keratinizing NPC.

RESULTS

EBER was positive in 100% of children, compared to 90% of adults. Comparing children to adults, median Ki67 index was 49% and 30%, p53 positive tumors were 69% and 94%, positive Bcl-2 was 63% and 72%, and positive c-Kit was 88% and 28%, respectively.

CONCLUSION

No parameter had significant predictive values for survival, although c-Kit expression had a trend for better prognosis in the pediatric group. By univariate analysis of all 48 cases, positive c-Kit was associated with better survival (P = 0.029), largely due to the better survival of the pediatric group. By multivariate analysis, increased stage (P = 0.006) and older age (P = 0.044) correlated with worse prognosis.

Treatment results of 59 young patients with nasopharyngeal carcinoma

PURPOSE

To evaluate the outcome of patients </=30 years old with non-metastatic nasopharyngeal carcinoma and discover adverse prognostic factors.

MATERIALS AND METHODS

We performed a database search maintained by the Department of Radiation Oncology of Hacettepe University School of Medicine for patients with nasopharyngeal cancer who were </=30 years old at presentation. This search identified 59 (23.7%) patients among 248 patients treated between 1994 and 2001 that met the inclusion criteria for this retrospective study. Patients were staged according to AJCC 1997 classification. There were 1 (2%) patient with stage I, 7 (12%) with stage IIb, 25 (42%) with stage III, 9 (15%) with stage IVA, and 17 (29%) with stage IVB. Thirteen (22%) patients were stage T1, 16 (27%) were T2, 21 (36%) were T3, and 9 (15%) were T4. Nodal staging at presentation was as follows; 7 (12%) N0, 22 (37%) N1, 13 (22%) N2, 13 (22%) N3a, and 4 (7%) N3b. All patients were treated with fractionated external beam radiotherapy (EBRT) to a median dose of 65Gy. While 12 (20.3%) patients were treated with EBRT alone, 47 (79.7%) received chemotherapy beside EBRT. Twenty-five (42.3%) patients older than 17 years of age received brachytherapy boost in addition to EBRT.

RESULTS

The median follow-up time for all patients was 46 months (range, 1-111 months). While only 3 patients (5%) developed local recurrence (1/21 T3 and 2/9 T4 patients), 13 patients (22%) developed distant metastases (6/35 N1 and 2 and 7/17 N3 patients). None of the patients had regional failure. Four patients (6.7%) died due to the treatment related toxicity. The actuarial 5-year local control (LC), regional control (RC), distant metastasis-free survival (DMFS) and disease-free survival (DFS) rates were 96%, 100%, 76.5%, and 74.5%, respectively. The actuarial 5-year disease-specific survival (DSS) was 70.6%. DFS at 5 years is significantly longer in patients aged <16 years than ones >17 (90.5% versus 64.7%; p=0.02). Patients aged <16 years had longer 5 year DMFS (90.5% versus 67.7%; p=0.05) with a borderline significance. DMFS is significantly shorter in patients initially presented with N3 disease compared to N0-2 disease (58.8% versus 84.4%; p=0.04).

CONCLUSIONS

We suggest that RT combined with multiagent chemotherapy is effective in achieving satisfactory DFS and comparable OS in young patients with NPC. Results of both previous series and ours are evoking the necessity of early administration of efficient chemotherapeutic agents in addition to radiotherapy, but indistinct is the precise regimen and the intensity along the radiotherapy. All efforts towards decreasing late side effects of treatment should be encouraged in this long life expected group.

Nasopharyngeal carcinoma in children: ten years' experience at the Tata Memorial Hospital, Mumbai

PURPOSE

To evaluate the disease characteristics and outcome of children with nasopharyngeal carcinoma treated at the Tata Memorial Hospital, Mumbai.

METHODS AND MATERIALS

Between 1990 and 2000, 81 pediatric patients with a diagnosis of nasopharyngeal carcinoma were treated at the Tata Memorial Hospital. The median age was 14 years. The male/female ratio was 2.8:1. Of the 81 patients, 32 (39%), 21 (26%), and 28 (35%) had T1-T2, T3, and T4 (TNM International Union Against Cancer staging system, 1997), respectively. Ninety-one percent presented with nodal metastasis. Thirty patients (37%) had lymph nodes >6 cm, and 45 (56%) had bilateral nodes at presentation. Histologically, 77 patients (95%) had undifferentiated carcinoma. Eighty-five percent received neoadjuvant multiagent chemotherapy containing bleomycin, methotrexate, and cisplatin, followed by radiotherapy (RT).

RESULTS

After a median follow-up of 50 months, the disease-free survival (DFS) and overall survival (OS) rate for the entire group was 45% and 54%, respectively. Kaplan-Meier curves were used for evaluation of prognostic factors and were compared using the log-rank test. Nodal status had a significant impact on DFS (p = 0.021) and OS (p = 0.006). Complete responders to chemotherapy had superior DFS (p = 0.000) and OS (p = 0.000). RT doses >60 Gy resulted in better DFS (p = 0.020) and OS (p = 0.012). Combined chemotherapy plus RT resulted in improved DFS (p = 0.457) and OS (p = 0.296), although the difference was not statistically significant.

CONCLUSION

Combined modality management using chemotherapy and RT resulted in satisfactory locoregional control and OS in pediatric patients with nasopharyngeal carcinoma. Nodal involvement, response to chemotherapy, and RT dose were important prognostic factors.

Nasopharyngeal carcinoma in childhood and adolescence

Standard therapy for nasopharyngeal carcinoma (NPC) in children has generally followed the guidelines established for adults. We report here, the treatment outcomes in 32 children and adolescents with NPC and we discuss treatment approaches. Between 1993 and 1997, 32 NPC patients aged </=20 years (mean age 15 years) were treated in our institution; they represented 18% of all NPC cases seen during the same time period. 27 patients had no metastases at diagnosis; 26 of these were treated with primary chemotherapy combining epirubicin and cisplatin. Radiotherapy was then delivered to 22 patients at a mean dose of 70 Gy, either conventionally (6 patients) or bifractionated (16 patients). 5 patients had metastases at diagnosis and were treated with chemotherapy combining epirubicin, bleomycin and cisplatin before definitive radiotherapy. The objective response rate (OR) after chemotherapy was 90.9% at the primary site, with a 13.6% complete response (CR) rate. At nodal sites, the OR was 95.5% and the CR was 31.8%. Local control was obtained in all patients after definitive radiotherapy with a medium follow-up of 43.7 months. Late toxicity affecting quality of life was found in 26% of the children who were irradiated, especially among those under 15 years of age (skin fibrosis, 27%; trismus, 27%; hypothyroidism, 14%). No locoregional relapses were observed. Distant metastases occurred in 33% of cases, with a median delay of 4.7 months from the end of treatment. The 2- and 5-year overall survival (OS) rates were 76 and 56%, respectively. Disease-free survival (DFS) was 65% at 2 and 5 years. Therapeutic outcomes for childhood NPC were similar to those in adults, but with more radiotherapy-induced toxicity. New chemotherapeutic combinations and new radiotherapeutic techniques should be sought to improve both survival and quality of life.

Childhood nasopharyngeal carcinoma: from biology to treatment

Nasopharyngeal carcinoma is a rare disease in children with distinct epidemiological, histopathological, and clinical characteristics. Incidence varies widely around the world but bimodal incidence graphs show that in some populations a disproporionate number of cases occur in late childhood. Children with nasopharyngeal carcinoma almost always have the undifferentiated variant of the disease, which is associated with advanced locoregional spread and distant metastases. Both genetic and environmental factors contribute to the development of nasopharyngeal carcinoma, as evidenced by its risk factors which include: specific HLA subtypes; deletions of chromosomes 3p, 9p, 11q, 13q, and 14q; mutations of p53 and RB2/p130; polymorphism of the CYP2E1; and infection with Epstein-Barr virus. Traditional treatment consists of high-dose radiotherapy and cure rates range between 30% and 60%. The high incidence of failure due to systemic disease in children means that chemotherapy is preferable for first-line treatment in advanced-stage disease. Currently, cisplatin-based induction or adjuvant chemotherapy combinations are used along with high-dose radiotherapy. Although combined modality treatment has increased 5-year survival to 70-90%, late morbidity is a major concern.

Undifferentiated nasopharyngeal carcinoma in children and adolescents: comparison between staging systems

BACKGROUND

New criteria for classifying nasopharyngeal carcinoma were defined in the 5th edition of the American Joint Committee on Cancer (AJCC) staging manual. We investigated the clinical implications of the new system by comparing it with the 4th edition in a cohort of pediatric undifferentiated nasopharyngeal carcinoma (UNPC).

PATIENTS AND METHODS

We retrospectively restaged 54 patients younger than 17 years who had biopsy-proven UNPC, treated between 1965 and 1999 in a single institution.

RESULTS

Using the 5th edition an overall downstaging of the population according to T status, N status, and stage grouping was evident along with a better correlation with likelihood of survival. The comparison between local and advanced disease according to T stage (T1+T2 vs. T3+T4) became highly significant in the new system (P = 0.0011 vs. P = 0.067 in the 4th edition).

CONCLUSIONS

As far as prognostic categories are concerned, the 5th edition of the AJCC staging manual appears to be an improvement over the previous classification, even though for pediatric patients a uniform distribution among stages cannot be observed because most children present with advanced disease. The overall downstaging should be taken into consideration for the stratification of patients in future trials.