Clinical significance of cranial nerve deficit in the therapy of nasopharyngeal carcinoma

Outcome of Abducens Nerve Paralysis in Patients with Nasopharyngeal Carcinoma

PURPOSE

The objective of this study was to investigate the incidence, management and outcome of patients with nasopharyngeal carcinoma (NPC) who developed Vlth nerve palsy.

METHODS

Between December 1993 and December 1999, we investigated retrospectively the charts of 166 patients with NPC.

RESULTS

Twenty-eight of 166 patients (16.8%) had cranial nerve involvement at the time of the diagnosis of NPC. Sixteen (57.2%) were identified as having abducens nerve palsy. In 25% abducens nerve palsy was the presenting symptom. Three patients were able to compensate for their diplopia after prism correction or botulinum toxin-A injection, and six (50%) completely recovered from abducens nerve palsy after either radiotherapy or chemotherapy.

CONCLUSIONS

Abducens is the most common cranial nerve involved in NPC, radiotherapy and or chemotherapy relieves the paralysis in half the patients. Prism correction or botulinum toxin-A injection are effective non-invasive procedures for patients with significant diplopia.

Therapeutic outcome of nasopharyngeal carcinoma with cranial nerve palsy: a single institution experience of 104 patients

PURPOSE

Cranial nerve (CN) palsy is the main symptom in patients with locally advanced nasopharyngeal carcinoma (NPC). This study aimed to evaluate the therapeutic outcome of NPC with CN palsy and to analyze the prognostic factors.

PATIENTS AND METHODS

A total of 104 NPC patients with CN palsy curatively treated by conventional (n=44) or conformal (n=60) radiotherapy (RT) were enrolled. Upper CN palsy was present in 81 patients, lower CN palsy in four patients, and both upper and lower CN palsy in 19 patients. Forty-one patients had CN palsy for >2 months before diagnosis.

RESULTS

Complete recovery of CN palsy was observed in 74 patients. The actuarial 5-year locoregional control (LRC), distant metastasis-free survival (DMFS), and overall survival (OS) rates were 58.2%, 62.2%, and 38.4%, respectively. No significant difference was observed in CN recovery, LRC, DMFS, or OS for patients treated by conventional versus conformal technique. However, significant reduction of grade 3 or greater toxicities was found in those treated by the conformal technique (odds ratio =0.28).

CONCLUSION

Patients with CN palsy presenting >2 months before diagnosis were hard to recover from palsy. The LRC, OS, and recovery from CN palsy did not significantly change with the treatment evolution. Patients with complete recovery from CN palsy had longer OS.

T4-locally advanced nasopharyngeal carcinoma: prognostic influence of cranial nerve involvement in different radiotherapy techniques

BACKGROUND

Cranial nerve involvement at disease presentation of nasopharyngeal carcinoma was not uncommon. We investigated the prognosis of patients with T4-locally advanced NPC, with or without cranial nerve involvement, and compared the outcome of patients treated using different radiotherapy techniques.

METHODS

In this retrospective study, 83 T4-locally advanced NPC patients were diagnosed according to the seventh edition of the American Joint Committee on Cancer staging system. All patients were treated using three-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiation therapy (IMRT). The survival rate was analyzed using the Kaplan-Meier method.

RESULTS

The 5-year overall, locoregional-free, and disease-free survival rates of patients treated using IMRT were 88.9%, 75.2%, and 69.2%, respectively. The outcome in these patients was significantly better than that in patients treated using 3D-CRT, with survival rates of 58.2%, 54.4%, and 47.2%, respectively. There was no significant difference in the 5-year overall, locoregional-free, and disease-free survival rates of the patients with (64.2%, 60.5%, and 53.5%, resp.) and without (76.9%, 63.6%, and 57.6%, resp.) cranial nerve involvement.

CONCLUSION

Locally advanced NPC patients treated using IMRT had significantly better outcomes than patients treated using 3D-CRT. Our results showed that the outcome of T4 NPC patients with or without cranial nerve involvement was not different.

Headache as the sole symptom of nasopharyngeal carcinoma and its clinical implications

BACKGROUND

This study aimed to investigate the clinical features of NPC presenting with headache as the primary or sole symptom.

METHODS

The authors retrospectively identified 14 cases of NPC with headache as the initial presentation between 2003 and 2008. Headache characteristics, tumor staging, and treatment outcomes were assessed.

RESULTS

Most patients had either T4 (n = 12) or T3 (n = 1) tumor. The average duration of headaches prior to NPC diagnosis was 7.9 months. The location of the headaches was most commonly described as temporal or parietal with various pain patterns. Six patients (43%) experienced unilateral headache during attacks while the remaining patients reported bilateral or diffuse pain. Of the 14 patients, 10 (71%) experienced significant improvement in head pain during or after the treatment; most of them reported relief shortly after chemoradiation was initiated. The 5-year overall survival of these patients was similar to that of other NPC patients.

CONCLUSION

Headache can be the only symptom of NPC. A timely diagnosis, albeit challenging to physicians, provides good outcomes in terms of both pain relief and tumor control.

Concurrent chemoradiotherapy with carboplatin followed by carboplatin and 5-fluorouracil in locally advanced nasopharyngeal carcinoma

Background

This study aimed to evaluate acute major toxicities, the response rate, 3-year overall survival and progression-free survival rate of locally advanced nasopharyngeal carcinoma patients on concurrent carboplatin chemoradiotherapy followed by carboplatin and 5-fluorouracil.

Methods

A prospective study of fifty patients diagnosed with locally advanced nasopharyngeal carcinoma received conventional radiation therapy with a total dose of 6600-7000 cGy in 6-7 weeks and concurrent chemotherapy of three cycles of carboplatin during radiotherapy, followed by adjuvant chemotherapy using carboplatin plus 5-fluorouracil for two cycles.

Results

Weight loss and mucositis were the two most common acute major grades 3-4 toxicities (42%). Myelosuppression occurred subsequently, including leukopenia (30%), neutropenia (20%), anemia (12%), and thrombocytopenia (6%). Only 8% of patients developed grades 3-4 nausea and vomiting. No patients had renal and electrolyte abnormalities. Regarding the response evaluation, 100% of patients achieved an objective response rate of the primary tumor (92% complete response, and 8% partial response). Similarly, all patients also achieved an objective response rate of the neck node (64% complete response and 36% partial response). The 3-year overall survival rate and progression-free survival rate were 89.7% and 72.7%, respectively.

Conclusions

Concurrent chemoradiotherapy with carboplatin followed by carboplatin and 5- fluorouracil could be considered as an alternative regimen for locally advanced nasopharyngeal carcinoma patients pertaining to a good overall response rate, 3-year overall survival and progression-free survival rate with good tolerability.

Nasopharyngeal carcinoma: current management, future directions and dental implications

Nasopharyngeal carcinoma (NPC) is a distinct cancer of the head and neck. Approximately 70% of patients with NPC present with locally advanced disease. Phase III clinical trials support combined chemotherapy and radiotherapy for the initial treatment of these patients. Current treatment approaches for metastatic disease are variable. Oral complications of therapy for NPC are very common. In order to support cancer therapy the dental provider must be aware of the diagnosis, prognosis and approach to treatment. Dental care requires that radiation fields be understood as well as the permanent changes that occur with high dose radiation therapy. Radiation causes changes in bone and soft tissue that may result in acute and chronic oral complications. The most common acute complications are mucositis, infection, xerostomia and taste changes. Mucositis is of increased severity and duration when chemotherapy is combined with radiation therapy. Chronic complications are due to late effects of radiation therapy including hyposalivation, infection, taste change, dysphagia and trismus. Treatment innovations with molecularly targeted therapies and immunotherapy are being assessed to improve treatment outcomes in NPC and will impact oral complications and oral care.

Neurologic Complications of Head and Neck Cancers

Despite the physical proximity of head and neck cancers to neurologic structures there have been few reviews of the neurologic complications of these cancers. This article reviews the neurologic manifestations of primary cancers of the head and neck and the complications that may arise as a result of tumor invasion, surgery and reconstruction, and radiation therapy.

Nasopharyngeal carcinoma: the role of the dentist in assessment, early diagnosis and care before and after cancer therapy

Nasopharyngeal carcinoma (NPC) may present first to the dental profession as facial pain, neck masses, difficulty in speech and swallowing, ear, nose and throat symptoms, or as symptoms of temporomandibular disorders (TMD). Recognition of the signs and symptoms are essential in order to lead to the correct diagnosis, and to avoid inappropriate intervention that may further delay diagnosis and initiation of treatment of the cancer. Differentiation between NPC and TMD may be facilitated by specific questioning of other symptoms that are not frequently associated with TMD such as neck masses, nasal obstruction, recent unilateral hearing deficit and epistaxis. The general dentist can become involved at three stages of a patient's experience with NPC: Stage 1, recognition of signs and symptoms; Stage 2, pre-treatment dental assessment; and Stage 3, post-treatment support. This paper is intended to: (1) alert the general dentist of the signs and symptoms associated with NPC, such that timely and appropriate treatment may ensue; (2) provide a basic outline for assessment, preparation, palliation and continuing care of a patient diagnosed with NPC; and (3) underline the significant role of the general dentist in achieving an optimal quality of life for these patients

Hypoglossal nerve palsy in nasopharyngeal carcinoma

BACKGROUND

The aim of the study was to use magnetic resonance (MR) imaging to determine the cause of hypoglossal nerve palsy and the sites of injury in patients with nasopharyngeal carcinoma before radiation therapy and during postradiation therapy follow-up.

METHODS

The clinical records and MR studies of 21 patients with hypoglossal nerve palsy were retrospectively studied. These 21 patients belonged to a cohort of 387 patients with nasopharyngeal carcinoma (153 with newly diagnosed disease and 234 on postradiation follow-up) who underwent MR imaging in a 2.5-year period.

RESULTS

Four patients had hypoglossal nerve palsy at initial diagnosis and all of them had extensive skull base invasion from tumor extending postero-inferiorly to the level of the foramen magnum. The nerve was invaded in the carotid sheath (3), hypoglossal nerve canal (3), and premedullary cistern (1). In 17 patients developing hypoglossal nerve palsy after radiotherapy, only two (12%) had evidence of tumor recurrence. Radiation-induced neuropathy was the probable cause in 14 patients and 1 case was judged indeterminate. MR evidence of fibrosis was demonstrable along the course the nerve in four patients (29%), involving the carotid sheath (4), hypoglossal nerve canal (2), and premedullary cistern (1). No patient had MR evidence of radiation change in the brain stem. Seven patients had a history of a boost dose of radiation to the parapharyngeal region on one or both sides, and nerve palsy occurred on the boosted side in six of them.

CONCLUSION

Hypoglossal nerve palsy on presentation was caused by locally advanced nasopharyngeal tumor whereas a palsy arising after radiation therapy was more frequently caused by postradiation damage rather than cancer.

Presenting signs and symptoms of nasopharyngeal carcinoma

Pain in the head and neck may be due to multiple causes and difficult to localize. A definitive diagnosis can be difficult to make. The literature reports several cases of nasopharyngeal carcinoma presenting as temporomandibular disorders (TMD). The records of 52 patients with a diagnosis of nasopharyngeal carcinoma were reviewed to determine the frequency of symptoms that may be similar to TMD. In 13.5% of the patients common TMD signs and symptoms were present, such as clicking in the joint, pain while chewing, and limited opening. Of the patients reviewed, 44.2% described the location of their pain as headache, earache, or as jaw, midface, or neck pain. The most common description of pain was aching, dull, or pressing. Symptoms identified that may assist in differentiation of nasopharyngeal carcinoma from TMD include nosebleed, nasal stuffiness, altered hearing, and cervical lymph node enlargement. A patient with carcinoma of the nasopharynx may have symptoms that must be differentiated from TMD.

Cranial nerve involvement and base of the skull erosion in nasopharyngeal carcinoma

In a prospective study of 262 consecutive patients with nasopharyngeal carcinoma (NPC), using computed tomography (CT) as their baseline evaluation, erosion of the base of the skull and intracranial extension into the middle cranial fossa were found in 31.3% and 12.2% of patients, respectively. Thirty-four of these patients had cranial nerve involvement at presentation; 30 of them had involvement of one or more of the third to sixth cranial nerves. Most cases of intracranial extension of tumor were accompanied by erosion of the base of the skull, but the reverse was not true. All patients with cranial nerve palsy involving the third to sixth cranial nerves had associated erosion of the ipsilateral base of the skull. The CT evaluation of patients with cranial nerve involvement who are believed to harbor NPC should include thin cuts of the base of the skull for detection of subtle bone erosion. This may be the only clue to the presence of a small NPC. The prognostic significance of cranial nerve involvement, base of the skull erosion, and intracranial extension of the tumor on the survival of the group of 84 patients who had T4 tumors was evaluated with regression analysis using the Cox model. Only cranial nerve involvement was found to be a significant factor influencing survival.

Prognostic value of paranasopharyngeal extension of nasopharyngeal carcinoma on local control and short-term survival

The local tumor control of 262 patients with nasopharyngeal carcinoma (NPC) at median follow-up of 27 months was studied with reference to the paranasopharyngeal and other aspects of extranasopharyngeal extension of tumor, as well as to other possible prognostic factors. Only cranial nerve palsy, oropharyngeal involvement, and paranasopharyngeal extension of tumor were found to be significant in a multivariate analysis using Cox model for factors influencing local tumor control. Other factors and other parameters of extranasopharyngeal extension of tumor, namely, erosion of the base of skull, intracranial extension, and involvement of nasal fossa, were found not be significant. The degree of paranasopharyngeal extension in each side was correlated with scales measuring extranasopharyngeal extension of tumor in other directions (p = 0.001). Although the T stage and the paranasopharyngeal extension were individually found to be well correlated with local tumor control, the prognostic value of paranasopharyngeal extension remained significant among subgroups of patients with T3 and T4 disease (p = 0.1044 and 0.0010, respectively).

Magnetic resonance imaging, computed tomography and endosonography in the local staging of carcinoma of the cervix

Thirty-seven patients with carcinoma of the cervix were prospectively staged by examination under anaesthesia (EUA), transvaginal and transrectal ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI). Pathological correlation was available for 20 patients. In the pathologically staged patients, EUA agreed with the staging in 17, understaging three patients. Endosonography agreed with the staging in 19, CT in 16 and MRI in 18 patients. For the remaining 17 patients, endosonography agreed with the EUA findings in 13, CT in 12 and MRI in 12. This study has shown that endosonography and MRI are more accurate than CT in the local staging of carcinoma of the cervix. Computed tomography was least accurate in staging early tumours and differentiating between Stage Ib and IIb disease. Lymph node involvement was detected with equal frequency by both CT and MRI. Magnetic resonance imaging was useful in identifying vaginal and bladder wall involvement and in one patient showed features due to an unsuspected early pregnancy.