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Aldhahri SF, Barakeh MM, Almetary RJ, Alfirm RB, Almousa HM, Alsubaie HM. Patterns of treatment failure in patients with nasopharyngeal carcinoma and salvage treatment outcome: A retrospective analysis study. Am J Otolaryngol 2023; 44:103941. [PMID: 37392726 DOI: 10.1016/j.amjoto.2023.103941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/13/2023] [Accepted: 06/03/2023] [Indexed: 07/03/2023]
Abstract
INTRODUCTION In Saudi Arabia, head and neck cancers represent 6 % of all malignancies. 33 % of these are nasopharyngeal. Thus, we aimed to distinguish patterns of treatment failure and salvage treatment outcomes among patients with nasopharyngeal carcinoma (NPC). METHODS A retrospective review of patients treated for NPC in a tertiary care hospital. From May 2012 to January 2020, we retrospectively reviewed 175 patients that fit our inclusion criteria. Those who did not complete their treatment, started treatment in another institution, or did not complete a 3-year follow-up were excluded. In addition, the primary treatment outcome and the salvage treatment for those who failed initial treatment were collected and analyzed. RESULTS Patients were predominantly stage 4 disease. 67 % of the patients were alive without evidence of disease during their last follow-up. However, 75 % of failure occurs in the first 20 months of completing the treatment regimen. Neoadjuvant therapy and delays in referral play a significant role in treatment failure. For failed cases, concurrent salvage chemoradiotherapy showed the best survival. CONCLUSION Advanced stage 4A and T4 nasopharyngeal carcinoma should receive the maximum treatment, with a close follow-up, particularly during the first 2 years after treatment. Furthermore, the excellent outcome from salvage chemoradiotherapy and radiotherapy alone would make physicians aware of the importance of aggressive primary treatment.
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Affiliation(s)
- Saleh F Aldhahri
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Department of Otolaryngology-Head and Neck Surgery, King Fahad Medical City, Riyadh, Saudi Arabia.
| | - Maha M Barakeh
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Renad B Alfirm
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Hemail M Alsubaie
- Department of Otolaryngology-Head and Neck Surgery, King Abdullah Medical City, Makkah, Saudi Arabia
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Chan SC, Hsu CL, Yen TC, Ng SH, Liao CT, Wang HM. The role of 18F-FDG PET/CT metabolic tumour volume in predicting survival in patients with metastatic nasopharyngeal carcinoma. Oral Oncol 2012; 49:71-8. [PMID: 22959277 DOI: 10.1016/j.oraloncology.2012.07.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 07/26/2012] [Accepted: 07/26/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To investigate the role of PET-derived imaging markers in predicting metastatic nasopharyngeal carcinoma (NPC) outcomes. MATERIALS AND METHODS A total of 56 patients with metastatic NPC were enrolled. Before treatment, all of the participants underwent (18)F-FDG PET/CT. The following (18)F-FDG PET parameters were assessed: standardised uptake value, metabolic tumour volume (MTV), and total lesion glycolysis. Multivariate Cox proportional hazards models were used to identify the independent predictors of survival. RESULTS The multivariate analysis showed that performance status>1 (P=0.007), Epstein-Barr virus (EBV) DNA titre>5000 copies/mL (P=0.001), and MTV>110 mL (P=0.013) were independent risk factors for progression-free survival (PFS). Male sex (P=0.004), performance status>1 (P<0.0001), EBV DNA level>5000 copies/mL (P<0.0001), and MTV>110 mL (P=0.003) independently predicted overall survival (OS). The 2-year PFS and OS rates of the patients with MTV≤110 mL were 23.2% and 43%, respectively, compared with 0% and 9.1%, respectively, for those with MTV>110 mL. Combining the MTV with the EBV DNA titre allowed further survival stratification by dividing the patients into three groups with distinct PFS (2-year rates=30.8%, 7.1%, and 0%, P<0.0001) and OS (2-year rates=68.4%, 40%, and 0%, P<0.0001) rates. CONCLUSION The MTV appears to be an independent risk factor in metastatic NPC patients. This factor is complementary to the EBV DNA titre for predicting survival in metastatic NPC.
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Affiliation(s)
- Sheng-Chieh Chan
- Department of Nuclear Medicine, Chang Gung Memorial Hospital, Keelong, and Chang Gung University College of Medicine, Taoyuan, Taiwan
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Kuang WL, Zhou Q, Shen LF. Outcomes and prognostic factors of conformal radiotherapy versus intensity-modulated radiotherapy for nasopharyngeal carcinoma. Clin Transl Oncol 2012; 14:783-90. [DOI: 10.1007/s12094-012-0864-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 12/26/2011] [Indexed: 11/29/2022]
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Lee SW, Cho KJ, Park JH, Kim SY, Nam SY, Lee BJ, Kim SB, Choi SH, Kim JH, Ahn SD, Shin SS, Choi EK, Yu E. Expressions of Ku70 and DNA-PKcs as prognostic indicators of local control in nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys 2005; 62:1451-7. [PMID: 16029807 DOI: 10.1016/j.ijrobp.2004.12.049] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2004] [Revised: 12/10/2004] [Accepted: 12/17/2004] [Indexed: 11/29/2022]
Abstract
PURPOSE The objective of this study was to determine whether the expressions of the two components of DNA-dependent protein kinase, Ku70 and DNA-protein kinase catalytic subunit (DNA-PKcs), influence the response to radiotherapy (RT) and outcome of treatment of nondisseminated nasopharyngeal carcinoma (NPC) in patients who received definitive RT. METHODS AND MATERIALS Sixty-six patients with NPC who were treated with radiotherapy alone or with concurrent chemotherapy between June 1995 and December 2001 were divided into groups based on the levels of immunoreactivity for Ku70 and DNA-PKcs in pretreatment biopsy specimens. The overexpression of Ku70 or DNA-PKcs groups included patients whose biopsy specimens showed at least 50% immunopositive tumor cells; patients in which less than 50% of the tumor cells in the biopsy tissues were immunopositive were placed in the low Ku70 and DNA-PKcs groups. The immunoreactivities for Ku70 and DNA-PKcs were retrospectively compared with the sensitivity of the tumor to radiation and the patterns of therapy failure. Univariate analyses were performed to determine the prognostic factors that influenced locoregional control of NPC. RESULTS The 5-year locoregional control rate was significantly higher in the low Ku70 group (Ku-) (85%) than in the high Ku70 group (Ku+) (42%) (p = 0.0042). However, there were no differences in the metastases-free survival rates between the 2 groups (Ku70+, 82%; Ku70- 78%; p = 0.8672). Univariate analysis indicated that the overexpression of Ku70 surpassed other well-known predictive clinicopathologic parameters as an independent prognostic factor for locoregional control. Eighteen of 22 patients who had locoregional recurrences of the tumor displayed an overexpression of Ku70. No significant association was found between the level of DNA-PKcs expression and the clinical outcome. CONCLUSIONS Our data suggest that the level of Ku70 expression can be used as a molecular marker to predict the response to RT and the locoregional control after RT and concurrent chemotherapy in patients with nondisseminated NPC.
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Affiliation(s)
- Sang-Wook Lee
- Department of Radiation Oncology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, South Korea
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Yen TC, Chang YC, Chan SC, Chang JTC, Hsu CH, Lin KJ, Lin WJ, Fu YK, Ng SH. Are dual-phase 18F-FDG PET scans necessary in nasopharyngeal carcinoma to assess the primary tumour and loco-regional nodes? Eur J Nucl Med Mol Imaging 2004; 32:541-8. [PMID: 15625603 DOI: 10.1007/s00259-004-1719-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2004] [Accepted: 10/14/2004] [Indexed: 11/26/2022]
Abstract
PURPOSE This prospective study aimed to investigate the efficacy of dual-phase positron emission tomography (PET) in evaluating the loco-regional status of nasopharyngeal carcinoma (NPC). METHODS Eighty-four patients with newly diagnosed NPC and a fasting serum glucose level of <200 mg/dl were enrolled. [18F]fluoro-2-deoxy-D-glucose (18F-FDG) PET studies (at 40 min and 3 h after injection of 370 MBq 18F-FDG) and head and neck magnetic resonance imaging (MRI) were performed within 1 week. Diagnostic criteria for NPC comprised the histopathological findings, the joint judgments of the research team and the post-treatment outcome. Each lesion's maximum standardised uptake value (SUV) and retention index were obtained. SUV data were evaluated using a paired t test. Receiver operating characteristic curves and calculation of the area under the curve (AUC) determined the discriminative power. RESULTS 18F-FDG PET was significantly superior to MRI in identifying lower neck NPC nodal metastasis (AUC: 1 vs 0. 972, P=0.046) and overall loco-regional metastases (AUC: 0.985 vs 0.958, P=0.036). However, 18F-FDG PET was similar to MRI in detecting primary tumour, as well as retropharyngeal, upper neck and supraclavicular nodal metastases. There was no significant difference between early phase (40 min) and delayed phase (3 h) 18F-FDG PET in the detection of primary tumours (accuracy: 100% vs 100%) or loco-regional nodal metastasis (AUC: 0.984 vs 0.985, P=0.834). CONCLUSION 18F-FDG PET is superior to MRI in identifying lower neck nodal metastasis of NPC. Additional 3-h 18F-FDG PET contributes no further information in the detection of primary tumours or loco-regional metastatic nodes in untreated NPC patients.
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Affiliation(s)
- Tzu-Chen Yen
- Department of Nuclear Medicine, Chang Gung Memorial University Hospital, Linkou Medical Center, Taiwan
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6
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Abstract
The survival outcome of patients with systemic cancer differs significantly between individuals even within the same tumour type. We set out to illustrate this by analysing the factors determining survival in patients with metastatic disease from nasopharyngeal carcinoma (NPC) and to design a scoring system based on these prognostic factors. Patients referred between January 1994 and December 1999 were retrospectively analysed. Factors analysed included patient (age group, gender, performance status (BS) at diagnosis of metastases), disease (number of metastatic sites, specific metastatic sites, disease-free interval (DFI), metastases at presentation, presence of locoregional recurrence), and laboratory factors (leucocyte count, haemoglobin level, albumin level). Univariate and multivariable analyses were performed using the Cox proportion hazards model. A numerical score was derived from the regression coefficients of each independent prognostic variable. The prognostic index score (PIS) of each patient was calculated by totalling up the scores of each independent variable. Independently significant, negative prognostic factors were liver metastasis, lung metastasis, anaemia, poor PS, distant metastasis at initial diagnosis, and a DFI of <6 months. Three prognostic groups based on the PIS were obtained: (i) good risk (PIS=0-6); (ii) intermediate risk (7-10); (iii) poor risk (>or=11). The median survivals for these groups were 19.5, 10, and 5.8, months, respectively, (log rank test: P<0.0001). The variable prognosis of patients with disseminated NPC can be assessed by using easily available clinical information (patient, disease and laboratory factors). The PIS system will need to be validated on prospectively collected data of another cohort of patients.
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Affiliation(s)
- Y K Ong
- Department of Medical Oncology, National Cancer Centre, Singapore, Singapore
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Teo PM, Leung SF, Chan AT, Leung TW, Choi PH, Kwan WH, Lee WY, Chau RM, Yu PK, Johnson PJ. Final report of a randomized trial on altered-fractionated radiotherapy in nasopharyngeal carcinoma prematurely terminated by significant increase in neurologic complications. Int J Radiat Oncol Biol Phys 2000; 48:1311-22. [PMID: 11121628 DOI: 10.1016/s0360-3016(00)00786-0] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- P M Teo
- Department of Clinical Oncology, Prince of Wales Hospital, Shatin, Hong Kong, People's Republic of China.
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Abstract
BACKGROUND To assess the role of staging CT of the thorax in advanced nodal stage nasopharyngeal carcinoma and to examine the hypothesis that contiguous spread of nodal metastases from the supraclavicular region to the upper mediastinal region occurs in this cancer. METHODS Forty-four patients with newly diagnosed nasopharyngeal carcinoma with neck node metastases to the supraclavicular region (ie, AJCC N3b stage) underwent contrast-enhanced CT (CECT) thorax for staging. CT findings and clinical outcome were analyzed. RESULTS No patient was found to have intrathoracic metastasis, although 1 had hepatic metastases on CECT of the thorax, resulting in upstaging in 1 of 44 (2%) of patients. With a median follow-up time of 21 months, 3 patients had lung metastases and 2 had axillary nodal metastases develop without evidence of upper mediastinal nodal metastases. CONCLUSION Staging CECT of the thorax has a very low yield in nasopharyngeal carcinoma, even in advanced nodal disease. The hypothesis that contiguous spread of nodal metastases from the supraclavicular region to the upper mediastinum is not substantiated, and no evidence suggests that radiation therapy for N3b-stage disease needs to encompass the upper mediastinum.
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Affiliation(s)
- S Leung
- Department of Clinical Oncology, Prince of Wales Hospital, Shatin, Hong Kong, China
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Tang SG, See LC, Chen WC, Tsang S, Chang JT, Hong JH. The effect of nodal status on determinants of initial treatment response and patterns of relapse-free survival in nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys 2000; 47:867-73. [PMID: 10863054 DOI: 10.1016/s0360-3016(00)00490-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To study the effect of regional nodal status on predictors of treatment response, failure patterns, and the time-dependent nature of the various pattern of relapse via a hazard function analysis. METHODS AND MATERIALS We reviews tumor control data of 496 patients with nasopharyngeal carcinoma (NPC) to whom a radical course of radiotherapy (RT) with or without induction chemotherapy (CT) was given. All alive patients had a median follow-up period of 131 months. Primary tumor (T) and nodal (N) status were staged according to the TNM system of the American Joint Committee. Remote after-loading brachytherapy may be added to teletherapy in T1-2 lesions while induction CT could be given for N3 and/or T4 lesions. Hazard function analysis over 1-year interval was carried out for locoregional or distant relapse. RESULTS T stage and brachytherapy were two independent predictors for complete response (CR) at the primary site irrespective of nodal status, whereas N stage and brachytherapy are major determinants for regional CR in node (+) patients. Multivariate analysis revealed that contributors to a relatively long disease-free interval in (1) node (-) patients were for locoregional relapse, induction CT(-) (p = 0.0062) or brachytherapy (+) (p = 0.0268) and for distant relapse, none; (2) node (+) patients were for locoregional relapse, early T stage (p = 0.0377) or regional CR (p = 0.0075) and for distant relapse, induction CT(-) (p = 0.0001) or regional CR (p = 0.0001). In node (-) or (+) patients, primary CR rate yield no independent prognostic value on various types of disease-free survival. Hazard function analysis for relapse revealed that hazard rates are in general negatively correlated with time, being highest at the first year post-treatment, decreasing from time to time, and approaching zero after a longer follow-up period in patients with locoregional CR than in patients without. CONCLUSION Nodal status had no significant impact on predictors of primary CR, whereas in node (+) patients regional CR rate had an independent value in predicting disease-free survival to locoregional and distant relapse. Hazard function analysis revealed a decreasing hazard rate over a protracted post-treatment time in primary and regional CR patients. This indicates the continued risk of late recurrence in this subset of patients for whom long-term observation is recommended.
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Affiliation(s)
- S G Tang
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan
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10
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Abstract
BACKGROUND Distant metastasis is a more common pattern of failure than locoregional recurrence after adequate radiotherapy in patients with nasopharyngeal carcinoma (NPC). The objective of this Phase II study was to assess the efficacy and toxicity of weekly chemotherapy in NPC patients with distant metastasis. METHODS Patients with a histologic diagnosis of NPC and documented distant metastasis were eligible, including those who 1) had metastatic disease at presentation; 2) had developed metastatic disease during or at any time after local radiotherapy; or 3) had developed progressive disease or recurrence of metastasis after prior chemotherapy. The weekly chemotherapy regimen was comprised of 5-fluorouracil (5-FU), 1250 mg/m2, plus cisplatin, 25 mg/m2, as a 24-hour continuous intravenous infusion via a subcutaneous implanted port, using an ambulatory pump in an outpatient setting for the first 19 patients. Because of the low incidence and reduced severity of toxicity, the dosage of chemotherapy was escalated to 5-FU, 1667 mg/m2, plus cisplatin, 33.3 mg/m2, for the subsequent 25 patients. RESULTS Between October 1992 and June 1996, a total of 44 patients with metastatic NPC were studied. They were 36 males and 8 females with a median age of 48 years (range, 30-72 years). Poorly differentiated epidermoid carcinoma or undifferentiated carcinoma were the major pathologic types. Twenty-six patients had single organ metastasis, whereas 18 patients had multiple organ involvement. Locoregional disease existed simultaneously in 16 patients. The majority of patients had received previous radiotherapy (33 patients) and chemotherapy (23 patients: 16 as concurrent therapy for localized disease, 6 as salvage therapy for metastatic disease, and 1 for a postradiation adjuvant purpose). Among 38 patients with measurable disease, 8 obtained a complete response (CR) (21.1%), 12 obtained a partial response (PR) (31.6%), 17 had stable disease (SD) (44.7%), and 1 had progressive disease (2.6%). The median duration of CR, PR, and SD were 6.5 months, (range, 2-12 months), 5.5 months (range, 2-9 months), and 2.5 months (range, 1-6 months), respectively. Toxicity was found to be very mild. Only one patient developed a World Health Organization (WHO) Grade 1 mucositis. No visible alopecia and no treatment-related deaths occurred. WHO Grade 3-4 hematologic toxicities occurred in 1.0% of patients for leukopenia, 4.1% for anemia, and 2.9% for thrombocytopenia. CONCLUSIONS Data from the current study indicate that 24-hour weekly infusion of 5-FU plus cisplatin has moderate activity but very low toxicity for NPC patients with distant metastasis. Further study is necessary to find more effective therapy.
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Affiliation(s)
- J C Lin
- Department of Radiation Oncology, Taichung Veterans General Hospital, School of Medicine, China Medical College, Taiwan
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Teo P, Yu P, Lee WY, Leung SF, Kwan WH, Yu KH, Choi P, Johnson PJ. Significant prognosticators after primary radiotherapy in 903 nondisseminated nasopharyngeal carcinoma evaluated by computer tomography. Int J Radiat Oncol Biol Phys 1996; 36:291-304. [PMID: 8892451 DOI: 10.1016/s0360-3016(96)00323-9] [Citation(s) in RCA: 167] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the significant prognosticators in nasopharyngeal carcinoma (NPC). METHODS AND MATERIALS From 1984 to 1989, 903 treatment-naive nondisseminated (MO) NPC were given primary radical radiotherapy to 60-62.5 Gy in 6 weeks. All patients had computed tomographic (CT) and endoscopic evaluation of the primary tumor. Potentially significant parameters (the patient's age and sex, the anatomical structures infiltrated by the primary lesion, the cervical nodal characteristics, the tumor histological subtypes, and various treatment variables were analyzed by both monovariate and multivariate methods for each of the five clinical endpoints: actuarial survival, disease-free survival, free from distant metastasis, free from local failure, and free from regional failure. RESULTS The significant prognosticators predicting for an increased risk of distant metastases and poorer survival included male sex, skull base and cranial nerve(s) involvement, advanced Ho's N level, and presence of fixed or partially fixed nodes or nodes contralateral to the side of the bulk of the nasopharyngeal primary. Advanced patient age led to significantly worse survival and poorer local tumor control. Local and regional failures were both increased by tumor infiltrating the skull base and/or the cranial nerves. In addition, regional failure was increased significantly by advancing Ho's N level. Parapharyngeal tumor involvement was the strongest independent prognosticator that determined distant metastasis and survival rates in the absence of the overriding prognosticators of skull base infiltration, cranial nerve(s) palsy, and cervical nodal metastasis. CONCLUSIONS The significant prognosticators are delineated after the advent of CT and these should form the foundation of the modern stage classification for NPC.
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Affiliation(s)
- P Teo
- Clinical Oncology Department, Prince of Wales Hospital, Shatin, Hong Kong
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Abstract
BACKGROUND Distant metastases are common in patients with nasopharyngeal carcinoma (NPC), and their presence is the most important factor in limiting survival. We aimed to study the prognosticators determining survival subsequent to distant metastasis from NPC. METHODS A study by both mono- and multivariate analyses was carried out in 945 patients presenting between 1984 and 1989. Forty-two presented with metastases and 247 developed metastasis after primary radiotherapy. RESULTS Patients who presented with distant metastasis (M1-classification) had a significantly shorter survival than those who developed metastases after primary radiotherapy. The presence of hepatic metastases, short metastasis free interval, and older age at presentation significantly predicted short survival after the diagnosis of distant metastasis. Patients with metastases preceded by, and/or accompanied with, locoregional recurrence had comparable survival to those without, despite their association with a significantly longer metastasis free interval. A history of locoregional recurrence was however not compatible with long term, disease free survival, and, in its presence, advanced T-classification on presentation predicted poor survival subsequent to metastasis. Long term disease free survival (64-117 months) was attained in 4 young patients (age < 40 years) with isolated intrathoracic metastases in the absence of locoregional recurrence after achieving a complete response to aggressive treatment, with chemotherapy, radiotherapy, and/or surgery, usually multimodal. CONCLUSIONS Some of the clinical prognosticators have been identified and an attempt was made to subclassify distant metastases according to possible differences in prognosis. A subset of metastatic NPC was identified which is compatible with long term, disease free survival. Investigations during follow-up should be directed toward the early detection of such potentially salvageable cases.
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Affiliation(s)
- P M Teo
- Clinical Oncology Department, Prince of Wales Hospital, Shatin, Hong Kong
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13
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Abstract
From 1984 to 1989, 903 treatment-naive non-disseminated nasopharyngeal carcinomas (NPCs) were given primary radical radiotherapy. All patients had computed tomographic and endoscopic evaluation of the primary tumour. Potentially significant parameters were analysed by both univariate and multivariate methods for independent significance. In the whole group of patients, the male sex, skull base and cranial nerves(s) involvement, advanced Ho N-level, presence of fixed or partially fixed nodes and nodes contralateral to the side of the bulk of the nasopharyngeal primary, significantly determined survival and distant metastasis rates, whereas skull base and cranial nerve involvement, advanced age and male sex significantly worsened local control. However in the Ho T2No subgroup, parapharyngeal tumour involvement was the most significant prognosticator that determined distant metastasis and survival rates in the absence of the overriding prognosticators of skull base infiltration, cranial nerve(s) palsy, and cervical nodal metastasis. The local tumour control of the Ho T2No was adversely affected by the presence of oropharyngeal tumour extension. The administration of booster radiotherapy (20 Gy) after conventional radiotherapy (60-62.5 Gy) in tumours with parapharyngeal involvement has led to an improvement in local control, short of statistical significance.
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Affiliation(s)
- P Teo
- Clinical Oncology Department, LKSOPD Basement, Prince of Wales Hospital, Hong Kong, Hong Kong
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14
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Teo PM, Kwan WH, Leung SF, Leung WT, Chan A, Choi P, Yu P, Lee WY, Johnson P. Early tumour response and treatment toxicity after hyperfractionated radiotherapy in nasopharyngeal carcinoma. Br J Radiol 1996; 69:241-8. [PMID: 8800868 DOI: 10.1259/0007-1285-69-819-241] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The aim of the present study was to undertake a planned interim analysis of a prospective randomized trial comparing the tumour response and the acute and subacute complications of hyperfractionated radiotherapy and conventional radiotherapy in non-metastatic nasopharyngeal carcinoma (NPC). 100 patients with newly diagnosed non-metastatic NPC were randomized to receive either conventional radiotherapy (Arm I) or hyperfractionated radiotherapy (Arm II). Stratification was done according to the T-Stage (modified Ho's T-Stage classification). The biological effective dose (10 Gy) 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. Hyperfractionated radiotherapy was associated with significant mucositis which is of higher grade than conventional radiotherapy (p = 0.0001), but the duration of mucositis was similar between the two Arms and all study patients completed radiotherapy on schedule without interruption of radiotherapy. Early survival and tumour recurrence rates were comparable between the Arms. The preliminary results indicate that the hyperfractionated radiotherapy has excellent patient compliance in Chinese patients, with acceptable acute and subacute toxicities and the local and regional complete tumour response rates being comparable with conventional radiotherapy. The significance of the time required after start of radiotherapy to achieve a complete tumour response is discussed.
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Affiliation(s)
- P M Teo
- Clinical Oncology Department, Prince of Wales Hospital, Hong Kong
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15
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Teo PM, Leung TW, Chan AT, Yu P, Lee WY, Leung SF, Kwan WH, Johnson P. A retrospective study of the use of cisplatinum-5-fluorouracil neoadjuvant chemotherapy in cervical-node-positive nasopharyngeal carcinoma (NPC). Eur J Cancer B Oral Oncol 1995; 31B:373-9. [PMID: 8746267 DOI: 10.1016/0964-1955(95)00026-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A retrospective study on 422 nasopharyngeal carcinoma (NPC) patients with cervical nodal metastases treated between 1984 and 1987 was performed. 169 received neoadjuvant chemotherapy (CHEMO) with cisplatinum and 5-fluorouracil for two or three courses prior to definitive radiotherapy and 253 were treated by radical radiotherapy alone (NCHEMO). While the primary tumour (T-stage) prognosticators had been comparable between the two groups, CHEMO had significantly more advanced cervical nodal metastases with bulkier nodes and more low-cervical and supraclavicular nodes (P < 0.05) which could account for its overall worse survival, poorer regional tumour control and a trend towards worse systemic tumour control. The worse regional control in CHEMO for Ho's N1 could be the result of more bulky nodes and more tumours infiltrating the skull base and/or causing cranial nerve(s) palsy. There was no statistical or apparent difference between CHEMO and NCHEMO for the same Ho's overall stages of NPC with comparable nodal and primary tumour characteristics for the clinical endpoints of actuarial survival rate (ASR), disease-free survival rate (DFS), free of local failure survival rate (FLF), and free from distant metastases survival rate (FDM), despite the presence of significantly more fixed nodes and bulky nodes. This suggests a possible beneficial effect of the neoadjuvant chemotherapy. However, multivariate analysis has not shown the administration of the neoadjuvant chemotherapy to be of prognostic significance. Even though the chemotherapy was well tolerated with little toxicity, we recommend against the routine use of neoadjuvant chemotherapy in cervical-node-positive NPC outside the context of a prospective randomised clinical trial.
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Affiliation(s)
- P M Teo
- Clinical Oncology Department, Prince of Wales Hospital, Hong Kong
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Chan AT, Teo PM, Leung TW, Leung SF, Lee WY, Yeo W, Choi PH, Johnson PJ. A prospective randomized study of chemotherapy adjunctive to definitive radiotherapy in advanced nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys 1995; 33:569-77. [PMID: 7558945 DOI: 10.1016/0360-3016(95)00218-n] [Citation(s) in RCA: 204] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE A prospective randomized trial was conducted to compare chemoradiotherapy against radiotherapy alone in the treatment of locoregionally advanced nasopharyngeal carcinoma. METHODS AND MATERIALS Eighty-two patients with histologically proven nasopharyngeal carcinoma who had either Ho's N3 staging or any N stage with a nodal diameter of > or = 4 cm were entered. Seventy-seven patients were evaluated for tumor response and survival. The patients were randomized to receive two cycles of cisplatin 100 mg/m2 Day 1,5-fluorouracil 1000 mg/m2 24-h infusion Days 2, 3, and 4 before radical radiotherapy, and four cycles of postradiotherapy chemotherapy (37 patients) or radiotherapy alone (40 patients). All patients received radical radiotherapy to the nasopharynx and neck. The nasopharynx and upper neck were treated to 66 Gy by conventional fractionation and the lower neck to 58 Gy. Booster radiotherapy (7.5 Gy/two fractions/week) was given to any residual nodes after standard radiotherapy. RESULTS The patient characteristics, including staging, were similar in both arms. The overall response rate to neoadjuvant chemotherapy was 81% (19% complete response, 62% partial response). The rates of radiotherapy for boosting parapharyngeal disease or residual lymph nodes were not significantly different in the two arms. The overall complete response rate to chemoradiotherapy was 100%, and to radiotherapy alone, 95%. Toxicities in the chemoradiotherapy arm were mainly myelosuppression, nephrotoxicity, and nausea and vomiting. The degree of mucositis was not significantly different in the two arms. There was no treatment-related death. The median follow up was 28.5 months. The 2-year overall survival was 80% in the chemoradiotherapy arm and 80.5% in the radiotherapy arm. The 2-year disease-free survival was 68% in the chemoradiotherapy arm and 72% in the radiotherapy arm, without significant difference between the two arms. The locoregional relapse rate, distant metastatic rate, and median time to relapse were also not significantly different between the two arms. CONCLUSION Despite promising tumor response rates from Phase II trials, this prospective randomized trial has demonstrated no benefit from adjunctive chemotherapy to radiotherapy in the treatment of locoregionally advanced nasopharyngeal carcinoma.
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Affiliation(s)
- A T Chan
- Department of Clinical Oncology, Prince of Wales Hospital, Shatin, Hong Kong
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