Treatment outcome for synchronous locoregional failures of nasopharyngeal carcinoma.

To review the outcome and evaluate the prognostic factors in the treatment of synchronous locoregional failures of nasopharyngeal carcinoma (NPC). We reviewed the records of 43 patients with synchronous locoregional failures of NPC who received salvage treatment or chemotherapy between November 1986 and January 2001. The recurrent disease was stage II in 61%, stage III in 30%, and stage IV in 9%. The local disease was rT1-2 in 67% and rT3-4 in 33%, and the regional disease was rN1 in 91% and rN2 in 9%. Persistent disease, defined as failures within 4 months of completion of primary radiotherapy, occurred in 53.5% and recurrent disease in 46.5%. Seventeen patients received surgery for regional and/or local failures with or without combined radiotherapy (ST group), 14 patients received reirradiation to both local and regional disease (RT group), and 12 patients received palliative chemotherapy only (CT group). The median follow-up was 18 months (range, 4-153) and for the surviving patients it was 29 months (range, 6-153). The 3-year relapse-free survival (RFS) rate and disease-specific survival (DSS) rate after salvage treatment or chemotherapy were 17% and 38%, respectively. The 3-year RFS rates in stage II, III, and IV disease were 25%, 8%, and 0%, respectively. The corresponding 3-year DSS rates were 43%, 28%, and 38%. The 3-year RFS rates in the ST, RT, and CT group were 39%, 7%, and 0%, respectively. The corresponding 3-year DSS rates were 55%, 25%, and 25%. Patients whose local disease was treated by surgical resection had a 3-year local control rate of 71% compared with 38% by reirradiation using brachytherapy or external radiotherapy. For regional disease, the 3-year nodal control rate after radical neck dissection was 65% compared with 24% by reirradiation. Further locoregional failure represents the major failure pattern, and the proportion of patients who had further local, regional, and both locoregional failures were 16%, 9%, and 53%, respectively. Distant metastasis occurred in 30% of patients, and only 5% had isolated distant metastasis in the absence of locoregional failures. On multivariate analysis, treatment by reirradiation or chemotherapy alone and rN2 disease were independent factors that predicted poor survival, whereas treatment by reirradiation or chemotherapy alone was the only independent factor that predicted further relapse or failure. Proper selection of patients for aggressive salvage treatment and individualization of treatment are important in managing patients with synchronous locoregional failures of NPC. A significant proportion of patients with early stage locoregional failures can still achieve long-term disease control and survival after aggressive salvage treatment using surgery with or without combined radiotherapy. In patients with more advanced disease, treatment by reirradiation alone or palliative chemotherapy is largely ineffective and is associated with a poor outcome.

Chua DT ，Wei WI ，Sham JS ，Cheng AC ，Au G ... -  《HEAD AND NECK-JOURNAL FOR THE SCIENCES AND SPECIALTIES OF THE HEAD AND NECK》

Survival outcome of patients with nasopharyngeal carcinoma with first local failure: a study by the Hong Kong Nasopharyngeal Carcinoma Study Group.

The purpose of this article is to report the overall survival (OS) outcome of patients with nasopharyngeal carcinoma (NPC) with local failure who received salvage treatment and to identify prognostic factors for OS. Between January 1996 and December 2000, 2915 patients received primary radiotherapy (RT) with or without chemotherapy for nonmetastatic NPC. At a median follow-up of 3.1 years, 319 patients had developed local failure as the first failure, with or without synchronous regional/distant failure. OS was calculated from the start of primary RT. Univariate and multivariate analyses were performed to identify prognostic factors for OS in patients with isolated local failure. The T classification distribution of the local failure (rT classification) was as follows: 68 (21%) rT1 to T2a, 92 (29%) rT2b, 82 (26%) rT3, and 77 (24%) rT4. The rT classification was the same as the initial T classification in 82% of patients. Two hundred seventy-five patients (86%) had isolated local failure, and 232 (84%) of them did not have any distant metastasis or regional failure develop during follow-up. Salvage treatment was given to 200 patients (73%) with isolated local failure. One hundred fifty-nine patients (80%) received reirradiation (108 external beam RT [EBRT], 44 brachytherapy, and seven EBRT plus brachytherapy), 22 patients (11%) underwent nasopharyngectomy with or without postoperative RT, and 19 patients (9%) were treated with chemotherapy alone. Four patients died of RT complications, and one died of chemotherapy toxicity in the absence of active NPC. The 3-year actuarial OS for patients with isolated local failure was 74%. On multivariate analysis, advanced initial T classification (hazard ratio [HR], 1.44; p = .0006) and the use of salvage treatment (HR, 0.54; p = .0038) were independent prognostic factors. For the subgroups of patients who had the same recurrent and initial T classification, salvage treatment was associated with improved OS only in the subgroup with T1 to T2 local failure (n = 127; p = 0.0446), but not in the subgroups with T3 (n = 48) or T4 (n = 54) disease. Most patients with first local failure have localized disease. Salvage treatment is feasible in most of the patients with clinically isolated local failure. Patients who had early initial T classification have a more favorable prognosis. Subgroup analysis suggests that salvage treatment only prolongs survival in patients with T1 to T2 recurrent disease.

Yu KH ，Leung SF ，Tung SY ，Zee B ，Chua DT ，Sze WM ，Law SC ，Kam MK ，Leung TW ，Sham JS ，Lee AW ，Au JS ，Hui EP ，Sze WK ，Cheng AC ，Yau TK ，Ngan RK ，Wong FC ，Au GK ，Chan AT ，Hong Kong Nasopharyngeal Carcinoma Study Group ... -  《HEAD AND NECK-JOURNAL FOR THE SCIENCES AND SPECIALTIES OF THE HEAD AND NECK》

Prognostic factors and outcome for nasopharyngeal carcinoma.

Farias TP ，Dias FL ，Lima RA ，Kligerman J ，de Sá GM ，Barbosa MM ，Gonçalves FB Jr ... -  《-》

Adjuvant fractionated high-dose-rate intracavitary brachytherapy after external beam radiotherapy in Tl and T2 nasopharyngeal carcinoma.

The value of high-dose-rate intracavitary brachytherapy (HDRIB) for persistent or recurrent nasopharyngeal carcinoma has been well described; however, the benefit of routine adjuvant fractionated HDRIB following external beam radiation therapy (EBRT) has not been completely determined. The objective of this analysis was to evaluate the outcome of two fractions of adjuvant HDRIB treatment in Tl and T2 nasopharyngeal carcinoma. Thirty-three consecutive and nonselected patients who had Tl and T2 non-disseminated nasopharyngeal carcinoma were treated according to an IRB approved institutional research protocol between March 1999 and July 2001. By the 1997 AJCC cancer staging classification, 22 patients (67%) had Tl disease and 11 patients (33%) had T2 disease. Seventeen of these patients who had stage I or stage II disease (i.e., NO or Nl) were treated with EBRT followed by two fractions of adjuvant HDRIB (group 1); 16 patients who had stage III or stage IV disease (i.e., N2 or N3) were treated with concurrent cisplatin, EBRT and adjuvant HDRIB and subsequent adjuvant cisplatin and fluorouracil (5-FU) chemotherapy (group 2). EBRT was delivered by daily conventional fractionation to a total dose of 66 Gy to the primary tumor. Nodal disease received 66 Gy if it was less than 3 cm in maximum diameter and 70 Gy if larger or there was palpable residual disease after 66 Gy. A total of 10 Gy of HDRIB in 2 equal fractions of 5 Gy spaced 1 week apart was delivered starting 1 week after the completion of EBRT. All patients were assessed for treatment response, local control, survival, and toxicity. The median follow up for all 29 surviving patients is 29 months (range: 17-38 months). One patient died 7 months and one died 18 months after radiation therapy from the effects of distant metastases; two died of unrelated causes. At the time of this analysis, one patient (3%) had persistent local disease and one patient (3%) developed pathologically confirmed local recurrence in the nasopharynx. In addition, one patient (3%) developed recurrence only in a neck node followed by distant metastasis, and two patients (6%) developed distant metastasis without locoregional relapse. The 2-year local control rate at the primary site was 93.6%, and the overall survival and disease-free survival rates were 82% and 74% respectively. All patients experienced some degree of acute and/or late toxicity related to radiation therapy. Ten patients (30%) experienced grade 3 acute and/or late toxicity and six patients (18%) developed grade 4 acute and/or late toxicity. No grade 5 toxicity occurred. No unexpected damage of structures within the HDRIB fields was detected. EBRT supplemented by two fractions of adjuvant HDRIB produced a 93.6% local control rate for Tl and T2 nasopharyngeal cancer at 2 years of follow up, with acceptable rates of acute and late toxicity. Brief adjuvant HDRIB appears to permit dose escalation safely, even in patients who receive chemotherapy concurrently with conventional radiation therapy. This strategy needs to be optimized and then tested in a prospective randomized phase III trial to learn if it can improve outcome.

Lu JJ ，Shakespeare TP ，Tan LK ，Goh BC ，Cooper JS ... -  《HEAD AND NECK-JOURNAL FOR THE SCIENCES AND SPECIALTIES OF THE HEAD AND NECK》

Management and outcome of recurrent well-differentiated thyroid carcinoma.

Palme CE ，Waseem Z ，Raza SN ，Eski S ，Walfish P ，Freeman JL ... -  《archives of otolaryngology-head & neck surgery》