Chien-Hsun Chen

Impact of Intracranial Extension on Survival in Stage IV Nasopharyngeal Carcinoma: Identification of a Subset of Patients with Better Prognosis

OBJECTIVE T-stage is an imperfect prognostic indicator for patients with nasopharyngeal carcinoma. We evaluated the effect of extent of intracranial involvement on survival after conventional radiotherapy in patients with Stage T4 nasopharyngeal carcinoma. METHODS We conducted a retrospective analysis of the results of computed tomography, magnetic resonance imaging and treatment outcomes in 84 consecutive patients with Stage T4 nasopharyngeal carcinoma during the period September 1993 to December 2002 in Taiwan. The patients were subcategorized into those who had limited intracranial involvement (primary nasopharyngeal tumors with involvement of the unilateral cavernous sinus or the parasellar region only) or extensive involvement (extension of the tumors to the bilateral cavernous sinus or the parasellar region, into the orbit and the ethmoid sinus anteriorly, or to the prepontine region and the posterior cranial fossa). RESULTS Extensive intracranial involvement was found in 51.2% of the patients. Among these patients, the 5-year rate of overall survival after conventional radiotherapy was only 3.4%. In contrast, the 5-year survival among patients with limited intracranial involvement was 42.9%. This difference was significant (P < 0.001). In the multivariate analysis, extensive intracranial involvement, advanced age and a nodal status of N3 correlated with poor overall survival (all P < 0.05). CONCLUSIONS Among patients with T4 nasopharyngeal carcinoma, better treatment outcomes were associated with limited intracranial involvement. We conclude that a subdivision of Stage T4 nasopharyngeal carcinoma disease based on the extent of intracranial involvement would provide better prognostic information.

A Case of Squamous Cell Carcinoma Arising from Presacral (Retrorectal) Epidermoid Cyst

Epidermoid cyst of the presacral space is a rare congenital lesion. Cases of malignance arising from the lesion are extremely rare. After searching the literature, there are only 1 image report in English literature (PubMed) and 4 cases reports in Japanese literature of the disease. Here we report a 62-year-old female who was diagnosed with presacral cyst before surgery. Wide excision of the cystic tumor by Kraskes operation was performed. The pathology showed squamous cell carcinoma. Because of tumor rapture during operation, adjuvant radiotherapy 50 Gray/ 25 fractions was performed. After 1 year follow up, there is no evidence of disease.

Solitary Extramedullary Plasmacytoma of the Head and Neck: Treatment Outcome in 6 Patients and a Review of Literature

Purpose: Solitary extramedullary plasmacytoma of the head and neck (EMPHN) is a rare disease. The objective of this study was to review the treatment results of EMPHN patients in a single institution in TaiwanMethods and Materials: The cases of 6 patients (4 males and 2 females) diagnosed at our hospital with EMPHN between 1980 and 2010 were reviewed. The median age of the patients was 64 years (range, 54-79 years). Two patients underwent surgery alone, 2 patients underwent radiotherapy alone, and 2 patients underwent surgery and adjuvant radiotherapy. The dose of radiotherapy was 50-50.4 grays (Gy) in 25-28 fractions.Results: The median follow-up duration was 5 years. The primary tumor sites were the nasal cavity (2), paranasal sinuses (2), oropharynx (1), and nasopharynx (1). Local recurrence was observed in 2 patients who underwent surgery alone and local control was achieved in 1 after salvage surgery (no evidence of disease after salvage surgery in the follow up 3 years period). Local control was achieved in 2 patients treated with surgery and adjuvant radiotherapy. Distant metastasis to the skin and bone without evidence of local recurrence was observed in 2 patients treated with radiotherapy alone. None of the patients progressed to multiple myeloma during follow-up evaluations and no severe radiotherapy-related morbidity was observed. One patient who treated with surgery alone died from recurrent EMPHN within the follow-up duration.Conclusions: Local control of the tumor in the primary site was achieved in 4 patients with EMPHN who underwent radiotherapy alone or adjuvant, although 2 of these patients presented with distant metastasis. According to the review of literature and our results, radiotherapy might be safe and effective for local control of EMPHN.

Treatment Outcome of Neoadjuvant Chemoradiotherapy for Esophageal Squamous Cell Carcinoma in Our Institution

Purpose: In this retrospective study, we evaluated the treatment outcome following neoadjuvant chemoradiotherapy for esophageal cancer and the impact of tumor regression and post operative nodal status.Materials and Methods: Sixty-four patients of esophageal cancer treated with neoadjuvant chemoradiotherapy from June, 1999 to April, 2011 were followed retrospectively. Tumor regression grade (TRG), post operative nodal status, pathologic stage, pattern of recurrence and overall survival (OS) of these patients were recorded and analyzed. Disease-free and overall survival rates were calculated with Kaplan-Meier method and group comparisons were based on the log-rank test. Cox regression analysis was the method applied when several factors were assessed simultaneously.Results: Median survival is 24.2 months (range, 3-92 months). Comparing TRG 1 with TRG 2-4, the OS was not significantly different (P = 0.549). When TRG1-2 was compared with TRG3-4, there was a trend of significant difference in OS (P = 0.089). The median survival was 23.6 months in the N- group, compared with 13.5 months in the N+ group (P ＜ 0.001). In univariate survival analysis, N+ (P ＜ 0.001) and vascular involvement (P = 0.041) significantly influence survival probabilities. N+ was significantly (P = 0.001) associated with distant metastasis and TRG 3-4 (P = 0.008) with locoregional recurrence. By multivariate analysis, only N+ significantly influence OS (P = 0.004) and vascular involvement (P = 0.658) was not significant.Conclusion: For those who are receiving neoadjuvant chemoradiotherapy, achieving node-negative status is a significant prognostic factor for the outcome. As for histomorphologic tumor regression, it has a less predictive factor.

Intracranial Hemangiopericytoma: A Case Report and Literatures Review

Hemangiopericytomas are rare soft tissue tumors that develop mainly in the lower extremities, retroperitoneum or pelvis and rarely occur in the larynx, spleen, bone, meninges or thorax. This case is that of a 35-year-old man with intracranial hemangiopericytoma which was treated with craniotomy and partial removal of tumor. This was followed by post operative radiotherapy using conventional wedge pair technique with total dose of 63 Gy in 35 fractions to the residual tumor. MRI (magnetic resonance image) of brain showed no recurrence or other abnormal finding at a 10-year follow-up. The patient has long-term tumor control after surgery and post-operative radiotherapy.

Small Cell Carcinoma of External Auditory Canal: A Case Report

Extrapulmonary small cell carcinoma arising from head and neck is extremely rare. We report a 51-year-old woman with small cell carcinoma of right external auditory canal. A wide excision surgery was performed. Right side neck lymph node metastasis was found after operation. She underwent chemotherapy with 6 courses of cisplatin and etoposide. The posttreatment CT scan of head and neck disclosed complete remission of lymphadenopathy and no local recurrence of primary tumor. Then she received local radiotherapy using IMRT technique with 60 Gy in 30 fractions to tumor bed and 54 Gy in 30 fractions to regional lymphatics. The treatment course of radiation was completed smoothly. However, the patient developed liver metastases during the radiotherapy course and then died 12 months after the initial diagnosis. We believe that although radiotherapy have benefit for local control, chemotherapy is of the most importance for extrapulmonary small cell carcinoma.

Malignant Myoepithelioma of Soft Palate: A Case Report

Malignant myoepithelioma, a rare tumor mostly located in the parotid gland, accounts for less than 1% of salivary gland neoplasms. Here, we report a case of malignant soft palate myoepithelioma. A 36-year-old woman had a painless mass over the soft palate for 4 years: she first visited our hospital in May 1998; received a biopsy; and was initially diagnosed with pleomorphic adenoma. After local excision of the tumor in September 1998, the myoepithelioma was confirmed. Lymph nodes over the right submandibular area were subsequently identified in 2001. Using fine needle aspiration, undifferentiated squamous cell carcinoma of nasopharyngeal origin was ascertained. The patient underwent a course of concurrent chemoradiotherapy ending in December 2001. Four months later, residual lymph nodes were excised. The tumor cells were diagnosed as malignant myoepithelioma. A CT scan in January 2005 showed a mass lesion in the right maxillary sinus and palate. Wide excision confirmed the diagnosis of recurrent malignant myoepithelioma. A further CT scan in October 2007 showed a mass involving the right maxillary sinus. After wide excision, local recurrence was confirmed. Local radiotherapy in a dose of 50.4 Gy in 28 fractions was initiated and ended in January 2008. Eight months later, a CT scan asserted a mass in the right aryepiglottic fold. After excision, recurrent malignant myoepithelioma was confirmed. This patient was free of the disease in the last OPD follow-up in February 2009.

Postoperative Radiation Therapy in Patients with Pathologic Risks of Stage IB to IIA Cervical Carcinoma

Purpose : To investigate the prognostic impact of pathologic risk factors and failure patterns in patients with stage IB to IIA cervical carcinoma treated with postoperative adjuvant pelvic irradiation. Material and Method : Between April 1991 to December 2000, 130 patients with FIGO IB to IIA carcinoma of the cervix were treated with radical hysterectomy, bilateral pelvic lymphadenectomy and postoperative radiation therapy. Nineteen patients received systemic chemotherapy. All the patients had at least one of the following pathologic risk factors: 1. positive pelvic nodal metastasis, 2. multiple positive lymph nodes, 3. parametrial invasion, 4. vascular space invasion, 5. positive surgical margin, 6. bulky tumor size ＞ 4 cm, 7. multiple pathologic risk factors. The radiation dose delivered to the whole pelvis range from 41-54 Gy in 1.8 Gy fractions. One hundred twenty-four patients received 2.5-21.5 Gy intracavitary brachytherapy. Results : The patients were followed for a median of 57.9 months (range: 4.1 - 129.9). The 5-year overall survival and disease free survival rate were 76.5% and 76.1%, respectively. A total of 29 (22.3%) patients developed recurrence. Six recurrences were in the pelvis alone. Sixteen patients recurred only at sites outside the pelvis. Seven patients had both pelvic and distant recurrences. We demonstrated that only vascular space invasion had significant effect on disease free survival by univariate analysis (p = 0.05). Vascular space invasion and multiple pathologic risk factors were significantly correlated with higher incidence of distant metastasis. (p = 0.05 and p = 0.02, respectively). In multivariate analysis of these factors showed that only vascular space invasion remained significant risk factors (p = 0.05). Therapeutic complications occurred in 20 (15%) patients, including gastrointestinal in 12 (9%) patients or genitourinary in 8 (6%) patients. The overall 5-year complication-free rate was 91%. Ten (8%) of those patients had grade 3 and 4 late morbidity. Conclusion : Our study suggested that postoperative radiotherapy after radical hysterectomy give reasonable survival in early stage carcinoma of the cervix. Poor survival and higher incidence of distant metastasis were observed if presence of vascular space invasion or multiple pathologic risk factors.

Post-Operative Combination of Radiotherapy and Chemotherapy in Esophageal Cancer

Purpose: To evaluate the effect of post-operative concurrent chemoradiotherapy (CCRT) and to determine the prognostic factors in esophageal cancer. Materials and Methods: From October 1991 to November 2000, fifty-six patients with esophageal cancer received post-operative radiotherapy at VGH-KS. Twenty-three patients were treated with radiotherapy (RT) alone at 50 Gy and others underwent RT combined with chemotherapy (C/T) consisting of cisplatin plus 5-flurouracil (5-FU). There was no significant difference in patient characteristics between two groups, except in tumor length. We compared overall, disease-free, loco-regional-free and distant-metastasis-free survival rates between two groups. We also analyzed various prognostic factors including age, tumor length, tumor stage, status of surgical margin, lymph node (LN) metastasis, vascular or neural invasion, and the time interval between operation and radiotherapy. Results: The median follow-up time was 16 months. For all patients, the overall survival (OS) at 5 years was 20.2%, and the disease-free survival (DFS) was 19.1 %. Loco regional failure occurred in 14.3% of patients and 35.7% of patients developed distant metastasis. The 2-year and 5-year overall survival rates were 42.7% and 23.7% for RT group and 41.0% and 16.0% for CCRT group. There was no significant difference in as and DFS between two groups (p= 0.694 and 0.875). In lymph node metastatic patients, overall and disease-free survivals of CCRT group were not superior to those of RT group (p= 0.273 and 0.486). In CCRT group, there was also no significant difference in as and DFS between the patients receiving less than 3 cycles of C/T and those receiving more (p= 0.968 and 0.406, respectively). By the uni-variate analysis, we found that neural invasion, numbers of LN metastases and involved LN levels, and the percentage of positive dissected LN affected the survival rates. The only prognostic factor of survivals in the multi-variate analysis was the involvement of more than one LN level. Conclusion: Based on our analysis, post-operative combination therapy is no better than adjuvant radiotherapy alone in disease control. The most important prognostic factors affecting the post-operative survival rate of patients are the number of positive lymph node and LN levels involved, the percentage of positive dissected LN and neural invasion.