Guopei Zhu

Is elective irradiation to the lower neck necessary for N0 nasopharyngeal carcinoma

PURPOSEnTo summarize our experience and treatment results in lymph node-negative nasopharyngeal carcinoma treated in a single institution.nnnMETHODS AND MATERIALSnFrom January 2000 to December 2003, 410 patients with lymph node-negative nasopharyngeal carcinoma were retrospectively analyzed. The T-stage distribution was 18.8% in T1, 54.6% in T2 (T2a, 41 patients; T2b, 183 patients), 13.2% in T3, and 13.4% in T4. All patients received radiotherapy to the nasopharynx, skull base, and upper neck drainage areas, including levels II, III, and VA. The dose was 64-74 Gy, 1. 8-2.0 Gy per fraction over 6.5-7.5 weeks to the primary tumor with (60)Co or 6-MV X-rays, and 50-56 Gy to levels II, III, and VA. Residual disease was boosted with either (192)Ir afterloading brachytherapy or small external beam fields.nnnRESULTSnThe median follow-up time was 54 months (range, 3-90 months). Four patients developed neck recurrence, and only 1 patient (0.2%) experienced relapse outside the irradiation fields. The 5-year overall survival rate was 84.2%. The 5-year relapse-free survival rate, distant metastasis-free survival rate, and disease-free survival rate were 88.6%, 90.6% and 80.1%, respectively. Both univariate and multivariate analyses demonstrated that T classification was the only significant prognostic factor for predicting overall survival. The observed serious late toxicities were radiation-induced brain damage (7 cases), cranial nerve palsy (16 cases), and severe trismus (13 cases; the distance between the incisors was < or = 1 cm).nnnCONCLUSIONnElective levels II, III, and VA irradiation is suitable for nasopharyngeal carcinoma without neck lymph node metastasis.

Patterns of lymph node metastasis from nasopharyngeal carcinoma based on the 2013 updated consensus guidelines for neck node levels

PURPOSEnTo explore patterns of node distribution in nasopharyngeal carcinoma (NPC) based on the 2013 updated guidelines for neck node levels.nnnMETHODS AND MATERIALSnWe retrospectively reviewed the imaging documents of 3100 cases of newly diagnosed NPC between January 2010 and January 2013. All patients received an MRI scan. The scan range extended from 2 cm above the anterior clinoid process to the inferior margin of the sternal end of the clavicle. All MR images were evaluated by the multi-disciplinary treatment group of NPC.nnnRESULTSnA total of 2679 (86.4%) cases had involved lymph nodes. The detailed distribution was: level Ia 0, level Ib 115 (4.3%), level IIa 1798 (67.1%), level IIb 2341 (87.4%), level III 1184 (44.2%), level IVa 350 (13.1%), level IVb 28 (1.0%), level Va,b 995 (37.1%), level Vc 49 (1.8%), level VI 0, level VIIa 2012 (75.1%), level VIIb 178 (6.6%), level VIII 53 (2.0%), level IX 2, level Xa 2, level Xb 3. Among patients with level VII involvement, only 6 (0.3%) were located at the medial group. Of the patients with level II disease, the upper borders of metastatic nodes in 25.9% cases were beyond the caudal edge of C1. Patients with level VIII, or IX, or X node metastasis were always with extensive ipsilateral lymphadenopathy, and the total number of involved nodes was ⩾6. There were 35 cases of lymphadenopathy beyond the range of the updated guidelines, located inside the trapezius muscles, but posterior to level V.nnnCONCLUSIONSnThis is the first description of nodal spread patterns based on the updated consensus guidelines. Involvement of the retropharyngeal nodes was mainly located at the lateral group, the medial group was rarely seen. The suggested upper border of level II cannot fully cover all the involved level II nodes. The posterior level V border is not enough to cover all level V lymphadenopathies for NPC.

A phase III randomized study comparing neoadjuvant chemotherapy with concurrent chemotherapy combined with radiotherapy for locoregionally advanced nasopharyngeal carcinoma: Updated long-term survival outcomes

OBJECTIVEnTo determine whether concurrent chemoradiotherapy (CCRT) can improve survival rates compared to the neoadjuvant chemotherapy (NACT) regimen in locoregionally advanced nasopharyngeal carcinoma (NPC) patients.nnnMATERIALS AND METHODSnA total of 338 patients with biopsy-proven NPC were randomly assigned to receive NACT followed by radical radiotherapy (RT) then adjuvant chemotherapy (AC) or CCRT followed by AC.nnnRESULTSnWith a median follow-up of 60 months, the 5-year overall survival (OS) rate did not differ significantly between two groups (75.5% vs 79.4% in CCRT and NACT group respectively, P=0.47, HR=0.84, 95%CI 0.53-1.33). Metastasis-free survival (MFS) rate was significantly improved by the CCRT (79.0% vs 86.9%, P=0.05, HR=0.59, 95%CI 0.35-1.00). Subgroup analysis indicated that the benefit of CCRT was derived from N0/N1 tumors (78.0% vs 93.5%, P=0.05, HR=0.35, 95%CI 0.12-0.99). Higher rates of mucositis (52.4% vs. 35.9% P=0.02) and vomiting (13.7% vs. 4.7% P=0.00) were noted in the CCRT arm. Late toxicities were similar in two groups.nnnCONCLUSIONSnThe updated results demonstrated no significant survival benefit of CCRT over NACT in patients with locoregionally advanced NPC. CCRT only showed significant MFS efficacy in T3-4N0-1 populations.

Preliminary results of a phase III randomized study comparing chemotherapy neoadjuvantly or concurrently with radiotherapy for locoregionally advanced nasopharyngeal carcinoma

The current study was conducted to compare neoadjuvant chemotherapy (NACT) with concurrent chemotherapy for efficacy, toxicities and compliance of locoregionally advanced nasopharyngeal carcinoma (NPC). Eligible patients were randomized to NACTxa0+xa0radiotherapy (RT)xa0+xa0adjuvant chemotherapy (AC) arm or concurrent chemoradiotherapy(CCRT)xa0+xa0AC arm. Two arms received same conventional RT at a planned dose of 70xa0Gy. Neoadjuvant chemotherapy comprised cisplatin 90xa0mg/m2 (30xa0mg/m2/day) and 5-fluorouracil 1,500xa0mg/m2 (500xa0mg/m2/day) over 3xa0days for two 21-day cycles. The same regimen at equal dosage was administered on the 1st and 22nd days of the radiotherapy as concurrent chemotherapy. Four cycles of the same chemotherapy regimen were given to both two arms as AC. A total of 338 NPC patients were recruited. 170 patients were randomized to NACT arm and 168 patients to CCRT arm. The median duration of follow-up was 38xa0months. The 3-year OS and DFS rates were 95.9 versus 94.5% (Pxa0=xa00.54) and 78.5 versus 82.5% (Pxa0=xa00.16), respectively, in NACT and CCRT arms. An unplanned subgroup analysis according to the N-classification suggested that CCRT improves MFS in patients with N0-1 disease (80.1 vs. 94.9%, Pxa0=xa00.034). Among the acute toxicities observed, the rates of grade 3/4 mucositis (52.4 vs. 35.9% Pxa0=xa00.023) and vomiting (13.7 vs. 4.7% Pxa0=xa00.000) were significantly higher in CCRT arm. Our preliminary results only showed an advantage of CCRT over NACT in NPC patients with limited N disease in MFS. More acute toxicities were observed in CCRT arm and a trend of better tolerance was observed in NACT arm.

Experience with combination of cisplatin plus gemcitabine chemotherapy and intensity-modulated radiotherapy for locoregionally advanced nasopharyngeal carcinoma.

The purpose of this study was to evaluate the efficacy and toxicity of cisplatin plus gemcitabine chemotherapy and intensity-modulated radiation therapy (IMRT) for locoregionally advanced nasopharyngeal carcinoma (NPC). A total of 54 patients (stage IIB: 6, stage III: 24, stage IVA–B: 24) with locoregionally advanced NPC were treated with cisplatin 25xa0mg/m2 intravenously on days 1–3, and gemcitabine 1,000xa0mg/m2 of 30-min intravenous infusion on daysxa01 and 8, every 3xa0weeks for two cycles as neoadjuvant chemotherapy. Two cycles of the same regimen were administered as adjuvant chemotherapy 28xa0days after the end of radiotherapy. The prescription doses were 66–70.4xa0Gy to the gross tumor volume (GTV), 66xa0Gy to positive neck nodes, 60xa0Gy to the high-risk clinical target volume and 54xa0Gy to the low-risk clinical target volume. The overall response rate to neoadjuvant chemotherapy was 88.6%. Toxicity was mainly grade 1/2 myelosuppression. All patients completed IMRT. The median follow-up duration was 30xa0months (range, 12–60xa0months). The 3-year locoregional control, metastasis-free rate and overall survival were 94.9%, 86.2% and 87.7%, respectively. Severe late toxicities included grade 3 trismus in one patient, grade 3 hearing impairment in one patient and cranial nerve XII palsy in one patient. No grade 4 late toxicities were observed. A combination of cisplatin plus gemcitabine chemotherapy and intensity-modulated radiotherapy for locoregionally advanced NPC is well-tolerated, convenient, effective and warrants further studies.

Multi-modality management for loco-regionally advanced laryngeal and hypopharyngeal cancer: balancing the benefit of efficacy and functional preservation

The 5-year overall survival (OS) of loco-regionally advanced laryngeal and hypopharyngeal carcinoma (LA-LHC) has declined over the past two decades following the wide application of non-surgical approaches. We aimed to define the new role of open surgery combined with adjuvant chemoradiotherapy in the treatment of LA-LHC for improving survival while maintaining a functional larynx. In the current study, 90 LA-LHC patients treated with open surgery followed by postoperative RT/CRT in our institute from May 2005 to December 2012 were retrospectively analyzed. OS, disease-free survival (DFS), loco-regional failure-free survival (LRFFS) and distant metastasis-free survival (DMFS) were calculated, and prognostic factors were analyzed. Functional larynx preservation results were evaluated according to the head and neck quality of life (QoL) Scale. With a median follow-up period of 37xa0months, the 3- and 5-year OS, DFS, LRFFS and DMFS were 71.3, 63.7, 85.9, 73.7 and 55.9, 53.0, 81.6, 71.9xa0%, respectively. Vascular embolism and extracapsular extensionxa0(ECE) of the lymph nodes were prognostic factors for poorer OS (pxa0=xa00.045 and 0.046, respectively). Vascular embolism was the only prognostic factor for poorer DMFS (pxa0=xa00.005). Patients who underwent a conservative partial laryngectomy (CPL) experienced a higher QoL in the domains of speech, swallowing and emotion. Functional larynx preservation was achieved in 36/45 patients (80xa0%) who received CPL. The results of our study demonstrated that CPL followed by adequate adjuvant therapy could achieve superior oncological results compared with non-surgical approaches in LA-LHC patients while also maintaining satisfactory functional larynx in a majority of patients.

Omission of chemotherapy in early stage nasopharyngeal carcinoma treated with IMRT a paired cohort study

AbstractThe objective of this study was to evaluate the necessity of concurrent chemotherapy in T1-2N1 nasopharyngeal carcinoma (NPC) patients treated with intensity-modulated radiation therapy (IMRT).The retrospective analysis was conducted using the paired comparison method. We matched cases to controls using the greedy matching algorithm with 1:1 control to case ratio. Controls were matched to cases by factors including age, gender, T stage, and duration of RT. The control group included patients received IMRT alone. In another group, concurrent chemotherapy (DDP 40u200amg/m2/w) was administrated to each paired patient.From Jan 2009 to Dec 2011, a total of 86 well-balanced T1-2N1 (2002 UICC staging system) NPC patients were retrospectively analyzed. Half of them (43 patients) received radical IMRT alone and another 43 received concurrent chemotherapy with IMRT (CCRT). Median follow-up is 37.4 months (4.8–66.2 months). All patients received a radiation dose of 66Gy/30Fx. In the CCRT group, all patients received a cumulative dose of ≥200u200amg/m2. The differences of 3-year overall survival (OS), 3-year progression-free survival (PFS), 3-year relapse-free survival (RFS), and 3-year metastasis-free survival (MFS) between 2 groups were not significant (Pu200a>u200a0.05). The most frequently increased toxicities related to chemotherapy were mild to moderate leukopenia (Pu200a=u200a0.003) and mild anemia (Pu200a=u200a0.008).Omission of weekly cisplatin chemotherapy resulted in comparable survival outcomes to CCRT in IMRT populations. More data from future randomized trials are warranted to further confirm it.

A clinical analysis of 37 cases with lymphoepithelial carcinoma of the major salivary gland treated by surgical resection and postoperative radiotherapy: a single institution study

The present study was undertaken to evaluate the diagnostic approaches, treatment results and failure patterns of lymphoepithelial carcinoma of the major salivary gland (LECSG). Patients were treated by definitive surgical resection and postoperative radiotherapy in an attempt to identify the proper strategies for the management of this disease. Patients with a histological diagnosis of primary lymphoepithelial carcinoma in the major salivary gland that was treated at our institution between January 2005 and December 2011 were comprehensively analyzed. An en bloc radical excision, which generally removes the salivary gland with level II and Ib lymph nodes, followed by postoperative radiotherapy was the standard treatment for this group of patients. Radical neck dissection was only performed in patients with metastatic lymphadenopathy. Postoperative irradiation was delivered to the tumor bed and involved nodes at a dose of 60xa0Gy and to the ipsilateral cervical lymph nodes at a dose of 56xa0Gy. Clinical and pathological factors correlated with locoregional control (LRC), progression-free survival (PFS) and overall survival (OS) were analyzed using the log-rank test and a Cox proportional hazards model. A total of 37 patients with a median age of 45xa0years were enrolled in this study. The study population consisted of 21 males and 16 females. There were seven patients with stage I disease, 10 patients with stage II disease, nine patients with stage III disease and 11 patients with stage IV disease. With a median follow-up of 39xa0months (range 12–90xa0months), the 3-year LRC, PFS and OS were 94.3, 91.6, and 92.9xa0%, respectively. Only two patients died of local–regional recurrences and distant metastases. No statistically significant prognostic predictors of LRC, PFS and OS were found. The presence of positive cervical lymph nodes showed a trend toward poorer outcome. Surgical resection with postoperative radiotherapy is a reasonable and proper treatment approach in the definitive management of LECSG and results in a favorable prognosis for a significant proportion of patients. No clinicopathological or therapeutic features were found to be suitable predictive factors for prognosis; thus, disease progression should be carefully monitored, especially for those patients with cervical node involvement.

Magnetic resonance sialography for investigating major salivary gland duct system after intensity-modulated radiotherapy of nasopharyngeal carcinoma

BackgroundWe investigated the value of magnetic resonance sialography for evaluating xerostomia induced by intensity-modulated radiotherapy for nasopharyngeal carcinoma.MethodsFourteen patients with nasopharyngeal carcinoma were treated with intensity-modulated radiotherapy. Salivary function was assessed by magnetic resonance sialography and subjective evaluation criteria pre-treatment, 1xa0week and 1xa0year post-radiotherapy. A magnetic resonance sialography categorical scoring system was used to compare the visibility of salivary ducts.ResultsThe average mean dose was 38.93xa0Gy to the parotid glands and 59.34xa0Gy to the submandibular glands. Before radiotherapy, the visibility scores of both the parotid and submandibular ducts increased after secretion stimulation. The scores decreased and the response to stimulation was attenuated 1xa0week post-radiotherapy. For most of the parotid ducts, the visibility score improved at 1xa0year post-radiotherapy both at rest and under stimulation, but not for the submandibular ducts. With a median follow-up of 12.3xa0months, 8/12 patients had grade 1 xerostomia and 4/12 had grade 2 xerostomia.ConclusionsMagnetic resonance sialography allows non-invasive evaluation of radiation-induced ductal changes in the major salivary glands and enables reliable prediction of radiation-induced xerostomia.