Na-Na Chung

Impact of magnetic resonance imaging versus CT on nasopharyngeal carcinoma: Primary tumor target delineation for radiotherapy

Our aim was to assess the capacity of CT versus MRI for delineating to the primary tumor extent of nasopharyngeal carcinoma (NPC) in treated patients.

Induction Chemotherapy With Mitomycin, Epirubicin, Cisplatin, Fluorouracil, and Leucovorin Followed by Radiotherapy in the Treatment of Locoregionally Advanced Nasopharyngeal Carcinoma

PURPOSE Survival in advanced nasopharyngeal carcinoma (NPC) is compromised by distant metastasis. Because mitomycin is active against hypoxic and G0 cells, which may help to eradicate micrometastasis, we investigated the effect of mitomycin-containing cisplatin-based induction chemotherapy. PATIENTS AND METHODS Recruited for this study were American Joint Committee on Cancer (AJCC) 1992 staging system stage IV NPC patients with the following adverse features: obvious intracranial invasion, supraclavicular or bilateral neck lymph node metastasis, large neck node (> 6 cm), or elevated serum lactate dehydrogenase (LDH) level. Patients were given three cycles of chemotherapy before radiotherapy. The chemotherapy comprised a 3-week cycle of mitomycin, epirubicin, and cisplatin on day 1 and fluorouracil and leucovorin on day 8 (MEPFL). RESULTS From January 1994 to December 1997, 111 patients were recruited. The median follow-up period was 43 months. The actuarial 5-year overall survival rate was 70% (95% confidence interval [CI], 60% to 80%; n = 111). For patients having completed radiotherapy (n = 100), the 5-year locoregional control rate was 70% (95% CI, 55% to 84%) and the distant metastasis-free rate was 81% (95% CI, 73% to 89%). The 5-year distant metastasis-free rate of N3a and N3b disease of AJCC 1997 staging system were 79% (95% CI, 62% to 95%) and 74% (95% CI, 60% to 89%), respectively. By Cox multivariate analysis, high pretreatment serum LDH level (P = .04) and neck nodal enlargement before radiotherapy (P = .001) were adverse prognostic factors of survival. CONCLUSION The good 5-year survival of N3 disease supports the effectiveness of induction MEPFL in the primary treatment of advanced NPC. Further investigation to incorporate concurrent chemoradiotherapy is warranted.

Preliminary Results of Three-Dimensional Conformal Radiotherapy and Thalidomide for Advanced Hepatocellular Carcinoma

Purpose : The purpose of this study was to evaluate the response and therapeutic results of advanced hepatocellular carcinoma (HCC) treated with three-dimensional conformal radiotherapy (3D-CRT) and thalidomide. Materials and Methods : From October 1999 to September 2002, thirty-three advanced HCC patients who had been treated with 3D-CRT and thalidomide were reviewed. The mean age was 61.36 years old (range: 36-80 years old). Three-dimensional CRT was delivered at 1.5 Gy per fraction using 6 or 10 MV photons, twice a day and 5 days a week for a total dose of 45- 75 Gy. The mean treatment volume was 369.59 ml (range: 32.54-2094.82 ml). The dosage of thalidomide was 200 mg/day in 25 patients, 300 mg/day in 5 patients, and 400 mg/day in 3 patients. Results : Sixty-four percent [21/33; 1 complete response (CR), 20 partial response (PR)] of patients responded in 淯T field?and 12.1% (4/33; 4 PR) of patients responded in 烋on-irradiated lesion? When therapeutic outcome was determined by the different tumor patterns, the responses of 淯T field?for the recurrent tumor, huge mass, HCC with metastatic lesions and multiple lesions were 80.0% (8/10; 1 CR, 7 PR), 71.4% (5/7; 5 PR), 61.5% (8/13; 8 PR), and 0% (0/3; 2 SD and 1 PD), respectively (p = 0.234). Furthermore, the responses of 烋on-irradiated lesion?for the recurrent tumor, huge mass, HCC with metastatic lesions and multiple lesions were 10.0% (1/10; 1 PR), 14.3% (1/7; 1 PR), 15.4% (2/13; 2 PR), and 0% (0/3; all 3 PD), respectively (p = 0.778). The mean and median survival times were 327 and 242 days, respectively. The adverse effects of 3D-CRT and thalidomide include constipation (26/33, 78.8%), drowsiness and sedation (15/33, 45.5%), skin rash (11/33, 33.3%), lower extremity edema (20/33, 60.6%), peripheral neuropathy (2/33, 6.1%), dizziness (1/33, 3.0%), orthostatic hypotension (1/33, 3.0%), leukopenia (5/33, 15.2%), transient elevation in liver function tests (9/33, 27.3%), and epigastralgia (8/33, 24.2%). Conclusions : Our experience concluded that 3D-CRT combined with thalidomide might be a safe and effective treatment modality for unresectable HCC patients. The preliminary data showed quite promising result. It is valuable to study the potential role of 3D-CRT combined with thalidomide in the treatment strategy for HCC at various stages.

Preliminary Results of Fractionated Stereotactic Radiotherapy in Patients with Advanced Hepatocellular Carcinoma

Purpose: The treatment result of advanced hepatocellular carcinoma failed from previous TACE is often unsatisfactory. To minimize the acute and late adverse effects of liver irradiation and preserve maximal normal liver tissue, fractionated stereotactic radiotherapy (R/T) is used in our institute. Materials & Methods: Twenty-three patients with advanced hepatocellular carcinoma received fractionated stereotactic radiotherapy with 55Gy in 22 fractions. All patients were assessable for side effects and response. Results: The mean regression of turner volume was 29% at 1 month after completion of R?T, 41% at 2 months and 55% at 3 months. In 17 patients with elevated serum alpha-fetoptein (AFP), 15 (88%) were found to have response in the first month after R/T, 10 (59%) had regression of more than 50% of the original level at the first month after R/T. Conclusion: For patients with advanced hepatocellular carcinoma, the fractionated stereotactic radiotherapy is a feasible modality and deserves further follow-up for outcome and toxicity.

Radiotherapy of Conjunctival Lymphoma with A Specially Designed Lens Block

Purpose:To evaluate and discuss the therapeutic results and technique of conjunctival lymphoma. Materials and Methods: This retrospective study was to review the 10 patients with conjunctival lymphoma treated at National Taiwan University Hospital from 1988 to 1996. There were 8 men and 2 women. The range of age was 32 - 75 years old, mean: 59.1 years old. Most of the patients presented with conjunctival mass, reddish eyes and forelgn body sensation. The conjunctival lesions in all patients were treated with a single anterior field which covered the entire conjunctiva, using 3 MeV to 10 MeV electron beam. Total dose of 30 Gy to 50 Gy was delivered in 15 to 25 fractions over 23 to 33 days. In all cases, a specially designed lead shield was used to protect the lens. The follow-up time ranged from 24 months to 124 months. Results: All patients were doing well with no sign of active localized or distant disease till the closing date of the study. Moreover, the complications, including decreased visual acuity, cataract and photophobia, were minimal. Conclusion: Lymphoma clinically localized to conjunctiva as the initial presentation can be cured by radiation therapy with a dosage of 30 Gy to 40 Gy. The complications of radiation therapy can be minimized with sophisticated treatment technique and well protection of the highly radiosensitive lens.

Lymphoma with Intraspinal Extramedullary Involvement as Initial Presentation

Purpose: To review the treatment results of lymphoma with initial presentation of spinal cord or cauda equina compression. Materials and Methods: Lymphoma with cord or cauda equina compression as initial presentation were seen in 9 patients in our hospital between 1977 to 1996. Among them, six patients presented with stage IE primary spinal epidurl involvement, whereas the others has stage ⅡE, ⅢE and ⅣE disease (1 patient each). Except for one Hodgkins lymphoma and one lymphosarcoma, all of the other patients were non-Hodgkins lymphoma with unfavorable histologic grading, mostly were the intermediate grade classification according to the Warking Formulation. After decompression surgery, the subsequent treatments of these patients were radiotherapy (2 patients), chemotherapy (1 patient), and combination of both treatment modalities (6 patients). Results: A prodromal phase of local back pain occurred in all patients, with duration from 1 to 10 months, followed by a second phase of rapidly progressive signs of cord compression. After treatment, 5 patients achieved complete remission: among with, one died of chemotherapy complication, one died of intercurrent disease, one had distant metastasis, and only 2 patients remained disease free. The other 4 patients who got partial remission were all dead of this disease. Conclusion: Lymphoma with spinal epidural or intradural involvement at initial presentation is an aggressive disease. An intensive treatment combination with irradiation, chemotherapy, and surgery, is suggested in order to achieve good local control and longterm survival.

Prlmary Radiotherapy Treatment Results of Maxillary Sinus Squamous Cell Carcinoma

Purpose: Evaluating 5-year survival rates of maxillary sinus squamous cell carcinoma treated by different methods. Materials and Methods: From 1997 to 1991, 61 patients of maxillary sinus squamous cell carcinoma were included in our study. There were 11 patients with T3 (18%) disease and 50 patients with T4 (82%) disease. Eighteen patients (29.5%) were treated by radiotherapy alone (RT), 32 patients (52.5%) by combined surgery and radiotherapy (SRT) and 11 patients (18.0%) by combined radiotherapy with intra-arterial 5-FU infusion chemotherapy and antrostomy drainage (CRT). Results: Five-year survival rates were 5.6%, 34.4% and 54.5% in RT, SRT and CRT groups, respectively. Statistical significant difference (p＜0.05) of survival rates was noted. Regional neck nodal metastasis at initial diagnosis carried significant worse survival results than initial NO state (7.1% vs. 36.2%, p=0.0003). Multivariate analysis revealed that treatment methods, sex and N stages significantly influenced the 5-year survival rate. Conclusion: Combined treatment was superior to radiotherapy alone in 5-year survival rates.

Treatment Results of Oral Tongue Cancer

Purpose: To evaluate the therapeutic results of oral tongue cancer patients treated with curative intent at the National Taiwan University Hospital. Materials and Methods: From 1977 to 1994, 161 oral tongue cancer patients were treated by different modalities, including surgery alone (85 patients), radiotherapy alone (40 patients) and surgery followed by radiotherapy (36 patients). Patients were grouped according to the American Joint Committee on Cancer (AJCC) staging system. Among these 161 patients, 33 (20%) were categorized as stage I; 53 (33%) stage II; 37 (23%) stage III and 38 (24%) stage IV. All of them were squamous cell carcinoma with a male to female ratio of approximately 4:1. The treatment results of primary control, neck node control, outcomes and complications were analyzed. Results: More than four fifths of the lesions were located on the lateral border of the tongue and less than 5% were either on the dorsum or undersurface. Primary control rates of Ti and T2 diseases in the OP alone group were 90% and 86%, respectively. The T3 patients of OP+REF group had better primary control rate as 67%. Primary control of T4 disease was very poor hi our three treatment groups. Even for the early disease, patients receiving surgical resection of primary tumor without further neck treatment have a higher risk (28%) of neck failure. Five-year survival rates of stage Ⅲ patients were: R/T alone, 17%; OP alone, 24%; OP+R/T, 61%. Eighty-four percent and 72% recurrence in T3/T4 and T1/T2, respectively, occurred within one year after treatment. Overall, 86% recurrence occurred within the first 2 years. Sixteen patients (10%) showed evidence of distant metastasis; most commonly presented in the lung (75%). The risk of osteonecrosis was similar between OP+R/T group (6%) and R/T alone group (3%). Conclusion: In our study, surgery can control primary tumors effectively in Ti and T2 lesions. Advanced (T3 and T4) disease is unlikely to be cured by radiation therapy or surgery alone and therefore is best managed by a planned combination of surgery and radiation therapy. For stageⅢ group, five-year survival rate was significantly improved (p＜O.O5) for patients who were treated with surgery and postoperative radiotherapy. When the primary lesion is treated by simple excision, neck failure is not uncommon and adjuvant radiotherapy to the neck lymphatics may decrease its occurrence. There was 14% of recurrence occurred beyond the first 2 years which indicated that a long period of follow-up was important for tongue cancer patients.

Treatment Results of Malignant Lymphoma of Nasopharynx at National Taiwan University Hospital

Purpose: To evaluate the therapeutic results of nasopharyngeal malignant lymphoma treated at NTUH over the past fifteen years (1979-1993). Materials & Methods: Forty patients with malignant lymphoma of nasopharynx visited our hospital in the past fifteen years and their data were analyzed. The age of the patients ranged from 13 to 81 years old. There were 20 male patients and 20 female patients. Stage I and LI patients were 18 and 22, respectively. According to histopathologic classification, patients with low grade, intermediate grade and high grade malignant lymphoma were 10, 26 and 4, respectively. Seven patients received radical radiotherapy and 15 patients received chemotherapy. The remaining 10 patients were treated by combined chemotherapy and irradiation. Eight patients did not receive any treatment. Results: The actuarial five-year survival rates for nasopharyngeal malignant lymphoma patients with Stage I, II were 65.7% and 27.3%, respectively. When classified by the Rappaport classification, the actuarial five-year survival rates for patients of nodular type and diffuse type were 72.7% and 33.5%, respectively. The actuarial five-year survival rates for patients of Low grade, intermediate grade and high grade nasopharyngeal malignant lymphoma were 80.0%, 39.0%, and 50.0%, respectively. The actuarial five- year survival rates for patients treated with radiotherapy, chemotherapy and combined treatment modalities were 100.0%, 58.7%, and 30.0%, respectively. Conclusion: Lymphoma clinically localized to nasopharynx can be cured by radiotherapy. When classified by histopathology, patients with low grade or nodular type can be successfully treated using local radiotherapy alone. Chemotherapy used as primary treatment (with or without adjuvant radiotherapy) may be benefit for intermediate grade or diffuse type patients.

Treatment Results of Laryngeal Cancer by Badiotherapy with or Without Surgery

Purpose: To evaluate the therapeutic results of laryngeal cancer patients treated at Department of Radiation Oncology of NTUII over the past ten years (1981-1990). Materials & Methods: One hundred and thirty-three laryngeal cancer patients treated at our clinic were analyzed clinically. All of them were squamous cell carcinoma. The age of the patients ranged from 34 to 84 years old with the highest incidence at the 60-69 age group. There were 128 male patients and 5 female patients with male to female ratio as 26:1. The numbers of patients in stage I to IV were 25, 21, 22, and 65, respectively. Stage IV patients accounted for about half of the cases. The numbers of supraglottic, glottic, and subglottic cancers were 51, 72, and 10, respectively. Glottic type accounted for more than half of the cases. Fifty-seven patients received primary radiotherapy. The other 76 patients received surgery before radiotherapy. Results: The overall actuarial five-year survival rate was 54.7%. The actuarial five-year survival rates for patients of stages Ⅰ, Ⅱ,Ⅲ and Ⅳ were 78.7%, 58.3%, 54%, and 44.4%, respectively. The five-year survival rates for supraglottic, glottic and subglottic cancers were 34.7%, 70.5%, and 38.9%, respectively. Conclusion: Recurrence after radiotherapy was salvaged by surgery satisfactorily in stages I and II, but the prognosis was poor for recurrent patients with initial stages III and IV. A life-long follow-up after radical radiotherapy is essential for early detection of recurrence and earlier salvage to improve the therapeutic result.