Elsevier

Radiotherapy and Oncology

Volume 54, Issue 2, 1 February 2000, Pages 135-142
Radiotherapy and Oncology

Locally recurrent nasopharyngeal carcinoma

https://doi.org/10.1016/S0167-8140(99)00177-2Get rights and content

Abstract

Purpose: To assess the outcome of and determine prognostic factors for locally recurrent nasopharyngeal carcinoma (NPC) in patients treated with a second course of radiotherapy (RT).

Materials and methods: From 1982 to 1995, 186 NPC patients, who had initially been treated in the Department of Radiation Oncology, Chang Gung Memorial Hospital-Linkou, developed local recurrence in the nasopharynx and were re-treated with RT (≥20 Gy). The time from the initial RT to re-treatment ranged from 8 to 136 months (median: 23 months). All patients were treated with external RT and conformal radiotherapy was used in 35 patients after 1993. Fifteen received radiosurgery as a boost treatment. The RT dose at the nasopharyngeal tumor area ranged from 20 to 67.2 Gy (median 50 Gy). Eighty-two patients received one to eight courses of cisplatin-based chemotherapy in addition to RT.

Results: The 1-, 3- and 5-year survival was 54.9, 22.1 and 12.4%, respectively. Patients whose tumor relapsed later than 2 years after the first treatment had a better survival than those with earlier relapse (3-year survival: 30.1 vs. 10.8%; P=0.015), but the difference became insignificant in patients who received ≥50 Gy. Patients without evidence of intracranial invasion or cranial nerve palsy had better survival than those with such lesions (3-year survival: 30.9 vs. 3.7%; P=0.006). A re-treatment dose ≥50 Gy yielded better survival (3-year survival: 22.8 vs. 18.5%; P=0.003). Addition use of radiosurgery may improve survival. The use of chemotherapy did not improve survival. Conformal radiotherapy resulted in significantly fewer severe complications than conventional RT.

Conclusions: A repeat course of RT for locally recurrent NPC successfully prolongs survival in a significant number of patients. Intracranial invasion and/or cranial nerve palsy and re-treatment dose affect the prognosis, with a dose of ≥50 Gy significantly improving survival. Radiosurgery boost may also improve survival. Our preliminary data indicates that conformal radiotherapy may decrease the severity of radiation-induced complications. However; longer follow-up and larger sample size is necessary to document the findings.

Introduction

Nasopharyngeal carcinoma (NPC) is a common malignancy in Taiwan [16]. Radiotherapy is the major treatment modality, and the overall 5-year survival approaches 50–70% [9], [18], [25], [30]. The causes of treatment failure area either local recurrence or distant metastasis. The extent of the primary tumor is closely related to the degree of achievable local tumor control [9], [20], [30]. Primary tumor control can be achieved in up to 80–90% of small tumors, but in only 50–60% of advanced tumors, despite total radiation doses are usually up to 70 Gy [25], [27], [29]. Recurrence of the primary tumor is one of the major causes of death from this disease, especially with locally advanced tumors. A major issue in discussions of the treatment of NPC is the management of these primary recurrent tumors.

Re-treatment for local recurrent NPC with additional course of radiotherapy will induce high complications for high radiation dose. How to increase re-treatment effect but did not elevate too much complication is a major consideration to treat the local recurrent NPC. There were a lot of new treatment modalities to approach the recurrent tumor. Conformal radiotherapy will reduce the radiation dose the normal tissue may reduce the complications. Radiosurgery has the benefit of a rapid fall-off in radiation dose, increasing the radiation therapeutic ratio. The use of radiosurgery for recurrent NPC appears to have significant potential [2], [7]. Surgery for recurrent NPC has also been attempted with some success but the definite role remained uncertain [13], [15], [33]. Chemotherapy has been used for recurrent NPC, producing partial and complete responses in the range 60–70% [4], [10], [12]; however, long-term tumor control is rarely achieved.

In this paper, we report our experience in treating recurrent NPC at Chang Gung Memorial Hospital, Linkou from 1982 to 1995. In particular, we tried to identify factors and the potential role of new treatment modalities for this disease.

Section snippets

Patient characteristics

From 1982 to 1995, 205 NPC patients initially treated in the Department of Radiation Oncology, Chang Gung Memorial Hospital, Linkou, had local failure in the nasopharynx and were re-treated with radiotherapy as the primary modality. We excluded the patients with combined relapse in neck and/or distant sites in this discussion. All patients had received >64.8 Gy in their initial course; details of the radiotherapy procedure have been described previously [3], [29]. Recurrence was documented by

Survival

The 1-, 2- and 3-year survival was 54.9, 30.2 and 22.1%, respectively. Four patients were lost to follow-up. One hundred and forty patients had died by the end of the study. Twenty patients subsequently developed distant metastasis. The usual sites of metastasis were lung (9), bone (8), liver (4), brain (1) and soft tissue (1). Three patients had metastasis in two different sites. Two patients died of unrelated causes: one in a car accident and the other of a cerebrovascular accident.

Death was

Discussion

Patients with recurrent nasopharyngeal carcinoma have a very poor prognosis if they are not treated. Yan et al. [34] reported only one 5-year survivor in a group of 276 patients with recurrent disease who received no further treatment. The 3- and 5-year survival in our subjects was 22.1 and 12.4%. Most of our patients presented with advanced recurrence; almost 60% had rT3 or rT4 lesions, despite regular follow-up after treatment of their primary disease. Our data show that stage at which

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