Persistent Nasopharyngeal Carcinoma Research Articles

Combining Transoral Nasopharyngeal Brush and Plasma Epstein-Barr Virus DNA in Detecting Locally Recurrent Nasopharyngeal Carcinoma.

To evaluate the sensitivities and specificities of Epstein-Barr virus (EBV) DNA in the detection of locally recurrent or persistent nasopharyngeal carcinoma (NPC) through nasopharyngeal (NP) brush biopsy and plasma, respectively, and whether a combination of both would be superior to the individual tests. A case-control study was conducted from September 2016 to June 2022. A multicentre study at 3 tertiary referral centers in Hong Kong was conducted by the Department of Otorhinolaryngology, Head andNeck Surgery, The Chinese University of Hong Kong. Twenty-seven patients with biopsy-confirmed locally recurrent NPCwere recruited as study subjects. Magnetic resonance imaging was performed to rule out regional recurrence. The control group consisted of 58 patients with a prior history of NPC who were now disease-free based on endoscopic and imaging findings. Patients underwent both the transoral NP brush (NP Screen®) and blood for plasma Epstein-Barr DNA levels. The sensitivity and specificity of the combined modalities were 84.62% and 85.19%, respectively. The positive predictive value was 73.33% and the negative predictive value was 92.0%. The combination of NP brush biopsy and plasma EBVDNA is potentially an additional surveillance modality in detecting the local recurrence of NPC. Further study with a larger sample size would be required to validate the cutoff values.

Neck lymph node status on survival of regionally recurrent or persistent nasopharyngeal carcinoma

The aim of this study was to evaluate the impact of lymph node status from neck dissection pathological specimens on the survival for isolated regional nodal recurrence or persistence after primary treatment of nasopharyngeal carcinoma. Through a retrospective cohort study performed in an academic tertiary referral hospital in Hong Kong. Forty-six patients who underwent a salvage neck dissection between June 2001 and January 2013 for isolated regionally recurrent or persistent nasopharyngeal carcinoma was performed. Informed consent was waived for this retrospective study by The Joint CUHK-NTEC CREC. In the study forty-six patients had a salvage neck dissection for nodal failure with a mean age of 53 and 74% (34) were male. With a mean follow-up of 45.3 months, Overall survival, disease specific survival, loco-regional recurrence free survival, and regional recurrence free survival were 56.5%, 73.9%, 87.0%, and 91.3% respectively. For both univariate and multivariate analysis, patients with a number of positive lymph nodes more than 5 and a lymph node density more than 20% were significantly associated with poorer overall survival. Extracapsular spread and pathological cervical lymph node staging did not have an association with poorer survival. In conclusion, an absolute number of positive lymph nodes more than five and a lymph node density more than 20% were potentially useful prognostic factors affecting survival following a neck dissection for regional residual or recurrent nasopharyngeal carcinoma.

3D-image-guided high-dose-rate intracavitary brachytherapy for salvage treatment of locally persistent nasopharyngeal carcinoma

BackgroundTo evaluate the therapeutic benefit of 3D-image-guided high-dose-rate intracavitary brachytherapy (3D-image-guided HDR-BT) used as a salvage treatment of intensity modulated radiation therapy (IMRT) in patients with locally persistent nasopharyngeal carcinoma (NPC).MethodsThirty-two patients with locally persistent NPC after full dose of IMRT were evaluated retrospectively. 3D-image-guided HDR-BT treatment plan was performed on a 3D treatment planning system (PLATO BPS 14.2). The median dose of 16 Gy was delivered to the 100% isodose line of the Gross Tumor Volume.ResultsThe whole procedure was well tolerated under local anesthesia. The actuarial 5-y local control rate for 3D-image-guided HDR-BT was 93.8%, patients with early-T stage at initial diagnosis had 100% local control rate. The 5-y actuarial progression-free survival and distant metastasis-free survival rate were 78.1%, 87.5%. One patient developed and died of lung metastases. The 5-y actuarial overall survival rate was 96.9%.ConclusionsOur results showed that 3D-image-guided HDR-BT would provide excellent local control as a salvage therapeutic modality to IMRT for patients with locally persistent disease at initial diagnosis of early-T stage NPC.

Endoscopic endonasal anatomy of the nasopharynx in a cadaver model

Nasopharyngectomy is an accepted treatment for recurrent nasopharyngeal carcinoma following radiation with or without chemotherapy. Traditionally, the nasopharynx has been approached through relatively invasive "open" techniques including transpalatal, maxillary swing, and trans-mandibular-pterygoid approaches. Contemporary management has included the use of endoscopic techniques to exenterate tumors in this location. The purpose of the present study is to describe the endoscopic anatomy of this region through cadaveric dissection and to characterize the technical limitations of the approach. Five fresh cadaveric heads were dissected to study the endoscopic anatomy of the nasopharynx and associated structures. Endoscopic dissection of the nasopharynx was completed in all 5 specimens. Nasopharyngeal anatomy including the buccopharyngeal fascia, pharyngobasilar fascia, superior constrictor, longus capitus, longus coli, fossa of Rosenmuller, basisphenoid, auditory torus, and internal carotid artery were characterized. Surgical access to the nasopharynx has posed significant challenges in the treatment of recurrent or persistent nasopharyngeal carcinoma. This study demonstrated that endoscopic dissection of this region is feasible and has the potential to completely exenterate these lesions.

Verification and dosimetric impact of Acuros XB algorithm on intensity modulated stereotactic radiotherapy for locally persistent nasopharyngeal carcinoma

The main aim of the current study was to assess the dosimetric impact on intensity modulated stereotactic radiotherapy (IMSRT) for locally persistent nasopharyngeal carcinoma (NPC) due to the recalculation from the Anisotropic Analytical Algorithm (AAA) to the recently released Acuros XB (AXB) algorithm. The dosimetric accuracy of using AXB in predicting air∕tissue interface doses from an open single small field in a simple geometric phantom and intensity modulated small fields in an anthropomorphic phantom was also investigated. The central axis percentage depth doses (PDD) of a rectangular phantom containing an air cavity were calculated by both AAA and AXB from 6 MV beam with small field sizes (2 × 2 to 5 × 5 cm(2)). These data were compared to PDD measured by thin thermoluminescent dosimeters (TLDs) and Monte Carlo simulations. The doses predicted by AAA and AXB near air∕tissue interfaces from five different IMSRT plans were compared to the TLD measured doses in an anthropomorphic phantom. The PTV coverage, conformity and doses to organs at risk (OARs) calculated by AAA and AXB were compared for 12 patients, using identical beam setup, leaves movement and monitor units. Testing using the simple rectangular phantom demonstrated that AAA and AXB overestimated the PDD at the air∕tissue interfaces by up to 41% and 6%, respectively, from a 2 × 2 cm(2) field. The secondary build-up curves predicted by AXB caught up well with the measured data at around 2 mm beyond the air cavity. Testing using the anthropomorphic phantom showed that AAA overestimated the doses by up to 10%, while the measured doses matched those of the AXB to within 3%. Using AAA, the planning target coverage represented by 100% of the reference dose was estimated to be 4% higher than using AXB. The averaged minimum dose to the PTV predicted by AAA was about 4% higher and OARs doses 3% to 6% higher compared to AXB. AXB should be used whenever possible as the standard reference for IMSRT boost of NPC cases. The more accurate AXB indicating lower target coverage and lower minimum target dose compared to AAA should be noted.

Photodynamic therapy in the therapy for recurrent/persistent nasopharyngeal cancer

To determine the efficacy of Photodynamic therapy of patients with recurrent Nasopharyngeal Carcinoma we reviewed all available literature.Since the treatment options for recurrent or persistent Nasopharyngeal Carcinoma are limited, the survival rates poor and the complications severe; there is definitely a place for alternative treatment modalities with more efficacy and less morbidity. Photodynamic therapy (PDT) has the potential to be a very effective local treatment modality for recurrent or persistent nasopharyngeal cancer, without the severe side effects seen with re-irradiation. This review shows all reported results of Photodynamic therapy in the treatment for Nasopharyngeal Carcinoma.

Influence of [ 18F] fluorodeoxyglucose positron emission tomography on salvage treatment decision making for locally persistent nasopharyngeal carcinoma

The purpose of this study was to evaluate the role of [18F] fluorodeoxyglucose positron emission tomography (FDG-PET) in influencing salvage treatment decision making for locally persistent nasopharyngeal carcinoma (NPC). A total of 33 NPC patients with histologic persistence at nasopharynx 1 to 6 weeks after a full course of radiotherapy underwent both computed tomography (CT) and FDG-PET/CT simulation at the same treatment position. The salvage treatment decisions, with regard to the decision to offer salvage treatment and the definition of gross tumor volume (GTV), were made before knowledge of the FDG-PET findings. Subsequently the salvage treatment decisions were made again based on the FDG-PET findings and compared with the pre-FDG-PET decisions. All 33 patients were referred for salvage treatment in the pre-FDG-PET decision. After knowledge of the FDG-PET results, the decision to offer salvage treatment was withdrawn in 4 of 33 patients (12.1%), as no abnormal uptake of FDG was found at nasopharynx. Spontaneous remission was observed in repeat biopsies and no local recurrence was found in these 4 cases. For the remaining 29 patients, GTV based on FDG-PET was smaller than GTV based on CT in 24 (82.8%) cases and was greater in 5 (17.2%) cases, respectively. The target volume had to be significantly modified in 9 of 29 patients (31%), as GTV based on FDG-PET images failed to be enclosed by the treated volume in the salvage treatment plan performed based on GTV based on CT simulation images. Use of FDG-PET was found to influence the salvage treatment decision making for locally persistent NPC by identifying patients who were not likely to benefit from additional treatment and by improving accuracy of GTV definition in salvage treatment planning.

Nasopharyngeal intracavitary brachytherapy

Locally persistent nasopharyngeal carcinoma (NPC) carries an increased risk of local failure if additional treatment is not given. It has been shown that intracavitary brachytherapy is effective in the treatment of patients with T1 and T2a NPC, although its role in the treatment of T2b disease had remained uncertain. The objectives of the current study were to evaluate the outcomes of patients with T2b, locally persistent NPC who were treated with high-dose-rate (HDR) intracavitary brachytherapy and to explore whether routine brachytherapy boost could improve the local control of patients who had T2b NPC at initial diagnosis. Thirty-four patients with locally persistent NPC who were treated during 1992-2000 with HDR intracavitary brachytherapy were analyzed retrospectively. All patients had T2b disease at initial diagnosis. They were treated with HDR intracavitary brachytherapy at doses of 22.5-24.0 grays (Gy) in 3 weekly sessions. To compare the efficacy of brachytherapy, another 403 consecutive patients with nonmetastatic T2b NPC who were treated with curative intent by external radiotherapy (ERT) during the same period were evaluated. An improvement in the 5-year actuarial local failure-free survival rate (brachytherapy group vs. ERT group: 96.9% vs. 81.5%; P = 0.024), the disease-specific survival rate (84.5% vs. 68.1%; P = 0.021), and the overall survival rate (78.3% vs. 63.1%; P = 0.034) was demonstrated in the group that had locally persistent NPC who were salvaged with brachytherapy. In assessing local control, the addition of brachytherapy was just short of statistical significance on multivariate analysis (P = 0.054). The complication rates were comparable between the brachytherapy group and the ERT group. The results suggested that patients with T2b NPC who have locally persistent disease can be salvaged effectively with brachytherapy. Their local control was even better than that achieved by patients who had clinical remission of local disease at the completion of ERT. Furthermore, it is possible that routine brachytherapy boost, after the completion of ERT, may improve local control in patients who have T2b disease at initial diagnosis. However, its exact benefit can be elucidated only by prospective, randomized studies.

Three-dimensional conformal radiotherapy versus intracavitary brachytherapy for salvage treatment of locally persistent nasopharyngeal carcinoma

Purpose To compare the outcomes of three-dimensional conformal radiotherapy (3D-CRT) and intracavitary brachytherapy (ICBT) as salvage treatment for locally persistent nasopharyngeal carcinoma. Methods and materials Between March 1994 and November 2001, a total of 117 patients with locally persistent nasopharyngeal carcinoma received salvage treatment for 2–8 weeks (median, 4 weeks) after a full course of conventional external beam RT. Of the 117 patients, 54 were salvaged with 3D-CRT (3D group) and 63 with ICBT (BT group). No statistically significant differences were found in the patient characteristics between the two groups ( p >0.05). In the 3D group, the planning target volume for 3D-CRT was defined as the persistent disease plus a 5-mm margin; three to seven static conformal coplanar or noncoplanar portals were delivered for each fraction. The median salvage dose was 24 Gy (range, 18–38 Gy), with fraction size of 2.0 Gy/d. In the BT group, a median salvage dose of 20 Gy (range, 15–30 Gy) was delivered with a 192Ir source, at 5 Gy/fraction, twice weekly. The brachytherapy dose was prescribed at a distance of 1 cm from the center of the surface as defined by the sources, irrespective of the extent of persistent disease. The actuarial rates of survival were estimated using the Kaplan-Meier method. Potential differences in the actuarial outcomes between groups were evaluated using the Mantel log–rank test. Multivariate analyses were performed with the Cox regression proportional hazards model. Results The 5-year actuarial rates of overall survival, disease-specific survival, and local failure-free survival for the 3D group and BT group were 64.50% vs. 55.78% ( p = 0.33), 70.03% vs. 59.56% ( p = 0.11), and 88.93% vs. 76.28% ( p = 0.07), respectively. Subgroup analysis showed that the 5-year actuarial local failure-free survival rate of patients with initially diagnosed T3-T4 disease for the 3D group and BT group was 84.01% vs. 60.50% ( p = 0.03). The incidence of Grade 3-4 late complications was comparable between the two groups. Multivariate analyses performed in the whole group showed that T stage at initial diagnosis and the salvage technique (3D-CRT or ICBT) were the statistically significant, independent prognostic factors for local failure-free survival ( p = 0.00 and p = 0.02, respectively). Conclusion 3D-CRT seemed to provide better local control than ICBT as a salvage treatment for locally persistent nasopharyngeal carcinoma, especially in patients with initially diagnosed T3-T4 disease. CT/MRI evaluation of the extent of persistent disease is recommended for technique selection of salvage RT. Patients should be cautioned about the potentially increased complications. The optional time for salvage treatment remains controversial.

Facial palsy from metastatic nasopharyngeal carcinoma at various sites: Three reports

Nasopharyngeal carcinoma that causes clinically evident facial palsy is uncommon. This article describes and discusses a series of cases that illustrates how nasopharyngeal carcinoma caused facial palsy as a result of facial nerve involvement at three sites: the cerebellopontine angle, the middle ear, and the parotid. The maxim, "All that palsies is not Bell's," is particularly relevant with respect to patients who have previously been treated for advanced nasopharyngeal carcinoma. In these patients, recurrent or persistent nasopharyngeal carcinoma involving the cerebellopontine angle, temporal bone, or parotid should be excluded.

Salvage brachytherapy for patients with locally persistent nasopharyngeal carcinoma

Purpose: Locally persistent nasopharyngeal carcinoma (NPC) carries an increased risk of local failure if additional treatment is not given. This study was conducted to evaluate the outcomes of patients with locally persistent NPC as treated by high-dose-rate (HDR) intracavitary brachytherapy, and to explore whether routine brachytherapy boost could improve the local control. Methods and Materials: Eighty-seven patients with locally persistent NPC treated during 1990–1998 with HDR intracavitary brachytherapy were retrospectively analyzed. Fibreoptic nasopharyngoscopy was performed 3–6 weeks after completion of the primary external radiation therapy (ERT). Biopsies were only taken from suspicious areas. Those with complete regression of local disease were put on observation. Eighty-seven patients were shown to have persistent viable disease at a median time of 6 weeks post-RT. The distribution according to Ho’s staging system at initial diagnosis was as follows: Stage I—8, II—33, III—41, IV—5; T1—19, T2—48, T3—20; N0—32, N1—22, N2—28, N3—5. CT scan for restaging was not performed after the documentation of persistent disease. Our policy was to treat all patients with persistent disease with brachytherapy irrespective of the extent of disease just prior to brachytherapy. They were treated with HDR intracavitary brachytherapy, with either cobalt sources or an iridium source, giving 22.5–24 Gy in 3 weekly sessions in all but 4 patients. This dose was prescribed at a distance of 1.5 cm from the center of the surface as defined by the sources in the first six patients and subsequently reduced to 1 cm for the others. Twelve patients were treated with neoadjuvant chemotherapy. To compare the efficacy of brachytherapy, another 383 consecutive nonmetastatic patients, treated with curative intent by ERT, during the years 1990–1993, were evaluated. Multivariate analysis was performed using the Cox regression proportional hazards model. Results: The 5-year actuarial local failure–free survival (LFFS) rates and disease-specific survival rates for the brachytherapy group and ERT group were 85% and 76.6% ( p = 0.15), and 72% and 67.8% ( p = 0.2), respectively. The corresponding 5-year actuarial LFFS rates for T1, T2, and T3 disease were 94.7%, 88.2%, 67.4%, and 84.1%, 79.8%, 62.6%. In assessing the local control, only the T staging was significant on multivariate analysis ( p = 0.0004). Other parameters such as age, sex, and persistence of disease (giving brachytherapy) were all nonsignificant. Complications were comparable between the two groups. In the persistent group, the local failure rates of the patients treated with and without neoadjuvant chemotherapy were 17% (2/12) and 13% (10/75) respectively. When analyzed according to different brachytherapy sources, the 5-year LFFS rates of the T1, T2, and T3 patients treated with iridium and cobalt sources were 100% vs. 85.7 ( p = 0.19), 93.6% vs. 70% ( p = 0.04), and 67.7% vs. 60% ( p = 0.72). The difference was statistically significant for the T2 groups. When early T-stage (T1 and T2) patients were grouped together for analysis, the iridium group again showed a statistically significant improvement in 5-year LFFS rate when it was compared with the cobalt group (95.3% vs. 76.5%, p = 0.03) and the ERT alone group (95.3% vs. 81.5%, p = 0.03). The improvement of local control is attributed to a higher nasopharyngeal mucosal dose that is achieved by using small-size flexible applicators with an iridium source. It is interesting to note that the 5-year LFFS rates for the ERT alone group (T1: 84.1%, T2: 79.8%, T3: 62.6%) are comparable to the corresponding rates of the cobalt group. This information supports our speculation that an adequate booster treatment could compensate for inadequate primary treatment. The prognosis of patients with locally recurrent NPC is grave. Maximizing the local control is therefore crucial for the survival of the patients. The good local control of early T-stage locally persistent NPC patients receiving brachytherapy supports the incorporation of brachytherapy into the primary treatment program. The 5-year LFFS rates for T3 disease treated with and without brachytherapy were unsatisfactory (iridium group: 67.7%; cobalt group: 60%; ERT alone group: 62.6%). A more aggressive approach to improve the local control of Ho’s T3 disease should be explored. Conclusion: Our experience suggests that locally persistent NPC can be effectively salvaged by brachytherapy. The local control of patients with early T-stage NPC at initial diagnosis is even better than those having clinical remission of local disease at the completion of ERT. Furthermore, it is possible that routine brachytherapy boost, after the completion of ERT, could improve the local control. The exact benefit, however, can only be elucidated by prospective randomized studies.

Stereotactic radiosurgery as a salvage treatment for locally persistent and recurrent nasopharyngeal carcinoma

Stereotactic radiosurgery as a salvage treatment for locally persistent and recurrent nasopharyngeal carcinoma

18F-2-fluoro-2-deoxy-D-glucose positron emission tomography of head and neck in patients with nasopharyngeal carcinomas

Positron emission tomography (PET) with 18F-2-fluoro-2-deoxy-D-glucose (FDG) demonstrates increased tracer uptake in head and neck carcinomas. This study was undertaken to evaluate FDG-PET for the detection of nasopharyngeal carcinoma (NPC) and cervical lymph node metastasis, as well as to determine the effectiveness of FDG-PET for the diagnosis of recurrent or persistent NPC in irradiated fields. Twenty patients with suspected NPC were enrolled in this study. Ten patients had not received treatment for NPC. The remaining 10 patients were suspected to have recurrent or persistent NPC after radiotherapy. Following FDG-PET imaging, each patient underwent biopsy of suspicious lesions to establish a final diagnosis. The FDG-PET studies were analyzed two ways: i) Each tomogram slice was visually inspected. Abnormal FDG uptake on tomogram was compared to sites of suspected NPC, based on clinical examination, as well CT and MRI results. ii) Computer quantified radioactivity within the region of interest was compared to radioactivity in the cerebellum and to radioactivity in the normal aerodigestive mucosa. i) All proven NPC were detected as areas of increased FDG uptake by visual inspection (accuracy 100%). ii) The differences in levels of radioactivity between NPC and normal tissues were very large: radioactivity ratio of NPC/cerebellum ranged from 102% to 294%, and that of NPC/mucosa ranged from 130% to 704%. iii) All 5 cases of cervical lymph node metastasis were detected. FDG-PET studies of head and neck may prove valuable for distinguishing NPC (increased radioactivity) from scar tissue (reduced radioactivity). Its application may facilitate the diagnosis of recurrent NPC, as fibrosis and distortion of normal architecture in irradiated fields do not affect the accuracy of FDG-PET for the detection of NPC.

435 - Re-treatment of locally recurrent or persistent nasopharyngeal carcinoma by second course radiotherapy

435 - Re-treatment of locally recurrent or persistent nasopharyngeal carcinoma by second course radiotherapy

Transpalatal insertion of radioactive gold grain for the treatment of persistent and recurrent nasopharyngeal carcinoma

Purpose: To evaluate the efficacy of radioactive gold grain implant via the split palate approach in the control of locally recurrent or persistent nasopharyngeal carcinoma. Methods and Material : Forty-three patients, 10 for persistent NPC, 28 for first relapse in the nasopharynx, and five for second relapse in the nasopharynx, were treated. The diameter of the tumors at the time of gold grain implant ranged from 0.5 to 5 cm, the number of gold grains inserted varied from 4 to 14, the median number was seven. Results : There was no significant difference in the control of the primary tumor for persistent disease (80% at 5 years), first relapse (61 % at 5 years) and second relapse (80% at 3 years), p = 0.8845. The difference in survival between the three subgroups of patients, however, was highly significant ( p = 0.0040). Thirty patients had CT evaluation before gold grain implant and the tumor was found confined to the nasopharynx in 21, in the remaining nine patients erosion of the sphenoid sinus or other parts of the base of skull was noted. The difference in the control between those patients with tumors confined to the nasopharynx and those patients with extranasopharyngeal extension of tumor almost reached statistical significance (81% and 44% respectively at 5 years, p = 0.0554). For the six patients who developed local recurrence after gold grain implant and were evaluable for the pattern of failure, the recurrent tumors were considered originating from another region of the nasopharynx in four, and infield failure in the other two cases. Conclusion : Radioactive gold grain implant as salvage treatment provides satisfactory control of persistent and recurrent nasopharyngeal carcinoma. The local control was better when the tumor was localized to the nasopharynx, thus underlines the importance of close follow-up for early recognition of relapse and persistent tumor. However, such patients still suffered from high incidence of regional and distant failure, the pathophysiology and management of which require further investigation.

Re-Treatment of Nasopharyngeal Carcinoma in 53 Patients: International Journal of Radiation Oncology, Biology, and Physics, Vol. 22, No. 5, 1992, pp. 941–947

Fifty-three patients with locally recurrent or persistent nasopharyngeal carcinoma were re-treated with megavoltage radiation therapy at The University of Texas M. D. Anderson Cancer Center from 1954 through 1989. The time from initial treatment to re-treatment ranged from 2 to 189 months (median 33 months). Documented local disease was confined to the nasopharynx in 27 patients (Group 1), while in the other 26 patients there was local spread beyond the nasopharynx (Group 2). At the time of re-treatment, nodal disease was present in 27 of the 53 cases. Forty-two patients were re-treated with external beam therapy alone and 11 with a component of brachytherapy. Re-treatment doses specified at the nasopharyngeal vault ranged from 27.5 to 99 Gy (median 57 Gy), and total cumulative dose ranged from 80 to 160 Gy (median 112 Gy). Overall 5-year actuarial local control (LC), disease-free survival (DFS), and survival rates were 35%, 18%, and 21%, respectively. Patients with Group 1 disease did better than those with Group 2 disease in terms of 5-year survival, 32% versus 9% (p = 0.01) and 5-year DFS, 23% versus 12% (p = 0.002). Nodal status at the time of re-treatment did not predict for LC or survival. The 5-year survival of patients with lymphoepitheliomas was 28% compared with 13% for patients with squamous cell carcinomas (p = 0.04). Eight patients developed severe complications from re-treatment, of which five involving the brain (two), spinal cord (one), and lower cranial nerves (two) were fatal. The incidence of severe complications was related to the total cumulative dose of external beam irradiation: 4% for patients receiving doses less than or equal to 100 Gy compared with 39% for those patients who received doses greater than 100 Gy (p = 0.066). Beginning in 1977, a combination of external beam therapy (20 to 30 Gy) and intracavitary cesium (40 to 50 Gy surface dose) was used in selected cases: 9 of the 53 patients were re-treated with this combination. Of these, 7 achieved LC with a follow-up of 7 to 102 months and none sustained a severe complication. Five-year actuarial LC, DFS, and survival in this group were 67%, 44% and 60% respectively.

Re-treatment of nasopharyngeal carcinoma in 53 patients

Fifty-three patients with locally recurrent or persistent nasopharyngeal carcinoma were re-treated with megavoltage radiation therapy at The University of Texas M. D. Anderson Cancer Center from 1954 through 1989. The time from initial treatment to re-treatment ranged from 2 to 189 months (median 33 months). Documented local disease was confined to the nasopharynx in 27 patients (Group 1), while in the other 26 patients there was local spread beyond the nasopharynx (Group 2). At the time of re-treatment, nodal disease was present in 27 of the 53 cases. Forty-two patients were re-treated with external beam therapy alone and 11 with a component of brachytherapy. Re-treatment doses specified at the nasopharyngeal vault ranged from 27.5 to 99 Gy (median 57 Gy), and total cumulative dose ranged from 80 to 160 Gy (median 112 Gy). Overall 5-year actuarial local control (LC), diseasefree survival (DFS), and survival rates were 35%, 18%, and 21%, respectively. Patients with Group 1 disease did better than those with Group 2 disease in terms of 5-year survival, 32% versus 9% ( p = 0.01) and 5-year DFS, 23% versus 12% ( p = 0.002). Nodal status at the time of re-treatment did not predict for LC or survival. The 5-year survival of patients with lymphoepitheliomas was 28% compared with 13% for patients with squamous cell carcinomas ( p = 0.04). Eight patients developed severe complications from re-treatment, of which five involving the brain (two), spinal cord (one), and lower cranial nerves (two) were fatal. The incidence of severe complications was related to the total cumulative dose of external beam irradiation: 4% for patients receiving doses ≤ 100 Gy compared with 39% for those patients who received doses > 100 Gy ( p = 0.066). Beginning in 1977, a combination of external beam therapy (20 to 30 Gy) and intracavitary cesium (40 to 50 Gy surface dose) was used in selected cases: 9 of the 53 patients were re-treated with this combination. Of these, 7 achieved LC with a follow-up of 7 to 102 months and none sustained a severe complication. Five-year actuarial LC, DFS, and survival in this group were 67%, 44% and 60% respectively.

Treatment of persistent and recurrent nasopharyngeal carcinoma by brachytherapy.

The early results of brachytherapy for persistent and recurrent nasopharyngeal carcinoma in 30 patients is presented. Fifteen patients were treated by intracavitary caesium, 12 patients were treated by interstitial gold grain implant using the split-palate approach and three patients were treated by both intracavitary caesium and interstitial gold grain implant for the first and second relapse in the nasopharynx, respectively. The overall tumour control rate for intracavitary caesium was 5/18 (28%) with median follow-up of 25.2 months, and for interstitial gold grain implant it was 9/14 (64%) with median follow-up of 16.5 months. Interstitial gold grain implantation appears to be effective in the treatment of persistent and recurrent nasopharyngeal carcinoma.