Analysis of 1379 Patients With Nasopharyngeal Carcinoma Treated by Radiationt

DEXINGQIN, MD, MCSRO:' YUHUA HU, MD: JIEHUA YAN, MD: GUOZHENxu, MD: WEIMINGCAl, MD: XUELINWU, MD: DEXIANCAO, MD,:!:AND XIANZHIGU, MD, MCSRO'

One thousand three hundred seventy-nine nasopharyngeal carcinoma (NPC) patients were treated rom !arch 19"# to $ecem%er 197#& 'wenty-two percent had stage ( or (( and 7#) *tage ((( or (+ had lesions& 'wo hundred twenty-,v radiographs were used %e ore 19-./ and teleco%alt was used rom 19-1 to 197#& 0actors in luencing the "-year survival rate avora%ly are youth o patient1 %eing emale1 pathologic condition (poorly di erentiated carcinoma1 2"&1 ) venus adenocarcinoma1 13))1 stage (*tage 11#-)1 *tage ((1 "9&")/ *tage (((1 2"&#)/ *tage (+1 39&3))1 decade admitted or treatment in the past (31) in the 19"Os1 2#&-) in the 197.s)1 total dose delivered to the nasopharyn4 (2. to 29 5y1 2-)/ 7. to 79 5y1 "2&1)/ 9. 5y or more1 -2)) and prophylactic radiation to the nec6 regions (with prophylactic irradiation1 "3&#)1 without prophylactic irradiation1 33))& 'his implies that prophylactic radiation o the nec6 is crucial even without positive clinical metastasis& 0or those who have a residual tumor in the primary site when 7. 5y has %een delivered1 the total dose may %e %oosted to more than 9. 5y with the cone-down techni7ue or on %asis o adding 3. 5y to the dose at which the primary lesion disappeared grossly& 'he common postirradiation complications are8 radiation myelitis1 trismus1 and otitis media& 9ecause disease recurred in some patients a ter the i th year1 NPC patients should %e ollowed or at least 1. years& Cancer -181117-11321 19##&

noma (NPC) patients treated in our department over a period o 31 years1 19"# to 197#1 we have ound that the "-year survival o this cancer had %een improved rom 31) (3" o 113) in the 19".s to 2#&2) (33# o -77) in the 197.s& 'his paper summari=es the e4perience gained %y trial and error reports and outlines several crucial points in the radiotherapeutic techni7ue1 some o which are still open to de%ate and re7uire urther studies& Patients Characteristics o patients included in the analysis were8 1 A pathologic diagnosis o nasopharyngeal carci noma/ other nonepithelial malignancies were e4cluded1
0rom the $epartments o ><adiation Oncology and ?Computer *ciences1 Cancer @ospital1 Chinese :cademy o !edical *ciences1 9eiAing1China1 ! $edicated to our colleague1$r1 Cui Ban Bi1 who participated in the 19-"preliminaryreport %ut died o %reast cancer in 19-91 C !em%er o Chinese*ocietyo <adiation Oncology(!C*<O)1 :ddress or reprints8 $e4ing Din1 !$1 !C*<O1 $epartment o <adiation Oncology1 Cancer @ospital1 Euo :n !en Fai1 9eiAing1 China1 :ccepted or pu%lication *eptem%er391 19#71

N: *;<(;* o 1379 consecutive nasopharyngeal carci

3& (nitial treatment used was radiation therapy unless distant metastases were evident at presentation& 3& $oses o at least 2. 5y to the nasopharyn4 were used& 2& Patients lost to ollow-up (12 patients G1)H) were scored as having died o cancer& *e48 male1 1.-7/ emale1 313 (se4 ratio1 3&2 to I" :ge ranged rom # to 72 years1 with the highest com plication rate in patients %etween the ages o 3. and -. years1 'he common symptoms were8 %lood-strea6ed nasal discharge1 tinnitus1 mass in the nec61 and headache1 :ll patients were staged according to the staging sys tem introduced at the *econd National *ymposium on Nasopharyngeal Carcinoma1 *hanghai1 19-" (:ppen di4)1 'here were 12 patients with #I )) *tage I disease1 3.1 (311#)) with *tage II,217 (3.13)) with *tage III and -27 (2-19)) with *tage (+ lesions1 'he *tage ((( and (+ lesions constituted 7#) o the series& !ethods Orthovoltage radiographs (33. ,+) were used %e ore 19-.& 'herea ter1 teleco%alt was used until 197#1 when linear accelerators replaced teleco%alt& 0or the primary lesion1 two large parallel opposing preauricular portals1

1117

111$

CANCER

March 1" 19##

A

+ol& -1

PA

"'P

:
0(5s& I: :N$ l9& -OCO dose distri%ution in nasopharyn4 irradiated %y two preauricular portals (- 4 9 ern) (P:)& **$ I 7" em& *$$ % "1&- em& (9) *chematic drawing o -OCO dose distri%ution in nasopharyn4 irradiated %y two preauricular (- x 9 em) (P:) ields supplemented %y two intraor%ital (2 4 2 ern) (3.J) #1&" portals& $ose loading8 'A:IO I 3&"8 I **$ % 7" cm& *$$ I "1&- em/ A: anterior8 1&: in raor%ital ield/ !:8 ma4illary sinus/ 9*8 %rain stem/ ': posterior/ 'A: preauricular ield8 N': nasopharyn4&

encompassing the nasopharyn4 and the adAacent %ase o the middle cranial ossa1 were used& 'hese portals were reduced routinely to include only the %ase o s6ull and the primary lesion1 which usually was located on the posterosuperior wall o the nasopharyn4 as the dose ap proached the curative level rom 2. 5y (0ig& (:)& Our resident doctors were re7uired to e4amine the tumor condition and enter the indings as drawings in the his tory record& 'hey noted the time and dosage at which the lesion disappeared& Our principle o curative therapy o the primary ocus is to carry the tumor dose to a%out 3. 5y %eyond the level at which the tumor disappeared in response to photon therapy& 'he inal dose is usually appro4imately 7. 5y1 which is considered to %e the cur ative dose or the nasopharyn4 and the %ase o s6ull& ( any residual tumor was grossly persistant a ter 7. 5y1 the primary lesion had to %e %oosted to higher doses& 9y using supplementary smaller anterior1 in raor%ital1 in tracavitary radium mould or intracavitary radiograph cone through the so t palate in addition to the reduced preauricular ields1 the total dose could %e %rought to 9. 5y or more (0ig& 19)& 'he cervical regions were irst irradiated to 2. 5y %y one anteroposterior tangential ield with the upper mar-

gin ( em a%ove the lower %order o the mandi%le and the lower margin %elow the lower %order o the clavicle1 covering the whole o the nec6 and the supraclavicular areas %ilaterally& 'he spinal cord was shielded %y a rec tangular %loc6 o low melting lead alloy1 3 em wide and - em thic6& 'wo %ilateral parallel opposing large ields1 usually 9 em X 12 em in si=e1 were used to deliver a mid-line dose o 3" to 3. 5y to the nec6& :s a rule1 most o the larger metastatic lymph nodes would resolve %y this time e4cept resistant ones& Cone-down portals were used to urther %oost the irradiation until the involved nodes either disappeared completely or changed into a pla7ue o so t and elastic tissue with unclear %oundaries1 which we regarded as the possi%le eradication o the metastases& *ometimes the mass would irst %ecome so t and reduced in si=e1 %ut as the dose approached the curative level it %ecame irm again1 possi%ly due to i %rosis& Ksually 7. to 1.. 5y is needed or complete control o the positive lymph nodes& 'he sole purpose o treating the nec6 lesions is to deliver a radical dose to the whole o the nec61 e ecting complete control o the met astatic oci and 6eeping the spinal dose under 2. 5y& :s nasopharyngeal carcinoma (NPC) can easily metastasi=e to nodes at an early stage1 all patients with NPC should

NO&-

NPC '<;:';$)Y <:$(:'(ON

Qin et al.

1119

receive treatment to the %ilateral cervicalLsupraclavicu lar regions as a preventive %asis& 0or recurrence in the nec61 reirradiation1 lymphadenectomy I or radical nec6 dissection were resorted to& 0or recurrence in the naso pharyn41 either a second course o radiation or surgery was given& 'he latter was especially valid or recurrence near the mid-line& No chemotherapy was given unless distant metastases were evident& <esults

1.. 9. #. 7. -. ". 2. ).
3. 1.

Remote Survival 0/ NPC

'en year survival rate is needed to assess the validity o radiotherapy or NPC& (n our series1 the survival curve gives a sharp decline rom #3) (112" o 1379) in the irst year a ter radiation down to 21&2) ("71 o 1379) in the i th year (0ig& 3)& Oet1 it continues to slope down to 37&9) (3"3 o 9.-) in the tenth year1 then to 1-) (93 o "#.) in the 1"th year& 0rom then on it re mains lat1 luctuating %etween 13) and 17) to the 3"th year& Bi6e %reast cancer1 an apprecia%le amount o NPC patients e4perience recrudescence o the disease long a ter the conclusion o therapy/ the longest interval %e tween recurrence in the nasopharyn4 was 32 yearsP *ince 12) o patients still succum% to this cancer or its se7uellae %etween the i th and tenth year1 we %elieve that a 1. year survival is necessary to assess the e ective ness o treatment or nasopharyngeal carcinoma&

** :'!(*+*
(93/580) (27/219)
1 3 32 " 10 yearN 1-MM l&M
3.

-17>( -L3")

15 1379

25

0(5& 3&

*urvivarlateo

patientswithNPC&

Gradual Improvement in Results From 19"# to 1 !"# Innovation c$ %reatment %echni&ue

'he "-year survival rate o 21&2) overall ("71 o 1379)1 indicates that the results o radiotherapy or NPC in our hospital had gradually improved rom 31 ) (3"L113) in the late 19".s to 3"&3) (3.#L"9.) in the 19-.s and then to "3&3) (137L3"7) in the late 197.s ('a%le ()& Com%ining the advanced lesions (stage ((( and (+)1 the same phenomenon was o%served& 'he ive year survival rate improved rom 39) to 39&7) to 2.&1 ) and inally to 2#) during the same time period& 'his was

achieved through the gradual innovation o the tech ni7ue1 individuali=ation o each patientQs gradual adop tion o initial large portal treatment ollowed %y cone down techni7ue1 using convergent small %eams or iso lated cancerous e4tensions1 and a%andoning the super luous modalities& 9y timely o%taining help rom our head and nec6 surgeon I or certain resistant or re current lesions as well as ac7uiring aid rom our radio physicists especially in clinical dosimetry and the 7uality assurance practiced in our routine clinical wor6& 'hese improvements are rendered possi%le %y the gradual ac cumulation o e4perience o our radiotherapists over 3. years& Our %elie is that no urther improvement is li6ely without concomitant use o immunotherapy1 chemo therapy1 radiosensiti=ers or traditional chinese medici nal her%sL and radiotherapy& I! is our wish to analy=e the prognostic actors which are the %asis o our improve ment in treating NPC&

Pro'nosticFactors
:naly=ing actors in luencing the patientsQ prognosis1 we classi y them as two types/ non modi ying prognostic

':9B; 1& 19"#-19-.

5radual(mprovemenitn <esultso <adiotherapy or NPC

19-1-197. 1971-197"

(19"#-197#) 19"#-197#

197--197#

*tage
11

No&
3L3 3L1-L37 12L77 3.L1.2 3"L113

Percent
1..R ".R "9 1# 39 31

No&
3L3 -2L1.9 "7L1-. #"L31# 123L27# 3.#L"9.

Percent
-7 "9 337 39&7 3"&3

No&
7L7 -7L131 -.L133 "7L1-. 117L393 191L23.

Percent
1..R "" 232.&1 2"&"

No&
1L3 2"L-" "#L9# 33L93 91L19. 137L3"7

Percent
".R -9 "9 327&9 "3&3

No&
13L12 179L3.1 191L217 1#9L-27 3#.L1.-2 "71L1379

Percent
#"9&" 2"&# 39&3 3"&7 21&2

III III ,

(+ 'otal

(+

NPC8nasopharyngeaclarcinoma&

S(nsu iciennto& o patients&

113. 19##
':9B;3&

C:NC;< March J "

+ol& -1

(n luence o *tage on Prognosis o NPC *urvival rates

':9B;"&

(n luence o *e4 on Prognosis o NPC 1.-year survival rateR No& 1#.L-93 73L313 Percent 3"&9 32

"-year survival rateR 3.-year No& 1L3R "L19 1.L"9 11L139 37L319 Percent ". 317 # 13 *e4 !ale 0emale
P - .&."&

"-year *tage ( II III (+ 'otal No& 13L12 179L3.1 191L217 1#9L-27 "71L1379 Percent #"9&" 2"&# 39&3 21&2 No&

1.-year Percent -7 23 39 31 3#

No&
23-L1.-7 12"L313

Percent 39&9 2-&2

-L9R 7#L1#3 -9L339 1..L27" 3"3L9.-

. (nsu icient num%er o patients&

':9B;3& (n luence o :ge on Prognosis o NPC ("-year survival rate1 1379 NPC) "-year survival rate :ge group .-9 1.-19 3.-39 3.-39 2.-29 ".-"9 -.--9 7.-79 'otal No& 3L3 21L-" -.L132 1"9L3-. 197L2-" // L323 33L1.1 3L9 "71L1379 Percent 1.. -3 2" 22&3 23&2 33 33 33 21&2

NPC8 nasopharyngeal carcinoma&

NPC8 nasopharyngeal carcinoma&

actors inherently present when the patient is irst seen& 'hey can %e used only to predict the chance o survival& 'he other type1 the modi ying prognostic actors1 through understanding the techni7ue o treatment1 modi ication can %e made to increase the patientQs chance o %eing cured& Nonmodi$(in' pro'nostic $actors) 1& *tage8 :mong the survival rates in the i th1 tenth1 and the 3.th year1 there is always a reduction o 1. to

':9B;2&

(n luence o Pathology on Prognosis o NPC ("-year survival1 1379 NPC) "-year survival rate

Pathologic classi ication Poorly di erentiated ca *7uamous cell ca :naplastic ca Knc1assi ia%le ca :denoca 'otal

No&
2.9L9.23L1.9 37L1.9 #1L327 1L# "71L1379

Percent 2"&1 39 32 33 13 21&2

N$C8 nasopharyngeal carcinoma/ Ca8 carcinoma&

3.) in survival rate as the stage progresses through *tage ( to (+ ('a%le 3)& 5enerally1 the survival rate o *tage III patients is indicative o the mean o all our stages grouped together& I! should %e noted that our pa tients had come rom a populace lac6ing in periodic cancer screening& 'here ore advanced lesions are pre ponderant& 3& :ge8 Knli6e malignant lymphoma1 gastric cancer and cancer o the %reast1 the survival rate o NPC in creases or younger patients& (n -7 patients under 19 years o age1 -2) (23) survived or more than " years which is 33) higher than the overall " year survival o the whole series& 9oth o the two patients under 9 years old survived or more than " years& (n contrast1 patients older than age ". gave much poorer results/ 31&7) (113 o 3"3) which is less than hal the survival rate or those patients under age 19 ('a%le 3)& 3& Pathologic classi ication8 'he pathologic su%typing o NPC seems not to %e important in in luencing pa tientsQ prognoses e4cept in the case o adenocarcinoma which1 %eing resistant to radiation1 should %e given higher doses as reported %y +i6ram and his associates in 19#"&3 Only one o eight patients su ering rom adeno carcinoma in our series survived " years or longer ('a%le 2)& 2& *e48 'a%le " shows the more avora%le outcome o the emale patients in terms o " and 1. year survival rates with di erences o statistic signi icance (P - .&.")& :lthough we noted pregnancy as a gravely detrimental e ect on patients with NPC12 the role o the hormone in this cancer is still o%scure& "& 9ony destruction o %ase o s6ull8 9ony destruc tion at the %ase o s6ull apprecia%ly a ects a patientQs prognosis& Patients positive or %ony destruction gave only 37) ("- o 3.") " year survival in contrast to 2"&3) (2#1 o 1.-1) or those without it ('a%le -)& 'he di er ence therein is statistically signi icance (P - .&.")& Our "2 patients with dou%t ul destruction gave a similar sur vival rate1 3#) (1"L"2) to those positive or destruction& 'his may have %een due to the poor 7uality o the su% mentovertical proAection which had %een the chie means o demonstrating %ony destruction %e ore C' was installed in our hospital in 1979& *ince then& C' has almost totally replaced radiograph ilms %eing more >sensitive> and accurate in detecting %ony anomalies at

No&-

NPC
':9B;-&

0REA0ED )Y RADIA0ION

Qin et al.

1131

(n luence o $estruction o 9ase o *6ull on Prognosis o NPC "-year survival

9ase o s6ull %ony destruction No destruction *uspicious o destruction

No& 2#1L1.-1 1"L"2

Percent

8g88/&8/18&8MM8&8&M8&88Q&8
'otal

$estruction positive Not recorded

"-L3." 19L"9 "71L1379

33 21&2

NPC8 nasopharyngeal carcinoma&

the %ase o s6ull&Q 'oday1 with newer acilities on hand1 we are studying the validity o !<( in comparison with C' or NPC& :s the nasopharyn4 is located %eneath the %ony %ase o the middle cranial ossa1 posterior cranial ossa involvement signi ies more e4tensive invasion and graver prognosis& (t gave a "-year survival o 1#) (2L33) as compared with 3#) ("3L1#3) involving the middle cranial ossa ('a%le 7)& -& Paralysis o cranial nerves8 Presence o cranial nerve paralysis reduced the patientQs chance o survival %y 33) (27&-) to 3-)) and @ornerQs syndrome which always coe4isted with paralysis o other nerves (syn drome retroparotidean space)1 implies a grave prog nosis1 only 9) (3 o 33) o patients survived " years ('a%le #)& Modi$(in' pro'nostic $actors) 1& Prophylactic irradiation o the nec68 Fe divided the nec6 region into =ones/ upper1 middle1 lower nec6 and supraclavicular =ones separated %y three hori=ontal imaginary lines running parallel to/ the hyoid %one a%ove the lower %order o thyrocricoid mem%rane in the midsegment o the nec6 and another hori=ontal line 3 123 a%ove and parallel to the upper %order o the clavi cle&> *ince 19"# when our hospital irst opened1 we have tried various types o portals %est suited to the nec6 metastasis/ those covering only the area o the metas tasis1 those e4tending downward %eyond the involved nodes and those e4tending two =ones& 'he results o% tained show the importance o prophylactic irradiation o the nec6 through wide portals and are shown in 'a%le 9& Fe chose 91" patients who had %een treated %y our standard techni7ue1 e g ! anteriotangential ield o di erent si=es with the spinal cord shielded ollowed %y le t and right motion through %eams which are inally sup plemented %y local %ooster doses1 to prove the impor tance o rational use o portals or the nec6& 'he %est way o treating the nec6 is to two-=one e4tension or use whole nec6 prophylactic irradiation& :s can %e seen in 'a%le 91 the poorest survival resulted rom the small portals1 which covered only the metastatic lymph nodes1 and gave a " year survival rate o only 33) (3- o 113)&

:s we enlarged the nec6 portals downwards %y one =one1 the " year survival rate increased to 2"&.) (32# o ""1)& 'he survival rate urther increased to "3&#) (13" o 3"1) when two more =ones were irradiated prophy lactically& 'he di erences in the survival rates which resulted rom this e4tension is o paramount importance (P T .&.")& :t present1 our standard method is to irra diate the whole nec6 %ilaterally even i the lymph nodes are involved or not& Our e4perience o treating *tage ( lesions (with no palpa%le nodes in the nec6) is to irra diate the whole nec6 %ilaterally to a dose o 2. to ". 5yL2 to " wee6s without urther %oosting& Patients with carcinoma-positive nec6 glands should %e treated as de scri%ed in the !ethods section& 3& Optimum dose at the nasopharyn4 and the proper way o delivery8 Our routine re7uires the assistant resi':9B;7& (n luence o *ite o 9ony $estruction on Prognosis o NpcR "-year survival *ite o destruction !iddle cranial ossa Posterior cranial ossa 'otal No& "3L1#3 2L33 "-L3." Percent 3# 1# 37

NPC8 nasopharyngeal carcinoma& S 3." patients positive or destruction& ':9B;#& (n luence o Cranial Nerve Paralysis on Prognosis o NPC "-year survival Cranial nerve paralysis No paralysis *uspicious o paralysis Paralysis present Not recorded @ornerQs syndrome ,! 'otal No& 2"2L9"2 3L-R 99L377 1"L23 3L33 "71L1379 Percent 27&33" 9

SO

21&2

NPC8 nasopharyngeal carcinoma& S (nsu icient num%er o patients& t @ornerQs syndrome always coe4isted with paralysis o other nerves&

1133
':9B;9&

C:NC;< (n luence o Prophylactic Nec6 (rradiation on Prognosis o NPC? "-year survi val rate

March 1" 19##

':9B; ((& (n luence o (ntracavitary <adium on the Prognosis o NPC "-year survival rate

+ol& -1

Eones o prophylactic e4tension No e4tension One-=one e4tension 'wo-=one e4tension

No& 3-L113 32#L""1 13"L3"1

Percent 33 2"&. "3&#

p
T.&." T.&."

<adiation 'eleco%alt only -OCO, <a Orthovoltage 4-rays only Orthovoltage 4-rays , <a

No& 3##L-9# 3L12 1#L29 13L39

Percent 3 21& 12 37 31

NPC8 nasopharyngeal carcinoma& ? 91" patients treated %y standard techni7ue&

<a8 radiation/ NPC8 nasopharyngeal carcinoma&

dents to e4amine tumor condition every wee6 and enter it into the history record with drawings and dose re ceived at that time& 'hey ma6e special note when the tumor disappears and this dose is designated as the >res olution dose> which1 or NPC1 is usually 2. to ". 5y& 'he total dose re7uired or a speci ic patient is com monly 3. 5y greater than >resolution dose1> i.e.. a%out 7. 5y& 'his amount o radiation is usually delivered to the nasopharyn4 and the adAacent %ase o s6ull %y two preauricular portals on the sides o the ace (0ig& l:)& 9ecause stage (+ disease is characteri=ed %y distant me tastasis1 only *tage (1 (( and ((( lesions were evaluated to ind the optimum dose or the primary ocus& :s shown in 'a%le 1.1 the optimum dose or cure o the primary lesion is not restricted to speci ic value1 rather it lies in a considera%le range1 -. to 9. 5y or more& Ordinarily1 7. to #. 5y is considered ade7uate& (n some patients1 we would see very resistant lesions presenting as a tumor mass in the nasopharyn4 when the dose reached 7. 5y& 0or this type o tumor1 a cone-down technic is adopted %y delineating the portals with the patient under the luoroscope (or later1 simulator) to reduce the area o radiation to 2 to " em in diameter& 'hree or our cone down portals/ one or two in ront and two on the sides o the ace1 are usually used and the ractionation assumes the >assault> way %y giving 2 5y1 twice a wee61 with the total dose pushed up to #. 5y or even 9. 5y (0ig& 19)& 9eyond 9. 5y1 we would hesitate to carry on the radia-

tion urther i the tumor has shown partial regression e4cept under very special circumstances& (ntracavitary radium mould or intraoral cone directed towards the posterosuperior wall o the nasopharyn4 through the so t palate is sometimes tried or %oosting& (t must %e emphasi=ed that dosages a%ove #. 5y have never %een routinely used or ear o radiation inAury and supra lethal e ect/ dosages greater than #. 5y are always given to resistant lesions& 'he %etter result o the group o patients who received more than 9. 5y (-2)1 39L-1) had aroused much discrepancy in China1 %ecause some re rain rom administering radiation %eyond 7. G4, 'o settle this dispute1 one o the authors (U@O) is reviewing the records o patients who received 7. 5y or more& @er aim is to determine the validity o high doses or resis tant NPC& 'here will %e another paper devoted to a retrospective analysis o high dosages or resistant NPC and a prospective randomi=ed trial on the same su%Aect to test a similar view o +i6ram et al* who reported a higher rate o recurrence in lower doses& Case Report
BVE1 male1 3. years o age (history No& 1..3..)1 was ad mitted in Uune 19-- or one-sided headache1 %loody nasal dis charge1 hearing di iculty1 trismus and cervical masses or 3 months& 9iopsy or the nasopharyn4 proved to %e poorly di erentiated carcinoma& 'he primary lesion was ound to have e4tended into the pterygoid ossa and he was staged as having a *tage ((( lesion& 'eleco%alt irradiation was initiated Uune 171 19-- to :ugust 321 19--& Fhen #. 5y was delivered through two preauricular portals supplemented %y two anterior in raor%ital %ooster portals1 the primary lesion was ound to per sist& 'hen1 through an intraoral cone1 an air dose o 1#.. c5y was delivered& 'he total dose was calculated to %e 92.. c5y& I! was not until two months a ter the conclusion o his treatment that the primary tumor inally disappeared& (n $ecem%er 19#-1 3. years - months a ter irradiation1 the patient was ree o tumor and a%le to wor6&

':9B; 1.& (n luence o $ose at the Primary Besion on Prognosis o NPC? $ose in nasopharyn4 (5y) 2.-29 ".-"9 -.--9 7.-79 #.-#9 M9. "-year survival No& -L13 13L37 72L1-177L337 73L13# 39L-1 Percent 23" 2" "2&1 "7 -2

NPC8 nasopharyngeal carcinoma& . 733 patients with *tage I ((& and ((( lesions&

3N (ntracavitary radium8 $uring the early 19-.s part o our patients were routinely given intracavitary radia tion as a %ooster to the conventional e4ternal irradia tion& (ntracavitary radiation was not administered on

No&-

NPC '<;:';$ 9O <:$(:'(ON

Qin et al.
':9B;13& Capa%ility o *urviving NPC Patients " and 1. Oears : ter <adiotherapy survivors No& 3#3
(**

1133

the %asis o a randomi=ed trial& 'he intracavitary im plant1 consisting o si4 l O-mg radium tu%es arranged in inserted in the nasopharyn4 through the mouth with the help o two catheters introduced rom the nasal cavities& 'he implant was inserted as soon as the primary lesion had resolved enough so as the nasopharyngeal cavity could accommodate it1 %ut %e ore the reaction in the mucous mem%rane %ecame severe& ;ach o the two ap plications1 spaced 7 to 1. days apart1 would deliver 13.. mg-hr which was e7uivalent to 3... c5y1 totalling 2... c5y on the sur ace o the mucous mem%rane according to Paterson-Par6erQs radium dosage calculation&Q 'he non validity o intracavitary radium %oosting is shown in 'a%le II 'he lower "-year survival rates o patients who received intracavitary radium1 especially those who were treated %y teleco%alt1 may have %een due to the in creased hematogenous metastasis resulting rom the trauma o the implant& :lthough others reported the %ene its o intracavitary radiation1 we inally a%olished its use&>

,arno s6yQs per ormance status 9.-1.. ull time wor6 7.-#. pan time wor6 1.--. una%le to wor6 Not recorded 'otal

survivors No&
(*O

Percent 29&37&3 17 1..

Percent 1. -. 33 7 1..

3-

91 23

"9 1#

"71

3"3

NPC8 nasopharyngeal carcinoma& %lood %orn metastasis1 2#&3) (2-3 o 9"9)& 'hose pa tients who developed hematogenous metastasis together with recurrence in the nasopharyn4 andLor the nec6 were scored as having died o %lood %orn metastasis& 2." (23&3)) patients died o recurrences in the head and nec6 regions& (n 91 (9&")) patients the cause o death was not clear& Ksing the per ormance status introduced %y ,ar no s6y1QW our data o the surviving patients show that 7-&7) (23# o "71) o them were wor6ing " years a ter their initial radiotherapy and 7.) (17- o 3"3) o them had %een a%le to do so in another " years although 1-) to 33) o them had lost their a%ility to wor6 ('a%le 13)& <;0;<;NC;* 1& Vu 5E1 Bi D@1 @u O@ et al. Bymphadenectomy as a de initive management o the residual lesion in the nec6 a ter radiotherapy or nasopharyngeal carcinoma8 :nalysis o 2# cases& Chin + ,ncol 19#1/ 38133-13" (in Chinese)& 3& Cai F!1 @u O@1 Ehang @V et al. Com%ination o Chinese her%al medicine and radiotherapy in the treatment o nasopharyngeal carcinoma& +ournal 0/ -merican Colle'e c$ %raduional Chinese Medi cine 19#3/38 1-#& 3& +i6ram 91 !isha K91 *trong ;F et al. Patterns o ailure in carcinoma o the nasopharyn4& lnt + Radial ,neal .ioi Ph(s
1 "/0

Complications and Se&uelae

(rradiation o NPC will inevita%ly a ect the vital organs in the head and nec6 area1 %rain1 and spinal cord& (t re7uently gives rise to complications and se7uelae& Our data show that 1#&2) o patients developed radia tion encephalornyelopathy which included those as mild as the transient mani estations o BhermitteQs sign and those as serious and atal as transverse myelopathy and paraplegia& Ne4t in incidence are trismus (9&#)) and otitis media (#&#))& 'he incidence o radiation enceph alomyelopathy increases with the dose received in the nasopharyn4 ('a%le 13)&9

Cause o$ Failure and Per$ormance Status o$ the Survivors

: total o 9"9 (-9&")) o the 1379 patients have died as o this writing& 'he most common cause o ailure is ':9B;13& <elation o <adiation ;ncephalomyelopathy and $ose in the Nasopharyn4 (1379 patients) (ncidence o encephalomye1.pat hy $ose in nasopharyn4 (5y) 2.-29 ".-"9 -.--9 7.-79 #.-#9 TP89. 'otal No& 3L2# 33L1.# 72L333 9-L"-1 3#L332 33L1." 3"2L1379 Percent 2 3. 33 17 17 31 1#&2

11812""-12"9& 2& +an U@1 Biao C*1 @u O@& Pregnancy and nasopharyngeal carci noma8 : prognostic evaluation o 37 patients& Int J Radiat ,ncol .ioI Ph(s 19#2/ 1.8#"1-#""& "& Ou E@1 Vu 5E1 @uang O<1 @u O@1 *u VE1 5u VE& +alue o computed tomography in staging the primary lesion ('sstaging) o nasopharyngeal carcinoma (NPC)8 :n analysis o "2 patients with special re erence to the parapharyngeal space& Inc + Radial ,ncol .ioi Ph(s 19#"/ 1183123-3127& -& @u O@1 Oin F91 Bi 'B1 @a VF1 'u 5O& 'he technic and result o radiotherapy or nasopharyngeal carcinoma8 : preliminary report& Chin J Roent'enol1 1/0 1.82-7-2-9 (in Chinese)& 7& Paterson <& 'he radium dosage& (n8 Paterson <1 ed& 'he 'reat ment o !alignant $isease %y <adiotherapy1 ed& 3& Bondon8 ;dward :rnold Btd1 19-3/ 131-13#& #& Chang CP1 Biu '01 Chang OF1 Cao *B& <adiation therapy o nasopharyngealcarcinoma& -cta Radiol 2,neol3 19#./ 19823323#& 9& Din OV1 @u O@1 5u VE et al. :n analysis o 3.7 cases o irradiation encephalornyelopathy1 Chin J Roent'enol 19#3/ 1783#9393 (in Chinese)& 1.& ,arno s6y $:& 'he use o nitrogen mustards in the palliative treatment o carcinoma& Cancer 192#/ 18-32--3#&

1156

C:NC;<

March 1" 19##

:PP;N$(V

+ol& -1

*taging *ystem& as (ntroduced at the *econd National *ymposium on Nasopharyngeal Carcinoma1 *hanghai1 China

19-"1

'

'O No visi%le tumor in the nasopharyn4& '( Primary tumor involving one wall o the nasopharyn4& '3 Primary tumor involving two or more walls o the nasopharyn4& '3 Primary tumor e4tending %eyond nasopharyn4 involving one o the ollowing groups o structures8 (& 'he continuous so t tissues1 the neigh%oring sinuses or cavities& 3& 'he %one o the %ase o the s6ull& 3& Cranial nerves1 (1 ((1 (((& (+1 + andLor +(& '2 :s in '3 %ut involving two or more groups o structures&

M !O !( *tage I (( III (+

:%sence o distant metastasis& Presence o distant metastasis& '(NO!O& 'O-(N1!O/ '3NO-(!O& 'O-3N3!O/ '3N.-3!O& '.-2N3!O/ '2N.-2!O/ 'O-2NO-2!(&

TO
NO N1 N5 N7 N6

01

05

07

06

NO :%sence o palpa%le lymph node in the nec6& N ( 0reely mova%le lymph node in the upper cervical region1 on one or %oth sides1 diameter less than 3 em1 N3 ;ntirely or partially i4ed lymph nodes in the cervical region on one or %oth sides1 diameter under # ern& N3 Cervical lymph nodes enlargement together with involvement o one o nerve (V1 V1 V(& V(( andLor sympathetic ganglion& N2 Cervical lymph node enlargement1 over # cm in diameter or with involvement o the supraclavicular ossa&

II

III IV