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Jurnal Ca Nasofaring
Jurnal Ca Nasofaring
Jurnal Ca Nasofaring
Nasopharyngeal Carcinomas:
Prognostic Factors and Treatment Features
M.D.**; ZAFER ZDO GAN,
ZEYNEL YOLOGLU,
M.D.*
The Departments of Radiology* and Radiation Oncology**, Ankara Oncology Education and Research Hospital,
Ankara, Turkey.
ABSTRACT
Purpose: We retrospectively evaluated the clinical,
radiological and pathological features determining the
prognosis of patients with nasopharyngeal carcinoma in
Ankara Oncology Hospital, Turkey.
INTRODUCTION
The nasopharynx is a cuboidal cavity formed
by muscle and fascia with an epithelial mucosal
covering. Nasopharyngeal carcinoma is a rare
tumor that arises in this epithelium [1] . It is
more common in males by a margin of about 2
to 1 and its incidence peaks at 50 to 60 years
of age; a small peak also occurs during late
childhood [1].
Nasopharyngeal carcinoma is highly radiosensitive and radical external beam radiotherapy is the mainstay of treatment for this neoplasm and its regional lymph node metastasis
[2]. There have been studies on prognostic factors of nasopharyngeal carcinoma; however,
their outcomes are still controversial [1-9]. So,
radiology and radiation oncology clinics collectively reevaluated prognostic factors which
influence survival of the patients treated with
nasopharyngeal carcinoma.
230
Nasopharyngeal Carcinomas
231
232
Cox regression analysis. We entered type, diameter, therapy, T-stage and N-stage as categorical variables in Cox regression analysis. A pvalue of 0.05 or less at 95% confidence interval
was considered to be statistically significant.
Primary endpoints of this study were diseasefree and overall survivals.
RESULTS
Table (1) demonstrates the demographic data
of patients with nasopharyngeal carcinoma. The
mean and median follow-up periods were 24.9
27.7 and 14 months (range, 1-170 months),
respectively.
In our series, eight of 259 patients had concomitant second malignancies: Seven carcinomas (lung, larynx, breast, testis, thyroid, renal
and prostate) and one gluteal alveolar rabdomyosarcoma. Our clinical signs and symptoms
were 179 neck masses (69.1%), 35 nasal obstructions (13.5%), 21 hearing losses and ear
fellnesses (8.1%) and 16 epistaxes (6.2%), five
diplopia (2.0%), seven tinnitus (2.7%) and seven
dysphasia (2.7%).
As a treatment modality, a total of 65 patients
received only radiotherapy. Among them, sixtyone patients (24.7%) had 60Gy, while four
patients (1.6%) had <60Gy.
There were eight patients with distant metastasis on diagnosis; in addition 56 patients
with metastasis were detected after diagnosis.
These eight patients were excluded from metastasis and progression evaluation for systemic
failure. Of these 56 patients, there were 41
skeletal, 23 lung, 13 hepatic and 10 other organ
metastases. The most frequently involved sites
of skeletal metastasis were the vertebrae, cranium and pelvis, in order. There were 38 locoregional recurrences and the median time for this
was thirteen months.
Prognostic factors for overall survival by
univariate and multivariate analysis are shown
in tables (2,3). Five-year disease-free, diseasespecific, overall, locoregional recurrence-free
and metastasis-free survivals were 454%,
763%, 723%, 763% and 664%, respectively.
The prognostic factors for the disease-free
survival were gender, diameter, oropharynx,
bone/sinus, intracranial, parapharyngeal, T-
stage, N-stage, therapy and response on univariate analysis. Nevertheless, these were age (p=
0.018), gender (p=0.032), type (p=0.044), therapy (p=0.019), N-stage (p=0.005) and response
(p<0.001) on multivariate analysis. The fiveyear disease-free survival rates were as follows:
40 year (466%), >40 year (445%); female
(597%) and male (404%); type 1 (289%),
type 2 (497%) and type 3 (475%); radiotherapy (578%), combined chemo-radiotherapy
(444%). N0 stage (849%), N1 (466%), N2
(416%), N3a (0%) and N3b (0%); response
(514%) and no response (0%).
Patients (%)
Total
Female/Male
Age (median; range)
Follow-up (median; range)
259 (100)a
74 (28.5)/185 (71.2)
46; 9-89 years
14; 1-170 months
WHO type:
1
2
3
29 (11.2)
67 (25.8)
163 (62.7)
Diameter:
<1cm
1-3cm
>3cm
31 (12.0)
62 (23.9)
166 (64.1)
T-stage:
1
2a/2b
3
4
46 (17.8)
43 (16.6)/93 (35.9)
41 (15.8)
36 (13.9)
N-stage:
0
1
2
3a/3b
30 (11.6)
111 (42.9)
102 (39.4)
8 (3.1)/8 (3.1)
Therapy:
Radiotherapy
Chemotherapy
Combinedb
<60Gy radiotherapy
No therapy
65 (25.9)
7 (2.8)
175 (69.7)
4 (1.6)
8 (3.1)
Response to treatmentc:
No
Yes
27 (11.1)
217 (88.9)
Nasopharyngeal Carcinomas
233
Disease-free survival
Disease-specific
Overall survival
0.221b; 0.018c
0.017; 0.032
0.057; 0.044
<0.001; 0.112
0.014; 0.089
0.980
0.005; 0.565
0.004; 0.828
<0.001; 0.471
0.891; 0.852
<0.001; 0.923
<0.001; 0.005
<0.001; 0.019
<0.001; <0.001
0.296; 0.178
0.066; 0.240
0.616; 0.880
<0.001; 0.259
0.768; 0.811
0.754
0.142; 0.401
0.060; 0.464
<0.001; 0.925
0.924; 0.849
<0.001; 0.670
<0.001; 0.001
<0.001; 0.144
<0.001; 0.009
0.364; 0.476
0.327; 0.914
0.553; 0.884
<0.001; 0.327
0.588; 0.522
0.587
0.280; 0.522
0.071; 0.448
<0.001; 0.940
0.724; 0.743
<0.001; 0.632
<0.001; <0.001
<0.001; 0.465
<0.001; 0.001
Recurrence-free survival
Metastasis-free survival
0.239b; 0.016c
0.870; 0.873
0.026; 0.012
0.002; 0.129
0.051; 0.124
0.968
0.065; 0.048
0.522; 0.592
<0.001; 0.145
0.350; 0.738
0.021; 0.141
0.157; 0.366
<0.001; 0.455
<0.001; 0.179
0.476; 0.930
0.113; 0.036
0.050; 0.053
<0.001; 0.741
0.026; 0.101
0.737
0.054; 0.940
0.116; 0.677
<0.001; 0.643
0.560; 0.729
<0.001; 0.779
0.011; 0.683
0.167; 0.421
<0.001; <0.001
The prognostic factors that affected diseasespecific survival were diameter, parapharyngeal,
T-stage, N-stage, therapy and response, whereas
they were N-stage (p=0.001) and response
(p=0.009) on multivariate analysis. Five-year
disease-specific survival rates were; N0 stage
(946%), N1 (825%), N2 (736%), N3a (0%)
and N3b (0%); response (813%) and no response (4411%).
234
However, the prognostic factors for locoregional recurrence were type, diameter, parapharyngeal, T-stage, therapy and response on
univariate analysis. These were age (p=0.016),
type (0.012) and bone/sinus (p=0.048) on multivariate analysis. Five-year recurrence-free
survival rates of them were as follows: 40year (785%) and >40-year (755%); type 1
(6012%), type 2 (895%), type 3 (744%)
and no bone/sinus (804%) and bone/sinus
(687%).
Prognostic factors affecting distant metastasis were type, diameter, oropharynx, parapharyngeal, T-stage, N-stage and response on
univariate analysis, while they were gender
(p=0.036) and response (p<0.001) on multivariate analysis. Five-year metastasis-free survival
rates of them were as follows: Female (747%)
and male (625%); response (684%) and no
response (0%).
WHO type
Cures
Complication due
to therapy
Follow-up/
fatality
34/F
T2b/N3b
Hemorrhage
1/year
58/F
T2b/n1
No
5/no
62/M
T4/N1
No
2a/no
33/F
T2a/N0
No
2a/no
33/M
T2b/N1
No
2b/yes
46/M
T2b/N2
10
No
27c/no
14/M
T2b/N1
Pancytopenia
3b/yes
Age/gender
p valuea
Disease-free survival
0.191
445
4510
Disease-specific survival
0.502
784
848
Overall survival
0.634
745
848
Recurrence-free survival
0.554
755
6910
Metastasis-free survival
0.190
585
7710
Nasopharyngeal Carcinomas
235
Etiology
34/F
Chemotherapy
Cures/total dose
Fatal complication
Massive hemorrhage
Yes
Yes
14/M
Chemotherapy
Pancytopeniaa
80/M
Radiotherapy
70 Gy
Nutrient deficiency
Yes
48/F
Radiotherapy
42 Gy
Nutrient deficiency
Yes
37/M
Radiotherapy
70 Gy
No
No
47/M
Radiotherapy
70 Gy
Radio-necrosisc
47/M
Radiotherapy
72 Gy
Radio-necrosisd
No
14/M
Radiotherapy
68 Gy
No
DISCUSSION
The incidence of nasopharyngeal carcinoma
is 0.35 per 100,000 populations in Turkey [5].
The prognostic value of the tumor type is not
definitive; some series reported that type 2 and
3 diseases had better prognosis than type 1 [1],
but the others reported that histopathology did
not have for response and survival in their series
[5]. In our series, tumor type was found predictive in progression and locoregional recurrence
at which type 1 had the worst prognosis.
Patients under 40 years of age had a better
prognosis for overall survival in some series
[2]; we observed the same finding for diseasefree and recurrence-free survivals. Female patients had better prognosis on disease-free survival in Erkal et al.s report [5]; likewise, this
was the case for disease-free and metastasisfree survivals in our series.
The nasopharynx has a rich lymphatic network and approximately 90% of patients develop lymphadenopathy in their life-span. We
detected 88.4% of patients with cervical lymph
node involvement, of which 42.9% was unilateral. High-grade tumors with large and/or multiple bilateral and/or lower neck lymphadenopathy are associated with high incidence (5070%) of distant metastases [3]. T-stage and Nstage usually determine the natural history for
nasopharyngeal carcinomas [5]. The multifarious
extensions of nasopharyngeal carcinoma and
the proximity to organs whose functions must
be preserved render the radiotherapy technique
236
could increase survival rates. In our series, Nstage and response were found the most important independent predictors on survival. Age,
gender, type, therapy and bone/sinus involvement were predictive parameters, as well.
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