PURPOSE: To investigate the clinical manifestations and treatment outcomes in patients with stage T4M0 nasopharyngeal carcinoma.

MATERIALS AND METHODS: Findings in 179 patients (age range, 13–78 years) with American Joint Committee on Cancer stage T4M0 nasopharyngeal carcinoma treated from January 1983 to February 1992 with a minimum follow-up of at least 5 years were reviewed. Of the 179 patients, 166 (92.7%) had World Health Organization type II or III disease. Forty-one patients (22.9%) had no lymph nodal involvement; 138 patients (77.1%) had metastatic nodal involvement in the neck. All patients underwent radiation therapy; 39 patients also received different forms of chemotherapy. The radiation therapy doses were usually 70–74 Gy administered to the primary tumor over 7 or 8 weeks, 70–74 Gy to the neck region in patients with nodal involvement, or 50–60 Gy administered to the neck region over 5 or 6 weeks in patients without neck nodal involvement.

RESULTS: In 100 patients, radiation therapy failed in the primary tumor alone (n = 28), neck nodes alone (n = 5), and distant metastases alone (n = 43) or at a combination of sites (n = 24). The cumulative failure rates for the primary tumor, neck metastases, and distant metastases were 25.1% (n = 45), 14.0% (n = 25), and 33.0% (n = 59), respectively. The 5-year primary disease–free, distant disease–free, and overall survival rates were 68.7%, 56.5%, and 28.6%, respectively. Results of salvage treatment for relapse were unsatisfactory.

CONCLUSION: In about three-tenths of patients, T4M0 nasopharyngeal carcinoma can be cured with conventional high-dose radiation therapy.

Index terms: Nasopharynx, neoplasms, 263.37 • Nasopharynx, therapeutic radiology, 263.1299 • Nerves, neoplasms, 146.38, 151.38, 152.38, 154.38 • Skull, base, 12.33 • Skull, secondary neoplasms, 12.33

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L. Licitra

Although radiation therapy is effective in the management of patients with early stage nasopharyngeal cancer, a high rate of local-regional failure and distant dissemination is expected in patients with advanced disease. This has prompted studies on the addition of chemotherapy to radiation therapy. Chemotherapy has been used as a neoadjuvant and, less frequently, concomitantly with radiation therapy or as an adjuvant to it. In this issue of Annals of Oncology, Oh et al. [1] report a small series of patients prospectively treated with neoadjuvant chemotherapy, followed by chemoradiation therapy (CCRT). This study is of interest because there are only a few other studies reported so far employing both neoadjuvant chemotherapy and CCRT [2, 3].

It is widely believed that the main benefit from CCRT should be local, by increasing the activity of radiation therapy , whereas the benefit from adjuvant or neoadjuvant chemotherapy should be systemic, by targeting micrometastatic disease. These are known, respectively, as the ‘local cooperation’ and the ‘spatial cooperation’ between chemotherapy and radiotherapy.

However, recent trials in nasopharyngeal cancer suggest an unexpected local cooperation for neoadjuvant chemotherapy, and, on the other side, concomitant chemoradiotherapy (CCRT) could result in a reduced metastatic rate, at least in some patient subgroups, thus displaying spatial cooperation.

Indeed, most of the evidence in favour of chemotherapy in nasopharyngeal cancer derives from studies using CCRT [4, 5]. A meta-analysis including >1 500 patients, randomized in six studies was published recently [6]. Most such studies employed neoadjuvant chemotherapy, while in one of them chemotherapy was included after radiotherapy, and in another chemotherapy was given concomitantly with radiation, followed by adjuvant chemotherapy. By combining these studies, a summary odds ratio of 0.62 (95% CI 0.52–0.78) was yielded, indicating a 37% increase in 2-year disease-free survival (DFS) and a 20% improvement in survival at 2 to 4 years in favour of chemotherapy. However, this survival benefit was substantially influenced by one study, the Intergroup trial [4], which used CCRT. Unfortunately, this trial included a large number of differentiated cancers (only 40% of cases had WHO type III nasopharyngeal cancer). This might in part explain the benefit from CCRT, in line with favourable results of CCRT in head and neck squamous cell carcinoma. An improvement in distant metastasis-free survival (DMFS) would have been expected mainly in undifferentiated nasopharyngeal cancer (UNPC), but the low number of these patients made it impossible to establish whether UNPC patients benefited from adjuvant chemotherapy. In addition, only 55% of patients received the planned three cycles of adjuvant chemotherapy, and 40% received one or no cycle. This challenges the feasibility of adjuvant chemotherapy in irradiated patients. That adjuvant chemotherapy is difficult in head and neck cancer patients has already been shown by previous studies. It follows that either cisplatin plus fluorouracil was so active in this series that these results were achieved irrespective of dose intensity, or most probably, CCRT wields its activity both at the local and the distant level, perhaps through better local-regional control [7]. After publication of the meta-analysis, four more randomized trials have been made available. All trials were carried out in geographical areas where the disease is endemic, so that a high proportion of UNPC patients were included [5, 8–10]. Three trials employed adjuvant or neoadjuvant chemotherapy, one only CCRT. The trial by Chi et al. [8] confirmed the negative results of an old trial [11], which showed that adjuvant chemotherapy, even if CDDP-based, is of no benefit (although with a lower systemic relapse rate). The study by Hareyama et al. [9] on neoadjuvant cisplatin and fluorouracil was able to show a favourable trend in DMFS, with no improvement in terms of DFS, survival or local-regional control. The trial by Chan et al. [10], mainly including CCRT patients, was unable to show a difference in terms of progression-free survival (PFS). However, PFS was significantly prolonged in patients with advanced tumour and nodal stage. The beneficial effect was obtained in this subgroup mainly by reducing distant failures, although a trend towards better local control was also observed. Finally, the most recent trial showed a significant impact from CCRT in terms of both DFS and overall survival. The main contribution of chemotherapy was seen at the tumour site, but also at the regional and distant sites, though without reaching statistical significance. By doing so, distant failures outnumbered local recurrences. Therefore, the results of Chan et al. [10] and Lin et al. [5] indicate a role for CCRT in improving local-regional control and DMFS. It is noteworthy that the only trial with a positive effect was that employing two cycles of concurrent polychemotherapy. These observations suggest that the maximal therapeutic benefit could be obtained by combining full-dose chemotherapy and CCRT. However, this can be done only when chemotherapy is given before CCRT. In fact, timing is critical, since the interaction between chemotherapy and radiation therapy may prohibitively increase the risk of side-effects, given the site of origin of this neoplasm. Generally, polychemotherapy is used when medical therapy is given in a neoadjuvant fashion, while single-agent chemotherapy is preferred when given in combination with radiation therapy. One might assume that polychemotherapy is more effective against systemic disease than monochemotherapy.

This is the background of treatment protocols such as that reported by Oh et al. in this issue [1]. These preliminary phase II studies suggest an excellent disease control and survival, with good tolerability and feasibility of both chemotherapy and radiation therapy, according to the planned schedules. In one trial, radiation therapy was delivered, mainly for tolerability concerns, at a total dose of 60 Gy, which may be considered relatively low. The achievement of excellent local-regional control in this series suggests that lower doses of radiation therapy may be acceptable if combined with chemotherapy. The reduction in tumour bulk at the T site would allow full irradiation of gross residual disease, thus maximizing local control and sparing normal tissues. This would imply lower late toxicity, which is still of some concern. Unfortunately, late toxicities from combined treatments in already closed studies have not been fully documented yet, and a more prolonged follow-up is needed.

Therefore, what next?

Whether neoadjuvant chemotherapy followed by CCRT is superior to CCRT alone, or to CCRT followed by adjuvant chemotherapy, should now be tested within comparative trials.
An effort should be made to identify patients who are most likely to benefit from neoadjuvant chemotherapy followed by CCRT. Who are they likely to be? Probably, those with both a high local and systemic risk, though one could not rule out that patients with just a high local risk might benefit, given the possible local cooperation of neoadjuvant chemotherapy with subsequent CCRT. A number of retrospective studies have attempted to identify patients who are more likely to fail at the primary site and/or distantly. Multivariate analyses showed that some factors may predict a higher risk of local failure and/or distant metastases [12, 13].

Regarding the first point, one should consider that new radiotherapy techniques, such as intensity modulated radiotherapy (IMRT), allowing both dose escalation and better treatment profiling, might challenge again the need for chemotherapy within integrated protocols. Secondly, incorporating an adjuvant chemotherapy arm in next-generation trials might be useless, for the very simple reason that adjuvant chemotherapy is hardly feasible, at least with the same dose/intensity as neoadjuvant chemotherapy.

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Jerome M. Vaeth and Franz Buschke

Seven of twenty-two patients treated with intracavitary Co⁶⁰ therapy for nasopharyngeal neoplasms remained controlled for more than five years.

No patient treated with intracavitary Co⁶⁰ therapy alone has remained alive.

Of the seven surviving patients, four received external irradiation in conjunction with intracavitary therapy in doses which in themselves may well have controlled the disease, and the contribution of the intracavitary therapy cannot be assessed.

Of ten patients treated for disease, recurrent or uncontrolled, following external irradiation, intracavitary therapy was effective for control of the disease for five years in two patients. One of these patients has no demonstrable disease ten years after the last treatment. The other is alive but with recurrent local disease nine years and eight months after the last treatment.

Analysis of the material agreed with the long established experience that intracavitary irradiation for nasopharyngeal tumors is occasionally helpful in the treatment of limited mucosal recurrence or as an adjunct complementing medium-volt external irradiation. For the definitive treatment of untreated nasopharyngeal neoplasms, reliance in control is placed on through external irradiation of nasopharynx and regional lymphatics.

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The nasopharynx is the upper part of the pharynx (throat) behind the nose. The pharynx is a hollow tube about 5 inches long that starts behind the nose and ends at the top of the trachea (windpipe) and esophagus (the tube that goes from the throat to the stomach). Air and food pass through the pharynx on the way to the trachea or the esophagus. The nostrils lead into the nasopharynx. An opening on each side of the nasopharynx leads into an ear. Nasopharyngeal cancer most commonly starts in the squamous cells that line the oropharynx (the part of the throat behind the mouth).

Chinese or Asian ancestry.

Exposure to the Epstein-Barr virus: The Epstein-Barr virus has been associated with certain cancers, including nasopharyngeal cancer and some lymphomas.

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Nobukazu Fuwa, Yoshiyuki Ito, Takeshi Kodaira, Akira Matsumoto, Minoru Kamata, Kazuhisa Furutani, Hiroyuki Tatibana, Masahiro Sasaoka and Kozo Morita

Background: The present study was conducted to evaluate the therapeutic results of alternating chemoradiotherapy for locally advanced nasopharyngeal cancer (NPC).

Methods: The subjects consisted of six patients with stage III nasopharyngeal cancer and 26 patients with stage IV nasopharyngeal cancer. Using 6 MV photons, radiotherapy was performed at an exposure of 1.8–2.0 Gy five times per week. That is, a total absorbed dose of 36–40 Gy was irradiated between the base of the skull and supraclavicular fossa. After decreasing the irradiation field, an absorbed dose of 26–30 Gy was additionally given thereafter. One course of chemotherapy consisted of the administration of 5-fluorouracil (5-FU) at a dose of 700 mg/m2/24 h for 5 days (days 1–5) and cisplatin (CDDP) at a dose of 50 mg/m2/24 h for 2 days (days 6–7) and a total of 2–3 courses of chemotherapy were performed. During the alternating chemoradiotherapy, chemotherapy was performed initially and 3–5 days after completing the chemotherapy, radiotherapy was performed for 3–4 weeks. Thereafter, chemotherapy and radiotherapy were performed alternately.

Results: The scheduled courses of alternating chemoradiotherapy were completed in 30 (94%) of 32 patients. Although one patient developed shock induced by metal allergy to CDDP, no severe adverse effects were noted in any other patients. In these 32 patients, the overall 5-year survival rate was 75% (95% confidence interval: 60–90%) and the progression-free survival rate was 63% (95% CI: 46–89%).

Conclusions: This method of alternating chemoradiotherapy yielded higher or at least similar survival rates and lower toxicities than concurrent chemoradiotherapy and is worth trying in a multi-institutional study.

Although the incidence of nasopharyngeal cancer is high in the southern part of China (1,2), its incidence in Japan is rather low and is similar to that in Western countries (3). Owing to its anatomical characteristics, the surgical treatment of nasopharyngeal cancer is very difficult to perform. In addition, most cases of nasopharyngeal cancer are histologically classified as undifferentiated carcinoma with relatively high radiosensitivity. Therefore, radiotherapy is the first choice of treatment modality for nasopharyngeal cancer (4–8). However, although nasopharyngeal cancer is more sensitive than other head and neck cancers to radiotherapy, the overall 5-year survival rate reported in a large series was 41% (9). Therefore, various combinations of radiotherapy and chemotherapy, such as concurrent chemoradiotherapy (10–12), neoadjuvant therapy (13–17), adjuvant therapy (18,19) and alternating therapy (20), have been attempted.

Although many phase II studies previously reported useful combinations of radiotherapy and chemotherapy (10,18,20–23), only four randomized phase III studies evaluated the anti-tumor effects of chemoradiotherapy in comparison with those of radiotherapy alone (24–27). Two of these four studies reported that the progression-free survival (PFS) rate was significantly more satisfactory in patients treated with chemoradiotherapy than in those treated with radiotherapy alone (24,27). In particular, very satisfactory therapeutic results were obtained in the Intergroup 0099, in which cisplatin (CDDP) was administered concurrently with radiotherapy and the combination of CDDP and 5-fluorouracil (5-FU) was subsequently administered after radiotherapy (24). Therefore, the above combination of chemotherapy and radiotherapy may become a standard treatment modality for nasopharyngeal cancer in the future.

In 1987, we initiated alternating chemoradiotherapy using CDDP and 5-FU. Although the number of subjects was limited, our previous non-randomized study showed therapeutic results similar to those of chemoradiotherapy demonstrated by the Intergroup 0099 trial. In the present study, we evaluated the therapeutic results of alternating chemoradiotherapy, together with its usefulness and controversial points.

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Because of a documented increased incidence, nasopharyngeal cancer should be considered when signs or symptoms of ear, nose and throat disease are present in patients from southern China (in particular, Hong Kong and the province of Guangdong) or Southeast Asia. Environmental factors, the Epstein-Barr virus and genetic factors have been associated with the development of nasopharyngeal cancer. Patients with this malignancy most often present with a cervical mass from metastatic spread to a lymph node. Other possible presentations include ipsilateral serous otitis, hearing loss, nasal obstruction, frank epistaxis, purulent or bloody rhinorrhea, and facial neuropathy or facial nerve palsies. Radiotherapy is often curative. The addition of chemotherapy has produced high response rates in local and regionally advanced disease. (Am Fam Physician 2001;63:1776-82,1785.)

Although nasopharyngeal cancer is rare in the general U.S. population, it is significantly more likely to occur in refugees from Southeast Asia who have come to the United States in the past 25 years. Once diagnosed, the malignancy has great potential for cure. This article provides a brief overview of nasopharyngeal cancer, with emphasis on its occurrence in patients from Southeast Asia.

Illustrative Case

A 47-year-old Hmong man presented to his family physician with bloody rhinorrhea, epistaxis, right-sided hearing loss and headache of two weeks’ duration. (The Hmong, also known as the Miao or Meo, are mountain-dwelling peoples of China, Vietnam, Laos and Thailand.) The patient’s medical history was remarkable for colon cancer at 36 years of age, which evidently responded to Hmong therapies (nonsurgical). There was no family history of cancer. The patient had never smoked; he used alcohol rarely and did not use illicit drugs. The patient’s family had fled from Laos to the United States in the mid-1970s.

The review of systems was remarkable only for fatigue in the previous few weeks. The physical examination revealed right middle ear effusion, right hemifacial and periauricular hyperesthesia, and a trace of mucoid, bloody discharge in the nares. Neither cervical nor clavicular adenopathy was present.

Subsequent endoscopic biopsy of the right nasopharynx demonstrated mixed keratinizing squamous cell carcinoma and nonkeratinizing squamous cell carcinoma. Magnetic resonance imaging (MRI) showed a right nasopharyngeal mass with erosion into the sphenoid sinus.

Nasopharyngeal cancer was diagnosed and determined to be stage III (T3 N0: tumor invasion into the bony structures and/or paranasal sinuses; no regional lymph node metastasis). The patient underwent concurrent chemotherapy and radiotherapy; he experienced postirradiation headache and facial neuropathy. One year later, follow-up MRI studies showed nearly complete tumor regression.

Epidemiology

Nasopharyngeal cancer accounts for fewer than 1 percent of malignancies in North America, western Europe and Japan, with incidence rates of one to one and one-half cases per 100,000 population per year.(1) This malignancy has an intermediate incidence of five to nine cases per 100,000 population per year in inhabitants of northern China, the Mediterranean basin (southern Italy, Greece and Turkey), North Africa and Southeast Asia (Thailand, Vietnam, Indonesia,…

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A 32-year-old Chinese woman presented to the ENT clinic with a nonhealing ulcer in the oral cavity that had been present for 3 months. Examination revealed the presence of leukoplakia on the left anterior tonsillar pillar; a punch biopsy of the pillar showed mild chronic inflammation. We also made an incidental finding of a mass that had arisen from the left posterior wall of the postnasal space (figure 1). A biopsy of the postnasal space again revealed chronic inflammation. Magnetic resonance imaging (MRI) demonstrated a left-sided nasopharyngeal mixed lipomatous tumor that was submucosal in origin.

The patient underwent endoscopic resection of the tumor. The operative finding was that of a 3-cm nasopharyngeal mass that has arisen from the posterior wall of the nasopharynx and obstructed the eustachian tube.

Histology identified an immature teratoma that was made up of tissue derived from various germ-cell layers and comprised mature glial/neurofibrillary tissue with scattered neurons predominant (figure 2). Mature adipose tissue, fibrous tissue, and a few apocrine glands were also present. Abundant calcifications were surrounded by an area of a foreign-body giant-cell reaction. In addition, an area containing immature neuroepithelial tissue was also noted; the tissue was characterized by round, hyperchromatic nuclei, a rosette-like arrangement, and a fibrillary background. The immature area constituted approximately 10% of the tumor mass. No somatic malignancy was evident.
 chromogranin, glial fibrillary acid protein (GFAP), and S- 100 protein. The glial tissue was positive for GFAP, and the neurons expressed synaptophysin. There were no malignant sarcomatous or carcinomatous areas.

True teratomas are neoplasms that are made up of tissue from the ectoderm, mesoderm, and endoderm. These tissues are usually alien to the site in which they arise. They are arranged in a haphazard fashion, and their degree of maturity varies. Teratomas usually originate in the midline of the sacrococcygeal, gonadal, retroperitoneal, and mediastinal regions.

Head and neck teratomas account for fewer than 10% of all teratomas; when they do occur, most arise in the cervical region: (1-3) They are usually present at birth, and affected patients manifest signs and symptoms of airway obstruction. The second most common location of head and neck teratomas is the nasopharynx, usually arising from the superior or lateral wall. (1) Affected patients typically present with nasal obstruction.

Teratomas in childhood are usually benign. Some authors believe that these immature tissues are consistent with the immaturity of the host, but others believe that tissue immaturity suggests a malignant change.

Treatment is usually surgical excision. Surgery should be undertaken on an urgent basis, especially in a patient who presents with signs and symptoms of airway obstruction.

References

(1.) Ward RF, April M. Teratomas of the head and neck. Otolaryngol Clin North Am 1989;22:621-9.

(2.) Billmire DF, Grosfeld JL. Teratomas in childhood: Analysis of 142 cases. J Pediatr Surg 1986;21:548-51.

(3.) Carr MM, Thorner P, Phillips JH. Congenital teratomas of the head and neck. J Otolaryngol 1997;26:246-52.

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Radiation therapy (RT) has been the most important treatment modality with curative potential in treating patients with cancer of the nasopharynx, the part of the pharynx that lies above the soft palate. This is due to several factors: (1) undifferentiated carcinoma, or tumour cells with no resemblance at all to normal glandular or surface lining cells, is quite radiosensitive and is more common than squamous cell carcinoma; (2) more than two-thirds of the patients present with cervical lymph node metastases at time of diagnosis; (3) about half of the patients present with bilateral cervical metastases; (4) retropharyngeal lymph node, which is difficult to remove surgically, is frequently involved at rather earlier stages.

Local control and survival rates have been improved by increasing the radiation dose since 1950’s, and favorable 10-year survival rates ranging from 65 to 77 percent were achievable in patients with early stage disease by high dose radiation therapy. However, the long-term survival rates in those with high T or N stages are not satisfactory because of either poor local control or frequent distant metastases. The addition of systemic chemotherapy to high dose RT has been widely tried in an effort to overcome these limitations.

Three sequences of combining chemotherapy RT have been tried: chemotherapy before surgery followed by radiation therapy; adjuvant chemotherapy after RT; and concurrent radiochemotherapy. Based on several phase III trials, positive role of chemotherapy that was added to RT in locally advanced nasopharynx cancer was proved, and the concurrent fashion was regarded, if not conclusive, as the most effective strategy.

High dose radiation therapy with concurrent systemic chemotherapy in the patients with locally advanced nasopharynx cancer has been the treatment policy at a South Korean medical institute since 1995. Staff members at the institute set out to analyze and report the failure patterns and survival outcomes associated with this treatment. Their findings can be found in the research effort, “High Dose Radiation Therapy Concurrent with Chemotherapy in Locally Advanced Nasopharynx Cancer,” authored by Min Kyu Kang, MD, Yong Chan Ahn, MD, Won Park, MD, Keunchil Park, MD, Chung-Hwan Baek, MD, Young Ik Son, MD, Jeong Eun Lee, MD, Young Je Park, MD, Hee Rim Nam, MD, Kyoung Ju Kim, MD, Do Hoon Lim, MD, and Seung Jae Huh, MD, all from the Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. Their findings are to be presented at the 6th International Conference on Head and Neck Cancer (http://www.sic2004.org) being held August 7-11, 2004, at the Wardman Park Marriott, in Washington, D.C.

Methodology:

Sixty patients with nasopharynx cancer received high dose curative radiation therapy at the authors’ institute from April, 1995, to May 2001. Excluding eight patients who received high dose RT alone, 52 were given high dose radiation therapy with concurrent systemic chemotherapy. To be eligible for this treatment protocol, patients needed to (1) have locally advanced stage disease, (2) be in ECOG performance score from 0 to 2, (3) have no major medical illness that would hinder this rather aggressive approach, (4) have adequate hematopoietic, hepatic, and renal reserves, (5) have no past history of malignancy other the current diagnosis, and (6) consent to this protocol.

The treatment consisted of:

Radiation therapy:

RT was administered using 4 MV or 6 MV x-rays generated from a linear accelerator. Conventional fractionation schedule to deliver five daily fraction of 1.8 Gy per week was used. Serial shrinking field technique was applied to all patients, and the median doses to the primary lesions and grossly enlarged lymph nodes, were 72 (64~80) Gy and 59.4 (37.8~72) Gy. The elective lymphatic irradiation volume and its radiation dose were individually determined based on the initial clinical findings, and the median elective lymphatic irradiation dose was 45 (36~45) Gy.

Chemotherapy:

Two types of chemotherapy regimen and schedule were used. Eight patients received Regimen A: two cycles of concurrent FP chemotherapy (5-fluorodeoxyuridine 1,000 mg/m2/day, continuous intravenous infusion for four days + cisplatin 75 mg/m2, intravenous infusion on day 1) at four weeks’ interval plus four cycles of adjuvant chemotherapy with the same doses schedule following radiation therapy. Regimen B included: three cycles of concurrent CDDP single agent chemotherapy (cisplatin 100 mg/m2, intravenous infusion on day 1) at three weeks’ interval plus three cycles of adjuvant FP chemotherapy (5-fluorodeoxyuridine 800 mg/m2/day, continuous intravenous infusion for five days + cisplatin 75 mg/m2, intravenous infusion on day 1) at three weeks’ interval following RT. Regimen B was used in 44 patients who were enrolled during the later study period since July, 1996.

All the patients were examined by fiberoptic nasopharyngoscopy on weekly-basis during the RT course. The response was evaluated based by CT or MR images taken within one month of radiotherapy completion. Following completion of the planned treatment schedule including adjuvant chemotherapy, CT, or MR images were repeated every three to four months for the first two years, and every four to six months thereafter.

Results:

This study was unique in that the radiation therapy boost technique used for most of the patients in the study was characterized by three-dimensional conformal techniques, while other high dose radiation therapy trials used conventional two-dimensional ways. Resulting side effects by radiation therapy were much lower in incidence and milder in severity. As for chemotherapy regimen, eight patients received FP regimen with poor compliance. However, after changing into a single agent (CDDP) regimen for 44 patients during their radiation therapy, providing a radiosensitizing effect rather than curative cancericidal effect, compliance became much better.

Conclusions:

This difference based on the chemotherapy regimen has been first proved in this study, even though this study was not conducted in a prospective randomized fashion. These factors enabled the researchers to achieve high local control rate and survival compared with other trials of concurrent radiochemotherapy.

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This book has been created for patients who have decided to make education and research an integral part of the treatment process. Although it also gives information useful to doctors, caregivers and other health professionals, it tells patients where and how to look for information covering virtually all topics related to nasopharyngeal cancer (also nasopharynx cancer), from the essentials to the most advanced areas of research. The title of this book includes the word official. This reflects the fact that the sourcebook draws from public, academic, government, and peer-reviewed research. Selected readings from various agencies are reproduced to give you some of the latest official information available to date on nasopharyngeal cancer. Given patients’ increasing sophistication in using the Internet, abundant references to reliable Internet-based resources are provided throughout this sourcebook. Where possible, guidance is provided on how to obtain free-of-charge, primary research results as well as more detailed information via the Internet. E-book and electronic versions of this sourcebook are fully interactive with each of the Internet sites mentioned (clicking on a hyperlink automatically opens your browser to the site indicated). Hard-copy users of this sourcebook can type cited Web addresses directly into their browsers to obtain access to the corresponding sites. In addition to extensive references accessible via the Internet, chapters include glossaries of technical or uncommon terms.

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The nasopharynx is the upper part of the pharynx (throat) behind the nose. The pharynx is a hollow tube about 5 inches long that starts behind the nose and ends at the top of the trachea (windpipe) and esophagus (the tube that goes from the throat to the stomach). Air and food pass through the pharynx on the way to the trachea or the esophagus. The nostrils lead into the nasopharynx. An opening on each side of the nasopharynx leads into an ear. Nasopharyngeal cancer most commonly starts in the squamous cells that line the oropharynx (the part of the throat behind the mouth).

Ethnic background and exposure to the Epstein-Barr virus can affect the risk of developing nasopharyngeal cancer.

Anything that increases your risk of getting a disease is called a risk factor. Risk factors may include the following:

—                  Chinese or Asian ancestry.

—                  Exposure to the Epstein-Barr virus: The Epstein-Barr virus has been associated with certain cancers, including nasopharyngeal cancer and some lymphomas.

Possible signs of nasopharyngeal cancer include trouble breathing, speaking, or hearing.

These and other symptoms may be caused by nasopharyngeal cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

—                  A lump in the nose or neck.

—                  A sore throat.

—                  Trouble breathing or speaking.

—                  Nosebleeds.

—                  Trouble hearing.

—                  Pain or ringing in the ear.

—                  Headaches.

Tests that examine the nose and throat

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