Release: July 29, 2000
Contact: Kenneth Satterfield
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In San Francisco (7/28-8/2)
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SKULL-BASED SURGERY NOW EFFECTIVE AGAINST RECURRENT NASOPHARYNGEAL CARCINOMA
Patients with this recurrent disease may find "salvage surgery" a better treatment alternative than radiation
San Francisco, CA -- Nasopharyngeal carcinoma (NPC) is the most common cancer of the head and neck in the southeastern part of China, Taiwan, Hong Kong and Singapore. NPC refers to the malignant tumors arising from epithelial cells lining the nasopharyngeal space. The disease is known to be Epstein-Barr virus related, and unlike other epithelial tumors from other parts of the upper aerodigestive tract, the mainstay treatment of NPC is radiotherapy. This is because most NPCs are undifferentiated carcinomas and very sensitive to radiation therapy. The complexity of the nasopharyngeal anatomy made radical surgery infeasible.
Today, better understanding of the anatomy and spread of nasopharyngeal tumors and vast advancement in skull base surgery have changed the perception of the nasopharynx as a surgical "no man's land." Consequently, a team of head and neck surgeons from Taiwan have demonstrated that a nasopharyngectomy, or salvage surgery, is an effective control of NPC recurrence when radiation therapy fails.
The authors of the study, "Salvage Surgery for Recurrent Nasopharyngeal Carcinoma," are Sheng-Po Hao MD; Ngan-Ming Tsang MD, DSc; and Chen-Nen Chang MD, all from the Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan, Republic of China. The findings were presented before the 5th International Conference on Head and Neck Cancer, being held July 29 through August 2, at the San Francisco Marriott, San Francisco, CA. More than 1,500 leading head and neck surgeons from the United States and 46 nations will gather to hear the latest medical research in the diagnosis, treatment, and reconstruction associated with head and neck cancer. The medical conference is sponsored by the American Head and Neck Society, www.headandneckcancer.org.
The purpose of the study was to evaluate the result of salvage surgery, or nasopharyngectomy, for patients with primary recurrence of nasopharyngeal carcinoma after radiation therapy.
Methodology: From July 1993 to December 1999, at Chang Gung Memorial Hospital and Chang Gung University, 13 men and five women were operated on after a local recurrence of nasopharyngeal carcinoma following radiotherapy. The age distribution was from 30 to 62 years old. Previously, 17 patients had undergone one course of radiotherapy with a dose of more than 6600 cGy, while one patient underwent second course of radiotherapy for his primary recurrence. The preferred method of preoperative radiologic diagnosis was magnetic resonance imaging (MRI) scans; however, in the beginning of this study, two patients had computed tomography (CT) only. Preoperatively, the tumors were classified as rT1, 8; rT2b, 1, rT3, 5; and rT4, 4 according to AJC staging system.
Two patients had previous sinus surgery, including one caldwell luc operation and one functional endoscopic sinus surgery. One patient had persistent cervical metastasis after radiotherapy and then underwent modified radical neck dissection before nasopharyngectomy. Another patient had recurrent neck disease after completion of nasopharyngectomy for his primary recurrence and then underwent modified radical neck dissection. The nasopharyngectomy was carried out via a facial translocation approach, and five patients needed a combined neurosurgical approach (three subtemporal, two subfrontal) and appropriate neurosurgical resection. Seven patients who had tumor-positive or close surgical resection margins further underwent a second course of radiotherapy postoperatively.
Patient selection: All patients had biopsy-proven primary recurrence. Diligent systemic work-up with chest X-ray, abdominal sonography, and Tc99m bone scan was carried out before operation, and if any of these examinations was reported positive, the patient would enter re-radiation therapy protocol and would not have surgery.
All patients had a minimum follow-up of three months. Statistical analysis of data was carried out with the Statistical Package for the Social Sciences (SPSS 7.5, Inc, Chicago, IL) computer software. The actuarial overall survival and the actuarial local tumor control were calculated by the Kaplan-Meier method.
Results: Of the 18 patients, 15 had negative margins while three had micro-residual diseases. There was no surgical mortality, and the morbidity rate was only 22 percent (4/18) including cerebrospinal rhinorrhea, flap necrosis, osteoradionecrosis (ORN) of the translocated facial bone graft, and mild epiphora, each diagnosed in one patient. The patient who had postoperative cerebrospinal rhinorrhea died of brain involvement three months after surgery.
These 18 patients were followed for three to 61 months. To date, three patients died of local disease (including two with micro-residual disease), and two patients had local control but lived with nodal metastases. The two year actuarial survival was 86 percent while the local control rate was 78 percent.
Five patients who had skull base or intracranial extension needed a combined neurosurgical resection; one died of local recurrence in the brain, and one lived with metastatic axillary nodes. Four of five patients had local control. Among them, three patients were followed up for more than 14 months. Of the 18 patients, 16 had undifferentiated carcinomas (WHO type III), and two had squamous cell carcinomas (WHO type I). In three patients, no cancer was found in the surgical specimens, although their preoperative biopsy clearly demonstrated recurrent cancer.
Conclusions: The researchers believe this study offers a positive outcome for salvage surgery as a treatment for recurrent NPC. The procedure should be considered a better alternative to irradiation when the disease reoccurs.
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