Familial Nasopharyngeal Carcinoma 6

Early Stage Nasopharyngeal Cancer: A Highly Curative Disease with Radiation Therapy 14510.4.4RadiosurgeryRecurrent disease after primary radiotherapy orchemoradiotherapy has been treated with radiosurgery,with promising results (Cmelak et al. 1997;Xiao et al. 2001; Chua et al. 2003a, b; Roh et al. 2008).One of the advantages of this technique overbrachytherapy salvage is that inverse planning optimizationcan be used to spare normal tissues andhopefully reduce complications. This is particularlyattractive in the case of bulky locally advanced recurrenceswith irregular shapes, typically in close proximityto critical structures. Such recurrences areusually not amenable to salvage with brachytherapy.Both single fraction (Cmelak et al. 1997) and fractionated(Xiao et al. 2001; Roh et al. 2008) stereotacticsalvage has been reported. For single fractionradiosurgery, the dose to the optic nerve, optic chiasm,brainstem, and cavernous sinus should be keptunder 8 Gy when the recurrence does not directlyinvolve these structures. Complications have ofcourse been reported, including cranial nerve palsies,bone and soft tissue necrosis, CSF leaks, and trismus(Cmelak et al. 1997; Roh et al. 2008).More recently, radiosurgery as a component ofprimary treatment for nasopharyngeal cancer hasbeen reported (Le et al. 2003; Hara et al. 2008).These patients were locally advanced cases treatedat Stanford University with Cyberknife radiosurgery,now totaling 82 cases. Reported local controlhas been excellent in this series, 98% at 5 years, with70% survival. Temporal lobe necrosis has occurredin ten patients (nine of which were T4 primaries),and retinopathy occurred in three patients. Forearly stage disease, radiosurgery has not yet beenreported, and presumably the risk of complicationswould be less.10.5ConclusionsDespite the excellent results obtained with combinationchemoradiotherapy for locally advancednasopharyngeal carcinoma, radiation therapy aloneremains a viable option for low-risk cases. A reviewof the literature indicates that including all stage Iand II patients in this group is not appropriate, andthat there is a subset of stage II patients for whichchemotherapy is beneficial. In the US population, ithas been common practice to consider T2b patientslocally advanced, and candidates for enrollment inconcurrent chemoradiotherapy trials. In view of thehigher incidence of WHO type 1 histology in thewestern world, and the poorer prognosis of this subgroup,this is appropriate. Recent evidence suggeststhat T2N1 patients in endemic areas also benefitfrom the addition of chemotherapy. In addition, variationsin the staging systems used lead to some ambiguityin the definition of high risk, and as a resultpatients with bulky disease that are not strictly T3should be considered for more aggressive therapy.Randomized trials to establish the benefit of concurrentchemotherapy and refine an appropriate regimenare needed.It has long been known that radiation dose playsan important role in achieving optimal results fornasopharyngeal cancer (Marks et al. 1982; Vikramet al. 1985). Brachytherapy and radiosurgery aremethods that can be effective in delivering this doseappropriately, if performed with appropriate respectfor normal tissue tolerance.ReferencesAJCC (1977) AJCC Cancer Staging Manual. Philadelphia,Lippincott RavenAJCC (1992) AJCC Cancer Staging Manual. Philadelphia,Lippincott RavenAJCC (1998) AJCC Cancer Staging Manual. Philadelphia,Lippencott RavenAl-Sarraf M, LeBlanc M, et al (1998) Chemoradiotherapy versusradiotherapy in patients with advanced nasopharyngealcancer: phase III randomized Intergroup study 0099.J Clin Oncol 16(4):1310–1317Au JS, Law CK, et al (2003) In-depth evaluation of the AJCC/UICC 1997 staging system of nasopharyngeal carcinoma:prognostic homogeneity and proposed refinements. IntJ Radiat Oncol Biol Phys 56(2):413–426Cao XP, Lu TX, et al (2007) Prospective study on long-termefficacy of external plus intracavitary radiotherapy onstage I-II nasopharyngeal carcinoma. Ai Zheng 26(2):204–207Chan AT, Ngan RK, et al (2004) Final results of a phase III randomizedstudy of concurrent weekly cisplatin-RT versusRT alone in locoregionally advanced nasopharyngeal carcinoma(NPC). Proceedings of the American Society ofClinical Oncology. J Clin Oncol 22:493aChan AT, Teo PM, et al (1995) A prospective randomized studyof chemotherapy adjunctive to definitive radiotherapy inadvanced nasopharyngeal carcinoma. Int J Radiat OncolBiol Phys 33(3):569–577Chan AT, Teo PM, et al (2002) Concurrent chemotherapyradiotherapycompared with radiotherapy alone inlocoregionally advanced nasopharyngeal carcinoma: