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Title: Nasopharyngeal carcinoma with cranial nerve palsy: The importance of MRI for radiotherapy

Abstract

Purpose: To evaluate various prognostic factors and the impact of imaging modalities on tumor control in patients with nasopharyngeal cancer (NPC) with cranial nerve (China) palsy. Material and Methods: Between September 1979 and December 2000, 330 NPC patients with CN palsy received radical radiotherapy (RT) by the conventional opposing technique at Chang Gung Memorial Hospital-Linkou. Imaging methods used varied over that period, and included conventional tomography (Tm) for 47 patients, computerized tomography (CT) for 195 patients, and magnetic resonance image (MRI) for 88 patients. Upper CN (II-VI) palsy was found in 268 patients, lower CN (IX-XII) in 13, and 49 patients had both. The most commonly involved CN were V or VI or both (23%, 12%, and 16%, respectively). All patients had good performance status (World Health Organization <2). The median external RT dose was 70.2 Gy (range, 63-77.5 Gy). Brachytherapy was also given to 156 patients in addition to external RT, delivered by the remote after-loading, high-dose-rate technique. A total of 139 patients received cisplatin-based chemotherapy, in 115 received as neoadjuvant or adjuvant chemotherapy and in 24 concomitant with RT. Recovery from CN palsy occurred in 171 patients during or after radiotherapy. Patients who died without a specific causemore » identified were regarded as having died with persistent disease. Results: The 3-year, 5-year, and 10-year overall survival was 47.1%, 34.4%, and 22.2%. The 3-year, 5-year, and 10-year disease-specific survival (DSS) rates were 50.4%, 37.8%, and 25.9%. The 5-year DSS for patients staged with MRI, CT, and Tm were 46.9%, 36.7%, and 21.9%, respectively (p = 0.016). The difference between MRI and CT was significant (p = 0.015). The 3-year and 5-year local control rates were 62% and 53%, respectively. The 5-year local control was 68.2% if excluding patients who died without a specific cause. Patients who had an MRI had a significantly better tumor control rate than those evaluated with CT or Tm, with a 15-30% improvement in local tumor control and survival. Patients with extensive CN palsy had worse survival than those with only lower CN or upper CN involvement (5-year DSS 20.4% vs. 43.2% and 40.4%, respectively; p < 0.001). Patients who recovered from CN palsy had better survival than those who did not (47% vs. 26%, p < 0.001). Brachytherapy was associated with poorer local control, whereas a total external dose of more than 70 Gy improved local tumor control and marginally improved DSS. Subgroup analysis in CT and MRI patients group, either DSS or OS was significantly associated with imaging modality, N stage, or location of or remission of CN palsy. Conclusion: The use of MRI was associated with improved tumor control and survival of patients with NPC causing CN palsy. Patients recovering from CN palsy had better survival. A higher radiation dose delivered by external beam may achieve better tumor control than brachytherapy.« less

Authors:
 [1];  [2];  [1];  [2];  [3];  [2];  [3];  [2];  [4];  [2];  [3];  [2];  [5];  [2];  [6];  [2];  [7]
  1. Department of Radiation Oncology, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan (China)
  2. (China)
  3. Department of Ear, Nose, and Throat, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan (China)
  4. Department of 1st Radiology, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan (China)
  5. Department of Hematology/Oncology, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan (China)
  6. Department of Medical Technology, Chang Gung University, Taoyuan, Taiwan (China)
  7. Department of Ear, Nose, and Throat, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan (China) and Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan (China). E-mail: cgmhnog@yahoo.com
Publication Date:
OSTI Identifier:
20788226
Resource Type:
Journal Article
Resource Relation:
Journal Name: International Journal of Radiation Oncology, Biology and Physics; Journal Volume: 63; Journal Issue: 5; Other Information: DOI: 10.1016/j.ijrobp.2005.05.042; PII: S0360-3016(05)00952-1; Copyright (c) 2005 Elsevier Science B.V., Amsterdam, The Netherlands, All rights reserved; Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; BRACHYTHERAPY; CARCINOMAS; CHEMOTHERAPY; COMPUTERIZED TOMOGRAPHY; CYANIDES; DOSE RATES; HOSPITALS; NMR IMAGING; PATIENTS; PERFORMANCE; RADIATION DOSES

Citation Formats

Chang, Joseph T.-C., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Lin, C.-Y., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Chen, T.-M., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Kang, C.-J., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Ng, S.-H., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Chen, I.-H., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Wang, H.-M., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Cheng, A.-J., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, and Liao, C.-T. Nasopharyngeal carcinoma with cranial nerve palsy: The importance of MRI for radiotherapy. United States: N. p., 2005. Web. doi:10.1016/J.IJROBP.2005.0.
Chang, Joseph T.-C., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Lin, C.-Y., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Chen, T.-M., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Kang, C.-J., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Ng, S.-H., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Chen, I.-H., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Wang, H.-M., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Cheng, A.-J., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, & Liao, C.-T. Nasopharyngeal carcinoma with cranial nerve palsy: The importance of MRI for radiotherapy. United States. doi:10.1016/J.IJROBP.2005.0.
Chang, Joseph T.-C., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Lin, C.-Y., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Chen, T.-M., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Kang, C.-J., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Ng, S.-H., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Chen, I.-H., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Wang, H.-M., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, Cheng, A.-J., Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan, and Liao, C.-T. Thu . "Nasopharyngeal carcinoma with cranial nerve palsy: The importance of MRI for radiotherapy". United States. doi:10.1016/J.IJROBP.2005.0.
@article{osti_20788226,
title = {Nasopharyngeal carcinoma with cranial nerve palsy: The importance of MRI for radiotherapy},
author = {Chang, Joseph T.-C. and Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan and Lin, C.-Y. and Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan and Chen, T.-M. and Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan and Kang, C.-J. and Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan and Ng, S.-H. and Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan and Chen, I.-H. and Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan and Wang, H.-M. and Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan and Cheng, A.-J. and Taipei Chang Gung Head and Neck Oncology Group, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan and Liao, C.-T.},
abstractNote = {Purpose: To evaluate various prognostic factors and the impact of imaging modalities on tumor control in patients with nasopharyngeal cancer (NPC) with cranial nerve (China) palsy. Material and Methods: Between September 1979 and December 2000, 330 NPC patients with CN palsy received radical radiotherapy (RT) by the conventional opposing technique at Chang Gung Memorial Hospital-Linkou. Imaging methods used varied over that period, and included conventional tomography (Tm) for 47 patients, computerized tomography (CT) for 195 patients, and magnetic resonance image (MRI) for 88 patients. Upper CN (II-VI) palsy was found in 268 patients, lower CN (IX-XII) in 13, and 49 patients had both. The most commonly involved CN were V or VI or both (23%, 12%, and 16%, respectively). All patients had good performance status (World Health Organization <2). The median external RT dose was 70.2 Gy (range, 63-77.5 Gy). Brachytherapy was also given to 156 patients in addition to external RT, delivered by the remote after-loading, high-dose-rate technique. A total of 139 patients received cisplatin-based chemotherapy, in 115 received as neoadjuvant or adjuvant chemotherapy and in 24 concomitant with RT. Recovery from CN palsy occurred in 171 patients during or after radiotherapy. Patients who died without a specific cause identified were regarded as having died with persistent disease. Results: The 3-year, 5-year, and 10-year overall survival was 47.1%, 34.4%, and 22.2%. The 3-year, 5-year, and 10-year disease-specific survival (DSS) rates were 50.4%, 37.8%, and 25.9%. The 5-year DSS for patients staged with MRI, CT, and Tm were 46.9%, 36.7%, and 21.9%, respectively (p = 0.016). The difference between MRI and CT was significant (p = 0.015). The 3-year and 5-year local control rates were 62% and 53%, respectively. The 5-year local control was 68.2% if excluding patients who died without a specific cause. Patients who had an MRI had a significantly better tumor control rate than those evaluated with CT or Tm, with a 15-30% improvement in local tumor control and survival. Patients with extensive CN palsy had worse survival than those with only lower CN or upper CN involvement (5-year DSS 20.4% vs. 43.2% and 40.4%, respectively; p < 0.001). Patients who recovered from CN palsy had better survival than those who did not (47% vs. 26%, p < 0.001). Brachytherapy was associated with poorer local control, whereas a total external dose of more than 70 Gy improved local tumor control and marginally improved DSS. Subgroup analysis in CT and MRI patients group, either DSS or OS was significantly associated with imaging modality, N stage, or location of or remission of CN palsy. Conclusion: The use of MRI was associated with improved tumor control and survival of patients with NPC causing CN palsy. Patients recovering from CN palsy had better survival. A higher radiation dose delivered by external beam may achieve better tumor control than brachytherapy.},
doi = {10.1016/J.IJROBP.2005.0},
journal = {International Journal of Radiation Oncology, Biology and Physics},
number = 5,
volume = 63,
place = {United States},
year = {Thu Dec 01 00:00:00 EST 2005},
month = {Thu Dec 01 00:00:00 EST 2005}
}
  • Purpose: To address the characteristics and the causative factors of radiation-induced cranial nerve palsy (CNP) in nasopharyngeal carcinoma (NPC) patients with an extensive period of followed-up. Patients and Methods: A total of 317 consecutive and nonselected patients treated with definitive external-beam radiotherapy between November 1962 and February 1995 participated in this study. The median doses to the nasopharynx and upper neck were 71 Gy (range, 55-86 Gy) and 61 Gy (range, 34-72 Gy), respectively. Conventional fractionation was used in 287 patients (90.5%). Forty-five patients (14.2%) received chemotherapy. Results: The median follow-up was 11.4 years (range, 5.1-38.0 years). Ninety-eight patients (30.9%)more » developed CNP, with a median latent period of 7.6 years (range, 0.3-34 years). Patients had a higher rate of CNP (81 cases, 25.5%) in lower-group cranial nerves compared with upper group (44 cases, 13.9%) ({chi}{sup 2} = 34.444, p < 0.001). Fifty-nine cases experienced CNP in more than one cranial nerve. Twenty-two of 27 cases (68.8%) of intragroup CNP and 11 of 32 cases (40.7%) of intergroup CNP occurred synchronously ({chi}{sup 2} = 4.661, p = 0.031). The cumulative incidences of CNP were 10.4%, 22.4%, 35.5%, and 44.5% at 5, 10, 15, and 20 years, respectively. Multivariate analyses revealed that CNP at diagnosis, chemotherapy, total radiation dose to the nasopharynx, and upper neck fibrosis were independent risk factors for developing radiation-induced CNP. Conclusion: Radiation-induced fibrosis may play an important role in radiation-induced CNP. The incidence of CNP after definitive radiotherapy for NPC remains high after long-term follow-up and is dose and fractionation dependent.« less
  • Purpose: To subclassify patients with the T4 classification nasopharyngeal carcinoma (NPC), according to the seventh edition of the American Joint Committee on Cancer staging system, using magnetic resonance imaging (MRI), and to evaluate the prognostic value of subclassification after intensity-modulated radiotherapy (IMRT). Methods and Materials: A total of 140 patients who underwent MRI and were subsequently histologically diagnosed with nondisseminated classification T4 NPC received IMRT as their primary treatment and were included in this retrospective study. T4 patients were subclassified into two grades: T4a was defined as a primary nasopharyngeal tumor with involvement of the masticator space only; and T4bmore » was defined as involvement of the intracranial region, cranial nerves, and/or orbit. Results: The 5-year overall survival (OS) rate and distant metastasis-free survival (DMFS) rate for T4a patients (82.5% and 87.0%, respectively), were significantly higher than for T4b patients (62.6% and 66.8%; p = 0.033 and p = 0.036, respectively). The T4a/b subclassification was an independent prognostic factor for OS (hazard ratio = 2.331, p = 0.032) and DMFS (hazard ratio = 2.602, p = 0.034), and had no significant effect on local relapse-free survival. Conclusions: Subclassification of T4 patients, as T4a or T4b, using MRI according to the site of invasion, has prognostic value for the outcomes of IMRT treatment in NPC.« less
  • Purpose: To analyze the variation of sketching the parotid for patients with nasopharyngeal carcinoma who underwent radiotherapy based on computed tomography (CT) and magnetic resonance(MR) images. Methods: 41 nasopharyngeal cancer patients were randomly selected. Each patient underwent MR and CT scanning. The Gross Tumor Volume and Organs at risk were contoured on both contrasted CT and T1-MR images. For each patient, one radiotherapist sketched the parotid on CT and MR images for 10 times, and 10 different radiotherapists were asked to sketching the parotid on CT and MR images only one time. The inter- and intra-observers volumes and outline variationsmore » were compared. Results: The volumes of parotid contoured by inter-observer on CT and MR images were 34.6±12.1cm{sup 3}(left),34.3±9.0cm{sup 3}(right) and 24.6±7.6cm{sup 3}(L),23.2±8.1cm{sup 3}(R); In the same way, for intra-observer on CT and MR images the volumes were 28.2±7.6cm{sup 3}(L),29.4±9.4cm{sup 3}(R) and 24.4±7.6cm{sup 3}(L),22.5±7.4cm{sup 3}(R), respectively. The variable ratios of volume on MR images were 4.7±0.7%(L),5.0±0.6%(R) for inter-observer and 2.3±0.4%(L),2.1±0.7%(R) for intra-observer. Similarly, The inter- and intra-observer ratios for contouring on CT images reached 18.0±4.8%(L),17.4±4.6%(R) and 6.3±1.5%(L),6.8±1.5%(R), respectively. Conclusion: Contouring the parotids on MR images was more accurate and reproducible than that on CT images.« less
  • Purpose: The presence of Epstein-Barr virus latent membrane protein-1 (LMP-1) gene in nasopharyngeal swabs indicates the presence of nasopharyngeal carcinoma (NPC) mucosal tumor cells. This study was undertaken to investigate whether the time taken for LMP-1 to disappear after initiation of primary radiotherapy (RT) was inversely associated with NPC local control. Methods and Materials: During July 1999 and October 2002, there were 127 nondisseminated NPC patients receiving serial examinations of nasopharyngeal swabbing with detection of LMP-1 during the RT course. The time for LMP-1 regression was defined as the number of days after initiation of RT for LMP-1 results tomore » turn negative. The primary outcome was local control, which was represented by freedom from local recurrence. Results: The time for LMP-1 regression showed a statistically significant influence on NPC local control both univariately (p < 0.0001) and multivariately (p = 0.004). In multivariate analysis, the administration of chemotherapy conferred a significantly more favorable local control (p = 0.03). Advanced T status ({>=} T2b), overall treatment time of external photon radiotherapy longer than 55 days, and older age showed trends toward being poor prognosticators. The time for LMP-1 regression was very heterogeneous. According to the quartiles of the time for LMP-1 regression, we defined the pattern of LMP-1 regression as late regression if it required 40 days or more. Kaplan-Meier plots indicated that the patients with late regression had a significantly worse local control than those with intermediate or early regression (p 0.0129). Conclusion: Among the potential prognostic factors examined in this study, the time for LMP-1 regression was the most independently significant factor that was inversely associated with NPC local control.« less
  • Purpose: To study the contour and dosimetric feature of organs at risk (OARs) applying magnetic resonance imaging (MRI) images in intensity modulated radiation therapy (IMRT) of nasopharyngeal carcinoma (NPC) compared to computed tomography (CT) images. Methods: 35 NPC patients was selected into this trail. CT simulation with non-contrast and contrast enhanced scan, MRI simulation with non-contrast and contrast enhanced T1, T2 and diffusion weighted imaging were achieved sequentially. And the OARs were contoured on the CT and MRI images after rigid registration respectively. 9 beams IMRT plan with equal division angle were designed for every patients, and the prescription dosemore » for tumor target was set as 72Gy (2.4Gy/ fration). The boundary display, volume and dose-volume indices of each organ were compared between on MRI and CT images. Results: Compared to CT, MRI showed clearer boundary of brainstem, spinal cord, the deep lobe of Parotid gland and the optical nerve in canal. MRI images increase the volume of lens, optical nerve, while reducing the volume of eye slightly, and the maximum dose of lens, the mean dose of eyes and optical raised in different percentage, while there was no statistical differences were found. The left and right parotid volume on MRI increased by 7.07%, 8.13%, and the mean dose raised by 14.95% (4.01Gy), 18.76% (4.95Gy) with statistical significant difference (p<0.05). The brainstem volume reduced by 9.33% (p<0.05), and the dose of 0.1cm3 volume (D0.1cm3) reduced by mean 8.46% (4.32Gy), and D0.1cm3 of spinal cord increased by 1.5Gy on MRI. Conclusion: It is credible to evaluate the radiation dose of lens, eye and the spinal cord, while it should be necessary to evaluate the dose of brainstem, parotid and the optical nerve applying MRI images sometime, it will be more meaningful for these organs with high risk of radiation injury.« less