En bloc resection concept for endoscopic endonasal nasopharyngectomy： surgical anatomy and outcome

Background Nasopharyngeal carcinoma （NPC） patients have a 19%-56% locoregional recurrence rate after primary therapy.For those recurrent NPC （rNPC） patients,re-irradiation may cause some complications.In recent years,endoscopic endonasal nasopharyngectomy （EEN） has become a surgical option for rNPC patients.Here we introduce the concept of en bloc excision （EBE） technique for EEN,including the surgical technique and clinical outcomes.Methods A retrospective study was conducted covering September 2009 to May 2013,involving the collection of Iocoregional rNPC cases from two institutions （Kuang-Tien General Hospital （KTGH） in Taiwan and National University Health System （NUHS） in Singapore）.These patients failed prior therapy and then underwent EEN.We reported the 2-year overall survival rate,the 2-year disease-free survival rate,and related complications.Results Nine patients （five from KTGH and four from NUHS） completed this study,with five,two,and two patients of recurrence tumors （rT1）,rT2,and rT3,respectively.The mean age was 46.4 years （range 32-63）; the mean follow-up period was 24.9 months （range 10-45）.The 2-year survival rate and the 2-year disease-free rate were 100% and 80%,respectively,in five patients.No significant complications or cases of mortality occurred.Conclusions The EBE concept of EEN is suitable for early rT1 and has relatively encouraging short-term outcomes.In selected rT2,careful EBE can be performed by expanding the surgical field.A clear view of the internal carotid arteryrelated anatomy is indispensable.In the future,more series may be needed to determine the role of EEN in rNPC patients.

Minimally invasive surgery alone compared with intensity-modulated radiotherapy for primary stage I nasopharyngeal carcinoma

Background:The National Comprehensive Cancer Network guidelines recommend intensity-modulated radiotherapy(IMRT)as the primary curative treatment for newly diagnosed nasopharyngeal carcinoma(NPC),but the radiation-related complications and relatively high medical costs remain a consequential burden for the patients.Endoscopic nasopharyngectomy(ENPG)was successfully applied in recurrent NPC with radiation free and relatively low medical costs.In this study,we examined whether ENPG could be an effective treatment for localized stage I NPC.Methods:Ten newly diagnosed localized stage I NPC patients voluntarily received ENPG alone from June 2007 to September 2017 in Sun Yat-sen University Cancer Center.Simultaneously,the data of 329 stage I NPC patients treated with IMRT were collected and used as a reference cohort.The survival outcomes,quality of life(QOL),and medical costs between two groups were compared.Results:After a median follow-up of 59.0 months(95%CI 53.4-64.6),no death,locoregional recurrence,or distant metastasis was observed in the 10 patients treated with ENPG.The 5-year overall survival,local relapse-free survival,regional relapse-free survival,and distant metastasis-free survival among the ENPG-treated patients was similar to that among the IMRT-treated patients(100%vs.99.1%,100%vs.97.7%,100%vs.99.0%,100%vs.97.4%,respectively,P>0.05).In addition,compared with IMRT,ENPG was associated with decreased total medical costs($4090.42±1502.65 vs.$12620.88±4242.65,P<0.001)and improved QOL scores including dry mouth(3.3±10.5 vs.34.4±25.8,P<0.001)and sticky saliva(3.3±10.5 vs.32.6±23.3,P<0.001).Conclusions:ENPG alone was associated with promising long-term survival outcomes,low medical costs,and satisfactory QOL and might therefore be an alternative strategy for treating newly diagnosed localized stage I NPC patients who refused radiotherapy.However,the application of ENPG should be prudent,and prospective clinical tri-als were needed to further verify the results.

Salvage surgery for nasopharyngeal cancer

Nasopharyngeal carcinoma (NPC) is a special type of head and neck cancer with a widely variable geographical variation in incidence.The central location of the tumor inside the head coupled with the radiosensitivity of the tumor to radiation made radiation therapy the first choice in primary treatment of NPC.Advances in radiotherapy and chemotherapy have markedly improved the local control of NPC.Unfortunately, a small but significant number of patients still suffered from loco-regional failures that would be amenable to re-treatment.Traditional form of retreatment was to employ a second course of radiation.The efficacy of re-irradiation to treat local of regional recurrent NPC has been suboptimal.Moreover, the local tissue had already received a high dose of radiation and the second radiation could result in radiation toxicities to the local tissue, leading to significant complications.Surgical salvage, on the other hand, could spare the patients from complications of retreatment.Due to the difficult access of the nasopharynx, various surgical approaches had been devised for nasopharyngectomy.The maxillary swing approach had the largest published experience with over 300 cases from various centers.In the recent decade, the endoscopic approach with or without robotic assistance had gained popularity for resecting small, centrally located recurrences.This minimally invasive approach further reduced the morbidity for treating locally recurrent NPC.Nodal recurrences had been a rare entity after the introduction of modern radiotherapy technique and concurrent chemotherapy.Treatment of nodal failure with second radiation has dismal results.Surgical removal of the lymph node harboring the recurrence should be in the form of a formal radical neck dissection.In cases of extensive nodal recurrence where microscopic disease may be present after a formal neck dissection, additional radiotherapy can be delivered with after-loading brachytherapy.Surgical treatment played a definitive role in salvage of loco-regional failures of nasopharyngeal carcinoma.

Nasopharyngeal carcinoma-Improving cure with technology and clinical trials

Nasopharyngeal carcinoma is a unique cancer in the head and neck region.It has a very distinct geographic variation of incidence with more than ten times difference in incidence in high risk population compared with low-risk population.No other head and neck cancer has this large worldwide variation of incidence.It remained commonest cancer in young male adults below the age of 50 in southern China.