I

Analysis of 1379 Patients With NasopharyngealCarcinoma Treated by Radiationt

DEXINGQIN, MD, MCSRO:'§ YUHUA HU, MD: JIEHUA YAN, MD: GUOZHENxu, MD: WEIMINGCAl, MD: XUELINWU, MD: DEXIANCAO, MD,:!:AND XIANZHIGU, MD, MCSRO·'§

One thousand three hundred seventy-nine nasopharyngeal carcinoma (NPC) patients were treated from March 1958 to December 1978. Twenty-two percent had stage I or II and 78% Stage III or IV had lesions. Two hundred twenty-Kv radiographs were used before 1960; and telecobalt was used from1961 to 1978. Factors influencing the 5-year survival rate favorably are youth of patient, being female, pathologic condition (poorly differentiated carcinoma, 45.1 % venus adenocarcinoma, 13%), stage (Stage1,86%, Stage II, 59.5%; Stage III, 45.8%; Stage IV, 29.2%), decade admitted for treatment in the past(31% in the 195Os, 48.6% in the 1970s), total dose delivered to the nasopharynx (40 to 49 Gy, 46%; 70 to79 Gy, 54.1%; 90 Gy or more, 64%) and prophylactic radiation to the neck regions (with prophylactic irradiation, 53.8%, without prophylactic irradiation, 23%). This implies that prophylactic radiation of the neck is crucial even without positive clinical metastasis. For those who have a residual tumor in the primary site when 70 Gy has been delivered, the total dose may be boosted to more than 90 Gy with the cone-down technique or on basis of adding 20 Gy to the dose at which the primary lesion disappeared grossly. The common postirradiation complications are: radiation myelitis, trismus, and otitis media. Because disease recurred in some patients after the fifth year, NPC patients should be followed for at least 10 years.

Cancer 61:1117-1124, 1988.

NA SERIES of 1379 consecutive nasopharyngeal carcinoma (NPC) patients treated in our department over

a period of 21 years, 1958 to 1978, we have found that the 5-year survival of this cancer had been improved from 31% (35 of 112) in the 1950s to 48.4% (328 of 677) in the 1970s. This paper summarizes the experience gained by trial and error reports and outlines several crucial points in the radiotherapeutic technique, some of which are still open to debate and require further studies.

Patients

Characteristics of patients included in the analysis were:

1. A pathologic diagnosis of nasopharyngeal carcinoma; other nonepithelial malignancies were excluded,

From the Departments of "Radiation Oncology and *Computer Sciences, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing,China,

t Dedicated to our colleague,Dr, Cui Lan Li, who participated in

the 1965preliminaryreport but died of breast cancer in 1969,§ Member of ChineseSocietyof Radiation

Oncology(MCSRO),Address for reprints: Dexing Qin, MD, MCSRO, Department of

Radiation Oncology, Cancer Hospital, Zuo An Men Wai, Beijing, China,

Acceptedfor publication September29, 1987,

2. Initial treatment used was radiation therapy unless distant metastases were evident at presentation.

3. Doses of at least 40 Gy to the nasopharynx were used.

4. Patients lost to follow-up (14 patients [1%]) werescored as having died of cancer.

Sex: male, 1067; female, 312 (sex ratio, 3.4 to I).Age ranged from 8 to 74 years, with the highest com

plication rate in patients between the ages of 30 and 60 years,

The common symptoms were: blood-streaked nasal discharge, tinnitus, mass in the neck, and headache,

All patients were staged according to the staging sys tem introduced at the Second National Symposium on Nasopharyngeal Carcinoma, Shanghai, 1965 (Appen dix), There were 14 patients with (I%) Stage I disease,301 (21,8%) with Stage II,417 (30,3%) with Stage III and647 (46,9%) with Stage IV lesions, The Stage III and IVlesions constituted 78% of the series.

Methods

Orthovoltage radiographs (220 KV) were used before1960. Thereafter, telecobalt was used until 1978, when linear accelerators replaced telecobalt. For the primary lesion, two large parallel opposing preauricular portals,

1117

1118 CANCER March 15 1988 Vol. 61

A

A

PA

"'PA

FIGs. IA AND lB. 6OCO dose distribution in nasopharynx irradiated by two preauricular portals (6 x 9 ern) (PA). SSD = 75 em. SDD = 51.6 em. (B) Schematic drawing of 6OCO dose distribution in nasopharynx irradiated by two preauricular (6 x 9 em) (PA) fields supplemented by twointraorbital (4 x 4 ern) (30°) (10) portals. Dose loading: PA:IO = 3.5: I. SSD = 75 cm. SDD = 51.6 em; A: anterior: 10: infraorbital field; MA:maxillary sinus; BS: brain stem; P: posterior; PA: preauricular field: NP: nasopharynx.

encompassing the nasopharynx and the adjacent base of the middle cranial fossa, were used. These portals were reduced routinely to include only the base of skull and the primary lesion, which usually was located on the posterosuperior wall of the nasopharynx as the dose ap proached the curative level from 40 Gy (Fig. IA). Our resident doctors were required to examine the tumor condition and enter the findings as drawings in the his tory record. They noted the time and dosage at which the lesion disappeared. Our principle of curative therapy of the primary focus is to carry the tumor dose to about20 Gy beyond the level at which the tumor disappearedin response to photon therapy. The final dose is usually approximately 70 Gy, which is considered to be the cur ative dose for the nasopharynx and the base of skull. If any residual tumor was grossly persistant after 70 Gy, the primary lesion had to be boosted to higher doses. By using supplementary smaller anterior, infraorbital, in tracavitary radium mould or intracavitary radiograph cone through the soft palate in addition to the reduced preauricular fields, the total dose could be brought to 90Gy or more (Fig. 1B).

The cervical regions were first irradiated to 40 Gy by one anteroposterior tangential field with the upper mar-

gin I em above the lower border of the mandible and the lower margin below the lower border of the clavicle, covering the whole of the neck and the supraclavicular areas bilaterally. The spinal cord was shielded by a rectangular block of low melting lead alloy, 3 em wide and6 em thick. Two bilateral parallel opposing large fields,usually 9 em X 14 em in size, were used to deliver a mid-line dose of25 to 30 Gy to the neck. As a rule, most of the larger metastatic lymph nodes would resolve by this time except resistant ones. Cone-down portals were used to further boost the irradiation until the involved nodes either disappeared completely or changed into a plaque of soft and elastic tissue with unclear boundaries, which we regarded as the possible eradication of the metastases. Sometimes the mass would first become soft and reduced in size, but as the dose approached the curative level it became firm again, possibly due to fi brosis. Usually 70 to 100 Gy is needed for complete control of the positive lymph nodes. The sole purpose of treating the neck lesions is to deliver a radical dose to the whole of the neck, effecting complete control of the met astatic foci and keeping the spinal dose under 40 Gy. As nasopharyngeal carcinoma (NPC) can easily metastasize to nodes at an early stage, all patients with NPC should

"

NO.6 NPC TREATEDBY RADIATION Qin et al. 1119

receive treatment to the bilateral cervical/supraclavicu lar regions as a preventive basis. For recurrence in the neck, reirradiation, lymphadenectomy I or radical neck dissection were resorted to. For recurrence in the naso pharynx, either a second course of radiation or surgery was given. The latter was especially valid for recurrence near the mid-line. No chemotherapy was given unless distant metastases were evident.

Results

Remote Survival 0/ NPC

Ten year survival rate is needed to assess the validity of radiotherapy for NPC. In our series, the survival curve gives a sharp decline from 83% (1145 of 1379) inthe first year after radiation down to 41.4% (571 of

100

90

80

70

60

50

40

)0

20

10

1 2 3 4 5

--.:'!"-;- -17"( 6/35)16~~ l.~(93/580) (27/219)

10 15 20 25year_

1379) in the fifth year (Fig. 2). Yet, it continues to slope down to 27.9% (253 of 906) in the tenth year, then to16% (93 of 580) in the 15th year. From then on it re mains flat, fluctuating between 12% and 17% to the 25th year. Like breast cancer, an appreciable amount ofNPC patients experience recrudescence of the disease long after the conclusion of therapy; the longest interval be tween recurrence in the nasopharynx was 24 years! Since 14% of patients still succumb to this cancer or its sequellae between the fifth and tenth year, we believe that a 10 year survival is necessary to assess the effective ness of treatment for nasopharyngeal carcinoma.

Gradual Improvement in Results From 1958 to 1978- Innovation cf Treatment Technique

The 5-year survival rate of 41.4% overall (571 of1379), indicates that the results of radiotherapy for NPC in our hospital had gradually improved from 31 % (35/112) in the late 1950s to 35.3% (208/590) in the1960s and then to 53.3% (137/257) in the late 1970s(Table I). Combining the advanced lesions (stage III and IV), the same phenomenon was observed. The five year survival rate improved from 29% to 29.7% to 40.1 % and finally to 48% during the same time period. This was

FIG. 2. Survivarlateof 1379 patientswithNPC.

achieved through the gradual innovation of the tech nique, individualization of each patient's gradual adop tion of initial large portal treatment followed by cone down technique, using convergent small beams for isolated cancerous extensions, and abandoning the superfluous modalities. By timely obtaining help from our head and neck surgeon I for certain resistant or re current lesions as well as acquiring aid from our radio physicists especially in clinical dosimetry and the quality assurance practiced in our routine clinical work. These improvements are rendered possible by the gradual ac cumulation of experience of our radiotherapists over 20 years. Our belief is that no further improvement is likely without concomitant use of immunotherapy, chemo therapy, radiosensitizers or traditional chinese medici nal herbs/ and radiotherapy. It is our wish to analyze the prognostic factors which are the basis of our improve ment in treating NPC.

PrognosticFactors

Analyzing factors influencing the patients' prognosis, we classify them as two types; non modifying prognostic

TABLE 1. GradualImprovemenitn Resultsof RadiotherapyforNPC (1958-1978)

1958-1960 1961-1970 1971-1975 1976-1978 1958-1978

Stage No. Percent No. Percent No. Percent No. Percent No. Percent

I 2/2 100· 2/3 67 7/7 100· 1/2 50· 12/14 8611 3/6 50· 64/109 59 67/121 55 45/65 69 179/301 59.5III 16/27 59 57/160 36 60/132 46 58/98 59 191/417 45.8IV 14/77 18 85/318 27 57/160 36 33/92 36 189/647 29.2

III + IV 30/104 29 142/478 29.7 117/292 40.1 91/190 47.9 380/1064 35.7

Total 35/112 31 208/590 35.3 191/420 45.5 137/257 53.3 571/1379 41.4

NPC:nasopharyngeaclarcinoma. •Insufficiennto. of patients.

Poorly differentiated ca 409/906 45.1 vival rate, 28% (15/54) to those positive for destruction.Squamous cell ca 43/109 39 This may have been due to the poor quality of the sub

1120 CANCER March J 5 1988

Vol. 61

TABLE2. Influence of Stage on Prognosis of NPC

Survival rates

TABLE5. Influence of Sex on Prognosis of NPC

5-year survival rate· 10-year survival rate·

5-year 10-year 20-year Sex No. Percent No. Percent

Stage No. Percent No. Percent No. Percent

I 12/14 86 6/9· 67 1/2· 50II 179/301 59.5 78/183 43 5/19 26III 191/417 45.8 69/239 29 10/59 17IV 189/647 29.2 100/475 21 11/139 8

MaleFemale

• P < 0.05.

426/1067145/312

39.946.4

180/69373/213

25.934

Total 571/1379 41.4 253/906 28 27/219 12

NPC: nasopharyngeal carcinoma.* Insufficient number of patients.

TABLE3. Influence of Age on Prognosis of NPC (5-year survival rate, 1379 NPC)

5-year survival rate

Age group No. Percent

0-9 2/2 10010-19 41/65 6320-29 60/134 4530-39 159/360 44.240-49 197/465 42.450-59 77/243 3260-69 33/101 3370-79 2/9 22

Total 571/1379 41.4

NPC: nasopharyngeal carcinoma.

factors inherently present when the patient is first seen. They can be used only to predict the chance of survival. The other type, the modifying prognostic factors, through understanding the technique of treatment, modification can be made to increase the patient's chance of being cured.

Nonmodifying prognostic factors:

1. Stage: Among the survival rates in the fifth, tenth, and the 20th year, there is always a reduction of 10 to

TABLE4. Influence of Pathology on Prognosis of NPC (5-year survival, 1379 NPC)

5-year survival rate

Pathologic classification No. Percent

20% in survival rate as the stage progresses throughStage I to IV (Table 2). Generally, the survival rate of Stage III patients is indicative of the mean of all four stages grouped together. It should be noted that our patients had come from a populace lacking in periodic cancer screening. Therefore advanced lesions are preponderant.

2. Age: Unlike malignant lymphoma, gastric cancer and cancer of the breast, the survival rate of NPC in creases for younger patients. In 67 patients under 19 years of age, 64% (43) survived for more than 5 years which is 23% higher than the overall 5 year survival of the whole series. Both of the two patients under 9 years old survived for more than 5 years. In contrast, patients older than age 50 gave much poorer results; 31.7% (112 of 353) which is less than half the survival rate for those patients under age 19 (Table 3).

3. Pathologic classification: The pathologic subtyping of NPC seems not to be important in influencing patients' prognoses except in the case of adenocarcinoma which, being resistant to radiation, should be given higher doses as reported by Vikram and his associates in1985.3 Only one of eight patients suffering from adeno carcinoma in our series survived 5 years or longer (Table 4).

4. Sex: Table 5 shows the more favorable outcome of the female patients in terms of 5 and 10 year survival rates with differences of statistic significance (P < 0.05). Although we noted pregnancy as a gravely detrimental effect on patients with NPC,4 the role of the hormone in this cancer is still obscure.

5. Bony destruction of base of skull: Bony destruc tion at the base of skull appreciably affects a patient's prognosis. Patients positive for bony destruction gaveonly 27% (56 of205) 5 year survival in contrast to 45.3% (481 of 1061) for those without it (Table 6). The differ ence therein is statistically significance (P < 0.05). Our54 patients with doubtful destruction gave a similar sur

Anaplastic ca Unc1assifiable ca Adenoca

Total

37/10981/247

1/8

571/1379

343313

41.4

mentovertical projection which had been the chief means of demonstrating bony destruction before CT was installed in our hospital in 1979. Since then. CT has almost totally replaced radiograph films being more

NDC: nasopharyngeal carcinoma; Ca: carcinoma. "sensitive" and accurate in detecting bony anomalies at

No.6 NPC TREATED BY RADIATION Qin et al. 1121

TABLE6. Influence of Destruction of Base of Skull on Prognosis of NPC

Base of skull bony destruction

5-year survival

No. Percent p

No destructionSuspicious of destruction

481/106115/54 i

:g::;.:;,:.:~~:.:.~:.::'.:

Destruction positiveNot recorded

Total

56/20519/59

571/1379

32

41.4

NPC: nasopharyngeal carcinoma.

the base of skull.' Today, with newer facilities on hand, we are studying the validity of MRI in comparison with CT for NPC. As the nasopharynx is located beneath the bony base of the middle cranial fossa, posterior cranial fossa involvement signifies more extensive invasion and graver prognosis. It gave a 5-year survival of 18% (4/22) as compared with 28% (52/183) involving the middle cranial fossa (Table 7).

6. Paralysis of cranial nerves: Presence of cranial nerve paralysis reduced the patient's chance of survival by 22% (47.6% to 26%) and Horner's syndrome which always coexisted with paralysis of other nerves (syn drome retroparotidean space), implies a grave prog nosis, only 9% (3 of 33) of patients survived 5 years (Table 8).

Modifying prognostic factors:

1. Prophylactic irradiation of the neck: We divided the neck region into zones; upper, middle, lower neck and supraclavicular zones separated by three horizontal imaginary lines running parallel to; the hyoid bone above the lower border ofthyrocricoid membrane in the midsegment of the neck and another horizontal line 2

As we enlarged the neck portals downwards by one zone, the 5 year survival rate increased to 45.0% (248 of551). The survival rate further increased to 53.8% (135 of 251) when two more zones were irradiated prophy lactically. The differences in the survival rates which resulted from this extension is of paramount importance (P < 0.05). At present, our standard method is to irra diate the whole neck bilaterally even if the lymph nodes are involved or not. Our experience of treating Stage I lesions (with no palpable nodes in the neck) is to irra diate the whole neck bilaterally to a dose of 40 to 50Gy/4 to 5 weeks without further boosting. Patients with carcinoma-positive neck glands should be treated as de scribed in the Methods section.

2. Optimum dose at the nasopharynx and the properway of delivery: Our routine requires the assistant resi-

TABLE7. Influence of Site of Bony Destruction on Prognosis of Npc·

5-year survival

Site of destruction No. Percent

ern above and parallel to the upper border of the clavicle." Since 1958 when our hospital first opened, we have tried various types of portals best suited to the neck metastasis; those covering only the area of the metastasis, those extending downward beyond the involved

Middle cranial fossaPosterior cranial fossa

Total

NPC: nasopharyngeal carcinoma.

52/183 284/22 18

56/205 27

nodes and those extending two zones. The results ob tained show the importance of prophylactic irradiation of the neck through wide portals and are shown in Table9. We chose 915 patients who had been treated by ourstandard technique, e.g., anteriotangential field of different sizes with the spinal cord shielded followed by left

• 205 patients positive for destruction.

TABLE8. Influence of Cranial Nerve Paralysis on Prognosis of NPC

5-year survival

Cranial nerve paralysis No. Percent

and right motion through beams which are finally supplemented by local booster doses, to prove the impor

No paralysisSuspicious of paralysis

454/9543/6·

47.6SO

Paralysis present 99/377 26tance of rational use of portals for the neck. The best Not recorded 15/42 35way of treating the neck is to two-zone extension or use Horner's syndrome +t 3/33 9

whole neck prophylactic irradiation. As can be seen in Total 571/1379 41.4Table 9, the poorest survival resulted from the smallportals, which covered only the metastatic lymph nodes, and gave a 5 year survival rate of only 23% (26 of 113).

NPC: nasopharyngeal carcinoma.• Insufficient number of patients.t Horner's syndrome always coexisted with paralysis of other nerves.

No extensionOne-zone extension

26/113248/551

23

<0.05

Telecobalt only

05 6OCO+ Ra

288/6982/14

41.14

Two-zone extension 135/251 53.8 Orthovoltage x-rays only 18/49 37Orthovoltage x-rays + Ra 12/39 31

1122 CANCER March 15 1988 Vol. 61

TABLE9. Influence of Prophylactic Neck Irradiation on Prognosis of NPC*

TABLE II. Influence of Intracavitary Radium on the Prognosis of NPC

Zones of prophylactic5-year survi val rate 5-year survival rate

extension No. Percent p Radiation No. Percent

3

NPC: nasopharyngeal carcinoma.* 915 patients treated by standard technique.

dents to examine tumor condition every week and enter it into the history record with drawings and dose re ceived at that time. They make special note when the tumor disappears and this dose is designated as the "res olution dose" which, for NPC, is usually 40 to 50 Gy. The total dose required for a specific patient is commonly 20 Gy greater than "resolution dose," i.e.. about70 Gy. This amount of radiation is usually delivered to the nasopharynx and the adjacent base of skull by two preauricular portals on the sides of the face (Fig. lA). Because stage IV disease is characterized by distant me tastasis, only Stage I, II and III lesions were evaluated to find the optimum dose for the primary focus. As shown in Table 10, the optimum dose for cure of the primary lesion is not restricted to specific value, rather it lies in a considerable range, 60 to 90 Gy or more. Ordinarily, 70 to 80 Gy is considered adequate. In some patients, we would see very resistant lesions presenting as a tumor mass in the nasopharynx when the dose reached 70 Gy. For this type of tumor, a cone-down technic is adopted by delineating the portals with the patient under the fluoroscope (or later, simulator) to reduce the area of radiation to 4 to 5 em in diameter. Three or four cone down portals; one or two in front and two on the sides of the face, are usually used and the fractionation assumes the "assault" way by giving 4 Gy, twice a week, with the total dose pushed up to 80 Gy or even 90 Gy (Fig. 1B). Beyond 90 Gy, we would hesitate to carry on the radia-

TABLE 10. Influence of Dose at the Primary Lesion on Prognosis of NPC*

5-year survivalDose in nasopharynx

(Gy) No. Percent

40-49 6/13 4650-59 13/37 3560-69 74/166 4570-79 177/327 54.180-89 73/128 57~90 39/61 64

NPC: nasopharyngeal carcinoma.* 732 patients with Stage I. II. and III lesions.

Ra: radiation; NPC: nasopharyngeal carcinoma.

tion further if the tumor has shown partial regression except under very special circumstances. Intracavitary radium mould or intraoral cone directed towards the posterosuperior wall of the nasopharynx through the soft palate is sometimes tried for boosting. It must be emphasized that dosages above 80 Gy have never been routinely used for fear of radiation injury and supra lethal effect; dosages greater than 80 Gy are always given to resistant lesions. The better result of the group of patients who received more than 90 Gy (64%, 39/61) had aroused much discrepancy in China, because some refrain from administering radiation beyond 70 Gy, To settle this dispute, one of the authors (JHY) is reviewing the records of patients who received 70 Gy or more. Her aim is to determine the validity of high doses for resis tant NPC. There will be another paper devoted to a retrospective analysis of high dosages for resistant NPC and a prospective randomized trial on the same subject to test a similar view of Vikram et al? who reported a higher rate of recurrence in lower doses.

Case Report

LXZ, male, 20 years of age (history No. 100200), was ad mitted in June 1966 for one-sided headache, bloody nasal dis charge, hearing difficulty, trismus and cervical masses for 2 months. Biopsy for the nasopharynx proved to be poorly dif ferentiated carcinoma. The primary lesion was found to have extended into the pterygoid fossa and he was staged as having a Stage III lesion. Telecobalt irradiation was initiated June 17,1966 to August 24, 1966. When 80 Gy was delivered through two preauricular portals supplemented by two anterior in fraorbital booster portals, the primary lesion was found to per sist. Then, through an intraoral cone, an air dose of 1800 cGy was delivered. The total dose was calculated to be 9400 cGy. It was not until two months after the conclusion of his treatment that the primary tumor finally disappeared. In December1986, 20 years 6 months after irradiation, the patient was free of tumor and able to work.

3_ Intracavitary radium: During the early 1960s part of our patients were routinely given intracavitary radia tion as a booster to the conventional external irradia tion. Intracavitary radiation was not administered on

No.6 NPC TREATED BY RADIATION Qin et al. 1123

the basis of a randomized trial. The intracavitary implant, consisting of six l O-mg radium tubes arranged in

TABLE13. Capability of Surviving NPC Patients 5 and 10 Years After Radiotherapy

inserted in the nasopharynx through the mouth with the help of two catheters introduced from the nasal cavities. Karnofsky's

survivors survivors

The implant was inserted as soon as the primary lesion had resolved enough so as the nasopharyngeal cavity could accommodate it, but before the reaction in the mucous membrane became severe. Each of the two ap plications, spaced 7 to 10 days apart, would deliver 1200 mg-hr which was equivalent to 2000 cGy, totalling 4000 cGy on the surface of the mucous membrane accordingto Paterson-Parker's radium dosage calculation.' Thenon validity of intracavitary radium boosting is shown in Table II. The lower 5-year survival rates of patients who received intracavitary radium, especially those who were treated by telecobalt, may have been due to the in creased hematogenous metastasis resulting from the trauma of the implant. Although others reported the benefits of intracavitary radiation, we finally abolished its use."

Complications and Sequelae

Irradiation of NPC will inevitably affect the vital organs in the head and neck area, brain, and spinal cord. It frequently gives rise to complications and sequelae. Our data show that 18.4% of patients developed radia tion encephalornyelopathy which included those as mild as the transient manifestations of Lhermitte's sign and those as serious and fatal as transverse myelopathy and paraplegia. Next in incidence are trismus (9.8%) and otitis media (8.8%). The incidence of radiation enceph alomyelopathy increases with the dose received in the nasopharynx (Table 12).9

Cause of Failure and Performance Status of theSurvivors

A total of959 (69.5%) of the 1379 patients have died as of this writing. The most common cause of failure is

TABLE12. Relation of Radiation Encephalomyelopathy and Dose in the Nasopharynx (1379 patients)

Incidence of encephalomye10pathy

Dose in nasopharynx (Gy) No. Percent

40-49 2/48 450-59 22/108 2060-69 74/333 2270-79 96/561 1780-89 38/224 17<!:90 22/105 21

Total 254/1379 18.4

performance status No. Percent No. Percent

90-100 full time work 283 49.6 26 1070-80 pan time work ISS 27.2 ISO 6010-60 unable to work 91 16 59 23Not recorded 42 7 18 7Total 571 100 253 100

NPC: nasopharyngeal carcinoma.

blood born metastasis, 48.2% (463 of 959). Those pa tients who developed hematogenous metastasis together with recurrence in the nasopharynx and/or the neck were scored as having died of blood born metastasis. 405 (42.2%) patients died of recurrences in the head and neck regions. In 91 (9.5%) patients the cause of death was not clear.

Using the performance status introduced by Karnofsky,'? our data of the surviving patients show that76.7% (438 of 571) of them were working 5 years after their initial radiotherapy and 70% (176 of253) of them had been able to do so in another 5 years although 16% to 23% of them had lost their ability to work (Table 13).

REFERENCES

1. Xu GZ, Li QH, Hu YH et al. Lymphadenectomy as a definitive management of the residual lesion in the neck after radiotherapy for nasopharyngeal carcinoma: Analysis of 48 cases. Chin J Oncol 1981;3:123-125 (in Chinese).

2. Cai WM, Hu YH, Zhang HX et al. Combination of Chinese herbal medicine and radiotherapy in the treatment of nasopharyngeal carcinoma. Journal 0/ American College cf Traduional Chinese Medi cine 1982;2: 1-8.

3. Vikram B, Misha UB, Strong EW et al. Patterns of failure incarcinoma of the nasopharynx. lnt J Radial Oneal Bioi Phys 1985;11:1455-1459.

4. Van JH, Liao CS, Hu YH. Pregnancy and nasopharyngeal carci

noma: A prognostic evaluation of 27 patients. Int J Radiat Oncol BioI Phys 1984; 10:851-855.

5. Yu ZH, Xu GZ, Huang YR, Hu YH, Su XZ, Gu XZ. Value ofcomputed tomography in staging the primary lesion (Tsstaging) ofnasopharyngeal carcinoma (NPC): An analysis of 54 patients with special reference to the parapharyngeal space. Inc J Radial Oncol Bioi Phys 1985; 11:2143-2147.

6. Hu YH, Yin WB, Li TL, Ha XW, Tu GY. The technic and result

of radiotherapy for nasopharyngeal carcinoma: A preliminary report.Chin J Roentgenol1965; 10:467-469 (in Chinese).

7. Paterson R. The radium dosage. In: Paterson R, ed. The Treat ment of Malignant Disease by Radiotherapy, ed. 3. London: Edward Arnold Ltd, 1963; 121-138.

8. Chang CP, Liu TF, Chang YW, Cao SL. Radiation therapy of nasopharyngealcarcinoma. Acta Radiol [Oneol) 1980; 19:433-438.

9. Qin OX, Hu YH, Gu XZ et al. An analysis of 307 cases of irradiation encephalornyelopathy, Chin J Roentgenol 1983; 17:289-293 (in Chinese).

10. Karnofsky DA. The use of nitrogen mustards in the palliative treatment of carcinoma. Cancer 1948; 1:634-638.

APPENDIX

Staging System. as Introduced at the Second National Symposium on Nasopharyngeal Carcinoma, 1965, Shanghai, China

1124 CANCER March 15 1988 Vol. 61

TTO No visible tumor in the nasopharynx.

MMO Absence of distant metastasis.

TI Primary tumor involving one wall of the nasopharynx.T2 Primary tumor involving two or more walls of the naso-

pharynx.T3 Primary tumor extending beyond nasopharynx involving one

of the following groups of structures:I. The continuous soft tissues, the neighboring sinuses or

MI StageIII III IV

Presence of distant metastasis.

TINOMO.TO-IN1MO; T2NO-IMO. TO-3N2MO; T3N0-2MO.T0-4N3MO; T4N0-4MO; TO-4NO-4MI.

cavities.2. The bone of the base of the skull.

TO T1 T2 T3 T4

3. Cranial nerves, I, II, III. IV, V and/or VI.T4 As in T3 but involving two or more groups of structures.

NNO Absence of palpable lymph node in the neck.N I Freely movable lymph node in the upper cervical region, on

one or both sides, diameter less than 3 em,N2 Entirely or partially fixed lymph nodes in the cervical region

on one or both sides, diameter under 8 ern.N3 Cervical lymph nodes enlargement together with involvement

of one of nerve IX, X, XI. XII and/or sympathetic ganglion.N4 Cervical lymph node enlargement, over 8 cm in diameter or

with involvement of the supraclavicular fossa.

NO I I IN1 IIN2

N3

N4

III

IV