Endoscopic surgery is superior to intensity‐modulated radiotherapy in the treatment of advanced recurrent nasopharyngeal carcinoma

Abstract

Background:The choice between endoscopic surgery and re-radiotherapy as the main treatment modality in patients with advanced recurrent nasopharyngeal carcinoma (rNPC) remains controversial. Therefore, in this study, we compared the efficacies of endoscopic surgery and intensity-modulated radiotherapy (IMRT) in patients with rNPC. Methods: All patients with advanced rNPC (T3 and T4) who underwent salvage treatment were enrolled from January 2009 to December 2020. Overall survival (OS) was analyzed using a log-rank analysis. Univariate and multivariate analyses of OS were performed using a Cox regression model. Common treatment-related complications of endoscopic surgery were compared with those of IMRT. Results:The numbers of patients with T3 and T4 tumors were 163 (64.2%) and 91 (35.8%), respectively; 192 patients underwent endoscopic surgery, 51 received IMRT, and 11 received three-dimensional conformal radiotherapy (3D-CRT). The 3-year OS of patients treated with endoscopic surgery was 59.3%, which was significantly higher than that of patients treated with IMRT (34.7%, p < 0.001) or 3D-CRT (43.6%, p = 0.012). Multivariate analyses showed that IMRT was an independent risk factor for OS compared with endoscopic surgery (hazard ratio, 2.068; 95% confidence interval, 1.395-3.069, p < 0.001). Complications of aural fullness (p = 0.001), nasopharyngeal necrosis (p = 0.004), nasopharyngeal hemorrhage (p = 0.004), dysphagia (p < 0.001), and cerebral infarction (p = 0.030) were significantly lower in the endoscopic surgery group than in the IMRT group. Conclusion:Endoscopic surgery may be a more promising salvage treatment than IMRT to maximize survival and minimize treatment-related complications Wanpeng Li, Qianqian Zhang, and Fu Chen contributed equally to this work.

Preliminary evidence for endoscopic surgery combined with postoperative anti-PD-1 immunotherapy in advanced recurrent nasopharyngeal carcinoma

“…The most common treatment for rNPC is salvage surgery and IMRT. Evidence is accumulating that endoscopic surgery is superior to IMRT in the treatment of rNPC [ 9 , 20 ]. Hua et al reported that the 3-year overall survival (OS) in surgery groups of rT3 and rT4 tumours was 68.8 and 36.9%, respectively, which was longer than that of patients receiving IMRT [ 5 ].…”

“…Several studies have suggested that recurrences amenable to surgery with favourable outcomes and a high likelihood of negative margins include the majority of rT1 and early rT2 disease and selected rT3 disease with a small disease volume and minimal skull base involvement [ 21 – 23 ]. With the development of arterial embolization techniques and the accumulation of surgeons’ anatomical experience related to the nasopharyx and skull base, indications are expanding to include rT3 and rT4 disease [ 9 , 24 – 26 ]. Wong et al [ 25 ] reported favourable patient outcomes with advanced rNPC (rT3 and rT4) who underwent an endoscopic approach, and the two-year OS (66.7%) and DFS (40.0%) results basically agreed with the our previous data (OS: 67.1%; DFS: 37.3%) [ 27 ].…”

“…ENPG demonstrated a better survival outcome (5-year overall survival: 77.1% for ENPG vs. 55.5% for reirradiation), improved quality of life, and a significant decline of treatment-related complications for rNPC compared with reirradiation [ 8 ]. Our previous study suggested that the 3-year OS of patients treated with endoscopic surgery (59.3%) was significantly higher than that of patients treated with IMRT (34.7%, p < 0.001) in a cohort of 243 patients with advanced rNPC (rT3 and rT4) [ 9 ]. For these patients with rT3 and rT4 undergoing endoscopic surgery, there is still a risk of tumor residual and recurrence even if the surgical margins are negative.…”

Innovative Fudan rT staging in endoscopic surgery for recurrent nasopharyngeal carcinoma

“…The exclusion criteria were as follows: (1) patients with ICA embolization or external carotid‐intracranial artery bypass grafting before surgery; (2) patients with retropharyngeal and/or cervical lymph node metastasis; (3) patients with distant organ metastasis; and (4) a lack of important clinical variable data and follow‐up data. In addition, extensive invasion of intracranial structures, especially important blood vessels and nerves, or invasion of intracranial structures after previous radiotherapy with obvious radiation‐induced brain edema are also considered as contraindications of endoscopic surgery 9,23 …”

“…In addition, extensive invasion of intracranial structures, especially important blood vessels and nerves, or invasion of intracranial structures after previous radiotherapy with obvious radiation-induced brain edema are also considered as contraindications of endoscopic surgery. 9,23 We collected the demographic characteristics, pathological classification, AJCC/UICC rT staging, closest distance between the tumor margin and ICA on enhanced MRI (distance ≥ 5 mm, 1.8 mm < distance < 5 mm, and distance ≤ 1.8 mm), invasion of the dura mater, overall survival time, and survival time without tumor progression. The criteria for dural invasion were based on the criteria set in the study of McIntyre et al, as "the presence of ≥2 mm of dural thickening, loss of hypointense zone, and nodular dural enhancement."…”