The use of autologous stem
cell transplantation in the treatment of regionally advanced
nasopharyngeal carcinoma
AYH Leung,1 AKW Lie,1 YL
Kwong,1 GC Ooi,2 CC Yau,3 R.
Liang 1
1 Department of Medicine, 2Department of
Diagnostic Radiology, 3Department of Clinical Oncology,
Queen Mary Hospital, University of Hong Kong
Correspondence: Dr. AYH Leung, Department of Medicine, Queen Mary
Hospital, 102 Pokfulam Road, Hong Kong SAR, China E-mail:
ayhleung@hkucc.hku.hk
Abstract
Nasopharyngeal carcinoma (NPC) is endemic in Southeast Asia. Localized disease is curable with radical radiotherapy but disease with regional lymph node metastasis tends to recur. We report our experience in three patients with regionally advanced NPC treated with high dose chemotherapy followed by peripheral blood stem cell transplantation.
Text
Nasopharyngeal carcinoma (NPC)
is uncommon in Western countries but is endemic in Southeast Asia,
with an annual incidence of 15 to 20 per 100,000. Localized
disease is curable with radical radiotherapy but disease with
regional lymph node metastasis tends to recur with a 5-year
survival rate of only 10 -40%.1 In these patients, the
optimal treatment is not defined. We report our experience in
three patients with regionally advanced NPC treated with high dose
chemotherapy followed by peripheral blood stem cell
transplantation. In our institution, patients with regionally
advanced NPC were treated with radical radiotherapy followed by
adjuvant chemotherapy comprising three courses of cisplatin and
fluouracil. Those undergoing autologous peripheral blood stem cell
transplantation (PBSCT) followed standard stem cell mobilization
protocol using cyclophosphamide (1.5 g/m2 for once)
followed by granulocyte-colony stimulating factor (G-CSF) at 10
mg/kg for seven to nine days. Conditioning regimen comprised
carboplatin (400 mg/m2), etoposide (300
mg/m2) and cyclophosphamide (1500 mg/m2).
Anti-microbial prophylaxis was given according to standard
protocols. Patient #1. A 21-year old woman presented with
left cervical lymphadenopathy in 1996. Examination of the
nasopharynx (NP) showed a tumor on the right side, and biopsy
revealed undifferentiated NPC. Magnetic resonance imaging (MRI) of
the NP and the neck reviewed bilateral deep upper and posterior
cervical triangle lymphadenopathy and a right NP mass (T1N3M0).
She achieved complete remission (CR) after standard treatment and
underwent PBSCT in 1997 with uneventful course (table
1). She managed to gave
birth to a normal baby two years afterwards and remained in CR
four years after the transplantation. Patient #2. A 47-year
old man presented with left cervical lymphadenopathy in 1996 with
MRI showing a large tumor on the left side of the NP, extending to
the oropharynx and obliterating the left para-pharyngeal plane,
with multiple enlarged cervical lymph nodes (T3N3Mx). Biopsy of
the NP showed undifferentiated carcinoma. He achieved CR after
initial treatment and received autologous PBSCT in the same year.
A suspicious 1 cm opacity was noted in the left lung on CXR two
months after PBSCT, which progressed to multiple lung metastases
shortly thereafter. The disease did not respond to salvage
chemotherapy and he succumbed to respiratory failure due to
multiple lung metastases in 1997. Patient #3. A 35-year-old
man with undifferentiated NPC presented with left cervical
lymphadenopathy in 1997. MRI showed a soft tissue tumor at the
roof and posterolateral wall of the NP, involving the left
internal carotid, the left paravertebral muscles and the left
skull base, with multiple metastatic cervical lymphadenopathy
(T2N2M0). He achieved CR after treatment and received autologous
PBSCT in 1998. Seven months post BMT, he developed left axillary
lymphadenopathy and CT thorax showed multiple lung metastases,
mediastinal and hilar lymphadenopathy. He received external
radiotherapy to the left axilla with no response. He died of
pulmonary metastases one year after transplantation. Al-Sarraf et
al.2 have reported an improved two-year progression
free survival in patients with regionally advanced NPC receiving
combined chemo-irradiation as compared with those who only
received radiotherapy (52 vs 15 months). However, NPC in
Caucasians is different histologically (less than half of the
tumours are of the undifferentiated type, as compared with 95% in
Asian patients) and biologically (Epstein-Barr viral infection is
absent, but is invariable in Asian patients), so that these
results may not be directly relevant to Asian
population.3 Studies in Chinese patients with
regionally advanced NPC failed to document a survival benefit of
combination chemo-irradiation over radiotherapy alone.1
Reports in literatures on the use of autologous PBSCT in NPC are
scarce. In this report, haematopoietic reconstitution was achieved
within the second and the third week after PBSCT and one patient
remained disease-free four years after transplantation whereas the
other two have distant metastases shortly afterwards (two and
seven months). All three patients have histologically identical
NPC with extensive regional lymph node involvement at presentation
and could attain CR at transplantation. The survivor, however, had
a younger age (21 versus 47 and 35 years old) and less extensive
disease (T1 versus T2 and T3) at presentation and these were in
keeping with those reported by Yang et al.4 showing
that T-stage and age of the patients are important prognostic
factors for disease control.
In conclusion, autologous stem cell transplantation may be
explored as an option for the treatment of regionally advanced NPC
but its effect on disease outcome and patient survival should be
ascertained with a larger cohort of patients.
