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Nasopharyngeal carcinoma: treatments and outcomes in the 20th century

¹ 41 Ewhurst Avenue, Sanderstead, South Croydon, Surrey CR2 0DH, UK and ² Department of Radiation Oncology, Allan Blair Cancer Centre, 4101 Dewdney Avenue, Regina, Saskatchewan, S4T 7T1 Canada

View larger version (38K): [in a new window]   Figure 1. Christie Hospital, Manchester, technique of the 1940s [30].

View larger version (131K): [in a new window]   Figure 2. Four examples of Fuzhou-developed nasopharyngeal carcinoma applicators. The microSelectron-HDR (Nucletron B. V., Veenendaal, The Netherlands) catheters are inserted into the rubber tubes shown, which have an outer diameter of 5 mm and an internal diameter of 2.5 mm. The rubber-type material spacer between the tubes ensures that the catheters are kept at 10–15 mm distance from the soft palate. Only topical anaesthesia is required and the applicators are cheap and easy to construct, as with the designs of the 1920s, and therefore reliance does not have to be placed on expensive, commercially available applicators [31].

View larger version (52K): [in a new window]   Figure 3. Typical arrangement of four treatment fields for nasopharyngeal carcinoma in the 1940s together with isodose distributions. The isodose curves numbered 4, 8, 12, 16 and 20 are in units of roentgen min-1. Displaying the dose distributions in sagittal and coronal planes is an early attempt at trying to produce a three-dimensional (3D) view [35]. Even in the late 1960s manual calculation (maybe using an analogue computing device as distinct from a digital computer) in two or three orthogonal planes was the only way of showing a 3D distribution.

View larger version (64K): [in a new window]   Figure 4. Nasopharyngeal carcinoma patient with radium fields (left) and X-ray fields (right) 2 days after treatment (top), on the 34th day of treatment (centre) with three fields clearly marked on the patient's skin on both sides of the face, and 10 days after the end of treatment (bottom). The study involved one side of the face being treated using teleradium and the other side of the face being treated using X-rays [35].

View larger version (37K): [in a new window]   Figure 5. Skin reaction graph for the nasopharyngeal carcinoma (NPC) patient in Figure 4, for bothradium and X-ray fields for the skin of the temple. Treatment was described as follows. "A 5 cm field was placed in each preauricular region, a 5 cm field in each superior labial region, and an 8 cm field in each superior cervical region" [35]. The total dose received by the skin of the neck in 40 days was 7400 roentgen (r) from the radium beam and 5500 r from the X-ray beam. The total dose received on the skin of the temple in 46 days from the radium beam was 8700 r and from the X-ray beam 6500 r. Of the 20 cases of NPC treated, the "percentage cured" was estimated to be 25% with a 95% confidence interval of 9–51%. This, as expected from the small number of cases, is very wide [35].

View larger version (50K): [in a new window]   Figure 6. Schematic diagram of seven telecobalt treatment fieldpositions and shapes, including shielding blocks, for a typical 1960s two-phase treatment [5].

View larger version (32K): [in a new window]   Figure 7. Overall 5-year survival rates for nasopharyngeal carcinoma cases treated at the Cancer Hospital of the Medical University of Shanghai, to show improvement of treatment results with differenttreatment periods. (Courtesy of Professor Liu Taifu, Cancer Hospital of the Medical University of Shanghai.)

View larger version (81K): [in a new window]   Figure 8. A set of normal classical Ho's nasopharyngeal carcinoma views for (a) lateral, (b) submento-vertical, (c) occipito-submental, (d) 25° occipital-mental and (e) occipito-maxillary views.

View larger version (56K): [in a new window]   Figure 9. A set of abnormal classical Ho's nasopharyngeal carcinoma views showing (a) lateral, (b) submento-vertical, (c) Towne's (30° fronto-occipital), (d) 25° occipital-mental and (e) occipito-maxillary views.

View larger version (124K): [in a new window]   Figure 10. CT scan of a patient who presented with right-sided ptosis.

View larger version (116K): [in a new window]   Figure 11. MR scans of the same patient as Figure 10, to show the corresponding axial scan as Figure 10. Sagittal scans are a useful adjunct for tumour localization.

View larger version (177K): [in a new window]   Figure 12. Three-dimensional representation of patient contour, with critical structures outlined: spinal cord and eyes.

View larger version (53K): [in a new window]   Figure 13. Three-dimensional radiotherapy planning for a tumour that extends from the nasopharynx to the nasal fossa.

View larger version (104K): [in a new window]   Figure 14. The Hong Kong technique to boost parapharyngeal space. The patient's neck is turned to one side, slightly extended, and skin marks are made to delineate the field.

View larger version (122K): [in a new window]   Figure 15. Follow-up CT scan may show asymmetry of the nasopharynx. This has to be correlated with other clinical findings and direct/indirect nasopharyngoscopy.