Judit Olajos

The aim of this study was to investigate the familial clustering of nasopharyngeal carcinoma (NPC) in a non-endemic geographical region on the basis of two case reports and a review of the literature. Following an upper respiratory infection, NPC (WHO type III) was detected in a 57-year-old female (Case 1) who presented with nasal symptoms and a year later in her 36-year-old son (Case 2) who presented with enlarged lymph nodes. After a full diagnostic work-up, cT2a cN0 cM0 (stage IIA; Case 1) and cT2a cN2 cM0 (stage III; Case 2) disease were identified, and telecobalt irradiation was administered to both patients. The mother achieved complete remission and has been disease-free during a 14-year follow-up period. After initial complete remission, the son experienced regional (cervical) and base of the skull relapses within 2 years, which were treated unsuccessfully by means of radical neck dissection, a second course of radiotherapy and chemotherapy. Epstein–Barr virus (EBV) was detected in pathology sections from both patients. The authors review 20 additional well-documented cases of familial clustering of NPC in non-endemic geographical regions from the English language literature. This clinical entity typically has WHO type III histology; it may occur following an upper respiratory tract infection, and EBV-related serological titers were elevated in all 20 investigated cases. No consequent promoting factors were identified. The present two cases and the review of the literature strongly suggest that familial clustering of NPC in non-endemic geographical areas may be related to EBV infections. The difference in outcome of our two cases may be explained by the fact that the disease in Case 2 was diagnosed 1 year later than that in Case 1 and hence at a more advanced stage.

SummaryBackgroundHungary suffers from one of the highest levels of cancer morbidity, with over 700 new cases per 100000 inhabitants per year. This situation necessitates, among others, investigation of the current state of radiotherapeutic care, and its infrastructural and staffing conditions.AimThe aim of this paper is to present the current state of Hungarian radiotherapy.ResultsAlthough the number of radiation treatments increased substantially between 1995 and 2003 (16544 vs. 26316), together with a considerable increase in the linear accelerator equivalent (LAE) value (15.9 vs 29.45), about one-third of the patients who would profit from radiotherapy do not receive this form of treatment. Radiotherapeutic care is provided at 13 centers in 7 geographical regions, with widely varying infrastructural and staffing conditions, characterized by a mean LAE value of 4.2 (range: 0–8.45), a 1 LAE value for a mean of 343500 inhabitants (range: 0–731500), and a mean annual workload of 353 patients per radiation oncologist (range: 255–424), 532 patients per physicist (range: 255–911) and 149 per radiation technologist (range: 71–300). These conditions result in a waiting list of between 0 and 42 days for non-emergency cases and a mean of 260 radiotherapy-treated patients per 100000 inhabitants (range: 111–434) in the different geographical regions, which is far below the expected Hungarian value of 403 radiotherapy-treated cases/year.ConclusionsAttainment of an adequate radiotherapeutic service with an acceptable waiting time throughout Hungary requires the creation of 2 additional centers and the reconstruction of 1 existing center, the provision of 9 new linacs, the replacement of 10 functioning telecobalt units with linacs, and increases of 54% in the number of radiation oncologists, 51% in the number of physicists and 65% in the number of radiation technologists

In the period between 1993 and 2000, 20 patients with nasopharyngael cancer were re-irradiated for locally recurrent carcinomas. The median duration between primary treatment and recurrence was 30 months. Brachytherapy was the method most frequently used in 10 cases alone, and in 8 cases in combination with external beam therapy. 2 patients underwent only external beam therapy. The external irradiation was performed with CT/MRI-based treatment planning. Brachytherapy involved a high dose rate afterloading method. The cumulative dose of re-irradiation was 20-60 Gy. After a median follow-up of 37 months the overall survival and the local control were 60% (12/20) and 58% (7/12), respectively. 7 of the 12 surviving patients are currently tumour-free. After primary irradiation xerostomy occurred in all patients as an unavoidable side-effect of the treatment. A severe (grade 3 or higher according to the Common Toxicity Criteria version 2.0) late-side effect has so far been observed in 2 cases (10%). Authors' results lie in the medial range of the data in the international literature, though the rate of radiogen side-effects in the patient group is low. Both results are assumed to be a consequence of the re-irradiation dose being lower than the value considered optimum in the recent literature. Re-irradiation of locally recurrent nasopharyngeal cancers is an efficient treatment modality, which should be used as a combination of external beam therapy and brachytherapy. The optimum cumulative dose is about 50-60 Gy. This dose results in a 5 years survival rate of about 40% with an acceptable (30%) risk. The results of re-irradiation may be improved, if PET is used to determine the extent of the surviving tumour tissue. This can help in the choice of the proper treatment modality.

Whole-body FDG PET examinations in 10 cases of epipharyngeal tumour (8 males, 2 females, mean age: 48 years) have been performed since January 1999. The PET examinations were aimed at the accurate staging, follow-up of the patients after the treatment, identification of recurrencies and localization of the unknown primary tumor. Functional imaging resulted in "upstaging" in 3 patients as compared to staging by the conventional diagnostic tools. Four additional patients with hyperplastic epipharyngeal tissue were investigated for occult primary cancer after negative results of multiple excisions, resulting in one case of primary epipharyngeal cancer. Correct staging, early detection of recurrencies, localization of occult primary tumor and the better post-therapeutic assessment of epipharyngeal masses all facilitate a more reasonable therapeutic approach, which may improve survival results.