| Part I:Long-term treatment outcomes and prognosis of mucosal melanoma of the head and neck:194 cases from a single institutionObjective:This study aimed to evaluate the clinical features,treatment outcomes,failure patterns and prognostic factors of mucosal melanoma of the head and neck(MMHN)in patients who were treated at our institutionMaterials and Methods:Between 1982 and 2017,194 patients with non-metastatic MMHN were treated at our institution.Of the patients,114 were male and 80 were female,with a median age of 54 years.The primary sites of the tumour included the nasal cavity(53.1%),the oral cavity(31.4),and the paranasal sinus cavity(6.7%).Other sites of the tumour included the palpebralconjunctiva,nasopharynx,pharynx,and larynx.182 patients were staged according to the AJCC staging system of MMHN,71(39%)patients were of stage ?,99(54%)patients were of stage IVA,and 12(7%)patients were of stage IVB Patients with oral mucosal melanoma had a higher incidence of nodal metastases at diagnosis compared with those with sinonasal melanoma(57.6%vs.4.3%,p<0.001).The treatment modalities mainly included surgery alone,which was performed in 83 patients,surgery combined with radiotherapy,which was performed in 96 patients(preoperative RT or postoperative RT),and radiotherapy alone,which was performed in 15 patients.87 patients received chemotherapy and 55 patients received biotherapy.Results:With a median follow-up time of 77 months(5-272 months),the 5-year overall survival rate(OS),local recurrence-free survival rate(LRFS),regional recurrence-free survival rate(RRFS)and distant metastasis-free survival(DMFS)were 41.4%,57.8%,76.5%and 46.5%,respectively.Regarding the different treatment modalities,the 5-year OS was 42.3%in the surgery group and 42.5%in the surgery combined with radiotherapy group(p=0.601),while,the 5-year LRFS rate was 39.3%in the surgery group and 75.6%in the surgery combined with radiotherapy(p<0.001).According to the AJCC 7th edition staging system for MMHN,the 5-year OS for patients with stage ?,stage IVA,and stage IVB MMHN were 62.2%,32.7%and 16.7%,respectively(p<0.001).In total,141 patients had developed treatment failure.Distant failure was the major failure pattern(64.5%),followed by local failure(48.9%)and regional faiure(24.1%).Primary site,T stage,N stage,TNM stage,surgical margins and biotherapy were predictors for the 5-year OS rate.Primary site,surgical margins and ajuvant radiotherapy were predictors for the 5-year LRFS rate.Ajuvant radiotherapy was predictor for the 5-year RRFS rate.Primary site,T stage,N stage,TNM stage,surgical margins and chemotherapy were predictors for the 5-year DMFS rate.In the multivariate analysis,the tumour located in the paranasal cavity,stage ? and positive surgical margins were independent negative prognostic factors for OS;the tumour located in the paranasal cavity,positive surgical margins and surgery alone without adjuvant radiotherapy were independent negative prognostic factors for LRFS;stage ? was independent negative prognostic factors for DMFS.Conclusions:The addition of radiotherapy improves the local control rate of MMHN.The tumour located in the paranasal cavity,stage ? and positive surgical margins were independent negative prognostic factors for the OS in patients with MMHN.The AJCC 7th edition staging system for MMHN appears to effectively stage this disease.Distant metastasis was the major failure pattern.Part II:Patterns of regional spread and the value of prophylactic neck treatment for oral mucosal melanomaObjective:To investigate the patterns of regional lymphatic spreading,the value of prophylactic neck treatment(PNT),the failure patterns and prognostic factors in oral mucosal melanoma(OMM).Materials and Methods:This is a retrospective analysis of 61 OMM patients with non-metastatic treated in our institution between Jun.1984 and Oct.2016.The median age was 48 years(19-74 years),with a male-to-female ratio of 1.6:1.The primary sites were as follow:gingiva(37 cases,60.7%),hard palate(19 cases,31.1%),lip(3 cases,4.9%)and tongue(2 cases,3.3%).According to the AJCC staging system of mucosal melanoma of the head and neck,17(28.8%)patients were of stage ?,41(69.5%)patients were of stage IVA,and 7(1.7%)patients were of stage IVB.For 31 clinical NO patients,prophylactic neck dissection was performed in 18 patients while prophylactic neck radiation was performed in 2 patients.The prophylactic neck treatment was defined as at least ipsilateral neck dissection/radiation.A total 16 patients have received PNT.Results:Overall,55.7%(34/61)of the patients were clinical/pathological N+.The most frequently involved locations were the level Ib(76%),followed by level ?(35%)and level?(26%).The pathway of regional LN spread followed a regular pattern,skip metastasis was only observed in 3 patients.For cN0 patients,the 5-year regional failure-free survival rate was 91.7%in patients who have received PNT and 52.4%in patients who have not received PNT(P=0.036).The regional failure rate was 6%for patients underwent PNT,while 46%in patients who have not underwent PNT(P=0.035).As to the regional failure pattern,the most frequently failure sites were level Ib(93%),level ?(50%)and level ?(36%).According to the multivariate analysis,the tumour with ulcer was the independent negative prognostic factor for OS.Conclusions:OMM has a high rate of cervical lymph node metastases.The pathway of regional LN spread followed a regular pattern.The most frequently involved regions for clinical/pathological N+ and regional failure were both level Ib-?.At least ipsilateral level Ib-? prophylactic neck treatment reduced the regional failure significantly,it should be recommended for OMM patients with cN0.Part ?:Treatment outcomes and prognostic factors for patients with nasopharyngeal carcinoma treated with intensity-modulated radiotherapyObjective:To retrospectively analyze the treatment outcomes,failure pattern,acute toxicities and prognostic factors for nasopharyngeal carcinoma(NPC)patients treated with intensity-modulated radiotherapy(IMRT).Materials and Methods:2025 newly diagnosed non-metastatic NPC patients who were treated with definitive IMRT in our institution between 2003 and 2017 were identified for analysis.After restaged according to the AJCC 8th edition of TNM stage classification,there were 2.1%,12.8%,43.0%and 42.1%in stage ?,?,? and IVA,respectievly.The median radiation dose to gross tumor volume(GTV)was 73.92Gy.The majority of patients with stage ? and stage ? received radiotherapy(RT)alone or concurrent chemoradiotherapy(CCRT).Induction chemotherapy followed RT or CCRT(IC+RT/CCRT)and CCRT are the main treatment modalities for patients of stage IVA.A 1:1 matched study created by using propensity score matching(PSM)method was conducted to confirm the role of different treatment modalities in patients of different stages.Results:With a median follow-up time of 73 months,the 5-year overall survival rate(OS),disease-specific survival rate(DSS),disease-free survival rate(DFS),local recurrence-free survival rate(LRPS),regional recurrence-free survival rate(RRFS)and distant metastasis-free survival rate(DMFS)were 78.6%,80.2%,71.5%,92.6%,95.2%and 81.8%,respectively.In total,519 patients had developed treatment failure.Distant failure was the major failure pattern(69.2%),followed by local failure(29.8%)and regional failure(17.7%).According to the multivariate analysis,age>47,smoking,LDH>250 IU/L and stage IVA were independent negative prognostic factors for both OS and DFS,age>47,smoking,T4 were independent negative prognostic factors for LRFS,smoking and N3 were independent negative prognostic factors for RRFS,smoking,LDH>250 IU/L and N3 were independent negative prognostic factors for DMFS.After PSM analysis,CCRT group yielded better LRFS than RT alone in patients with stage II but not regarding to OS,DSS,DFS,RRFS and DMFS.For stage ? patients,there is no survival difference between CCRT group and RT alone group.For stage IVA patients,there were no survival differences between IC+CCRT/RT group and CCRT group.Conclusions:IMRT improves the treatment outcomes for patients with NPC.especially regarding to local control.Distant metastasis has become the major reason for failure.Adding concurrent chemotherapy did not improve survival in patients of stage ? and stage ? except improved local control in patients of stage ?.The treatment outcome of stage IVA was relatively poor and induction chemotherapy did not improve survival when compared with CCRT. |
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