Cancer Treatment: Nasopharyngeal Carcinoma Overview
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Questions and Answers

The primary treatment for locoregionally confined nasopharyngeal carcinoma is chemotherapy.

False

Bilateral neck radiation is necessary due to the common occurrence of metastasis in contralateral nodes.

True

Audiological investigations are not part of the pre-treatment planning for nasopharyngeal carcinoma.

False

Radical radiation therapy doses for nasopharyngeal carcinoma typically range from 60 to 75Gy.

<p>False</p> Signup and view all the answers

Prophylactic nodal treatment is optional in the management of nasopharyngeal carcinoma due to the low incidence of neck relapse.

<p>False</p> Signup and view all the answers

IMRT can only deliver uniform radiation doses to all organs without any modulation.

<p>False</p> Signup and view all the answers

Concurrent chemotherapy and radiation are exclusively recommended for patients with Stage I nasopharyngeal carcinoma (NPC).

<p>False</p> Signup and view all the answers

One of the advantages of IMRT is the preservation of salivary function by sparing the parotid glands from high doses of radiation.

<p>True</p> Signup and view all the answers

IMRT is less effective than traditional 3D conformal radiotherapy in achieving a good dose differential between tumors and surrounding normal organs.

<p>False</p> Signup and view all the answers

Chemotherapy can only be administered in a single approach for the management of nasopharyngeal carcinoma.

<p>False</p> Signup and view all the answers

The combination of induction chemotherapy and concurrent chemotherapy can lead to rapid tumour growth prior to radiotherapy.

<p>False</p> Signup and view all the answers

Induction chemotherapy followed by concurrent systemic therapy is not supported for treatment of locoregionally advanced nasopharyngeal cancer.

<p>False</p> Signup and view all the answers

Less than 5% of patients experience isolated failure in the neck lymph nodes after chemoradiation for NPC.

<p>True</p> Signup and view all the answers

Lymph nodes responding to initial treatment may take around six months to become clinically negative.

<p>False</p> Signup and view all the answers

Xerostomia is a complication of radiotherapy characterized by increased saliva production.

<p>False</p> Signup and view all the answers

Hearing impairment after radiotherapy is commonly associated with disturbances of the Eustachian tube function.

<p>True</p> Signup and view all the answers

Cranial nerve palsies can occur due to both incomplete healing from tumors and radiation damage.

<p>True</p> Signup and view all the answers

Soft tissue fibrosis resulting from radiotherapy can improve neck movement.

<p>False</p> Signup and view all the answers

The treatment of head and neck cancers has no association with endocrine disorders.

<p>False</p> Signup and view all the answers

Complete resolution of metastatic cervical lymph nodes signals a lower chance of recurrence after treatment.

<p>False</p> Signup and view all the answers

Radical radiation therapy doses for nasopharyngeal carcinoma typically consist of 66 to 70Gy in 33-35 fractions.

<p>True</p> Signup and view all the answers

Pre-treatment planning for nasopharyngeal carcinoma does not include dental clearance.

<p>False</p> Signup and view all the answers

The nasopharyngeal carcinoma tumor is not radiosensitive, requiring chemotherapy as the primary treatment.

<p>False</p> Signup and view all the answers

Bilateral neck radiation is recommended for nasopharyngeal carcinoma due to the small size of the nasopharynx and potential for cross midline spread.

<p>True</p> Signup and view all the answers

Cervical nodal irradiation is optional in the management of nasopharyngeal carcinoma because neck relapse is not common.

<p>False</p> Signup and view all the answers

IMRT allows for the simultaneous treatment of different targets/organs at the same fractional dose of treatment.

<p>False</p> Signup and view all the answers

Concurrent system therapy is recommended for patients diagnosed with Stage II-IVB nasopharyngeal carcinoma.

<p>True</p> Signup and view all the answers

IMRT employs a uniform delivery of high doses to the tumor while providing varying doses to surrounding tissues.

<p>True</p> Signup and view all the answers

Radiation does not have a significant impact on preserving the salivary function in patients receiving treatment for nasopharyngeal carcinoma.

<p>False</p> Signup and view all the answers

Chemotherapy in the management of nasopharyngeal carcinoma can only be administered concurrently or adjuvantly.

<p>False</p> Signup and view all the answers

Induction chemotherapy followed by concurrent systemic therapy/RT is potentially ineffective for locoregionally advanced nasopharyngeal cancer.

<p>False</p> Signup and view all the answers

The approximate incidence of isolated failure in cervical lymph nodes following chemoradiation for nasopharyngeal carcinoma exceeds 10%.

<p>False</p> Signup and view all the answers

Persistent disturbance of Eustachian tube function is a common issue following hearing impairment post-radiotherapy.

<p>True</p> Signup and view all the answers

Xerostomia may result from chemotherapy, but not radiotherapy.

<p>False</p> Signup and view all the answers

Soft tissue fibrosis after radiotherapy can restrict mouth opening and neck movement.

<p>True</p> Signup and view all the answers

Hypopituitarism is identified as an endocrine disorder that may arise following treatment for nasopharyngeal carcinoma.

<p>True</p> Signup and view all the answers

Cranial nerve damage is solely a result of tumor growth and not related to radiation damage.

<p>False</p> Signup and view all the answers

Metastatic cervical lymph nodes may reappear even after complete resolution post-chemoradiation.

<p>True</p> Signup and view all the answers

Induction chemotherapy is associated with worse distant control compared to adjuvant chemotherapy in advanced nasopharyngeal cancer.

<p>False</p> Signup and view all the answers

It takes around four months for lymph nodes to become negative clinically following initial treatments like radiotherapy.

<p>False</p> Signup and view all the answers

Study Notes

Introduction

  • Multidisciplinary team approach is vital for optimum treatment planning.
  • Main treatment is radiation therapy, with or without chemotherapy.
  • Treatment can be for Primary Cancer (Newly Diagnosed NPC), Recurrent Cancer, or Advanced Disease.

TNM AJCC

  • This is a cancer staging system that indicates the extent of the cancer based on tumor (T), node (N), and metastases (M).

Pre-treatment planning

  • Audiological investigations are done before treatment.
  • Dental clearance is crucial to ensure oral hygiene.
  • Hematological and biochemical investigations include FBC, renal profile, liver function, and random blood sugar.

Treatment

  • Radiotherapy is the primary treatment for localized nasopharyngeal carcinoma.
  • Prophylactic nodal treatment is needed due to the frequent spread to paranasopharyngeal and cervical lymphatics.
  • Treatment targets include the nasopharynx, paranasopharyngeal space, oropharynx, base of skull, specific sinuses, and the posterior half of the maxillary antrum.
  • Bilateral neck radiation is needed due to the small size of the nasopharynx, its frequent midline crossing, and common contralateral node metastasis.
  • Stages I: Radiation therapy is the main treatment.
  • Stages II-IVA: Concurrent chemotherapy and radiation therapy are recommended.

Intensity Modulated Radiotherapy (IMRT)

  • IMRT is an advanced form of 3D conformal radiotherapy that conforms high doses to the tumor while sparing normal tissues.
  • It can achieve a good dose differential between the tumor and surrounding organs, allowing for dose escalation in the tumor without overdosing normal organs.
  • It allows for different doses to different targets/organs simultaneously, thus permitting different fractional doses at the same treatment fraction.
  • It enables the primary tumor and the upper neck nodes to be treated in one volume throughout.
  • Chemotherapy given neoadjuvantly, concurrently, adjuvantly, or in combination can improve local control and address distant metastases.

Locoregional advanced disease

  • Induction chemotherapy followed by concurrent systemic therapy/RT is recommended for locoregionally advanced NPC.
  • Induction chemotherapy before therapy/RT for locally advanced NPC might impact tumor control compared to systemic therapy/RT without additional chemotherapy.
  • This approach also shows better distant control than adjuvant chemotherapy alone.

Metastatic cervical lymph nodes

  • The presence of metastatic cancer in the cervical lymph nodes, or imaging features of disease or clinical progression, requires salvage therapy.
  • Persistent or recurrent nodal disease treated with further external radiation has a five-year overall survival rate of approximately 19.7%.

Complications Of Radiotherapy

  • Potential complications include xerostomia (dry mouth), hearing impairment, soft tissue fibrosis restricting movement or mouth opening, cranial nerve palsies, skull base osteomyelitis/ necrosis, and endocrine disorders.

Surgical treatment for recurrent disease

  • Traditional open surgical approaches have high morbidity associated with them.
  • Endoscopic endonasal nasopharyngectomy is a minimally invasive approach that offers improved survival with less morbidity.
  • Five-year overall survival rates after nasopharyngectomy range from 42.1% to 52%.
  • Salvage endoscopic nasopharyngectomy has shown higher 3-year OS rates than re-irradiation for rT3 and rT4 tumors.

Prognostic factors

  • Poor prognostic factors for survival after nasopharyngectomy include advanced T stage, lymph node metastasis, invasion of skull base, invasion of parapharyngeal space, and positive surgical margin.

Persistent or recurrent neck disease

  • Salvage surgery (radical neck dissection) has a five-year tumor control rate of 66% in the neck.
  • The rationale for radical neck dissection for persistent or recurrent neck disease, even in single lymph nodes, is based on the finding that:
    • Serial whole specimen section studies of curative radical neck dissections revealed a higher number of positive nodes than clinically evident.
    • Over 70% of the nodes exhibited extracapsular spread.
    • 30% of positive nodes were located close to the spinal accessory nerve.

Introduction

  • Nasopharyngeal carcinoma (NPC) management involves a multidisciplinary team approach.
  • The primary treatment is radiation therapy, which may be combined with chemotherapy.
  • Treatment strategies are tailored for different stages and types of NPC:
    • Primary Cancer (Newly Diagnosed NPC)
    • Recurrent Cancer
    • Advanced Disease

TNM Staging

  • The TNM staging system (American Joint Commision on Cancer - AJCC) is used to assess the extent of cancer.

Pre-Treatment Planning

  • Audiological investigations are conducted to evaluate hearing function.
  • Dental clearance ensures oral hygiene is maintained as the radiation field affects the oral cavity. Poor oral hygiene can lead to dental complications, so extraction of unhealthy teeth is done.
  • Hematological and biochemical investigations are performed before treatment:
    • FBC (Full Blood Count)
    • Renal profile
    • Liver function
    • Random blood sugar

Treatment

  • Radiotherapy is the mainstay of treatment for locoregionally confined NPC due to its radiosensitivity.
  • Prophylactic nodal treatment is mandatory as NPC often spreads to paranasopharyngeal and cervical lymphatics.
  • Radiation therapy can adequately cover these areas.

Stage I NPC Treatment

  • Radiation therapy is the primary treatment modality.
  • Radical radiation therapy involves doses of 66 to 70Gy in 33-35 fractions over 6-7 weeks.
  • The radiation target volume includes the nasopharynx, paranasopharyngeal space, oropharynx, base of skull, sphenoid sinus, posterior ethmoid sinus, and posterior half of maxillary antrum.
  • Cervical nodal irradiation is mandatory to prevent neck relapse.
  • Bilateral neck radiation is often necessary due to the size and location of the nasopharynx.

Stages II-IVA NPC Treatment

  • Concurrent chemotherapy and radiation therapy are recommended.
  • Systemic therapy (chemotherapy) may be given before (induction), during (concurrent), or after (adjuvant) radiotherapy.

Intensity Modulated Radiotherapy (IMRT)

  • IMRT is an advanced form of 3D conformal radiotherapy.
  • IMRT conforms high doses to the tumor while delivering low doses to normal tissues.
  • IMRT allows fine modulation of radiation intensity within each beam.
  • IMRT plan for head-neck cancer demonstrates high-dose conformation to the target volume while sparing surrounding normal structures.

IMRT Advantages

  • Organ preservation: IMRT helps preserve salivary function by sparing the parotid glands from high doses of radiation.
  • Good dose differential: IMRT achieves high doses in the tumor without overdosing normal organs, improving local control and minimizing side effects.
  • Simultaneous treatment: IMRT enables different targets to receive different fractional doses at the same treatment fraction.
  • Comprehensive targeting: IMRT allows treatment of the primary tumor and upper neck nodes in one volume.

Chemotherapy for NPC

  • Chemotherapy is considered for management of distant metastases and local failure.
  • Chemotherapy regimens may be neoadjuvant, concurrent, adjuvant, or a combination.
  • Combined induction and concurrent chemotherapy can lead to rapid tumor shrinkage before radiotherapy and better disease control in advanced T-stage NPC.

Locoregionally Advanced Disease

  • Induction chemotherapy followed by concurrent systemic therapy/radiotherapy is recommended for locoregionally advanced NPC.
  • Induction chemotherapy before systemic therapy/radiotherapy may improve tumor control in locally advanced NPC.
  • Induction chemotherapy is associated with better distant control compared to adjuvant chemotherapy.

Metastatic Cervical Lymph Nodes

  • Following chemoradiation, the incidence of isolated failure in neck lymph nodes is less than 5%.
  • Metastatic cervical lymph nodes may persist or reappear after initial treatment.
  • Lymph nodes that respond to initial treatment typically take about three months to become clinically negative.

Complications of Radiotherapy

  • Xerostomia: dry mouth, poor oral hygiene, dental caries
  • Hearing impairment: persistent Eustachian tube dysfunction and chemotherapy-induced ototoxicity
  • Soft tissue fibrosis: restriction of neck movement or mouth opening
  • Cranial nerve palsies: incomplete healing of tumor-related damage, especially affecting cranial nerves IX, X, XI, and XII
  • Skull base osteomyelitis/necrosis
  • Endocrine disorders: hypopituitarism, hypothyroidism, hypothalamic dysfunction

Follow Up

  • Regular follow-up is crucial to monitor for recurrence.

Recurrent NPC

  • NPC can recur locally, locoregionally, or at distant metastatic sites.
  • Recurrent nasopharyngeal carcinoma (rNPC) at the primary and/or regional site after definitive radiotherapy occurs in 8.4% to 10.9% of cases.
  • Most local recurrences happen within the first three years, with up to 80% within the first five years.

Treatment Options for Recurrent NPC

  • Primary site recurrence:
    • rT1 and rT2: Endoscopic nasopharyngectomy or brachytherapy
    • rT3, selected rT4, and nodal recurrence: Nasopharyngectomy, radical neck dissection, or re-irradiation
  • Salvage treatment: Surgery, re-irradiation, or chemotherapy are options for rNPC.
  • Nasopharyngectomy: Provides a higher 5-year survival rate (40-60%) compared to re-irradiation (8-36%).
  • Re-irradiation: Often associated with serious complications, including cranial nerve palsies and osteoradionecrosis, and may decrease quality of life.
  • Chemotherapy: Primarily used for palliative purposes in patients not suitable for surgery or re-irradiation.

Adverse Features Associated with Recurrent NPC

  • Extranodal extension
  • Positive margins
  • Close margins
  • pT3 or pT4 primary tumor
  • pN2 or pN3 nodal disease
  • Perineural invasion
  • Vascular invasion
  • Lymphatic invasion

Surgical Approach for Recurrent NPC

  • Surgical management of rNPC has become a preferred alternative to re-irradiation.
  • Traditional surgical approaches such as transpalatal, transinfratemporal fossa, transcervical, midface degloving, and maxillary swing have been associated with 5-year overall survival ranging from 30 to 62%.
  • However, these techniques are associated with high morbidity, including palatal defects, trismus, dysphagia, and nasal regurgitation.

Minimally Invasive Endoscopic Approach

  • The development of minimally invasive endoscopic endonasal nasopharyngectomy has addressed the limitations of open surgical approaches.
  • Endoscopic endoscopic nasopharyngectomy offers better neurological and masticatory function preservation.
  • Endoscopic surgery provides excellent visibility, less tissue trauma, and faster recovery with reduced complications.
  • Five-year overall survival rates following nasopharyngectomy range from 42.1% to 52%.
  • Survival rates are higher for rT1 and rT2 stages (49.1-73% and 24.7-40%) compared to higher T stages.

Endoscopic vs. Open Surgery in Recurrent NPC

  • Studies have shown improved survival in advanced-stage recurrent NPC when treated with endoscopic surgery.
  • Li et al. reported a 3-year OS rate of 59.5% for patients undergoing salvage endoscopic nasopharyngectomy, compared to a 3-year OS of 49.0% for those undergoing re-irradiation.

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This quiz focuses on the treatment planning for nasopharyngeal carcinoma using a multidisciplinary approach. It covers essential topics such as radiation therapy, TNM staging, pre-treatment investigations, and targeted treatment areas. Test your knowledge on the vital steps involved in managing this type of cancer effectively.

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