This article appears in the following Annals of Oncology issue: ESMO Clinical Recommendations [View the issue table of contents]
ESMO clinical recommendations |
Nasopharyngeal cancer: ESMO Clinical Recommendations for diagnosis, treatment and follow-up
1 Department of Clinical Oncology, Prince of Wales Hospital, Chinese University, Hong Kong
2 Medical Oncology Service, Vall d'Hebron University Hospital, Barcelona, Spain
* Correspondence to: ESMO Guidelines Working Group, ESMO Head Office, Via L. Taddei 4, CH-6962 Viganello-Lugano, Switzerland; E-mail: clinicalrecommendations{at}esmo.org
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incidence |
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 Top incidence diagnosisstaging and risk assessmenttreatmentfollow-uptreatment of recurrent or...notesreferences |
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The age-standardized incidence (per 100 000) of nasopharyngeal cancer (NPC) in Europe is between 0.1 and 2.2. In endemic areas, such as Southern China, the incidence is much higher at 26.9. There is an intermediate incidence in populations in the Mediterranean basin.
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diagnosis |
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Topincidencediagnosisstaging and risk assessmenttreatmentfollow-uptreatment of recurrent or...notesreferences |
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Definitive diagnosis is made by endoscopic guided biopsy of the primary nasopharyngeal tumor. The histologic type should be classified according to World Health Organization classification.
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staging and risk assessment |
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Topincidencediagnosisstaging and risk assessmenttreatmentfollow-uptreatment of recurrent or...notesreferences |
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NPC is clinically staged according to the International Union Against Cancer (UICC) and American Joint Committee on Cancer (AJCC) staging system (Table 1).
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Routine staging procedures include history, physical examination including cranial nerve examination, complete blood cell count, serum biochemistry (including liver function test), chest X-ray, nasopharyngoscopy, computed tomography (CT) scan or magnetic resonance imaging (MRI) of nasopharynx and base of skull and neck. MRI is preferred if available [III, B].
Imaging for distant metastases including isotope bone scan and CT scan of chest and upper abdomen could be considered for at-risk subsets (node positive, especially N3 stage) and for those patients with clinical or biochemical abnormalities detected [III, B]. The use of positron emission tomography is under investigation and findings seem promising.
Both the pre-treatment and post-treatment plasma/serum load of Epstein–Barr viral DNA has been shown to be of prognostic value [III, B].
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treatment |
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Topincidencediagnosisstaging and risk assessmenttreatmentfollow-uptreatment of recurrent or...notesreferences |
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Radiation therapy (RT) is the mainstay of treatment and is an essential component of curative-intent treatment of nondisseminated NPC. Stages I and IIA disease are treated by RT alone, while stage III and IVA, B disease are treated by RT with concurrent chemotherapy [I, A]. Concurrent chemotherapy could also be considered for stage IIB disease [III, B].
Radiation therapy is targeted to the primary tumor and adjacent regions considered at risk of microscopic spread from the tumor and to both sides of the neck. Elective nodal irradiation is recommended for N0 stage disease. The consensus is that a total dose of 70 Gy is needed for eradication of gross tumor and 50 Gy for elective treatment of potential risk sites. To minimize the risk of late toxicity (particularly to adjacent neurological structures), fractional dose >2 Gy per daily fraction and excessive acceleration with multiple fractions >1.9 Gy/fraction should be avoided [III, A]. Intensity-modulated RT may offer improvement in local tumor control [III, B], and reduction in radiation xerostomia in early-stage disease [II, B].
The standard agent used in concurrent chemotherapy-RT is cisplatin [I, A].
Even though adjuvant chemotherapy on its own has not been documented to confer survival advantage, adjuvant cisplatin and fluorouracil combined with concurrent cisplatin-RT may be beneficial.
Induction chemotherapy has been shown to improve disease-free survival and may be considered in locally advanced disease although it is not seen as standard treatment [II, B].
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follow-up |
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Topincidencediagnosisstaging and risk assessmenttreatmentfollow-uptreatment of recurrent or...notesreferences |
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Follow-up for patients includes periodic examination of the nasopharynx and neck, cranial nerve function and evaluation of systemic complaints to identify distant metastasis. Evaluation of thyroid function in patients with irradiation to the neck is recommended.
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treatment of recurrent or metastatic disease |
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Topincidencediagnosisstaging and risk assessmenttreatmentfollow-uptreatment of recurrent or...notesreferences |
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Small local recurrences are potentially curable and the main issue is choice of the most appropriate therapeutic options, which include nasopharyngectomy, brachytherapy, radiosurgery, stereotactic RT, intensity-modulated RT, or a combination of surgery and RT, with or without concurrent chemotherapy. Treatment decisions are tailored to the specific situation of individual cases, taking into consideration the volume, location and extent of the recurrent tumor [III, B].
Regional recurrence is managed by radical neck dissection if resectable [III, B].
In metastatic NPC, palliative chemotherapy should be considered for patients with adequate performance status. Platinum-5 flurouracil combination regimens are commonly used as first line therapy. Other active agents include paclitaxel, docetaxel, gemcitabine, capecitabine, irinotecan, vinorelbine, ifosfamide, doxorubicin and oxaliplatin, which can be used as single agents or in combination [III, C].
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notes |
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Topincidencediagnosisstaging and risk assessmenttreatmentfollow-uptreatment of recurrent or...notesreferences |
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Levels of Evidence [I–V] and Grades of Recommendation [A–D] as used by the American Society of Clinical Oncology are given in square brackets. Statements without grading were considered justified standard clinical practice by the experts and the ESMO faculty.
Coordinating authors for the ESMO Guidelines Working Group: A. T. C. Chan, E. P. Hui, S. F. Leung, Department of Clinical Oncology, State Key Laboratory in Oncology in South China, Sir YK Pao Centre for Cancer, Hong Kong Cancer Institute, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, People's Republic of China.
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footnotes |
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Approved by the ESMO Guidelines Working Group: December 2006, last update September 2008. This publication supercedes the previously published version—Ann Oncol 2008; 19 (Suppl 2): ii81–ii82.
Conflict of interest: the authors have reported no conflicts of interest.
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references |
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1. Curado MP, Edwards B, Shin HR, et al. Cancer Incidence in Five Continents, Vol. IX. IARC Scientific Publications No. 160 (2007) Lyon: IARC.
2. Shanmugaratnam K, Sobin LH. The World Health Organization histological classification of tumours of the upper respiratory tract and ear. A commentary on the second edition. Cancer (1993) 71:2689–2697.[CrossRef][Web of Science][Medline]
3. Lo YM, Chan LY, Lo KW, et al. Quantitative analysis of cell-free Epstein–Barr virus DNA in plasma of patients with nasopharyngeal carcinoma. Cancer Res (1999) 59:1188–1191.
4. Chan AT, Lo YM, Zee B, et al. Plasma Epstein–Barr virus DNA and residual disease after radiotherapy for undifferentiated nasopharyngeal carcinoma. J Natl Cancer Inst (2002) 94:1614–1619.
5. Leung SF, Zee B, Ma BB, et al. Plasma Epstein–Barr viral deoxyribonucleic acid quantitation complements TNM staging in nasopharyngeal carcinoma prognostication. J Clin Oncol (2006) 34:5414–5418.
6. Al-Sarraf M, LeBlanc M, Giri PG, et al. Chemoradiotherapy versus radiotherapy in patients with advanced nasopharyngeal cancer: phase III randomized Intergroup study 0099. J Clin Oncol (1998) 16:1310–1317.
7. Chan AT, Leung SF, Ngan RK, et al. Overall survival after concurrent cisplatin-radiotherapy compared with radiotherapy alone in locoregionally advanced nasopharyngeal carcinoma. J Natl Cancer Inst (2005) 97:536–539.
8. Lin JC, Jan JS, Hsu CY, et al. Phase III study of concurrent chemoradiotherapy versus radiotherapy alone for advanced nasopharyngeal carcinoma: positive effect on overall and progression-free survival. J Clin Oncol (2003) 21:631–637.
9. Kwong DL, Sham JS, Au GK, et al. Concurrent and adjuvant chemotherapy for nasopharyngeal carcinoma: a factorial study. J Clin Oncol (2004) 22:2643–2653.
10. Wee J, Tan EH, Tai BC, et al. Randomized trial of radiotherapy versus concurrent chemoradiotherapy followed by adjuvant chemotherapy in patients with American Joint Committee on Cancer/International Union against cancer stage III and IV nasopharyngeal cancer of the endemic variety. J Clin Oncol (2005) 23:6730–6738.
11. Lee AWM, Lau WH, Tung SY, et al. Preliminary results of a randomized study on therapeutic gain by concurrent chemotherapy for regionally-advanced nasopharyngeal carcinoma: NPC-9901 Trial by the Hong Kong Nasopharyngeal Cancer Study Group. J Clin Oncol (2005) 23:6966–6975.
12. Baujat B, Audry H, Bourhis J, et al. Chemotherapy in locally advanced nasopharyngeal carcinoma: an individual patient data meta-analysis of eight randomized trials and 1753 patients. Int J Radiat Oncol Biol Phys (2006) 64:47–56.[CrossRef][Web of Science][Medline]
13. Chua DT, Ma J, Sham JS, et al. Long-term survival after cisplatin-based induction chemotherapy and radiotherapy for nasopharyngeal carcinoma: a pooled data analysis of two phase III trials. J Clin Oncol (2005) 23:1118–1124.
14. Kam MK, Leung SF, Zee B, et al. Prospective randomized study of intensity-modulated radiotherapy on salivary gland function in early-stage nasopharyngeal carcinoma patients. J Clin Oncol (2007) 25:4873–4879.
15. Ma BB, Chan AT. Recent perspectives in the role of chemotherapy in the management of advanced nasopharyngeal carcinoma. Cancer (2005) 103:22–31.[CrossRef][Web of Science][Medline]
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