Nasopharyngeal carcinoma (NPC) - UCL

Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme

Nasopharyngeal carcinoma (NPC)

NPC 1 Mar. 2006


Nasopharyngeal carcinoma (NPC) • Work-up procedure • TNM staging • Primary treatment • Follow-up • Treatment of recurrent and/or metastatic disease • References NPC 2 Mar. 2006

Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Standard clinical evaluation l l l l l

l l l

l

NPC 3 Mar. 2006

complete history of the disease weight and weight loss fiberoptic examination of H&N mucosa neck examination evaluation of cranial nerves (I, II, III, IV, V, VI, VIII, IX, XII)including audiometry drawing of any lesions biopsy under local anesthesia endoscopy under general anesthesia with biopsies if risk factors (tobacco and/or alcohol) and/or no visualization of primary tumor FNA of neck lymphnodes if primary not accessible for biopsy

Evidence Option Type C Type C Type C Type C Type C

Std. Std. Std. Std. Std.

Type C Type C Type C

Std. Std. Std.

Type C

Std.


Advanced clinical evaluation l l l l

NPC 4 Mar. 2006

ophtalmologic examination dental examination by oral surgeon nutritional assessment others (if required)

Evidence Option Type C Type C Type C Type C

Std. Std. Std. Indiv.


Laboratory tests l

l l

NPC 5 Mar. 2006

Evidence Option

hemogram, coagulation tests, liver enzymes, Type C kidney function (including a creatinine clearance) serology: anti-VCA IgA Type C pituitary function: cortisol, TSH, free T4, LH, Type C FSH, GH, free testosterone and testosterone (male only), progesterone and oestradiol (female only), prolactine, IGF-1

Std.

Std. Std.


Imaging l l

l

l 1

NPC 6 Mar. 2006

local: MRI ± CT scan1 metastatic work-up: chest X-ray, thoracic and abdominal CT scan, bone scintigraphy additional examination depending on previous findings PET scan

See guidelines for loco-regional imaging

Evidence Option Type C Type C

Std. Std.

Type C

Std.

-

Invest.


Pathology l l

1

NPC 7 Mar. 2006

WHO classification1 Immunohistochemistry for EBV (LMP1)

See pathology guidelines


Std. Std.


Nasopharyngeal carcinoma (NPC) • Work-up procedure • TNM staging • Primary treatment • Follow-up • Treatment of recurrent and/or metastatic disease • References

NPC 8 Mar. 2006


Staging l l

NPC 9 Mar. 2006

TNM classification (5th ed., 1997) Who International Classification of Diseases for Oncology (ICD-O 9 or ICD-O 10)

Evidence

Option

Type C Type C

Std. Std.


TNM/AJCC 1997 Staging • Tis: Carcinoma in situ • T1: Tumor confined to the nasopharynx • T2: Tumor extends to soft tissues of oropharynx and/or nasal fossa T2a: without parapharyngeal extension T2b: with parapharyngeal extension • T3: Tumor invades bony structures and/or paranasal sinuses • T4: Tumor with intracranial extension and/or involvement of cranial nerves, infratemporal fossa, hypopharynx or orbit

NPC 10 Mar. 2006


TNM/AJCC 1997 Staging • • • • •

NPC 11 Mar. 2006

N0: no regional node metastasis Nx: regional nodes cannot be assessed N1: unilateral metastasis in node(s), ≤ 6 cm, above the supraclavicular fossa N2: bilateral metastasis in node(s), ≤ 6 cm, above the supraclavicular fossa N3: metastasis in node(s) N3a: > 6 cm N3b: extension to the supraclavicular fossa


TNM/AJCC 1997 Staging

• MX: Distant metastasis cannot be assessed • M0: No distant metastasis • M1: Distant metastasis

NPC 12 Mar. 2006


Nasopharyngeal carcinoma (NPC)

• Work-up procedure • TNM staging • Primary treatment • Follow-up • Treatment of recurrent and/or metastatic disease • References NPC 13 Mar. 2006

Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Primary treatment l

l

NPC 14 Mar. 2006

T1-N0-M0 / T2-N0-M0 Ext. RxTh Brachytherapy boost T1-T2, ≥ N1, M0 / T3-T4, any N, M0 Ext RxTh+concomitant CH+adjuvant CH Surgery (RMND, RND or ERND unilateral or bilateral) for persitent N disease at 3 months


Std. Indiv.

Type 2 Type R

Std Std.


Primary treatment: RxTh regimen l

l

l

l

NPC 15 Mar. 2006

Target volumes Bilateral levels II-V + RP nodes: prophylactic dose involved node(s) + NPharynx: curative dose Technique -conformal -IMRT radiotherapy Dose prophylactic dose: 50 Gy curative dose: T1, N1: 66 Gy ≥T2, ≥N2: 70 Gy 5% dose reduction for UCNT(WHO 2-3) Fractionation daily 2Gy/fraction

Evidence Option Type C

Std.

Type C

Std.

Type 3 Type 3

Std. Invest.

Type C Type C Type C Type R

Std. Std. Std. Std.

Type C

Std.


Target Volumes: nasopharynx Level of evidence : type 3 / option : standard Stage

Ipsilateral neck

Controlateral neck

N0-N2

II-III-IV-V + RP ± sus. clav.1

II-III-IV-V + RP ± sus. clav.1

N3

II-III-IV-V +RP ± adjacent structures according to clinical and radiological data1

II-III-IV-V +RP ± sus. clav.1

1Supra-clavicular

NPC 16 Mar. 2006

nodes when involvement of level IV and/or Vb


Primary treatment: CH regimen Intergroup study regimen 2 l Concomitant: cddp 100 mg/m J1, J22, J43 2 l Adjuvant: cddp 80 mg/m J71, J99, J127 5Fu 1 g/m2 J71-74, J99-102, J127-130

NPC 17 Mar. 2006

Evidence Option Type 2

Std.



NPC 18 Mar. 2006

Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme Follow-up l

l

l

l

NPC 19 Mar. 2006

Clinical examination -fiberoptic and neck palpation every 3 months (first 2 years), every 6 months (years 3-5), then every year (> 5 years) -dental examination every 6 months Imaging -all T: MRI ± CT 2-3 months after end of RxTh -≥ T2: MRI ± CT every 6 months for 2 years Laboratory tests -serology: anti-VCA IgA at each clinical examination (if elevated before treatment) -thyroid and pituitary function: according to clinical findings Evolution of late toxicity (EORTC/RTOG) scale

Evidence Option Type C

Std.

Type C

Std.

Type C

Std.

Type C

Std.

Type C

Std.

Type C

Std.

Type C

Std.



NPC 20 Mar. 2006


Salvage treatment for recurrent disease l

l

l

l

NPC 21 Mar. 2006

rT1-N0 / rT2-N0 RxTh Salvage surgery Chemotherapy T0-≥ rN1, M0 Neck dissection rT3 / rT4, any rN Chemotherapy Metastasis Chemotherapy + RxTh Best supportive care

Evidence Option Type 3 Type 3 Type 3

Indiv. Indiv. Std.

Type 3

Indiv.

Type 3

Std.

Type 3 Type 3

Std. Indiv.



NPC 22 Mar. 2006


References • Ahmad A, Stefani S. Distant metastases of nasopharyngeal carcinoma: a study of 256 male patients. J Surg Oncol. 1986; 33: 194-197. • Al-Sarraf M, LeBlanc M, Giri PG, Fu KK, Cooper J, Vuong T, Forastiere AA, Adams G, Sakr WA, Schuller DE, Ensley JF. Chemoradiotherapy versus radiotherapy in patients with advanced nasopharyngeal cancer: phase III randomized Intergroup study 0099. J Clin Oncol. 1998 16(4):1310-7. • AJCC Cancer StagingManual fifth edition. Lippincott Williams & Wilkins, Philadelphia, 1997 • Ang KK, Peters LJ, Weber RS. Concomitant boost radiotherapy schedules in the treatment of oropharynx and nasopharynx. Int J Radiat Oncol Biol Phys 1990; 19: 1339- 1345. • Chan AT, Teo PM, Leung TW, Leung SF, Lee WY, Yeo W, Choi PH, Johnson PJ. A prospective randomized study of chemotherapy adjunctive to definitive radiotherapy in advanced nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys. 1995, 5;33(3):569-77. • Chua DT, Sham JS, Choy D, Lorvidhaya V, Sumitsawan Y, Thongprasert S, Vootiprux V, Cheirsilpa A, Azhar T, Reksodiputro AH. Preliminary report of the Asian-Oceanian Clinical Oncology Association randomized trial comparing cisplatin and epirubicin followed by radiotherapy versus radiotherapy alone in the treatment of patients with locoregionally advanced nasopharyngeal carcinoma. Asian-Oceanian Clinical Oncology Association Nasopharynx Cancer Study Group. Cancer. 1998 Dec 1;83(11):2270-83. NPC 23 Mar. 2006


References

NPC 24 Mar. 2006

• Cvitkovic E, Bachouchi M, Boussen H, Busson P, Rousselet G, Mahjoubi R, Flores P, Tursz T, Armand JP, Azli N. Leukemoid reaction, bone marrow invasion, fever of unknown origin, and metastatic pattern in the natural history of advanced undifferentiated carcinoma of nasopharyngeal type: a review of 255 consecutive cases. J Clin Oncol. 1993 Dec;11(12):2434-42. • de-Vathaire F, Sancho-Garnier H, de-The H, Pieddeloup C, Schwaab G, Ho JH, Ellouz R, Micheau C, Cammoun M, Cachin Y, et al. Prognostic value of EBV markers in the clinical management of nasopharyngeal carcinoma (NPC): a multicenter follow-up study. Int J Cancer 1988;42:176-81 • Fandi A et al. Nasopharyngeal Cancer: Epidemiology, Staging, and Treatment. Seminars in Oncology 1994, 21: 382-397. • Geara FB, Sanguineti G, Tucker SL, et al.: Carcinoma of the nasopharynx treated by radiotherapy alone: determinants of distant metastasis and survival. Radiother.Oncol. 43(1): 53-61, 1997. • Kwong D, Sham J, Choy D. The effect of loco-regional control on distant metastatic dissemination in carcinoma of the nasopharynx: an analysis of 1301 patients. Int J Radiat Oncol Biol Phys 1994; 30: 1029-1036. • Lee AW, Poon YF, Foo W, Law SC, Cheung FK, Chan DK, Tung SY, Thaw M, Ho JH. Retrospective analysis of 5037 patients with nasopharyngeal carcinoma treated during 1976-1985: overall survival and patterns of failure. Int J Radiat Oncol Biol Phys. 1992;23(2):261-70. • Lee AW, Foo W, Law SC, Poon YF, Sze WM, O SK, Tung SY, Chappell R, Lau WH, Ho JH. Recurrent nasopharyngeal carcinoma: the puzzles of long latency. Int J Radiat Oncol Biol Phys. 1999 Apr 1;44(1):149-56.


References • Lee AWM, Foo W, Law SC, Poon YF, Sze WM, O SK et al. Reirradiation for recurrent nasopharyngeal carcinoma: factors affecting the therapeutic ratio and ways for improvement. Int J Radiat Oncol Biol Phys 1997; 38: 43-52. • Lee AW, Law SC, Hg SH et al. Retrospective analysis of nasopharyngeal carcinoma treated during 1976-1985: late complications following megavoltage irradiation. Br. J. Radiol. 66: 528-536, 1993. • Liebowitz D. Nasopharyngeal Carcinoma: The Epstein-Barr Virus association. Seminars in Oncology 1994, 21: 376-381. • Neel HB 3d, Taylor WF. New staging system for nasopharyngeal carcinoma. Long-term outcome. Arch Otolaryngol Head Neck Surg. 1989 Nov;115(11):1293-303. • Qin DX, Hu YH, Yan JH, Xu GZ, Cai WM, Wu XL, Cao DX, Gu XZ. Analysis of 1379 patients with nasopharyngeal carcinoma treated by radiation. Cancer. 1988;61(6):1117-24. • .Perez CA, Devineni VR, Marcial-Vega V, et al.: Carcinoma of the nasopharynx: factors affecting prognosis. Int J Rad Onc Biol Phys 23(2): 271-280, 1992. • Sanguineti G, Geara FB, Garden AS, Tucker SL, Ang KK, Morrison WH. Carcinoma of the nasopharynx treated by radiotherapy alone: determinants of local and regional control. Int J Rad Onc Biol Phys 1997; 37: 985-996. NPC 25 Mar. 2006


References • Preliminary results of a randomized trial comparing neoadjuvant chemotherapy (cisplatin, epirubicin, bleomycin) plus radiotherapy vs. radiotherapy alone in stage IV(> or = N2, M0) undifferentiated nasopharyngeal carcinoma: a positive effect on progression-free survival. International Nasopharynx Cancer Study Group. VUMCA I trial. Int J Radiat Oncol Biol Phys. 1996 Jun 1;35(3):463-9. • Tang SGJ, Lin FJ, Chen MS, Liaw CC, Leung WM, Hong JH. Prognostic factors of nasopharyngeal carcinoma: a multivariate analysis. Int J Biol Oncol Phys 1990; 19: 1143-1149. • Teo PM, Leung SF, Lee WY, et al.: Intracavitary brachytherapy significantly enhances local control of early T-stage nasopharyngeal carcinoma: the existence of a dose-tumor-control relationship above conventional tumoricidal dose. Int. J. of Radiat. Oncol.Biol. Physics 46: 445,458, 2000. • Wang CC. Accelerated hyperfractionation radiotherapy for cancer of the nasopharynx. Techniques and results. Cancer 1989; 63: 2461-67. • World Health Organization. International Histological Classification of Tumours. Histological typing of tumours of the upper respiratory tract and ear. Second Edition. Springer Verlag, 1991

NPC 26 Mar. 2006