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Case History

Image not available. A 55-year old English patient has been diagnosed with T3 N1 M0 nasopharyngeal carcinoma.

What is the treatment in this case?

What additional evaluations and supportive measures should be considered before and during his treatment?

Is the approach you have recommended for this patient applicable worldwide?

Background

What is the treatment in this case?

Image not available. Current best practice requires a multidisciplinary team approach in managing nasopharyngeal carcinoma (NPC). This patient's tumour has invaded the bony structures and/or paranasal sinuses with unilateral metastasis of lymph node(s), and is Image not available.6 cm in greatest dimension above the supraclavicular fossa. This falls into American Joint Committee of Cancer (AJCC) stage III. NPC is a disease that is sensitive to radiotherapy and chemotherapy. Unlike other cancers of the head and neck region where surgery is preferred, early stage NPC is mainly treated with radiotherapy (Figure 44.1). For stage III and locally confined stage IV disease, 50–80% of patients develop recurrent or metastatic disease within 5 years of treatment with radiotherapy alone. Although chemotherapy was used only for palliation of metastatic disease in the past, it has now become an integral part of the treatment of locally advanced NPC.

Figure 44.1

Algorithm for the management of nasopharyngeal carcinoma.

Chemotherapy in the concurrent setting is aimed at enhancing and complementing radiation by exploiting the radiosensitizing properties of cisplatin and/or 5-fluorouracil (5-FU). The activity of cisplatin in squamous cell cancer in the head and neck led to several landmark trials in the 1980s and 1990s that showed improved loco-regional control and overall survival. The Intergroup trial 0099 compared standard radiotherapy alone with radiotherapy plus cisplatin followed by adjuvant cisplatin and 5-FU for stage III and IV NPC. Marked reduction in loco-regional recurrence and distant metastases was noted. The rate of 3-year progression-free survival (PFS) was 24% and 69% in the radiotherapy and chemoradiotherapy arm, respectively. The 3-year survival rate was 46% in the radiotherapy arm compared with 76% in the chemoradiotherapy arm.1 Other trials also confirmed benefit, though less dramatic and greater in locally advanced than in early-stage disease.2,3 A recent meta-analysis confirmed the overall survival benefit of chemotherapy concomitant with radiotherapy.4 Standard radiotherapy treatment delivers around 70 Gy in 2 Gy fractions to tumour and gross lymphadenopathy and 50 Gy to lower-risk neck nodal stations.5 Although in other squamous cell cancers of the head and neck, concurrent cisplatin and 5-FU may be preferred, published guidelines for NPC recommend the Intergroup regimen of concurrent single-agent cisplatin 100 mg/m2 every 21 days followed by adjuvant cisplatin and 5-FU.5 The improved results with chemotherapy do come, however, with increased toxicity.

Recently, use of concomitant cetuximab rather than platinum in head and neck cancer has been considered with the publication of ...

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