Treatment

NPC is generally both radio- and chemosensitive. Radiotherapy is the mainstay of treatment. The role of surgery is restricted to staging and the elective dissection of neck nodes that have not regressed three months after radiotherapy.

Radiotherapy planning is complicated in this disease. The primary tumour should be irradiated with a wide margin including the base of the skull. The neck is invariably irradiated owing to the high frequency

Table 24.1 Ho staging scheme (1989)

T1

Tumour confined to nasopharynx

T2n

Nasal involvement without parapharyngeal space involvement

or T3 features

T2o

Oropharyngeal involvement without T3 features

T2p

Parapharyngeal involvement without T3 features

T3q

Parapharyngeal involvement with T3 features

T3a

Bone involvement below base of skull including floor of sphenoid

sinus

T3b

Involvement of base of skull

T3C

Cranial nerve involvement

T3d

Involvement of orbit,laryngopharynx,or infratemporal fossa

N0

No cervical lymph nodes palpable

N1

Nodes wholly above the skin crease extending laterally and

backwards from just below the thyroid notch

N2

Nodes palpable between the skin crease and supraclavicular

fossa

N3

Nodes palpable in the supraclavicular fossa or skin involvement

The groups can be condensed to five stages:

Stage I

T1 N0

Stage II T2 and/or N1

Stage III T3 and/or N2

Stage IV N3 involvement irrespective of T stage

Stage V

Haematologous spread or nodal involvement below clavicles

Table 24.2 UICC staging (1992)

T1

Tumour limited to one subsite in the nasopharynx

T2

Tumour involving more than one subsite

T3

Tumour invades nasal cavity and/or nasopharynx

T4

Tumour invades skull and/or cranial nerves

N0

No regional lymph nodes

N1

Single ipsilateral node <3 cm

N2a

Single ipsilateral node >3 cm

N2b

Multiple ipsilateral nodes >3 cm but <6 cm

N2C

Bilateral or contralateral nodes all <6 cm

N3

Any node >6 cm

of overt and occult neck metastases. However, the radiation dose to the brain, eyes, and spinal cord must be kept within tolerance. In order to reduce acute reactions as much normal mucosa as possible must be excluded from the irradiated volume. In general, doses of 65-70 Gy are given to the primary site in 6.5-7 weeks. Involved areas of the neck are treated to 60 Gy with boosts of 70 Gy with electrons if necessary. Parapharyngeal masses are also boosted. Brachytherapy may be used to increase the dose to the primary site.

Local or regional recurrence developing two or more years after radiotherapy can be successfully treated by a second radical course of radiotherapy with a reported five-year survival of 25-35% but with considerably increased morbidity.

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