Nasopharyngeal carcinoma (NPC)
Transcript of Nasopharyngeal carcinoma (NPC)
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 1Mar. 2006
Nasopharyngeal carcinoma (NPC)
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 2Mar. 2006
• Work-up procedure
• TNM staging
• Primary treatment
• Follow-up
• Treatment of recurrent and/orand/or metastatic metastatic disease
• References
Nasopharyngeal carcinoma (NPC)
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 3Mar. 2006
Standard clinical evaluation Evidence Option
l complete history of the diseasel weight and weight lossl fiberoptic examination of H&N mucosal neck examinationl evaluation of cranial nerves (I, II, III, IV, V, VI,
VIII, IX, XII)including audiometryl drawing of any lesionsl biopsy under local anesthesial endoscopy under general anesthesia with biopsies
if risk factors (tobacco and/or alcohol) and/or novisualization of primary tumor
l FNA of neck lymphnodes if primary not accessible for biopsy
Type CType CType CType CType C
Type CType CType C
Type C
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Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 4Mar. 2006
Advanced clinical evaluation Evidence Option
l ophtalmologic examinationl dental examination by oral surgeonl nutritional assessmentl others (if required)
Type CType CType CType C
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Indiv.
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 5Mar. 2006
Laboratory tests Evidence Option
l hemogram, coagulation tests, liver enzymes, kidney function (including a creatinine clearance)
l serology: anti-VCA IgAl pituitary function: cortisol, TSH, free T4, LH,
FSH, GH, free testosterone and testosterone (male only), progesterone and oestradiol (femaleonly), prolactine, IGF-1
Type C
Type CType C
Std.
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Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 6Mar. 2006
Imaging Evidence Option
l local: MRI ± CT scan1
l metastatic work-up: chest X-ray, thoracic andabdominal CT scan, bone scintigraphy
l additional examination depending on previousfindings
l PET scan
Type CType C
Type C
-
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Invest.1See guidelines for loco-regional imaging
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 7Mar. 2006
Pathology Evidence Option
l WHO classification1
l Immunohistochemistry for EBV (LMP1)Type CType C
Std.Std.
1See pathology guidelines
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 8Mar. 2006
• Work-up procedure• TNM staging• Primary treatment• Follow-up• Treatment of recurrent and/orand/or metastaticmetastatic disease• References
Nasopharyngeal carcinoma (NPC)
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 9Mar. 2006
Staging Evidence Option
l TNM classification (5th ed., 1997) Type C Std.l Who International Classification of Diseases for
Oncology (ICD-O 9 or ICD-O 10)Type C Std.
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 10Mar. 2006
•• TisTis: Carcinoma in situ: Carcinoma in situ•• T1: Tumor confined to the T1: Tumor confined to the nasopharynxnasopharynx•• T2: Tumor extends to soft tissues of T2: Tumor extends to soft tissues of oropharynx oropharynx and/or nasal and/or nasal fossafossa
T2a: without T2a: without parapharyngeal parapharyngeal extensionextensionT2b: with T2b: with parapharyngeal parapharyngeal extensionextension
•• T3: Tumor invades bony structures and/or T3: Tumor invades bony structures and/or paranasal paranasal sinusessinuses•• T4: Tumor with T4: Tumor with intracranial intracranial extension and/or involvement extension and/or involvement
of cranial nerves, of cranial nerves, infratemporal fossainfratemporal fossa, hypopharynx or orbit , hypopharynx or orbit
TNM/AJCC 1997 StagingTNM/AJCC 1997 Staging
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 11Mar. 2006
TNM/AJCC 1997 StagingTNM/AJCC 1997 Staging
• 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 cmN3b: extension to the supraclavicular fossa
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 12Mar. 2006
TNM/AJCC 1997 StagingTNM/AJCC 1997 Staging
•• MX: Distant MX: Distant metastasis cannot bemetastasis cannot be assessedassessed•• M0: No distant M0: No distant metastasismetastasis•• M1: Distant M1: Distant metastasismetastasis
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 13Mar. 2006
• Work-up procedure• TNM staging• Primary treatment• Follow-up• Treatment of recurrent and/orand/or metastatic metastatic disease• References
Nasopharyngeal carcinoma (NPC)
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 14Mar. 2006
Primary treatment Evidence Option
l T1-N0-M0 / T2-N0-M0Ext. RxThBrachytherapy boost
l T1-T2, ≥ N1, M0 / T3-T4, any N, M0Ext RxTh+concomitant CH+adjuvant CHSurgery (RMND, RND or ERND unilateral or bilateral) for persitent N disease at 3 months
Type CType C
Type 2Type R
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Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 15Mar. 2006
Primary treatment: RxTh regimen Evidence Option
l Target volumesBilateral levels II-V + RP nodes: prophylactic doseinvolved node(s) + NPharynx: curative dose
l Technique-conformal-IMRT radiotherapy
l Doseprophylactic dose: 50 Gycurative dose: T1, N1: 66 Gy
≥T2, ≥N2: 70 Gy5% dose reduction for UCNT(WHO 2-3)
l Fractionationdaily 2Gy/fraction
Type C
Type C
Type 3Type 3
Type CType CType CType R
Type C
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Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 16Mar. 2006
Target Volumes: Target Volumes: nasopharynxnasopharynxLevel of evidence : type 3 / option : standardLevel 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 II-III-IV-V +RP ± sus. clav.1structures according to clinical
and radiological data1
1Supra-clavicular nodes when involvement of level IV and/or Vb
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 17Mar. 2006
Primary treatment: CH regimen Evidence Option
Intergroup study regimenl Concomitant: cddp 100 mg/m2 J1, J22, J43l Adjuvant: cddp 80 mg/m2 J71, J99, J127
5Fu 1 g/m2 J71-74, J99-102, J127-130
Type 2 Std.
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 18Mar. 2006
• Work-up procedure• TNM staging• Primary treatment• Follow-up• Treatment of recurrent and/orand/or metastatic metastatic disease• References
Nasopharyngeal carcinoma (NPC)
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 19Mar. 2006
Follow-up Evidence Option
l 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
l Imaging-all T: MRI ± CT 2-3 months after end of RxTh-≥ T2: MRI ± CT every 6 months for 2 years
l Laboratory tests-serology: anti-VCA IgA at each clinical examination (if elevated before treatment)-thyroid and pituitary function: according to clinical findings
l Evolution of late toxicity (EORTC/RTOG) scale
Type C
Type C
Type C
Type C
Type C
Type C
Type C
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Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 20Mar. 2006
• Work-up procedure• TNM staging• Primary treatment• Follow-up• Treatment of recurrent and/orand/or metastaticmetastatic disease• References
Nasopharyngeal carcinoma (NPC)
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 21Mar. 2006
Salvage treatment for recurrent disease Evidence Option
l rT1-N0 / rT2-N0RxThSalvage surgeryChemotherapy
l T0-≥ rN1, M0Neck dissection
l rT3 / rT4, any rNChemotherapy
l MetastasisChemotherapy + RxThBest supportive care
Type 3Type 3Type 3
Type 3
Type 3
Type 3Type 3
Indiv.Indiv.Std.
Indiv.
Std.
Std.Indiv.
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 22Mar. 2006
• Work-up procedure• TNM staging• Primary treatment• Follow-up• Treatment of recurrent and/orand/or metastatic metastatic disease• References
Nasopharyngeal carcinoma (NPC)
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 23Mar. 2006
ReferencesReferences• Ahmad A, Stefani S. Distant metastases of nasopharyngeal carcinoma: a study of 256 male patients.
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• AJCC Cancer StagingManual fifth edition. Lippincott Williams & Wilkins, Philadelphia, 1997• Ang KK, Peters LJ, Weber RS. Concomitant boost radiotherapy schedules in the treatment of
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Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 24Mar. 2006
ReferencesReferences• Cvitkovic E, Bachouchi M, Boussen H, Busson P, Rousselet G, Mahjoubi R, Flores P, Tursz T,
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• 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.
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Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 25Mar. 2006
ReferencesReferences
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• 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.
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• Sanguineti G, Geara FB, Garden AS, Tucker SL, Ang KK, Morrison WH. Carcinoma of thenasopharynx treated by radiotherapy alone: determinants of local and regional control. Int J Rad Onc Biol Phys 1997; 37: 985-996.
Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme
NPC 26Mar. 2006
ReferencesReferences
• 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 nasopharyngealcarcinoma: 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. Histologicaltyping of tumours of the upper respiratory tract and ear. Second Edition. Springer Verlag, 1991