Carcinoma Nasopharynx

Carcinoma Nasopharynx
Moderator: Dr Sushmita Ghoshal

Anatomy
Department of Radiotherapy, PGIMER, Chandigarh

Anatomy
Foramen
rotundum
Foramen
ovale
Foramen
spinosum
Foramen
lacerum

Parapharyngeal Space
• The parapharyngeal Prestyloid Space
space is located deep

within the neck lateral
to the pharynx and
medial to the ramus of
the mandible.
• Shape of an inverted
pyramid with the floor
at the skull base and
it’s tip at the greater
cornu of the hyoid bone
• Two compartments : Retrostyloid Space
– Prestyloid
– Retrostyloid
Lymphatic Drainage
• Richest lymphatic plexus in the head
and neck region.
• Submucosal lymphatics congregate
at the pretubal region – “pretubal
plexus”.
• These then pass on to the
retropharyngeal nodes as 8 -12
trunks which decussate in the
midline.
• Lymphatic trunks pierce the level of
the base of the skull and run between
the pharyngobasilar fascia and the
longus capitis.
• The lymphatic trunks drain in three
directions:
– To the retropharyngeal nodes.
– To do the posterior cervical nodal and
the confluence of the 11th, cranial
nerve and the jugular lymph node
chains, situated atofthe
Department tip of thePGIMER, Chandigarh
Radiotherapy,
Anatomy: RPLN
• The retropharyngeal nodes are
present in two groups.
– Median group.
– Lateral group.
• The median group consists of 1
- 2 nodes interconnected in the
midline.
• The lateral group consists of 1-
3 nodes located between the
lateral aspect of the posterior
pharyngeal wall and the carotid
artery.
• These nodes are present from
the vertebral levels C1- C3.
• The superior-most lymph node
of the latter group is also
known as the node of Rouviere.
• This node lies in front of the
arch of the Atlas being
separatedDepartment
from it ofby
Radiotherapy, PGIMER, Chandigarh
the longus
CT anatomy

Incidence

Incidence: Sex

Clinical Features
• Most common: Asymptomatic cervical
lymphadenopathy (87%)
• MC node involved is the posterior deep cervical
(direct drainage from the lateral pharyngeal)
• Other presenting symptoms:
– Nasal twang to speech
– Unilateral serous otitis media ( in adults)
– Cranial nerve palsy:
• U/L Cr nv. II to VI (petrosphenoidal syndrome of
Jacod)
• U/L Cr nv. XI to XII ( Retroparotid syndrome of
Villaret.)
• Cr nv V and VI most commonly involved.
• Cr nv I, VII and VIII rarely involved.
– Sore throat : Oropharyngeal extension
– Pain: Compression of Vth cranial nerve ( facial pain)
– Trismus: Mandibular nerve involvement or pterygoid
muscle invasion.
Cranial Nerve involvement
50
45
40
35
30
25
20
15
10
5
0
I II III IV V VI VII VIII IX X XI XII
Lederman et al Leung et al

Local Spread
Sphenoid sinus
Cavernous Sinus
Nasal cavity & PNS

Base of Skull, Clivus
Orbital invasion
Lateral Parapharyngeal space

Middle ear cavity
Oropharynx (tonsillar pillars)

C1 vertebrae

Nodal Spread

Etiology
Normal Epithelium
Deletion of Chromosomes 3p and 9p
Low Grade Dysplasia
Inactivation of Chromosome p14, 15 and 16
High Grade Dysplasia

Gain Chromosome 12
EBV infection Deletion 11 and 13
Invasive Carcinoma
P53 Mutation
Metastatic Carcinoma

Investigations
• Staging:
– CT
– MRI
– Endoscopy
– PET scan
– Chest Xray
– USG Abdomen
– Bone Scans
• Other Investigations
– EBV Serology

Staging
• Several staging systems are in use:
– Complex anatomy and spread patterns
– Lack of international consensus:
• Separate Chinese, Hong Kong and
American staging systems
• Systems available:
– Fletcher (1967)
– Ho’s staging (1978)
– IUAC (1988)
– Huaqing staging (1994)
– AJCC (2002)
Comparison
Syste Staging
m T1 T2 T3 T4
Fletch < 1 cm > 1 cm but Beyond Involving skull
er diameter confined to nasopharynx base or cranial
(1967) nasopharynx nerves
Ho Confined Extending to nasal Bone/ Cranial NA
(1978) to fossa or nerve/ orbital /
nasophary oropharynx hypopharyngea
nx l/
infratemporal
fossa
IUAC Limited to Extending to two No bony Bony
involvement
(1988) one site in sites in destruction destruction
nasophary nasopharynx including
nx to
Limited Involving the Pterygoid eustachian
Infratemporal
Huaqin tube /
g nasophary nasal cavity, process / fossa
(1994) nx oropharynx, posterior cavernous
anterior cervical cranial nerve / sinus / PNS /
vertebrae, PPS posterior direct invasion
before SO line cervical of C2 or C1 /
vertebrae / anterior cranial
BOS / PPS nerves
beyond SO
Ho’s vs AJCC

AJCC system: T staging
• T1:
– Tumor confined to the nasopharynx
• T2:
– Tumor extends to soft tissues
• T2a : Extends to the oropharynx or the nasal
fossa
• 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, orbit,
Department of Radiotherapy, or masticator
PGIMER, Chandigarh space
AJCC system: N staging
• N0:
– No regional lymph node
metastasis
• N1:
– Unilateral metastasis in lymph
node(s), < 6 cm in greatest
dimension, above the
supraclavicular fossa
• N2:
– Bilateral metastasis in lymph
node(s), < 6 cm in greatest
dimension, above the Ho’s Triangle
supraclavicular fossa
• N3:
– N3a: Metastasis in a lymph
node(s) >6 cm
– N3b: Extension to the
Staging: AJCC 2002
Stage I Stage IIA Stage IIB
Stage III Stage IVA Stage IVB

Pathology
• Some authors consider carcinomas to be of
two types:
– Keratinizing
– Non keratinizing
• Others consider carcinomas to be of 4
types:
– Keratinizing Squamous
– Non Keratinizing Squamous
– Lymphoepithelioma
– Undifferentiated carcinomas
• WHO 3 types:
– Type I : SCC
– Type II : Non Keratinizing carcinoma
– Type III : Undifferentiated carcinoma
Endemic NPC
• Known to occur in China, Hong Kong, South Eastern
Asia, Greenland
• Associated with EBV virus infection
• In India similar pathology seen in Kashmiris.
• Present a decade younger.
• Not associated with smoking or alcohol
consumption
• Associated with undifferentiated carcinoma ( WHO II
and III)
• Associated with more advanced disease at
presentation
• Nodal stage also more advanced and more
frequently involved.
• Both chemo and radio sensitive
– Histologically more vascularized (Better Rx response)
– Greater % of cell in the growth fraction.
• Better loco regional control and survival than
Prognostic factors
• Most important stage.
• Parapharyngeal extension is associated with a
poorer prognosis.
• A Chinese series found that 4th cranial nerve
involvement – poor prognosis.
• Nodal disease status:
– Bilateral cervical lymphadenopathy
– Supraclavicular lymphadenopathy
– Lymph node fixity
• Lymphoepithelioma histology: better prognosis
• Undifferentiated histology: better prognosis
• Molecular markers:
– Ki -67 over expression
– P 53
– E – cadherin expression

Treatment strategy
Stage
Early stage
External Late stage

EBRT + ICBT
Radiation
KPS > 70 KPS < 70
Concurrent Palliative
Chemoradiation Radiotherapy

Dose response
• Significant dose response
relationship exists.
• Several series demonstrate that an
increased-dose leads to better
survival
– Doses of 90 Gy delivered by boost
increase the local control and the distant
metastasis free rate significantly over
doses > 70 Gy
– Price however paid in increased
morbidity
• Local recurrence rate reduced with
the useDepartment
of larger fields (Field size
of Radiotherapy, PGIMER, Chandigarh
2
Dose-response
100%
90%
80%
70%
60% T1
50% T2
40% T3
T4
30%
20%
10%
0%
50 - 60 Gy 60 - 67.5 Gy > 67.5 Gy

Doses used
• Radical radiotherapy:
– 60 – 66 Gy in 2 Gy per fraction over 6 – 6 ½
weeks
– Higher dose can be given with more conformal
techniques:
• ICBT
• IMRT
• 3 DCRT
– In our patients with poor nutrition, advanced
disease and absence of individualized care split
course radiotherapy is an alternative
• 35 Gy in 15 #
• 25 – 30 Gy in 10 – 15 # after 2-3 weeks
• Palliative radiotherapy:
– 30 Gy / 10#
– 20 Gy / 5#
– 800 -1000 cGy single fraction
Treatment volume
• The nasopharynx.
• Posterior 2 cm of nasal cavity.
• Posterior ethmoid sinuses.
• Entire sphenoid sinus and the basiocciput
• Cavernous sinus.
• Base of skull, including the foramen ovale,
carotid canal and foramen spinosum.
• Pterygoid fossae
• Posterior 1/3rd of maxillary sinus.
• Lateral and posterior oropharyngeal wall to
the level of mid-tonsillar fossa
? Posterior 1/4th of orbit ( Fletcher – YES,
Perez - NO )
Nodal volumes
• The entire neck is at high risk for
microscopic spread of disease.
• The neck nodes that should be
treated are:
– Upper deep jugular
– Submandibular
– Jugulodigastric
– Midjugular
– Posterior cervical
– Retropharyngeal

Treatment planning
• Positioning:
– Supine position.
– Head should be extended
• Immobilization
– To ensure accuracy in setup patient should be
immobilized with a custom-made thermoplastic
cast.
• Localization:
– All nodes are delineated with the use of radio –
opaque lead wires.
– The outer canthus the eye opposite to which
simulation film is taken is marked with a lead
wire.
– Tumor localization performed with the help of CT
and clinical details.
Techniques
• Techniques
– Conventional technique
– Three-dimensional conformal radiation therapy.
– Intensity-modulated radiotherapy.
– Image-guided radiotherapy.
• Energy selection:
– Co60 : 1.25 MeV
– LINAC : 4 – 6 MV
– Higher-energies used in certain Western centers
during the boost phase to:
• Reduce dose to the mandible,
temporomandibular joints, ears and
subcutaneous tissue (lateral edge effect)
– Kutcher and associates however warn that use of
these high energy beams may be associated
with underdosage near the surface and near the
paranasal sinus cavities.
Portal selection
• For Initial Phase:
– Two parallel opposing fields
– Three field approach
• For the boost phase:

– Fletcher’s Technique ( 4 fields – antral
boost)
– Anterolateral wedge pair technique
– Ho’s technique ( with separate
parapharyngeal boost)

Two field technique
• Clinical field markings:
– Superior border:
• 2.5 cm above the zygomatic arch
• 5 cm above the zygomatic arch in case of
intracranial extension
– Anterior border:
• 2 cm beyond the anterior most extent of the
disease (usually placed just along the lateral
canthus of the eye)
– Posterior border:
• Along the tip of the mastoid or behind the
posterior most extent of cervical
lymphadenopathy
– Inferior border:
• Along the superior
Department border
of Radiotherapy, PGIMER,of the clavicle
Chandigarh
Two Field technique
• Radiological boundaries:
– Superior border:
• Splitting the pituitary fossa and extending
along the superior surface of the
sphenoid sinus
• In case of IC extension to include at least
1 cm above the pituitary fossa.
– Anterior border:
• At least 2 cm of the nasal cavity and
maxillary antrum.
• At least 2 cm margin to the gross tumor
extent
– Posterior border:
• Kept open if gross cervical LAD
•
Technique

Three field technique
• The superior, anterior and posterior
boundaries are kept as same.
• Inferior boundary restricted to the
level of the thyroid notch unless
cervical LAD is present
• In latter case matching done more
inferiorly.
• Dose prescription done usually at 3
cm depth.
• Several measures need to be taken
to circumvent the problem of field
Field Matching
• Without asymmetrical jaws:
– Using laryngeal block:
• A laryngeal block is placed at the level of the
larynx.
• The block has a thickness such that it is located
1cm medial to the lateral border of thyroid
cartilage
• The block extends from the superior border of the
lower field to 2 cm below the level of the cricoid
cartilages.
– Using collimator tilt:
• A collimator rotation may be given for the lateral
fields to counteract the divergence of the lower
anterior field – 5° for Co 60.
• May increase the dose to the supero-anterior
portion of the field where the eyes are located
• With asymmetrical jaws:
– Using an isocentric technique with half beam block for
3 fields overdosage at the field junction can be
avoided.
– Alternative is to use half beam block in the lower
Additional modifications
• In both 3 field and 2 field
techniques a higher dose
can be given to the eye
due to the beam 5° 10°
divergence.
0. 1.2
• Lateral fields need to 5
angled – a “posterior” tilt
needs to be given
• Magnitude by which the 1.
1
2.
5
field edge shifts at the
midline ( for Co60)
– 5° – 0.5 cm
– 10° – 1.2 cm
Actual Implementation
Lateral Canthus
75°
2
5°
70°
2

Doses Prescribed
• 40 – 44 Gy in 2 Gy per fraction over 20 – 22
fractions ( 4 – 4½ weeks) for the entire
field.
• Rest of the dose ( 20 – 26 Gy) to delivered
with spine shielding:
– Lateral fields:
• Posterior border drawn along the junction of
the posterior 1/3rd and the anterior 2/3rd of the
vertebral bodies ( Co60).
• In LINACs the posterior edge of the vertebrae
may be choosen.
• Clinically marked straight along the lobule of
ear.
– Anterior fields:
•
Boosting neck nodes
• Photons only:
– Antero-posterior glancing fields ( ±
wedges) – Medial border is 2 cm from
midline.
– Additional boost radiation may be
delivered by posterior fields to increase
the dose to the posterior cervical nodes
after the course of RT is completed.
• Electrons:
– Direct abutting lateral fields used.
– Energy selected 9 MeV
– Prescribed at 85% isodose ( Usually 3
cm depth)
– 6 x 6 cm usually adequate
Nasopharynx Boost
• A 4 field approach can be used to
boost the nasopharynx to additional
10 – 15 Gy.
• Volume treated is roughly cuboidal
and has the dimensions of 7 cm x 6
cm.
• The anterior fields are tilted
“medially” by 20° – 30° in order to
– Increase the dose to the Posterior
nasopharynx
– Spare the anterior nasal cavity and the
deeper brain-stem
• Opposing lateral
Department fields
of Radiotherapy, also
PGIMER, used with
Chandigarh
Field marking
• The boundaries for the anterior facial fields
are:
– Superiorly – below the eyeball
– Medially – 1 cm in either side of midline
– Inferiorly – upto the commissure of lips
– Laterally – Usually a distance of 6 cm – allow
beam fall-off.
• In order to ensure that the superior border
of the anterior field matches the lateral
fields the head position is adjusted
(hyperextended) based upon the collimator
lights.
• Beam weights are adjusted to ensure that
the brainDepartment
doesn't receive
of Radiotherapy, excess
PGIMER, Chandigarhdose.
4 field technique

Dose distribution

Nasopharynx Boost
• In case of gross anterior extension:
– Three field, lateral wedge pair arrangement is
preferred
– Anterior border of the lateral fields are extended
to cover the anterior disease adequately
– Alternative technique is to use differential beam
weights
– Electrons may be used to supplement the doses
to the anterior diseases with lateral photon
fields.
• In lateralized anterior extension:
– Anterior field may be “wedged” with thin end
towards side where disease is present.
• In inferior extension:
– Boost fields are by necessity parallel opposing.
Ho’s Technique
• Proponent: Prof John H C Ho
• Developed: late 1960s
• Extensive experience : 3 decades
• Special features:
– Different CTV specification
– Field arrangements and patient position are
different.
– Arrangement of different shields specified based
upon bony anatomy – customized shields not
necessary.
– Reproducible treatment plan.
– Lack of CT planning facilities circumvented.
– Ease of use in a busy radiotherapy department
Cost saving additional factor.
• Over 10,000 patients have been treated in
Hong Kong – excellent long term results in
early disease T1,
Department T2 and
of Radiotherapy, T3.Chandigarh
PGIMER,
Ho’s technique: Planning
• Patient is immobilized in FLEXED
head position in the initial phase.
• Similar to the planning technique for
pituitary.
• Allows easier shielding of the
brainstem and the oral cavity and
reduces the field size requirements.
• Dose: 40 Gy in 20 #

• Three field arrangement:
0.5 cm above the
– Opposed lateral fields anterior clinoid process
irradiate the upper cervical
lymphatics ( upto level III)
en bloc.
– An anterior field irradiates
the lower field.
– Shielding of the lateral
fields is done to adjust for
Bisecting
the beam overlap with the the maxillary
anterior field. antrum
– In the lower anterior field a Below vocal cords C6

midline shield is placed
throughout the treatment.

• Specialized arrangement
of shielding is done for
all patients.
– Brain Stem: Shielded with
5 HVL block placed in a
manner such that it is 0.5
cm behind the upper edge
of the clivus and 1 cm
below the lower edge.
– Eye: 5 HVL shield placed
1.5 cm behind the lateral
canthus.
– Posterior tongue also
shielded with standard
block.
– Pituitary and temporal
• In the boost phase a 3 field
arrangement was used.
• Patient was replanned in the
EXTENDED head position
with oral stent.
• Anterior cervico-facial field
was used in all patients
• Lower border of the later
fields reduced down to level
of angle of mandible.
• Allowed dose reduction to:
TM joints, ear, parotids &
pinnae.
• Dose prescribed: 22.5 Gy in
9#
• Total tumor dose was 62.5
Gy in 29#
• Biologically equivalent to 66
Gy in 33#Department of Radiotherapy, PGIMER, Chandigarh
• In patients with
parapharyngeal
disease a posterior
oblique boost was
given after the 2nd
phase.
• Dose prescribed
was 20 Gy /10#
• This field was
usually 5.5 cm x 8
cm in size.
• Ascending ramus
of the mandible
Ho’s vs 3D CRT and IMRT
T1 NO MO
T4 N2 MO
Kam et al: IJROBP 2003

Results by Ho’s Technique

Conventional Radiation

Conventional Radiation

Altered fractionation
• Concomitant boost technique has
been evaluated in a large series by
Teo et al (IJROBP 2000).
• Study prematurely terminated as:
– 40% incidence of temporal lobe
neuropathy
– 17% incidence of cranial nerve palsies
– 50% patients had one or other form of
neurological complication
– 2.6% treatment related mortality
– Neural complications were more severe
and occurred earlier than conventional
techniques.
Conformal Radiation
• Includes 3 D CRT , IMRT and IGRT
• Potential:
– Dose escalation
– Conformal avoidance
• Results are immature for IMRT
• Largest series of IMRT by Kam et al:
– 63 patients
– Median F/U 30 months
– Only 4 had local failure ( None marginal miss)
– OS was 90%
– Distant metastasis primary cause of failure
– Grade III mucositis: 41% patients
– Late toxicity till 2 yrs : Xerostomia (21%)

Brachytherapy
• The following requirements should be
fulfilled prior to taking up a patient for
brachytherapy:
– Tumor thickness less than 10 mm.
– Absence of intracranial, paranasal sinus and
oropharyngeal involvement.
– Absence of involvement of underlying bone or
infratemporal fossa.
– Absence of metastatic disease.
– Expertise in nasopharyngeal intracavitary
brachytherapy.
“In effect, nasopharyngeal brachytherapy is

ineffective in tumors extending beyond the
Techniques
• Techniques:
– Temporary intracavitary application
– Temporary interstitial implantation
– Permanent interstitial implantation
• Dose-rates used:
– Low dose rate (LDR).
– High dose rate (HDR).
• Situations used:
– Routine use as a boost after XRT ( Hong Kong,
China and Netherlands)
– Use with documented residual disease ( USA)
– Recurrence ( Hong Kong, USA - Syed and
Chinese Series)
History of brachytherapy
• In 1920s, Pierquin and Richard Ra226 tube
Cork
were the first persons is to
employ brachytherapy in the
treatment of nasopharyngeal
carcinomas.
• In the Christie hospital at
Manchester, Peterson used a
15 mg radium tube inserted in
a cork with a diameter of 15 to
20 mm.
• The dose prescribed was 80
rads in seven days to a depth String at
of 0.5 cm. either end of
the cork
Peterson described this
technique as a useful
alternative to small field X-
ray technique butofnot
Department superior
Radiotherapy, PGIMER, Chandigarh
Applicator Design
• Several applicator
designs available:
– Mould technique
– Levendag’s
– Forzhou (Chinese
district)
– Simple catheter
based

Mould Technique
• Customized mould
prepared for each patient
• Uses a special quick setting
silicone jel to take the
nasopharyngeal
impression.
• The source placement for
an average nasopharynx
are:
– 2 sources for 1 wall
– 3 sources for two adjoining
wall
– 4 sources for 3 walls
• Intersource
separation kept
Technique of Insertion

Rotterdam Applicator
• Designed by Levendag.
• Designed so that the applicator could be
worn by the patient comfortably
continuously throughout the fractionated
course of treatment given.
• Made up of silicone which is flexible and
closely conforms to the curvature of the
nasopharynx.
• Applicator design based upon a 3 D model
of the nasopharynx ( based on CT of two
patients)
• Allows closer fit to the base of the skull and
situated at a fixed distance from the soft
palate.
• A silicone bridge and flange used to fix the
Rotterdam Applicator
• Tube diameter
– Outer diameter 15 F (5.5
mm)
– Inner diameter 9 F ( 3.5
mm)
• Can accommodate the 6 F
HDR source easily.
• Two tubes ensure catheter
stability.
• The tubes are diverging at
the base

Prescription and points
• Several anatomical points defined by
Levendag to calculated dose to the tumor
as well as critical normal tissues.
• Tumor points:
– Na (Nasopharynx) – 2
– BOS (Base of Skull) - 2
– R (Node of Rouviere) - 1
• Normal Tissue points:
– OC ( Optic Chiasm) - 1
– P (Pituitary gland) - 1
– C (Cord) – 1
– Pa (Soft Palate) – 2
– Re (Retina) - 2
– No ( Nose) - 2

Prescription points
OC
P
OC
Line 1 BOS P
BOS BOS
Re
Li
Na
ne
Re Re
Na
2
Na
No
No
R C No
Pa
R C
Pa Pa

Dose prescribed
• In case EBRT given in dose of 60 Gy:
– 3 Gy x 2 fractions per day for 6 fractions
by HDR
– Total dose ~ 78 Gy
– Minimum interfraction gap of 6 hrs.
• In case of EBRT given in dose of 70
Gy:
– 3 Gy x 2 fractions for 4 fractions by HDR
– Total dose ~ 82 Gy
– Minimum interfraction gap of 6 hrs.

Advantages
• Comfortable applicator – can be kept
between fractions
• Optimization possible – Na, BOS and the R
points.
• Can be reused after steam sterilization.
• Reduced normal tissue dose – to the retina,
palate and the nasal cavity
• In earlier work Levendag used to use two
other points:
– FL point:
• corresponding to the BOS point
• Approximates the position of the foramen
lacerum
– FO point:
• Situated at the foramen ovale
Disadvantages
• Nasal synechia have been observed
in few patients.
– Corresponds to the hyperdose sleeve of
200% isodose around the applicator.
– Approximately occurs in a radius of 6
mm around the source axis after
standard prescription
– Reduced by use of nasal pack for 7 days
after ICBT
• Optimization can result in increased
dose to some points (especially the
spinal point).
Chemoradiation
• Sequence:
– Induction
– Concurrent
– Adjuvant
• Concurrent regimen is best.
• Principle:
– Local cooperation
– Spatial cooperation
• We use Concurrent Cisplatin in doses
of 50 mg/m2 D1 and D22.
Results: NACT

Results: Adjuvant CT
• Adjuvant Chemotherapy:
– Of no benefit even if CDDP based.
– Chi et al reported results of a phase III
randomized trial (2002) N = 157
– Adjuvant chemotherapy with 24 hr
infusional Cisplatin 20 mg/m2, 5-
fluorouracil 2,200 mg/m2, and leucovorin
120 mg/m2 x 9 cycles after 70 Gy XRT
• 5-year overall survival 60.5% vs. 54.5%
(p = 0.5)
• 5 yr relapse-free survival rates 49.5% vs.
54.4% (p = 0.38)
Results: Concurrent CT
• Huncharek et al performed a meta-analysis in 2002.
• 6 RCTs included
• Statistically significant increase in the disease free
survival by approximately 20% to 40%
• OS improved by ~ 20% (Statistically NS)
• Better results with Cisplatin + 5 FU based regimen (
Al Sarraf)

Results : Metastatic disease

NPC in Children
• Problem of long term toxicity:
– Skull deformities
– Neurological deficits
– Pituitary dysfunction
– Hearing impairment
– TM joint ankylosis
– Visual defects
• RT is the treatment modality of choice:
– Dose 50 -60 Gy
– Boost only after skull growth is complete (15yrs)
– Lower neck usually not treated if clinically –ve.
• Outcome:
– DFS is 70 – 80% in T1 and T2 tumors
– DFS is 40 – 50% in T3 – T 4 tumors

Recurrence
• 2 types described (Wang et al)
– Persistent disease
– Relapse: Appearing 1 yr after treatment.
• Detecting recurrence:
– Tc99m SPECT
– MRI – High signal intensity on T1
weighted spin echo images
• Options:
– Palliative treatment
– Radiation therapy
– Surgery

Surgery
• Usually indicated in situations like
isolated nodal recurrence
• Local recurrences have been
salvaged by extensive craniofacial
surgery

Radiotherapy
• EBRT
• Brachytherapy
– Both temporary and permanent implants used.
– Best results from Gold grain implantation.
• IMRT and 3 DCRT
– Investigational
• Sterotactic Radiosurgery
• Chemotherapy
– Cisplatin or taxane based
– Mainstay in:
• Distant spread
• Early recurrence
• Extensive disease
Radiotherapy
• External radiotherapy:
– High energy beams are better choosen
– Small 6 x 6 field used to treat site of
local recurrence
– Doses in range of 20 – 30 Gy.
– Indications:
• Limited tumour size,
• a relatively long period since previous
irradiation (minimal time period ~ 1 year)
• Good performance status and
• Lack of evidence of skin or soft tissue
damage (skin fibrosis, atrophy or
telangiectasis) from the previous
irradiation course
Results of RT

Results

Neurological Sequelae
• Hypothalamo-Pituitary dysfunction
– Median incidence of clinical dysfunction is 3%.
– Cumulative incidence of endocrine dysfunction
higher at 67% at 2 yrs.
– Most common disturbance seen in GH secretion.
– Thyroid hormone production affected the least.
• Hearing defects:
– Almost 7% patients become deaf with standard
therapy.
– Otitis media seen in 14% patients
– Prolonged tinnitus may be seen in 30% patients
• Temporal lobe injury:
– Incidence as high as 3% after 2 yrs.
– Toxicity more in altered fractionation regimens
• Cranial nerve injury:
– The incidence is as high as 6%.
Other Sequelae
• Significant xerostomia can be seen in
as high as 80 %
• Some degree of xerostomia is seen
all patients.
• Fibrosis of the subcutaneous tissue is
seen when doses exceeding 50 Gy
are used in almost 16% patients.
• Significant trismus, can occur in 5 to
10% patients.
• This particular complication can be
reduced by using a three-field
approach for boosting the
nasopharynx.
Conclusions
• Nasopharyngeal malignancies make
up a different population of head and
neck malignancies.
• These are eminently radio sensitive
and curable.
• Treatment planning is by necessity
complicated and time consuming.
• Brachytherapy can be used for
boosting the local activities.
• Chemoradiation is standard
treatment in locally advanced tumors
Thank You

Carcinoma Nasopharynx

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Carcinoma Nasopharynx

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Carcinoma Nasopharynx

Moderator: Dr Sushmita Ghoshal

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

space is located deep

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Nasal cavity & PNS

Lateral Parapharyngeal space

Oropharynx (tonsillar pillars)

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Low Grade Dysplasia

Inactivation of Chromosome p14, 15 and 16

High Grade Dysplasia

EBV infection Deletion 11 and 13

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Stage I Stage IIA Stage IIB

Stage III Stage IVA Stage IVB

Department of Radiotherapy, PGIMER, Chandigarh

External Late stage

KPS > 70 KPS < 70

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

• For the boost phase:

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

– In the lower anterior field a Below vocal cords C6

Department of Radiotherapy, PGIMER, Chandigarh

Kam et al: IJROBP 2003

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

“In effect, nasopharyngeal brachytherapy is

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh

Department of Radiotherapy, PGIMER, Chandigarh