Early Stage Nasopharyngeal Cancer: 10

A Highly Curative Disease with Radiation Therapy

Roger Ove, Ron R. Allison, and Jiade J. Lu

CONTENTS
10.1
10.1 Introduction 137 Introduction
10.2 Evolution of Staging 138
10.3 Management Strategy for Early
Historically, surgery and radiotherapy were the main-
Stage NPC 140 stays of therapy for nasopharyngeal cancer. Owing to
10.3.1 Radiotherapy Alone: Historical Data 140 the difficulty of the surgical approach to the nasophar-
10.3.2 Radiotherapy Alone for Early Stage ynx, and the difficulty in excising tumors in this loca-
Disease 140 tion with adequate margins, radiotherapy has been
10.3.3 Chemotherapy and Early
Stage Disease 141
the primary modality since 1950 (Wilson 1950).
This was also due in part to the good results obtained
10.4 Radiation Therapy Technique in the with radiotherapy. More recently, phase III data has
Treatment of Early Stage NPC 143
10.4.1 Altered Fractionation 143 established the role of concurrent chemotherapy with
10.4.2 Intensity Modulation 143 or without sequential adjuvant chemotherapy as the
10.4.3 Brachytherapy 144 cornerstone of treatment for the majority of cases.
10.4.4 Radiosurgery 145 The landmark trial that established this was the
10.5 Conclusions 145 Intergroup 0099 trial, more recently supported by
larger trials from Asia (Chan et al. 1995, 2002, 2004;
References 145 Al-Sarraf et al. 1998; Chua et al. 1998; Ma et al.
2001; Lee et al. 2004; Wee et al. 2004). These trials
have been limited to advanced stage disease, with the
definition of “advanced” varying based on the staging
system used.
Nasopharyngeal cancer in the western world is
relatively rare and typically presents as advanced
stage disease. No randomized data are available to
assess the benefit of concurrent chemotherapy for
early stage disease in this population, nor is it likely
to materialize. As a result, in the community it is com-
Roger Ove, MD, PhD mon practice to employ chemoradiation for all stages
Department of Radiation Oncology, Leo Jenkins Cancer of disease. Even in the much larger Asian trials, early
Center, The Brody School of Medicine at ECU, 600 Moye Blvd.,
Greenville NC, 27834, USA stage disease is not directly addressed. However, the
Ron R. Allison, MD results with radiotherapy as monotherapy have been
Department of Radiation Oncology, The Brody School of quite good for early stage disease, and the benefit of
Medicine at ECU, 600 Moye Blvd., Greenville, NC 27834, USA adding chemotherapy, either sequential or concur-
Jiade J. Lu, MD, MBA rent, is not at all clear. This issue is confused by the
Department of Radiation Oncology, National University
Cancer Institute, National University Health System, National fact that the definition of early stage has migrated
University of Singapore, 5 Lower Kent Ridge Road, Singapore over time, and it is important to interpret the results
119074, Republic of Singapore of studies in the context of the staging used.
138 R. Ove, R. R. Allison, and J. J. Lu
Another confounding factor in analyzing results
of historical series is that the results of modern series
show a substantial improvement in survival. This is
quite likely due to improvements in imaging and
advances in radiotherapy technology (intensity-
modulated radiotherapy, IMRT), and increased dose
with techniques such as intracavitary brachytherapy.
A substantial portion of this improvement is most
likely due to stage migration, as more accurate stag-
ing secondary to improved imaging and the availabil-
ity of positron emission tomography (PET) will tend
to upstage patients formerly thought to be low risk.
For carefully selected patients, radiotherapy alone
can offer excellent results. However, it is important
not to neglect the benefits of multidisciplinary man-
agement for these patients, as for locally advanced
cases. Attention to nutrition, swallowing function,
dental issues, social support, and potential complica-
tions of therapy remain important. In addition, the
multidisciplinary environment provides an appro-
priate forum for review of pathology in clinical con-
text, and a mechanism for input from all appropriate
specialties regarding imaging and staging.
10.2
Evolution of Staging
Staging of nasopharyngeal cancer, as with most
malignancies, is a complex issue that evolves over
time as prognostic factors become apparent. As the
management of the disease tends to be nonsurgical,
staging is clinical rather than pathological. Several
staging systems have been used over the past 20
years, and the prognostic significance of various risk
factors is a complex issue. Early American Joint
Committee on Cancer (AJCC) classifications (1977
and 1992) for head and neck cancer typically resulted
in a stage III or IV grouping for most nasopharyn-
geal malignancies, owing to the high incidence of
clinically involved neck disease (AJCC 1977, 1992). (A
detailed discussion on the staging of NPC is out of
the scope of this chapter and is detailed in chapter 24.
However, knowledge on evolution of the staging
especially for early stage disease is partinent)
In Asia, the Ho staging system (Ho 1972) is com-
monly used, and may result in superior prognostic
separation of patient groups when compared with the
1977 AJCC system or the 1967 Uniform International
Committee on Cancer (UICC) system (Ho 1978; Teo
et al. 1991). Because of the high incidence of lymph
node involvement with nasopharyngeal cancer, the Ho
system separates patients based on the level of lymph
node involvement (Table 10.1). The 1992 AJCC system,
unchanged from AJCC 1977, included some patients
with N1 disease in stage III, but the remaining patients
with nodal involvement and metastases outside the
neck were all grouped together into stage IV. Nodal
involvement appears in stage II of the Ho system, and
supraclavicular metastases are represented in a sepa-
rate stage IV (Table 10.1). The AJCC system now incor-
porates some of the aspects of the Ho system (AJCC
1998). The current AJCC system is superior to both the
Ho system and the previous AJCC system (Cooper
et al. 1998; Au et al. 2003). Further refinement may lead
to improvement in risk stratification. For example, T4
patients with intracranial invasion or involvement of
the orbit or cranial nerves have a poor prognosis (Au
et al. 2003). However, the benefits of such refinement
must be weighed against the benefits of staging stabil-
ity over time, simplicity, and accuracy of reporting.
In the mid-1990s, data from several investigators
indicated that lateral invasion into the parapharyn-
geal space was associated with higher risk of failure
(Chua et al. 1996; Teo et al. 1996; Xiao et al. 2002).
Such invasion is of increased prognostic significance
in patients without other more significant risk fac-
tors, such as cranial nerve invasion or lymph node
positivity. Parapharyngeal space invasion predicts for
decreased survival, disease-free survival, and local
control. The 1997 (and current) AJCC staging system
separates T2 into T2a and T2b based on this risk
stratification, and subsequent chemoradiation trials
have included T2bN0 patients. Between 75 and 90%
of patients with T2 disease are stage T2b. Posterior
involvement of the parapharyngeal space (posterior
to the styloid process) portends a worse prognosis in
some series, but this has not been consistently
reported (Chua et al. 1996; Xiao et al. 2002). The
Chinese staging system adopted in 1992 classifies
parapharyngeal involvement posterior to the styloid
process as T3, while anterior involvement is T2 (Hong
et al. 2000; Ma et al. 2001). Retropharyngeal lymph
node involvement does not appear to be an indepen-
dent risk factor for recurrence (Chua et al. 1997).
In reviewing the various staging systems, with
regard to their impact on the definition of early stage
disease, one sees that the current AJCC system is simi-
lar to the Ho and Chinese system. The older AJCC sys-
tems would classify patients with nasal cavity or
oropharyngeal involvement as T3, while this is classi-
fied as T2 in the other systems. Thus, patients with
such involvement treated on older trials using the
 Early Stage Nasopharyngeal Cancer: A Highly Curative Disease with Radiation Therapy 139

Table 10.1. Staging systems

Current and 1997 AJCC 1992 AJCC Ho 1992 Chinese

T1:confined to nasopharynx T1:one subsite T1:confined to nasopharynx T1:confined to nasopharynx

T2:soft tissue invasion (nasal T2:more than one subsite T2:nasal fossa, oropharynx, T2:nasal cavity, oropharynx, soft
cavity or oropharynx) muscle or nerves below base of palate, cervical prevertebral soft
a: Without parapharyngeal skull tissue, parapharyngeal anterior to
extension the SOa line
b: With parapharyngeal
extension
T3:bony or paranasal sinus T3:nasal cavity and/or orophar- T3a:bone involvement below T3:posterior to SOa line, either
extension ynx involvement base of skull anterior or posterior cranial
nerves, skull base, pterygoid
plates, pterygopalatine fossa.
T4:intercranial extension or T4:invades adjacent structure T3b:involves base of skull T4:both anterior and posterior
cranial nerve or infratemporal T3c:cranial nerves cranial nerves, paranasal sinuses,
fossa, hypopharynx or orbital cavernous sinus, orbit, infratem-
T3d:orbits, laryngopharynx or
involvement poral fossa, C1 or C2
infratemporal fossa
N1:unilateral, ≤6 cm N1:single ipsilateral ≤3 cm node N1:upper neck above thyroid N1:mobile nodes <4 cm above
notch hyoid
N2:bilateral, ≤6 cm N2a:single ipsilateral >3, ≤6 cm N2:below thyroid notch above N2:nodes below hyoid or 4–7 cm
line joining end of clavicle and
superior margin of trapezius
N3a:>6 cm node N2b:or multiple ipsilateral nodes N3:supraclavicular or skin N3:supraclavicular, fixed, skin
all ≤6 cm involvement involvement, or >7 cm
N3b:supraclavicular involvement N2c:bilateral or contralateral
nodes all ≤6 cm
Stage I: T1N0M0 N3:>6 cm node
Stage IIA: T2aN0M0 M1:metastases M1:metastases M1:metastases
Stage IIB Stage I: T1 N0M0 Stage I: T1N0 Stage I: T1N0M0
T1N1M0
T2N1M0
T2aN1M0
T2bN0M0
T2bN1M0
Stage III Stage II: T2 N0M0 Stage II: T2 and/or N1 Stage II: T2N0–1M0 or
T1N2M0 T1–2N1M0
T2aN2M0
T2bN2M0
T3N0M0
T3N1M0
T3N2M0
Stage IVA Stage III Stage III: T3 and/or N2 Stage III: T3N0–2M0 or
T4N0M0 T3 N0M0 T1–3N2M0
T4N1M0 T1N1M0 Stage IV: N3 (any T)
T4N2M0 T1N1M0 Stage IVA: T4N0–3M0
T2N1M0 Stage V: M1 or T1–4N3M0
T3N1M0 Stage IVB: M1
Stage IVB: any T N3M0 Stage IV
T4N0M0
T4N1M0
Any T N2M0
Any T N3M0
IVC: any T any N M1 Any T any N M1
a
The SO (stylo-occipital) line extends from the styloid process to posterior edge of the occipital foramen
140 R. Ove, R. R. Allison, and J. J. Lu
AJCC system, in particular the Intergroup 0099 trial,
included some patients that would be classified as T2
with modern staging. Thus, there may well be a benefit
to concurrent chemotherapy for such patients, and it
may be reasonable to extrapolate that bulk of disease
is an indication to consider more aggressive therapy.
10.3
Management Strategy for Early Stage NPC
10.3.1
Radiotherapy Alone: Historical Data
Historically, radiotherapy alone was used for both
early stage and advanced nasopharyngeal carcinoma.
Interpreting the results of studies from various parts
of the world is difficult, as the prognostic roles of
Epstein–Barr Virus (EBV) and histological classifica-
tions are incompletely understood. Undifferentiated
tumors (WHO type 3) tend to be more prevalent in
Southern China and Hong Kong, and there is a higher
incidence of EBV positivity, which is poor prognostic
factor (Yip et al. 1994). Paradoxically, in nasopharyn-
geal cancer the better differentiated keratinizing
squamous histology (WHO type 1) carries the worst
prognosis among histological subtypes (Neel and
Taylor 1989). Thus, both western and Asian popula-
tions are characterized by differing high-risk factors,
with a higher percentage of WHO type 1 than type 2
or 3 disease in the west, but a lower incidence of high
EBV titers. Early stage disease is also more common
in the Asian population, where nasopharyngeal can-
cer is more common, screening is practical, and clini-
cians are more familiar with the disease.
It may be these counteracting factors balance one
another. The results of radiation therapy alone series
in the United States at MD Anderson Cancer Center
(MDACC) (Sanguineti et al. 1997), Denmark
(Wilson 1950), and Hong Kong (Lee et al. 1992)
achieved roughly similar 10-year survival of 34, 37, and
43%, respectively. The Hong Kong series somewhat
superior results may be due to a higher percentage of
node negative disease (39%) and relatively few patients
with WHO type 1 histology (0.3%) (Lee et al. 1992).
The MDACC series is a classic western series detail-
ing the long-term outcome in a relatively large popu-
lation (184) of patients treated with radiotherapy
alone (Sanguineti et al. 1997). The 1992 AJCC stag-
ing system was used. T-classification, squamous his-
tology, and cranial nerve deficits were poor prognostic
factors for local control. Poorly differentiated or
undifferentiated carcinoma, or lymphoepithelioma,
experienced only half the local failure rate of better
differentiated squamous cell carcinomas. T stage was
correlated with local control, but not with neck con-
trol, and in general actuarial neck control was better
than control at the primary site. Five-year local con-
trol for T1, T2, T3, and T4 were 93%, 79%, 68%, and
53%, respectively. Twenty percent of the patients were
T1–2N0 or T1–2N1. These results illustrate that radio-
therapy alone for early stage lesions can achieve excel-
lent results, but for more advanced lesions the outcome
was suboptimal, leading to a series of sequential and
concurrent chemoradiotherapy trials.
Other western series are similarly very limited in
providing insight into early stage disease, as the dis-
ease tends to be diagnosed late, and the overall inci-
dence of nasopharyngeal cancer is low. However,
sizeable numbers of early stage patients have been
reported in recent years from endemic areas.
10.3.2
Radiotherapy Alone for Early Stage Disease
A large series of 362 early stage patients was recently
reported from China, where chemotherapy for stage I
and II cases is not routinely used, as it is considered
experimental (Xiao et al. 2009). The Chinese staging
system was used for these cases, a system that is simi-
lar to the AJCC system with respect to early stage dis-
ease (Hong et al. 2000; Ma et al. 2001). In the Chinese
system, N1 refers to small mobile nodes in the high
neck. The majority of these patients were treated with
external beam radiotherapy alone, with 20% receiving
a portion of the dose via an intracavitary brachyther-
apy boost. Conventional RT was used (not IMRT). The
majority of the patients had poorly differentiated
squamous cell carcinoma, and three quarters were T2.
T2N1 patients were found to have a worse prognosis
than the other stage I and II patients (T1–2N0 and
T1N1). Distant disease was the primary pattern of fail-
ure, particularly in the case of T2N1 patients.
The authors analyzed the failure rates and survival
by specific stage, and found 5 year survival of:
T1N0 96.6%
T2N0 91.3%
T1N1 85.8%
T2N1 73.1%
The overall 5-year survival was 85%, and local control
was approximately 90% and did not vary among the
groups. Roughly 20% of the T2N1 patients suffered a
distant failure, while distant metastases free survival
 Early Stage Nasopharyngeal Cancer: A Highly Curative Disease with Radiation Therapy 141

Table 10.2. Survival for stage I patients treated with radiotherapy alone

Reference Location Patients Staging Brachy f/u (year) Survival

Chang et al. (1996) Taiwan 183a AJCC77 Yes 5 86%

Cooper et al. (1998) US 19 AJCC97 No 3 75%
Ozyar et al. (1999) Turkey 8 AJCC97 No 3 100%
Cheng et al. (2000) Taiwan 11 AJCC97 No 3 92% DFS
Chua et al. (2003a, b) Hong Kong 50 AJCC97 No 10 98% DSS
Leung et al. (2005) Hong Kong 113 AJCC97 No 5 85%
Yen et al. (2005) Taiwan 51 AJCC97 Yes 5 82%
Lu et al. (2005) China 35 Chinese No 4 89%
Cao et al. (2007) China 53 Chinese Yes 5 91–95%
Lu et al. (2004) Singapore 13 AJCC97 Yes 2 100%
Kwong et al. (2004) Hong Kong 33 AJCC97 No 3 100%
Fang et al. (2008) Taiwan 15 AJCC97 No 3 94–100%
Tham et al. (2009) Singapore 21 AJCC97 Yes 3 93%
Xiao et al. (2009) China 62 Chinese Yes 5 95%

Overall survival is given if available. The majority of the references are from endemic areas, due to the relative rarity of early
stage nasopharyngeal carcinoma in the western world
DFS disease-free survival; Overall survival not reported; DSS disease-specific survival. Overall survival not reported
a
T1-T2N0 mixed for this publication

was 95% for the other groups. The majority (91%) of
the T2 patients has parapharyngeal space invasion,
and would be classified as T2b with the current AJCC
staging system. The authors conclude that chemo-
therapy may be helpful for T2N1, and suggest that the
topic be explored in a randomized trial.
A similar series from Hong Kong reported on 141
stage I and II patients treated with radiotherapy alone
(Chua et al. 2003a, b). The patients were restaged per
the current AJCC system, and all were treated with
radiotherapy alone. Fifty seven were node positive.
Stage I patients had outstanding results, with 10-year
disease specific survival of 98%, recurrence free sur-
vival 94%, local control 96%, and 2% distant failure.
For stage II patients, the numbers were considerably
worse, with 60% disease specific survival and 36%
distant metastases, although local control was good
at 93%. N1 status was found to be more important
than T2 disease, consistent with the recent series
from China (Xiao et al. 2009).
In most series that break down stage II into those
with or without T2b disease (parapharyngeal involve-
ment), the majority of stage II patients have such
progression. Thus, results for stage II disease is often
considerably worse than stage I. Table 10.1 shows the
overall survival for publications that reported a sub-
stantial number of stage I patients treated with radio-
therapy alone. Table 10.2 shows the corresponding
results for stage II.
10.3.3
Chemotherapy and Early Stage Disease
There have been no randomized studies on the use of
concurrent chemotherapy with radiotherapy for
early stage (I and II) nasopharyngeal cancer, nor
were a substantial number of such patients included
in more general trials. Neoadjuvant chemotherapy
has been more commonly explored in the past, and
some data is available, with inconsistent results.
A retrospective series from Taiwan reported on a
subset of 44 early stage (I and II) patients among the
189 nasopharyngeal patients undergoing concurrent
chemoradiation or radiotherapy alone (Cheng et al.
2000). These patients were staged per AJCC 1997.
142 R. Ove, R. R. Allison, and J. J. Lu

Table 10.3. Survival for stage II patients treated with radiotherapy alone

Reference Location Patients Staging Brachy f/u (year) Survival

Chang et al. (1996) Taiwan 183a AJCC77 Yes 5 86%

Cooper et al. (1998) US 33 AJCC97 No 3 65%
Ozyar et al. (1999) Turkey 21 AJCC97 No 3 72%
Chua et al. (2003a, b) Hong Kong 91 AJCC97 No 10 60% DSS
Leung et al. (2005) Hong Kong 398 AJCC97 No 5 92%A,78%B
Yen et al. (2005) Taiwan 325 AJCC97 Yes 5 72%
Lu et al. (2005) China 215 Chinese No 4 91%
Cao et al. (2007) China 268 Chinese Yes 5 81–93%
Fang et al. (2008) Taiwan 78 AJCC97 No 3 80–89%
Tham et al. (2009) Singapore 52 AJCC97 Yes 3 88%
Xiao et al. (2009) China 300 Chinese Yes 5 85%

Two survival numbers appear for one series, which reflects the survival for stage IIA and IIB disease (overall stage II not
reported)
DSS disease-specific survival. Overall survival not reported
a
T1-T2N0 mixed for this publication

Of these 44 patients, 32 received concurrent chemo-
radiation, to a dose of 70 Gy with standard fraction-
ation and concurrent cisplatin and 5-FU. The patients
treated with radiotherapy alone were primarily stage
I. The locoregional control rate and disease-free sur-
vival at 3 years for the stage II chemoradiotherapy
group was no worse than that of the stage I patients
treated with radiotherapy alone, with 100% local
control for the chemoradiation stage II group. Patient
numbers in this retrospective data were relatively
low to make firm conclusions (Table 10.3).
Neoadjuvant chemotherapy was employed in mul-
tiple trials in endemic areas, with mixed results over-
all, and some of these included early stage patients.
The results of two phase III induction trials per-
formed in Hong Kong were pooled, with the early
stage patients combined and analyzed (Chua et al.
2006). The subgroup analysis pooled data from trials
incorporating platinum, bleomycin, and 5-FU fol-
lowed by radiotherapy, compared with radiotherapy
alone. The patients were restaged according to the
AJCC 1997 system. A total of 784 patients were
included. Surprisingly, differences in survival, local
control, and metastases were only seen in the stage I/
II patients. All the patients in the stage I/II group had
stage IIb disease (parapharyngeal space invasion or
N1). The 5-year survival rate was 79% in the com-
bined modality arm and 67% in the RT-alone arm (p
= 0.048). Local control was unchanged, but distant
metastasis-free survival was 86% when compared
with 74% (p = 0.0053). A weakness of this study is the
lack of concurrent chemotherapy, and the failure to
see any improvement with the addition of chemo-
therapy for higher stage patients.
A recent analysis from Seoul, Korea, reported on
the outcomes of 60 early stage nasopharyngeal can-
cer patients treated with radiotherapy alone or com-
bination chemotherapy and radiotherapy (Song
et al. 2008). Twenty-nine patients received induction
chemotherapy, in most cases with cisplatin and 5-FU.
Concurrent chemotherapy was not used. One patient
received carboplatin, and two received docetaxel as
part of the induction regimen. Of the 60 patients, 17
were AJCC 1997 stage I or IIa, and 43 were stage IIb,
equally distributed between the groups. There was
no significant difference in survival, local control,
metastases, or disease-free survival, and results were
numerically superior in the radiotherapy alone
group. The patients receiving chemotherapy were
treated at later dates (after 1996) predominantly, but
otherwise the groups were relatively well balanced. In
multivariate analysis, delay in the onset of radiother-
apy was significantly associated with locoregional
failure in the IIb patients (p = 0.044). Weaknesses of
this study include being retrospective, as selection
bias may have favored adding chemotherapy for
 Early Stage Nasopharyngeal Cancer: A Highly Curative Disease with Radiation Therapy
higher risk patients despite that fact that risk factors
appeared balanced, and also the time span over,
which these patients were accrued (1986–2004).
However, most nasopharyngeal series show improved
outcomes for patients treated in more modern times,
and the opposite is seen here.
Locally advanced chemoradiation trials for
nasopharyngeal cancer show a clear benefit to con-
current chemotherapy, and less certain benefit to
sequential chemotherapy. Trials exploring the benefit
of concurrent chemotherapy in the setting of a high-
risk population of early-stage disease are lacking.
10.4
Radiation Therapy Technique in the
Treatment of Early Stage NPC
10.4.1
Altered Fractionation
Altered fractionation regimens, including hyperfrac-
tionation and concomitant boost accelerated frac-
tionation, have been explored in multiple head and
neck cancer trials, and typically nasopharyngeal pri-
maries are excluded. The U. S. Intergroup Study trial
0099 trial (Al-Sarraf et al. 1998) employed once
daily radiation therapy with or without chemother-
apy. There has been some activity exploring nasopha-
ryngeal cancer with altered fractionation regimens
because they have led to local control improvements
in other sites such as the oropharynx (Horiot et al.
1992; Fu et al. 2000).
Few randomized trials addressing the role of twice-
a-day irradiation vs. once-a-day irradiation in head
and neck cancer have included tumors of the
nasopharynx (Sanchiz et al. 1990; Teo et al. 2000).
Sanchiz and colleagues’ (1990) trial included 892
locally advanced head and neck cancers (UICC stage
T3-T4, N0–3, M0). The patients were randomized to
daily radiotherapy (Group A), twice-daily irradiation
(Group B), and once daily irradiation with 5-fluorou-
racil (5-FU) (Group C). This study included 92 patients
with nasopharyngeal cancer, a practice that stopped
once results of the Intergroup 0099 study determined
a standard of care for nasopharyngeal cancer. Disease-
free survival and survival were improved with both
hyperfractionation and chemotherapy (Groups B and
C), in comparison with Group A. No difference was
seen between the hyperfractionation group and the
chemotherapy group. Inadequate details and patient
143
numbers are available to assess the efficacy of hyper-
fractionation for early stage disease.
A randomized trial specific to the nasopharynx
was conducted in Hong Kong and accrued 159
patients, and compared conventional radiotherapy
with accelerated hyperfractionated radiotherapy
(Teo et al. 2000). All patients in this study were N0 or
N1 (Ho stage). Data at 5 years demonstrated no dif-
ference in survival or disease control, but there was
an increased incidence of neurological injury with
the experimental arm, with increased temporal lobe
necrosis, optic apparatus injury, and brainstem/cord
injury. Conventional two-dimensional radiotherapy
technique was employed in this study, and it is possi-
ble that with modern technique and increased inter-
fraction interval the results could be improved. An
increase in acute and late complications secondary to
accelerated fractionation for nasopharyngeal carci-
noma, without improvement in disease control, has
been reported elsewhere (El-Weshi et al. 2001). The
University of Florida employed hyperfractionation in
45 of 82 patients undergoing radiotherapy (with or
without chemotherapy) for nasopharyngeal carci-
noma, and reported no increase in efficacy or compli-
cations (Mendenhall et al. 2006).
10.4.2
Intensity Modulation
IMRT has essentially become standard of care for the
majority of head and neck cancer sites. IMRT is a
useful technique for the nasopharynx, due to the
proximity of critical structures to the target. With
conventional therapy, there is considerable risk of
late morbidity. Several dosimetric studies have dem-
onstrated an improvement for IMRT over conven-
tional techniques and 3D conformal techniques in
the setting of nasopharyngeal cancer (Verhey 1999;
Sultanem et al. 2000; Hunt et al. 2001; Munter
et al. 2002; Lee et al. 2003). There are several single
institution series demonstrating the efficacy of IMRT
for head and neck cancer in general (Chao et al.
2003) and for the nasopharynx in particular (Lee
et al. 2002), and a phase II multiinstitutional trial has
been conducted by the RTOG (RTOG 0225).
RTOG 0225 utilized an integrated boost technique
of the boost, with 2.12 Gy delivered to the primary
PTV while 1.8 Gy is delivered to an intermediate sub-
clinical PTV, both over 33 fractions. The low neck
and regions at lesser risk received lesser doses. The
regimen was based on UCSF experience, showing
144 R. Ove, R. R. Allison, and J. J. Lu
excellent results for 67 nasopharynx patients treated
with IMRT (Lee et al. 2002). At 4 years, local control
was 97% and regional control 98%. Xerostomia was
remarkably mild, considering the need to cover the
bilateral neck.
For early stage disease, results with IMRT have
been promising, as described in a series of 203
nasopharyngeal patients from Taiwan treated with
either IMRT or conformal techniques (Fang et al.
2008). Roughly half were treated with IMRT. Forty-
five of the patients were AJCC 1997 stage I or II.
Quality of life was superior for the IMRT group, with
no significant difference in oncologic measures.
Three year survival for the IMRT group was 94 and
89% for stage I and II, respectively. The correspond-
ing survival numbers for conformal radiotherapy
were 100 and 80%. A series of 33 T1N0 patients
treated in Hong Kong established good results at 3
year follow-up, with 100% overall survival and local
control, with one neck failure (Kwong et al. 2004).
Mean parotid dose was high, at 38 Gy, but 85% of
patients recovered 25% of their baseline parotid
function at 2 years. The National Cancer Centre in
Singapore published its nasopharyngeal experience,
which included 72 stage I and II patients (Tham et al.
2009). Disease-free survival was excellent, at approxi-
mately 95% for T1 and 90% for stage II, but detailed
morbidity information was not reported. Some
patients also received an intracavitary boost.
It has been argued that IMRT should not be used
for head and neck cancer if the upper aspects of neck
level II require treatment bilaterally, as sparing
parotid function will prevent adequate coverage of
the upper portions of level II. In the case of nasopha-
ryngeal cancers, early stage or otherwise, it is cer-
tainly the case that level II should be treated. At
present, it appears that using IMRT in this scenario
has important benefits, with a reduction in the risk of
CNS complications, improved parotid function, and
no unusual incidence of neck failures. Although mean
parotid doses tend to be higher than for other ipsilat-
eral head and neck cancers, there does appear to be a
clinical reduction in xerostomia and improvement in
quality of life (Hsiung et al. 2006; Fang et al. 2008).
10.4.3
Brachytherapy
Intracavitary brachytherapy is often used to boost the
primary site. Owing to the limitation of the effective
treatment range, brachytherapy is considered more
effective in early T-classification disease. Technical
details and dosing are often omitted from publica-
tions, and the technique has been used selectively. The
typical technique utilizes one or two pediatric endo-
tracheal tubes, with sources placed between the pos-
terior wall of the maxillary sinus and the free edge of
the soft palate. Dose is then prescribed to a point or
surface 0.5 cm deep to the vault mucosa, pending nor-
mal tissue tolerance of adjacent structures (Wang
et al. 1975). Custom applicators are also commercially
available. Both high-dose rate (HDR) and low-dose
rate brachytherapy have been used.
Brachytherapy boosts have been associated with
improved local control, and allow a higher dose to be
delivered than could be safely delivered with con-
ventional external beam techniques (Wang 1991).
Retrospective data suggest that early stage patients
treated with conventional radiotherapy technique
benefit from a brachytherapy boost, with both
improvement in local control and survival seen
(Chang et al. 1996; Cao et al. 2007). The use of
brachytherapy has declined in recent years as the
use of IMRT has become more widespread, but HDR
has been used with IMRT for nasopharyngeal cancer
(Tham et al. 2009). HDR brachytherapy has been
studied prospectively, with 100% local control
achieved for a series of stage I and II patients (Lu
et al. 2004). The regimen used was 5 Gy × 2 delivered
1 week apart, after delivering 66 Gy to the primary
site with conventional external beam radiotherapy.
Dose was prescribed 1 cm superior to the midpoint
of the sources.
HDR brachytherapy is not without risk, particu-
larly late complications, and care must be taken if
target tissue is adjacent to the optic apparatus. For
early stage disease, normal anatomy will most likely
lead to acceptable tolerances with standard tech-
nique. Complications have been reported, however.
The largest published series employing routine HDR
brachytherapy for early stage nasopharyngeal carci-
noma treated 133 patients, with 64.8–68.4 Gy exter-
nal beam RT and 1–3 HDR boosts of 5–5.5 Gy each
(Chang et al. 1996). The results were compared to a
similar cohort treated with external beam RT alone,
dosed slightly higher at 68.4–72 Gy. Brachytherapy
use was associated with improved survival and local
control. It was also associated with perforation of the
sphenoid sinus floor, necrosis of soft tissue, and other
complications involving the palate. The authors rec-
ommended limiting the fraction size, but limiting
the number of fractions to two 5 Gy fractions is very
likely safe and effective.
 Early Stage Nasopharyngeal Cancer: A Highly Curative Disease with Radiation Therapy
10.4.4
Radiosurgery
Recurrent disease after primary radiotherapy or
chemoradiotherapy has been treated with radiosur-
gery, with promising results (Cmelak et al. 1997;
Xiao et al. 2001; Chua et al. 2003a, b; Roh et al. 2008).
One of the advantages of this technique over
brachytherapy salvage is that inverse planning opti-
mization can be used to spare normal tissues and
hopefully reduce complications. This is particularly
attractive in the case of bulky locally advanced recur-
rences with irregular shapes, typically in close prox-
imity to critical structures. Such recurrences are
usually not amenable to salvage with brachytherapy.
Both single fraction (Cmelak et al. 1997) and frac-
tionated (Xiao et al. 2001; Roh et al. 2008) stereotac-
tic salvage has been reported. For single fraction
radiosurgery, the dose to the optic nerve, optic chi-
asm, brainstem, and cavernous sinus should be kept
under 8 Gy when the recurrence does not directly
involve these structures. Complications have of
course been reported, including cranial nerve palsies,
bone and soft tissue necrosis, CSF leaks, and trismus
(Cmelak et al. 1997; Roh et al. 2008).
More recently, radiosurgery as a component of
primary treatment for nasopharyngeal cancer has
been reported (Le et al. 2003; Hara et al. 2008).
These patients were locally advanced cases treated
at Stanford University with Cyberknife radiosur-
gery, now totaling 82 cases. Reported local control
has been excellent in this series, 98% at 5 years, with
70% survival. Temporal lobe necrosis has occurred
in ten patients (nine of which were T4 primaries),
and retinopathy occurred in three patients. For
early stage disease, radiosurgery has not yet been
reported, and presumably the risk of complications
would be less.
10.5
Conclusions
Despite the excellent results obtained with combina-
tion chemoradiotherapy for locally advanced
nasopharyngeal carcinoma, radiation therapy alone
remains a viable option for low-risk cases. A review
of the literature indicates that including all stage I
and II patients in this group is not appropriate, and
that there is a subset of stage II patients for which
chemotherapy is beneficial. In the US population, it
145
has been common practice to consider T2b patients
locally advanced, and candidates for enrollment in
concurrent chemoradiotherapy trials. In view of the
higher incidence of WHO type 1 histology in the
western world, and the poorer prognosis of this sub-
group, this is appropriate. Recent evidence suggests
that T2N1 patients in endemic areas also benefit
from the addition of chemotherapy. In addition, vari-
ations in the staging systems used lead to some ambi-
guity in the definition of high risk, and as a result
patients with bulky disease that are not strictly T3
should be considered for more aggressive therapy.
Randomized trials to establish the benefit of concur-
rent chemotherapy and refine an appropriate regi-
men are needed.
It has long been known that radiation dose plays
an important role in achieving optimal results for
nasopharyngeal cancer (Marks et al. 1982; Vikram
et al. 1985). Brachytherapy and radiosurgery are
methods that can be effective in delivering this dose
appropriately, if performed with appropriate respect
for normal tissue tolerance.
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