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Nasopharyngeal Carcinoma: Management of localised disease
Dr Joseph Wee FRCRNational Cancer Centre SingaporeDuke-NUS Medical School, Singapore
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• “I have no conflicts of interest to disclose.”
Disclosure
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• Diagnostic work up• Staging• Radiotherapy• Follow up• Role of chemotherapy
Lecture Outline
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• Naso-endoscope and Biopsy• Staging
– MRI– CT PNS, thorax, abdomen and Bone Scan or PET-CT
• Bloods– FBC, u/e/Cr, LFT– EBV DNA– Hepatitis B screening– ? LDH, CRP
• Planning CT
Diagnostic Workup
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Staging – 7th edition
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Staging – 8th edition
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Staging – 8th edition
Lydiatt et al, CA 2017
Pan et al, Cancer 2016
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Staging – 8th edition
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Staging – 8th edition
Pan et al, Cancer 2016
Lydiatt et al, CA 2017
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• Diagnostic work up• Staging• Radiotherapy• Follow up• Role of chemotherapy
Lecture Outline
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RT - Planning CT
Lee et al, R&O 2018
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IMRT
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IMRT – Target Delineation - CTVp
IMRT – Target Delineation - CTVp
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IMRT – Target Delineation - CTVn
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IMRT – Target Delineation - CTVn
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IMRT – Target Delineation - CTVn
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IMRT – Target Delineation - OAR
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IMRT – Target Delineation - OAR
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• 70Gy in 33-35 fractions– Boost
• ?improve local control in 2D era (9% per Gy)• Brachytherapy, stereotactic boost• Risks of neurovascular complications
– IMRT era • Simultaneous integrated boost (SIB)
Total dose of RT
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IMRT Outcomes
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T4 failures
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GTV underdosing
GTV <66.5Gy > 3.4cc
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Marginal failures
70Gy to post NACT GTV64Gy to disappeared GTV
No survival detrimentBetter toxicity profile
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GTVp
GTVp > 48cc
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Late Toxicities
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NACT to reduce late toxicities
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How to avoid TLN
Two dosimetric features (D0.5cc and D10), is significantlyassociated with TLN status (P < .001)
rV40 < 10% or aV40 < 5cc
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TLN – genetic susceptibility
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Dysphagia
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Hippocampus sparing RT
RTOG Atlas
Radiation-induced neurocognitive function decline
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• Proton therapy– Kills less circulating T cells
Proton Therapy
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Follow up EBV DNA
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Salvage Surgery
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Endoscopic Nasopharyngectomy
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OS LRFS DMFS Gr 5 toxicity5 year 41% 72% 85% 33%
Salvage Re-RT
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Carbon ion for recurrent NPC
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• Diagnostic work up• Staging• Radiotherapy• Follow up• Role of chemotherapy
Lecture Outline
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• Early Stage – Stage 1, 2
Role of Chemotherapy : Can we individualize?
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T1 – Good local and Distant control
Oral Oncology 2018
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T2 - distant control
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T2 - distant control
Limited to those with N1 disease
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Benefit is Distant Control and not Loco-regional Control
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LN > 3 cmEBV > 4000 copies
Summary (1) – Early Stage Tumours
• T1N0-1 (LN<3cm) - IMRT• T2N0-1 (LN<3cm) - IMRT• T1-2N1 (LN>3cm, EBV>4000) - ddp-IMRT
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Standard of Care: Stage 3, 4
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2 trials – results expected very soon
• HK 0501– Al-Sarraf vs Reverse Al-Sarraf
• SYSUCC– Induction Cis-Gem Cis-IMRT vs Cis-IMRT
Food for thought #2
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• HK 0501– Induction is superior to Adjuvant
• SYSUCC– Induction is superior to CCRT
• When than can you omit Induction?
• Cis-Gem; Cis-Xeloda; Cis-5FU or TPF
• ?? Must it be ddp-RT – or should we be doing trials looking at ?5FU-RT or ?cyclo-RT
Scenario : If both trials are positive
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Thank you
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