If receive induction chemotherapy
Dose
Delineation
Sequence
and options
Stage II to IVA (AJCC 8th) NPC
N0
T3N0
N2-3
& T3-
4N1
&
T4N0
N1
Chemotherapy
is not routinely
recommended but
may be offered if
there are adverse
features, such
as bulky tumor
volumes or high EBV
DNA copy number
Concurrent
chemoradiotherapy
should be
offered. Adjuvant
or induction
chemotherapy may
also be offered.
Induction
chemotherapy
should be offered
in addition to
concurrent
chemoradiotherapy
For those who don't receive induction
chemotherapy plus concurrent
chemoradiotherapy, then concurrent
hemoradiotherapy plus adjuvant
chemotherapy should be offered
a
Concurrent
chemotherapy
may be offered,
particularly for T2N1
patients
Prescribed dose of 70 Gy in
33–35 fractions (2.0–2.12 Gy
per fraction) delivered over 7
weeks (once daily, 5 fractions
per week) should be offered.
Radiation dose may be
adjusted according to tumor
volume and its response to
(chemo-)radiotherapy
For patients who have
undergone induction
chemotherapy, the pre-
induction scan should be fused
with the post-induction CT
simulation dataset to illustrate
initial disease extent. Gross
tumor volume should generally
follow pre-induction tumor
extent, especially within bony
anatomy
Delineation of elective nodal volumes should cover bilateral neck from
retropharyngeal lymph nodes to level IV and V. Level 1b may be omitted in
prophylactic volume unless there's involvement of the anterior half of nasal cavity
or if there are level II lymph nodes with extranodal extension or size greater than
2 cm or bilateral involvement. Omission of lower neck volume in uninvolved side
of neck may be considered if the neck contains no equivocal lymph node(s)
IMRT with daily image guidance
should be offered; both SEQ-
and SIB-IMRT are acceptable
Stage
II
disease
Stage
III–IVA
disease
Radiotherapy Chemotherapy Induction
Target delineation should follow
consensus guidelines and exploit
technical opportunities including
image fusion. MRI image fusion
with CT for target delineation is
mandatory, especially to appreciate
potential tumor extension
at skull base and rule out or
confirm presence of cranial nerve
involvement and/or intracranial
extension
Treatment
Figure 1. Stage II to IVA Nasopharyngeal Carcinoma
