1) Radiotherapy is the primary treatment for nasopharyngeal carcinoma due to the excellent response to radiation and proximity to critical structures making surgery difficult. 2) Concurrent chemoradiation provides the greatest survival benefits compared to radiotherapy alone or adjuvant chemotherapy alone based on multiple studies. A network meta-analysis found the treatments with the highest probability of benefit were chemoradiation followed by adjuvant chemotherapy. 3) Positioning and immobilization techniques such as thermoplastic masks are used to precisely deliver high radiation doses to target volumes while sparing surrounding healthy tissues. Intensity-modulated radiotherapy has improved the conformality and reduced side effects compared to 3D conformal radiotherapy.

1. Radiotherapy in Nasopharynx
Dr Pallavi Kalbande

2. Indications for RT
T1 T2 N0
RT only
T1 T2 N1
CTRT
T3 T4 N0
CTRT CHT
N2 N3 or
T3 T4 N1
CTRT alone
NACT
CTRT CTRT
CHT

3. Why
Radiotherapy?
Excellent response to RT and
Chemotherapy
Proximity to critical structure
Anatomic location
Surgical exposure and clearance
RP nodes cannot be surgically treated

4. Basic principles of RT
• Primary plus whole neck need to be treated
• 70 Gy or equivalent dose – Primary plus involved nodes
• 60 Gy – High risk of involvement
• 50 -54 Prophylactic dose
• Total dose is the main determining factor in out come
• Increased dose per fraction – long term toxixity
• T1-T2- 5 yr LC- 90-100%
• T3-T4 –40-70% with 70 Gy

6. Positioning and immobilization
• supine with head and shoulders immobilised
with 5 clamp thermoplastic mask
• chin is elevated to spare the oral cavity and
orbit
• spine should be kept as straight as possible if
posterior neck nodes are present, to facilitate
matching of an electron boost
• A mouth bite may be used to depress the
tongue
• If IMRT is used, the patient can be immobilised
with the chin in a neutral position

8. Ho’s Technique

9. Anatomical Landmarks

11. Inferior border at the
anterior commissure of lip

13. 2D to
IMRT

14. 3DCRT and IMRT
• CT scan slices measuring 3–5 mm are
obtained
• From 2 cm above the superior orbital
ridge (to include the skull base) to the
arch of the aorta inferiorly
• Intravenous contrast
• Reference marks are placed on the shell
at the CT visit to aid verification

15. GTV primary and nodes

16. High risk CTV_HR (CTV_70)

17. Intermediate risk CTV_IR (CTV_63)
• CTV_HR + 5mm

19. RT prescription

21. Conventional Vs IMRT

27. 5yr Efficacy results

28. Acute complications

29. Late complications

30. Addition of chemotherapy

31. Intergroup Trial
N=193
Concurrent Chemo RT
70 Gy/ 35# + 3 cycles of CDDP
RT alone
Adjuvant Chemotherapy
(CDDP + 5 FU)
x 3
Al sarraf et al JCO 98 16:

32. U.S. Intergroup 0099
• 3Y PFS 69% (CRT) vs. 24% (RT
alone), p <0.001
• 45% 3yrs PFS
• 3Y OS 76% (CRT) vs. 46%
(RT alone), p =0.005
• 30% 3 yrs OS benefit
Al sarraf et al JCO 98 16: 1310-7

33. U.S. Intergroup 0099
Issues
• Flawed study design
•Are the benefits from chemo due to concurrent administration, adjuvant, or
both?
• Terminated early after interim analysis showed survival benefit
• RT alone arm performed worse than expected
• Old RT techniques
• Many patients enrolled had WHO type I NPC (not EBV- associated)
• Adjuvant PF chemotherapy only feasible in some patients

35. Subsequent Asian Trials
Contradictory
3Y OS Rate of DM
Wee, JCO, 2005
(Singapore)
221 pts
WHO type II/II
Mostly T3-4 +/or
N2-3
Cis/RT ➟ PF X3 80% 18%
RT alone 65% 38%
p =0.0061 p =0.0029
Lee, JCO, 2005
(Hong Kong)
348 pts
WHO type II/II
Mostly N2-3
Cis/RT ➟ PF X3 78% 24%
RT alone 78% 27%
p =0.97 p =0.96
J Clin Oncol 23:6730-6738. J
Clin Oncol 23:6966-6975.

36. P=.004
NS
NS
J Clin Oncol 22:4604-4612. © 2004 by American Society of

37. • HR for death=0.82 (95% CI 0.71-0.95)
• 6% absolute survival benefit at 5yrs
• Greatest benefit from concurrent chemo
HR=0.60 (concurrent)
HR=0.97 (adjuvant)
Int. J. Radiation Oncology Biol. Phys., Vol. 64, No. 1, pp.
Meta-analysis in MAC-NPC- Collaborative Group

39. • The aim of this study was to update the meta-analysis,
include recent trials, and to analyse separately the benefit of
concomitant plus adjuvant chemotherapy
• 19 trials and 4806 patients
• Median follow-up was 7·7 years

40. Results
• Addition of chemotherapy to radiotherapy significantly
improved overall survival absolute benefit at 5 years 6·3%.
PFS, LRC was also better
• Concomitant plus adjuvant chemotherapy had maximum
benefit then concomitant without adjuvant chemotherapy
• but not adjuvant chemotherapy alone or induction
chemotherapy alone

43. Network Meta-analysis
• All randomized trials of radiotherapy (RT) with or without chemotherapy in
nonmetastatic nasopharyngeal carcinoma were considered
• 20 trials and 5,144 patients were included
• Treatments were grouped into seven categories:
• RT alone (RT)
• IC followed by RT (IC-RT)
• RT followed by AC (RTAC)
• IC followed by RT followed by AC (IC-RT-AC)
• concomitant chemoradiotherapy (CRT)
• IC followed by CRT (IC-CRT)
• CRT followed by AC (CRT-AC)

46. Conclusion
• Results The three treatments with the highest probability of
benefit on overall survival (OS) were
• CRT-AC
• CRT
• IC-CRT

48. IMPT
• first nine patients treated with IMPT for NPC
• With a median follow-up of just over 2 years
• no patients developed local or regional
recurrence
• one patient developed distant metastatic
disease and subsequently died.

49. Altered fractionation

50. Study design
• 189 eligible patients were randomized to one of four treatment
groups
• CF
• CF + C
• AF
• AF + C
Concurrent-adjuvant chemotherapy combined with AF significantly
reduced failure and cancer-specific deaths
major late toxicity and incidental deaths were statistically insignificant