Management of nasopharyngeal carcinoma: ESMO-EURACAN Guidelines

Staging and risk assessment

• Routine staging procedures include medical history, physical examination with cranial nerve examination, CBC, serum biochemistry (including liver and renal function tests and LDH), nasopharyngoscopy and radiological imaging.
• MRI is the most accurate way of defining local and nodal tumour staging and it should be preferred whenever available and according to the centre's expertise.
• FDG-PET adds further accuracy in nodal staging, is the best imaging method for detecting distant metastases and is recommended at least in locally advanced disease.
• Baseline audiometric testing, dental examination, nutritional status evaluation, ophthalmological and endocrine evaluation should be performed as appropriate.
• Pre-treatment QoL scales may be suggested to better delineate the individual risk and to prompt medical or physical support before the start of treatment.
• Pre- and post-treatment plasma/serum load of EBV DNA has prognostic value.

Treatment

• The optimal treatment strategy for patients with advanced NPC should be discussed in an MDT. Patients should be treated at high-volume facilities.
• IMRT (Intensity-modulated radiotherapy)Intensity-modulated RT is the mainstay of treatment.
  
• Overall, RT is targeted according to the primary tumour, pathological nodes and adjacent regions considered at-risk of microscopic spread from the tumour, and generally to both sides of the neck (levels II-V and retropharyngeal nodes).
• A total dose of 70 Gy is needed for the eradication of macroscopic disease and 50-60 Gy for the treatment of potential at-risk sites.
• Planning optimisation in terms of prioritisation and dose constraints for target and radiosensitive structures is fundamental.
• Stage I-II disease is treated by RT alone; for stage II disease, this approach is only used when IMRT is adopted.