Management of nasopharyngeal carcinoma: ESMO-EURACAN Guidelines

• Stage III and IVA disease are treated by CRT. The standard agent used is cisplatin.
• The most commonly used regimen is cisplatin 100 mg/m2 every 3 weeks concomitantly to RT. Weekly cisplatin (40 mg/m2/week) has also been shown to improve OS. The optimal cumulative total dose of concurrent cisplatin should be higher than 200 mg/m2.
• Concurrent nedaplatin was found to be non-inferior to concurrent cisplatin.
• Concurrent carboplatin is an available option but the evidence is conflicting.
• Intensification of the systemic treatment is needed for stage III-IVA non-keratinising NPC.
• ICT with cisplatin and gemcitabine followed by CRT for locally advanced NPC is associated with a benefit in RFS, OS and distant RFS, with more acute but not late toxicities versus CRT alone.
• The selection of patients to receive more ChT (post-chemotherapy) in addition to CRT in the form of either ICT or AC is a therapeutic area that is being explored in ongoing randomised controlled trials.
  
• In cases of persistent, high EBV DNA values after definitive treatment, a personalised approach with non-cross-resistant drugs or participation in a clinical trial is suggested.
• Small, local recurrences are potentially curable. The main therapeutic options include nasopharyngectomy, brachytherapy, radiosurgery, SRT, IMRT or a combination of surgery and RT, with or without concurrent ChT.
• Local recurrences not invading the carotid artery or extending intracranially are candidates for nasopharyngectomy; local recurrence, stage rT1-rT3 might benefit more from endoscopic nasopharyngectomy than IMRT.
• Lymphatic recurrences in the neck can be treated with neck dissection.
• In metastatic NPC, palliative ChT should be considered for patients with an adequate PS. A combination of platinum and gemcitabine is the first-line choice and improves OS.
• In patients with newly diagnosed, metastatic NPC, the addition of locoregional RT to systemic therapy improves locoregional control and ultimately OS.
• No standard second-line treatment exists. Active agents include paclitaxel, docetaxel, 5-FU, capecitabine, irinotecan, vinorelbine, ifosfamide, doxorubicin, oxaliplatin and cetuximab, which can be used as single agents or in selected combinations.
• Immunotherapy represents a promising strategy in this setting but its therapeutic positioning is still to be defined.
• CTL adoptive immunotherapy has demonstrated activity in highly pre-treated patients.
• Oligometastatic patients may achieve long-term survival after aggressive treatment, including chemotherapy, surgery or definitive RT to the metastases.

Personalised Medicine

• The first radiological imaging is suggested 3 months after completion of curative treatment. Sensitivity of MRI and PET are similar, whereas the specificity of PET is higher and so helps to differentiate between post-irradiation changes and recurrent tumours.
• Further follow-up for patients includes periodic examination of the nasopharynx and neck, cranial nerve function and evaluation of systemic complaints to identify distant metastasis. For T2-T4 tumours, MRI might be used on a 6-monthly basis for at least for the first 3 years after treatment.
• Plasma EBV DNA is a promising marker for the diagnosis of recurrence [II, B] and should be evaluated at least every year.
• Evaluation of thyroid function in patients who have received RT to the neck is recommended annually; pituitary function should also be evaluated according to signs/symptoms.

Reference:

"Nasopharyngeal carcinoma: ESMO-EURACAN Clinical Practice Guidelines for diagnosis, treatment and follow-up," is published in the journal journal Annals of Oncology.