Carcinoma Nasopharynx

Carcinoma Nasopharynx
Moderator: Dr Sushmita Ghoshal
Anatomy
Department of Radiotherapy, PGIMER, Chandigarh
Anatomy
Foramen rotundum Foramen ovale Foramen spinosum Foramen lacerum
Parapharyngeal Space
The parapharyngeal space is located deep within the neck lateral to the pharynx
and medial to the ramus of the mandible. Shape of an inverted pyramid with the f
loor at the skull base and its tip at the greater cornu of the hyoid bone Two com
partments :
Prestyloid Space
Retrostyloid Space
Prestyloid Department Retrostyloid of Radiotherapy, PGIMER, Chandigarh
Lymphatic Drainage
Richest lymphatic plexus in the head and neck region. Submucosal lymphatics cong
regate at the pretubal region pretubal plexus. These then pass on to the retrophar
yngeal nodes as 8 -12 trunks which decussate in the midline. Lymphatic trunks pi
erce the level of the base of the skull and run between the pharyngobasilar fasc
ia and the longus capitis. The lymphatic trunks drain in three directions:
To the retropharyngeal nodes. To do the posterior cervical nodal and the conflue
nce of the 11th, cranial nerve and the jugular lymph node chains, situated atof
Radiotherapy, PGIMER, Chandigarh Department the tip of the
Anatomy: RPLN
The retropharyngeal nodes are present in two groups. The median group consists o
f 1 - 2 nodes interconnected in the midline. The lateral group consists of 13 no
des located between the lateral aspect of the posterior pharyngeal wall and the
carotid artery. These nodes are present from the vertebral levels C1- C3. The su
perior-most lymph node of the latter group is also known as the node of Rouviere
. This node lies in front of the arch of the Atlas being separatedDepartment of
Radiotherapy, PGIMER, Chandigarh from it by the longus
Median group. Lateral group.
CT anatomy
Incidence
Incidence: Sex
Clinical Features
Most common: Asymptomatic cervical lymphadenopathy (87%) MC node involved is the
posterior deep cervical (direct drainage from the lateral pharyngeal) Other pre
senting symptoms:
Nasal twang to speech Unilateral serous otitis media ( in adults) Cranial nerve
palsy: U/L Cr nv. II to VI (petrosphenoidal syndrome of Jacod) U/L Cr nv. XI to
XII ( Retroparotid syndrome of Villaret.) Cr nv V and VI most commonly involved.
Cr nv I, VII and VIII rarely involved. Sore throat : Oropharyngeal extension Pa
in: Compression of Vth cranial nerve ( facial pain) Trismus: Mandibular nerve in
volvement or pterygoid Department of Radiotherapy, PGIMER, Chandigarh muscle inv
asion.
Cranial Nerve involvement

50 45 40 35 30 25 20 15 10 5 0 I II III IV V VI VII VIII IX Leung et al X XI XII
Lederman et al
Local Spread
Sphenoid sinus Cavernous Sinus
Base of Skull, Clivus
Nasal cavity & PNS Orbital invasion
Lateral Parapharyngeal space Middle ear cavity Oropharynx (tonsillar pillars) C1
vertebrae
Nodal Spread
Etiology
Normal Epithelium
Deletion of Chromosomes 3p and 9p
Low Grade Dysplasia
Inactivation of Chromosome p14, 15 and 16
High Grade Dysplasia
EBV infection
Gain Chromosome 12 Deletion 11 and 13
Invasive Carcinoma
P53 Mutation
Metastatic Carcinoma
Investigations
Staging:
CT MRI Endoscopy PET scan Chest Xray USG Abdomen Bone Scans
Other Investigations
EBV Serology
Staging
Several staging systems are in use:
Complex anatomy and spread patterns Lack of international consensus:
Separate Chinese, Hong Kong and American staging systems
Systems available:
Fletcher (1967) Hos staging (1978) IUAC (1988) Huaqing staging (1994) AJCC (2002)
Comparison
Syste m Fletch er (1967) Ho (1978) Staging T1
< 1 cm diameter Confined to nasophary nx Limited to one site in nasophary nx Lim
ited to
T2
> 1 cm but confined to nasopharynx Extending to nasal fossa or oropharynx
T3
Beyond nasopharynx Bone/ Cranial nerve/ orbital / hypopharyngea l/ infratemporal
fossa No bony involvement destruction
T4
Involving skull base or cranial nerves NA
IUAC (1988) Huaqin g (1994)
Extending to two sites in nasopharynx Involving the nasal cavity, oropharynx, an
terior cervical vertebrae, PPS before SO line
Pterygoid nasophary process / nx posterior cranial nerve / posterior cervical ve
rtebrae / BOS / PPS Department of Radiotherapy, PGIMER, Chandigarh beyond SO
Bony destruction including eustachian Infratemporal tube fossa / cavernous sinus
/ PNS / direct invasion of C2 or C1 / anterior cranial nerves
Hos vs AJCC
AJCC system: T staging

T1:
Tumor confined to the nasopharynx
T2:
Tumor extends to soft tissues T2a : Extends to the oropharynx or the nasal fossa
T2b : With parapharyngeal extension
T3:
Tumor invades bony structures and/or paranasal sinuses
T4:
Tumor with intracranial extension and/or involvement of cranial nerves, infratem
poral fossa, hypopharynx, orbit, or masticator space Department of Radiotherapy,
PGIMER, Chandigarh
AJCC system: N staging

N0:
No regional lymph node metastasis
N1:
Unilateral metastasis in lymph node(s), < 6 cm in greatest dimension, above the
supraclavicular fossa
N2:
Bilateral metastasis in lymph node(s), < 6 cm in greatest dimension, above the s
upraclavicular fossa
Hos Triangle
N3:
N3a: Metastasis in a lymph node(s) >6 cm Department of N3b: Extension toRadiothe
rapy, PGIMER, Chandigarh the
Staging: AJCC 2002

Stage I
Stage IIA
Stage IIB
Stage III
Stage IVA
Stage IVB
Pathology
Some authors consider carcinomas to be of two types:
Keratinizing Non keratinizing
Others consider carcinomas to be of 4 types:
Keratinizing Squamous Non Keratinizing Squamous Lymphoepithelioma Undifferentiat
ed carcinomas
WHO 3 types:
Type I : SCC Type II : Non Keratinizing carcinoma Department of Radiotherapy, PG
IMER, Chandigarh Type III : Undifferentiated carcinoma
Endemic NPC
Known to occur in China, Hong Kong, South Eastern Asia, Greenland Associated wit
h EBV virus infection In India similar pathology seen in Kashmiris. Present a de
cade younger. Not associated with smoking or alcohol consumption Associated with
undifferentiated carcinoma ( WHO II and III) Associated with more advanced dise
ase at presentation Nodal stage also more advanced and more frequently involved.
Both chemo and radio sensitive
Histologically more vascularized (Better Rx response) Greater % of cell in the g
rowth fraction.
Better loco regional control and survival than
Prognostic factors
Most important stage. Parapharyngeal extension is associated with a poorer progn
osis. A Chinese series found that 4th cranial nerve involvement poor prognosis.
Nodal disease status:
Bilateral cervical lymphadenopathy Supraclavicular lymphadenopathy Lymph node fi
xity
Lymphoepithelioma histology: better prognosis Undifferentiated histology: better
prognosis Molecular markers:
Ki -67 over expression P 53 E cadherin expression
Treatment strategy
Stage Early stage External Radiation Late stage
EBRT + ICBT
KPS > 70
KPS < 70
Concurrent Chemoradiation
Palliative Radiotherapy
Dose response
Significant dose response relationship exists. Several series demonstrate that a
n increased-dose leads to better survival
Doses of 90 Gy delivered by boost increase the local control and the distant met
astasis free rate significantly over doses > 70 Gy Price however paid in increas
ed morbidity
Local recurrence rate reduced with the useDepartment of Radiotherapy, PGIMER, Ch
andigarh size of larger fields (Field
2
Dose-response
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 50 - 60 Gy 60 - 67.5 Gy > 67.5 Gy T1
T2 T3 T4
Doses used
Radical radiotherapy:
60 66 Gy in 2 Gy per fraction over 6 6 weeks Higher dose can be given with more
conformal techniques: ICBT IMRT 3 DCRT In our patients with poor nutrition, adva
nced disease and absence of individualized care split course radiotherapy is an
alternative 35 Gy in 15 # 25 30 Gy in 10 15 # after 2-3 weeks 30 Gy / 10# 20 Gy
/ 5# 800 -1000 cGy single fraction Department of Radiotherapy, PGIMER, Chandigar
h
Palliative radiotherapy:
Treatment volume
? The nasopharynx. Posterior 2 cm of nasal cavity. Posterior ethmoid sinuse
tire sphenoid sinus and the basiocciput Cavernous sinus. Base of skull, includin
g the foramen ovale, carotid canal and foramen spinosum. Pterygoid fossae Poster
ior 1/3rd of maxillary sinus. Lateral and posterior oropharyngeal wall to the le
vel of mid-tonsillar fossa Posterior 1/4th of orbit ( Fletcher YES, Perez - NO )
Nodal volumes
The entire neck is at high risk for microscopic spread of disease. The neck node
s that should be treated are:
Upper deep jugular Submandibular Jugulodigastric Midjugular Posterior cervical R
etropharyngeal
Treatment planning
Positioning:
Supine position. Head should be extended
Immobilization
To ensure accuracy in setup patient should be immobilized with a custom-made the
rmoplastic cast.
Localization:
All nodes are delineated with the use of radio opaque lead wires. The outer cant
hus the eye opposite to which simulation film is taken is marked with a lead wir
e. Tumor localization performed with the help of CT Department of Radiotherapy,
PGIMER, Chandigarh and clinical details.
Techniques
Techniques
Conventional technique Three-dimensional conformal radiation therapy. Intensitymodulated radiotherapy. Image-guided radiotherapy.
Energy selection:
Co60 : 1.25 MeV LINAC : 4 6 MV Higher-energies used in certain Western centers d
uring the boost phase to: Reduce dose to the mandible, temporomandibular joints,
ears and subcutaneous tissue (lateral edge effect) Kutcher and associates howev
er warn that use of these high energy beams may be associated with underdosage n
ear the surface and near the paranasal sinus cavities.
Portal selection
For Initial Phase:
Two parallel opposing fields Three field approach
For the boost phase:
Fletchers Technique ( 4 fields antral boost) Anterolateral wedge pair technique H
os technique ( with separate parapharyngeal boost)
Two field technique

Clinical field markings:
Superior border: 2.5 cm above the zygomatic arch 5 cm above the zygomatic arch i
n case of intracranial extension Anterior border: 2 cm beyond the anterior most
extent of the disease (usually placed just along the lateral canthus of the eye)
Posterior border: Along the tip of the mastoid or behind the posterior most ext
ent of cervical lymphadenopathy Inferior border: Department of Radiotherapy, PGI
MER, Chandigarh Along the superior border of the clavicle
Two Field technique

Radiological boundaries:
Superior border:
Splitting the pituitary fossa and extending along the superior surface of the sp
henoid sinus In case of IC extension to include at least 1 cm above the pituitar
y fossa.
Anterior border:
At least 2 cm of the nasal cavity and maxillary antrum. At least 2 cm margin to
the gross tumor extent
Posterior border:
Kept open if gross cervical LAD Department of Radiotherapy, PGIMER, Chandigarh
Technique
Three field technique

The superior, anterior and posterior boundaries are kept as same. Inferior bound
ary restricted to the level of the thyroid notch unless cervical LAD is present
In latter case matching done more inferiorly. Dose prescription done usually at
3 cm depth. Several measures need to be taken to circumventRadiotherapy, PGIMER,
Chandigarh field the problem of Department of
Field Matching
Without asymmetrical jaws:
Using laryngeal block: A laryngeal block is placed at the level of the larynx. T
he block has a thickness such that it is located 1cm medial to the lateral borde
r of thyroid cartilage The block extends from the superior border of the lower f
ield to 2 cm below the level of the cricoid cartilages. Using collimator tilt: A
collimator rotation may be given for the lateral fields to counteract the diver
gence of the lower anterior field 5 for Co 60. May increase the dose to the super
o-anterior portion of the field where the eyes are located Using an isocentric t
echnique with half beam block for 3 fields overdosage at the field junction can
be avoided. Department Alternative is to of Radiotherapy, PGIMER, Chandigarh low
er use half beam block in the
With asymmetrical jaws:
Additional modifications
In both 3 field and 2 field techniques a higher dose can be given to the eye due
to the beam divergence. Lateral fields need to angled a posterior tilt needs to b
e given Magnitude by which the field edge shifts at the midline ( for Co60)
5 0.5 cm 10 1.2 cm
5 10 0. 1.2 5
1. 1
2. 5
Actual Implementation
Lateral Canthus
2 75 5 2 70
Doses Prescribed
40 44 Gy in 2 Gy per fraction over 20 22 fractions ( 4 4 weeks) for the entire fi
eld. Rest of the dose ( 20 26 Gy) to delivered with spine shielding:
Lateral fields: Posterior border drawn along the junction of the posterior 1/3rd
and the anterior 2/3rd of the vertebral bodies ( Co60). In LINACs the posterior
edge of the vertebrae may be choosen. Clinically marked straight along the lobu
le of ear. Anterior fields: Department of Radiotherapy, PGIMER, Chandigarh
Boosting neck nodes

Photons only:
Antero-posterior glancing fields (
wedges) Medial border is 2 cm from midline. A
dditional boost radiation may be delivered by posterior fields to increase the d
ose to the posterior cervical nodes after the course of RT is completed.
Electrons:
Direct abutting lateral fields used. Energy selected 9 MeV Prescribed at 85% iso
dose ( Usually 3 cm depth) Department of Radiotherapy, PGIMER, Chandigarh 6 x 6
cm usually adequate
Nasopharynx Boost
A 4 field approach can be used to boost the nasopharynx to additional 10 15 Gy.
Volume treated is roughly cuboidal and has the dimensions of 7 cm x 6 cm. The an
terior fields are tilted medially by 20 30 in order to
Increase the dose to the Posterior nasopharynx Spare the anterior nasal cavity a
nd the deeper brain-stem
Department of Radiotherapy, PGIMER, Chandigarh Opposing lateral fields also used
with
Field marking
The boundaries for the anterior facial fields are:
Superiorly below the eyeball Medially 1 cm in either side of midline Inferiorly
upto the commissure of lips Laterally Usually a distance of 6 cm allow beam fall
-off.
In order to ensure that the superior border of the anterior field matches the la
teral fields the head position is adjusted (hyperextended) based upon the collim
ator lights. Beam weights are adjusted to ensure that Department of Radiotherapy
, PGIMER, Chandigarh the brain doesnt receive excess dose.
4 field technique
Dose distribution
Nasopharynx Boost
In case of gross anterior extension:
Three field, lateral wedge pair arrangement is preferred Anterior border of the
lateral fields are extended to cover the anterior disease adequately Alternative
technique is to use differential beam weights Electrons may be used to suppleme
nt the doses to the anterior diseases with lateral photon fields.
In lateralized anterior extension:
Anterior field may be wedged with thin end towards side where disease is present.
In inferior extension:
Boost fields are by necessity parallel opposing.
Hos Technique
Proponent: Prof John H C Ho Developed: late 1960s Extensive experience : 3 decad
es Special features:
Over 10,000 patients have been treated in Hong Kong excellent long term results
in Department of Radiotherapy, PGIMER, Chandigarh early disease T1, T2 and T3.
Different CTV specification Field arrangements and patient position are differen
t. Arrangement of different shields specified based upon bony anatomy customized
shields not necessary. Reproducible treatment plan. Lack of CT planning facilit
ies circumvented. Ease of use in a busy radiotherapy department Cost saving addi
tional factor.
Hos technique: Planning

Patient is immobilized in FLEXED head position in the initial phase. Similar to
the planning technique for pituitary. Allows easier shielding of the brainstem a
nd the oral cavity and reduces the field size requirements. Dose: 40 Gy in 20 #

Three field arrangement:
Opposed lateral fields irradiate the upper cervical lymphatics ( upto level III)
en bloc. An anterior field irradiates the lower field. Shielding of the lateral
fields is done to adjust for the beam overlap with the anterior field. In the l
ower anterior field a midline shield is placed throughout the treatment.
0.5 cm above the anterior clinoid process
Bisecting the maxillary antrum Below vocal cords C6

Specialized arrangement of shielding is done for all patients.
Brain Stem: Shielded with 5 HVL block placed in a manner such that it is 0.5 cm
behind the upper edge of the clivus and 1 cm below the lower edge. Eye: 5 HVL sh
ield placed 1.5 cm behind the lateral canthus. Posterior tongue also shielded wi
th standard block. Department of Radiotherapy, PGIMER, Chandigarh Pituitary and
temporal

In the boost phase a 3 field arrangement was used. Patient was replanned in the
EXTENDED head position with oral stent. Anterior cervico-facial field was used i
n all patients Lower border of the later fields reduced down to level of angle o
f mandible. Allowed dose reduction to: TM joints, ear, parotids & pinnae. Dose p
rescribed: 22.5 Gy in 9# Total tumor dose was 62.5 Gy in 29# Biologically equiva
lent to 66 Gy in 33#Department of Radiotherapy, PGIMER, Chandigarh

In patients with parapharyngeal disease a posterior oblique boost was given afte
r the 2nd phase. Dose prescribed was 20 Gy /10# This field was usually 5.5 cm x
8 cm in size. Ascending ramus of the mandible
Hos vs 3D CRT and IMRT

T1 NO MO
T4 N2 MO
Kam et al: IJROBP 2003
Results by Hos Technique

Conventional Radiation
Conventional Radiation
Altered fractionation
Concomitant boost technique has been evaluated in a large series by Teo et al (I
JROBP 2000). Study prematurely terminated as:
40% incidence of temporal lobe neuropathy 17% incidence of cranial nerve palsies
50% patients had one or other form of neurological complication 2.6% treatment
related mortality Neural complications were more severe and occurred earlier tha
n conventional techniques.
Conformal Radiation
Includes 3 D CRT , IMRT and IGRT Potential:
Dose escalation Conformal avoidance
Results are immature for IMRT Largest series of IMRT by Kam et al:
63 patients Median F/U 30 months Only 4 had local failure ( None marginal miss)
OS was 90% Distant metastasis primary cause of failure Grade III mucositis: 41%
patients Late toxicity till 2 yrs : Xerostomia (21%)
Brachytherapy
The following requirements should be fulfilled prior to taking up a patient for
brachytherapy:
Tumor thickness less than 10 mm. Absence of intracranial, paranasal sinus and or
opharyngeal involvement. Absence of involvement of underlying bone or infratempo
ral fossa. Absence of metastatic disease. Expertise in nasopharyngeal intracavit
ary brachytherapy.
In effect, nasopharyngeal brachytherapy is ineffective in tumors extending beyond
the Department of Radiotherapy, PGIMER, Chandigarh
Techniques
Techniques:
Temporary intracavitary application Temporary interstitial implantation Permanen
t interstitial implantation
Dose-rates used:
Low dose rate (LDR). High dose rate (HDR).
Situations used:
Routine use as a boost after XRT ( Hong Kong, China and Netherlands) Use with do
cumented residual disease ( USA) Recurrence ( Hong Kong, USA - Syed and Chinese
Series) Radiotherapy, PGIMER, Chandigarh Department of
History of brachytherapy
In 1920s, Pierquin and Richard were the first persons is to employ brachytherapy
in the treatment of nasopharyngeal carcinomas. In the Christie hospital at Manc
hester, Peterson used a 15 mg radium tube inserted in a cork with a diameter of
15 to 20 mm. The dose prescribed was 80 rads in seven days to a depth of 0.5 cm.
Ra226 tube Cork
String at either end of the cork
Peterson described this technique as a useful alternative to small field XDepart
ment not superior ray technique butof Radiotherapy, PGIMER, Chandigarh
Applicator Design
Several applicator designs available:
Mould technique Levendags Forzhou (Chinese district) Simple catheter based
Mould Technique
Customized mould prepared for each patient Uses a special quick setting silicone
jel to take the nasopharyngeal impression. The source placement for an average
nasopharynx are:
2 sources for 1 wall 3 sources for two adjoining wall 4 sources for 3 walls
Department of Radiotherapy, Intersource separation PGIMER, Chandigarh kept
Technique of Insertion
Rotterdam Applicator
Designed by Levendag. Designed so that the applicator could be worn by the patie
nt comfortably continuously throughout the fractionated course of treatment give
n. Made up of silicone which is flexible and closely conforms to the curvature o
f the nasopharynx. Applicator design based upon a 3 D model of the nasopharynx (
based on CT of two patients) Allows closer fit to the base of the skull and sit
uated at a fixed distance from the soft palate. Department of Radiotherapy, PGIM
ER, A silicone bridge and flangeChandigarh to fix the used
Rotterdam Applicator
Tube diameter
Outer diameter 15 F (5.5 mm) Inner diameter 9 F ( 3.5 mm)
Can accommodate the 6 F HDR source easily. Two tubes ensure catheter stability.
The tubes are diverging at the base
Prescription and points

Several anatomical points defined by Levendag to calculated dose to the tumor as
well as critical normal tissues. Tumor points:
Na (Nasopharynx) 2 BOS (Base of Skull) - 2 R (Node of Rouviere) - 1 OC (
hiasm) - 1 P (Pituitary gland) - 1 C (Cord) 1 Pa (Soft Palate) 2 Re (Retina) - 2
No ( Nose) - 2
Normal Tissue points:
Prescription points
OC P BOS Na BOS Re Na No R Pa C Pa OC P BOS Na Re
Line 1
Re
2 ne Li
No Pa R C
No
Dose prescribed
In case EBRT given in dose of 60 Gy:
3 Gy x 2 fractions per day for 6 fractions by HDR Total dose ~ 78 Gy Minimum int
erfraction gap of 6 hrs.
In case of EBRT given in dose of 70 Gy:
3 Gy x 2 fractions for 4 fractions by HDR Total dose ~ 82 Gy Minimum interfracti
on gap of 6 hrs.
Advantages
Comfortable applicator can be kept between fractions Optimization possible Na, B
OS and the R points. Can be reused after steam sterilization. Reduced normal tis
sue dose to the retina, palate and the nasal cavity In earlier work Levendag use
d to use two other points:
FL point: corresponding to the BOS point Approximates the position of the forame
n lacerum FO point: Department Situated at of Radiotherapy, PGIMER, Chandigarh t
he foramen ovale
Disadvantages
Nasal synechia have been observed in few patients.
Corresponds to the hyperdose sleeve of 200% isodose around the applicator. Appro
ximately occurs in a radius of 6 mm around the source axis after standard prescr
iption Reduced by use of nasal pack for 7 days after ICBT
Optimization can result in increased dose to some points (especially the spinal
point). Radiotherapy, PGIMER, Chandigarh Department of
Chemoradiation
Sequence:
Induction Concurrent Adjuvant
Concurrent regimen is best. Principle:
Local cooperation Spatial cooperation
We use Concurrent Cisplatin in doses of 50 mg/m2 D1 and D22.
Results: NACT
Results: Adjuvant CT
Adjuvant Chemotherapy:
Of no benefit even if CDDP based. Chi et al reported results of a phase III rand
omized trial (2002) N = 157 Adjuvant chemotherapy with 24 hr infusional Cisplati
n 20 mg/m2, 5fluorouracil 2,200 mg/m2, and leucovorin 120 mg/m2 x 9 cycles after
70 Gy XRT
5-year overall survival 60.5% vs. 54.5% (p = 0.5) 5 yr relapse-free survival rat
es 49.5% vs. 54.4% (p = 0.38)
Results: Concurrent CT
Huncharek et al performed a meta-analysis in 2002. 6 RCTs included Statistically
significant increase in the disease free survival by approximately 20% to 40% O
S improved by ~ 20% (Statistically NS) Better results with Cisplatin + 5 FU base
d regimen ( Al Sarraf)
Results : Metastatic disease

NPC in Children
Problem of long term toxicity:
Skull deformities Neurological deficits Pituitary dysfunction Hearing impairment
TM joint ankylosis Visual defects
RT is the treatment modality of choice:
Outcome:
Dose 50 -60 Gy Boost only after skull growth is complete (15yrs) Lower neck usua
lly not treated if clinically ve. DFS is 70 80% in T1 and T2 tumors DFS is 40 50%
in T3 T 4 tumors
Recurrence
2 types described (Wang et al)
Persistent disease Relapse: Appearing 1 yr after treatment.
Detecting recurrence:
Tc99m SPECT MRI High signal intensity on T1 weighted spin echo images
Options:
Palliative treatment Radiation therapy Surgery
Surgery
Usually indicated in situations like isolated nodal recurrence Local recurrences
have been salvaged by extensive craniofacial surgery
Radiotherapy
EBRT Brachytherapy
Both temporary and permanent implants used. Best results from Gold grain implant
ation.
IMRT and 3 DCRT
Investigational
Sterotactic Radiosurgery Chemotherapy
Cisplatin or taxane based Mainstay in: Distant spread Early recurrence Extensive
disease
Radiotherapy
External radiotherapy:
High energy beams are better choosen Small 6 x 6 field used to treat site of loc
al recurrence Doses in range of 20 30 Gy. Indications:
Limited tumour size, a relatively long period since previous irradiation (minima
l time period ~ 1 year) Good performance status and Lack of evidence of skin or
soft tissue damage (skin fibrosis, atrophy or telangiectasis) from the previous
irradiation of Radiotherapy, PGIMER, Chandigarh course Department
Results of RT
Results
Neurological Sequelae
Hypothalamo-Pituitary dysfunction
Median incidence of clinical dysfunction is 3%. Cumulative incidence of endocrin
e dysfunction higher at 67% at 2 yrs. Most common disturbance seen in GH secreti
on.
Thyroid hormone production affected the least.
Hearing defects:
Temporal lobe injury: Cranial nerve injury:
Almost 7% patients become deaf with standard therapy. Otitis media seen in 14% p
atients Prolonged tinnitus may be seen in 30% patients Incidence as high as 3% a
fter 2 yrs. Toxicity more in altered fractionation regimens The incidence is as
high as 6%.
Other Sequelae
Significant xerostomia can be seen in as high as 80 % Some degree of xerostomia
is seen all patients. Fibrosis of the subcutaneous tissue is seen when doses exc
eeding 50 Gy are used in almost 16% patients. Significant trismus, can occur in
5 to 10% patients. This particular complication can be reduced by using a threefield approach for boosting the Department of Radiotherapy, PGIMER, Chandigarh n
asopharynx.
Conclusions
Nasopharyngeal malignancies make up a different population of head and neck mali
gnancies. These are eminently radio sensitive and curable. Treatment planning is
by necessity complicated and time consuming. Brachytherapy can be used for boos
ting the local activities. Chemoradiation is standard treatment in oflocally PGI
MER, Chandigarh tumors advanced Department Radiotherapy,
Thank You

Carcinoma Nasopharynx

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Carcinoma Nasopharynx

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Carcinoma Nasopharynx

Moderator: Dr Sushmita Ghoshal

Cranial Nerve involvement

AJCC system: T staging

AJCC system: N staging

Staging: AJCC 2002

Two field technique

Two Field technique

Three field technique

Boosting neck nodes

Hos technique: Planning

Hos technique: Planning

Hos technique: Planning

Hos technique: Planning

Hos technique: Planning

Hos vs 3D CRT and IMRT

Results by Hos Technique

Prescription and points

Results : Metastatic disease

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