Last updated March 15, 2022

Chemotherapy in Combination With Radiotherapy for Definitive-Intent Treatment of Stage II-IVA Nasopharyngeal Carcinoma

Recommendations

Radiotherapy

1.1. For all patients with nasopharyngeal carcinoma (NPC), intensity-modulated radiotherapy (IMRT) with daily image guidance should be offered. If IMRT is unavailable, patients should be transferred to institutions that could implement IMRT whenever possible. (EBBHS)
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1.2. For all patients with NPC, both sequential boost and simultaneous integrated boost radiotherapy may be offered. (EBBIM)
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1.3. For all patients with NPC, a 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. (EBBHS)
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1.4. For all patients with NPC, gross tumor volume should be carefully delineated. 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 the potential tumor extension at the skull base and rule out or confirm the presence of cranial nerve involvement and/or intracranial extension. (ICBIS)
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1.5. For patients with NPC who have undergone induction chemotherapy, the preinduction scan should be fused with the postinduction CT simulation data set to illustrate the initial disease extent. The gross tumor volume should generally follow the preinduction tumor extent, especially within bony anatomy. (ICBIM)
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1.6. The delineation of elective nodal volumes should follow international consensus guidelines and cover the bilateral neck from the retropharyngeal lymph nodes to level IV and V. Level 1b may be omitted in prophylactic volume unless there is involvement of the anterior half of the nasal cavity or if there are level II lymph nodes with extranodal extension or size > 2 cm or bilateral involvement. Omission of lower neck volume in the uninvolved side of the neck may be considered if the neck contains no equivocal lymph node(s). (ICBIM)
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Chemotherapy Sequence

2.1. For patients with T2N0 (AJCC 8th) NPC, 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. (EBBIM)
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2.2. For patients with T1-2N1 (AJCC 8th) NPC, concurrent chemotherapy may be offered, particularly for T2 N1 patients. (EBBIM)
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2.3. For patients with Stage III-IVA (except T3N0) (AJCC 8th) NPC, induction chemotherapy should be offered in addition to concurrent chemoradiotherapy. (EBBHS)
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2.4. For patients with Stage III-IVA (except T3N0) (AJCC 8th) NPC who do not receive induction chemotherapy plus concurrent chemoradiotherapy, then concurrent chemoradiotherapy plus adjuvant chemotherapy should be offered. (EBBIM)
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2.5. For patients with T3N0 (AJCC 8th) NPC, concurrent chemoradiotherapy should be offered. Adjuvant or induction chemotherapy may also be offered. (EBBIM)
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Concurrent Chemotherapy

3.1. For all patients with NPC without contraindications, concurrent cisplatin, given weekly (40 mg/m2) or once every 3 weeks (triweekly) (100 mg/m2, or at least 80 mg/m2), should be offered along with radiotherapy. (EBBHS)
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3.2. For all patients with NPC without contraindications, in the concurrent chemotherapy setting, 3 doses of triweekly or 7 doses of weekly cisplatin should be attempted to achieve a cumulative dose of at least 200 mg/m2. (ICBIM)
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3.3. For patients with NPC with a contraindication to cisplatin, nedaplatin (100 mg/m2 triweekly) may be offered for concurrent chemoradiotherapy. Other options that may be offered are carboplatin (area under curve [AUC], 5-6 triweekly) or oxaliplatin (70 mg/m2 weekly). (EBBIS)
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3.4. For patients with NPC with a contraindication to platinum-based chemotherapy, fluoropyrimidines (eg, capecitabine, 5-fluorouracil, and tegafur) with concurrent radiotherapy may be offered. (EBBLW)
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Induction Chemotherapy

4.1. For all patients with NPC receiving induction chemotherapy, platinum-based induction regimens should be offered. The following regimens may be used in the absence of medical contraindications: GP (gemcitabine: 1,000 mg/m2 d1, d8; cisplatin 80 mg/m2 d1) or TPF (docetaxel 60-75 mg/m2 d1; cisplatin 60-75 mg/m2 d1; 5-fluorouracil 600-750 mg/m2 per day, continuous intravenous infusion d1-5); others include PF (cisplatin 80-100 mg/m2 d1; 5-fluorouracil 800-1,000 mg/m2 per day, continuous intravenous infusion d1-5), PX (cisplatin 100 mg/m2 d1; capecitabine 2000 mg/m2 per day, d1-14), and TP (docetaxel 75 mg/m2 d1; cisplatin 75 mg/m2 d1). (EBBIS)
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4.2. For patients with NPC receiving induction chemotherapy, the regimens should be administered every three weeks for a total of three cycles, or at the minimum two cycles. (EBBIS)
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4.3. For patients with NPC receiving induction chemotherapy, chemoradiotherapy should be commenced within 21-28 days from the first day of the last cycle of induction chemotherapy. (ICBIM)
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Adjuvant Chemotherapy

5.1. For all patients with NPC receiving adjuvant chemotherapy, PF (cisplatin 80 mg/m2 d1 or 20 mg/m2 per day, d1-5; 5-fluorouracil 1,000 mg/m2 per day, continuous intravenous infusion d1-4, or 800 mg/m2 per day, continuous intravenous infusion d1-5) administered every 4 weeks for a total of 3 cycles should be offered. (EBBHS)
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5.2. For all patients with NPC receiving adjuvant chemotherapy and with a contraindication to cisplatin, carboplatin (AUC 5) may be combined with 5-fluorouracil. (EBBIM)
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5.3. For all patients with NPC receiving adjuvant chemotherapy and with a contraindication to platinum-containing chemotherapy, the use of non–platinum-based regimens remains experimental at this time and should not be offered routinely outside the context of a clinical trial. (EBBIS)
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Recommendation Grading

Overview

Title

Chemotherapy in Combination With Radiotherapy for Definitive-Intent Treatment of Stage II-IVA Nasopharyngeal Carcinoma

Authoring Organization

Publication Month/Year

March 1, 2021

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult

Health Care Settings

Ambulatory, Home health, Hospital

Intended Users

Social worker, physician, nurse practitioner, nurse, physician assistant

Scope

Management, Treatment

Keywords

chemotherapy, radiotherapy, Adjuvant chemotherapy, Definitive-Intent Treatment, Stage II-IVA Nasopharyngeal Carcinoma

Supplemental Methodology Resources

Data Supplement, Evidence Tables

Methodology

Number of Source Documents
183
Literature Search Start Date
January 1, 1990
Literature Search End Date
August 1, 2020