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

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)

1.2. For all patients with NPC, both sequential boost and simultaneous integrated boost radiotherapy may be offered. (EBBIM)

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)

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)

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)

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)