Nasopharyngeal carcinoma (NPC)

1. Staging
a. Chest imaging
b. MRI with gadolinium of nasopharnx and base of skull to clavicles and/or CT with contrast or PET CT and CT with contrast
c. Dental evaluation
d. Speech and swallowing evaluation
e. Imaging for distant mets (chest, liver, bone) for WHO class 2-3/N2-3 disease (may include PET and/or CT

2. JH guidelines
a. Neoadjuvant
- 3 cycles of 3 weeks: D1 cisplatin 100mg/m2 and bleomycin 15mg then D2-5 bleomycin 12mg/m2
- 2-3 cycles of 3 weeks: D1 cisplatin 60mg/m2 and epirubicin 110mg/m2 D1

3. Treatment
a. T1, N0, M0 and T2a, N0, M0: definitive RT to nasopharyny and elective RT to neck
b. T1-T2a, N1-3; T2b-T4, any N:
Cisplatin 100mg/m2 on D1/22/43 of cisplatin 40mg/m2 every wk + RT (>= 70 Gy) to primary and gross nodal disease and bilateral neck: >= 50 Gy
= followed by=
Cisplatin 80 mg/m2 D1 + 5FU 1000mg/m2 Ca x 4 days, repeat every 4 wk x 3 courses
= KIV=
Neck dissection if residual tumour
c. Metastatic: Platinum based combination chemotherapy – if complete response, definitive RT to primary and neck
d. Unresectable T4b: PS0-1 concurrent cisplatin chemoRT or induction chemotherapy flw by chemoRT, PS2 definitive RT +/- concurrent systemic therapy, PS3 definitive RT or BSC = neck dissection if feasible and primary site controlled

4. Regimens
a. Chemoradiation followed by adjuvant chemotherapy: cisplatin + RT followed by cisplatin/5FU
b. Recurrent, unresectable or metastatic (incurable)
i. Combination therapy
- cisplatin/carboplatin + 5FU +/- cetuximab
- cisplatin or carboplatin + docetaxel or paclitaxel
- cisplatin/cetuximab
ii. Single agent: cisplatin, carboplatin, paclitaxel, docetaxel, 5FU, methotrexate, ifosfamide, bleomycin, gemcitabine (NPC), cetuximab


4. Follow up
a. Physical exam y1 q1-3mo, y2 q2-4 mo, y3-5 q4-6mo, >5y 6-12 mo
b. Post-treatment baseline imaging of primary and neck recommended within 6 mo of treatment, reimaging as indicated
c. Chest imaging as clinically indicated
d. TSH every 6-12 mo if neck irradiated
e. Speech, hearing and swallowing evaluation and rehab, dental evaluation