Pre-staging examination :
1.Medical history and physical examination
2.Nasopharyngeal examination and biopsy for pathology
3.Biochemical complete set and blood routine, EKG
4.Imaging examination.
A, PET/CT (good economy)
B, MRI of nasopharynx, MRI of neck, CT of chest, CT enhancement of upper abdomen, whole body bone imaging
C. MRI of nasopharynx, MRI of neck (N0), CT of chest, ultrasound of upper abdomen, whole-body bone imaging in case of pain
Attachment: radiotherapy localization images
Radiotherapy localization will be performed in a CT-enhanced 3-5mm thin layer scan in the radiotherapy position after facial and cervical membrane fixation, generally ranging from 2cm above the brow arch to 2cm below the head of the clavicle (the top of the head for intracranial invasion). Since precise radiotherapy requires CT/MRI image fusion to accurately outline the tumor, external nasopharyngeal MRI/non-standard MRI/MRI prior to 2 chemotherapy sessions will require a new MRI examination (with layer thickness and scan series requirements).
Therefore, it is recommended that CT of the neck and CT of the nasopharynx should generally not be performed prior to transfer to the radiotherapy department to avoid wastage.
It is strongly recommended to transfer to the radiotherapy department as soon as pathology is obtained to allow for the most reasonable scheduling of radiotherapy and various examinations.
2002AJCC TNM staging
T1 Tumor confined to nasopharynx
T2 Tumor invades soft tissue
T2a Tumor invades oropharynx and/or nasal cavity without parapharyngeal space invasion*
T2b Parapharyngeal space invasion*
T3 Tumor invading skull base bone and/or sinuses
T4 Tumor invasion of intracranial and/or cranial nerves, infratemporal fossa, hypopharynx, orbit, or masticatory muscle space
*Note: Parapharyngeal interstitial invasion is defined as tumor infiltration in the posterior-lateral direction, breaking through the pharyngeal skull base fascia
Regional lymph nodes (N)
Nx Regional lymph nodes cannot be evaluated
N0 No regional lymph node metastasis
N1 Unilateral lymph node metastasis with maximum diameter ≤ 6 cm and lymph nodes located above the supraclavicular fossa*
N2 Bilateral lymph node metastasis, maximum diameter ≤ 6 cm, lymph nodes located above the supraclavicular fossa*
N3 Lymph nodes* >6 cm in maximum diameter and/or metastasis to the supraclavicular fossa
N3a Lymph nodes >6 cm in maximum diameter
N3b Metastasis to the supraclavicular fossa**
*Note: Midline lymph nodes are considered to be ipsilateral lymph nodes.
**The supraclavicular region or fossa site is relevant to the staging of nasopharyngeal carcinoma, and Ho describes the definition of this triangular region, which includes three points.
(1) the superior border of the sternoclavicular junction (2) the superior border of the lateral end of the clavicle (acromion) (3) the cervical-shoulder junction. It is important to note that this includes the IV and V areas on the lateral side of the foot. Lymph nodes accompanying the supraclavicular fossa (including some or all) are considered N3b.
Distant metastases (M)
Mx Distant metastases could not be evaluated
M0 No distant metastasis
M1 with distant metastasis
T1N0M0 , T2aN0M0 IMRT nasopharyngeal radiotherapy 66Gy + 54Gy in the upper neck
3DCRT nasopharyngeal radiotherapy 70Gy+upper neck 50Gy
TNM staging : TxNxM1 platinum (DDP) combined with chemotherapy, nasopharyngeal and neck radiotherapy for CR
T1-2aN1-3M0 ,T2b-T4NxM0 radiotherapy combination
1, T1N0M0 , T2aN0M0
Post-staging radiotherapy positioning in radiotherapy department, IMRT nasopharynx 66Gy/30 times + plus neck 54Gy/30 times; or 3DCRT: 36Gy/18 times in face and neck field, post-staging radiotherapy neck 50Gy, nasopharynx 64-70Gy. follow-up after radiotherapy.
2.Any TNM1
TPF (TPX), PF (PX), GP (especially for pulmonary metastases) chemotherapy, bone metastases plus 6 courses of zolay phosphate treatment, good economic status plus EGFR antibody. After 2-4 courses of chemotherapy, for those who achieve CR, 66-70 Gy of radiotherapy for primary foci, 56-66 Gy of radiotherapy for neck, 40-50 Gy of radiotherapy for bone and other isolated metastases. 3-4 courses of chemotherapy after radiotherapy; change chemotherapy regimen for PR or below, symptomatic treatment, etc.
3.T1-2aN1-3M0,T2b-T4NxM0(IIb-IVb )
T4 and T3 tumors invade the adjacent spinal cord, brainstem and other key organs that need to be protected, and N3 and N2 patients close to 6 cm have a high rate of distant metastasis. The rest of patients with early stage can be treated with concurrent radiotherapy.
IMRT nasopharynx 72 Gy/32 times + plus neck 59.4 Gy/32 times (GTVln66Gy), lower neck without lymph node metastasis can be treated with anterior and posterior field radiotherapy 54 Gy; or late small field additive IMRT technique, nasopharynx 72 Gy/30 times (1.8Gy*30 times + 1.5Gy*12 times) + plus neck 60Gy/30 times (GTVln70Gy ). Concurrent chemotherapy DDP100mg/m2 d1,d22,d43, or DDP40mg/m2/W*7 weeks. Adjuvant chemotherapy can be given for 3-4 courses 4 weeks after the end of radiotherapy.
In a small number of patients, after adjuvant chemotherapy, neck debulking is recommended for those who still have residual cervical lymph nodes as assessed by MRI or PET/CT.