1. Nasopharyngeal carcinoma
Radiation therapy
ศ.พญ.ลักษณา โพชนุกูล

2. ระยะโรค T1 T2 T3 T4

3. ระยะโรค N1 N2 N3a N3b Large node > 6 cm SPC LN Unilateral LN
Bilateral LN
< 6 cm

4. บทบาทของรังสีรักษา
Curative treatment
Palliative treatment

5. Stage 2 (more than T1 N0)  concurrent chemoRT + adjuvant chemotherapy
Curative treatment
Stage 1- T1 N0  RT alone
Stage 2 (more than T1 N0)  concurrent chemoRT + adjuvant chemotherapy

6. T1N0 – RT alone
ERT Gy
33-35F

7. Concurrent chemoradiation adjuvant chemotherapy
CA Nasopharynx
Locally advanced
Concurrent chemoradiation
adjuvant chemotherapy
ERT 70 Gy F

8. Radiation techniques IMRT (VMAT) รังสีสามมิติแปรความเข้ม
- improve tumor control  survival
- decrease normal tissue toxicities

9. Favor IMRT over 2 D for local control and OS (meta-analysis)
Zhang 2015

10. RT Technical development 2 D  IMRT

11. 2 D RT for T1-T2 lesions xerostomia
High dose to normal organs – salivary glands

12. 2 D RT for T4 N3 lesion Inadequate dose coverage
Unacceptable dose to critical organs – brainstem, optic nerves, chiasm

13. รังสีสามมิติแปรความเข้ม รังสีสามมิติแปรความเข้มแบบเกลียวหมุน
IMRT (Intensity modulated radiation therapy) VMAT (volumetric arc therapy)
รังสีสามมิติแปรความเข้ม
IMRT
รังสีสามมิติแปรความเข้มแบบเกลียวหมุน
VMAT

14. IMRT/VMAT RT for T1-T2 lesions
Adequate dose coverage to targets
Decrease RT dose to parotid glands
Minimize RT dose to critical structures

15. IMRT/VMAT RT for T3-T4 lesions
Adequate dose coverage to targets
Minimize RT dose to critical structures
Decrease RT dose to parotid glands

16. Radiation techniques IMRT (VMAT) รังสีสามมิติแปรความเข้ม
- improve tumor control  survival
- decrease normal tissue toxicities

17. Decrease dose to brainstem with IMRT /VMAT
60 Gy dose display
3 D
45 Gy dose display

18. Optic nerve & Chiasm Keep dose < 60 Gy With IMRT/VMAT
To decrease risk of optic neuropathy

19. Cochlea Sensorineural Hearing loss (SNHL)
Incidence of SNHL
IMRT %
Conventional 55%
Petsuksiri J. 2011

20. Temporal lobe necrosis
Limit RT dose to temporal lobe < 60 Gy
Zhang 2015

21. Decrease risk of xerostomia
Parotid glands
Try to keep mean dose to < 26 Gy
Decrease risk of xerostomia

22. Constrictor muscles : Swallowing difficulties
Limit dose to constrictor m.
with VMAT/IMRT
Keep mean dose < 50 Gy

23. Recommendation: IMRT vs. 2D RT Desirable vs undesirable consequence
Overall survival 13%
Local control 7%
Qol (26-30)
Less hearing loss 59%
Resource
Techniques
Opportunity cost
K.Thephamongkhol

24. Image guided radiation therapy IGRT - kV (2D)
Image verification
before beam on
Systematic error (Sigma) – displacement during the course of treatment – SD of average setup variation per patient in the group of patients
Random error (delta) – day to day variation – root mean square of SD of all patients
Margin = 2.5 sigma delta
DRR – CT planning
kV – on board imaging

25. Image guided radiation therapy IGRT
Cone beam CT (CBCT) - 3D
Image verification
before beam on
CT simulation
On board imaging

26. Chemotherapy for stage 2-4
During RT course (concurrent chemotherapy)
Cisplatin/Carboplatin q 21 days level 1A/B evidence
Cisplatin/Carboplatin q 7 days level 2A/B evidence
Total chemo
4-6 cycles
(q d)
Adjuvant chemotherapy
Cisplatin + 5 FU (PF) q 28 days

27. CCRT--> CT Survival Cisplatinum based chemotherapy RT 76% 46%
INTERGROUP 99 (RTOG 88-17) CHEMOTHERAPY FOR locally advanced NPC
76%
CCRT--> CT
46%
Survival RT
p < .001
Cisplatinum based chemotherapy

28. Palliative treatment – M1RT
Chemotherapy

29. Chemotherapy for metastasis/recurrence
Cisplatin/Carboplatin q 21 days level 1
Cisplatin/Carboplatin + 5 FU q 28 days level 2
Carboplatin/ Paclitaxel q 21 day level 3
Paclitaxel q 21 days level 3

30. Palliative radiation therapy for metastatic/ recurrent disease
Metastatic disease - bone metastasis
Locoregional recurrence