Treatment of Nasopharyngeal Cancer

Nasopharyngeal cancer is a rare head and neck tumor. This neoplasm is difficult to remove surgically. Therefore, in most cases, a combination of chemotherapy and radiation therapy is used to treat the disease. Surgical interventions are performed to remove metastases in the cervical lymph nodes. In the advanced stages, doctors in developed countries resort to targeted therapy and immunotherapy.

Content

1. What is nasopharyngeal cancer?
2. Principles of treatment
3. Radiation therapy
4. Surgical treatment
5. Drug therapy
6. Treatment in Europe with Booking Health

What is nasopharyngeal cancer?

The pharynx is an organ located between the oral cavity and the esophagus. It consists of three parts. The top one is at the level of the nose. It is called the nasopharynx. The other two parts are the oropharynx and the laryngopharynx.

Nasopharyngeal cancer is a malignant tumor that develops in the upper part of the throat. The risk factors for the disease are as follows:

• Epstein-Barr virus (EBV infection); 
• chronic nasopharyngitis. 

Among the histological types, non-keratinizing undifferentiated carcinoma is more common. Meanwhile, non-keratinizing differentiated carcinoma and keratinizing squamous cell carcinoma are less common. The treatment is the same regardless of histological type. Types without keratinization have a better prognosis.

Rare nasopharyngeal tumors are: 

• adenocarcinoma; 
• adenoid cystic carcinoma;
• lymphoma. 

In most cases, symptoms manifest themselves after the spread of metastasis to lymph nodes. Patients go to the doctor with complaints of neck swelling and swollen lymph nodes, which is usually a painless process.

Other possible symptoms associated with the local spread of the tumor are as follows:

• tinnitus; 
• hearing loss, usually unilateral;
• runny nose;
• difficulty nasal breathing; 
• nosebleed;
• headache;
• facial pain;
• impaired sensitivity of the facial skin;
• pain when opening the mouth;
• blurred vision; 
• difficulty breathing;
• difficulty speaking. 

To diagnose the disease, the specialists use anterior and posterior rhinoscopy, nasopharyngoscopy. These methods allow examining the nose and nasopharynx to visually detect the tumor. To confirm the diagnosis, the doctor takes an imprint smear or makes a biopsy. After the histological examination of the material in the laboratory, the type of tumor is specified.

Clarifying diagnostic examinations: 

• PCR for EBV infection; 
• lymph node puncture to detect metastases; 
• CT scan of the facial skull; 
• MRI of the neck. 

Additional diagnostic examinations are required to determine the stage of the disease and select the optimal treatment tactics.

Principles of treatment

Surgery is the main treatment for most oncological diseases. However, nasopharyngeal cancer is an exception. Surgical interventions for this disease are rare, and they are aimed mainly at removing metastases in the lymph nodes of the neck.

The initial treatment of the disease involves the use of one of the following approaches:

• Chemotherapy is followed by chemoradiotherapy (simultaneous irradiation of the tumor and chemotherapy).
• Chemoradiotherapy is followed by chemotherapy. This option is more common. In comparative studies, it has proved better patient survival rates.

After the initial treatment, the response is assessed. If nasopharyngeal cancer has completely regressed, all metastases have disappeared, then the patient is monitored. He does not need any other treatment, at least until a nasopharyngeal cancer recurrence occurs.

In some cases, metastases in the lymph nodes do not disappear after initial treatment. Then they have to be removed using surgical techniques. Doctors perform a neck dissection. Doctors abroad can perform it using endoscopic techniques – through short incisions. This option does not significantly reduce the invasiveness of the surgical intervention itself, since during the surgery a large amount of soft tissues in the neck are removed. Nonetheless, the aesthetic result will be better, since the doctor will make short incisions on the neck instead of one long one.

Treatment options for end-stage nasopharyngeal cancer are as follows:

• drug treatment (chemotherapy, targeted therapy, immunotherapy);
• chemoradiotherapy – only in the presence of single metastases, if the doctor believes that they can be destroyed along with the primary tumor;
• surgical treatment – only if the doctor believes that it is possible to remove or destroy single metastases and the primary nasopharyngeal tumor with radiation.

In the event of a relapse, most patients receive only drug treatment. Doctors rarely resort to repeated surgical interventions and chemoradiotherapy.

Radiation therapy

Radiation therapy for nasopharyngeal cancer is considered the main treatment option. It is combined with chemotherapy often.

Advanced methods of radiation therapy provide high rates of patient survival. In many patients, nasopharyngeal cancer can be cured completely. The results are comparable to surgical interventions. At the same time, cancer treatment with radiation therapy can be:

• non-invasive; 
• painless; 
• does not require long-term rehabilitation; 
• does not cause aesthetic defects. 

In the case of nasopharyngeal cancer, doctors carefully examine patients before starting radiation therapy. Unlike surgery, they will not have the results of a histological examination of the surgical material, which provides the most accurate diagnosis of nasopharyngeal cancer. Therefore, it is important to assess the exact boundaries of the tumor and detect metastases in the lymph nodes before irradiation.

Doctors in countries with advanced medicine use the following methods: 

• contrast-enhanced computed tomography is the main method for clarifying the diagnosis;
• MRI is used less frequently, mainly for the study of the central nervous system, to detect nasopharyngeal cancer metastases;
• cervical lymph node ultrasound scanning;
• swollen lymph node puncture – to check whether the tumor has spread to them, to decide on the amount of radiation or the need for lymph node dissection;
• radionuclide diagnosis of nasopharyngeal cancer with suspected distant metastases.

Before radiation therapy, the oral cavity is sanitized. It is necessary to check the teeth at the dentist and, if required, treat diseases to avoid infectious complications.

Doctors abroad use the most advanced options for radiation therapy. For head and neck tumors, including nasopharyngeal cancer, it must be very accurate. This is because the tumor is surrounded by important organs and tissues. Such organs as the brain, larynx, esophagus, large vessels and nerves, thyroid gland are located nearby.

Hospitals in developed countries use the following types of radiation therapy for nasopharyngeal cancer: 

IMRT (Intensity-modulated radiation therapy). The variant of three-dimensional irradiation is one of the safest. IMRT is used in cases of anatomical proximity of functionally important organs and irregular tumor configuration. With its help, even cancer that is around an organ at risk can be safely irradiated: for example, if it surrounds a large artery. The dose of radiation corresponds to the three-dimensional shape of the tumor by controlling or modulating the intensity of the radiation beam. The radiation dose intensity increases near the total tumor volume. It is reduced or absent for adjacent normal tissues. As a result, IMRT provides better tumor targeting, reduces the risk of side effects, and improves treatment outcomes. In studies, IMRT has proved most advantages in irradiating head and neck tumors compared to other types of cancer. The main advantage is treatment toxicity reduction.

VMAT (Volumetric modulated arc therapy). This is a new and improved version of IMRT. Nasopharyngeal cancer is irradiated using a rotating gantry along one or more arcs. The speed and shape of the beam changes. The main benefit is reduced delivery time for the required dose of radiation. VMAT is characterized by a sparing effect on organs at risk. Most of the benefits have been demonstrated in studies for the treatment of nasopharyngeal, oropharyngeal, and laryngopharyngeal cancers.

Proton therapy. This is advanced and the safest method of irradiating nasopharyngeal cancer. This is a particle therapy that uses proton beams. Unlike photons, which are commonly used to irradiate malignant tumors, protons emit most of the radiation inside the tumor. Therefore, they almost do not damage the surrounding tissue. The risk of complications is even lower than with IMRT or VMAT. But nasopharyngeal cancer treatment with proton therapy is more expensive. The technique is not available in every hospital. In most European countries, there are 1-3 proton therapy centers, and in Germany there are 6 such centers.

Surgical treatment

With nasopharyngeal cancer, surgery for primary tumor removal is usually not performed. It is technically complex. In addition, radiation therapy provides comparable results. At an early stage of nasopharyngeal cancer, the tumor can rarely be removed using endoscopic techniques through the nose.

More often, surgical treatment is used as part of combination treatment. The purpose of the surgical intervention is the removal of lymph nodes and soft tissues in the neck, in which nasopharyngeal cancer has metastasized or could metastasize. This operation is called a neck dissection. Doctors remove subcutaneous tissue with lymph nodes, muscles, blood vessels, nerves. The extent of surgery is different, depending on the stage of the disease and the risk of recurrence.

Neck lymph node dissection options for nasopharyngeal cancer are as follows: 

• selective – this option involves the removal of only the swollen lymph nodes closest to the tumor; 
• modified – this is the most commonly used option, which involves the removal of tissues between the lower jaw and collarbone, while maintaining the brachial plexus;
• radical – this is the most traumatic operation, involving the removal of almost all the lymph nodes of the neck, many muscles, nerves, and blood vessels.

Doctors strive to cure nasopharyngeal cancer using minimally traumatic techniques. Therefore, they seek to strike a balance in deciding the extent of lymph node dissection. The more tissue removed, the lower the risk of recurrence. At the same time, a significant extent of dissection for nasopharyngeal cancer increases the risk of complications. Therefore, surgeons strive to remove the minimum amount of tissue from which the patient is likely to be cured of nasopharyngeal cancer.

Here are some of the possible consequences of cervical lymph node dissection:

• speech disorders; 
• difficulty swallowing; 
• numbness of the skin of the ear; 
• impaired mobility of the lower lip; 
• shoulder muscle weakness. 

Neurological complications may be temporary or permanent. If the nerves are cut across, they can be sutured. But neck dissection often involves the complete removal of the nerves. In this case, neurological complications are irreversible.

Drug therapy

Chemotherapy is considered one of the main methods of nasopharyngeal cancer treatment. It often complements radiation therapy. Chemotherapy is a combination of several drugs.

Situations when chemotherapy is prescribed for nasopharyngeal cancer, are as follows: 

• before chemoradiotherapy (such chemotherapy is called induction);
• in combination with radiation therapy, as part of chemoradiotherapy (the main treatment for nasopharyngeal cancer);
• after chemoradiotherapy, to destroy the remaining cancer cells to avoid recurrent nasopharyngeal cancer;
• at the metastatic stage of nasopharyngeal cancer, if radiation therapy is not planned (chemotherapy is used as an independent method of controlling nasopharyngeal cancer).

Targeted therapy is used at the advanced stage, with nasopharyngeal cancer recurrence, with insufficient effectiveness of chemotherapy. This is a second-line treatment. Doctors use drugs from the group of EGFR (epidermal growth factor receptor) inhibitors. These are antibodies that destroy receptors. As a result, the protein that stimulates the division of cancer cells no longer works. EGFR inhibitors cannot cure nasopharyngeal cancer but can slow down the progression of cancer.

Immunotherapy is carried out using immune checkpoint inhibitors. These drugs are PD-1 inhibitors. They do not directly affect the tumor itself but enhance the antitumor immune response. Thanks to the effects of PD-1 inhibitors, nasopharyngeal cancer can no longer evade attacks from the immune system. As a result, primary tumor and metastatic foci decrease in size. Immunotherapy is most often used in the treatment of advanced stages. It is highly effective, so it can even be used as first-line therapy.

Treatment in Europe with Booking Health

To undergo treatment for nasopharyngeal cancer in one of the European hospitals, you are welcome to use the Booking Health service. On our website you can get information about this disease, methods of its treatment, find out the cost of treatment, and compare prices in different hospitals in order to book a medical care program at a favorable price. Treatment in Europe will be easier and faster for you, and the cost of treatment will be lower.

Please leave your request on the Booking Health website. Our specialist will contact you and consult you on treatment in Europe. Booking Health company will fully organize your trip to another country. We will provide the following benefits to you:

• We will select the best European hospital, whose doctors specialize in nasopharyngeal cancer treatment.
• We will solve the language barrier problem, and we will ensure communication with the doctor of the European hospital.
• We will reduce the waiting period for the medical care program. You will receive treatment on the most suitable dates.
• We will reduce the price. The cost of treatment in Europe will be reduced due to the lack of overpricing and additional coefficients for foreign patients.
• We will solve any organizational issues: we will prepare documents, meet you abroad and take you to the hospital, book a hotel, and provide interpreting services.
• We will prepare the program and translate medical documents. You do not have to repeat the previously performed diagnostic procedures.
• We will help you keep in touch with doctors after the treatment completion in Europe.
• We will organize additional diagnostic examinations and treatment in the European hospital.
• We will buy medicines abroad and forward them to your native country. 

Leading doctors from around the world will take care of your health. The Booking Health specialists will help reduce the cost of treatment, organize your trip to the European hospital, and you can fully focus on restoring your health.

Authors: 

The article was edited by medical experts, board certified doctors Dr. Nadezhda Ivanisova and Dr. Farrukh Ahmed. For the treatment of the conditions referred to in the article, you must consult a doctor; the information in the article is not intended for self-medication!

Our editorial policy, which details our commitment to accuracy and transparency, is available here. Click this link to review our policies.

Sources:

National Cancer Institute

American Cancer Society

Johns Hopkins Medicine