A 55-year-old Indian male with a 4-month history of right-sided neck swelling and epistaxis presents to the ENT clinic. Imaging (CT + MRI) shows a 4 cm nasopharyngeal mass with right cervical lymph nodes (largest 3 cm) and no distant metastases. Staging is T3N2M0. The patient is counselled about treatment options. Which of the following is the standard of care for this stage of nasopharyngeal carcinoma?

Explanation

## Management of Locally Advanced Nasopharyngeal Carcinoma (T3N2M0) ### Staging and Prognosis Context **Key Point:** T3N2M0 represents locally advanced nasopharyngeal carcinoma (Stage III). The primary tumour extends beyond nasopharynx; regional nodes are involved but no distant metastases. This stage requires multimodal therapy. ### Standard Treatment Algorithm ```mermaid flowchart TD A[Nasopharyngeal Carcinoma]:::outcome --> B{Stage?}:::decision B -->|Early T1-2N0| C[RT alone 70 Gy]:::action B -->|Locally advanced<br/>T3-4 or N1-3| D[Concurrent CCRT]:::action D --> E[Cisplatin 40 mg/m² weekly<br/>or 100 mg/m² 3-weekly]:::action E --> F[Adjuvant chemotherapy<br/>if high risk]:::action B -->|Metastatic M1| G[Palliative chemotherapy]:::action H[Surgery rarely used<br/>except salvage]:::urgent ``` ### Why Concurrent Chemoradiotherapy (CCRT)? **High-Yield:** Multiple randomized trials (RTOG, EORTC, VUMCA) have demonstrated that concurrent CCRT improves overall survival and locoregional control compared to RT alone in locally advanced NPC. | Treatment | 5-Year OS | Locoregional Control | Toxicity | | --- | --- | --- | --- | | RT alone (70 Gy) | ~40–50% | 60–70% | Moderate | | Concurrent CCRT | ~60–70% | 80–90% | Higher (acute mucositis, dysphagia) | | CCRT + Adjuvant CT | ~70–75% | 85–95% | Highest | **Clinical Pearl:** Cisplatin is the chemotherapy backbone. Dosing: 40 mg/m² weekly during RT (preferred in Asia) or 100 mg/m² every 3 weeks (Western regimen). Weekly dosing is better tolerated in concurrent setting. ### Role of Adjuvant Chemotherapy - **Indicated** if high-risk features: T4, N3, or non-keratinizing histology (EBV+) - Regimen: 2–3 cycles of cisplatin + 5-FU or gemcitabine after CCRT completion - Improves distant metastasis-free survival, particularly in endemic undifferentiated NPC ### Why NOT Surgery? **Warning:** Surgery (neck dissection, nasopharyngectomy) is NOT first-line for primary NPC because: 1. Nasopharynx is difficult to access surgically 2. High morbidity (velopharyngeal insufficiency, dysphagia) 3. Radiotherapy achieves superior locoregional control 4. **Surgery is reserved for salvage** (residual/recurrent disease after CCRT) or **neck dissection** if nodes do not respond to CCRT **Mnemonic:** **CCRT** = **C**isplatin + **C**oncurrent **R**adiotherapy + **T**umour = Gold standard for locally advanced NPC