Nasopharyngeal Cancer Follow-up

  • Author: Arnold C Paulino, MD; Chief Editor: Robert J Arceci, MD, PhD   more...
 
Updated: Apr 26, 2012
 

Further Inpatient Care

  • Certain types of chemotherapy will need to be administered on an inpatient basis.
  • Patients who develop febrile neutropenia need to be admitted for intravenous antibiotics. The antibiotic regimen usually consists of an antipseudomonal cephalosporin, with or without an aminoglycoside (especially in the context of renal dysfunction seen in patients receiving platinum-based chemotherapy) and/or an antistaphylococcal coverage.
  • Severe cases of malnutrition and dehydration may require inpatient management with support from a pediatric nutritionist.
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Further Outpatient Care

Radiation therapy is often administered on an outpatient basis. Follow-up is necessary after all radiation and chemotherapy has been administered.

Patients are evaluated every 3 months during the first year and every 6 months during the second and third years after treatment. Thereafter, follow-up is necessary every year.

Physical examination and a detailed history should be performed with each visit.

Imaging of the head and neck (CT or MRI), CT of the chest, and bone scan/positron emission tomography (PET) (if positive at distant metastatic sites at diagnosis) are usually performed every 3 months for the first year and then every 6 months for the next 2 years after therapy is completed to assess response.

A dental examination prior to radiotherapy and on a routine basis after therapy is recommended because of the possibility of caries and poor dental hygiene. Osteonecrosis of the mandible is a rare complication of radiotherapy and is often avoided with proper dental care.

As many children develop endocrine abnormalities after treatment, screening testing for hypothyroidism, growth hormone deficiency, and adrenal axis disorders should occur on a frequent basis after the completion of therapy.

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Inpatient & Outpatient Medications

Routine medications are not often administered and depend on treatment-related symptomatology.

Pneumocystis jiroveci pneumonia (also known as PCP) prophylaxis is recommended once chemotherapy starts and until 3 months after therapy is completed.

Annual influenza vaccination (inactivated or killed vaccine, also know as the "flu shot") is recommended for every pediatric patient.

Amifostine (Ethyol) may be used in the management of patients with nasopharyngeal cancer. This drug has been found to reduce xerostomia resulting from radiotherapy and nephrotoxicity resulting from cisplatin chemotherapy.

Pentoxifylline has been used for treatment of radiation-induced fibrosis.[27]

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Complications

  • Late toxicity of radiotherapy may include xerostomia, hypothyroidism, fibrosis of the neck with complete loss of range of motion, trismus, dental abnormalities, and hypoplasia of irradiated muscular and bony structures. Because of the high doses of radiotherapy used in this disease, these late toxicities can be significant, especially in younger children.
  • Endocrinopathies and growth retardation can occur secondary to radiotherapy to the pituitary gland. Panhypopituitarism can occur in some instances.
  • Sensorineural hearing loss may occur with the use of cisplatin and radiotherapy.[28]
  • Renal toxicity can occur in patients receiving cisplatin.
  • Caries and poor dental hygiene are associated complications. Osteonecrosis of the mandible is a rare complication of radiotherapy and is often avoided with proper dental care.
  • Second malignancy may occur in a child who has received previous radiotherapy. This risk is small but continues throughout life.
  • With proper radiotherapy techniques, the chance for development of radiation myelitis should be less than 1%.
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Prognosis

  • The results of clinical trials that include both radiation therapy and chemotherapy generally report long-term survival rates of 50-80% overall.[15, 29, 30]
  • In a study by Serin et al, the 5-year overall survival rate was 42% with radiotherapy alone and 58% with chemoradiation.[31]
  • Rodriguez-Galindo et al reported a 4-year event-free and overall survival rate of 77% and 75%, respectively, in a Phase II Pediatric Oncology Group clinical trial using radiation alone for patients with T1-T2N0M0 disease and radiation with neoadjuvant chemotherapy for all others.[19] Most were treated with 4 cycles of chemotherapy consisting of methotrexate, cisplatin, 5-fluorouracil, and leucovorin prior to radiotherapy.
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Patient Education

  • Patients and parents should be educated regarding the importance of follow-up after completion of all therapy. A detailed discussion of the risks of chemotherapy, especially the risk of febrile neutropenia, is necessary. Families should also be well informed of the issues of late effects.
  • For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education article Cancer of the Mouth and Throat.
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Contributor Information and Disclosures
Author

Arnold C Paulino, MD  Professor of Radiation Oncology, Methodist Hospital and Weill-Cornell Medical College; Associate Professor of Pediatrics, Baylor College of Medicine

Arnold C Paulino, MD is a member of the following medical societies: American Medical Association, American Radium Society, American Society for Therapeutic Radiology and Oncology, American Society of Clinical Oncology, Children's Oncology Group, International Society of Paediatric Oncology, and Radiological Society of North America

Disclosure: Nothing to disclose.

Coauthor(s)

Chrystal U Louis, MD, MPH  Assistant Professor, Texas Children's Cancer Center and Hematology Service, Center for Cell and Gene Therapy, Baylor College of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Samuel Gross, MD  Professor Emeritus, Department of Pediatrics, University of Florida; Clinical Professor, Department of Pediatrics, University of North Carolina; Adjunct Professor, Department of Pediatrics, Duke University

Samuel Gross, MD is a member of the following medical societies: American Association for Cancer Research, American Society for Blood and Marrow Transplantation, American Society of Clinical Oncology, American Society of Hematology, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Steven K Bergstrom, MD  Department of Pediatrics, Division of Hematology-Oncology, Kaiser Permanente Medical Center of Oakland

Steven K Bergstrom, MD is a member of the following medical societies: Alpha Omega Alpha, American Society of Clinical Oncology, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Children's Oncology Group, and International Society for Experimental Hematology

Disclosure: Nothing to disclose.

Helen SI Chan, MBBS, FRCP(C), FAAP  Associate Senior Scientist, Research Institute; Professor, Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto Faculty of Medicine, Canada

Helen SI Chan, MBBS, FRCP(C), FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American Society of Hematology, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Robert J Arceci, MD, PhD  King Fahd Professor of Pediatric Oncology, Professor of Pediatrics, Oncology and the Cellular and Molecular Medicine Graduate Program, Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine

Robert J Arceci, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Pediatric Society, American Society of Hematology, and American Society of Pediatric Hematology/Oncology

Disclosure: Nothing to disclose.

References

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MRI of the head and neck in a patient with nasopharyngeal carcinoma showing the primary tumor and cervical lymph node metastases
Intensity modulated radiotherapy images for a patient with nasopharyngeal carcinoma
Table 1. AJCC Staging for Nasopharyngeal Cancer
StageTNM
0TisNoM0
IT1N0M0
IIT1N1M0
T2N0M0
T2N1M0
IIIT1N2M0
T2N2M0
T3N0M0
T3N1M0
T3N2M0
IVAT4N0M0
T4N1M0
T4N2M0
IVBAny TN3M0
IVCAny TAny NMI
Table 2. Tumor (T) Staging
TXPrimary tumor cannot be assessed
T0No evidence of primary tumor
TisCarcinoma in situ
T1Tumor confined to the nasopharynx or extends to oropharynx and/or nasal cavity without parapharyngeal extension
T2Tumor with parapharyngeal extension
T3Tumor involves bony structures of skull base and/or paranasal sinuses
T4Tumor with intracranial extension and/or involvement of cranial nerves, hypopharynx, orbit, or with extension to the infratemporal fossa/masticator space
Table 3. Nodal (N) Staging
NXRegional lymph nodes cannot be assessed
N0No regional lymph node metastasis
N1Unilateral metastasis in cervical lymph node(s), less than or equal to 6 cm in greatest dimension, above the supraclavicular fossa, and/or unilateral or bilateral retropharyngeal lymph nodes, less than or equal to 6 cm in greatest dimension
N2Bilateral metastasis in a cervical lymph node (s), less than or equal to 6 cm in greatest dimension, above the supraclavicular fossa
N3Metastasis in a lymph node(s) greater than 6 cm and/or to supraclavicular fossa
N3aGreater than 6 cm in dimension
N3bExtension to supraclavicular fossa
Table 4. Metastasis (M) Staging
M0No distant metastasis
M1Distant metastasis
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