Join us   Log in  


Pages: 901-908
Print Article   Download XML  Download PDF

Reirradiation Using Intensity-Modulated Radiotherapy For Recurrent Nasopharyngeal Carcinoma:

-A Report of 10 Case Series From A Moroccan Center-

Author: Siham Jaba, Patricia Agbanglanon, Wilfried Bassané Alain Mossé, Gaël Kietga, Sanae Elmajjaoui, Hanan El Kacemi, Tayeb Kebdani, Noureddine Benjaafar

Category: JMSR Oncology


Aims and Methods: This study aimed to describe clinical outcomes and treatment-related toxicities after re-irradiation using intensity-modulated radiotherapy (IMRT) for patients with local and/or regional recurrent nasopharyngeal carcinoma (NPC) treated at the National Institute of Oncology Sidi Mohamed Ben Abdellah in Rabat- Morocco, between 2016 and 2019. The epidemiological data from the 10 patients were collected and studied. Results: Seven patients were female and 3 were male. Mean age at primary diagnosis was 39.3 years. At the time of initial diagnosis, induction chemotherapy was performed in 5 patients, and concurrent chemo-radiotherapy in all patients. The median interval between primary irradiation and recurrence was 5.3 years. Nine patients (90%) had locally advanced recurrent disease. Neoadjuvant chemotherapy was administered to 6 patients (60%) to downsize tumors before radiotherapy, and cisplatin-based concurrent chemo-radiotherapy was administrated to all patients. The mean re-irradiation dose was 61.8 Gy (range, 60-66 Gy). Treatment was delivered at 2 Gy/fraction daily, 5 days a week with a mean duration of 51 ± 5.3 days. Chemotherapy was interrupted in 2 patients (20%) during the concurrent phase to manage severe symptomatic or hematologic toxicities. After a mean follow-up time of 7.8 months, 4 patients died, 4 were alive and disease free and 2 were lost to follow-up. The median overall survival (OS) was 13 months with a 1-year OS rate of 46.9%. Fifty-eight per cent of patients experienced grade 3-4 late toxicities including various degree of hearing impairment, trismus and xerostomia. Conclusion: The use of innovative radiotherapy modalities such as IMRT has led to highly conformal radiation treatments, which allow smaller margins and decreased radiation doses to the normal organs at risk (OAR). IMRT should be considered as the preferred option in treating recurrent NPC.

Keywords: Intensity-modulated radiotherapy, Morocco, Recurrent nasopharyngeal carcinoma, Survival, Reirradiation


  1. Licitra L, Bernier J, Cvitkovic E, Grandi C, et al. Cancer of the nasopharynx. Crit Rev Oncol Hematol. 2003, Vol. 45(2), pp. 199–213.
  2. Bray F, Ferlay J, Soerjomataram I, Siegel RL, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018, Vol. 68(6), pp. 394–424.
  3. Ferlay J, Colombet M, Soerjomataram I, et al. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. Int J Cancer. 2019, Vol. 144(8), pp. 1941–1953.
  4. Tabuchi K, Nakayama M, Nishimura B, et al. Early detection of nasopharyngeal carcinoma. Int J Otolaryngology. 2011.
  5. Lee AW, Foo W, Mang O, Sze WM, et al. Changing epidemiology of nasopharyngeal carcinoma in Hong Kong over a 20-year period (1980–99): an encouraging reduction in both incidence and mortality. Int JCancer J. 2003, Vol. 103(5), pp. 680–5.
  6. Chaouki N, el Gueddari B. Epidemiological descriptive approach of cancer in Morocco through the activity of the National Institute of Oncology 1986–7. Bull Cancer. 1991, Vol. 78(7), pp. 603–9.
  7. Bouchbika Z, Haddad H, Benchakroun N, et al. Cancer incidence in Morocco: report from Casablanca registry 2005–2007. Pan African Med J. 2013, Vol. 16:31.
  8. Lee AW, Ma BB, Ng WT, Chan AT. Management of nasopharyngeal carcinoma: current practice and future perspective. J Clin Oncol. 2015, Vol. 33, pp. 3356–64.
  9. ML Chua, JT Wee, EP Hui, AT Chan. Nasopharyngeal carcinoma. Lancet. 2016, Vol. 387, pp. 1012–24.
  10. Zhang B, Mo Z, Du W, Wang Y, Liu L, Wei Y. Intensity- modulated radiation therapy versus 2D-RT or 3D-CRT for the treatment of nasopharyngeal carcinoma: a systematic review and metaanalysis. Oral Oncol. 2015, Vol. 51(11), pp. 1041–1046.
  11. Mao YP, Tang LL, Chen L, et al. Prognostic factors and failure patterns in non¬metastatic nasopharyngeal carcinoma after intensity¬modulated radiotherapy. Chin J Cancer. 2016, Vol. 35, p. 103.
  12. Zhang MX, Li J, Shen GP, et al. Intensity modulated radiotherapy prolongs the survival of patients with nasopharyngeal carcinoma compared with conventional two dimensional radiotherapy: a 10 years experience with a large cohort and long follow-up. Eur J Cancer. 2015, Vol. 51, pp. 2587–95.
  13. Chua DT, Wei WI, Sham JS, Hung KN, Au GK. Stereotactic radiosurgery versus gold grain implantation in salvaging local failures of nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys. 2007, Vol. 69, pp. 469–74.
  14. Leung TW, Tung SY, Sze WK, Sze WM, Wong VY, el al. Salvage brachytherapy for patients with locally persistent nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys. 2000, Vol. 47, pp. 405–12.
  15. Wei WI. Salvage surgery for recurrent primary nasopharyngeal carcinoma. Crit Rev Oncol Hematol. 2000, Vol. 33, pp. 91–8.
  16. Hua YJ, Han F, Lu LX, Mai HQ, et al. Long-term treatment outcome of recurrent nasopharyngeal carcinoma treated with salvage intensity modulated radiotherapy. Eur J Cancer. 2012, Vol. 48, pp. 3422–8.
  17. Han F, Zhao C, Huang SM, Lu LX, et al. Long-term outcomes and prognostic factors of re-irradiation for locally recurrent nasopharyngeal carcinoma using intensity-modulated radiotherapy. Clin Oncol (R Coll Radiol). 2012, Vol. 24, pp. 569–76.
  18. HY Chen, XM Ma, M Ye, YL Hou, et al. Effectiveness and toxicities of intensity-modulated radiotherapy for patients with locally recurrent nasopharyngeal carcinoma. PLoS One. 2013, Vol. 8(9).
  19. DTT Chua, JST Sham, DLW Kwong, et al. Locally recurrent nasopharyngeal carcinoma: Treatment results for patients with computer tomography assessment. Int J Radiat Oncol Biol Phys. 1998, Vol. 41, pp. 379–386.
  20. Teo PML, Kwan WH, Chan ATC, et al. How successful is high dose (???? 60 Gy) re-irradiation using mainly external beams in salvaging local failures of nasopharyngeal carcinoma?. Int J Radiat Oncol Biol Phys. 1998, Vol. 40, pp. 897–913.
  21. Kong L, Wang L, Shen C, Hu C, Wang L, Lu JJ. Salvage intensity-modulated radiation therapy (IMRT) for locally recurrent nasopharyngeal cancer after definitive IMRT: a novel scenario of the modern era. Sci Rep. 2016, p. 6.
  22. Chan OS, Sze HC, Lee MC, Chan LL, et al. Re-irradiation with intensity-modulated radiotherapy for locally recurrent T3 to T4 nasopharyngeal carcinoma. Head Neck. 2017, Vol. 39, pp. 533–40.
  23. Wang CC. Re-irradiation of recurrent nasopharyngeal carcinoma-treatment techniques and results. International Journal of Radiation Oncology Biology Physics. Vol. 13(7), pp. 953-956.
  24. Lee AWM, Foo W, Law SCK, et al. Re-irradiation for recurrent nasopharyngeal carcinoma: Factors affecting the therapeutic ratio and ways for improvement. Int J Radiat Oncol Biol Phys. 1997, Vol. 38, pp. 43–52.
  25. Leong YH, Soon YY, Lee KM, Wong LC, et al. Long-term outcomes after re-irradiation in nasopharyngeal carcinoma with intensity-modulated radiotherapy: a meta-analysis. Head Neck. 2018, Vol. 40(3), pp. 622-631.
  26. Tian YM, Zhao C, Guo Y, Huang Y, et al. Effect of total dose and fraction size on survival of patients with locally recurrent nasopharyngeal carcinoma treated with intensity-modulated radiotherapy: a phase 2, single-center, randomized controlled trial. Cancer. 2014, Vol. 120, pp. 3502–9.
  27. Qiu S, Lin S, Tham IW, Pan J, et al. Intensity-modulated radiation therapy in the salvage of locally recurrent nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys. 2012, Vol. 83, pp. 676–83.
  28. Qiu S, Lu J, Zheng W, Xu L, et al. Advantages of intensity modulated radiotherapy in recurrent T1–2 nasopharyngeal carcinoma: a retrospective study. BMC Cancer. 2014, Vol. 14, p. 797.
  29. Chua DT, Sham JS, Leung LH, Au GK. Re-irradiation of nasopharyngeal carcinoma with intensity-modulated radiotherapy. Radiother Oncol. 2005, Vol. 77, pp. 290–4.
  30. Doescher J, Veit JA, Hoffmann TK. The 8th edition of the AJCC Cancer Staging Manual: Updates in otorhinolaryngology, head and neck surgery. 2017, Vol. 8.
  31. Lee AWM, Poon YF, Foo W, et al. Retrospective analysis of 5037 patients with nasopharyngeal carcinoma treated during 1976-1985. Overall survival and patterns of failure. Int J Radiat Oncol Biol Phys. 1992, Vol. 23, pp. 261–270.
  32. Altun M, Fandi A, Dupuis O, et al. Undifferentiated nasopha- ryngeal cancer (UNCT): Current diagnostic and therapeutic aspects. Int J Radiat Oncol Biol Phys. 1995, Vol. 32, pp. 859–877.
  33. Lee AWM, Law SCK, Foo W, et al. Retrospective analysis of patients with nasopharyngeal carcinoma treated during 1976-1985: Survival after local recurrence. Int J Radiat Oncol Biol Phys. 1993, Vol. 26, pp. 773–782.
  34. Yan JH, Hu YH, Gu XZ. Radiation therapy of recurrent nasopharyngeal carcinoma: Report on 219 patients. Acta Radiol Oncol. 1983, Vol. 22, pp. 23–28.
  35. Chang JTC, See LC, Liao CT, Ng SH, Wang CH, et al. Locally recurrent nasopharyngeal carcinoma. Radiotherapy and Oncology. 2000, Vol. 54, 2, pp. 135-142.
  36. Chang JTC, See LC, Liao CT, et al. Locally recurrent nasopharyngeal carcinoma. Radiother Oncol. 2000, Vol. 54, pp. 135– 142.
  37. JM Hwang, KK Fu, TL Philips. Results and prognostic factors in the retreatment of locally recurrent nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys. 1998, Vol. 41, pp. 1099–1111.
  38. McDonald MW, Moore MG, Johnstone PA. Risk of carotid blowout after re-irradiation of the head and neck: a systematic review. Int J Radiat Oncol Biol Phys. 2012, Vol. 82, pp. 1083–9.
  39. Lee AWM, Ng WT, Chan JYW, Corry J, et al. Management of locally recurrent nasopharyngeal carcinoma. Cancer Treat Rev. 2019, Vol. 79.
  40. McNeese MD, Fletcher GH. Retreatment of recurrent nasopharyngeal carcinoma. Radiology. 1981, Vol. 138, pp. 191–193.
  41. Li YQ, Tian YM, Tan SH, Liu MZ, et al. Prognostic model for stratification of radioresistant nasopharynx carcinoma to curative salvage radiotherapy. J Clin Oncol. 2018, Vol. 36(9), pp. 891-899.
  42. Choo R, Tannock I. Chemotherapy for recurrent or metastatic carcinoma of the nasopharynx. A review of the Princess Margaret Hospital experience. Cancer. 1991, Vol. 68, pp. 2120-2124.
  43. Gebbia V, Zerillo G, Restivo G, et al. Chemotherapeutic treatment of recurrent and/or metastatic nasopharyngeal carcinoma: a retrospective analysis of 40 cases. Br. J. Cancer. 1993, Vol. 68, pp. 191-194.
  44. Koutcher L, Lee N, Zelefsky M, Chan K, et al. Re-irradiation of locally recurrent nasopharynx cancer with external beam radiotherapy with or without brachytherapy. Int J Radiat Oncol Biol Phys. 2010, Vol. 76, pp. 130–7.
  45. Poon D, Yap SP, Wong ZW, Cheung YB, et al. Concurrent chemoradiotherapy in locoregionally recurrent nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys. 2004, Vol. 59, pp. 1312–8.
  46. Chua DT, Sham JS, Au GK. Induction chemotherapy with cisplatin and gemcitabine followed by re-irradiation for locally recurrent nasopharyngeal carcinoma. Am J Clin Oncol. 2005, Vol. 28, pp. 464–71.
  47. Ng WT, Ngan RKC, Kwong DLW, Tung SY, et al. Prospective, multicenter, phase 2 trial of induction chemotherapy followed by bio-chemoradiotherapy for locally advanced recurrent nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys. 2018, Vol. 100, pp. 630–8.
  48. Chan AT, Leong SF, Ngan RK, et al. Overall survival after concurrent cisplatin-radiotherapy compared with radiotherapy alone in locoregionally advanced nasopharyngeal carcinoma. J Natl Cancer Inst. 2005, Vol. 97, pp. 536-539.
  49. Sham JST, Choy D, Wei WI, Yau CC. Value of clinical follow-up for local nasopharyngeal carcinoma relapse. Head Neck. 1992, Vol. 14, pp. 208-217.
  50. Chen YP, Tang LL, Yang Q, et al. Induction chemotherapy plus concurrent chemoradiotherapy in endemic nasopharyngeal carcinoma: individual patient data pooled analysis of four randomized trials. Clin Cancer Res. 2018, Vol. 24, pp. 1824–33.
  51. Ng SH, Wan YL, Ko SF, Chang JT. MRI of nasopharyngeal carcinoma with emphasis on relationship to radiotherapy. J. Mag. Reson. Imag. 1998, Vol. 8, pp. 327-336.
  52. National Comprehensive Cancer Network. Recent updates to NCCN clinical practice guidelines in oncology (NCCN Guidelines®). 2019.
  53. Chan AT, Gregoire V, Lefebvre JL, Licitra L, et al. Nasopharyngeal cancer: EHNS-ESMO-ESTRO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2012, Vol. 23, 7, pp. 83-5