Making the cut.

Top Line: What is the best approach to locally recurrent nasopharyngeal carcinoma (NPC) following prior definitive radiation?

The Study: Such questions are usually the subject of retrospective or population-based comparisons with recognized bias towards improved outcomes for patients who are selected for a resection. But here we have two well-timed papers to update our approach to recurrent NPC. First up are international consensus recommendations on re-irradiation of recurrent NPC. A point of unanimous agreement among the various expert approaches was that resectable recurrences should be managed with surgery. This brings us to the second study where we have an actual randomized trial of surgery versus re-irradiation for locally recurrent, but resectable, nasopharyngeal carcinoma. This Chinese phase 3 trial enrolled 200 patients with local-only recurrence of NPC that was deemed to be resectable and was conducted at three centers with particular expertise in the endoscopic procedure. Enrollees were randomized to re-irradiation or endoscopic nasopharyngectomy. Overall survival at three years was significantly higher after surgery (86%) than re-irradiation (68%). Late radiation effects appeared to play an important role in survival outcomes by contributing to death in 20% of re-irradiation patients compared to 5% of surgery patients. Importantly, though, both this trial and the expert recommendations stress the fact that successful resection of recurrent NPC requires experience and expertise that may not be widely available.

TBL: Among patients with resectable, locally recurrent NPC, expert endoscopic resection is associated with much higher overall survival compared to re-irradiation with late radiation effects being a major contributor to overall mortality. | Liu, Lancet Oncol 2021 and Ng, Int J Radiat Oncol Biol Phys 2021