Management of Chemotherapy for Stage II Nasopharyngeal Carcinoma in the Intensity-Modulated Radiotherapy Era: A Review

Nasopharyngeal carcinoma is an endemic disease with a high prevalence in Southeast Asia, Mediterranean countries, and Northern Africa. With substantial advances in screening and diagnosis, increasingly more early-stage (stage I~II) patients are being diagnosed. The undebated treatment modality for stage I patients is radiotherapy alone. However, controversies exist for patients with stage II disease, mostly revolving around the management of chemotherapy. However, the use of intensity-modulated radiotherapy for the treatment of nasopharyngeal carcinoma has increased recently, which has drastically improved survival outcomes. Thus, many oncologists have considered omitting chemotherapy for stage II patients in the intensity-modulated radiotherapy era. Unfortunately, prospective studies comparing concurrent radio-chemotherapy with intensity-modulated radiotherapy alone are limited. Notably, stage II nasopharyngeal carcinoma consists of three subgroups, among which stage T2N1M0 disease is unique and potentially warrants additional treatment including chemotherapy. Additionally, molecular biology techniques are advancing at an incredible speed. Instead of adopting a one-size-fits-all recommendation, exploring potential predictive biomarkers to select patients who are likely to derive benefit from chemotherapy is a better choice. In this review, we summarize the data from studies and reviews regarding chemotherapy for stage II nasopharyngeal carcinoma in the intensity-modulated radiotherapy era and discuss chemotherapy utility. Eventually, we conclude that IMRT alone may be sufficient for stage II nasopharyngeal carcinoma, but this needs to be verified by prospective studies in the near future, the evidence collected thus far suggests that concurrent chemo-radiotherapy without induction or adjuvant chemotherapy is yet to be necessary for patients with stage II disease.