What is your preferred treatment for locally advanced poorly differentiated carcinoma of the nasopharynx with bulky neck nodes that is EBER negative and p16 negative?

I prefer concurrent chemoradiation first if this can be started in a timely fashion and deemed reasonable by my radiation oncology colleagues. Discussion in multidisciplinary tumor board would be of immense value here. I would strongly consider adjuvant chemo based on Intergroup 0099 study in which 22% of patients had keratinized squamous cell ca, which were likely EBV negative.

If there is an expected delay in starting radiation, or if the tumor board/radiation oncology colleagues recommend an induction chemotherapy approach, I prefer the cisplatin/gemcitabine regimen which is much more tolerable and avoids the need for infusional 5-FU. Moreover, it has been studied specifically in this population. Both the landmarks studies, TAX 323 and T...

To date, there is no data as to whether induction chemotherapy followed by chemoradiation vs chemoradiation followed by adjuvant chemotherapy should be administered. Moreover, either option is listed as standard of care treatment by the Head and Neck NCCN guidelines for locally advanced EBV (-), p16 (-) nasopharyngeal cancer. With that said, either approach is acceptable. However, in face of the this patient's bulky disease, I would favor the use of induction chemotherapy. As noted in Dr. @Dr. First Last's response, Gemcitabine and cisplatin or TPF may be used (see references in her response). I would favor the use of Gemcitabine and cisplatin as this regimen will be much better tolerated compared to TPF. Additionally, such patients should ...

Cis/XRT then adjuvant cis/5FU.