REVIEW

CURRENT
OPINION The role of nasopharyngectomy in the management
of nasopharyngeal carcinoma
Wei-Hsin Wang a,b, Chien-Fu Yeh b,c, and Ming-Ying Lan b,c

Purpose of review
Recently, endoscopic nasopharyngectomy (ENPG) has become an effective treatment for locally recurrent
nasopharyngeal carcinoma (NPC). This article reviews recent publications on ENPG and specifically
addresses the surgical anatomy of the nasopharynx and discusses several important issues regarding ENPG.
Recent findings
The surgical techniques for ENPG have been previously described in several studies. The latest published
data revealed good outcomes of ENPG compared with intensity-modulated radiation therapy (IMRT) in
recurrent NPC. In addition, ENPG avoids severe reirradiation side effects. This review highlights the
surgical anatomy of ENPG, which is important in preventing possible serious complications.
Summary
ENPG is a good option for managing recurrent NPC. Careful preoperative evaluation and a full
understanding of the surgical anatomy help in preventing damage to nearby critical neurovascular
structure. Long-term follow-up is still needed to evaluate its eventual morbidity and efficacy.
Keywords
endoscopic, nasopharyngeal carcinoma, nasopharyngectomy, recurrence

INTRODUCTION ENDOSCOPIC NASOPHARYNGECTOMY

Nasopharyngeal carcinoma (NPC) is a malignant
tumour that arises in the epithelial lining of the
nasopharynx. The highest incidence of NPC is
observed in southern China [1]. According to the
tumour extent and location, patients may develop
nasal obstruction, nasal bleeding, otitis media with
hearing impairment, neck mass or other neurologi-
cal symptoms, such as headache and facial numb-
ness. Endoscopy can confirm tumour characteristics
and location. Three histological classifications,
including type I (keratinizing), type II (nonkerati-
nizing) and type III (undifferentiated), were estab-
lished by the WHO. Patients with NPC are inclined
to have metastasis to the cervical lymph nodes or
distant sites, including the lung, bone and liver. The
mainstay treatment for NPC is radiotherapy or che-
moradiotherapy [2]. After primary treatment, 5–
20% of patients develop local recurrence in the
nasopharyngeal region [3,4]. In the past, reirradia-
tion, surgical excision and chemotherapy were the
treatment options for local recurrent NPC. In recent
years, with advances in endoscopic surgical techni-
ques, endoscopic nasopharyngectomy (ENPG) has
become an effective treatment with good survival
outcomes and low complication rates [5].
The first ENPG was reported in 2005 [6]. The
restricted working space of the nasopharynx, as well
as the proximity of the internal carotid artery (ICA),
is the main challenge of ENPG. However, advances
in surgical techniques of the endoscopic endonasal
approach as well as a better understanding of naso-
pharyngeal anatomy overcomes the difficulties
encountered in the previous era. The indication
of ENPG in NPC is mainly residual or locally recur-
rent NPC. Nasopharyngectomy is conventionally
performed using open approaches, including the
maxillary swing, transpalatal approach, transman-
dibular approach or transinfratemporal fossa
a
Department of Neurosurgery, Taipei Veterans General Hospital, bSchool
of Medicine, National Yang Ming Chiao Tung University and cDepartment
of Otorhinolaryngology-Head and Neck Surgery, Taipei Veterans General
Hospital, Taipei, Taiwan
Correspondence to Ming-Ying Lan, Department of Otorhinolaryngology-
Head and Neck Surgery, Taipei Veterans General Hospital, No.201, Sec.
2, Shipai Rd., Beitou District, Taipei City 11217, Taiwan.
Tel: +886 2 2875 7337; fax: +886 2 2875 7338;
e-mail: mingyinglan@gmail.com
Curr Opin Otolaryngol Head Neck Surg 2022, 30:3–12
DOI:10.1097/MOO.0000000000000780

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Nose and paranasal sinuses
KEY POINTS
 ENPG provides promising outcomes compared with
IMRT for recurrent NPC.
 The ICA is the most critical structure in
nasopharyngectomy, and several surgical landmarks,
such as Vidian nerve, pterygosphenoid fissures, the
posterior trunk of V3 and cartilaginous part of the
Eustachian tube, help to identify different segments
of ICA.
 Meticulous preoperative evaluation and full
understanding of the surgical anatomy are important to
prevent damage to nearby critical neurovascular
structure.
 Cases with postoperative positive margins may require
further treatment with radiotherapy or chemotherapy.
 Long-term follow-up is still needed to evaluate eventual
morbidity and efficacy of ENPG.
approach [7–9]. However, open approaches may
have significant morbidities, such as cosmetic prob-
lems, facial numbness and scarring, oronasal fistula,
palatal incompetence, trismus, ectropion, epiphora
and carotid artery rupture [10]. As ENPG is less
invasive, it avoids the most morbidities which
may be encountered during open approaches [11].
SURGICAL CLASSIFICATIONS OF
ENDOSCOPIC NASOPHARYNGECTOMY
Castelnuovo et al. [12] were the first to report the
types of ENPG. They categorized ENPGs into three
types as follows: type I, resection of the posterior
nasopharyngeal wall; type II, resection superiorly to
the sphenoid; type III, trans-pterygoid approach to
the posterolateral nasopharynx with removal of the
pterygoid plates and Eustachian tube, while control-
ling the ICA [12]. They reported no cases of periop-
erative mortality or major complications. The 5-year
overall survival (OS), disease-specific survival (DSS)
and disease-free survival (DFS) were 75.1, 80.9 and
58.1%, respectively [12]. However, their survival
rates could not be compared with those of other
studies due to heterogeneous diseases, in which only
23 cases were NPC.
&
Liu et al. [13 ] categorized ENPG into four types
based on stepwise exposed anatomical structures
and the 2010 American Joint Committee on Cancer
NPC staging system as follows: type I with resection
of the nasopharynx and sinuses; type II with lateral
extension to the parapharyngeal space; type III with
lateral extension to the floor of the middle cranial
fossa and infratemporal fossa and superior
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extension to the orbital apex and the cavernous
sinus back to the prevertebral region; and type IV
with resection of the involved ICA following type III
&
[13 ]. Promising results were shown using transnasal
endoscopic nasopharyngectomy in the manage-
ment of locally recurrent NPC. However, only a 2-
year survival data have been reported. Long-term
follow-up is needed.
SURGICAL ANATOMY FOR ENDOSCOPIC
NASOPHARYNGECTOMY
Nasopharyngectomy for recurrent NPC is challeng-
ing because of the infiltrative behaviour of the
tumour and the complicated surroundings after
radiotherapy. Therefore, the identification of key
anatomical landmarks is essential for maximal
tumour resection and for preventing surgical com-
plications.
Nasopharynx
In the sagittal plane, the nasopharynx is located
between the level of the choanae (same level as
the sphenoid sinus floor) and the soft palate
(Fig. 1a). The posterior wall of the nasopharynx is
the inferior clivus, which is covered by a mucosal
layer, pharyngobasilar fascia and prevertebral
muscles (longus capitis and rectus capitis muscles),
respectively, from superficial to deep (Fig. 1b–d).
The pharyngobasilar fascia is thick in the rostral
and firmly connected to the skull base posteriorly
on the pharyngeal tubercle of the occipital bone,
laterally on the petrous part of the temporal bone,
and anteriorly on the medial pterygoid plate of the
sphenoid bone. In the caudal direction, it reduces
the thickness and provides attachment to the supe-
rior constrictor muscle. The sinus of Morgagni is a
defect of the pharyngobasilar fascia in the postero-
lateral aspect of the nasopharynx. The structures
passing through it are the cartilaginous Eustachian
tube and tensor veli palatini muscle. The sinus of
Morgagni allows communication between the naso-
pharynx and middle ear, and it also provides a
corridor for NPC to invade laterally. Posterior sep-
tectomy followed by flattening of the maxillary crest
inferiorly and sphenoid sinus floor superiorly is
usually required to completely explore the naso-
pharynx (Fig. 1b). The lateral wall of the nasophar-
ynx is composed of pterygoid plates and a
cartilaginous Eustachian tube. For advanced recur-
rent NPC, extended medial maxillectomy and trans-
pterygoid approaches are required for lateral
extension of the endoscopic nasopharyngectomy
(Fig. 2).
Volume 30  Number 1  February 2022
 Role of nasopharyngectomy in NPC Wang et al.

FIGURE 1. (a) The nasopharynx can be seen directly by the endoscopic endonasal approach. (b) Posterior septectomy with
flattening of the sphenoid floor has been done to completely explore the nasopharynx. (c, d) The posterior wall of the
nasopharynx was exposed in layers. E. Tube, Eustachian Tube; Inf. Turb., Inferior Turbinate; Lon. Cap. Muscle, Longus Capitis
Muscle; Mid. Turb., Middle Turbinate; Nasoph., Nasopharynx; Palatov. Artery, Palatovaginal Artery; Pharyn. Fascia,
Pharyngobasilar Fascia; Rec. Cap. Muscle, Rectus Capitis Muscle; Ros. Fossa, Rosenmuller Fossa.

Eustachian tube Pterygopalatine fossa and upper

The Eustachian tube consists of a bony part and a
cartilaginous part. The bony part is near the middle
ear and approximately one-third of its length
(Fig. 3c, d). The cartilaginous part has a pharyngeal
opening on the lateral nasopharynx and lies in the
sulcus between the petrous part of the temporal
bone and the great wing of the sphenoid bone.
The torus tubarius is a mucosal elevation behind
the nasopharyngeal opening. Rosenmuller fossa is
the space formed through mucosal reflection and
just posterior to the torus tubarius. Rosenmuller
fossa is the most common site of origin of NPC.
The Eustachian tube is closely related to the ICA,
especially the petrous ICA [14]. Well tolerated tran-
section of the Eustachian tube is a key step for
efficient tumour removal in endoscopic nasophar-
yngectomy (Fig. 3c, d).
parapharyngeal space
If a further lateral extension of the nasopharyngec-
tomy is required, the transpterygoid approach to the
pterygopalatine fossa with drilling of pterygoid
plates and process may be required to explore the
upper parapharyngeal space. The exposure of the
pterygopalatine fossa provides the advantages of
controlling the sphenopalatine artery and identify-
ing the Vidian nerve early on. The Vidian nerve is
the most reliable landmark for localizing the lac-
erum ICA (Fig. 3c) [15–18].
After aggressive drilling of the pterygoid plates
and displacement of the pterygoid muscles, the
posterior trunk of V3 can be identified. The upper
parapharyngeal space with parapharyngeal ICA can
be identified just posterior to the posterior trunk of
&
V3 (Fig. 3a, b) [19 ]. For advanced NPC, the

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Nose and paranasal sinuses

FIGURE 2. (a, b) Medial maxillectomy and transpterygoid approach for lateral extension of the endoscopic
nasopharyngectomy. (c, d) Pterygoid process and medial pterygoid plate have been removed to expose the foramen lacerum.
Vidian nerve identified backward from pterygopalatine fossa (yellow dotted) is the constant landmark leading to lacerum ICA.
(e, f) Infratemporal fossa was exposed and V3 can be identified following the lateral pterygoid plate superiorly. DPA,
Descending Palatine Artery; Gr. Pal. N., Greater Palatine Nerve; IMA, Internal Maxillary Artery; Infraorb. N., Infraorbital
Nerve; Lat. Pteryg. M., Lateral Pterygoid Muscle; Lat. Pteryg. Plate, Lateral Pterygoid Plate; Paracliv. ICA, Paraclival ICA; Perp.
Plate of Palatine B., Perpendicular Plate of Palatine Bone; Post. Lat. Nas. A., Posterior Lateral Nasal Artery; Sep. A, Septal
Artery; SPA, Sphenopalatine Artery; Sph. Sinus, Sphenoid Sinus; V3, Mandibular Nerve.

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 Role of nasopharyngectomy in NPC Wang et al.

FIGURE 3. (a) Endoscopic endonasal view of the cartilaginous Eustachian tube, foramen lacerum fibrocartilage, Vidian nerve,
foramen ovale and parapharyngeal ICA. There is a bony strut, mandibular strut, located between the deep end of Vidian canal
and foramen ovale. The Vidian nerve, mandibular strut and the V3 are seen from medial to lateral, respectively. The cartilaginous
Eustachian tube connects tightly with foramen lacerum fibrocartilage below the level of Vidian canal. (b) Highlight the white
dotted circle. The parapharyngeal ICA can be identified posteriorly to the posterior trunk of V3. (c, d) The asterisk is the well
tolerated entry zone to transect the cartilaginous Eustachian tube from the foramen lacerum fibrocartilage without injury of
lacerum ICA. (e, f) The cartilaginous Eustachian tube has been removed to expose the parapharyngeal ICA. Bon. ET, Bony
Eustachian Tube; Cart. ET, Cartilaginous Eustachian Tube; Fibrocart., foramen lacerum fibrocartilage; For. Ovale, Foramen
Ovale; LVP, Levator Veli Palatini; M. Strut, Mandibular Strut; Paracliv. ICA, Paraclival ICA; Paraph. ICA, Parapharyngeal ICA;
Post. Tr., Posterior Trunk of V3; Pteryg. Fissu., Pterygosphenoidal Fissure; TVP, Tensor Veli Palatini; Vidian N., Vidian Nerve.

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Nose and paranasal sinuses
trajectory of V3 exiting from the foramen ovale may
provide a natural corridor for tumour invasion to
the temporal base and intracranial space.
Internal carotid artery
The ICA is the most critical structure in nasophar-
yngectomy. Regardless of whether preoperative
embolization or a covering stent has been per-
formed, identification of different segments of the
ICA provides efficacy in maximal resection of the
tumour. The segments of the ICA involved in naso-
pharyngectomy include the parapharyngeal seg-
ment, petrous segment and lacerum segment,
from inferior to superior. Parapharyngeal ICA cours-
ing superiorly in the parapharyngeal space, curves
into the carotid canal and continues as the petrous
ICA. The useful surgical landmarks to identify the
parapharyngeal ICA include the posterior trunk of
V3 and its surrounding fat, sphenoid spine and
&
styloid aponeurosis (Fig. 3f) [19 ]. The petrous ICA
is located in the petrous part of the temporal bone
and courses anteriorly and medially toward the
foramen lacerum. The surgical landmark for the
petrous ICA is the cartilaginous part of the Eusta-
chian tube. The cartilaginous Eustachian tube runs
lateral, inferior and anterior to the petrous ICA and
is separated by the lateral bony wall of the carotid
canal [14]. After exiting the carotid canal, the
petrous ICA curves superiorly above the fibrocarti-
laginous tissues of the foramen lacerum. The lac-
erum ICA is a genus that passes through the upper
part of the foramen lacerum. The surgical landmarks
to localise the lacerum ICA include Vidian nerve and
pterygosphenoid fissures (Figure 2d, 3e) [18].
The Vidian nerve is located slightly inferior and
lateral to the lacerum ICA. The pterygosphenoidal
fissure, the fibrous tissue between the pterygoid
process and the floor of the sphenoid sinus, leads
to medial and lower aspects of the lacerum ICA. The
Vidian nerve and pterygosphenoidal fissure con-
verge posteriorly to form the anterior wall of the
lower part of the foramen lacerum, which serves as a
well tolerated entry zone in nasopharyngectomy to
detach the cartilaginous Eustachian tube without
injury to the lacerum ICA (Fig. 3c, e).
ISSUES REGARDING ENDOSCOPIC
NASOPHARYNGECTOMY
Advantages
ENPG directly resects radioresistant recurrent
tumours. Therefore, ENPG avoids an external scar
and can preserve most of its function. With the
advancement of endoscopic magnification, improved
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visualisation of the complicated anatomy of the naso-
pharyngeal area helps in preventing damage to the
nearby critical neurovascular structure. Moreover, an
angled view of the endoscope facilitates the identifi-
cation of tumour margins. Compared with intensity-
modulated radiation therapy (IMRT), ENPG could
avoid the high rate of toxic effects of severe reirradia-
tion, which is the major mortality of salvage IMRT [5].
Positive margin
&&
In the study by Liu et al. [20 ], 94% of patients had
clear resection margins, while six patients had a
positive surgical margin who received further ther-
apy, including salvage surgery, concurrent chemo-
radiotherapy or palliative chemotherapy. In the
study by Castelnuovo et al. [12], a negative margin
was achieved in 92% of cases. In the Shanghai EENT
Hospital’s study, a positive surgical margin was noted
in 15.8% of patients, which is higher than in other
studies due to the inclusion of more advanced stage
&
(rT4) cases [13 ]. For those with a positive surgical
margin, further treatment with radiotherapy or che-
motherapy should be considered.
Complications
Complications of ENPG include intraoperative and
postoperative haemorrhage, wound infection, tem-
porary postoperative masticatory impairment, mid-
dle ear effusion and turbinate synechiae. It is highly
related to the extent of ENPG, as well as the experi-
ence of surgeons [5].
Reconstruction of the surgical defect
Mucosal flaps are often used to repair nasopharyn-
geal defects, in which the nasoseptal flap is the most
&&
common. In the study by Liu et al. [20 ], 48 (48%) of
100 patients receiving ENPG used a mucosal flap.
However, Castelnuovo et al. [12] used a nasoseptal
flap only when an expanded resection with expo-
sure of the ICA and/or skull base was performed. In
cases of radiation-induced degeneration of the nasal
mucosa or extremely large defects that need to be
covered, the temporoparietal fascia flap should be
harvested as the graft [12]. For patients needing
post-OP radiotherapy, covering the ICA and skull
base with flaps prevents possible complications after
radiotherapy, such as carotid artery rupture or
osteoradionecrosis of the skull bases.
Contraindication
&&
Liu et al. [20 ] defined unresectable recurrent
NPC cases as extensive invasion of the skull base
Volume 30  Number 1  February 2022

or if the distance from the tumour margins to the
ICA is less than 0.5 cm. Regarding the lymph
nodes, patients with unresectable lymph node
recurrence were excluded, such as lymph tumour
invasion of the common carotid artery or retro-
&&
pharyngeal lymph node recurrence [20 ]. In the
study by Castelnuovo et al. [12], the contraindica-
tions of ENPG were massive intracranial intradural
involvement, orbital content invasion and encase-
ment of the ICA by the tumour. There is currently
no consensus regarding the contraindications
for ENPG.
Internal carotid artery management
ICA stenting is suggested for patients with laterally
extended tumours, especially when tumours invade
the parapharyngeal, petrous or cavernous segment
of the ICA. ICA stenting is helpful for intraoperative
identification of the ICA, which is safer for manag-
ing vessels intraoperatively. Therefore, ICA stenting
could prevent the ICA from iatrogenic injuries and
reduce the postoperative risk of complications [12].
&&
In the group of Liu et al. [20 ], who required
expanded ENPG (type IV) to achieve radical extirpa-
tion, they occluded the involved ICA for those
passing the balloon occlusion test, except for one
patient receiving an extracranial–intracranial vas-
cular bypass due to failure of the balloon occlusion
&
test [13 ].
COMPARISON OF ENDOSCOPIC
NASOPHARYNGECTOMY WITH
REIRRADIATION
You et al. [21] compared salvage ENPG with IMRT in
limited recurrent NPC patients and found that
ENPG was associated with a relatively good OS
and quality of life, and significantly decreased treat-
ment-related complications and medical costs.
Recently, the first and the only randomized con-
trolled trial conducted in China showed that the 3-
year OS was significantly improved in the ENPG
group compared with the IMRT group (85.8 vs.
68.0%) in patients with resectable locally recurrent
NPC, as well as DFS and locoregional recurrence-free
&&
survival (LRFS) [20 ]. They defined resectable
locally recurrent tumours as tumours confined to
the nasopharyngeal cavity, the postnaris or nasal
septum, the superficial parapharyngeal space or the
base wall of the sphenoid sinus. Moreover, treat-
ment-related adverse event rates were lower in the
ENPG group than in the IMRT group. Therefore,
ENPG should be considered as the standard treat-
ment option for resectable locally recurrent NPC.
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Role of nasopharyngectomy in NPC Wang et al.
However, long-term follow-up is needed to evaluate
&&
its eventual morbidity and efficacy [20 ].
Zou et al. [22] investigated 410 patients with
recurrent NPC. They noticed that ENPG and IMRT
were associated with improved OS and distant
metastasis-free survival (DMFS) compared with 2D
conventional radiotherapy in early recurrent disease
[22]. However, there was no difference in survival
between ENPG and IMRT in patients with recurrent
T3. Therefore, they suggested that combining ENPG
and IMRT may be considered in patients with
advanced recurrent NPC, which needs further study
&&
[20 ].
LITERATURE REVIEW OF ENDOSCOPIC
NASOPHARYNGECTOMY
In 2005, Yoshizaki et al. [6] first reported four recur-
rent T2 NPC cases treated with transseptal ENPG.
Except for one case with massive parapharyngeal
extension, the other three cases were successfully
resected [6]. In 2008, Ko et al. [23] reported 28
recurrent T1–2 NPC cases treated with ENPG. The
2-year OS and 2-year DFS rates were 59.4 and 57.6%
[23]. In 2009, Chen et al. [24] reported 37 patients
treated with ENPG, and the series included recur-
rent T1–T3 cases. Only one patient had a positive
margin and the 2-year OS, LRFS and progression-
free survival (PFS) rates were 84.2, 86.3 and 82.6%,
respectively [24]. In 2013, Castelnuovo et al. [12]
developed a new classification of nasopharyngeal
endoscopic resection (NER) (types I, II and III) and
successfully treated 23 cases of T1–T4 NPC. In 2017,
&&
Liu et al. [20 ] reported 91 patients (recurrent T1–4)
treated with ENPG. They described a type IV NER
that could remove the tumour, including the ICA.
Seventeen patients (18.6%) had positive margins.
The 2-year OS and DFS rates were 64.8 and 57.5%,
respectively. The 5-year OS and DFS rates were 38.3
&
and 30.2%, respectively [25]. In 2021, Li et al. [26 ]
reported 189 NPC cases (recurrent T1–T4) treated
with ENPG. Thirty-two (16.9%) patients had a posi-
tive margin, and 11 (5.8%) received postoperative
RT. The 1, 3 and 5-year OS rates were 82.2, 59.5 and
43.6%, respectively. The 5-year OS rates of patients
with recurrent T1, T2, T3 and T4 disease were 42.5,
&
54.4, 44.1 and 32.5%, respectively [26 ]. A meta-
analysis of 23 studies and 792 recurrent NPC
patients indicated that the combined 2-year OS
rates in recurrent T1, T2, T3 and T4 patients were
100, 87, 78 and 38%, respectively. In addition, the
combined 2-year DFS rates in recurrent T1 and T2
&&
patients were 96% and 86%, respectively [27 ]. The
related ENPG studies are summarized in Table 1
& &
[28 ,29 ,30–41].
www.co-otolaryngology.com 9
 10
Table 1. Literature reviews for ENPG in recurrent NPC

Survival (years)
Year Ref. Country Cases T classification Positive margin Post-RT OS DFS DSS LRFS DMFS PFS
&&
2021 Liu et al. [20 ] China 100 rNPC (T13) 6 (6%) 3 (3%)
&
2021 Liu et al. [13 ] China 101 rNPC (T14) 76.2% (2) 53.6% (2)
&
2021 Thamboo et al. [28 ] USA 13 rNPC (T13) 3 (23%) 3 (23%) 84.6% (5) 53.9% (5)
&
2021 Li et al. [26 ] China 189 rNPC (T14) 32 (16.9%) 11 (5.8%) 82.2% (1)
59.5% (3)
Nose and paranasal sinuses

43.6% (5)
T1 42.5% (5)
T2 54.4% (5)

www.co-otolaryngology.com
T3 44.1% (5)
T4 32.5% (5)
&
2021 Wang et al. [29 ] China 37 rNPC (T23) 1 (2.7%) 1 (2.7%) 88.7% (2) 72% (2) 97.3% (2) 72% (2)
2017 Vlantis et al. [30] Hong Kong 18 rNPC (T12) 2 (11.1%) 0 100% (2) 90% (2)
2017 Liu et al. [25] China 91 rNPC (T14) 17 (18.6%) 9 (9.9%) 64.8% (2) 57.5% (2)
38.3% (5) 30.2% (5)
2017 Weng et al. [31] China 36 rNPC (T14) 3 (8.3%) 36 (100%)
2017 Wong et al. [32] Malaysia 15 rNPC (T34) 6 (40%) 0 66.7% (2) 40% (2) 73.3% (2)
2015 You et al. [21] China 72 rNPC (T13) 77.1% (5)
2014 Zou et al. [22] China 92 rNPC (T14) 78.1% (5)
2014 Emanuelli et al. [33] Romania 8 rNPC (T1) 0 1 (12.5%) 100% (2) 88.9% (2)
2013 Castelnuovo et al. [12] Italy 23 pNPT (T14) þ
rNPT (T14)
2012 Ho et al. [34] USA 13 rNPC (T13) 4 (30.8%) 5 (38.5%) 100% (2) 69.2% (2)
2012 Villaret et al. [35] Austria 3 rNPC (T1,3) 0 0
2011 Chen et al. [36] China 18 rNPC
2011 Chen et al. [37] China 12 rNPC (T13) 1 (8.3%) 1 (8.3%)
2010 Castelnuovo et al. [38] Italy 8 pNPC (T1,2,4) þ 0
rNPC (T13)
2009 Chen et al. [24] China 37 rNPC (T13) 1 (2.7%) 0 84.2% (2) 86.3% (2) 82.6% (2)
2009 Rohaizam et al. [39] Malaysia 6 rNPC (T1) 0 0
2009 Tay et al. [40] Singapore 2 rNPC 100% (5)

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2008 Ko et al. [23] Taiwan 28 rNPC (T12) 3 (10.7%) 2 (7.1%) 59.4% (2) 57.6% (2)
2007 Chen et al. [41] Taiwan 6 rNPC (T12) 0 0
2005 Yoshizaki et al. [6] Japan 4 rNPC (T2)

DFS, disease-free survival; DMFS, distant metastasis-free survival; DSS, disease specific survival; ENPG, endoscopic nasopharyngectomy; LRFS, locoregional recurrence free survival; NPC, nasopharyngeal carcinoma;
OS, overall survival; PFS, progression-free survival; rNPC, recurrent NPC; RT, radiotherapy.

Volume 30  Number 1  February 2022


CONCLUSION
ENPG provides promising outcomes compared
with IMRT for recurrent NPC. Meticulous preoper-
ative evaluation and full understanding of the sur-
gical anatomy are important to prevent possible
severe complications, such as ICA injury. Cases
with postoperative positive margins may require
further radiation or chemotherapy. Long-term fol-
low-up is still needed to evaluate eventual morbid-
ity and efficacy.
Acknowledgements
None.
Financial support and sponsorship
This research was supported by the grants from the
Taipei Veterans General Hospital (V110C-054).
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
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Volume 30  Number 1  February 2022