Nasopharyngeal cancer

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 15 Apr 2025

Last updated: 15 Apr 2025

Nasopharyngeal cancer (NPC) most commonly presents with a neck mass. Epistaxis, nasal obstruction, unilateral otitis media with effusion (serous otitis media), tinnitus, or impaired hearing in one ear should raise suspicion of NPC, particularly in an Asian patient.

Risk factors for NPC include a history of Epstein-Barr virus (EBV) infection, diet rich in salted fish, smoking or other tobacco use, and a family history of NPC in a first-degree relative.

Confirm the diagnosis with endoscopic biopsy of the primary tumor and/or fine-needle aspiration/core biopsy of neck nodal metastasis.

Radiation therapy is the main treatment modality for nonmetastatic NPC. Some patients with early-stage NPC can be treated with radiation therapy alone. Concurrent chemotherapy is added for locally advanced disease. Surgery, reradiation, and chemotherapy are options for locoregional nasopharyngeal/neck nodal recurrence and metastatic disease. Documentation of remission after completion of treatment is important and can be done with clinical and radiographic assessments.

Plasma EBV after treatment can provide prognostic information and it can also be used for early detection of recurrences.

Definition

NPC most often refers to squamous cell carcinoma (SCC) of the nasopharynx. It is a head and neck cancer arising from epithelial cells with three histopathologic subtypes: nonkeratinizing SCC, keratinizing SCC, and basaloid SCC.[1] Other malignant tumors of the nasopharynx (e.g., adenocarcinoma, adenoid cystic carcinoma, lymphoma, melanoma, and sarcoma) are extremely rare in comparison and are not covered in this topic.

History and exam

Key diagnostic factors

neck mass
epistaxis or bloody nasal discharge
nasal obstruction
tinnitus or impaired hearing
unilateral otitis media with effusion
cranial nerve palsy

Full details

Other diagnostic factors

headaches
diplopia or strabismus
facial numbness
fever
night sweats
unintentional weight loss

Full details

Risk factors

Epstein-Barr virus (EBV) infection
diet high in salted fish
first-degree relative with nasopharyngeal cancer (NPC)
smoking
human papilloma virus (HPV) infection

Full details

Diagnostic tests

1st tests to order

nasopharyngoscopy
tumor biopsy
MRI of the nasopharynx, skull base, and neck (to clavicles)
18F-FDG-PET/chest CT

Full details

Tests to consider

plasma Epstein-Barr virus (EBV) DNA
Epstein-Barr virus-encoded RNA in situ hybridization (EBER ISH)

Full details

Treatment algorithm

ACUTE

stage 1 (T1, N0, M0)

stage 2 (T2, N0, M0)

stage 2 (T0 (EBV+)-T2, N1, M0)

stage 3 (T3, N0, M0)

stage 3-4A (T3, N1-3, M0; OR T4, N0-3, M0; OR T0 (EBV+)-2, N2-3, M0)

metastatic disease

ONGOING

locoregional nasopharyngeal and/or neck nodal recurrence

Contributors

Authors

Hyunseok Kang, MD, MPH

Professor

Department of Medicine

University of California

San Francisco

Disclosures

HK has been paid by Coherus Biosciences, and HLB Group for serving their scientific advisory board. HK is a paid consultant for PIN therapeutics and Bayer. HK has been paid by MitoImmune for serving the data safety monitoring board. HK's institution has been paid by PDS Biotechnology, NeoImmuneTech, Lilly, Remix Therapeutics, and Merus for contracted research. HK's institution has been paid by NRG Oncology's grant program. HK has been paid by Wiley, OncLive, Massachusetts Medical Association, and AXIS medical education for developing educational content.

Jason Chan, MD

Assistant Professor

Department of Radiation Oncology

University of California

San Francisco

Disclosures

JC declares that he has no competing interests.

Peer reviewers

Kevin J. Harrington, PhD, FRCP, FRCR

Head of Division of Radiotherapy and Imaging

The Institute of Cancer Research

London

Disclosures

KJH has received honoraria for Scientific Advisory Boards and/or Lectures/Symposia from Arch Oncology, AstraZeneca, BMS, Boehringer-Ingelheim, Codiak, F-Star, Inzen, Johnson and Johnson, Merck-Serono, MSD, Pfizer, and Replimune.

Lawrence R. Lustig, MD

BMJ Best Practice ENT expert panel member

Professor and Chair

Department of Otolaryngology

Columbia University Vagelos College of Physicians and Surgeons

New York

Disclosures

LRL declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Chen YP, Ismaila N, Chua MLK, et al. Chemotherapy in combination with radiotherapy for definitive-intent treatment of stage II-IVA nasopharyngeal carcinoma: CSCO and ASCO guideline. J Clin Oncol. 2021 Mar 1;39(7):840-59.Full text Abstract

Bossi P, Chan AT, Licitra L, et al. Nasopharyngeal carcinoma: ESMO-EURACAN clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2021 Apr;32(4):452-65.Full text Abstract

National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: head and neck cancers [internet publication].Full text

Maghami E, Ismaila N, Alvarez A, et al. Diagnosis and management of squamous cell carcinoma of unknown primary in the head and neck: ASCO guideline. J Clin Oncol. 2020 Aug 1;38(22):2570-96.Full text Abstract

Lee AWM, Lee VHF, Ng WT, et al. A systematic review and recommendations on the use of plasma EBV DNA for nasopharyngeal carcinoma. Eur J Cancer. 2021 Aug;153:109-22. Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Nasopharyngeal polyposis
- Nasopharyngeal angiofibroma
- Lymphoma
More Differentials
Guidelines
- NCCN clinical practice guidelines in oncology: head and neck cancers
- Diagnosis and management of squamous cell carcinoma of unknown primary in the head and neck
More Guidelines
Videos
How to examine the nasal cavity
More videos
Log in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer

Nasopharyngeal cancer

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

stage 1 (T1, N0, M0)

stage 2 (T2, N0, M0)

stage 2 (T0 (EBV+)-T2, N1, M0)

stage 3 (T3, N0, M0)

stage 3-4A (T3, N1-3, M0; OR T4, N0-3, M0; OR T0 (EBV+)-2, N2-3, M0)

metastatic disease

locoregional nasopharyngeal and/or neck nodal recurrence

Contributors

Authors

Hyunseok Kang, MD, MPH

Disclosures

Jason Chan, MD

Disclosures

Peer reviewers

Kevin J. Harrington, PhD, FRCP, FRCR

Disclosures

Lawrence R. Lustig, MD

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice