Target volume delineation of the neck for radiotherapy in nasopharyngeal carcinoma: CSTRO, CACA, CSCO, HNCIG, ESTRO, and ASTRO guidelines and contouring atlas

Ling-Long Tang¹, Cheng-Long Huang¹, Shao-Jun Lin², Quynh-Thu Le³, Brian O'Sullivan⁴, Sue S Yom⁵, Shao Hui Huang⁴, Annie W Chan⁶, Nancy Lee⁷, Jian-Ji Pan², Michael Benedict A Mejia⁸, Yong Chan Ahn⁹, Kenneth C W Wong¹⁰, Lachlan McDowell¹¹, Ester Orlandi¹², Jeppe Friborg¹³, Yu-Pei Chen¹, Koichi Yasuda¹⁴, Takeshi Kodaira¹⁵, Alexander C Whitley¹⁶, Ann D King¹⁷, Gregorius Ben Prajogi¹⁸, Ezra Hahn⁴, Jin-Ching Lin¹⁹, Naomi Kiyota²⁰, Victor Lee²¹, Peng-Jie Ji¹, Ying Hitchcock²², Frank Hoebers²³, Pierre Blanchard²⁴, Sung Ho Moon²⁵, Wan Zamaniah Wan Ishak²⁶, Kevin J Harrington²⁷, Kun-Yu Yang²⁸, A Dimitrios Colevas²⁹, Anna Lee³⁰, Chao-Su Hu³¹, David Rosenthal³⁰, Farzan Siddiqui³², Johannes Albertus Langendijk³³, Jin-Yi Lang³⁴, Jun-Lin Yi³⁵, Liang-Fang Shen³⁶, Ji-Bin Li³⁷, Li-Zhi Liu³⁸, Anne W M Lee³⁹, Hai-Qiang Mai⁴⁰, Ming-Kai Yang⁴¹, Ying Sun¹, Melvin L K Chua⁴², Jun Ma⁴³

Affiliations

¹ Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China.
² Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fujian Key Laboratory of Translational Cancer Medicine, Fuzhou, China.
³ Department of Radiation Oncology, Stanford University, Stanford, CA, USA.
⁴ Department of Radiation Oncology, the Princess Margaret Cancer Centre/University of Toronto, Toronto, ON, Canada; Department of Otolaryngology-Head & Neck Surgery, the Princess Margaret Cancer Centre/University of Toronto, Toronto, ON, Canada.
⁵ Department of Radiation Oncology, and Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, CA, USA.
⁶ Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
⁷ Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
⁸ Department of Radiation Oncology, Benavides Cancer Institute, University of Santo Tomas Hospital, Manila, Philippines.
⁹ Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Department of Radiation Oncology, CHA Ilsan Medical Center, CHA University, Pocheon, South Korea.
¹⁰ State Key Laboratory of Translational Oncology, Sir YK Pao Centre for Cancer, Department of Clinical Oncology, Hong Kong Cancer Institute, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.
¹¹ Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, QLD, Australia.
¹² Radiation Oncology Clinical Department, National Center for Oncological Hadrontherapy, Pavia, Italy.
¹³ Department of Oncology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.
¹⁴ Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Japan.
¹⁵ Department of Radiation Oncology, Aichi Cancer Center Hospital, Nagoya, Japan.
¹⁶ Central Alabama Radiation Oncology, Montgomery, AL, USA.
¹⁷ Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China.
¹⁸ Department of Radiation Oncology, Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
¹⁹ Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan.
²⁰ Kobe University Hospital, Cancer Center, Kobe, Japan.
²¹ Department of Clinical Oncology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.
²² University of Utah Huntsman Cancer Institute, Greg Stoddard, University of Utah, Salt Lake City, UT, USA.
²³ Department of Radiation Oncology (Maastro), GROW Research Institute for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, Netherlands.
²⁴ Department of Radiation Oncology, Université Paris-Saclay, INSERM U1018 Oncostat, Gustave-Roussy, Villejuif, France.
²⁵ Proton Therapy Center, National Cancer Center, Goyang-si, South Korea.
²⁶ Department of Clinical Oncology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
²⁷ The Institute of Cancer Research, Royal Marsden Hospital, London, UK.
²⁸ Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
²⁹ Department of Medicine (Oncology), Stanford University, Stanford, CA, USA.
³⁰ Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
³¹ Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.
³² Department of Radiation Oncology, Henry Ford Cancer Institute and Hospital, Detroit, MI, USA.
³³ Department of Radiation Oncology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands.
³⁴ Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
³⁵ Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
³⁶ Department of Radiation Oncology, Xiangya Hospital of Central South University, Changsha, China.
³⁷ Clinical Trials Center, Sun Yat-sen University Cancer Center, Guangzhou, China.
³⁸ Department of Radiology, Sun Yat-sen University Cancer Center, Guangzhou, China.
³⁹ Clinical Oncology Centre, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
⁴⁰ Department of Nasopharyngeal Carcinoma, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China.
⁴¹ Changsha, China.
⁴² Division of Radiation Oncology, National Cancer Centre, Singapore.
⁴³ Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China. Electronic address: majun2@mail.sysu.edu.cn.

PMID: 40907527
DOI: 10.1016/S1470-2045(25)00327-4

Review

Target volume delineation of the neck for radiotherapy in nasopharyngeal carcinoma: CSTRO, CACA, CSCO, HNCIG, ESTRO, and ASTRO guidelines and contouring atlas

Ling-Long Tang et al. Lancet Oncol. 2025 Sep.

. 2025 Sep;26(9):e488-e498.

doi: 10.1016/S1470-2045(25)00327-4.

Authors

Affiliations

¹ Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China.
² Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fujian Key Laboratory of Translational Cancer Medicine, Fuzhou, China.
³ Department of Radiation Oncology, Stanford University, Stanford, CA, USA.
⁴ Department of Radiation Oncology, the Princess Margaret Cancer Centre/University of Toronto, Toronto, ON, Canada; Department of Otolaryngology-Head & Neck Surgery, the Princess Margaret Cancer Centre/University of Toronto, Toronto, ON, Canada.
⁵ Department of Radiation Oncology, and Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, CA, USA.
⁶ Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
⁷ Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
⁸ Department of Radiation Oncology, Benavides Cancer Institute, University of Santo Tomas Hospital, Manila, Philippines.
⁹ Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Department of Radiation Oncology, CHA Ilsan Medical Center, CHA University, Pocheon, South Korea.
¹⁰ State Key Laboratory of Translational Oncology, Sir YK Pao Centre for Cancer, Department of Clinical Oncology, Hong Kong Cancer Institute, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.
¹¹ Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, QLD, Australia.
¹² Radiation Oncology Clinical Department, National Center for Oncological Hadrontherapy, Pavia, Italy.
¹³ Department of Oncology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.
¹⁴ Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Japan.
¹⁵ Department of Radiation Oncology, Aichi Cancer Center Hospital, Nagoya, Japan.
¹⁶ Central Alabama Radiation Oncology, Montgomery, AL, USA.
¹⁷ Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China.
¹⁸ Department of Radiation Oncology, Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
¹⁹ Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan.
²⁰ Kobe University Hospital, Cancer Center, Kobe, Japan.
²¹ Department of Clinical Oncology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.
²² University of Utah Huntsman Cancer Institute, Greg Stoddard, University of Utah, Salt Lake City, UT, USA.
²³ Department of Radiation Oncology (Maastro), GROW Research Institute for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, Netherlands.
²⁴ Department of Radiation Oncology, Université Paris-Saclay, INSERM U1018 Oncostat, Gustave-Roussy, Villejuif, France.
²⁵ Proton Therapy Center, National Cancer Center, Goyang-si, South Korea.
²⁶ Department of Clinical Oncology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
²⁷ The Institute of Cancer Research, Royal Marsden Hospital, London, UK.
²⁸ Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
²⁹ Department of Medicine (Oncology), Stanford University, Stanford, CA, USA.
³⁰ Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
³¹ Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.
³² Department of Radiation Oncology, Henry Ford Cancer Institute and Hospital, Detroit, MI, USA.
³³ Department of Radiation Oncology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands.
³⁴ Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
³⁵ Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
³⁶ Department of Radiation Oncology, Xiangya Hospital of Central South University, Changsha, China.
³⁷ Clinical Trials Center, Sun Yat-sen University Cancer Center, Guangzhou, China.
³⁸ Department of Radiology, Sun Yat-sen University Cancer Center, Guangzhou, China.
³⁹ Clinical Oncology Centre, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
⁴⁰ Department of Nasopharyngeal Carcinoma, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China.
⁴¹ Changsha, China.
⁴² Division of Radiation Oncology, National Cancer Centre, Singapore.
⁴³ Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China. Electronic address: majun2@mail.sysu.edu.cn.

PMID: 40907527
DOI: 10.1016/S1470-2045(25)00327-4

Abstract

The Chinese Society for Therapeutic Radiology Oncology, the Chinese Anti-Cancer Association, the Chinese Society of Clinical Oncology, the Head and Neck Cancer International Group, the European Society for Radiotherapy and Oncology, and the American Society for Radiation Oncology collaboratively developed evidence-based guidelines and a comprehensive contouring atlas for neck target volume delineation in nasopharyngeal carcinoma. These guidelines address five key challenges in modern radiotherapy practice: margin design of clinical target volume; nodal target volume delineation after induction chemotherapy; delineation of equivocal nodes evident on imaging; low-risk clinical target volume delineation based on regional stepwise extension patterns; and modifications for anatomical boundaries of lymphatic areas. Developed through a rigorous systematic review and expert appraisal process by a panel of 50 international, multidisciplinary members from 17 countries and regions, these guidelines incorporate the latest advances in nasopharyngeal carcinoma diagnosis and treatment. They reflect contemporary therapeutic concepts and elaborate on current practice variations. These guidelines aim to standardise global practice, substantially improving consistency and reducing variability in nasopharyngeal carcinoma radiotherapy target delineation.

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Conflict of interest statement

Declaration of interests TK receives Health Science Research Grants for the Grant-in-Aid for Cancer Research (Ministry of Health, Labour and Welfare of Japan), and National Cancer for Research and Development Funds (Japan); speakers bureau fees from Merck Biopharma, Hitachi, Merck & Co, Janssen Pharmaceutical, AstraZeneca, Otsuka Pharmaceutical Factory, Shizuoka Cancer Center, Tohoku University, and Sapporo Medical University; and writing fees from Nankodo, Tokyo Igakusha, Gakken Holdings, Nagoya University Press, Gan to Kagakuryoho Publishing, Gakken Medical Shujunsha, and Convention Linkage. SSY discloses research grants from Merck, EMD Serono, Bristol-Myers Squibb, and Nanobiotix; royalties from UpToDate and Springer; and honoraria from the American Society for Radiation Oncology and Elsevier. NL has received honoraria from Shanghai JoAnn Medical Technology, Lizhi Network Technology, Yingming Consulting, and Varian; serves on advisory boards for Galera, GSK, LEO Pharma, Merck, Merck Serono, and Nanobiotix; and holds stock in LEO Pharma. MLKC declares research grants from Bayer, Beigene, Decipher Biosciences, and ImmunoSCAPE; holds a patent for High Sensitivity Lateral Flow Immunoassay For Detection of Analyte in Sample (10202107837T, Singapore); serves on advisory boards for AstraZeneca, Janssen, Merck & Co, Seagen, and the Varian Thought Leadership Council; holds board positions as Director of Digital Life Line and Trustee of Alice's Arc Charity for Pediatric RMS; owns stock ownership in Digital Life Line; and has received other financial support from AstraZeneca, Decipher Bioscience, and Varian. JF acknowledges research grants from Siemens-Varian and serves as a board member of the European Head and Neck Society. HL reports research grants from Ion Beam Applications, the EU, and the Dutch Cancer Society; consulting fees from Ion Beam Applications; serves as Chair of the Safety Monitoring Committee for the UPGRADE trial, and on advisory boards for Ion Beam Applications and RaySearch; and has institutional collaborative research contracts with financial support from Ion Beam Applications, RaySearch, Elekta, Mirada, and Siemens. FS discloses research grants from Siemens-Varian; honoraria and travel support from Varian Medical System, the American College of Radiology, and Castle Biosciences; participation on the Varian Noona Medical Advisory Board; and leadership roles as chair of the Henry Ford Medical Group Board of Governors and Vice-Chair of the Department of Radiation Oncology. HL declares research grants from Ion Beam Applications, the EU, and the Dutch Cancer Society; consulting fees from Ion Beam Applications; advisory role for University Medical Center Nijmegen, Ion Beam Applications, and RaySearch; and institutional collaborative research contracts with financial support from Ion Beam Applications, RaySearch, Elekta, Mirada, and Siemens. All other authors declare no competing interests.

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Target volume delineation of the neck for radiotherapy in nasopharyngeal carcinoma: CSTRO, CACA, CSCO, HNCIG, ESTRO, and ASTRO guidelines and contouring atlas

Affiliations

Target volume delineation of the neck for radiotherapy in nasopharyngeal carcinoma: CSTRO, CACA, CSCO, HNCIG, ESTRO, and ASTRO guidelines and contouring atlas

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