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Page 2 of 11 Pang et al. Mini-invasive Surg 2024;8:27 https://dx.doi.org/10.20517/2574-1225.2023.124

[2]
the incidence rate is around three cases per 100,000 individuals . The development of NPC is influenced by
[3]
both genetic and environmental factors . Nasopharyngeal squamous cell carcinoma is the predominant
[4,5]
subtype in these regions. Radiotherapy remains the cornerstone of treatment , with intensity-modulated
radiation therapy (IMRT) emerging as the preferred method. IMRT has led to impressive outcomes, with a
5-year local recurrence-free survival rate of 94.6% for cases without distant metastasis . Despite these
[6]
[6]
advancements, recurrence remains a challenge, afflicting 10%-40% of patients . Additionally, many patients
experience side effects from radiotherapy, such as dry mouth and mucositis, which significantly affect their
[7]
quality of life . For those with recurrent NPC, treatment options typically include surgery and re-
irradiation. Although re-irradiation carries a high risk of complications, salvage surgery often provides a
safer and more effective alternative [4,5,8] . Surgical approaches are also important in the management of
nasopharyngeal adenocarcinoma and early-stage NPC [9,10] . This review systematically outlines the surgical
treatment methods for NPC and assesses their therapeutic efficacy.

Pathological features
NPC encompasses a range of pathological variants, including keratinizing squamous cell carcinoma (K-
NPC), non-keratinizing squamous cell carcinoma (NK-NPC), undifferentiated carcinoma, adenocarcinoma,
and lymphoma . NK-NPC is the predominant subtype, accounting for approximately 95% of all NPC cases
[11]
[12]
in regions such as China . Additionally, nasopharyngeal adenocarcinoma, often considered a “low-grade”
malignancy due to its relatively less aggressive nature, warrants attention. In contrast, nasopharyngeal
lymphoma makes up about 15% of all head and neck lymphoma diagnoses.

Anatomical considerations
The intricate anatomy of the nasopharynx presents significant challenges for surgical interventions targeting
malignancies in this region. Positioned posterior to the nasal cavity and above the soft palate, the
nasopharynx occupies a confined space by critical anatomical structures. It is supported by an osseous
framework consisting mainly of the sphenoid bone, the basilar segment of the occipital bone, and the
petrous facets of the temporal bones. This complex structure requires careful surgical navigation to avoid
[13]
damage to adjacent vital structures . The proximity of key neurovascular structures, such as the internal
carotid artery, jugular vein, and multiple cranial nerves, necessitates a precise surgical approach to prevent
severe bleeding or neurological injury. Additionally, the dense lymphatic network of the nasopharynx
increases the risk of early lymphatic spread of malignancies. Thus, a thorough understanding of lymphatic
drainage pathways is crucial for achieving effective surgical excision and performing appropriate cervical
dissection.

The challenges of surgery in the nasopharynx are amplified by its complex anatomy, posterior location, and
restricted access, which significantly limit surgical reach. Traditional surgical techniques are often
insufficient, necessitating the use of advanced methods such as endoscopic or transnasal approaches . The
[14]
primary goal remains to preserve key functions - such as hearing, eustachian tube function, and cranial
nerve integrity - while achieving effective cancer control. This balance highlights the complexity of surgical
procedures for NPC. The close proximity of critical structures increases the risk of complications, including
cranial nerve damage, vascular traumas, and cerebrospinal fluid leaks, as well as the potential for
locoregional relapse due to residual microscopic disease. However, advances in surgical techniques and
improved imaging techniques offer promising solutions, paving the way for more effective and minimally
invasive approaches to managing NPC .
[15]