The role of radiotherapy and the current strategies to improve outcome in nasopharyngeal carcinoma are reviewed. Emphasis is on the factors, which may provide a more accurate selection of patients for more aggressive treatments. Clinical data suggest that local failure and distant metastases are separate events. Thus, strategies to optimize one of them are not expected to impact significantly on the other. Patients with advanced T stage disease, cranial nerve palsy, bulky primary lesions and well differentiated tumors may benefit from more local aggressive treatment. These include higher dose radiotherapy throughout conformal 3D radiotherapy and brachytherapy. Altered fractionation schedules and concomitant chemotherapy may also enhance the results obtained by conventional external beam radiotherapy. Patients with advanced neck disease and/or low neck nodes are candidates for additional systemic treatments as well. The role of technical innovations in radiotherapy delivery and that of altered fractionation schedules are unknown, even if results from phase II studies are promising. Regarding chemotherapy, have shown some impact of chemotherapy on outcome. However, additional testing is needed in order to improve the therapeutic index and validate its rationale.

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