5. nasopharyngeal carcinoma

Nasopharyngeal Carcinoma

Dr. Krishna Koirala

2016-05-202016-05-20

Introduction• Nasopharyngeal carcinoma is a non -

lymphomatous squamous-cell carcinoma that

occurs in the epithelial lining of the nasopharynx

• It frequently arises from the pharyngeal recess

(fossa of Rosenmüller) posteromedial to the

medial crura of the eustachian tube opening in

the nasopharynx

Epidemiology•Accounts for 85% adult nasopharyngeal malignancies and 30% pediatric nasopharyngeal malignancies

•Race : Common in Chinese & North African people

•Sex : Male preponderance of 3:1

•Age : Bimodal presentation with Small peak at 15-25 yrs and a large peak at 55-65yrs

•Gross : Proliferative, Ulcerative & Infiltrative types

•Histology : 85% Squamous cell carcinoma, 10% Lymphomas, 5% Mixed

Etiology• Genetic • Commonest in Southern Chinese population

( Mongoloid race) • HLA – A ,B and DR loci situated on the short arm of

chromosome 6 • Viral : Epstein-Barr Virus• Environmental

• Exposure to nitrosamines (dry salted fish), polycyclic hydrocarbons (smoke from incense & wood)

• Smoking , chronic nasal infection, poor ventilation of nasopharynx

W.H.O. Classification (Histological)

Type 1:

• Keratinizing squamous cell carcinoma

Type 2:

• Non-keratinizing (transitional) carcinoma

Type 3:

• Undifferentiated (anaplastic) carcinoma

Clinical Features1. Neck swelling (60%)

• Lateral retropharyngeal LN of Rouviere

• B/L, enlarged jugulodigastric, upper & middle deep cervical nodes and posterior triangle nodes

2. Nasal (40%)

• Blood stained nasal mucus, epistaxis, nose block, foul smelling nasal discharge

3. Otologic (30%) : Conductive deafness, tinnitus

4. Ophthalmologic (20%)

• Diplopia & ophthalmoplegia (involvement of CN III, IV, VI), Proptosis (orbit invasion) & blindness (involvement of CN II)

5. Neurologic (20 %)

• Jugular foramen syndrome: CN IX, X, XI involved by lateral retropharyngeal lymph node

• Horner's syndrome: sympathetic chain involvement

6. Severe Headache

• Skull base erosion

7. Trotter's triad

• Conductive deafness: Eustachian Tube block

• Ipsilateral temporo -parietal neuralgia: Trigeminal nerve involvement

• Ipsilateral palatal paralysis: Vagus nerve damage

8. Distant metastasis

• Bone, lungs & liver

Investigations1. Nasopharyngoscopy & Diagnostic Nasal

Endoscopy• Mass seen in nasopharynx at fossa of Rosenmüller

2. Nasopharyngeal tumor biopsy: blind /under vision

3. F.N.A.C. of neck node: done in occult primary

4. C.T. scan head & neck4. C.T. scan head & neck

• Tumor extentTumor extent

• Skull base erosion Skull base erosion

• Cervical lymph node metastasis Cervical lymph node metastasis

5. M.R.I. head & neck: for intracranial extension.

6. Tests for metastases

• C.T. chest and abdomen, bone scan, P.E.T. scan, liver function tests

7. Serologic tests

• Immuno-fluorescence for IgA antibodies to Viral Capsid Antigen, Ig G antibodies to Early Antigen

Diagnostic Nasal Endoscopy

Computerized Tomogram Scan

CT scan: retropharyngeal node

CT scan: Infratemporal fossa & orbit involvement

CT scan: Sella involvement

Magnetic Resonance Imaging

M.R.I.: intracranial extension

Endoscopic Biopsy

Whole body bone scan

Positron Emission Tomography

T.N.M. stagingT1 = confined to nasopharynx

T2 = soft tissue involvement in oropharynx or

nasal cavity or Parapharyngeal space

T3 = invasion of bony structures or P.N.S.

T4 = intracranial, involvement of orbit, cranial

nerves, infratemporal fossa, hypopharynx

N0 = no evidence of regional lymph nodes

N1 = unilateral N2 = bilateral

(Both are above supraclavicular fossa & < 6 cm)

N3 = > 6 cm or in supraclavicular fossa

M0 = no evidence of distant metastasis

M1 = distant metastasis present

T.N.M. staging

• Stage I = T1 N0 M0

• Stage II = T2 or N1 M0

• Stage III = T3 or N2 M0

• Stage IV = T4 or N3 or M1

Treatment modalities 1. Teletherapy or External beam

radiotherapy

2. Brachytherapy

3. Chemotherapy

4. Surgery

5. Immunotherapy against E.B.V.

6. Vaccination against EBV: experimental

External beam irradiation• 2 lateral fields: nasopharynx, skull base & upper neck

sparing temporal lobe, pituitary & spinal cord• 1 anterior field: lower neck; sparing spinal cord &

larynx

Brachytherapy• Used for small tumor, residual or recurrent tumor

• Interstitial: Radioactive source (Radium, Iridium, Iodine, Gold) inserted into tumor tissue

• Intracavitary: Radioactive source placed inside the catheter or moulds & inserted into nasopharynx

• High dose rate (HDR): High intensity radiation delivered with precision under computer guidance

Interstitial Brachytherapy

Intracavitary Brachytherapy

High Dose Rate Brachytherapy

Chemotherapy

Drugs used1. Cisplatin

2. 5-Fluorouracil

Indications1. Radiation failure

2. Palliation in distant metastasis

Surgery1. Nasopharyngectomy, Cryosurgery :

for residual or recurrent tumor

2. Radical neck dissection: for radio-resistant neck node metastasis

3. Palliative debulking: for T4 tumors4. Myringotomy & grommet insertion:

for persistent otitis media with effusion

Radical neck dissection & Interstitial Brachytherapy

Treatment ProtocolT1 = External Radiotherapy (6500 c Gy)

T2 = External Radiotherapy (7000 c Gy)

T3 & T4 = Radiotherapy + Chemotherapy

Brachytherapy / Salvage surgery if required

N0 = External Radiotherapy (5000 c Gy)

N+ = External Radiotherapy (6000 cGy) +

Chemotherapy

Prognosis• W.H.O. Type 2 & 3 carcinomas have good

response to radiotherapy & better survival rates

• Average 5 year survival rates for treated patients

Stage I = 95 – 100 %

Stage II = 60 – 80 %

Stage III = 30 – 60 %

Stage IV = 20 – 30 %