10a. Nasopharyngeal Carcinoma

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    Anteriorly -- nasal cavityPosteriorly -- skull base and vertebral

    bodies

    Inferiorly -- oropharynx and soft palate

    Laterally --

    Eustachian tubes

    Fossa of Rosenmuller

    Close association with skull base foramen

    Mucosa

    Epithelium - tissue of origin of NPC

    Stratified squamous epithelium

    Pseudostratified columnar epithelium

    Salivary, Lymphoid structures

    Anatomy

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    Incidence

    Higher incidence in Chinease & Taiwan

    Chinease gene increase incidence of NPC

    Age > 40 years

    Emigration fromhigh incidence to low incidence

    area reduces incidence of NPC

    Male : female = 3:1

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    Risk factor

    1. Genetic maker of NPC HLA-A2 ( found in Chinease

    population)

    2. EB-virus

    3. Nitrosamines

    4. Polycyclic hydrocarbons

    5. Chronic nasal sinus infection6. Poor hygiene

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    The most common is squamous cell carcinoma

    Most common position is Rosenmuller fossa

    Mass lesionexophytic mass

    Ulcerative mass

    Infiltrative mass / Endophytic.

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    Histopathology

    Base on predominant histologic type

    WHO type 1 : Squamous cell carcinoma

    nonkeratizing

    WHO type 2 : Trasitional cell carcinoma

    WHO type 3 : Undifferentiated carcimomas

    Lymphoepitheliomas

    Anaplastic carcinomas

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    WHO type 1

    Squamous cell carcinoma nonkeratizing

    Strong intracellular bridges

    Less keratin production

    Less associate EBV

    25% of case

    Radioresistanttumor

    WHO type 2

    Trasitional cell carcinoma

    Not produce keratin

    Greater degree of tumor pleomorphism

    Most common is papil lary morphology

    12% of case

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    WHO type 3

    Undifferentiated carcimomas

    Lymphoepitheliomas, Anaplastic carcinomas,Clear cell carcinoma, Spindle cell carcinoma

    Most common cell type of NPC

    Clear nucleus

    63% aggressive behavior

    Radiosensitive

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    Tumor Spreading

    Anterior : involve hard palate, medial pterygoid plate,

    ethmoid & maxillary sinus

    Lateral : involve internal jugular V, internal carotid A, CN

    IX X XI XII, Medial : Eustachian tube involvement, mastoid air cell

    Superior : involve base of skull, throught foramen lacerum

    & cavernous sinus

    Inferior : oropharynx & soft palate

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    Lym phat ic spreading

    Most common is neck node spreading

    Bilateral involvement

    Most common position is upper jugular node

    Least at submandibular & submental node

    Distance metastasis

    Most common is

    Bone

    LungLiver

    Other sites are rare

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    Clinical Manifestat ion

    Related to location of primary tumor & course of disease

    Most common complaint is Hearing loss & lump in the neck

    1. Neck Sign / Neck mass

    Most common spread to neck lymph node

    Complaint neck mass

    Bilateral metastasis to lymph node is common

    Most common location is Upper jugular node

    retropharyngeal node induce headache

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    1. Upper jugular region

    2. Posterior cervical group

    3. M iddle & lower jugular

    group

    4. Supraclavicular group

    Frequency of lymph nodemanifestration

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    2. Nose sign

    Blood discharge anterior or posteriornasal drainage Obstruction of nasal pathway

    Epistaxis

    Halithosis

    Nasal congest

    3. Ear Sign

    Result from eustachian tubeinvolvement

    Sensation of ear blockage

    Serous otitis media

    Conductive hearing loss

    Tinitus

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    4. Neuro log ic sign (Cranial , Ear sign)

    Cranial nerve involvement found 25 - 28%

    Pain in the neck, facial pain, facial pareathesia ( CN V )

    Diplopia ..... ( CN VI )

    CN III & IV late phase ..... Ophthalmoplegia

    CN VII & VIII less involvement

    CN IX, X & XI can be found ..... Dysphagia

    Headache

    Horners syndrome - cervical sympathetics

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    Clinical Mani festation

    1. Neck lump 60%

    2. Ear (s) plugging & fullness 41%

    3. Hearing loss 37%

    4. Nasal bleeding 30%

    5. Nasal obstruction 29%

    6. Head pain 16%7. Ear pain 14%

    8. Neck pain 13%

    9. Weight loss 10%

    10. Diplopia 8%

    Symptom & sign of NPC fr equency at diagnostic in Mayo clini c ser ies

    Kuala Lumpur 1983, University of Malaya

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    1. Neck mass 68%

    2. Headache 58%

    3. Ear pain 52%

    4. Nasal obstruction, bloody discharge 48%

    5. Facial pareathesia 22%6. Dysphagia 16%

    7. Diplopia, strabismus 14%

    8. Facial pain, eye pain 12%

    9. Halithosis 12%

    10. Exopthalmos 2%

    Symp tom from NPC foun d in Sir iraj ho spi ta l 2532

    Clinical Mani festation

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    Other sign & sym ptom

    1. Loss of Weight

    2. Anorexia

    3. low grade fever

    4. Trismus

    5. Nasal regurgitation of fluid

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    Diagnostic Evaluation

    1. History and Physical examination

    2. Nasopharyngoscopy / Endoscopic nasopharyngoscopy3. Radiologic evaluation :

    Plain film head & neck

    CT scan head & neck ( for evaluation & treatment planning )

    MRI ( if intracranial extension )

    5. Histopathologic evaluation ...... Biopsy6. Immunology

    Indirect immunofluorescence for IgG & IgA antibodies to viral

    capsid antigen (VCA) & early antigen (EA)

    Most specific test for diagnosis

    Highly predictive of the clinical course

    not yet commercially availableAntibody-dependent cellular cytotoxicity ( ADCC )

    Often predict the clinical course of WHO type 2&3

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    Clinical Staging

    T classification

    Tis carcinoma in situT1 tumor confine in one site of nasopharynx no tumor visible

    T2 tumor involve 2 site

    T3 extension of tumor into nasal cavity or oropharynx

    T4 tumor invasion of skull or cranial involvement

    N Classif ication

    Nx node cannot be assessed

    N0 no regional lymph node positive

    N1 single ipsi lateral lymph node size < 3 cm.

    N2a single ipsi lateral lymph node size 3 - 6 cm.

    N2b mul tiple ipsi lateral lypmh node size < 6 cm.

    N2c bilateral or contr alateral lymph node size < 6 cm.

    N3 lymph node size > 6 cm.

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    M classification

    Mx not assessed

    M0 no distance metastasisM1 distance metastasis present

    Stage I T1 N0 M0

    Stage I I T2 N0 M0

    Stage I I I T3 N0 M0

    T

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    Treatment

    1. Radiotherapy

    The most proper treatment

    60 - 70 Gy for 6 - 7 weeks

    75 Gy if present brain involvement

    Complication

    Dental caries

    Otitis media & otitis externa

    Trismus

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    2. Chemotherapy

    Control distance metastasisComplication

    Hair loss

    Nausea & vomitting

    Weight loss

    Anorexia

    3. Surgery

    Lymph node present after radiotherapy 4 - 6 weeksRecurrent lymph node enlargement

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    Prognosis

    5 years survival ( A.C. 1965 )

    Stage I 44%

    Stage II 30%

    Radiotherapy + Chemotherapy good result

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