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Nasopharyngeal CarcinomaDr Ravikumar

Nasopharyngeal Carcinoma

Anatomy

Epidermiology

Incidence Rare neoplasm in most parts of world Higher incidence in Chinease & Taiwan Chinease gene increase incidence of NPC Age > 40 years

Incidence Emigration from high incidence to low incidence area reduces incidence of NPC Male : female = 3:1

Age wise bimodal distribution is also common. In this type of age distribution two peaks are noted, i.e. 1. between ages 15 - 20, 2. the second peak during the 4th and 5th decades. This type of distribution is common in India.

Risk factor Genetic maker of NPC HLA-A2 found in Chinease population ) EB-virus Nitrosamines Polycyclic hydrocarbons Chronic nasal sinus infection Poor hygiene (

Pathology

Pathology The most common is squamous cell carcinoma Most common position is Rosenmuller fossa Mass lesion exophytic mass Ulcerative mass Infiltrative mass

Histopathology

Histopathology Base on predominant histologic type WHO type 1 : Squamous cell carcinoma nonkeratizing WHO type 2 : Trasitional cell carcinoma

Histopathology WHO type 3 : Undifferentiated carcimomas Lymphoepitheliomas Anaplastic carcinomas

WHO type 1 Squamous cell carcinoma nonkeratizing Strong intracellular bridges Less keratin production

Less associate EBV 25% of case Radioresistant tumor

WHO type 2 Trasitional cell carcinoma Not produce keratin Greater degree of tumor pleomorphism Most common is papillary morphology 12% of case

WHO type 3 Undifferentiated carcinomas Lymphoepitheliomas, Anaplastic carcinomas, Clear cell carcinoma, Spindle cell carcinoma Most common cell type of NPC Clear nucleus 63% aggressive behavior Radiosensitive

Tumor Spreading

Local SpreadSphenoid sinus Cavernous Sinus

Base of Skull, Clivus

Nasal cavity & PNS Orbital invasion

Lateral Parapharyngeal space Middle ear cavity Oropharynx (tonsillar pillars) C1 vertebrae

Local invasion Anterior : involve hard palate, medial pterygoid plate, ethmoid & maxillary sinus Lateral : involve internal jugular V, internal carotid A, CN IX X XI XII,

Local invasion Medial : Eustachian tube involvement, mastoid air cell Superior : involve base of skull, throught foramen lacerum & cavernous sinus Inferior : oropharynx & soft palate

Lymphatic 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 Lung Liver

Other sites are rare

Clinical Manifestation

Clinical Manifestation Related to location of primary tumor & course of disease Most common complaint is Hearing loss & lump in the neck

Neck mass Most common spread to neck lymph node Complaint neck mass Bilateral metastasis to lymph node is common

Neck mass Most common location is Upper jugular node ( compose of jugular node, spinal accessory node ) retropharyngeal node induce headache

Frequency of lymph node manifestration Upper jugular region Posterior cervical group Middle & lower jugular group Supraclavicular group

Nasal cavity involvement Blood-tinge anterior or posteriornasal drainage Obstruction of nasal pathway Epistaxis Halithosis

Ear involvement Result from eustachian tube involvement Sensation of ear blockage

Serous otitis media Conductive hearing loss Tinnitus

Neurologic involvement Cranial nerve involvement found 25 - 28% Pain in the neck, facial pain, facial pareathesia ( CN V ) Diplopia ( CN VI )

Neurologic involvement CN III & IV late phase CN VII & VIII less involvement

CN IX, X & XI can be found

Clinical Manifestation Neck lump Ear (s) plugging & fullness Hearing loss Nasal bleeding Nasal obstruction Head pain Ear pain Neck pain Weight loss Diplopia 60% 41% 37% 30% 29% 16% 14% 13% 10% 8%

Clinical Manifestation Neck mass Headache Ear pain Nasal obstruction, bloody discharge Facial pareathesia Dysphagia Diplopia, strabismus Facial pain, eye pain Halithosis Exopthalmos 68% 58% 52% 48% 22% 16% 14% 12% 12% 2%

Other sign & symptom Weight Anorexia low grade fever Trismus Nasal regurgitation of fluid

TROTTERS TRAID Conductive deafness Ipsilateral temporoparietal neuralagia Palatal paralysis

Presence of unilateral serous otitis media in an adult should raise suspicion of nasopharyngeal growth

Diagnostic Evaluation

Clinical evaluation History taking Physical examination Nasopharyngoscopy Endoscopic nasopharyngoscopy

Radiologic evaluation Plain film head & neck CT scan head & neck ( for evaluation & treatment planning ) MRI ( if intracranial extension )

Histopathologic evaluation Biopsy Most common site are roof of nasophalynx & Rosenmuller fossa

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 available

Immunology Antibody-dependent cellular cytotoxicity ( ADCC ) Often predict the clinical course of WHO type 2&3

Clinical Staging

Staging: AJCC 2002

Stage I

Stage IIA

Stage IIB

Stage III

Stage IVA

Stage IVB

Clinical Staging T classification Tis carcinoma in situ T1 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

Treatment Radiotherapy is the definitive treatment. Chemotherapy is used to supplement R.T. in advanced cases with cervical metastasis Role of surgery is only to take biopsy or to deal with cervical metastasis after the primary has been sterilized.58

Complications of R.T. Mucositis Xerostomia Dental caries Radiation myelitis Optic atrophy Brain stem damage

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Chemotherapy Control distance metastasis Complication Hair loss Nausea & vomitting Weight loss Anorexia

Surgery Lymph node present after radiotherapy 4 6 weeks Recurrent lymph node enlargement

Prognosis

Prognosis 5 years survival ( A.C. 1965 ) Stage I Stage II 44% 30%

Radiotherapy + Chemotherapy good result

Conclusions Nasopharyngeal malignancies make up a different population of head and neck malignancies. These are eminently radio sensitive and curable. Treatment planning is by necessity complicated and time consuming. Brachytherapy can be used for boosting the local activities. Chemoradiation is standard treatment in locally advanced tumors

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