Nasopharyngeal carcinoma

ABU SUFIAN HASSAN AHMED EL HAJ(E.N.T. Consultant)

Associate Professor Department of SurgeryFaculty of Medicine, University of Gezira

ANATOMY

ANATOMY

Introduction The Nasopharynx has a cuboidal shape, the lateral walls are formed by the Eustachian tube and the fosse of Rosenmuller.The roof, sloping downwards from the anterior to posterior, is boarder by pharyngeal Hypopharyx, pharyngeal tonsil, and pharyngeal bursa with the base of skull above.

Anteriorly, the Nasopharynx abutted the choanae and nasal cavity, posterior boundary is formed by the muscle of posterior pharyngeal wall. Inferiorly, the Nasopharynx ends at an imaginary horizontal line formed by the upper surface of the soft palate and the posterior pharyngeal wall.

Pathology of the Nose and Nasopharynx1. Congenital malformations.2. Inflammation.3. Infection and Granulomatus Diseases4. Trauma.5. neoplasm

1- Congenital malformations 1.Choanal stenosis or atresia.2.Involvmemt in cleft palate.3.Saddle nose in hypertelorism.

1.Choanal stenosis or atresia.

2. Inflammations & Infections.A. Acute Rhinitis or Rhino sinusitis B. Chronic Rhinitis or Rhino sinusitis - Nonspecific, - Specific

Cont.A. Acute Rhinitis or Rhino sinusitis Inflammation of the nasal mucosa with or with out Inflammation of the PNS mucosa due to: (i) Allergy (ii) Viral infection (iii) Bacterial infection

Cont.B. Chronic Rhinitis or Rhino- sinusitis: i- Chronic Non specific infection as, Bacterial infection

ii- Chronic specific infection as, 1- Tuberculosis 2- Leprosy 3- Scleroma 4- Fungal infections as, * Aspergillosis * Rhinosporidiosis * Candidiasis 5- Leishmaniasis

Nasal polyposis a. Allergic i- Allergic rhinitis ii- Vasomotor rhinitis * bilaterally * ethimoids * associated ;Asthma, penicillin& aspirin allergy.

Cont. nasal polpsNon allergic including antro-choanal polps

4. Trauma.

5.NeoplasmBenign tumors Malignant tumors

Benign tumors 1-Epithelial i- Papilloma : HPV , EBV a- Squamous ,fungiform : wart , in vestibule & septum. b- Inverted Papilloma (Tansitional) lateral wall , high recurrence , 10% malignant transformation (intermediate tumour)

Benign tumors 1-Epithelial Cont. c- Keratoacanthoma. (exposed skin to sun ___scc)d- Adenoma ( mucous glands).

Malignant tumors Epithelial Carcinoma a. Scc b. Tansitional type c. Adenocarcinama d. AnaplasticMalignant Melanoma

2- Vascular Benign tumors a. Capillary haemangioma b. Juvenile angiofibroma c. Haemangiopericytoma (intermediate tumour) Malignant tumors Haemangiopendothelioma(Angiosarcom)

3- Lymphoid tissue i- Lymphoma II- Myeloma

4- Neurogenici.Neurofibroma II. Nasal glioma (ectopic glial tissue) iii. Olfactory neuroblastomiv. Neurilemmoma (schwannoma) nerve sheath-

5- Bone and connective tissuesBenign tumors a. Osteoma b. Chondroma c. Ossifying fibroma Malignant tumors a. Fibrosarcoma b.Chondrosarcoma c. Osteogenic sarcoma

Tumours of the Nasopharynx Benign tumors a. Tansitional type papilloma b. Adenoma c. Cavernus haemangioma d. Juvenile angiofibroma

Malignant tumors 1-Carcinomas a. Anaplastic carcinoma including (lymphoepitheoma) b. Squamous cell carcinoma c. Tansitional type carcinoma d. Adenocarcinama.

Malignant tumors NPx2-Lymphoma and Myeloma 3-Sarcomas a.Rhabdomyosarcoma b. Fibrosarcoma c. Chondrosarcoma4- Chondroma arising from the base of skull

Nasopharyngeal carcinoma (NPC) is epidemiologically and histologically different from other head and neck cancers5

. It is an, Epstein-Barr Virus (EBV)associated carcinoma. It has been demonstrated that EBV is harbored in almost every NPC tumor, regardless of the degree of differentiation and geographic distribution.2, 3, 4,5

NPC highest incidence in the World is in Southeast China, Hong Kong and Mediterranean basin.

North Africa and Mediterranean basin. It commonly has poorly differentiated or undifferentiated pathology with a high incidence of cervical lymph node metastasis and great radiosensitivity and chemosensitivity1

Age distribution ranged from 11 to 82 years with mean age 44.25 years and median of 46 years. The male to female ratio was 2:1.

Table (2): Types of malignancies encountered at INMO.

No.TypeFrequencyPercentage1Hematology63323.82Breast50118.83GIT36713.84Head and neck31411.85Gynecology31011.66Urology22208.37Childhood tumors09303.58Soft tissue sarcoma08103.09Bone tumors06602.510Skin04701.811Others brain ,lung)2801.1Total2662100%

Graph 1: Sex distribution33.3%Female66.7%MALE

On the other hand it has low incidence in Europe, Japan and North America.(JCO, Abdelrahhim). Most cases presents with local disease and cervical lymphadenopathy.

Nasopharyngeal cancer (NPC) is a common cancer in Sudanese and affects men more than women.

Sudanese usually presents late with cervical lymphadenopathy.

The commonest histological types were

WHO type II and III.

CLINICAL PRESENTATIONS

NPC characterize by non-specific presentation. Most cases presents with local disease and/or cervical lymphadenopathy, approximately 60-90% of patients present with cervical nodal metastasis3, 11, 12, 13. Patients with nodal metastasis have, higher rates of treatment failure

Symptoms related to primary tumor include ear pain, nasal tone speech, hearing loss, trismus and symptoms and signs of other cranial nerves involvement 14. Larger tumors may cause nasal block and bleeding. In Sudan NPC is the leading cancer in men15.

CLINICAL PRESENTATIONS The patients had different clinical presentationsThe most common clinical presentation in the order of frequency was Cervical lymphadenopathy(73.2%).Nasal block(33.9%).Hearing impairment(27.7%).Epistaxis(22.3%). Ear pain(18.8%). Palatal paralysis(14.3%).

1- NECK MASS Cervical lymph nodes - More than 75% - unilateral or bilateral - Jugulodigastic L N

2. NASAL. > 40% Of patients may presented with Nasal symptoms, in the forms of: - Nasal bleeding - Nasal mass. - Nasal discharge.. - Nasal deformity - Nasal obstruction.

3- EAR > 30% Of patients may presented with otological symptoms, Include - Ear pain, - Hearing loss, - Ear discharge ( Secrotory otitis media) Eustachian tube obstruction

CRINIAL NERVES

Table (1) : Cranial nerve injury

NoNerveNo. of patientsPercent %1Optic 010.892Occulomotor076.253Trigeminent098.034Abducent119.825Facial098.036Glossopharngeal1614.297Vagus032.678Hypoglossal098.03Total = ( 112 )6558.03

DISTAL METASTASIS96%296%2%1%1%96%

INVESTIGATIONS1- RADIOLOGY -X-ray soft tissue lateral view of the neck. - CT scan nasophynx - MRI

CRINIAL NERVES 2 .ENDOSCOY 3. GENERAL

4. BODY SCAN

World Health Organization (WHO) classifies

NPC into 3 types according to histology.

Keratinizing squamous cell carcinoma is WHO type 1. Non keratinizing carcinoma is WHO type 2. Undifferentiated carcinomas and lymphoepithelioma are WHO type 3.

Risk factors in endemic areasEBV-association is reported to be strongly associated with types 2 and 33, 4. Risk factors in endemic areas include :i.EBV,ii salty diet, iii. volatile nitro,iii. HLA antigen haplotype9.

However, in non-endemic regions disease

is associated with alcohol and tobacco use9

Stage: Locally advanced and metastatic diseasewas observed in 85.4% of patients.Locally advanced disease includes all cases with any cranial nerve palsy, cervical lymphadenopathy or T4 lesions. Common sites for metastasis were bone, lung and Liver.

SUMMARY NPC is common in Sudanese population and tends to affect younger age group with male predominance. Most cases present with nodal involvement (CLN)or locally advanced disease. Patients had similar features of histology seen in endemic regions with predominance of WHO-3 histology type

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