Download pdf - 10a. Nasopharyngeal Carcinoma

8/10/2019 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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