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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 %