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Nasopharyngeal carcinoma
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- 2. Introduction • Nasopharyngeal carcinomais 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)
- 3. 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
- 4. Etiology • Genetic • Commonestin 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
- 5. W.H.O. Classification (Histological) Type 1: •Keratinizing squamous cell carcinoma Type 2: • Non-keratinizing (transitional) carcinoma Type 3: • Undifferentiated (anaplastic) carcinoma
- 6. Clinical Features 1. Neckswelling (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
- 7. 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
- 8. 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
- 10. Investigations 1. 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
- 11. 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
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- 15. CT scan: Infratemporalfossa & orbit involvement
- 16. CT scan: Sellainvolvement
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- 20. Whole body bonescan
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- 22. T.N.M. staging T1 =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
- 23. N0 = noevidence 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
- 24. T.N.M. staging • StageI = T1 N0 M0 • Stage II = T2 or N1 M0 • Stage III = T3 or N2 M0 • Stage IV = T4 or N3 or M1
- 25. Treatment modalities 1. Teletherapyor External beam radiotherapy 2. Brachytherapy 3. Chemotherapy 4. Surgery 5. Immunotherapy against E.B.V.
- 26. 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
- 27. Brachytherapy • Used forsmall 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
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- 30. High Dose RateBrachytherapy
- 31. Chemotherapy Drugs used 1. Cisplatin 2.5-Fluorouracil Indications 1. Radiation failure 2. Palliation in distant metastasis
- 32. Surgery 1. Nasopharyngectomy, Cryosurgery: for residual or recurrent tumor 2. Radical neck dissection: for radio- resistant neck node metastasis 3. Palliative debulking: for T4 tumors 4. Myringotomy & grommet insertion: for persistent otitis media with effusion
- 33. Radical neck dissection& Interstitial Brachytherapy
- 34. Treatment Protocol T1 =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)
- 35. Prognosis • W.H.O. Type2 & 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 %