Transcript Nasopharyngeal carcinoma

Nasopharyngeal
Carcinoma
Dr. Vishal Sharma
Introduction

85% adult nasopharyngeal malignancies are
carcinoma

Common pediatric malignancies of nasopharynx are rhabdomyosarcoma & lymphoma

30% pediatric nasopharyngeal malignancies are
carcinoma
Introduction
Race: More in Chinese & North African people
Sex: Male preponderance of 3:1
Age: Small peak: 12-18 yrs; large peak: 50-60 yrs
Gross: Proliferative, Ulcerative & Infiltrative types
Histology: 85% Squamous cell carcinoma,
10% Lymphomas, 5% Mixed
Aetiology
1. Genetic: Commonest in Chinese population.
HLA-A2 & HLA-B-Sin 2 histocompatibility locus
2. Viral: Epstein-Barr Virus
3. 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
Type 1: keratinizing squamous cell carcinoma
Type 2: non-keratinizing (transitional) carcinoma
 Without lymphoid stroma (intermediate cell)
 With lymphoid stroma (lympho-epithelial)
Type 3: undifferentiated (anaplastic) carcinoma
 Without lymphoid stroma (clear cell)
 With lymphoid stroma (lympho-epithelial)
Clinical Features
1. Neck swelling (60-90%): B/L, enlarged upper &
middle deep cervical nodes + posterior
triangle nodes (Rouviere's sign)
2. Nasal (40-75%): epistaxis, nose block, nasal
discharge
3. Otologic (40-70%): Conductive deafness, tinnitus
Clinical Features
4. Ophthalmologic (25-40%): Diplopia & ophthalmoplegia (involvement of CN III, IV, VI), Proptosis
(orbit invasion) & blindness (involvement of CN II).
5. Neurologic (25-40 %):
Jugular foramen syndrome: CN IX, X, XI involved
by lateral retropharyngeal lymph node
Horner's syndrome: sympathetic chain involvement
Clinical Features
6. Severe Headache: indicates skull base erosion
7. Trotter's triad:
Conductive deafness: Eustachian Tube block
+ I/L temporo-parietal neuralgia: Trigeminal damage
+ I/L palatal paralysis: Vagus damage
8. Distant metastasis: to bone, lung & liver
Neck swelling
Ptosis & adduction palsy
Left proptosis
Investigations
1. Nasopharyngoscopy & Diagnostic Nasal
Endoscopy: Tumor mass seen in nasopharynx
Commonest site is fossa of Rosenmüller
2. Nasopharyngeal tumor biopsy: seen or blind
3. F.N.A.C. of neck node: done in occult primary
4. C.T. scan head & neck: for tumor extent, skull
base erosion & cervical lymph node metastasis
Investigations
5. M.R.I. head & neck: for intracranial extension.
6. Tests for metastases: C.T. chest + abdomen,
bone scan, P.E.T. scan, liver function tests.
7. Serologic tests: Immuno-fluorescence for IgA
antibodies to Viral Capsid Antigen, IgG
antibodies to Early Antigen, Antibody
Dependent Cellular Cytotoxicity assay.
Nasopharyngoscopy
Diagnostic Nasal Endoscopy
Computerized Tomogram
CT scan: retropharyngeal node
CT scan: Infratemporal fossa &
orbit involvement
CT scan: sella involvement
Magnetic Resonance Imaging
MRI: parapharyngeal mass
MRI: neck node metastasis
M.R.I.: intracranial extension
Endoscopic biopsy
CT scan: liver metastasis
Whole body bone scan
Positron Emission Tomography
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
nerves, infratemporal fossa, hypopharynx
T.N.M. staging
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
Supraclavicular fossa
Synonym: Ho’s triangle
A = medial end of
clavicle
B = Lateral end of
clavicle
C = junction between
neck & shoulder
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
Differential Diagnosis
1. Juvenile angiofibroma
2. Rhabdomyosarcoma
3. Lymphoma
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
Cobalt Teletherapy
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
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 used:
1. Cisplatin
2. 5-Fluorouracil
Indications:
1. Radiation failure
2. Palliation in distant metastasis
Surgery
1. Nasopharyngectomy, Cryosurgery:
for residual or recurrent tumor
2. Radical neck dissection:
for radio-resistant lymph node metastasis
3. Palliative debulking: for T4 tumors
4. Myringotomy & grommet insertion:
for persistent otitis media with effusion
Radical neck dissection &
Interstitial Brachytherapy
Treatment Protocol
T1 = External Radiotherapy (6500 cGy)
T2 = External Radiotherapy (7000 cGy)
T3 & T4 = Radiotherapy + Chemotherapy 
Brachytherapy / Salvage surgery if required
N0 = External Radiotherapy (5000 cGy)
N1, N2, N3 = External Radiotherapy (6000 cGy)
+ Chemotherapy
Prognosis
W.H.O. Type 2 & 3 carcinomas have good
response to radiotherapy & better survival rates.
5 year survival rates for treated patients:
Stage I = 95 – 100 %
Stage II = 60 – 80 %
Stage III = 30 – 60 %
Stage IV = 20 – 30 %
Thank You