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Nasopharyngeal Carcinoma

Nasopharyngeal Carcinoma. Dr. Vishal Sharma. Introduction. 85% adult nasopharyngeal malignancies are carcinoma Common pediatric malignancies of naso-pharynx are rhabdomyosarcoma & lymphoma 30% pediatric nasopharyngeal malignancies are carcinoma. Introduction.

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Nasopharyngeal Carcinoma

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  1. Nasopharyngeal Carcinoma Dr. Vishal Sharma

  2. Introduction • 85% adult nasopharyngeal malignancies are carcinoma • Common pediatric malignancies of naso-pharynx are rhabdomyosarcoma & lymphoma • 30% pediatric nasopharyngeal malignancies are carcinoma

  3. 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

  4. 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

  5. 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)

  6. 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

  7. Clinical Features 4. Ophthalmologic (25-40%): Diplopia & ophthalmo-plegia (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 nodeHorner's syndrome: sympathetic chain involvement

  8. 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

  9. Neck swelling

  10. Ptosis & adduction palsy

  11. Left proptosis

  12. 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

  13. 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.

  14. Nasopharyngoscopy

  15. Diagnostic Nasal Endoscopy

  16. Computerized Tomogram

  17. CT scan: retropharyngeal node

  18. CT scan: Infratemporal fossa & orbit involvement

  19. CT scan: sella involvement

  20. Magnetic Resonance Imaging

  21. MRI: parapharyngeal mass

  22. MRI: neck node metastasis

  23. M.R.I.: intracranial extension

  24. Endoscopic biopsy

  25. CT scan: liver metastasis

  26. Whole body bone scan

  27. Positron Emission Tomography

  28. 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

  29. 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

  30. Supraclavicular fossa Synonym:Ho’s triangle A = medial end of clavicle B = Lateral end of clavicle C = junction between neck & shoulder

  31. 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

  32. Differential Diagnosis 1. Juvenile angiofibroma 2. Rhabdomyosarcoma 3. Lymphoma

  33. 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

  34. Cobalt Teletherapy

  35. 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

  36. 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

  37. Interstitial Brachytherapy

  38. Intracavitary Brachytherapy

  39. High Dose Rate Brachytherapy

  40. Chemotherapy Drugs used: 1. Cisplatin 2. 5-Fluorouracil Indications: 1. Radiation failure 2. Palliation in distant metastasis

  41. 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

  42. Radical neck dissection & Interstitial Brachytherapy

  43. 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

  44. 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 %

  45. Thank You

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