Nasopharyngeal Carcinoma

1. Nasopharyngeal Carcinoma พ.ท. ขจรเกียรติ ประสิทธิเวชชากูร

2. Epidermiology

3. Incidence • Rare neoplasm in most parts of world • Higher incidence in Chinease & Taiwan • Chinease gene increase incidence of NPC • Age > 40 years

4. Incidence • Emigration fromhigh incidence to low incidence area reduces incidence of NPC • Male : female = 3:1

5. Risk factor • Genetic maker of NPC  HLA-A2( found in Chineasepopulation ) • EB-virus • Nitrosamines • Polycyclic hydrocarbons • Chronic nasal sinus infection • Poor hygiene

6. Anatomy

8. Pathology

9. Pathology • The most common is squamous cell carcinoma • Most common position is Rosenmuller fossa • Mass lesion • exophytic mass • Ulcerative mass • Infiltrative mass

12. Histopathology

13. Histopathology • Base on predominant histologic type • WHO type 1 : Squamous cell carcinoma nonkeratizing • WHO type 2 : Trasitional cell carcinoma

14. Histopathology • WHO type 3 : Undifferentiated carcimomas • Lymphoepitheliomas • Anaplastic carcinomas

15. WHO type 1 • Squamous cell carcinoma nonkeratizing • Strong intracellular bridges • Less keratin production • Less associate EBV • 25% of case • Radioresistant tumor

16. WHO type 2 • Trasitional cell carcinoma • Not produce keratin • Greater degree of tumor pleomorphism • Most common is papillary morphology • 12% of case

17. 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

19. Tumor Spreading

20. Local invasion • Anterior : involve hard palate, medial pterygoid plate, ethmoid & maxillary sinus • Lateral : involve internal jugular V, internal carotid A, CN IX X XI XII,

21. Local invasion • Medial : Eustachian tube involvement, mastoid air cell • Superior : involve base of skull, throught foramen lacerum & cavernous sinus • Inferior : oropharynx & soft palate

23. Lymphatic spreading • Most common is neck node spreading • Bilateral involvement • Most common position is upper jugular node • Least at submandibular & submental node

24. Distance metastasis • Most common is • Bone • Lung • Liver • Other sites are rare

25. Clinical Manifestation

26. Clinical Manifestation • Related to location of primary tumor & course of disease • Most common complaint is Hearing loss & lump in the neck

27. Neck mass • Most common spread to neck lymph node • Complaint neck mass • Bilateral metastasis to lymph node is common

28. Neck mass • Most common location is Upper jugular node ( compose of jugular node, spinal accessory node ) • retropharyngeal node induce headache

30. Frequency of lymph node manifestration • Upper jugular region • Posterior cervical group • Middle & lower jugular group • Supraclavicular group

31. Nasal cavity involvement • Blood-tinge anterior or posteriornasal drainage • Obstruction of nasal pathway • Epistaxis • Halithosis • Nasal congest

32. Ear involvement • Result from eustachian tubeinvolvement • Sensation of ear blockage • Serous otitis media • Conductive hearing loss • Tinitus

33. Neurologic involvement • Cranial nerve involvement found 25 - 28% • Pain in the neck, facial pain, facial pareathesia ( CN V ) • Diplopia ( CN VI )

34. Neurologic involvement • CN III & IV late phase • CN VII & VIII  less involvement • CN IX, X & XI  can be found

35. Clinical Manifestation • Neck lump 60% • Ear (s) plugging & fullness 41% • Hearing loss 37% • Nasal bleeding 30% • Nasal obstruction 29% • Head pain 16% • Ear pain 14% • Neck pain 13% • Weight loss 10% • Diplopia 8% Symptom & sign of NPC frequency at diagnostic in Mayo clinic series Kuala Lumpur 1983, University of Malaya

36. Clinical Manifestation • Neck mass 68% • Headache 58% • Ear pain 52% • Nasal obstruction, bloody discharge 48% • Facial pareathesia 22% • Dysphagia 16% • Diplopia, strabismus 14% • Facial pain, eye pain 12% • Halithosis 12% • Exopthalmos 2% Symptom from NPC found in Siriraj hospital 2532

37. Other sign & symptom • Weight • Anorexia • low grade fever • Trismus • Nasal regurgitation of fluid

38. Diagnostic Evaluation

39. Clinical evaluation • History taking • Physical examination • Nasopharyngoscopy • Endoscopic nasopharyngoscopy

40. Radiologic evaluation • Plain film head & neck • CT scan head & neck ( for evaluation & treatment planning ) • MRI ( if intracranial extension )

41. Histopathologic evaluation • Biopsy • Most common site are roof of nasophalynx & Rosenmuller fossa

42. 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 available

43. Immunology • Antibody-dependent cellular cytotoxicity ( ADCC ) • Often predict the clinical course of WHO type 2&3

44. Clinical Staging

45. Clinical Staging • T classification • Tis carcinoma in situ • T1 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 cranialinvolvement

46. Clinical Staging • N Classification • Nx node cannot be assessed • N0 no regional lymph node positive • N1 single ipsilateral lymph node size< 3 cm.

47. Clinical Staging • N2a single ipsilateral lymph node size 3 - 6 cm. • N2b multiple ipsilateral lypmh node size < 6 cm. • N2cbilateral or contralateral lymph node size < 6 cm. • N3 lymph node size > 6 cm.

48. Clinical Staging • M classification • Mx not assessed • M0 no distance metastasis • M1 distance metastasis present

49. Stage grouping • Stage I T1 N0 M0 • Stage II T2 N0 M0 • Stage III T3 N0 M0 T<3 N1 M0 • Stage IV T4 N<1 M0 any T N 2-3 M0 any T any N M1

50. Treatment