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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 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 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 & 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
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
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.
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
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
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
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 %