nasopharyngeal carcinoma
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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Nasopharyngeal Carcinoma
Dr. Vishal Sharma
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Introduction
85% adult nasopharyngeal malignancies are
carcinoma
Common pediatric malignancies of naso-
pharynx are rhabdomyosarcoma & lymphoma
30% pediatric nasopharyngeal malignancies are
carcinoma
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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
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Aetiology1. 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
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W.H.O. classificationType 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)
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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
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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 node
Horner's syndrome: sympathetic chain involvement
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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
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Neck swelling
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Ptosis & adduction palsy
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Left proptosis
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Investigations1. 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
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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.
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Nasopharyngoscopy
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Diagnostic Nasal Endoscopy
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Computerized Tomogram
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CT scan: retropharyngeal node
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CT scan: Infratemporal fossa & orbit involvement
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CT scan: sella involvement
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Magnetic Resonance Imaging
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MRI: parapharyngeal mass
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MRI: neck node metastasis
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M.R.I.: intracranial extension
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Endoscopic biopsy
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CT scan: liver metastasis
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Whole body bone scan
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Positron Emission Tomography
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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
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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
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Supraclavicular fossa
Synonym: Ho’s triangle
A = medial end of
clavicle
B = Lateral end of
clavicle
C = junction between
neck & shoulder
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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
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Differential Diagnosis
1. Juvenile angiofibroma
2. Rhabdomyosarcoma
3. Lymphoma
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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
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Cobalt Teletherapy
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External beam irradiation2 lateral fields: nasopharynx, skull base & upper
neck; sparing temporal lobe, pituitary & spinal cord.
1 anterior field: lower neck; sparing spinal cord & larynx
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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
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Interstitial Brachytherapy
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Intracavitary Brachytherapy
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High Dose Rate Brachytherapy
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Chemotherapy
Drugs used:
1. Cisplatin
2. 5-Fluorouracil
Indications:
1. Radiation failure
2. Palliation in distant metastasis
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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
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Radical neck dissection & Interstitial Brachytherapy
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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
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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 %
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Thank You