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Published by: Michael Ghabour on Jul 03, 2011
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Nasopharyngeal Carcinoma

Michael Monir Khalil, M.Sc, M.RCS´London´


Rare in the US, more common in Asia High index of suspicion required for early diagnosis Nasopharyngeal malignancies
± SCCA (nasopharyngeal carcinoma) ± Lymphoma ± Salivary gland tumors ± Sarcomas

 Incidence ± Commenest malign. ± 80% of all nasoph. ± Nitrosamines. Of nasoph. ± Smoking. hydrocarbones.cancer  Age ± Old (40-60y) ± Sarcoms in young(15-20)   Sex : male/female 3/1 Aetiology ± EBV infection. . antibody titre to EBV.tum.

oropharynx and soft palate Laterally -± Eustachian tubes and tori ± Fossa of Rosenmuller .skull base and vertebral bodies Inferiorly -.Anatomy of Nasopharynx     Anteriorly -.nasal cavity Posteriorly -.most common location .

Lymphoid structures .tissue of origin of NPC ‡ Stratified squamous epithelium ‡ Pseudostratified columnar epithelium ± Salivary.Anatomy   Close association with skull base foramen Mucosa ± Epithelium .

.Pathology  Site ± Fossa of Rosenmuller. ± Lateral .wall. mixed salivary t. 85% ‡ Differentiation well-poor ‡ Keratonized or not ± Anaplastic c. commenest. post.cell carcinoma: commenest.(lymphoepithelioma) ± Adenocar. .  Microscopic ± Sq.superolat.

ET. oropharynx Lateraly:pt. ± Blood : rare. PVms.RPLN. hard palat. Inferiorly:soft.last 4 cr. common ‡ 1st.ms.. Posterioly:RFS. ‡ Superiorly:intracranial ext.ppfossa.Spread ± Direct ‡ ‡ ‡ ‡ Anteriory: nose.n.n. sympathatic ch. max. ± Lymphatic ‡ very early.. orbit. late . mand.s. then UDCLN ‡ Bilateral is common. PPS. through f lacerum carotid canal f oval.

Epidemiology  Environmental ± Viruses ‡ EBV.polycyclic hydrocarbons. poor ventilation . chronic nasal infection. poor hygiene.possible factor in WHO type I lesions ± Nitrosamines .salted fish ± Others .well documented viral ³fingerprints´ in tumor cells and also anti-EBV serologies with WHO type II and III NPC ‡ HPV .

Classification  WHO classes ± Based on light microscopy findings ± All SCCA by EM  Type I .³SCCA´ ± 25 % of NPC ± moderate to well differentiated cells similar to other SCCA ( keratin. intercellular bridges) .

Classification  Type II .³non-keratinizing´ carcinoma ± 12 % of NPC ± variable differentiation of cells ( mature to anaplastic) ± minimal if any keratin production ± may resemble transitional cell carcinoma of the bladder .

Classification  Type III .³undifferentiated´ carcinoma ± 60 % of NPC. majority of NPC in young patients ± Difficult to differentiate from lymphoma by light microscopy requiring special stains & markers ± Diverse group ‡ Lymphoepitheliomas. clear cell and anaplastic variants . spindle cell.

‡ unilateral CHL (SOM).: hard painless not tender. ‡ Referred otalgia. 1st mobile later fixed. 70% of presetation. ‡ UDCLN esp. ± Nodal manifest. JD node.Clinical Presentation  Initial symptoms ± Aural symp. 40%. may be 1st prest. . tinnitus. ‡ Silent areas.

6th: IC ext. through FL ‡ Cranial n palsies ± ± ± ± ± Trigeminal : early : facial pain.12: skull base or PPS by enlarged RF node. . Or bilat. ± Examination ‡ Fungating mass.:opthalomoplagia.canal): 1st affected.11. submucosal swelling  Neurological manifestation ‡ Vidian n(n.4th. ulcer.n. Increased ICT. ± Epistaxis: intermittent. Symathatic chain: Horner syndrome.disch.of pt. 3rd . diplopia 9. Rhinological manifestation ± Nasal obstruction: unilat. slight ± Fetid mucopur.10. numbness.

bone eros. ± Unilat. CD ± Unilat. Trotter triade: diagnostic: ± Immobile soft palate. bone erosion ± CT with contrast: extensions. ± Biopsy ± Tymanogram : shows SOM. ± Metastatic work up. nodal. Facial pain  Investigation ± Plain x-ray: mass. .

X. IV. XII .cervical sympathetics CN¶s IX.Clinical Presentation     Xerophthalmia .CN VI Ophthalmoplegia .extensive skull base . and VI ± cavernous sinus or superior orbital fissure   Horner¶s syndrome . Diplopia . petrosal n Facial pain . XI.CN III.Trigeminal n.greater sup.

submucosal ± NP may appear normal  Regional spread ± Usually ipsilateral first but bilateral not uncommon  Distant spread . lungs. bones . liver.Clinical Presentation  Nasopharyngeal examination ± Fossa of Rosenmuller most common location ± Variable appearance .exophytic.rare (<3%).

bone scans .Radiological evaluation  Contrast CT with bone and soft tissue windows ± imaging tool of choice for NPC  MRI ± soft tissue involvement. recurrences   CXR Chest CT.

chemistry profile.Laboratory evaluation  Special diagnostic tests (for types II & III) ± IgA antibodies for viral capsid antigen (VCA) ± IgG antibodies for early antigen (EA)  Special prognostic test (for types II & III) ± antibody-dependent cellular cytotoxicity (ADCC) assay ‡ higher titers indicate a better long-term prognosis  CBC. LFT¶s .

Staging  Variety of systems used ± Am Jt Comm for Ca Staging ± International Union Against Ca ± Ho System  Unique NPC prognostic factors often not considered and similar prognosis between stages .

0 ± WHO type I +1.0 ± Lower cervical node dx +1.5 ± Seven or more sx¶s +1.0.Staging  Neel and Taylor System ± Extensive primary tumor +0.0 ± -------------------------------------------------------  ADCC assay titer considered if available .5 ± Sx¶s present < 2 months before dx .

99 >2 .99 1 to 1.Staging     Stage A Stage B Stage C Stage D = = = = <0 0 to 0.

± Dose: 6500-7000 cGy ± Primary.Treatment  Radiotherapy of choice. pos. External beam radiation: both 1ry&neck. upper cervical nodes. lower nodes  Adjuvant brachytherapy ± mainly for residual/recurrent disease .

complications ± More severe when repeat treatments required ± Include ‡ xerostomia. later (patulous ET) ‡ Endocrine disorders .hypopituitarism.Treatment  External beam radiation . hypothalamic disfunction ‡ Soft tissue fibrosis including trismus ‡ Ophthalmologic problems ‡ Skull base necrosis . hypothyroidism.early (SOM). tooth decay ‡ ETD .

± Nasophryngectomy local recuurance .Treatment Surgical management  Mainly diagnostic .OR for panendo and bx  Surgical treatment: limited ± Radical neck dissection:persistant after full dose or RT.(regional failure with local control).Biopsy ± consider clinic bx if cooperative patient ± must obtain large biopsy ± clinically normal NP .

Treatment Surgical management  Primary lesion ± consider for residual or recurrent disease ± approaches ‡ ‡ ‡ ‡ ‡ infratemporal fossa transparotid temporal bone approach transmaxillary transmandibular transpalatal .

Treatment Surgical management  Regional disease ± Neck dissection may offer improved survival compared to repeat radiation of the neck  ETD ± BMT if symptomatic prior to XRT ± Post XRT ‡ observation period if symptoms not severe ‡ amplification may be more appropriate .

no proven long term benefit ± Mainly for palliation of distant disease  Immunotherapy ± Future treatment?? ± Vaccine?? .Treatment  Chemotherapy ± Variety of agents ± Chemotherapy + XRT .

Conclusion       Rare in North America. cervical and NP exams Three WHO types .better prognosis. more common in China 40% overall survival at 5 years Complete H&P. III . careful otologic. EBV assoc. neurologic. Treatment is primarily XRT .all from NP epithelium Types II.

Thank you .

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