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Nasopharyngeal

Carcinoma
Dr. Vishal Sharma

Introduction

85% adult nasopharyngeal malignancies are


carcinoma

Common pediatric malignancies of nasopharynx 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 & ophthalmoplegia (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

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

Neck swelling

Ptosis & adduction palsy

Left proptosis

Investigations
1. Nasopharyngoscopy & Diagnostic Nasal
Endoscopy: Tumor mass seen in nasopharynx
Commonest site is fossa of Rosenmller

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.

Nasopharyngoscopy

Diagnostic Nasal Endoscopy

Computerized Tomogram

CT scan: retropharyngeal node

CT scan: Infratemporal fossa &


orbit involvement

CT scan: sella involvement

Magnetic Resonance Imaging

MRI: parapharyngeal mass

MRI: neck node metastasis

M.R.I.: intracranial extension

Endoscopic biopsy

CT scan: liver metastasis

Whole body bone scan

Positron Emission Tomography

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: Hos 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

Cobalt Teletherapy

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

Interstitial Brachytherapy

Intracavitary Brachytherapy

High Dose Rate Brachytherapy

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:

Radical neck dissection &


Interstitial Brachytherapy

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 %

Thank You