NASOPHARYNGEAL CARCINOMA PRESENTATION.ppsx

Nasipharyngeal carcinoma

1. DR SAJJAD HAIDER
ENT DEPARTMENT

2. NASOPHARYNGEAL CARCINOMA
A TUMOR ARISING FROM THE EPITHELIAL CELLS THAT
COVERS THE SURFACE AND LINE THE NASOPHARYNX.
PSEUDOSTRATIFIED CILIATED COLUMNAR EPITHELIUM
WITH GOBLET CELLS LINE THE NASOPHARYNX.

3. ETIOLOGICAL FACTORS :
JUST LIKE FOR GERMINATION AND GROWTH OF PLANTS
THREE THINGS ARE REQUIRED :
1.SOIL
2.SEED
3.ENVIRONMENT

4. ETIOLOGICAL FACTORS :
SOIL: TISSUE OF BODY WITH GENETIC PECULARITY.
HLA A2, B14, B46 ARE ASSOCIATED WITH NPC.
ABOUT 10% OF NPC HAVE FAMILIAL CLUSTERING OF CASES.
SEED: CAUSATIVE ORGANISM IS EPV.
ENVIRONMENTAL FACTORS :
AGE,COOKING,OCCUPATION,NUTRITIONAL DEFICIENCIES,
SOCIOECONOMIC STATUS,TOBACCOO.

5. ENVIRONMENTAL FACTORS:
AGE : BIMODAL AGE PRESENTATION BETWEEN 15-20 YEARS
AND 55-65 YEARS.
GENDER : MORE COMMON IN MALES 3:1.
TOBACCO SMOKING .
CHINESE HERBAL MEDICINE .
DIET : SALTED FISH , PRESERVED VEGETABLES, SPICY MEAT,
OCCUPATION : INDUSTRIAL FUMES,WOOD DUST,EXPOPSURE
TO NICKEL.
HOUSEHOLD SMOKE AND FUMES.
NUTRITIONAL DEFICIENCIES LIKE VITAMIN A AND C.

6. EPSTEIN BARR VIRUS
IT IS A DNA VIRUS.
IT WAS FIRST ASSOCIATED WITH BURKITT LYMPHOMA.
EBV DNA IS PRESENT IN ALMOST ALL PATIENTS WITH
NON-KERATINIZING (POORLY DIFFERENTIATING AND
UNDIFFERENTIATED) NASOPHARYNGEAL CARCINOMA IN
BLOOD PLASMA.

7. GEOGRAPHICAL DISTRIBUTION OF DISEASE
IT COMPRISE 2% MALIGNANT TUMORS OF HEAD AND
NECK.
IN CHINA ,HONGKONG,INDONESIA ,SOUTH EAST ASIA,
NORTH AFRICA ,ALGERIA ; ITS INCIDENCE IS AS HIGH AS
18% .
JAPANESE AND KOREANS LIKE WESTERN POPULATION
HAVE ANNUAL INCIDENCE RATE OF LESS THAN 1 CASE
PER 100000

8. SITE OF ORIGIN :
FOSSA OF ROSSEN MULLER .
ALSO KNOWN POSTERIOR LATERAL RECESS.
LOCATED POSTEROSUPERIOR TO TORUS TUBERI.
POSTERIOR CUSHION OF EUSTACHIAN TUBE OPENING
FORMS ANTERIOR WALL OF FOSSA OF ROSENMULLER.
FORMED BY MUCOSAL REFLECTION OVER THE LONGUS
COLLI MUSCLE..

9. GROSS PRESENTATION OF TUMOR
PROLIFERATIVE GROWTH CAUSING NASAL OBSTRUCTION.
ULCERATIVE CAUSING EPISTAXIS.
INFILTRATIVE WHICH CAUSES CRANIAL NERVE
INVOLVEMENT.

10. SYMPTOMS OF NPC :
LUMP IN NECK (60-80%) +
NASAL SYMPTOMS (40%)
(OBSTRUCTION,EPISTAXIS,CACOSMIA)+
OTOLOGICAL SYMPTOMS (30%) (DUE TO EUSTACHIAN
TUBE BLOCK)+
NEUROLOGICAL SYMPTOMS 20% (HEADACHE , CRANIAL
NERVE PALSY V2)
MISCELLANEOUS (WEIGHT LOSS,ANOREXIA )
TROTTERS TRIAD

11. TROTTERS TRIAD
CONDUCTIVE
DEAFNESS
FACIAL PAIN
CN-5 INVOLVEMENT
PALATAL PALSY
(LOCAL INVASION OR
INVOLVEMENT OF CRANIAL
ACCESSORY NERVE)

12. MODE OF SPREAD :
DIRECT SPREAD (ANTERIOR-POSTERIOR-SUPERIOR-
INFERIOR).
VIA LYMPHATIC SPREAD.
VIA HEMATOGENOUS SPREAD.

13. DIRECT SPREAD OF TUMOR :
ANTERIORLY : NASAL CAVITY , PARANASAL SINUSES,ORBIT
,PTERYGOPALATINE FOSSA AND INFRATEMPORAL FOSSA.
POSTERIORLY: TO RETROPHARYNGEAL SPACE ,NODE OF
ROUVIER .
LATERALLY : TO PARAPHARYNGRAL SPACE THROUGH SINUS
OF MORGAGNI.
IN POST STYLOID COMPARTMENT :IT CAUSES VASCULAR
COMPRESSION OF CAROTID SHEATH ,LAST 4 CRANIAL
NERVES,AND CERVICAL SYMPATHETIC NERVES.
INFERIORLY:ORAL CAVITY AND RETROTONSILLAR REGIONS.
SUPERIORLY: INTO CRANIAL CAVITY ESPECIALLY THROUGH
FORAMEN OF LACERUM(LINCONI HIGHWAY).

14. LYMPHATIC SPREAD
MOST FREQUENTLY INVOLVED L.N ARE LEVEL 2 PLUS
LEVEL 5.
IT CAN BE DIVIDED INTO MEDIAN GROUP AND LATERAL
GROUP.
MEDIAN GROUP: RETROPHARYNGEAL LYMPH NODE.
LATERAL GROUP : UPPER INTERNAL JUGULAR CHAIN OR
LATERAL RETROPHARYNGEAL NODE ( NODE OF
ROUVIERE).
FIRST NOTICEABLE LYMPH NODE METASTATSIS IS UPPER
CERVICAL GROUP OF LYMPH NODES.

15. HEMATOGENOUS SPREAD
DISTANT METASTASIS OCCURS COMMONLY TO BONE LIKE
THORACOLUMBAR SPINE (50%) .
LUNG .
LIVER .

16. JUGULAR FORAMEN SYNDROME
INVOLVEMENT OF LAST 4 (9,10,11,12) CRANIAL NERVES
IN NPC .
COMPRESSION BY THE NODAL METASTASIS CLOSE TO
JUGULAR FORAMEN.

17. HISTOLOGICAL CLASSIFICATION :
TYPE 1 : KERATINIZING SQUAMOUS CELL CARCINOMA(25%).
TYPE 2 : NON-KERATININZING CARCINOMA (75-95%)
a)DIFFERENTIATING.
b)UNDIFFERENTIATED.

18. TNM CLASSIFICATION :
Primary tumor
1. T1—Tumor confined to nasopharynx.
2. T2a—Tumor extends to oropharynx/nasal cavity
without parapharyngealspread.
3. T2b—Tumor with parapharyngealextension.
4. T3—Tumor involves bony structures and/or paranasal
sinuses.
5. T4—Tumor invasion intracranial structures and/or
cranial nerves, infratemporalfossa, orbit, masticator
space or hypopharynx.

19. TNM CLASSIFICATION:
.
1. N0—No clinically positive nod e .
2. N1—Single clinically positive hemolateralnode 3 cm or
less in diameter.
3. N2—Single clinically positive homolateralnode >3 cm
but <6 cm or multiple clinically positive homolateral
nodes >6 cm in diameter.
4. N3—Massive homolateralnode(s), bilateral nodes or
contralateralnode(s). M: Distant metastasis 1. MX—Not
assessed 2. M0—No (Known) distant metastasis 3. M1—
Distant metastasis present.

20. INVESTIGATIONS :
1.DIAGNOSTIC NASAL ENDOSCOPY.
2.BIOPSY UNDER VISION.
3.FNAC FROM METASTATIC LYMPH NODE.
4.CT SCAN.
5.MRI (PREFERRED).
6.BONE SCAN FOR METS.
7.USG ABDOMEN FOR LIVER METS.
8.X RAY CHEST FOR LUNG METS.
9.PET (POSITRON EMISSION TOMOGRAPHY)
10.EBV IgGAND IgMSEROLOGY.
11.IgAANTIBODIES AGAINST VIRAL CAPSID ANTIGEN,EARLY
ANTIGEN,EBV NUCLEAR ANTIGEN.

21. PRIMARY TREATMENT :
1.EXTERNAL BEAM RADIATION THERAPY (IMRT)
CONTINUES TO BE MAINSTAY OF TREATMENT FOR THIS
LESION.
2.SURGICAL TREATMENT IS RESERVED FOR SALVAGE OF
RADIATION FAILURES.
3.DOSES OF 6500 TO 7000 cGYARE DIRECTED AT PRIMARY
LESION AND THE UPPER ECHELON LYMPH NODES.
4.BRACHYTHERAPY WITH IRIDIUM-192 IS OCCASIONALLY
USED AS AN ADJUVANT TO EXTERNAL BEAM RADIATION
OR IN CASES OF RESIDUAL TUMORS.

22. CHEMOTHERAPY :
NPC IS SENSITIVE TO BOTH RADIOTHERAPY AND
CHEMOTHERAPY.
CISPLATIN PLUS 5-FU ARE THE AGENT USED
CONCCURENTLY WITH RADIOTHERAPY.
WEEKLY (30-40mg/m2) DOSE IS STANDARD.

23. IMMUNOTHERAPY AND VACCINATION
CERTAIN ANTI-EBV ANTIBODIES HELP WITH IMPROVESD
PROGNOSIS
ALSO A VACCINE TO PROTECT AGAINST EBV RELATED
DISEASE MAY ONE DAY BE REALITY.

24. MONITORING OF TREATMENT:
ENDOSCOPY AND BIOPSY OF NASOPHARYNX TO
CONFIRM DISEASE RESOLUTION AFTER COMPLETION OF
RADIOTHERAPY.
IT SHOULD BE PERFORMED AFTER 12 WEEKS AFTER
COMPLETION OF TREATMENT.
LONG TERM FOLLOW UP IS ESSENTIAL.
REGULAR 2-3 MONTHS FOLLOW UPTO 2 YEARS
INCREASED TO 3-4 TIMES PER YEAR FOR NEXT 3 YEARS ,
FOLLOWED BY 6 MONTHS OR ANNUALLY.

25. COMPLICATIONS OF TREATMENT :
MUCOSITIS.
OTOLOGICAL INCLUDE OME ,OTITIS EXTERNA.
SENSORINEURAL HARING LOSS.
OLFACTORY DYSFUNCTION.
SALIVARY GLANLD DYSFUNCTION.
RHINOSINISITIS.
SWALLOWING PROBLEMS ARE VERY COMMON.
RADIATION INDUCED FIBROSIS.
OSTEORADIONECROSIS..
RADIATION INDUCED MALIGNANCIES.
INTERNAL CAROTID ARTERY ANEURYSM .

26. PROGNOSIS :
FIVE YEAR SURVIVAL IS 45-50% .
LOCAL RECUURRENCE AND DISTANT METASTASIS OCCURS
IN ABOUT 90% IN 2-3 YEARS.