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

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

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)

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 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

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

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: 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

Cobalt Teletherapy

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

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:

for persistent otitis media with effusion

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