Nasopharyngeal Carcinoma

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Nasopharyngeal Carcinoma

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Epidermiology
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Incidence

• Rare neoplasm in most parts of world
• Higher incidence in Chinease Taiwan
• Chinease gene increase incidence of NPC
• Age gt 40 years

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Incidence

• Emigration from high incidence to low incidence
  area ? reduces incidence of NPC
• Male female 31

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Risk factor

• Genetic maker of NPC ? HLA-A2 ( found in
  Chinease population )
• EB-virus
• Nitrosamines
• Polycyclic hydrocarbons
• Chronic nasal sinus infection
• Poor hygiene

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Anatomy
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Pathology
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Pathology

• The most common is squamous cell carcinoma
• Most common position is Rosenmuller fossa
• Mass lesion
• exophytic mass
• Ulcerative mass
• Infiltrative mass

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Histopathology
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Histopathology

• Base on predominant histologic type
• WHO type 1 Squamous cell carcinoma
  nonkeratizing
• WHO type 2 Trasitional cell carcinoma

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Histopathology

• WHO type 3 Undifferentiated carcimomas
• Lymphoepitheliomas
• Anaplastic carcinomas

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WHO type 1

• Squamous cell carcinoma nonkeratizing
• Strong intracellular bridges
• Less keratin production
• Less associate EBV
• 25 of case
• Radioresistant tumor

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WHO type 2

• Trasitional cell carcinoma
• Not produce keratin
• Greater degree of tumor pleomorphism
• Most common is papillary morphology
• 12 of case

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WHO type 3

• Undifferentiated carcimomas
• Lymphoepitheliomas, Anaplastic carcinomas, Clear
  cell carcinoma, Spindle cell carcinoma
• Most common cell type of NPC
• Clear nucleus
• 63 aggressive behavior
• Radiosensitive

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Tumor Spreading
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Local invasion

• Anterior involve hard palate, medial pterygoid
  plate, ethmoid maxillary sinus
• Lateral involve internal jugular V, internal
  carotid A, CN IX X XI XII,

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Local invasion

• Medial Eustachian tube involvement, mastoid air
  cell
• Superior involve base of skull, throught
  foramen lacerum cavernous sinus
• Inferior oropharynx
• soft palate

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Lymphatic spreading

• Most common is neck node spreading
• Bilateral involvement
• Most common position is upper jugular node
• Least at submandibular
• submental node

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Distance metastasis

• Most common is
• Bone
• Lung
• Liver
• Other sites are rare

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Clinical Manifestation
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Clinical Manifestation

• Related to location of primary tumor course of
  disease
• Most common complaint is Hearing loss lump in
  the neck

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Neck mass

• Most common spread to neck lymph node
• Complaint neck mass
• Bilateral metastasis to lymph node is common

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Neck mass

• Most common location is Upper jugular node (
  compose of jugular node, spinal accessory node )
• retropharyngeal node induce headache

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Frequency of lymph node manifestration

• Upper jugular region
• Posterior cervical group
• Middle lower jugular group
• Supraclavicular group

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Nasal cavity involvement

• Blood-tinge anterior or posteriornasal drainage
• Obstruction of nasal pathway
• Epistaxis
• Halithosis
• Nasal congest

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Ear involvement

• Result from eustachian tube involvement
• Sensation of ear blockage
• Serous otitis media
• Conductive hearing loss
• Tinitus

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Neurologic involvement

• Cranial nerve involvement found 25 - 28
• Pain in the neck, facial pain, facial pareathesia
  ( CN V )
• Diplopia ( CN VI )

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Neurologic involvement

• CN III IV ? late phase
• CN VII VIII ? less involvement
• CN IX, X XI ? can be found

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Clinical Manifestation

• Neck lump 60
• Ear (s) plugging fullness 41
• Hearing loss 37
• Nasal bleeding 30
• Nasal obstruction 29
• Head pain 16
• Ear pain 14
• Neck pain 13
• Weight loss 10
• Diplopia 8
• Symptom sign of NPC frequency at diagnostic in
  Mayo clinic series Kuala Lumpur 1983, University
  of Malaya

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Clinical Manifestation

• Neck mass 68
• Headache 58
• Ear pain 52
• Nasal obstruction, bloody discharge 48
• Facial pareathesia 22
• Dysphagia 16
• Diplopia, strabismus 14
• Facial pain, eye pain 12
• Halithosis 12
• Exopthalmos 2
• Symptom from NPC found in Siriraj hospital 2532

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Other sign symptom

• Weight
• Anorexia
• low grade fever
• Trismus
• Nasal regurgitation of fluid

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Diagnostic Evaluation
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Clinical evaluation

• History taking
• Physical examination
• Nasopharyngoscopy
• Endoscopic nasopharyngoscopy

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Radiologic evaluation

• Plain film head neck
• CT scan head neck ( for evaluation treatment
  planning )
• MRI ( if intracranial extension )

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Histopathologic evaluation

• Biopsy
• Most common site are roof of nasophalynx
  Rosenmuller fossa

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Immunology

• Indirect immunofluorescence for IgG IgA
  antibodies to viral capsid antigen (VCA) early
  antigen (EA)
• Most specific test for diagnosis
• Highly predictive of the clinical course
• not yet commercially available

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Immunology

• Antibody-dependent cellular cytotoxicity ( ADCC )
• Often predict the clinical course of WHO type 23

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Clinical Staging
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Clinical Staging

• T classification
• Tis carcinoma in situ
• T1 tumor confine in one site of nasopharynx no
  tumor visible
• T2 tumor involve 2 site
• T3 extension of tumor into nasal cavity or
  oropharynx
• T4 tumor invasion of skull or cranial involvement

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Clinical Staging

• N Classification
• Nx node cannot be assessed
• N0 no regional lymph node positive
• N1 single ipsilateral lymph node size lt 3 cm.

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Clinical Staging

• N2a single ipsilateral lymph node size 3 - 6
  cm.
• N2b multiple ipsilateral lypmh node size lt 6 cm.
• N2c bilateral or contralateral lymph node size lt
  6 cm.
• N3 lymph node size gt 6 cm.

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Clinical Staging

• M classification
• Mx not assessed
• M0 no distance metastasis
• M1 distance metastasis present

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Stage grouping

• Stage I T1 N0 M0
• Stage II T2 N0 M0
• Stage III T3 N0 M0
• Tlt3 N1 M0
• Stage IV T4 Nlt1 M0
• any T N 2-3 M0
• any T any N M1

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Treatment
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Radiotherapy

• The most proper treatment
• 60 - 70 Gy for 6 - 7 weeks
• 75 Gy if present brain involvement

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Radiotherapy

• Complication
• Dental caries
• Otitis media otitis externa
• Trismus

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Chemotherapy

• Control distance metastasis
• Complication
• Hair loss
• Nausea vomitting
• Weight loss
• Anorexia

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Surgery

• Lymph node present after radiotherapy 4 - 6
  weeks
• Recurrent lymph node enlargement

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Prognosis
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Prognosis

• 5 years survival ( A.C. 1965 )
• Stage I 44
• Stage II 30
• Radiotherapy Chemotherapy ? good result

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_ Thank You _