Nasopharyngeal Carcinoma
พ.ท. ขจรเกียรติ ประสิ ทธิเวชชากูร
Epidermiology
Incidence
• Rare neoplasm in most parts of world
• Higher incidence in Chinease & Taiwan
• Chinease gene increase incidence of
NPC
• Age > 40 years
Incidence
• Emigration from high incidence to low
incidence area  reduces incidence of
NPC
• Male : female = 3:1
Risk factor
• Genetic maker of NPC  HLA-A2
found in Chinease population )
•
•
•
•
•
EB-virus
Nitrosamines
Polycyclic hydrocarbons
Chronic nasal sinus infection
Poor hygiene
(
Anatomy
Pathology
Pathology
• The most common is squamous cell
carcinoma
• Most common position is Rosenmuller
fossa
• Mass lesion
– exophytic mass
– Ulcerative mass
– Infiltrative mass
Histopathology
Histopathology
• Base on predominant histologic type
• WHO type 1 : Squamous cell carcinoma
nonkeratizing
• WHO type 2 : Trasitional cell carcinoma
Histopathology
• WHO type 3 : Undifferentiated
carcimomas
– Lymphoepitheliomas
– Anaplastic carcinomas
WHO type 1
• Squamous cell carcinoma nonkeratizing
– Strong intracellular bridges
– Less keratin production
• Less associate EBV
• 25% of case
• Radioresistant tumor
WHO type 2
•
•
•
•
•
Trasitional cell carcinoma
Not produce keratin
Greater degree of tumor pleomorphism
Most common is papillary morphology
12% of case
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
Tumor Spreading
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,
Local invasion
• Medial : Eustachian tube involvement,
mastoid air cell
• Superior : involve base of skull, throught
foramen lacerum & cavernous sinus
• Inferior : oropharynx
& soft palate
Lymphatic spreading
• Most common is neck node spreading
• Bilateral involvement
• Most common position is upper jugular
node
• Least at submandibular
& submental node
Distance metastasis
• Most common is
– Bone
– Lung
– Liver
• Other sites are rare
Clinical Manifestation
Clinical Manifestation
• Related to location of primary tumor &
course of disease
• Most common complaint is Hearing
loss & lump in the neck
Neck mass
• Most common spread to neck lymph
node
• Complaint neck mass
• Bilateral metastasis to lymph node is
common
Neck mass
• Most common location is Upper jugular
node ( compose of jugular node, spinal
accessory node )
• retropharyngeal node induce headache
Frequency of lymph node
manifestration
•
•
•
•
Upper jugular region
Posterior cervical group
Middle & lower jugular group
Supraclavicular group
Nasal cavity involvement
• Blood-tinge anterior or posteriornasal
drainage
• Obstruction of nasal pathway
• Epistaxis
• Halithosis
• Nasal congest
Ear involvement
• Result from eustachian tube
involvement
• Sensation of ear blockage
• Serous otitis media
• Conductive hearing loss
• Tinitus
Neurologic involvement
• Cranial nerve involvement found 25 28%
• Pain in the neck, facial pain, facial
pareathesia ( CN V )
• Diplopia ( CN VI )
Neurologic involvement
• CN III & IV  late phase
• CN VII & VIII  less involvement
• CN IX, X & XI  can be found
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
Clinical Manifestation
•
•
•
•
•
•
•
•
•
•
Neck mass
Headache
Ear pain
Nasal obstruction, bloody discharge
Facial pareathesia
Dysphagia
Diplopia, strabismus
Facial pain, eye pain
Halithosis
Exopthalmos
68%
58%
52%
48%
22%
16%
14%
12%
12%
2%
Symptom from NPC found in Siriraj hospital 2532
Other sign & symptom
•
•
•
•
•
Weight
Anorexia
low grade fever
Trismus
Nasal regurgitation of fluid
Diagnostic Evaluation
Clinical evaluation
•
•
•
•
History taking
Physical examination
Nasopharyngoscopy
Endoscopic nasopharyngoscopy
Radiologic evaluation
• Plain film head & neck
• CT scan head & neck ( for evaluation &
treatment planning )
• MRI ( if intracranial extension )
Histopathologic evaluation
• Biopsy
• Most common site are roof of
nasophalynx & Rosenmuller fossa
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
Immunology
• Antibody-dependent cellular cytotoxicity
( ADCC )
– Often predict the clinical course of WHO
type 2&3
Clinical Staging
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
Clinical Staging
• N Classification
– Nx
node cannot be assessed
– N0
no regional lymph node positive
– N1
single ipsilateral lymph node size <
3 cm.
Clinical Staging
– N2a single ipsilateral lymph node size
3 - 6 cm.
– N2b multiple ipsilateral lypmh node size
< 6 cm.
– N2c bilateral or contralateral lymph node
size < 6 cm.
– N3
lymph node size > 6 cm.
Clinical Staging
• M classification
– Mx
– M0
– M1
not assessed
no distance metastasis
distance metastasis present
Stage grouping
• Stage I
• Stage II
• Stage III
• Stage IV
T1
T2
T3
T<3
T4
any T
any T
N0
N0
N0
N1
N<1
N 2-3
any N
M0
M0
M0
M0
M0
M0
M1
Treatment
Radiotherapy
• The most proper treatment
• 60 - 70 Gy for 6 - 7 weeks
• 75 Gy if present brain involvement
Radiotherapy
• Complication
– Dental caries
– Otitis media & otitis externa
– Trismus
Chemotherapy
• Control distance metastasis
• Complication
– Hair loss
– Nausea & vomitting
– Weight loss
– Anorexia
Surgery
• Lymph node present after radiotherapy
4 - 6 weeks
• Recurrent lymph node enlargement
Prognosis
Prognosis
• 5 years survival ( A.C. 1965 )
– Stage I
– Stage II
44%
30%
• Radiotherapy + Chemotherapy  good
result
^_^ Thank You ^_^