10a. Nasopharyngeal Carcinoma
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Transcript of 10a. Nasopharyngeal Carcinoma
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Anteriorly -- nasal cavityPosteriorly -- skull base and vertebral
bodies
Inferiorly -- oropharynx and soft palate
Laterally --
Eustachian tubes
Fossa of Rosenmuller
Close association with skull base foramen
Mucosa
Epithelium - tissue of origin of NPC
Stratified squamous epithelium
Pseudostratified columnar epithelium
Salivary, Lymphoid structures
Anatomy
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Incidence
Higher incidence in Chinease & Taiwan
Chinease gene increase incidence of NPC
Age > 40 years
Emigration fromhigh incidence to low incidence
area reduces incidence of NPC
Male : female = 3:1
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Risk factor
1. Genetic maker of NPC HLA-A2 ( found in Chinease
population)
2. EB-virus
3. Nitrosamines
4. Polycyclic hydrocarbons
5. Chronic nasal sinus infection6. Poor hygiene
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The most common is squamous cell carcinoma
Most common position is Rosenmuller fossa
Mass lesionexophytic mass
Ulcerative mass
Infiltrative mass / Endophytic.
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Histopathology
Base on predominant histologic type
WHO type 1 : Squamous cell carcinoma
nonkeratizing
WHO type 2 : Trasitional cell carcinoma
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
Radioresistanttumor
WHO type 2
Trasitional cell carcinoma
Not produce keratin
Greater degree of tumor pleomorphism
Most common is papil lary 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
Anterior : involve hard palate, medial pterygoid plate,
ethmoid & maxillary sinus
Lateral : involve internal jugular V, internal carotid A, CN
IX X XI XII, 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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Lym phat ic 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
LungLiver
Other sites are rare
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Clinical Manifestat ion
Related to location of primary tumor & course of disease
Most common complaint is Hearing loss & lump in the neck
1. Neck Sign / Neck mass
Most common spread to neck lymph node
Complaint neck mass
Bilateral metastasis to lymph node is common
Most common location is Upper jugular node
retropharyngeal node induce headache
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1. Upper jugular region
2. Posterior cervical group
3. M iddle & lower jugular
group
4. Supraclavicular group
Frequency of lymph nodemanifestration
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2. Nose sign
Blood discharge anterior or posteriornasal drainage Obstruction of nasal pathway
Epistaxis
Halithosis
Nasal congest
3. Ear Sign
Result from eustachian tubeinvolvement
Sensation of ear blockage
Serous otitis media
Conductive hearing loss
Tinitus
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4. Neuro log ic sign (Cranial , Ear sign)
Cranial nerve involvement found 25 - 28%
Pain in the neck, facial pain, facial pareathesia ( CN V )
Diplopia ..... ( CN VI )
CN III & IV late phase ..... Ophthalmoplegia
CN VII & VIII less involvement
CN IX, X & XI can be found ..... Dysphagia
Headache
Horners syndrome - cervical sympathetics
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Clinical Mani festation
1. Neck lump 60%
2. Ear (s) plugging & fullness 41%
3. Hearing loss 37%
4. Nasal bleeding 30%
5. Nasal obstruction 29%
6. Head pain 16%7. Ear pain 14%
8. Neck pain 13%
9. Weight loss 10%
10. Diplopia 8%
Symptom & sign of NPC fr equency at diagnostic in Mayo clini c ser ies
Kuala Lumpur 1983, University of Malaya
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1. Neck mass 68%
2. Headache 58%
3. Ear pain 52%
4. Nasal obstruction, bloody discharge 48%
5. Facial pareathesia 22%6. Dysphagia 16%
7. Diplopia, strabismus 14%
8. Facial pain, eye pain 12%
9. Halithosis 12%
10. Exopthalmos 2%
Symp tom from NPC foun d in Sir iraj ho spi ta l 2532
Clinical Mani festation
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Other sign & sym ptom
1. Loss of Weight
2. Anorexia
3. low grade fever
4. Trismus
5. Nasal regurgitation of fluid
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Diagnostic Evaluation
1. History and Physical examination
2. Nasopharyngoscopy / Endoscopic nasopharyngoscopy3. Radiologic evaluation :
Plain film head & neck
CT scan head & neck ( for evaluation & treatment planning )
MRI ( if intracranial extension )
5. Histopathologic evaluation ...... Biopsy6. 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 availableAntibody-dependent cellular cytotoxicity ( ADCC )
Often predict the clinical course of WHO type 2&3
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Clinical Staging
T classification
Tis carcinoma in situT1 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
N Classif ication
Nx node cannot be assessed
N0 no regional lymph node positive
N1 single ipsi lateral lymph node size < 3 cm.
N2a single ipsi lateral lymph node size 3 - 6 cm.
N2b mul tiple ipsi lateral lypmh node size < 6 cm.
N2c bilateral or contr alateral lymph node size < 6 cm.
N3 lymph node size > 6 cm.
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M classification
Mx not assessed
M0 no distance metastasisM1 distance metastasis present
Stage I T1 N0 M0
Stage I I T2 N0 M0
Stage I I I T3 N0 M0
T
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Treatment
1. Radiotherapy
The most proper treatment
60 - 70 Gy for 6 - 7 weeks
75 Gy if present brain involvement
Complication
Dental caries
Otitis media & otitis externa
Trismus
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2. Chemotherapy
Control distance metastasisComplication
Hair loss
Nausea & vomitting
Weight loss
Anorexia
3. Surgery
Lymph node present after radiotherapy 4 - 6 weeksRecurrent lymph node enlargement
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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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