ca Nasopharynx

1. Nasopharyngeal
Carcinoma
Dr. Krishna
Koirala
2016-05-202016-05-20

2. Introduction
• Nasopharyngeal carcinoma is a non -
lymphomatous squamous-cell carcinoma
that occurs in the epithelial lining of the
nasopharynx
• It frequently arises from the pharyngeal
recess (fossa of Rosenmüller)

3. Epidemiology
•Accounts for 85% adult nasopharyngeal
malignancies and 30% pediatric nasopharyngeal
malignancies
•Race : Common in Chinese & North African
people
•Sex : Male preponderance of 3:1
•Age : Bimodal presentation with Small peak
at 15-25 yrs and a large peak at 55-65yrs
•Gross : Proliferative, Ulcerative & Infiltrative
types

4. Etiology
• Genetic
• Commonest in Southern Chinese population
( Mongoloid race)
• HLA – A ,B and DR loci situated on the short
arm of chromosome 6
• Viral : Epstein-Barr Virus
• Environmental
• Exposure to nitrosamines (dry salted fish),
polycyclic hydrocarbons (smoke from incense
& wood)
• Smoking , chronic nasal infection, poor

5. W.H.O. Classification
(Histological)
Type 1:
• Keratinizing squamous cell carcinoma
Type 2:
• Non-keratinizing (transitional)
carcinoma
Type 3:
• Undifferentiated (anaplastic) carcinoma

6. Clinical Features
1. Neck swelling (60%)
• Lateral retropharyngeal LN of Rouviere
• B/L, enlarged jugulodigastric, upper &
middle deep cervical nodes and
posterior triangle nodes
2. Nasal (40%)
• Blood stained nasal mucus, epistaxis,
nose block, foul smelling nasal

7. 4. Ophthalmologic (20%)
• Diplopia & ophthalmoplegia
(involvement of CN III, IV, VI), Proptosis
(orbit invasion) & blindness
(involvement of CN II)
5. Neurologic (20 %)
• Jugular foramen syndrome: CN IX, X, XI
involved by lateral retropharyngeal
lymph node

8. 6. Severe Headache
• Skull base erosion
7. Trotter's triad
• Conductive deafness: Eustachian Tube
block
• Ipsilateral temporo -parietal neuralgia:
Trigeminal nerve involvement
• Ipsilateral palatal paralysis: Vagus
nerve damage

10. Investigations
1. Nasopharyngoscopy & Diagnostic Nasal
Endoscopy
• Mass seen in nasopharynx at fossa of
Rosenmüller
2. Nasopharyngeal tumor biopsy: blind
/under vision
3. F.N.A.C. of neck node: done in occult
primary

11. 5. M.R.I. head & neck: for intracranial
extension.
6. Tests for metastases
• C.T. chest and abdomen, bone scan,
P.E.T. scan, liver function tests
7. Serologic tests
• Immuno-fluorescence for IgA antibodies
to Viral Capsid Antigen, Ig G antibodies
to Early Antigen

12. Diagnostic Nasal Endoscopy

13. Computerized Tomogram Scan

14. CT scan: retropharyngeal
node

15. CT scan: Infratemporal fossa
& orbit involvement

16. CT scan: Sella involvement

17. Magnetic Resonance Imaging

18. M.R.I.: intracranial extension

19. Endoscopic Biopsy

20. Whole body bone scan

21. Positron Emission Tomography

22. 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

23. 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

24. 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

25. Treatment modalities
1. Teletherapy or External beam
radiotherapy
2. Brachytherapy
3. Chemotherapy
4. Surgery
5. Immunotherapy against E.B.V.

26. External beam irradiation
• 2 lateral fields: nasopharynx, skull base &
upper neck sparing temporal lobe, pituitary
& spinal cord
• 1 anterior field: lower neck; sparing spinal
cord & larynx

27. 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 the catheter or moulds & inserted
into nasopharynx

28. Interstitial Brachytherapy

29. Intracavitary Brachytherapy

30. High Dose Rate Brachytherapy

31. Chemotherapy
Drugs used
1. Cisplatin
2. 5-Fluorouracil
Indications
1. Radiation failure
2. Palliation in distant metastasis

32. Surgery
1. Nasopharyngectomy, Cryosurgery : for
residual or recurrent tumor
2. Radical neck dissection: for radio-
resistant neck node metastasis
3. Palliative debulking: for T4 tumors
4. Myringotomy & grommet insertion: for
persistent otitis media with effusion

33. Radical neck dissection &
Interstitial Brachytherapy

34. Treatment Protocol
T1 = External Radiotherapy (6500 c Gy)
T2 = External Radiotherapy (7000 c Gy)
T3 & T4 = Radiotherapy + Chemotherapy →
Brachytherapy / Salvage surgery if
required
N0 = External Radiotherapy (5000 c Gy)

35. Prognosis
• W.H.O. Type 2 & 3 carcinomas have good
response to radiotherapy & better
survival rates
• Average 5 year survival rates for treated
patients
Stage I = 95 – 100 %
Stage II = 60 – 80 %
Stage III = 30 – 60 %