Nasopharyngeal cancer Flashcards
What are the risk factors for NPC
- Diets high in preservatives (salted fish, eggs, vegetables)
- First degree relatives have a 6-8X higher risk than controls
- Syndrome: Dermatomyositis (patients have approximately 10% risk of developing NPC)
Which site in the nasopharynx does NPC most frequently occur?
Fossa of Rosenmuller: Recess located behind the torus tubarius
What is the WHO classification of different histological subtypes of NPC?
Keratinizing squamous cell carcinoma
Nonkeratinizing carcinoma
- Differentiated
- Undifferentiated
Basaloid squamous cell carcinoma
What are the clinical features of NPC?
Most patients are symptomatic at presentation
• Less than 1% are asymptomatic
– Incidental finding of nasopharyngeal mass on imaging
– EBV serology screening
Most common 2 symptoms: • Palpable neck lump – Due to metastatic cervical lymph nodes – Commonly located in superior aspect of neck – Level 2, 5a – Commonly matted, firm • Blood stained saliva or sputum – Blood from tumour gravitates and mixes with saliva or sputum
Nasal symptoms
– Nasal obstruction
– Blood stains in sputum or saliva
– Epistaxis is not common in NPC as tumour is located in post nasal space
Otologic symptoms
– Conductive hearing loss –> Eustachian tube dysfunction results in serous otitis media
– Unilateral Tinnitus
Presence of unilateral serous otitis media in an adult should raise suspicion of NPC!
Neurological symptoms
– CN6 most commonly involved –> Unilateral lateral rectus palsy – squint and diplopia
– CN5 next most common
• involvement through foramen lacerum
• Facial pain, high neck pain or paraesthesia
– CN9,10,12
• Jugular foramen syndrome
• Direct tumour extension or involvement of lateral retropharyngeal lymph
nodes
– Systemic metastases
– Bone, lung, liver
What is the clinical examination needed for NPC?
- Nasoendoscopy
– Most commonly exophytic mass in post nasal space
– Less commonly ulcerative
– 10% of NPC are submucosal and not visualised on the scope
– Mass is friable, contact bleeding - Cervical lymph node examination
- Otoscopy to look for OME
- Cranial nerve examination
What are the investigations needed for NPC?
- Post nasal space biopsies
- Clinic procedure performed under endoscopic guidance
- For tissue histology - Fine needle aspiration cytology of palpable lymph nodes
- Audiogram
- EBV serology
- Anti EBV VCA IgA
- Anti EBV EA IgA
5. Imaging: • To assess primary tumour: MRI PNS and Neck • To assess systemic involvement – CT Thorax, Liver – Bone scan OR – CT-PET
Where does NPC spread anteriorly?
Choana and nasal cavity
Where does NPC spread inferiorly
Oropharynx and hypopharynx
Where does NPC spread laterally?
Parapharyngeal space and infratemporal fossa (sinus of Morgagni)
Where does NPC spread superiorly?
- Foramen lacerum and foramen ovale (direct route of spread to middle cranial
fossa causing diplopia or ophthalmoplegia. - Spread along the posterior skull base involves jugular foramen (CN IX, X, XI), hypoglossal canal (CNXII) or sympathetic nerve (Horner syndrome).
What is the treatment of NPC?
NPC is primarily treated by Radiation therapy.
Stage 1 disease
– Single modality
– Radiation therapy
Stage 2, 3, 4 disease
– Multimodality
– Concurrent chemoradiation therapy
– +/- Induction chemotherapy
What are the common side effects of Radiotherapy?
Early complications – Mucositis – Xerostomia – Sinusitis – Crusting
Late complications – Otitis media with effusion – Sensorineural hearing loss – Trismus – Osteoradionecrosis – Carotid artery blowout
When is surgery indicated in NPC?
Mainly in recurrent or persistent local or regional disease
Recurrent nodal disease –> Radical or extended neck dissections
Recurrence in nasopharynx
– Surgical treatment: nasopharyngectomy
– Other options: brachytherapy, RT
