2. Introduction
NPC is a squamous-cell carcinoma arising from epithelial lining of the
nasopharynx.
Most common malignancy in the nasopharynx
Nasopharyngeal malignancies
SCCA (nasopharyngeal carcinoma)
Lymphoma
Salivary gland tumors
Sarcomas
3. Race: More in Chinese & North African people
Sex: Male preponderance of 3:1
Age: -Its incidence rate starts to rise after the second decade of life.
-Median age is 50 years .
Gross: Proliferative, Ulcerative & Infiltrative types
The most common location is Fossa of Rosenmuller
Introduction
8. Lymphatic drainage
Lateral Retropharyngeal L.N also called as
nodes of Röuviere, are the first nodes in the
lymphatic drainage of Nasopharynx.
Extends from base of skull to C3 cervical
vertebra.
12. Etiology
Genetic:
Commonest in Chinese population.
Genomic studies have revealed 3 HLA locus.
HLAA2; HLA B46; HLA B17 are associated with increased risk of NPC
Viruses:
EBV- well documented viral “fingerprints” in tumor cells and also anti-
EBV serologies with WHO type II and III NPC
HPV - possible factor in WHO type I lesions
13. Etiology
Environmental:
salted fish food contain nitrosamines: carcinogen
Lack of vit C in diet
Burning of incense & woods: polyaromatic hydrocarbon:carcinogen
Alcohol consumption & Cigarette smoking
occupational exposure to dust, smoke, and chemical fumes
14. W.H.O. classification of NPC
1- keratinizing squamous cell ( 25% )
2. Type II is non-keratinizing squamous carcinomas 12 %
3. Type III is the undifferentiated carcinomas 60 %
22. Diagnostic Evaluation
High index of suspicion required for early diagnosis
• Clinical evaluation
• Radiological evaluation
• Laboratory evaluation
• Histopathological evaluation
24. Diagnostic Evaluation
Clinical examination of nasophyrnx:
Indirect nasophayrngoscopy with mirror
Direct nasopharyngoscopy with fiber-optic scope
Rigid 0 and 30* Hopkins rod endoscope
27. Diagnostic Evaluation
Radiological Evaluation
Help to make the correct diagnosis
Help To know the disease stage
Help to determine the target volume of radiotherapy
Help to evaluate the treatment results
Follow-up
28. Diagnostic Evaluation
CT Scan
Extent of tumor
Neck node involvement
Skull base erosion
MRI – radiologic modality of choice
Determine if any intracranial extension of the tumour involves the brain
parenchyma or the cavernous sinus
MRI > CT for displaying both superficial and deep nasopharyngeal soft tissue
and for differentiating tumor from soft tissue.
35. Diagnostic Evaluation
Laboratory evaluation
CBC,
LFT’s
Special diagnostic tests (for types II & III)
IgA antibodies for viral capsid antigen (VCA)
IgG antibodies for early antigen (EA)
Antibody Dependent Cellular Cytotoxicity assay.
36. Diagnostic Evaluation
Biopsy : first necessary investigation for NPC
Endoscopic biopsy : Ideally it shuold be carried out
during the patient’s ist outpatient visit in suspected
cases.
The most common sites are roof of nasopharynx and
fossae of Rosenmuller.
FNA biopsy : should be done in suspicious neck
lump.
Histopathological Evaluation
37. T.N.M. staging
T1 = Tumour confined to the nasopharynx or extends to oropharynx and/or nasal cavity
T2 = Tumour with parapharyngeal extension
T3 = invasion of bony structures or P.N.S.
T4 = intracranial, involvement of orbit, cranial nerves, infratemporal fossa,
hypopharynx
38. T.N.M. staging
N0 = no evidence of regional lymph nodes
N1 = unilateral N2 = bilateral
(Both are above supraclavicular fossa & < 6 cm)
N3 = > 6 cm or in supraclavicular foss
N3a- greater than 6 cm in dimension
N3b- extension to the supraclavicular fossa
M0 = no evidence of distant metastasis
M1 = distant metastasis present
39. 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
41. Treatment
The management of NPC is unique for two reasons:
1-Tumor is in a relatively inaccessible location
2-Tumors is extremely radiosensitive
42. Treatment
Treatment Modalities
Radiotherapy (modality of choice)
Chemotherapy : combination with radiotherapy in advance
disease
Surgery :To salvage local and regional failure
43. Radiotherapy
Modes of radiotherapy
Teletherapy or External beam radiotherapy :Radiation beams projected to the
target area through skin
Brachytherapy :uses radioactive material which are placed in close contact with
tumor tissue .
Interstitial: Radioactive source inserted into tumor tissue
Intracavitary: Radioactive source placed inside catheter or moulds & inserted into
nasopharynx
44. Radiotherapy
Modes of radiotherapy
Intensity modulated radiation therapy (IMRT): recent development in
delivery of radiotherapy where maximum dose can be delivered to the tumor but
saving important normal structure
Stereotactic radiosurgery
delivers radiation therapy precisely to the tumor using a machine called a gamma
knife. This can be used to treat tumors that have invaded the base of the skull, or
tumors that have recurred at the base of the brain or skull.
45. primary treatment
Radiotherapy
External beam radiotherapy is most commonly delivered by opposed lateral fields
to encompass the primary tumor and upper neck
Treatment field has to cover nasopharynx ,paraphryngeal space ,oropharynx
,skull base,sphenoid sinus ,posterior ethmoid ,posterior half of maxillary sinus
Bilateral Cervical nodal irradiation is mandatory even in clinically node-negative
patients
47. primary treatment
Radiotherapy
65-70 GY for primary
65-70 GY for positive L.N
50-60 GY for negative L.N
It should be delivered single fraction daily ,five per week without interruption .
Proper shielding of all critical structures as well as surrounding normal tissue is
important.
48. primary treatment
Radiotherapy
Radiation boosts in the form of intracavitary brachytherapy for T1 to T2 lesions
have been used to improve local control rates
Stereotactic radiosurgery boosts may also be given for T3 and T4 lesions.
49. primary treatment
Chemotherapy
Chemotherapy is believed to act as radiosensitizer.
It helps to reduce the chance of distant metastasis.
For locally advanced disease (stage III-IV ) chemotherapy in addition to
radiotherapy appears to improve overall results.
Combination chemotherapy produces better responses
combination cisplatin/5-flurouracil is the most widely used
Indicates that concurrent chemoradiotherapy has a major role in advanced stage
NPC
51. primary treatment
FOLLOW-UP PLAN:
Close monitoring of the progress during and after treatment is necessary .
Follow-up endoscopy at 6–8 weeks and imaging at 10–12 weeks after
completion of radiotherapy or chemoradiotherapy is recommended to document
tumour responses.
malignancy detected after 10 weeks usually represents viable tumour and salvage
treatment is indicated
52. primary treatment
FOLLOW-UP PLAN:
Close monitoring of the progress during and after treatment is necessary .
The majority of relapses occur in first three years .
After primary treatment, patient should be seen :
Two-monthly for the first year
Three –monthly for 2nd and third year
Six –monthly thereafter.
Lifelong follow-up is needed as very late recurrence may also occur
53. primary treatment
FOLLOW-UP PLAN:
The response of local disease is best followed up by repeated nasoendoscopy .
Post-treatment biopsy indicated if there is any residual swelling at the primary
site .
Imaging is often needed to evaluate regional disease .
54. Salvage treatment
Treatment of recurrence
Recurrence at the primary site can be treated by surgery or re-irradiation.
Further dose of ERT may be considered.
Brachytherapy is preferred.
Cervical nodal recurrences are best treated by surgery .
55. Salvage treatment
surgery
• Due to deep location of nasopharynx, and anatomic proximity to critical
structures, radical surgery is typically not used
• Limited to
biopsy
Neck dissections for persistently enlarged lymph nodes
Nasopharyngectomy in persistent or recurrent disease
58. Salvage treatment
Inferior approaches :
Transplatal :For localized tumour in
the lower part of the posterior wall of the nasopharynx
Mandibular swing
59. lateral infratemporal fossa approach: When the main tumour
bulk is located in the paranasopharyngeal space close or
lateral to internal carotid artery
60. Salvage treatment
Surgical salvage for neck disease:
If a neck node persists in the absence of distant metastasis
,radical neck disection (RND)should be performed