Download Nasopharyngeal carcinoma

Nasopharyngeal
carcinoma
ABU SUFIAN HASSAN AHMED EL HAJ
(E.N.T. Consultant)
Associate Professor Department of Surgery
Faculty of Medicine, University of Gezira
ANATOMY
ANATOMY
Introduction
The Nasopharynx has a cuboidal
shape, the lateral walls are formed by the
Eustachian tube and the fosse of
Rosenmuller.The roof, sloping downwards
from the anterior to posterior, is boarder by
pharyngeal Hypopharyx, pharyngeal tonsil,
and pharyngeal bursa with the base of
skull above.
Anteriorly, the Nasopharynx abutted the
choanae and nasal cavity,
posterior boundary is formed by the muscle
of posterior pharyngeal wall.
Inferiorly, the Nasopharynx ends at an
imaginary horizontal line formed by the
upper surface of the soft palate and the
posterior pharyngeal wall.
Pathology of the Nose and
Nasopharynx
1. Congenital malformations.
2. Inflammation.
3. Infection and Granulomatus Diseases
4. Trauma.
5. neoplasm
1- Congenital malformations
1.Choanal stenosis or atresia.
2.Involvmemt in cleft palate.
3.Saddle nose in hypertelorism.
1.Choanal stenosis or atresia.
2. Inflammations & Infections.
A. Acute Rhinitis or Rhino sinusitis
B. Chronic Rhinitis or Rhino sinusitis
- Nonspecific,
- Specific
Cont.
A. Acute Rhinitis or Rhino sinusitis
Inflammation of the nasal mucosa with or
with out Inflammation of the PNS
mucosa due to:
(i) Allergy
(ii) Viral infection
(iii) Bacterial infection
Cont.
B. Chronic Rhinitis or Rhino- sinusitis:
i- Chronic Non specific infection as,
Bacterial infection
ii- Chronic specific infection as,
1- Tuberculosis
2- Leprosy
3- Scleroma
4- Fungal infections as,
* Aspergillosis
* Rhinosporidiosis
* Candidiasis
5- Leishmaniasis
Nasal polyposis
a. Allergic
i- Allergic rhinitis
ii- Vasomotor rhinitis
* bilaterally
* ethimoids
* associated ;Asthma, penicillin&
aspirin allergy.
Cont. nasal polps
Non –allergic including antro-choanal polps
4. Trauma.
5.Neoplasm
Benign tumors
Malignant tumors
Benign tumors
1-Epithelial
i- Papilloma : HPV , EBV
a- Squamous ,fungiform : wart , in
vestibule & septum.
b- Inverted Papilloma (Tansitional) lateral
wall , high recurrence , 10% malignant
transformation (intermediate tumour)
Benign tumors 1-Epithelial Cont.
c- Keratoacanthoma. (exposed skin to sun
___scc)
d- Adenoma ( mucous glands).
Malignant tumors Epithelial
Carcinoma
a. Scc
b. Tansitional – type
c. Adenocarcinama
d. Anaplastic
Malignant Melanoma
2- Vascular
Benign tumors
a. Capillary haemangioma
b. Juvenile angiofibroma
c. Haemangiopericytoma (intermediate
tumour)
Malignant tumors
Haemangiopendothelioma(Angiosarcom)
3- Lymphoid tissue
i- Lymphoma
II- Myeloma
4- Neurogenic
i.Neurofibroma
II. Nasal glioma (ectopic glial tissue)
iii. Olfactory neuroblastom
iv. Neurilemmoma (schwannoma) –nerve
sheath-
5- Bone and connective tissues
Benign tumors
a. Osteoma
b. Chondroma
c. Ossifying fibroma
Malignant tumors
a. Fibrosarcoma
b.Chondrosarcoma
c. Osteogenic sarcoma
Tumours of the Nasopharynx
Benign tumors
a. Tansitional – type papilloma
b. Adenoma
c. Cavernus haemangioma
d. Juvenile angiofibroma
Malignant tumors
1-Carcinomas
a. Anaplastic carcinoma including
(lymphoepitheoma)
b. Squamous cell carcinoma
c. Tansitional – type carcinoma
d. Adenocarcinama
.
Malignant tumors NPx
2-Lymphoma and Myeloma
3-Sarcomas
a.Rhabdomyosarcoma
b. Fibrosarcoma
c. Chondrosarcoma
4- Chondroma arising from the base of skull
Nasopharyngeal carcinoma (NPC) is
epidemiologically and histologically
different from other head and neck
cancers5
. It is an, Epstein-Barr Virus (EBV)–
associated carcinoma. It has been
demonstrated that EBV is harbored in
almost every NPC tumor, regardless of the
degree of differentiation and geographic
distribution.2, 3, 4,5
NPC highest incidence in the World is •
in Southeast China, Hong Kong and
Mediterranean basin.
North Africa and Mediterranean basin. It
commonly has poorly differentiated or
undifferentiated pathology with a high
incidence of cervical lymph node
metastasis and great radiosensitivity and
chemosensitivity1
Age distribution ranged from 11 to 82 •
years with mean age 44.25 years and
median of 46 years. The male to female
ratio was 2:1.
Table (2): Types of malignancies encountered at INMO.
No.
Type
Frequency
Percentage
1
Hematology
633
23.8
2
Breast
501
18.8
3
GIT
367
13.8
4
Head and neck
314
11.8
5
Gynecology
310
11.6
6
Urology
222
08.3
7
Childhood tumors
093
03.5
8
Soft tissue sarcoma
081
03.0
9
Bone tumors
066
02.5
10
Skin
047
01.8
11
Others brain ,lung)
28
01.1
2662
100%
Total
Graph 1: Sex distribution
sexsex
male
male
female
female
33.3%
Female
MALE
66.7%
On the other hand it has low incidence in
Europe, Japan and North America.(JCO,
Abdelrahhim). Most cases presents with
local disease and cervical
lymphadenopathy.
Nasopharyngeal cancer (NPC) is a
common cancer in Sudanese and affects
men more than women.
Sudanese usually presents late with
cervical lymphadenopathy.
The commonest histological types were
WHO type II and III.
CLINICAL PRESENTATIONS
NPC characterize by non-specific
presentation. Most cases presents with
local disease and/or cervical
lymphadenopathy, approximately 60-90%
of patients present with cervical nodal
metastasis3, 11, 12, 13.
Patients with nodal metastasis have,
higher rates of treatment failure
Symptoms related to primary tumor include
ear pain, nasal tone speech, hearing loss,
trismus and symptoms and signs of other
cranial nerves involvement 14.
Larger tumors may cause nasal block and
bleeding. In Sudan NPC is the leading
cancer in men15.
CLINICAL PRESENTATIONS
The patients had different clinical presentations
The most common clinical presentation in the
order of frequency was
Cervical lymphadenopathy(73.2%). .1
Nasal block(33.9%). .2
Hearing impairment(27.7%). .3
Epistaxis(22.3%). .4
Ear pain(18.8%). .5
Palatal paralysis(14.3%). .6
1- NECK MASS
Cervical lymph nodes
- More than 75%
- unilateral or bilateral
- Jugulodigastic L N
2. NASAL.
> 40% Of patients may presented with
Nasal symptoms, in the forms of:
- Nasal bleeding
- Nasal mass.
- Nasal discharge.
. - Nasal deformity
- Nasal obstruction.
3- EAR
> 30% Of patients may presented with
otological symptoms, Include
- Ear pain,
- Hearing loss,
- Ear discharge
( Secrotory otitis media)
Eustachian tube obstruction
CRINIAL NERVES
Table (1) : Cranial nerve injury
No
Nerve
No. of patients
1
Optic
2
Occulomotor
07
6.25
3
Trigeminent
09
8.03
4
Abducent
11
9.82
5
Facial
09
8.03
6
Glossopharngeal
16
14.29
7
Vagus
03
2.67
8
Hypoglossal
09
8.03
65
58.03
Total = ( 112 )
01
Percent %
0.89
DISTAL METASTASIS
lung
bone
liver
2%
1%
1%
96%
2
Missing
96%
INVESTIGATIONS
1- RADIOLOGY
-X-ray
soft tissue lateral view of the neck.
- CT scan
nasophynx
- MRI
CRINIAL NERVES
2 .ENDOSCOY
3. GENERAL
4. BODY SCAN
World Health Organization (WHO) classifies
NPC into 3 types according to histology.
Keratinizing squamous cell carcinoma is
WHO type 1. Non keratinizing carcinoma
is WHO type 2. Undifferentiated
carcinomas and lymphoepithelioma are
WHO type 3.
Risk factors in endemic areas
EBV-association is reported to be strongly
associated with types 2 and 33, 4.
Risk factors in endemic areas include :
i.EBV,ii salty diet, iii. volatile nitro,iii. HLA
antigen haplotype9.
However, in non-endemic regions disease
is associated with alcohol and tobacco use9
Stage:
Locally advanced and metastatic disease
was observed in 85.4% of patients.
Locally advanced disease includes all cases
with any cranial nerve palsy,
cervical lymphadenopathy or T4 lesions.
Common sites for metastasis were bone,
lung and Liver.
SUMMARY
NPC is common in Sudanese population
and tends to affect younger age group with
male predominance. Most cases present
with nodal involvement (CLN)or locally
advanced disease. Patients had similar
features of histology seen in endemic
regions with predominance of WHO-3
histology type
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