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Nasopharyngeal carcinoma
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Nasopharyngeal Carcinoma

nasopharyngeal carcinoma Pre Mx

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Nasopharyngeal Carcinoma

  1. 1. Premanagement in Carcinoma Nasopharynx Dr Sasikumar Sambasivam Moderator: Dr Jaishree Goyal
  2. 2. CT Anatomy Fossa of Rosenmuller
  3. 3. Sphenoidal sinus Carotid canal
  4. 4. Parapharyngeal Space • The parapharyngeal space is located deep within the neck lateral to the pharynx and medial to the ramus of the mandible. • Shape of an inverted pyramid with the floor at the skull base and it’s tip at the greater cornu of the hyoid bone • Two compartments : – Prestyloid – Retrostyloid
  5. 5. Lymphatic Drainage • • • • • Richest lymphatic plexus in the head and neck region. Submucosal lymphatics congregate at the pretubal region – “pretubal plexus”. These then pass on to the retropharyngeal nodes as 8 -12 trunks which decussate in the midline. Lymphatic trunks pierce the level of the base of the skull and run between the pharyngobasilar fascia and the longus capitis. The lymphatic trunks drain in three directions: – To the retropharyngeal nodes. – To the posterior triangle nodes and the confluence at the 11th, cranial nerve and the jugular lymph node chains, situated at the tip of the mastoid. – To the Jugulo-digastric nodes
  6. 6. RPLN • The retropharyngeal nodes are present in two groups. – Median group. – Lateral group. • The median group consists of 1 - 2 nodes interconnected in the midline. • The lateral group consists of 1- 3 nodes located between the lateral aspect of the posterior pharyngeal wall and the carotid artery. • These nodes are present from the vertebral levels C1- C3. • The superior-most lymph node of the latter group is also known as the node of Rouviere. • This node lies in front of the arch of the Atlas being separated from it by the longus colli muscle.
  7. 7. RPLN INVOLVEMENT IN NPC B/L RPLN
  8. 8. Incidence
  9. 9. Incidence: Sex
  10. 10. CAUSES • • • • Multifactorial Viral --- EBV genetic – chr 14 ,15 ,16; HLA A2,HLA B SIN2` Environmental– poor ventilation,exposure to dust,smoke • Diet-salted fish , dimethylnitrosoamine
  11. 11. Genetic path Normal Epithelium Deletion of Chromosomes 3p and 9p Low Grade Dysplasia Inactivation of Chromosome p14, 15 and 16 High Grade Dysplasia EBV infection Gain Chromosome 12 Deletion 11 and 13 Invasive Carcinoma P53 Mutation Metastatic Carcinoma
  12. 12. Local Invasion Nasal cavity & PNS Base of Skull, Clivus Orbital invasion Lateral Parapharyngeal space Middle ear cavity Oropharynx (tonsillar pillars) C1 vertebrae ANT
  13. 13. Nodal spread
  14. 14. Nodal Spread Clinically palpable
  15. 15. Hematogenous Spread • 3% @diagnosis, 18-50% during the course. • Mets in Advanced neck node states (N3). If in lower neck, chances are higher. • Bone > Liver> Lungs (A study by Hui et al.)
  16. 16. Clinical Features • • • • Most common: Asymptomatic cervical lymphadenopathy (87%) MC node involved is the upper posterior deep cervical (direct drainage from the lateral pharyngeal),parapharyngeal,and jugulodigastric nodes. The midjugular and midposterior cervical nodes are the next most commonly involved, followed by the lower jugular and supraclavicular nodes Other presenting symptoms: – Epistaxis (73%),Nasal twang to speech – Unilateral serous otitis media ( 62%) – Cranial nerve palsy(20%): Multiple inv; 2 syndromes – Sore throat : Oropharyngeal extension – Pain: Compression of Vth cranial nerve ( facial pain) – Trismus: Mandibular nerve involvement or pterygoid muscle invasion – Dermatomyositis (1%)
  17. 17. Cranial Nerve involvement 50 45 40 35 30 25 20 15 10 5 0 I II III IV V VI Lederman et al VII VIII IX Leung et al X XI XII
  18. 18. CN Syndromes in NPC  The Petrosphenoidal syndrome of Jacod: • unilateral neuralgia of the trigeminal (V) • unilateral ptosis (III), • complete ophthalmoplegia (III, IV, and V) • amaurosis (II).
  19. 19.  Syndrome of Retroparotid Space of Villaret: • difficulty in swallowing (IX and X); • perversion of taste in the posterior third of the tongue (IX); • Sensory issues in mucous membrane of the soft palate, pharynx, and larynx; respiratory and salivary problems (X); • hemiparesis of the soft palate; paralysis and atrophy of the trapezius and sternocleidomastoid muscles (XI) • unilateral paralysis and atrophy of the tongue (XII)+/-Horner syndrome(Cerv symp chain)
  20. 20. • • • • Work up: History and Clinical examination incl. Ear FOE Basic Investigations: CBC,CXR,LFT Staging: – – – – – MRI of Nasopharynx or CT USG Abdomen CT thorax /upper abdomen PET scan Bone Scans(for N3 status) • Other Investigations – EBV Serology-Ig A ,Anti VCA titres,EBV DNA levels
  21. 21. Extn into cavernous sinus Both FOR inv. MR IMAGES Cavernous sinus inv with FO Expansion of cavernous sinus
  22. 22. Staging • Several staging systems are in use: – Complex anatomy and spread patterns – Lack of international consensus: • Separate Chinese, Hong Kong and American staging systems • Systems available: – – – – – Fletcher (1967) Ho’s staging (1978) IUAC (1988) Huaqing staging (1994) AJCC(2010)
  23. 23. Comparison System Staging T1 Fletcher (1967) Ho (1978) IUAC (1988) Huaqing (1994) T2 T3 T4 < 1 cm diameter > 1 cm but confined to nasopharynx Beyond nasopharynx Involving skull base or cranial nerves Confined to nasopharynx Extending to nasal fossa or oropharynx Bone/ Cranial nerve/ orbital / hypopharyngeal / infratemporal fossa involvement NA Limited to one site in nasopharynx Extending to two sites in nasopharynx No bony destruction Bony destruction including eustachian tube Limited to nasopharynx Involving the nasal cavity, oropharynx, anterior cervical vertebrae, PPS before SO line Pterygoid process / posterior cranial nerve / posterior cervical vertebrae / BOS / PPS beyond SO line Infratemporal fossa / cavernous sinus / PNS / direct invasion of C2 or C1 / anterior cranial nerves
  24. 24. Ho’s vs AJCC 2010 HO AJCC T1 Tumor confined to the nasopharynx Tumor confined to the nasopharynx, or e/t oropharynx and/or nasal cavity without parapharyngeal extension T2 Tumor extended to the nasal fossa, oropharynx, or adjacent muscles or nerves below the base of the skull  Tumor with parapharyngeal extension T3 Tumor extending beyond T2 limits: T3a:Bone involvement below the base of the skull. T3b:Involvement of the base of the skull T3c:Involvement of the CN(s) T3d:Involvement of the orbits, laryngopharynx (hypopharynx), or infratemporal fossa - Tumor involves bony structures of skull base and/or paranasal sinuses T4 Tumor with intracranial extension and/or involvement of cranial  nerves, hypopharynx, orbit, or with extension to the infratemporal fossa/masticator space
  25. 25. A study:Staging of nasopharyngeal carcinoma: Evaluation of N-staging by Ho and UICC/AJCC systems A.W.M. Lee, W. Foo, Y.F. Poon, C.K. Law, D.K.K. Chan, S.K.O, S.Y. Tung, J.H.C. Ho Ho's system was superior in predicting distant failures, while the UICC/AJCC system was superior for nodal failures. N-staging can be further optimized by a newly proposed system incorporating fixity (movable versus fixed), level (upper-mid versus lower), size (greatest diameter ⩽6 cm versus >6 cm), and laterality (unilateral versus bilateral) as staging criteria.
  26. 26. AJCC system: T staging • T1: Tumor confined to the nasopharynx ,oropharynx or nasal cavity • T2: Tumor with parapharyngeal extension • T3: Tumor involves bony structures of skull base and/or paranasal sinuses • T4: Tumor with intracranial extension and/or involvement of cranial   nerves, hypopharynx, orbit, or with extension to the infratemporal fossa/masticator space
  27. 27. T Staging T1 T2
  28. 28. N staging • NX: Status cannot be assessed • N0: No regional lymph node metastasis • N1: – Unilateral metastasis in lymph node(s), < 6 cm in greatest dimension, above the supraclavicular fossa • N2: – Bilateral metastasis in lymph node(s), < 6 cm in greatest dimension, above the supraclavicular fossa • N3: – N3a: Metastasis in a lymph node(s) >6 cm – N3b: Extension to the supraclavicular fossa Ho’s Triangle
  29. 29. STAGING GROUP Stage III includes patients with T 1 –T2 disease with bilateral neck nodes or patients with T3 disease unilateral or bilateral neck nodes. Stage IVA includes patients with T4 disease while IVB includes patients with N3 disease Stage IVC stands for distant mets.
  30. 30. Pathology • Some authors consider carcinomas to be of two types: – Keratinizing – Non keratinizing • Others consider carcinomas to be of 4 types: – – – – Keratinizing Squamous Non Keratinizing Squamous Lymphoepithelioma Undifferentiated carcinomas • WHO 3 types: – Type I : SCC 20% -- elderly, less EBV titres, best prognosis – Type II : Non Keratinizing carcinoma 30-40% – Type III : Undifferentiated carcinoma 40-50%
  31. 31. Endemic NPC • • • • • • • • • Known to occur in China, Hong Kong, South Eastern Asia, Greenland Associated with EBV virus infection In India similar pathology seen in Kashmiris. Present a decade younger. Not associated with smoking or alcohol consumption WHO II and III Associated with more advanced disease at presentation Nodal stage also more advanced and more frequently involved. Both chemo and radio sensitive – Histologically more vascularized (Better Rx response) – Greater % of cell in the growth fraction. • • Better loco regional control and survival than sporadic variants. Several markers for predicting biological behavior
  32. 32. Prognostic factors • • • • Most important Nodal status F/b T stage Parapharyngeal extension is associated with a poorer prognosis. A Chinese series found that 4th cranial nerve involvement – poor prognosis. Nodal disease status: – Bilateral cervical lymphadenopathy – Supraclavicular lymphadenopathy – Lymph node fixity • Lymphoepithelioma histology & undifferntiated histology: better local control for T2 and T3 (Perez CA, Devineni VR, Marcial-Vega V, et al) • Molecular markers: – Ki -67 over expression – P 53 – E – cadherin expression
  33. 33. Thank You.
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nasopharyngeal carcinoma Pre Mx

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