Cancer of the nasopharynx

Cancer of the nasopharynxBYDr , Ibrahim Habib BarakatM.D.( E.N.T.)salamatuall@yahoo.comwww.facebook.com/Dr.Ibrahim.Barakat

Epidemiology of nasopharyngeal ca.Incidence : Rare o.6 per 100,000 l yr in U S ASouthern China is 50 times > U S A Age : 4TH to 5th decade Sex : male : female 2 to 3 : 1Etiology : Multifactorial : Viral , dietry , occupational , cigarette smoking

Viruses & human malignancies

Anatomy of the nasopharynxAnterior : post. Nasal choana , nasal septumPost : 2 cervical vertebrae , prevertebral and buccopharyngeal fasciaSup: basisephenoid , basiocciptInf : sup . Surface of soft palateLateral : maxilloph. Space , pterigoid plate, paraph. Spacepharynx

Fossa of RosenmullerEustachian tube opens in lateral wall of the nasopharynex , surrounded by torus tubarius ( cartilagenous elevation ) . A recess behind torus tubarius is called Rosenmuller fossa . Clinical importance : location for cancer to arise .

Blood supply of nasopharynxArterial : branches from E.C.A.Venous : pharyangeal plexus to I.J.V.Nerve supply of nasopharynxBranches from cranial nerve V2 , IX , X .

Sympathetic n.

Lymphatic drainage of the nasopharynxRetropharyngeal .Parapharyngeal .Jugular chain .L . N . Of spinal accesory chain in posterior triangle.Supraclavicular L . N .Contralateral neck.Epithelial lining of nasopharynx60% of nasopharynx is lined with Stratified squamous epithelium

Spread of nasopharyngeal ca.Ant : nasal cavity , paranasal sinuses , pterigopalatine fossa, orbital apex .Inferiorly : oropharynx.Superiorly : skull base , sphenoid body & sinus.Laterally : paraph. , pterigoid structures.

Pathology of tumors of nasopharynxEpithelial benignEpithelial malignantPapillomaPleomorphic adenomaOncocytomaBasal cell adenomaEctopic pituitary adenomaNasopharyngeal carcinoma.1- Squamous cell ca. 2- Non keatinizing ca. 3- Undifferentiated ca.Adenocarcinoma.Papillary adenocarcinoma.Mucoepidermoid carcinoma.Adenoid cyctic ca.Polymorph low grade adeno ca. Pathology of tumors of nasopharynxNon epithelial BenignNon epithelial malignantAngiofibroma.Fibroma.Haemangioma.Osteoma.Haemangioma.Haemangiopericytoma.Paraganglioma.Meningioma. Craniopharyngioma.Angiosarcoma.Kaposi sarcoma.Malignant haemagiopericytoma.Fibrosarcoma.Rabdomyosarcoma.Osteosarcoma.Malignant nerve sheath tumor.Chondrosarcoma.Chordoma.Malignant melanoma.Malignant lymphoma.2ry tumors

Tumour like lesions1- Cyst.2-Heterotopic pituitary tissue.3- Menengocele , meningoencephalocele.4- fibroinflammatory pseudotumour,5- infective granuloma.6- wegner,s granuloma.7- Pseudoepthliomatous hyperplasia.8- granuloma pyogenicum.9- lymphoid hyperplasia.10- oncocytic metaplasia.

Symptoms of nasopharyngeal caNeck mass , blood tinged mucus . EpistaxisNasal obstructionChange of voicePain Ozona - otalgia headacheDecreased hearing Cranial neuropathiesHallmark of terminal diseaseSevere pain & headache ((skull base erosionCranial neuropathies in N.PH.caCn VI most frequently affected .Cn ( II toVI ) Jacods syndrome due to cavernus sinus invasion .Cn ( IX XII ) & sympathetic n. Villarets syndrome retropharyngeal invasion5years boy presented with neck mass . On examination he had nasopharyngeal mass on the same side ( left )

Nasopharyngeal lymphepithelioma

Symptoms of advanced diseaseTrismusDysphagiaProptosisLung , bone , liver metastasis

examinationComplete examination of head & neck.Examination of nasopharynx with endoscopy Flexible or rigidBiopsyNasal cavity

Posterior nasal cavity

nasopharynx

Nasopharyngeal carcinoma

oropharynx

Upper hypopharynx

Lower hypopharynx

larynx

investigationlaboratoryradiological.c.b.c. ca , PO4 , alkaline phosphate. Urin analysisLiver functionKidney functionSerum IgAE.B.V. caspid antigenEBV DNA

X- ray chestC.T. scanM R IP .E .T.Bone scintigraphy

PET scan

Staging system for n.ph.caT stage TX : primary tumor cant be assessed .TO : no evidence of primary tumor .Tis : carcinoma in situ .Staging systems for N . Ph . Ca.T stage( 1ry tumour extent)T1 confined to nasopharynxT2 extend to oropharynx or nasal cavitya without parapharyngeal extentionB with parapharyngeal extentionT3 invade bones or PNST4 involvement of cranial nerves , intracranial content , infratemporal fossa , hypopharynx , orbitN stage lymph node diseaseN0 No L . N . Metastasis .N1 unilateral L . N (s) < or = 6 cmN2 bilateral L . N (s) < or = 6 cmN3 3a L . N (s) > 6 cm3b with extension to supraclavicular fossaM stage distant metastasisM0 abscentM1 present

Management of nasopharyngeal caSurgical teatmentNon surgical treatmentSurgical treatment

Biopsy neck dissection nasopharyngectomy Non surgical treatment

Effective radiotherapyIntracavitary brachytherapyNewer technologies : Steriostatic radiosurgeryIntensity modulated radiotherapy.chemotherapyAcute side effects of R. T.Skin reactionaltered tasteWeight loss fatigue mucositisXerostomia

Chronic side effects of R. T.Hypothyroidism

Chronic S . O . M .Serious side effects of R . T .Severe trismusOsteoradionecrosisPituitary dysfunctionCarotid artery stenosisBrain necrosisCranial neuropathySpinal myelitisR.T. induce 2nd malignant salivary g. , skin , thyroid sarcoma Surgical approaches to nasopharynx1- transnasal maxillary .A- lat. Rhinotomy .B- LeFort I osteotomy .c- extended subtotal maxillectomy .2- transpalatal .3- sublabial midfacial degloving approach .4- transfacial maxillary swing .5-transmandibular & mandibular swing .6- infratemporal approach .7- othersA- lateral transtemporal sphenoidal .B- transpharyngeal .C- transcervical .

Intracavitary brachytherapy

PROGNOSISWell differentiated n. ph. Ca. has poorer local control rates.Advanced undifferentiated n. ph. Ca. has higher distant metastasis .. Accepted 5 years survival rate is ( 40 % 50 %) Better result in female patient under age of 40Very poor prognosis in pregnancy concurrent within 1st year of treatment.Relapse and distant failure occurs within the 1st 2 or 3 years

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