Dr. Supreet Singh Nayyar,MS · PDF file 2012. 7. 27. · Dr. Supreet Singh Nayyar,...

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Transcript of Dr. Supreet Singh Nayyar,MS · PDF file 2012. 7. 27. · Dr. Supreet Singh Nayyar,...

  • Dr. Supreet Singh Nayyar, AFMC 2011

    www.nayyarENT.com

    1

    Nasopharyngeal Carcinoma

    (for more topics & ppts, visit www.nayyarENT.com )

    Epidemiology

     Highest incidence -- Guangdong Province of Southern China (50 per 100,000)

     Other places with high incidence

    o Hong Kong – 30/100,000

    o Singapore, Malaysia, Indonesia, Thailand, Filpinos

    o Alaskan Eskimos

    o Mediterranean basin

     Emigration reduces but still remains higher

     Other countries --1 per 100,000

     Recent trend in decrease in certain endemic region (Hong Kong)

     M:F :: 3:1

     Bimodal age distribution (20 & 50)

    Aetiology

     Multifactorial pathogenesis

    o Genetic factors supported by

     High in certain ethnic groups

     Familial clustering

     Low risk in immigrants

     Retained in successive emigrant generations

     HLA linkage shown by Simons (1975)

    http://www.nayyarent.com/

  • Dr. Supreet Singh Nayyar, AFMC 2011

    www.nayyarENT.com

    2

     Loci involved are HLA-A, B & DR.

     Hypothesis of NPC tumour suppressor gene on chromosome 3 & 9.

     Chromosomal abnormalities often present

    o Ebstein Barr Virus

     Liang in 1969 proposed the association with EBV.

     Factors in favour

     Raised antibodies

     Viral genome

     EBV receptors (Young et al)

    o Environmental carcinogens

     Salted fish, preserved food

     Dust, household smoke, industrial fumes & tobacco

     Formaldehyde, metal smelting, furnaces, wood dust

     Dietary carcinogens affect susceptible population

    EBV - Immunology & serology

     EBV - 95% of world population affected

     Primary infection chilhoodasymptomatic

    If in adultInfectious mononucleosis

     In either caseseroconversionpermanent immunity + some virus persistence

     Virus shed in salivahorizontal transmission

    dormant genomic form in lymphocytes & bone marrow environmental factors

    or ↓ immunity  reactivation

     Cell mediated immunity impaired  polyclonal proliferation of infected B cells

     Markers

    o IgA anti-Viral Capsid Antigen(VCA) – ↑ sensitivity-- screening

    o IgA anti Early Antigen(EA) -- ↑specificity

    o ↑ADCC (Antibody dependant cytotoxicity) assay against EBV membranegood

    prognosis

    o IgA against EBV specific DNAase marker after therapy

    o EBV DNA also marker during & after therapy

  • Dr. Supreet Singh Nayyar, AFMC 2011

    www.nayyarENT.com

    3

    Pathology

     Morphology of tumour range - Bulky growth to infiltrative one

     Histology classification (WHO-1991)

    o Type I-SCC (Keratinizing)

    o Type II- Non keratinizing carcinoma

    o Type III-Undifferentiated carcinoma

    Routes of spread

     Direct o Through foramen lacerum  called Linconi highway/ petro sphenoid route 

    Early involvement of cavernous sinus, optic nerve & orbit without erosion of base of skull

    o Anteriorly nasal cavity, PNS, pterygopalatine fossa and apex of orbit. o Posteriorly retropharyngeal space and node of Rouviere. o Laterally thru sinus of Morgagni parapharyngeal space o Superiorly body of sphenoid to the parasellar regions. o Inferiorlyoral cavity

     Lymphatic  retropharyngeal (node of Rouviere)  upper cervical LN

     Haematogenous  Bone, liver, lungs

    Clinical features

     Cervical lymphadenopathy 60%

    o Tendency for early lymphatic spread.

    o Retropharyngeal node of Rouviere – 1st echelon node.

    o Commonest first palpable node – Jugulodigastric node and apical node under

    sternomastoid muscle

     Epistaxis & Naso-respiratory symptoms

    o Commonly seen in advanced NPC’s

    o Complete nasal obstruction is a late presentation

    o Ozaena occurs as a result of tumour necrosis

     Audiological symptoms 30%

    o Serous otitis media is common

    o Adult Chinese patient with unresolving OME NPC until proved otherwise

    o Acute otitis media

    o Aural block

  • Dr. Supreet Singh Nayyar, AFMC 2011

    www.nayyarENT.com

    4

    o Tinnitus

    o Trotter’s triad  decreased hearing, mandibular pain, impaired soft palate

    mobility

     Neurological symptoms 20%

    o All cranial nerves can be affected

    o Signifies spread through foramina & Para pharyngeal space involvement

    o Frequently involved are V, VI, IX, & X.

    o Nerves IX & X are invariably involved together

    o Nerves of the ocular muscles are the next commonly affected  indicate

    cavernous sinus involvement

    o Horner’s syndrome

     Headache

    o Poor prognosis

    o Severe headache hallmark of terminal disease.

    o Signifies tumour erosion into skull base

    o If accompanied by trismusdisease very advanced extended into

    pterygopalatine fossa

     Distant metastasis 30%

    o Thoraco lumbar spine commonest

    o Followed by the lung and liver

    Diagnosis  Examination of ear, neck and cranial nerves

     Posterior rhinoscopy o Mass in Nasopharynx

     Transoral retrograde naso-pharyngoscopy o Fossae of rossenmuller wide open for evaluation. o Useful in gross DNS, small nasal cavity & Nasal polyposis

     Antegrade Naso- pharyngoscopy o Rigid

     Excellent optics  Wide angle of view

    o Flexible fibreoptic  Narrow diameter & flexible tip

     Nasopharyngeal biopsy o Transnasal - Hildyard biopsy forceps

     Blind  Post. Mirror rhinoscopy

  • Dr. Supreet Singh Nayyar, AFMC 2011

    www.nayyarENT.com

    5

     Endoscopy – rigid and flexible o Transoral

     Yankauer speculum  Rigid endoscopy

     Serolgy o IgA anti-VCA( high sensitivity, low specificity) o IgA anti-EA (low sensitivity, high specificity)

     Cytology o Typical of undifferentiated variety.

     Immunochemical staining o EBNA o EBV RNA o PCR for free EBV DNA

     Imaging o Tumour staging, RT planning, post treatment monitoring

     CT o Most widely used o Bony erosion

     MRI o Better soft tissue resolution, multiplanar images o More sensitive for marrow infiltration o Better defines nodal metastasis o In PNS diff between mucus and tumour

     Ultrasound o Confined to Dx and monitoring of regional and distant spread

     PET Scan o Differentiate post RT oedema from cancer in recurrences o Rule out distant metastasis

    (for more topics & ppts, visit www.nayyarENT.com )

    http://www.nayyarent.com/

  • Dr. Supreet Singh Nayyar, AFMC 2011

    www.nayyarENT.com

    6

    Staging

     Modified Ho’s classification Endemic regions

     AJCC  Publicatios & non endemic region

     Main difference  N criteria

  • Dr. Supreet Singh Nayyar, AFMC 2011

    www.nayyarENT.com

    7

    (for more topics & ppts, visit www.nayyarENT.com )

    http://www.nayyarent.com/

  • Dr. Supreet Singh Nayyar, AFMC 2011

    www.nayyarENT.com

    8

  • Dr. Supreet Singh Nayyar, AFMC 2011

    www.nayyarENT.com

    9

    Treatment

     Radiotherapy

    o Extremely radio sensitive

    o External Beam Radio Therapy (EBRT) primary modality

    o Two lateral opposing and one anterior field

    o Nasopharynx and both sides of neck covered.

    o Recommended dose is not less than 65Gy

    o Para pharyngeal boost to extend postero-lateral coverage

    o Stage I and II only RT

    o Stage III and IVB RT + CT

    o Additional dose of RT given by after loading Brachytherapy in advanced cancer

     Advanced disease chemotherapy added

    o 3 types

     Neoadjuvant

     Concurrent

     Adjuvant

    o Acts as radiosensitizer

    o Helps in controlling distant mets

    o Reduce bulk

    o Increases disease free survival

    o However no long term survival

    o Concurrent chemoradiation most impressive results

    Follow up

     Majority of relapses first 3 years

     2 monthly review 1st year 3 monthly review 2nd & 3rd yrs6 monthly

     Lifelong follow up

     Endoscopy biopsy, imaging for neck, thyroid function test ,X ray chest

    Salvage treatment

     Local recurrence

  • Dr. Supreet Singh Nayyar, AFMC 2011

    www.nayyarENT.com

    10

    Surgery

     Limited role

     Patient to be restaged

     Preoperatively the tumour stage difficult to define

     Best results with rT1 & rT2 cases without neck disease

     Surgical approaches

    o Anterior approach

     Lateral rhinotomy

     Transnasal transmaxillary

     Midfacial degloving

     Le Fort 1 osteotomy

     Maxillary swing

    o Inferior approach

     Trans