1. Nasopharyngeal Carcinoma
Dr. Vishal Sharma

2. Introduction 85% adult nasopharyngeal malignancies are carcinoma
Common pediatric malignancies of naso-pharynx are rhabdomyosarcoma & lymphoma
30% pediatric nasopharyngeal malignancies are carcinoma

3. Introduction Race: More in Chinese & North African people
Sex: Male preponderance of 3:1
Age: Small peak: yrs; large peak: yrs
Gross: Proliferative, Ulcerative & Infiltrative types
Histology: 85% Squamous cell carcinoma,
10% Lymphomas, 5% Mixed

4. Aetiology
1. Genetic: Commonest in Chinese population. HLA-A2 & HLA-B-Sin 2 histocompatibility locus
2. Viral: Epstein-Barr Virus
3. Environmental: Exposure to nitrosamines (dry salted fish), polycyclic hydrocarbons (smoke from incense & wood), smoking, chronic nasal infection, poor ventilation of nasopharynx

5. W.H.O. classification Type 1: keratinizing squamous cell carcinoma
Type 2: non-keratinizing (transitional) carcinoma
 Without lymphoid stroma (intermediate cell)
 With lymphoid stroma (lympho-epithelial)
Type 3: undifferentiated (anaplastic) carcinoma
 Without lymphoid stroma (clear cell)

6. Clinical Features 1. Neck swelling (60-90%): B/L, enlarged upper &
middle deep cervical nodes + posterior
triangle nodes (Rouviere's sign)
2. Nasal (40-75%): epistaxis, nose block, nasal
discharge
3. Otologic (40-70%): Conductive deafness, tinnitus

7. Clinical Features
4. Ophthalmologic (25-40%): Diplopia & ophthalmo-plegia (involvement of CN III, IV, VI), Proptosis (orbit invasion) & blindness (involvement of CN II).
5. Neurologic (25-40 %):
Jugular foramen syndrome: CN IX, X, XI involved by lateral retropharyngeal lymph node Horner's syndrome: sympathetic chain involvement

8. Clinical Features 6. Severe Headache: indicates skull base erosion
7. Trotter's triad:
Conductive deafness: Eustachian Tube block
+ I/L temporo-parietal neuralgia: Trigeminal damage
+ I/L palatal paralysis: Vagus damage
8. Distant metastasis: to bone, lung & liver

9. Neck swelling

10. Ptosis & adduction palsy

11. Left proptosis

13. Investigations 1. Nasopharyngoscopy & Diagnostic Nasal
Endoscopy: Tumor mass seen in nasopharynx
Commonest site is fossa of Rosenmüller
2. Nasopharyngeal tumor biopsy: seen or blind
3. F.N.A.C. of neck node: done in occult primary
4. C.T. scan head & neck: for tumor extent, skull base erosion & cervical lymph node metastasis

14. Investigations 5. M.R.I. head & neck: for intracranial extension.
6. Tests for metastases: C.T. chest + abdomen, bone scan, P.E.T. scan, liver function tests.
7. Serologic tests: Immuno-fluorescence for IgA antibodies to Viral Capsid Antigen, IgG antibodies to Early Antigen, Antibody Dependent Cellular Cytotoxicity assay.

15. Nasopharyngoscopy

16. Diagnostic Nasal Endoscopy

17. Computerized Tomogram

18. CT scan: retropharyngeal node

19. CT scan: Infratemporal fossa & orbit involvement

20. CT scan: sella involvement

21. Magnetic Resonance Imaging

22. MRI: parapharyngeal mass

23. MRI: neck node metastasis

24. M.R.I.: intracranial extension

25. Endoscopic biopsy

26. CT scan: liver metastasis

27. Whole body bone scan

28. Positron Emission Tomography

29. T.N.M. staging T1 = confined to nasopharynx
T2 = soft tissue involvement in oropharynx or
nasal cavity or parapharyngeal space
T3 = invasion of bony structures or P.N.S.
T4 = intracranial, involvement of orbit, cranial
nerves, infratemporal fossa, hypopharynx

30. 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 fossa
M0 = no evidence of distant metastasis
M1 = distant metastasis present

31. Supraclavicular fossa
Synonym: Ho’s triangle
A = medial end of
clavicle
B = Lateral end of
C = junction between
neck & shoulder

32. 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

33. Differential Diagnosis
1. Juvenile angiofibroma
2. Rhabdomyosarcoma
3. Lymphoma

34. Treatment modalities 2. Brachytherapy 3. Chemotherapy 4. Surgery
1. Teletherapy or External beam radiotherapy
2. Brachytherapy
3. Chemotherapy
4. Surgery
5. Immunotherapy against E.B.V.
6. Vaccination against EBV: experimental

35. Cobalt Teletherapy

36. External beam irradiation
2 lateral fields: nasopharynx, skull base & upper
neck; sparing temporal lobe, pituitary & spinal cord.
1 anterior field: lower neck; sparing spinal cord & larynx

37. Brachytherapy Used for small tumor, residual or recurrent tumor
Interstitial: Radioactive source (Radium, Iridium, Iodine, Gold) inserted into tumor tissue
Intracavitary: Radioactive source placed inside catheter or moulds & inserted into nasopharynx
High dose rate (HDR): High intensity radiation delivered with precision under computer guidance

38. Interstitial Brachytherapy

39. Intracavitary Brachytherapy

40. High Dose Rate Brachytherapy

41. Chemotherapy Drugs used: 1. Cisplatin 2. 5-Fluorouracil Indications:
1. Radiation failure
2. Palliation in distant metastasis

42. Surgery 1. Nasopharyngectomy, Cryosurgery:
for residual or recurrent tumor
2. Radical neck dissection:
for radio-resistant lymph node metastasis
3. Palliative debulking: for T4 tumors
4. Myringotomy & grommet insertion:
for persistent otitis media with effusion

43. Radical neck dissection & Interstitial Brachytherapy

44. Treatment Protocol T1 = External Radiotherapy (6500 cGy)
T3 & T4 = Radiotherapy + Chemotherapy 
Brachytherapy / Salvage surgery if required
N0 = External Radiotherapy (5000 cGy)
N1, N2, N3 = External Radiotherapy (6000 cGy)
+ Chemotherapy

45. Prognosis W.H.O. Type 2 & 3 carcinomas have good
response to radiotherapy & better survival rates.
5 year survival rates for treated patients:
Stage I = 95 – 100 %
Stage II = 60 – 80 %
Stage III = 30 – 60 %
Stage IV = 20 – 30 %

46. Thank You