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Nasopharyngeal Carcinoma

 
  1. Fossa of Rosenmuller:
    SITE: Above and behind the medial end of the Eustachian tube
    Depth -1.5-2.5 cm
  2. Boundaries
    1. Anteriorly    :   Eustachian tube & levator palatini
    2. Posteriorly  :   Retropharyngeal space
    3. Medially     :   Nasopharyngeal cavity
    4. Laterally    :   Tensor palatini and mandibular nerve
    5. Superiorly  :   Foramen lacerum, floor of carotid canal
  3. Sinus of Morgagni
  1. Shape : Semilunar gap
  2. Site: Gap between the superior constrictor and the skull base
  3. Content:
    1. Eustachian tube                            
    2. Tensor veli palatini
    3. Levalor veli palatini                      
    4. Palatine branch of ascending pharyngeal artery
  1. Lymphatic Drainage:
    1. Retropharyngeal lymph nodes
    2. Parapharyngeal nodes
    3. Jugulodigastric/accessory group of lymph nodes
  2. Diagnosis:
    1. C-T. Scan
    2. MR1: Intracranial extension
    3. For evaluating post- radiation changes
    4. Biopsy
  3. Epidemiology Of Nasopharyngeal Carcinoma:
    1. Geographical distribution:
      1. Cantonese race in china
      2. Taiwan, Indonesia
      3. India-N.E. Part
    2. Sex: Male: Female = 2-3:1
    3. Age: 10-20yrs
      55-65 yrs
  4. Environmental Factors:
    1. Epstein-Barr Virus
    2. Tobacco
    3. Drugs: Chinese herbal medicine
    4. Diet:
      1. Salted fish
      2. Preserved vegetables
      3. Nitrosamines
    5. Cooking habits: Household smoke
    6. Religious practices : Incense sticks
    7. Occupation : Metal smelting, Wood dust
Table: WHO classification based on histopathology
  Present WHO terminology Former terminology
Type I (25%)
 
Type II (12%)
 
 
 Type III (63%)
 
 
 
 
Squamous cell carcinoma
 
Non-keratinizing carcinoma
- Without lymphoid stroma
- With lymphoid stroma
Undifferentiated carcinoma
- Without lymphoid stroma
- With lymphoid stroma
Squamous cell carcinoma
 
Transitional cell carcinoma Intermediate
cell carcinoma Lymphoepithelial
carcinoma (Regaud)
Anaplastic carcinoma
Clear cell carcinoma
Lymphoepithelial carcinoma (Schminke)
Spindle cell carcinoma
 
  1. Histopathology:
  1. Squamous Cell Carcinoma (Commonest type)
  2. Non-Keratinizing Undifferentiated carcinoma
    1. Lymphoepithelioma
    2. Anaplastic
    3. Spindle cell
  1. Clinical Features:
    1. Painless cervical lymphadenopathy : 60%
    2. (commonestàJugulodigastric)
    3. Epistaxis and naso respiratory symptoms : 40%
    4. Audio logical symptoms (Tinnitus, otalgia, Deafness)  : 30%
    5. Neurological symptoms : 20% (Most commonly: V, VI, IX, X: 50%)
    6. Metastases:
      1. Distant: Bone (most common), lung and liver
  2. Trotter’s Triad:
    1. U/L middle ear effusion
    2. Paralysis of the soft palate (X nerve)               
    3. Pain (Ear/jaw/ tongue) (V nerve)
  3. Tolosa- Hunt Syndrome:
    1. U/L orbital pain
    2. [relapsing/ Remitting pain
    3. (III, IV and VI cranial nerve)]
    4. Paraesthesia of the forehead
    5. Lesion : Cavernous sinus/ superior orbital fissure
  4. Treatment
    1. Radiotherapy: Definitive treatment for nasopharyngeal carcinoma and its regional node metastasis, Recurrence following radiotherapy is due to parapharyngeal space involvement No neck; Not irradiated
    2. Brachytherapy:
      Transnasal intracavity brachytherapy: lr-192
    3. Complications
      1. Xerostomia                                                                    
      2. Mucositis
      3. Radiation otitis media with effusion                          
      4. Post radiation radionecrosis
      5. Lhermitte’s Sign (lightening pains):
        1. Uncommon complication
        2. Causes: Due to radiation injury to the cervical spinal cord
        3. Features: Like electrical sensation spreading into both arms, down the dorsal spin, and into both legs on neck flexion.
    4. Other Complications:
      1. Radiation myelitis                     
      2. Encephalomyelitis change
      3. Optic atrophy, Retinitis                           
      4. Temporal lobe necrosis
      5. Hypopituitarism
    5. Surgery: For radio resistant neck nodes and post radiation cervical metastases
      Approaches to the Tumor:
      1. Transpalatal approach : Confined to the nasopharynx
      2. Transpalatal with gingivobuccal : Additional access to pterygopalatine fossa incision (Sardana’s   approach)
      3. Trans nasal approach with transantral approach  :  Infratemporal fossa
      4. Lateral rhinotomy with Maxillectomy  :  Tumor in the nasal fossa spilling over to the pterygopalatine fossa
      5. Middle cranial fossa approach : For extension to the middle cranial fossa
      6. Anterior cranial fossa approach : For anterior fossa cranial fossa extension
      7. Most common site of origin : fossa of Rosenmüller
Results: 5 yrs survival: 40-50% with megavoltage radiation therapy.
 
P.S. Sero immunological index in N.P-C.
- IgA/VCA  : 97% : Specificity
                : 95% : Sensitivity VCA : Viral capsid antigen
- IgA/HA    :99%  : Specificity EA: Early antigen
                :90% Sensitivity

The two titres can be used for follow-up of the patient for recurrence & for occult tumors
IgA /VCA : for serological screening of nasopharyngeal carcinoma
  1. Genetic markers in nasopharyngeal carcinoma:
    HLA -A. B, DR: Short arm of chr 6
Prognosis: 
  • HLA-A2: Best prognosis (survival: 40%. 5 yrs survival)
  • HLA-B46: Highest frequency in china
  • HLA-A33-B58: worst prognosis (mostly young, onset < 30 yrs)




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