nasopharyngeal carcinoma Pre Mx

1. Premanagement in Carcinoma
Nasopharynx
Dr Sasikumar Sambasivam
Moderator: Dr Jaishree Goyal

4. CT Anatomy
Fossa of
Rosenmuller

5. Sphenoidal sinus
Carotid canal

6. 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

7. 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

8. 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.

9. RPLN INVOLVEMENT IN NPC
B/L RPLN

10. Incidence

11. Incidence: Sex

12. 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

13. 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

14. Local Invasion
Nasal cavity & PNS
Base of Skull, Clivus
Orbital invasion
Lateral Parapharyngeal space
Middle ear cavity
Oropharynx (tonsillar pillars)
C1 vertebrae
ANT

15. Nodal spread

16. Nodal Spread
Clinically palpable

17. 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.)

18. 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%)

19. 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

20. 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).

21.  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)

22. •
•
•
•
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

23. Extn into
cavernous sinus
Both FOR inv.
MR IMAGES
Cavernous sinus
inv with FO
Expansion of
cavernous sinus

24. 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)

25. 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

26. 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

27. 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.

28. 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

29. T Staging
T1
T2

30. 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

32. 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.

33. 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%

34. Endemic NPC
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•
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•
•
•
•
•
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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

35. 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

37. Thank You.