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Carcinoma
Dr. Vishal Sharma
Introduction
Introduction
Race: More in Chinese & North African people
Sex: Male preponderance of 3:1
Age: Small peak: 12-18 yrs; large peak: 50-60 yrs
Gross: Proliferative, Ulcerative & Infiltrative types
Histology: 85% Squamous cell carcinoma,
10% Lymphomas, 5% Mixed
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
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)
With lymphoid stroma (lympho-epithelial)
Clinical Features
1. Neck swelling (60-90%): B/L, enlarged upper &
Clinical Features
4. Ophthalmologic (25-40%): Diplopia & ophthalmoplegia (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
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
Neck swelling
Left proptosis
Investigations
1. Nasopharyngoscopy & Diagnostic Nasal
Endoscopy: Tumor mass seen in nasopharynx
Commonest site is fossa of Rosenmller
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.
Nasopharyngoscopy
Computerized Tomogram
Endoscopic biopsy
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
T.N.M. staging
N0 = no evidence of regional lymph nodes
N1 = unilateral
N2 = bilateral
Supraclavicular fossa
Synonym: Hos triangle
A = medial end of
clavicle
B = Lateral end of
clavicle
C = junction between
neck & shoulder
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
Differential Diagnosis
1. Juvenile angiofibroma
2. Rhabdomyosarcoma
3. Lymphoma
Treatment modalities
1. Teletherapy or External beam radiotherapy
2. Brachytherapy
3. Chemotherapy
4. Surgery
5. Immunotherapy against E.B.V.
6. Vaccination against EBV: experimental
Cobalt Teletherapy
Brachytherapy
Interstitial Brachytherapy
Intracavitary Brachytherapy
Chemotherapy
Drugs used:
1. Cisplatin
2. 5-Fluorouracil
Indications:
1. Radiation failure
2. Palliation in distant metastasis
Surgery
1. Nasopharyngectomy, Cryosurgery:
Treatment Protocol
T1 = External Radiotherapy (6500 cGy)
T2 = External Radiotherapy (7000 cGy)
T3 & T4 = Radiotherapy + Chemotherapy
Brachytherapy / Salvage surgery if required
N0 = External Radiotherapy (5000 cGy)
N1, N2, N3 = External Radiotherapy (6000 cGy)
+ Chemotherapy
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 %
Thank You