SlideShare a Scribd company logo
1 of 37
Premanagement in Carcinoma
Nasopharynx
Dr Sasikumar Sambasivam
Moderator: Dr Jaishree Goyal
Nasopharyngeal Carcinoma
Nasopharyngeal Carcinoma
CT Anatomy
Fossa of
Rosenmuller
Sphenoidal sinus

Carotid canal
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
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
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.
RPLN INVOLVEMENT IN NPC

B/L RPLN
Incidence
Incidence: Sex
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
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
Local Invasion

Nasal cavity & PNS

Base of Skull, Clivus

Orbital invasion

Lateral Parapharyngeal space
Middle ear cavity
Oropharynx (tonsillar pillars)
C1 vertebrae

ANT
Nodal spread
Nodal Spread
Clinically palpable
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.)
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%)
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
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).
 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)
•
•
•
•

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
Extn into
cavernous sinus

Both FOR inv.

MR IMAGES

Cavernous sinus
inv with FO
Expansion of
cavernous sinus
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)
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
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
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.
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
T Staging
T1

T2
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
Nasopharyngeal Carcinoma
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.
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%
Endemic NPC
•
•
•
•
•
•
•
•
•

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
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
Nasopharyngeal Carcinoma
Thank You.

More Related Content

What's hot

Nasopharyngeal cancer
Nasopharyngeal cancerNasopharyngeal cancer
Nasopharyngeal cancerDeepika Malik
 
Management of Carcinoma Larynx
Management of Carcinoma LarynxManagement of Carcinoma Larynx
Management of Carcinoma LarynxAnimesh Agrawal
 
Management of ca larynx and hypopharynx
Management of ca larynx and hypopharynxManagement of ca larynx and hypopharynx
Management of ca larynx and hypopharynxVarshu Goel
 
Tumours of nasal cavity & paranasal sinuses
Tumours of nasal cavity & paranasal sinuses  Tumours of nasal cavity & paranasal sinuses
Tumours of nasal cavity & paranasal sinuses Ibrahim Barakat
 
Management of ca maxillary sinus
Management of ca maxillary sinusManagement of ca maxillary sinus
Management of ca maxillary sinusDrAyush Garg
 
Managememt of Carcinoma Nasopharynx
Managememt  of Carcinoma NasopharynxManagememt  of Carcinoma Nasopharynx
Managememt of Carcinoma NasopharynxIsha Jaiswal
 
Management of nasopharyngeal cancer
Management of nasopharyngeal cancerManagement of nasopharyngeal cancer
Management of nasopharyngeal cancerSailendra Parida
 
managment of neck nodes with occult primary
managment of neck nodes with occult primarymanagment of neck nodes with occult primary
managment of neck nodes with occult primaryBharti Devnani
 
CARCINOMA MAXILLARY SINUS MANAGEMENT RADIATION ONCOLOGY
CARCINOMA MAXILLARY SINUS MANAGEMENT RADIATION ONCOLOGYCARCINOMA MAXILLARY SINUS MANAGEMENT RADIATION ONCOLOGY
CARCINOMA MAXILLARY SINUS MANAGEMENT RADIATION ONCOLOGYPaul George
 
Management of sinonasal tract tumors 27082018
Management of sinonasal tract tumors 27082018Management of sinonasal tract tumors 27082018
Management of sinonasal tract tumors 27082018Varshu Goel
 
Metastasis of Neck Node with Unknown Primary
Metastasis of Neck Node with Unknown Primary Metastasis of Neck Node with Unknown Primary
Metastasis of Neck Node with Unknown Primary Himanshu Soni
 
Olfactory neuroblastoma
Olfactory neuroblastomaOlfactory neuroblastoma
Olfactory neuroblastomaRitesh Mahajan
 
Surgical management of early laryngeal cancer dr.bhavin
Surgical management of early laryngeal cancer  dr.bhavinSurgical management of early laryngeal cancer  dr.bhavin
Surgical management of early laryngeal cancer dr.bhavinDr.Bhavin Vadodariya
 

What's hot (20)

Nasopharyngeal cancer
Nasopharyngeal cancerNasopharyngeal cancer
Nasopharyngeal cancer
 
Ca oropharynx
Ca oropharynxCa oropharynx
Ca oropharynx
 
Carcinoma Nasopharynx
Carcinoma NasopharynxCarcinoma Nasopharynx
Carcinoma Nasopharynx
 
Management of Carcinoma Larynx
Management of Carcinoma LarynxManagement of Carcinoma Larynx
Management of Carcinoma Larynx
 
Management of ca larynx and hypopharynx
Management of ca larynx and hypopharynxManagement of ca larynx and hypopharynx
Management of ca larynx and hypopharynx
 
Tumours of nasal cavity & paranasal sinuses
Tumours of nasal cavity & paranasal sinuses  Tumours of nasal cavity & paranasal sinuses
Tumours of nasal cavity & paranasal sinuses
 
Management of ca maxillary sinus
Management of ca maxillary sinusManagement of ca maxillary sinus
Management of ca maxillary sinus
 
Managememt of Carcinoma Nasopharynx
Managememt  of Carcinoma NasopharynxManagememt  of Carcinoma Nasopharynx
Managememt of Carcinoma Nasopharynx
 
Management of nasopharyngeal cancer
Management of nasopharyngeal cancerManagement of nasopharyngeal cancer
Management of nasopharyngeal cancer
 
Carcinoma larynx management
Carcinoma larynx managementCarcinoma larynx management
Carcinoma larynx management
 
ORO PHARYNX.pptx
ORO PHARYNX.pptxORO PHARYNX.pptx
ORO PHARYNX.pptx
 
managment of neck nodes with occult primary
managment of neck nodes with occult primarymanagment of neck nodes with occult primary
managment of neck nodes with occult primary
 
CARCINOMA MAXILLARY SINUS MANAGEMENT RADIATION ONCOLOGY
CARCINOMA MAXILLARY SINUS MANAGEMENT RADIATION ONCOLOGYCARCINOMA MAXILLARY SINUS MANAGEMENT RADIATION ONCOLOGY
CARCINOMA MAXILLARY SINUS MANAGEMENT RADIATION ONCOLOGY
 
Metastatic Neck node of Unknown Primary
Metastatic Neck node of Unknown PrimaryMetastatic Neck node of Unknown Primary
Metastatic Neck node of Unknown Primary
 
Management of sinonasal tract tumors 27082018
Management of sinonasal tract tumors 27082018Management of sinonasal tract tumors 27082018
Management of sinonasal tract tumors 27082018
 
Metastasis of Neck Node with Unknown Primary
Metastasis of Neck Node with Unknown Primary Metastasis of Neck Node with Unknown Primary
Metastasis of Neck Node with Unknown Primary
 
Olfactory neuroblastoma
Olfactory neuroblastomaOlfactory neuroblastoma
Olfactory neuroblastoma
 
Surgical management of early laryngeal cancer dr.bhavin
Surgical management of early laryngeal cancer  dr.bhavinSurgical management of early laryngeal cancer  dr.bhavin
Surgical management of early laryngeal cancer dr.bhavin
 
Carcinoma of hypopharynx
Carcinoma of hypopharynxCarcinoma of hypopharynx
Carcinoma of hypopharynx
 
Nasopharyngeal carcinoma
Nasopharyngeal carcinomaNasopharyngeal carcinoma
Nasopharyngeal carcinoma
 

Viewers also liked

ASKEP Ca nasofaring-fix
ASKEP Ca nasofaring-fixASKEP Ca nasofaring-fix
ASKEP Ca nasofaring-fixNely Eviana
 
27925999 karsinoma-nasofaring
27925999 karsinoma-nasofaring27925999 karsinoma-nasofaring
27925999 karsinoma-nasofaring0812200200
 
Skeletal muscle pathology MADE EASY by fahad
Skeletal muscle pathology MADE EASY by fahadSkeletal muscle pathology MADE EASY by fahad
Skeletal muscle pathology MADE EASY by fahadLWCH, UAE
 
Tumours of nasopharynx (2) itp class dr.davis - 03.06.16
Tumours of nasopharynx (2) itp class   dr.davis - 03.06.16Tumours of nasopharynx (2) itp class   dr.davis - 03.06.16
Tumours of nasopharynx (2) itp class dr.davis - 03.06.16ophthalmgmcri
 
Endobronchial Ultrasound Guidance of TBNA. Current Approach To Lung Cancer St...
Endobronchial Ultrasound Guidance of TBNA. Current Approach To Lung Cancer St...Endobronchial Ultrasound Guidance of TBNA. Current Approach To Lung Cancer St...
Endobronchial Ultrasound Guidance of TBNA. Current Approach To Lung Cancer St...Bassel Ericsoussi, MD
 
inflammatory Bowel disease
inflammatory Bowel diseaseinflammatory Bowel disease
inflammatory Bowel diseaseLWCH, UAE
 
Undescended testis
Undescended testisUndescended testis
Undescended testisGAURAV NAHAR
 
Surgical anatomy of salivary glands
Surgical anatomy of salivary glandsSurgical anatomy of salivary glands
Surgical anatomy of salivary glandsDr./ Ihab Samy
 
barium studies in gi pathologies
barium studies in gi pathologiesbarium studies in gi pathologies
barium studies in gi pathologiesAhmad Jawad
 

Viewers also liked (20)

Nasopharyngeal Carcinoma
Nasopharyngeal CarcinomaNasopharyngeal Carcinoma
Nasopharyngeal Carcinoma
 
ASKEP Ca nasofaring-fix
ASKEP Ca nasofaring-fixASKEP Ca nasofaring-fix
ASKEP Ca nasofaring-fix
 
27925999 karsinoma-nasofaring
27925999 karsinoma-nasofaring27925999 karsinoma-nasofaring
27925999 karsinoma-nasofaring
 
Nasopharynx
NasopharynxNasopharynx
Nasopharynx
 
Nasopharyngeal carcinoma
Nasopharyngeal carcinomaNasopharyngeal carcinoma
Nasopharyngeal carcinoma
 
Pharyngeal tumor
Pharyngeal tumorPharyngeal tumor
Pharyngeal tumor
 
Skeletal muscle pathology MADE EASY by fahad
Skeletal muscle pathology MADE EASY by fahadSkeletal muscle pathology MADE EASY by fahad
Skeletal muscle pathology MADE EASY by fahad
 
Urology
UrologyUrology
Urology
 
Tumours of nasopharynx (2) itp class dr.davis - 03.06.16
Tumours of nasopharynx (2) itp class   dr.davis - 03.06.16Tumours of nasopharynx (2) itp class   dr.davis - 03.06.16
Tumours of nasopharynx (2) itp class dr.davis - 03.06.16
 
Endobronchial Ultrasound Guidance of TBNA. Current Approach To Lung Cancer St...
Endobronchial Ultrasound Guidance of TBNA. Current Approach To Lung Cancer St...Endobronchial Ultrasound Guidance of TBNA. Current Approach To Lung Cancer St...
Endobronchial Ultrasound Guidance of TBNA. Current Approach To Lung Cancer St...
 
inflammatory Bowel disease
inflammatory Bowel diseaseinflammatory Bowel disease
inflammatory Bowel disease
 
Neoplasms of nasopharynx
Neoplasms of nasopharynxNeoplasms of nasopharynx
Neoplasms of nasopharynx
 
Pharyngeal tumor
Pharyngeal tumorPharyngeal tumor
Pharyngeal tumor
 
Ischemic Colitis
Ischemic ColitisIschemic Colitis
Ischemic Colitis
 
9 nasopharyngeal-carcinoma
9 nasopharyngeal-carcinoma9 nasopharyngeal-carcinoma
9 nasopharyngeal-carcinoma
 
Undescended testis
Undescended testisUndescended testis
Undescended testis
 
Surgical anatomy of salivary glands
Surgical anatomy of salivary glandsSurgical anatomy of salivary glands
Surgical anatomy of salivary glands
 
Meniere’s disease
Meniere’s diseaseMeniere’s disease
Meniere’s disease
 
barium studies in gi pathologies
barium studies in gi pathologiesbarium studies in gi pathologies
barium studies in gi pathologies
 
Neck dissection
Neck dissectionNeck dissection
Neck dissection
 

Similar to Nasopharyngeal Carcinoma

malignancies of the larynx
malignancies of the larynxmalignancies of the larynx
malignancies of the larynxSarthak Moharir
 
Cancer of the hypopharynx
Cancer  of  the hypopharynxCancer  of  the hypopharynx
Cancer of the hypopharynxMohamed Barakat
 
CA HYPOPHARYNX.pptx
CA HYPOPHARYNX.pptxCA HYPOPHARYNX.pptx
CA HYPOPHARYNX.pptxDr Monica P
 
Nasopharyngeal carcinoma
Nasopharyngeal carcinomaNasopharyngeal carcinoma
Nasopharyngeal carcinomakrishnakoirala4
 
Nasopharyngeal carcinoma
Nasopharyngeal carcinomaNasopharyngeal carcinoma
Nasopharyngeal carcinomakrishnakoirala4
 
Neck node management of unknown primary
Neck node management of unknown primaryNeck node management of unknown primary
Neck node management of unknown primaryDr Rekha Arya
 
Nasopharyngeal carcinoma2020
Nasopharyngeal carcinoma2020Nasopharyngeal carcinoma2020
Nasopharyngeal carcinoma2020Ronde Maklago
 
Nasopharyngeal carcinoma2020
Nasopharyngeal carcinoma2020Nasopharyngeal carcinoma2020
Nasopharyngeal carcinoma2020Yvonne Nyatundo
 
hypopharyngealcancer2-151012175726-lva1-app6892.pptx
hypopharyngealcancer2-151012175726-lva1-app6892.pptxhypopharyngealcancer2-151012175726-lva1-app6892.pptx
hypopharyngealcancer2-151012175726-lva1-app6892.pptxegodoc222
 
5-170108180933-converted.pptx
5-170108180933-converted.pptx5-170108180933-converted.pptx
5-170108180933-converted.pptxegodoc222
 
Cancer of the larynx presentation
Cancer  of  the larynx presentationCancer  of  the larynx presentation
Cancer of the larynx presentationMohamed Barakat
 
Seminar on cancer of larynx
Seminar on cancer of larynxSeminar on cancer of larynx
Seminar on cancer of larynxYousuf Choudhury
 

Similar to Nasopharyngeal Carcinoma (20)

malignancies of the larynx
malignancies of the larynxmalignancies of the larynx
malignancies of the larynx
 
Pharynx Lecture_3.doc
Pharynx Lecture_3.docPharynx Lecture_3.doc
Pharynx Lecture_3.doc
 
Cancer of the hypopharynx
Cancer  of  the hypopharynxCancer  of  the hypopharynx
Cancer of the hypopharynx
 
CA HYPOPHARYNX.pptx
CA HYPOPHARYNX.pptxCA HYPOPHARYNX.pptx
CA HYPOPHARYNX.pptx
 
Nasopharyngeal carcinoma
Nasopharyngeal carcinomaNasopharyngeal carcinoma
Nasopharyngeal carcinoma
 
Nasopharyngeal carcinoma
Nasopharyngeal carcinomaNasopharyngeal carcinoma
Nasopharyngeal carcinoma
 
Neck node management of unknown primary
Neck node management of unknown primaryNeck node management of unknown primary
Neck node management of unknown primary
 
JNA
JNAJNA
JNA
 
Nasopharyngeal carcinoma
Nasopharyngeal carcinomaNasopharyngeal carcinoma
Nasopharyngeal carcinoma
 
Nasopharyngeal Carcinoma.ppt
Nasopharyngeal Carcinoma.pptNasopharyngeal Carcinoma.ppt
Nasopharyngeal Carcinoma.ppt
 
Nasopharyngeal carcinoma2020
Nasopharyngeal carcinoma2020Nasopharyngeal carcinoma2020
Nasopharyngeal carcinoma2020
 
Pharyngeal cancer
Pharyngeal cancerPharyngeal cancer
Pharyngeal cancer
 
Cancer of the larynx
Cancer  of  the larynxCancer  of  the larynx
Cancer of the larynx
 
JNA.pptx
JNA.pptxJNA.pptx
JNA.pptx
 
Nasopharyngeal carcinoma2020
Nasopharyngeal carcinoma2020Nasopharyngeal carcinoma2020
Nasopharyngeal carcinoma2020
 
hypopharyngealcancer2-151012175726-lva1-app6892.pptx
hypopharyngealcancer2-151012175726-lva1-app6892.pptxhypopharyngealcancer2-151012175726-lva1-app6892.pptx
hypopharyngealcancer2-151012175726-lva1-app6892.pptx
 
5-170108180933-converted.pptx
5-170108180933-converted.pptx5-170108180933-converted.pptx
5-170108180933-converted.pptx
 
Laryngeal carcinoma
Laryngeal carcinomaLaryngeal carcinoma
Laryngeal carcinoma
 
Cancer of the larynx presentation
Cancer  of  the larynx presentationCancer  of  the larynx presentation
Cancer of the larynx presentation
 
Seminar on cancer of larynx
Seminar on cancer of larynxSeminar on cancer of larynx
Seminar on cancer of larynx
 

More from Sasikumar Sambasivam

More from Sasikumar Sambasivam (11)

'Say No to Tobacco' WHO WNTD 31st May
'Say No to Tobacco' WHO WNTD 31st May'Say No to Tobacco' WHO WNTD 31st May
'Say No to Tobacco' WHO WNTD 31st May
 
Role of Conformal Radiotherapy in HNC
Role of Conformal Radiotherapy in HNCRole of Conformal Radiotherapy in HNC
Role of Conformal Radiotherapy in HNC
 
Salivary gland tumors
Salivary gland tumorsSalivary gland tumors
Salivary gland tumors
 
Locally Advanced Carcinoma Prostate
Locally Advanced Carcinoma ProstateLocally Advanced Carcinoma Prostate
Locally Advanced Carcinoma Prostate
 
Carcinoma bladder
Carcinoma bladderCarcinoma bladder
Carcinoma bladder
 
Dose volume histogram
Dose volume histogramDose volume histogram
Dose volume histogram
 
Maliganant spinal cord compression main
Maliganant spinal cord compression mainMaliganant spinal cord compression main
Maliganant spinal cord compression main
 
Bone tumors pre management
Bone tumors pre managementBone tumors pre management
Bone tumors pre management
 
Intra Operative Radiotherapy
Intra Operative RadiotherapyIntra Operative Radiotherapy
Intra Operative Radiotherapy
 
Unusual nonepithelial tumors of the head and neck
Unusual nonepithelial tumors of the head and neckUnusual nonepithelial tumors of the head and neck
Unusual nonepithelial tumors of the head and neck
 
Central nervous system tumors in children
Central nervous system tumors in childrenCentral nervous system tumors in children
Central nervous system tumors in children
 

Recently uploaded

Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxMAsifAhmad
 
The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?Ryan Addison
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismusChandrasekar Reddy
 
World-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptxWorld-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptxsumanchaulagain3
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)Mohamed Rizk Khodair
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
Good Laboratory Practice (GLP) in Pharma-LikeWays.pptx
Good Laboratory Practice (GLP) in Pharma-LikeWays.pptxGood Laboratory Practice (GLP) in Pharma-LikeWays.pptx
Good Laboratory Practice (GLP) in Pharma-LikeWays.pptxLikeways
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyZurück zum Ursprung
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...Ganesan Yogananthem
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfMedicoseAcademics
 
Pregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfPregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfMedicoseAcademics
 

Recently uploaded (20)

Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
 
The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismus
 
World-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptxWorld-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptx
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
Good Laboratory Practice (GLP) in Pharma-LikeWays.pptx
Good Laboratory Practice (GLP) in Pharma-LikeWays.pptxGood Laboratory Practice (GLP) in Pharma-LikeWays.pptx
Good Laboratory Practice (GLP) in Pharma-LikeWays.pptx
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturally
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...
 
Cone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptxCone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptx
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdf
 
Pregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfPregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdf
 

Nasopharyngeal Carcinoma

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

Editor's Notes

  1. The posterior wall of the nasopharynx is made up of four anatomic layers: the mucous membrane of the pharynx; the pharyngeal aponeurosis; the superior constrictor muscle of the pharynx; and the buccopharyngeal fascia, which is loosely connected with the adjacent prevertebral fascia. The muscular wall of the nasopharynx is incomplete. In the upper nasopharynx, the lateral walls consist of only two layers: the mucous membrane and the pharyngeal aponeurosis. This area of muscular deficiency is called the sinus of Morgagni, through which the cartilaginous part of the eustachian tube enters the pharyngeal wall along with the levator veli palatini muscle.
  2. Superiorly bound by the base of the skull and overlies the carotid canal, jugular foramen, and hypoglossal foramen. The inferior border is the junction of the posterior belly of the digastric muscle and the greater cornu of the hyoid bone.  Medially, the boundary is made up of the buccopharyngeal or visceral fascia overlying the superior pharyngeal constrictors.  The lateral boundary is made up of the fascia over the medial pterygoid muscle, the ramus of the mandible, the posterior belly of the digastric muscle, and the fascia over the retromandibular deep portion of the parotid gland.  Anteriorly the limit is the pterygomandibular raphe.  The posterior limit is the dorsal layer of fascia making up the carotid sheath.  Fascia which extends from the styloid process to the tensor veli palantini muscle, called the tensor-vascular-styloid fascia, because it also contains the ascending palatine artery and vein, divides the parapharyngeal space into an anterolateral or prestyloid, and  a posteromedial, or retrostyloid compartments.  The prestyloid compartment contains fat, a portion of the retromandibular parotid gland, and some lymph nodes.  The retrostyloid compartment contains the internal carotid artery, internal jugular vein, cranial nerves IX-XII, sympathetic chain, and lymph nodes.  The parapharyngeal nodes superiorly are connected to the node of Rouviere in the lateral most retropharyngeal space.
  3. 3 PATHWAYS:1) lateral pharyngeal wall to the lateral pharyngeal (parapharyngeal) nodes in the lateral pharyngeal or retroparotid space. The uppermost of this group of nodes is the lateral retropharyngeal node of Rouvier 2)From these lateral pharyngeal nodes, efferent channels pass to the jugular chain, especially to the jugulodigastric (subdigastric) nodes. Some lymphatic channels may bypass the lateral pharyngeal wall and drain directly to the jugulodigastric node 3) Another path is by direct channel to the deep nodes of the posterior triangle, the spinal accessory nodes. The uppermost node of this chain lies beneath the sternocleidomastoid muscle at the tip of the mastoid process.
  4. The incidence is highest among people from southern China, particularly those originating from Kwantung Province, followed by the Chinese mixed populations of Southeast Asia and indigenous populations in Alaska.[1],[2] It is of intermediate incidence in North Africa and in the Philippines and it is rare among whites and Japanese. The age-adjusted incidence rate (per 100,000 population per year) ranges from 28.8 in Hong Kong, 17.2 in indigenous populations in Alaska, 16.8 in Singapore, 4.6 in the Philippines, 2.8 in Algeria, and 0.6 in the United States and Japan.[3],[4] The peak incidence occurs in the fourth and fifth decade of life, and the male/female ratio is 2 : 1 to 3 : 1.
  5. Inactivation of the tumor suppressor genes namely the Chromosomes 14, 15 and 16 are considered central steps in the pathogenesis of high grade dysplasia. The cause of NPC is most likely multifactorial. (1) viral, (2) genetic, and (3) environmental. Various environmental factors such as poor ventilation, occupational exposures to smoke or dusts, and diet have been implicated. The ingestion of salted fish during early childhood has been suggested as the most important environmental factor among the southern Chinese with NPC.[2,9,10] Dimethylnitrosamine, a carcinogen found in salted fish, has been shown to induce carcinoma in the upper respiratory tract of rats.[9]
  6. Lymph nodes are involved at presentation in 89%. There is unilateral involvement in 39% and bilateral involvement in 51%. Low-grade squamous cell carcinomas produce fewer metastases (73%) than high-grade carcinomas (92%). Metastases to submental and occipital nodes may appear when there is blockage of the common lymphatic pathways either by massive neck disease or by an untimely neck dissection. Upper posterior cervical, parapharyngeal, and jugulodigastric nodes. The midjugular and midposterior cervical nodes are the next most commonly involved, followed by the lower jugular and supraclavicular nodes
  7. The exact incidence of cranial nerve involvement varies from series to series being higher in Asian series and those using CT scans. 12% patients have clinically detected cranial nerve palsy while 29% have radiologically detected cranial nerve involvement.
  8. A, Sagittal T1-weighted MRI scan demonstrates abnormal soft tissue (arrows) in the region of the left cavernous sinus extending from the upper nasopharynx. B, Axial postcontrast T1-weighted image following fat saturation demonstrating an invasive carcinoma that extends across midline to involve both Rosenm?ller&apos;s fossae (arrows). C, Coronal T1-weighted postcontrast MRI scan demonstrating the invasive carcinoma of the nasopharynx (black arrows) with extension through the foramen ovale along the course of the third division of the fifth cranial nerve into the cavernous sinus (white arrows). D, Axial postcontrast T1-weighted image through the cavernous sinus demonstrating an enhancing tumor that has expanded the left cavernous sinus (arrows) as it courses along the third division of the fifth cranial nerve.
  9. SO line is the line connecting the styloid process to the posterior edge of the foramen magnum.
  10. Ho’s System was a better predictor of prognosis than the 1988 AJCC system but it failed to include the prognostic importance of parapharyngeal extension. Further 5 stages were given which was not same as the western standard. The new AJCC system includes the nodal staging of the Ho’s system which is of prognostic significance
  11. Midline nodes are considered unilateral. Supraclavicular zone or fossa is relevant to the staging of nasopharyngeal carcinoma and is the triangular region originally described by Ho. It is defined by 3 points: (1) the superior margin of the sternal end of the clavicle, (2) the superior margin of the lateral end of the clavicle, and (3) the point where the neck meets the shoulder. Note that this would include caudal portions of Levels IV and V. All cases with lymph nodes (whole or part) in the fossa are considered N3b.
  12. The Lymphoepitheliomas subtype consists of undifferentiated cells forming syncitial mass is along with which large number of small lymphocytes are interspersed. Some authors believe that this histology confers a higher local control rate, as well as better prognosis than squamous cell carcinoma. Overall, it has been found that patients with undifferentiated histology have a higher proportion of advanced stage at presentation.
  13. The biological markers include IgA , IgE , anti-VCA often are predictors of relapse. Similiarly high ADCC levels are correlated with a better prognsis.