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8 npc

  1. 1. Nasopharyngeal Carcinoma N P C Mai Hai-Qiang ( 麦海强 ) Department of NPC Sun Yat-Sen University Cancer Center
  2. 2. What is NPC ? ★ A very special type of head and neck cancer ★ Different from other malignancies of the upper aerodigestive tract with regard to - Epidemiology, -Histology, -Clinical presentations and -Treatment strategies.
  3. 3. N P C --- Canton Cancer <ul><li>80% of patients with NPC are found in </li></ul><ul><li>Southeast Asia, especially in southern </li></ul><ul><li>China : GuangDong Province </li></ul>Why is it called “ Canton Cancer ” ?
  4. 4. 一、 Epidemiology <ul><li>⑴ Evident geographic distribution difference </li></ul><ul><li>明显的地区性分布差异 </li></ul><ul><li>⑵ Specific susceptible population </li></ul><ul><li>特定的易感人群 </li></ul><ul><li>⑶ Family cluster phenomenon </li></ul><ul><li>家族史和家族聚集现象 </li></ul><ul><li>⑷ Stable Incidence Rate and Men to Women Ratio: 2 ~ 3.8:1 </li></ul><ul><li>发病率相对稳定 </li></ul><ul><li>⑸ Differences between high and low incidence areas </li></ul>
  5. 5. ⑴ Evident geographic distribution difference <ul><li>Endemic areas: </li></ul><ul><li>★ Highest incidence: GuangDong province. </li></ul><ul><li>★ High incidences: Southern China </li></ul><ul><li>GuangXi; HuNan; FuJian; JiangXi and Hainan. </li></ul><ul><li>★ High incidences: S outheast Asia </li></ul><ul><li>HongKong and Singapore Chinese </li></ul><ul><li>---Incidence Rate:30-50/100,000 </li></ul>
  6. 6. ⑴ Evident geographic distribution difference <ul><li>Outside of endemic areas: </li></ul><ul><li>---Incidence Rate: < 1 / 100,000 </li></ul><ul><li>★ Lowest incidences </li></ul><ul><li>are seen in north American Caucasians and Europeans, </li></ul><ul><li>Japanese and Indians. </li></ul><ul><li>★ Rare in Caucasians (white people) </li></ul>
  7. 7. <ul><li>★ Intermediate incidence </li></ul><ul><li>-- Emigrant Southern Chinese in USA, </li></ul><ul><li>-- Malaysia, </li></ul><ul><li>-- Singapore Malays </li></ul><ul><li>-- and the Eskimos in North America. </li></ul><ul><li>★ Intermediate incidence North Africa: The Arabs. </li></ul><ul><li>Incidence Rate: 5-10/100,000 </li></ul>⑴ Evident geographic distribution difference
  8. 8. 中国 ( 南方六省 ) 鼻咽癌分布情况 湖 南 江 西 福 建 广 西 广 东 海南
  9. 9. The High and Relatively High NPC Incidence Areas The Arctic Ocean Pacific Europe Asian Middle East Africa Oceania North America South America Latin America
  10. 10. ⑵ Specific susceptible population 特定的易感人群 <ul><li>Mongolian </li></ul><ul><li>Chinese </li></ul><ul><li>Cantonese </li></ul>
  11. 11. ⑵ Specific susceptible population 特定的易感人群 North America Eskimos
  12. 12. NPC incidence rates between Chinese immigrants and other racial residents in Los Angeles and Singapore 0.2 0.2 Vietnamese 0.5 0.5 Indian 2.0 6.5 Malayan 7.3 18.5 Chinese Singapore 0.3 0.2 Japanese 0.3 3.8 Philippine 2.8 9.8 Chinese 0.2 1.0 Ethiopian 0.2 0.5 Caucasian Los Angeles female male incidence rates (/10 5 /year) country race
  13. 13. NPC incidence Rate of Chinese in Sigapore(/10 5 ) 4.7 14.1 FuJian 1.3 6.2 ShangHai 4.8 12.6 KeJia 6.2 18.3 ChaoZhou 11.0 29.1 Cantonese Incidence Rate of NPC Male Female language
  14. 14. Death Rates in different dialectal populations in GuangDong Province(10 5 ) 1.96 5.32 KeJia 2.89 6.18 ChaoZhou 4.32-5.84 12.08-15.96 Cantonese Death Rate of NPC Male Female language
  15. 15. ⑶ Family cluster phenomenon <ul><li>Family history of cancer: 21.6% </li></ul><ul><li>Family history of NPC:12.3% </li></ul><ul><li>Statistics in GuangDong province </li></ul>
  16. 16. <ul><li>27% of NPC patients </li></ul><ul><li>in Greenland were found to have a family history of cancer among first-degree relatives </li></ul>⑶ Family cluster phenomenon
  17. 17. Famous Family ↓ □ male ■ NPC  Breast Cancer ○ female ● NPC  Male Liver Cancer 34.2% cancers 26.3% NPC ● ○ ●  ●■■■ □  □ ■ ○○ ■ □□□○ ■ □○□○□○○□□○○○□ ■ □□○ ■■ ○○ ○○□□□ ○○□□ ○□ □ ○□○□□ ○□ □○○○○□○○ □□ □○ □○ □○ ○○○ □□ □ □ ○ ○□ ○ ○○ □○ ○ ○○ ○ ○○ ● ○ ○ ● □ ■ □ ○ □ □ ○
  18. 18. 4 Stable Incidence Rate and Men to Women Ratio: 2 ~ 3.8 :1 发病率相对稳定 Changes of Cancer Incidence Rate during 30 Years
  19. 19. 5 Differences Between High and Low Incidence Areas Two frequency age peaks: 16-19 and 50-59 Quickly increase after the age of 30, and reaches the peak between 50-59 Age of disease onset The Low Incidence Areas The High Incidence Areas
  20. 20. 5 Pathology differences between high and low incidence areas Type I: Well-differentiated squamous carcinoma 角化性鳞状细胞癌 Type II: Differentiated Non-keratinising Carcinoma 分化型非角化性癌 Type III: Undifferentiated Non-keratinising Carcinoma 未分化型非角化性癌 WHO histological classification of nasopharyngeal carcinoma Type I Type II Type III
  21. 21. 5 Differences Between High and Low Incidence Areas Type II and III Type II and III The Low Incidence Areas The High Incidence Areas Well-differentiated squamous carcinoma accounts for 25% Type I Well-differentiated squamous carcinoma accounts for 1.67% Type I Pathology Type
  22. 22. 二、 Aetiology NPC Lung Cancer External Factors Internal Factors Internal Factors External Factors
  23. 23. 二 Aetiology NPC EB-Virus Hereditary Factors Environmental Factors
  24. 24. Hereditary susceptibility <ul><li>Loss of Tumor Suppressor Genes </li></ul><ul><li>like: 3p13-3p25; 7p32-qter; and 9p21-22. </li></ul><ul><li>Human Leucocyte Antigen (HLA) and </li></ul><ul><li>its cytochrome p4502E </li></ul><ul><li>are possibly NPC susceptibility genes. </li></ul><ul><li>NPC susceptibility genes are possibly located </li></ul><ul><li>in : 4p1511-q12 area. (2002, nature) </li></ul>
  25. 25. EBV---Epstein Barr Virus <ul><li>★ a DNA virus; </li></ul><ul><li>★ a member of the herpes sub-family </li></ul><ul><li>★ Infection of EBV is ubiquitous </li></ul><ul><li>★ In our country, EBV Infection occurs early </li></ul><ul><li>in life: 90% of population have been </li></ul><ul><li>infected by this virus in the age of 3-5. </li></ul><ul><li>★ EBV can stay in the body life-long </li></ul>
  26. 26. EBV---Epstein Barr Virus <ul><li>Antibodies IgA titres to EBV Antigens: </li></ul><ul><li>Viral Capsid Antigen ( VCA ) </li></ul><ul><li>Early Antigen ( EA ) </li></ul><ul><li>★ Usually VCA-IgA and EA-IgA positive rate and its </li></ul><ul><li>titres are much higher in NPC patients than in healthy </li></ul><ul><li>people and other cancer patients </li></ul><ul><li>★ Serve as a diagnostic marker. </li></ul><ul><li>★ Help doctors to identify NPC patients and to do early </li></ul><ul><li>diagnosis </li></ul>
  27. 27. Environmental Factors Nitrosamines 亚硝胺 salted fish  laboratory mice  cancer of nasal cavity cancer of nasopharynx Cantonese-style salted fish and other preserved foods
  28. 28. Environmental Factors <ul><li>Extensive exposure to smoke and dust </li></ul><ul><li>芳香烃 (aromatic hydrocarbon) : </li></ul><ul><li>▲ 其中的 3,4- 苯并芘 (3,4-benzpyrene) 已肯定是致癌 </li></ul><ul><li>性较强的物 </li></ul><ul><li>▲ 在鼻咽癌高发区的家庭内,每克烟尘中 3,4- 苯 </li></ul><ul><li>并芘含量达 16.83  g ,明显比低发区家庭高。 </li></ul><ul><li>▲ 动物实验中可以诱发大鼠鼻咽部肿瘤 </li></ul>
  29. 29. 硫酸镍 (nickel sulfate) 小剂量 DNP( 二亚硝基哌嗪)诱发大鼠鼻咽癌的过程中起促进癌变的作用 Evironmental Factors 微量元素 (microelements) 镍 ( nickel) 激发 EB 病毒 , 并促进其抗原表达 硒 (selenium) 鼻咽癌患者硒含量偏低 钙 (calcium) 低钙区与鼻咽癌高发区分布一致
  30. 30. 三 . Anatomy of Nasopharynx
  31. 31. Soft palate the torus sphenoid sinus clivus atlas axis Pharyngeal tonsil
  32. 32. 三 . Anatomy of Nasopharynx lateral pharyngeal Recess (fossa of Rosenmullar) the torus ( 隆突) Eustachian tube ( 耳咽管 ) nasal septum 鼻中膈 Choanae ( 后鼻孔 )
  33. 33. lateral pharyngeal recess (Fossa of Rosenmullar) the torus Soft palate
  34. 34. * Ascending palatine Ascending pharyngeal - main External carotid A Maxillary Supplying vessels
  35. 35. Maxillary
  36. 36. jugulodigastric Rouviere’s lymph nodes, Deep cervical lymph nodes, Supraclavicular lymph nodes Lymphatic Drainage Neck nodes
  37. 37. 四 Clinical presentations <ul><li>★ Neck Symptoms </li></ul><ul><li>★ Nasal Symptoms </li></ul><ul><li>★ Ear Symptoms </li></ul><ul><li>★ Neurological Symptoms </li></ul><ul><li>Cranial Nerve Paralysis </li></ul><ul><li>Headaches </li></ul>
  38. 38. Symptoms 1 <ul><li>★ Neck Symptoms: Lump in the neck 60-80% </li></ul>
  39. 39. jugulodigastric ( 颈静脉 二腹肌 )
  40. 40. Symptoms 2 <ul><li>★ Nasal symptoms </li></ul><ul><li>--Blood-stained nasal discharge (sputum 痰 ) : 70% </li></ul><ul><li>涕血或吸痰带血 (tumor friction with soft palate) </li></ul><ul><li>--Frequent nose bleeds (Epistaxis): 37% 鼻出血 </li></ul><ul><li>(when blood vessels broken) </li></ul><ul><li>--Nasal obstruction or stuffiness: 50% 鼻塞 </li></ul><ul><li>( Is a late finding indicating that a large tumor obstructing the posterior choanae) </li></ul>
  41. 41. Symptoms 3 <ul><li>★ Ear Symptoms: </li></ul><ul><li>-- Ringing in an ear (tinnitus 耳鸣 ) : 60% </li></ul><ul><li>-- Trouble hearing or hearing loss: 50% </li></ul><ul><li>-- Sense of fullness or pain in the ear : </li></ul><ul><li>(when tumor presses on or obstructs eustachian tube ) </li></ul>
  42. 42. Symptoms 4 <ul><li>★ Neurological Symptoms </li></ul><ul><li>▲ Cranial Nerve Paralysis: 45% </li></ul><ul><li>VI and V cranial nerves are the most </li></ul><ul><li>commonly affected. </li></ul><ul><li>▲ Headaches: 57-68% </li></ul><ul><li>due to skull base erosion or cranial nerve </li></ul><ul><li>irritation without bony involvement. </li></ul>
  43. 43. Cranial Nerves <ul><li>1. Olfactory 嗅 7. Facial 面 </li></ul><ul><li>2. Optic 视 8. Vestibulocochlear 听 </li></ul><ul><li>3. Oculomotor 动眼 9. Glossopharyngeal 舌咽 </li></ul><ul><li>4. Trochlear 滑车 10. Vagus 迷走 </li></ul><ul><li>5. Trigeminal 三叉 11. Spinal Accessory 副 </li></ul><ul><li>6. Abducens 外展 12. Hypoglossal 舌下 </li></ul><ul><li>颈交感神经 : cervical sympathetic nerve </li></ul>
  44. 44. Cranial Nerve Damage <ul><li>① 损害部位发生在其离颅 ( 或更下方 ) 的位置 </li></ul><ul><li>Damaged area is in or under the exit of cranial nerves </li></ul><ul><li>through bony base of skull </li></ul><ul><li>多见于原发灶的同侧 : Unilateral </li></ul><ul><li>V,VI 颅神经受侵较多 : </li></ul><ul><li>cranial nerves V and VI are the most common affected nerves. </li></ul>
  45. 45. Exit of cranial nerves through bony base of skull Middle cranial fossa Posterior cranial fossa
  46. 46. Exit of cranial nerves through bony base of skull Optic foramen: II Cribriform plate: I Superior orbital fissure: III, IV, V 1 , VI
  47. 47. Exit of cranial nerves through bony base of skull Hypoglossal canal: XII Foramen rotundum: V 2 Foramen ovale: V 3 Internal auditory meatus: VII, VIII Jugular foramen: IX, X, XI
  48. 48. ☺ Optic foramen 视神经孔 : II ☺ Superior orbital fissure 眶上裂 : III, IV, V 1 , VI ☺ Foramen rotundum 圆孔 : V 2 ☺ Foramen ovale 卵圆孔 : V 3 (Middle cranial fossa 中颅窝 ) ☺ Internal auditory meatus 内耳门 : VII, VIII ☺ Jugular foramen 颈静脉孔 : IX, X, XI ☺ Hypoglossal canal 舌下神经孔 : XII (Posterior cranial fossa 后颅窝 ) Exit of cranial nerves through bony base of skull
  49. 49. Cranial nerves III-VI are affected within the Cavernous sinus 破裂孔 III IV V 1 VI V 2 (Situated beside sella turcica)
  50. 50. Cavernous sinus 破裂孔 (Situated beside sella turcica)
  51. 51. Cavernous sinus
  52. 52. Parapharyngeal Space 茎突 Processus styloideus
  53. 53. 茎突 Processus styloideus
  54. 54. Parapharyngeal Space
  55. 55. Parapharyngeal Space involvement
  56. 56. Nerves IX-XII are primarily affected in the Parapharyngeal Space below the skull base <ul><li>9. Glossopharyngeal 舌咽 </li></ul><ul><li>10. Vagus 迷走 </li></ul><ul><li>11. Spinal Accessory 副 </li></ul><ul><li>12. Hypoglossal 舌下 </li></ul><ul><li>颈交感神经 : cervical sympathetic nerve </li></ul>
  57. 57. 常见颅神经损害症状 Symptoms of commonly affected cranial nerves <ul><li>3. 动眼神经 Oculomotor : </li></ul><ul><li>★ 路径: 中脑 (midbrain)  ( 海绵窦外侧壁 )  ( 眶上裂 ) </li></ul><ul><li> 内、上、下直肌、下斜肌和提上睑肌 </li></ul><ul><li>★ 症状: 眼球处于半固定状态(只能向外及外下方移 </li></ul><ul><li>动); 上眼睑下垂 ( ptosis) ,不能睁眼 . </li></ul><ul><li>★ 症状:  副交感纤维  瞳孔括约肌和睫状肌 </li></ul><ul><li> 瞳孔散大 (mydriasis) ,对光及调节反应消失 </li></ul><ul><li>(failure of accommodation) </li></ul>
  58. 58. Unilateral ptosis oculomotor nerve paralysis
  59. 59. <ul><li>5. 三叉神经 Trigeminal : </li></ul><ul><li>★ 路径: 运动纤维 (motor) V 3 : </li></ul><ul><li>脑桥 (pons)  (卵圆孔)  咀嚼肌 (masticatory muscles) (包括嚼肌、颞肌、翼内肌、翼外肌),鼓膜张肌和腭帆张肌等 </li></ul><ul><li>★ 症状: 张口时下颌向患侧偏歪 (jaw tilt) ,甚至张口 </li></ul><ul><li>障碍 Difficulty opening the mouth(trismus) </li></ul>常见颅神经损害症状 Symptoms of commonly affected cranial nerves
  60. 60. <ul><li>5. 三叉神经 Trigeminal : </li></ul><ul><li>★ 路径: 感觉纤维 (sensory) : </li></ul><ul><li>▲ 眼 支  (眶上裂)  眼外眦角以上皮肤 </li></ul><ul><li>▲ 上颌支  (圆孔)  外眦至口角间皮肤 </li></ul><ul><li>▲ 下颌支  (卵圆孔)  口角以下皮肤,舌前 2/3 </li></ul><ul><li>★ 症状: 支配区域感觉障碍 , 角膜反射消失。 </li></ul><ul><li>Numbness in the face or facial paresthesia </li></ul><ul><li>disappearance of corneal reflex </li></ul>常见颅神经损害症状 Symptoms of commonly affected cranial nerves
  61. 61. V1 V2 V3
  62. 62. (jaw tilt) ( ptosis) CN : III 、 V 、 VI (+)
  63. 63. <ul><li>6. 外展神经 VI: </li></ul><ul><li>★ 路径: 脑桥  ( 颞骨岩尖 )  ( 海绵窦 ) </li></ul><ul><li> ( 眶上裂 )  外直肌( lateral rectus muscle ) </li></ul><ul><li>★ 症状: 眼球不能外展,呈明显的内斜视 ( failure of abduction) , 产生复视 ( double vision: diplopia ) </li></ul>常见颅神经损害症状 Symptoms of commonly affected cranial nerves
  64. 64. 面神经损伤 (周围性面瘫)
  65. 65. CN : VI 、 XII ( + ) Horner ’s ( + ) tongue lateralized to affected side upon protrusion 舌肌萎缩,伸舌偏向患侧 failure of abduction 内斜视
  66. 66. <ul><li>9. 舌咽神经 Glossopharyngeal : </li></ul><ul><li>延脑 (medulla oblongata)  ( 颈静脉孔 )  茎突后区 </li></ul><ul><li>① 运动纤维: </li></ul><ul><li>* 患侧软腭下塌 (soft palate depression) ,悬雍垂偏向健侧,发“啊”音时软腭不能收缩 </li></ul><ul><li>② 感觉纤维: </li></ul><ul><li>* 咽部及舌后 1/3 感觉减退 (deficiency of taste sensation of posterior third of the tongue) </li></ul><ul><li>* 吞咽障碍 (dysphagia) </li></ul>常见颅神经损害症状 Symptoms of commonly affected cranial nerves
  67. 67. <ul><li>10. 迷走神经 vagus: </li></ul><ul><li>延脑  ( 颈静脉孔 )  (茎突后区) </li></ul><ul><li>① 咽支,喉上神经:  环甲肌;喉内粘膜 </li></ul><ul><li>② 喉返神经:  喉内小肌,声带,声门裂以下粘膜 </li></ul><ul><li>* 感觉: 咽、喉部麻痹, 呛咳 aspiration ; </li></ul><ul><li>* 运动: 声嘶 hoarseness (声带处于尸位) </li></ul>常见颅神经损害症状 Symptoms of commonly affected cranial nerves
  68. 68. <ul><li>12. 舌下神经 Hypoglossal : </li></ul><ul><li>延脑  ( 舌下神经孔 )  (茎突后区)  舌部肌肉 </li></ul><ul><li>* 伸舌时舌尖偏向患侧 (tongue lateralized to affected side upon protrusion) ,病变侧舌肌萎缩 (tongue atrophy) 和肌纤维震颤 </li></ul>常见颅神经损害症状 Symptoms of commonly affected cranial nerves
  69. 69. 颅 N 损害 涕 血 鼻 塞 外展障碍 耳鸣、听力↓ 伸舌右歪舌肌萎缩 头痛
  70. 70. 五 Diagnosis CT scan endoscopy laboratory
  71. 71. Procedure of diagnosis <ul><li>★ Take a complete medical history </li></ul><ul><li>Noting all symptoms and risk factors. </li></ul><ul><li>★ Clinical examination of NP: </li></ul><ul><li>Indirect mirror examination or </li></ul><ul><li>direct fibroscopic examination </li></ul><ul><li>★ Clinical examination of neck mass </li></ul><ul><li>★ EBV Serology : VCA-IgA; EA-IgA; EBV-DNaseAb </li></ul><ul><li>★ Imaging : CT or MRI of NP and neck </li></ul><ul><li>★ Pathology: - biopsy </li></ul>
  72. 72. Indirect mirror examination
  73. 73. With a forcep 钳子 Rarely used Inconvenient
  74. 74. Direct transnasal endoscopic examination Widely used
  75. 75. Anatomic Types Nodular Fungating Submucosal Inverting Ulcerating Mixed 菜 花 型 结 节 型 粘 膜 下 型 浸 润 型 溃 疡 型 混 合 型
  76. 76. Imaging Study <ul><li>★ Help to make the correct diagnosis </li></ul><ul><li>★ Help To know the disease stage </li></ul><ul><li>★ Help to determine the target volume of </li></ul><ul><li>radiotherapy </li></ul><ul><li>★ Help to evaluate the treatment results </li></ul><ul><li>★ Follow-up </li></ul>
  77. 77. Imaging Study
  78. 78. Imaging Study
  79. 79. Imaging Study
  80. 80. Imaging Study
  81. 81. MRI of NP ---- better than CT
  82. 82. MRI of NP ---- better than CT MRI is more sensitive than CT in detecting tumors of the nasopharynx and its possible spread to nearby tissues or lymph nodes.
  83. 83. More examination – To find Metastasis <ul><li>★ Chest x-ray: </li></ul><ul><li>to identify lung metastasis </li></ul><ul><li>★ Abdominal ultrasound: </li></ul><ul><li>to find liver metastasis. </li></ul><ul><li>★ ECT of bones: Radionuclide bone scan </li></ul><ul><li>Using very small amounts of radioactive </li></ul><ul><li>material to determine whether the cancer </li></ul><ul><li>has spread to the bones. </li></ul>
  84. 84. PET (positron emission tomography) <ul><li>This test creates an image of the body using an injection of a substance, such as glucose (sugar), in a low dose, radioactive form. </li></ul><ul><li>Since it is new, the benefit of PET scanning is not clearly proven, but some doctors may recommend it to look for cancers that cannot be identified by other scans or tests. </li></ul>
  85. 85. PET/CT
  86. 86. PET/CT 鼻咽部病灶
  87. 87. PET/CT
  88. 88. Pathological study <ul><li> The diagnosis can be made only after the </li></ul><ul><li>biopsy of the nasopharyngeal tumor </li></ul><ul><li> Neck nodes biopsy is done only when the </li></ul><ul><li>biopsy of the nasopharyngeal tumor is </li></ul><ul><li>impossible </li></ul>
  89. 89. 六 Clinical Types of NPC ▲ Ascending Type 上行性 ----- Type of Cranial Nerves damage ▲ Descending Type 下行性 ----- Type of Lymphatic Metastasis ▲ Mixed Type 混合性 ▲ Metastasis Type: 转移性
  90. 90. Ascending Type (Type of Cranial Nerves) Damages of II 、 III 、 IV 、 V cranial Nerves and/or skull base But No lymph node Metastasis !
  91. 91. Descending Type (Type of Lymphatic Metastasis) <ul><li>Very large lymph node </li></ul><ul><li>Metastasis </li></ul><ul><li>Without involvement of </li></ul><ul><li>cranial Nerves and/or </li></ul><ul><li>base of skull </li></ul>
  92. 92. Mixed Type <ul><li>lymph node Metastasis </li></ul><ul><li>+ damage of cranial Nerves and/or cranial base </li></ul>
  93. 93. Metastasis Type: 1.Bone 2.Liver 3.Lung 4.Other: abdominal nodes
  94. 94. Metastasis of NPC <ul><li>★ Bone is the most commonly affected area </li></ul><ul><li>( 骨盆 pelvis ;脊柱 vertebral column; 肋骨 ribs; 四肢 extremities) </li></ul><ul><li>★ Liver is the second most common affected area </li></ul><ul><li>★ Lung is the another common affected area </li></ul>
  95. 95. PET/CT: dorsal vertebra lumbar vertebra
  96. 97. Lung metastasis Liver metastasis
  97. 98. 八 Differentiated diagnosis <ul><li>Hyperplasia of adenoids </li></ul><ul><li>Tuberculosis </li></ul><ul><li>Median Necrotic Granuloma (NK/T lymphoma) </li></ul><ul><li>Fibroangioma </li></ul><ul><li>Chronic inflammation </li></ul><ul><li>Chordoma;craniopharyngioma </li></ul><ul><li>Cerviccal lymphadenitis </li></ul>
  98. 99. 八 Differential Diagnosis Adenoids 成人腺样体增生 鼻咽腺样体 成人淋巴组织增生 鼻咽扁桃体增生
  99. 100. Differential Diagnosis Median Necrotic Granuloma tuberculosis 鼻咽结核 中线坏死性肉芽肿
  100. 101. 青年男性多见 Fibroangioma
  101. 102. Clinical staging <ul><li>★ Make treatment strategy </li></ul><ul><li>★ Predict prognosis </li></ul><ul><li>★ TNM Staging System </li></ul><ul><li>▲ (T, tumor) </li></ul><ul><li>How large is the primary tumor </li></ul><ul><li>▲ (N, node) </li></ul><ul><li>Has the tumor spread to the lymph nodes? </li></ul><ul><li>▲ (M, metastasis) </li></ul><ul><li>Has the cancer spread to other parts of the body? </li></ul>
  102. 103. 九 NPC ’92 Clinical Classification
  103. 104. T staging <ul><li>T1: tumor limited to the nasopharynx. </li></ul><ul><li>T2: tumor involving nasal cavity, oropharynx, soft </li></ul><ul><li>palate, and parapharyngeal space. Extension </li></ul><ul><li>before SO-line </li></ul><ul><li>T3: tumor extension over SO-line , involving either anterior </li></ul><ul><li>or posterior cranial nerves, base of skull </li></ul><ul><li>pterygoprocesse zone, pterygopalatine fossa. </li></ul><ul><li>T4: tumor involving both anterior and posterior </li></ul><ul><li>cranial nerves, paranasal sinus, cavernous sinus, </li></ul><ul><li>orbit, infratemporal fossa, and direct invasion of </li></ul><ul><li>first and second cervical vertebrae </li></ul>
  104. 105. N - M Staging <ul><li>N1: Upper neck nodes < 4cm, mobile </li></ul><ul><li>N2: Lower neck nodes or nodes 4~7cm; </li></ul><ul><li>N3: Node >7cm or supraclavicular node,or </li></ul><ul><li>fixed node </li></ul>M0: no metastasis M1: metastasis
  105. 106. Treatment Option ★ Radiotherapy: Radical (根治手段) ★ Chemotherapy: Adjuvant ★ Operation: Complementary
  106. 107. Treatment protocol -- stratified therapy Radiotherapy + Induction or Concomitant + Adjuvant chemotherapy Radiotherapy + Induction or Adjuvant chemotherapy N2-3 Radiotherapy + Induction or Concomitant chemotherapy Radiotherapy N0-1 T3-4 T1-2
  107. 108. Brachytherapy is most often used to manage cancers that have recurred (come back) after treatment. It may also be used to treat the small original tumor. Intensity Modulated Radiation Therapy (IMRT) A new method of external radiation, known for delivering more effective doses of radiation while reducing the damage to healthy cells, thus causing fewer side effects. Stereotactic radiosurgery delivers radiation therapy precisely to the tumor using a machine called a gamma knife . This can be used to treat tumors that have invaded the base of the skull, or tumors that have recurred at the base of the brain or skull.
  108. 109. 80 年代的方法
  109. 110. 90 年代放射治疗 眼 鼻咽 口腔 大脑 脑干 鼻 LN 照射区 铅 挡 块 模拟定位照片和复位照片,示照射范围 (Ia)
  110. 111. 铅挡块
  111. 112. Radiotherapy: Radical
  112. 113. 90 年代放射治疗
  113. 114. 常规放射治疗 调强放射治疗 From Bucci, M. K. et al. CA Cancer J Clin 2005;55:117-134. 21 世纪放射治疗
  114. 115. 多页光栅 IMRT
  115. 116. IMRT 剂量分布图
  116. 117. External beam radiation - complications <ul><li>xerostomia, tooth decay </li></ul><ul><li>Endocrine disorders – hypopituitarism , hypothyroidism, hypothalamic disfunction </li></ul><ul><li>Soft tissue fibrosis including trismus </li></ul><ul><li>Ophthalmologic problems </li></ul><ul><li>Skull base necrosis </li></ul><ul><li>Hearing loss </li></ul><ul><li>temporal lobe necrosis;peripheral nerve damages(nerve atrophy). </li></ul>
  117. 118. Chemotherapy: combined <ul><li>诱导化疗 : Neo-adjuvant chemotherapy </li></ul><ul><li>recommended </li></ul><ul><li>辅助化疗 : Adjuvant chemotherapy </li></ul><ul><li>Selected patients </li></ul><ul><li>同时期化放疗 : </li></ul><ul><li>Concomitant Chemoradiotherapy </li></ul><ul><li>Standard </li></ul>
  118. 119. Protocols of chemotherapy <ul><li>PF: DDP+5-Fu the first line </li></ul><ul><li>PFB: DDP+5-FU+BLM </li></ul><ul><li>PT: Paclitaxol + DDP </li></ul><ul><li>GP: Gemcitabine + DDP </li></ul><ul><li>Taxotere + DDP </li></ul>
  119. 120. 5-year survival of 351 cases after combined stratified therapy (’92classification) 22% 50% 76% 90% Radiotherapy only (411 cases) 40.2% 62.3% 80% 95% Combined Therapy (351 cases) IVa III II I stage
  120. 121. Surgery -- for selected patients <ul><li>★ NP Residual disease </li></ul><ul><li>★ NP Recurrent disease </li></ul><ul><li>(when radiation therapy is contraindicated) </li></ul><ul><li>★ Residual cervical nodes </li></ul><ul><li>★ Recurrent cervical nodes </li></ul>
  121. 123. thanks for your attention !

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