Duong Tiến Tùng

1. CASE
 Bệnh nhân: Đặng Thanh T. Nam 41T
 Lý do vv: Hạch cổ
 Bệnh sử: Cách vào viện 3 tuần, BN thấy xuất hiện
hạch vùng cổ phải, không đau, to dần. Kèm đau
nửa đầu bên phải, chảy máu cam số lượng ít  vv
 Tiền sử: VGB điều trị thuốc nam
Thuốc lá 6 bao/năm
 Thăm khám: Hạch ở đoạn 1/3 dưới sau cơ ức đòn
chũm bên phải. Kích thước 2cm, bề mặt nhẵn,
cứng, không đau, di động được.

2.  CTM: HC: 4.21; Hb: 145; Hct: 0.411; BC: 10.24
 Nội soi TMH: - Lần 1: Viêm họng amydal mạn tính-TD
nang hố dưới lưỡi thành thiệt.
- Lần 2: Viêm họng-Amydal. Loét vòm.
 Siêu âm vùng cổ: Đa hạch vùng cổ phải, Hạch lớn nhất
kích thước 24.11mm. Nang nhỏ thùy phải tuyến giáp.
 Mô bệnh học: Hạch di căn Carcinoma không biệt hóa.
 Cần làm thêm những gì??
Điều trị như thế nào??
Tiên lượng ra sao?

3. NASOPHARYNGEAL
CANCER
Tùng-Y4

4. OVERVIEW
 Introduction
 Anatomy
 Epidemiology
 Etiology
 Clinical presentation
 Classification
 Staging
 Treatment
 Prognosis

5. INTRODUCTION
 Nasopharyngeal cancer is a cancer that starts in
the nasopharynx, the upper part of the throat
behind the nose and near the base of skull.
 Nasopharyngeal carcinoma (NPC): 85%
 Lymphomas: 10%
 Adenocarcinoma

6. ANATOMY
 Anteriorly
 Roof
 Posteriorly
 Inferiorly
 Lateral wall

8. NASOPHARYNX

10. EPIDEMIOLOGY
 World wide:
o 80,000 new cases/year
o 50,000 deaths/year
 Regional differences
o Endemic in southern China, Hong Kong
o Rare in west
o Intermediate in middle east

11. EPIDEMIOLOGY
 Incidence:
o Increases after 20 years and decreases after 60
years
o M:F 3:1

12. ETIOLOGY
 Multifactorial
Endemic
Virus
DietGenetic
Non-
endemic
Tobacco
Alcohol

13. VIRUS
 Epstein-Barr virus (EBV)
o Normal nasopharyngeal epithelia lack EBV
o EBV DNA and EBV gene were found in precursor
lesions and tumour cells
o Patients also demonstrate specific serologic
responses to various gene products of EBV (Ig A
against EBV)
 Human papilloma virus (HPV)

14. DIET

15. CLINICAL PRESENTATION
 Patients may remain asymptomatic for a prolonged
period
 Most presents with locally advanced disease

16. Painless neck mass 30-70 % /nodal metastasis
Hearing loss or ear drainage 25 % /ET tube involvement
Nasal bleeding or obstruction Nasal cavity
Cranial nerve deficit
VI and V2(V2 most commonly)
facial pain
Cavernous sinus involvement
headaches Intracranial extension
Trismus pterygoid muscle invasion
Proptosis Orbit
neck discomfort. Retropharyngeal node involvement
9,10 ,11 CN Para pharyngeal space involvement

17. NECK MASS

18. LEFT PROPTOSIS

19. METASTATIC POTENTIAL
 Most common site
Cervical nodes
Up to 90 %
Bilateral in 50 % cases.
 Distant metastasis
o Bone (75%)
o Lung, liver, and distant nodes

20. DIAGNOSTIC EVALUATION
 Diagnostic Nasal Endoscopy
 Aural Examination
 Head and Neck Examination
 Cranial Nerve Examination

21. DIAGNOSTIC NASAL ENDOSCOPY

22. CT-SCAN

23. MRI

24. WHOLE BODY BONE SCAN

25. PET-CT

26. ENDOSCOPIC BIOPSY

27. CLASSIFICATION
 WHO classes:
 Keratinizing squamous cell carcinoma (type I)
 Non-keratinizing differentiated carcinoma (type II)
 Undifferentiated carcinoma (type III)

29. STAGING
29

30. 30

31. 31

32. 32

33. 33

34. 34

35. 35

36. 36

38. 38

39. 39

40. TREATMENT
 Radiotherapy
 Chemotherapy
 Surgery

41. SURGERY
 Not indicated as a primary treatment
 To obtain biopsy
 Neck dissection
Residual neck nodes following RT
Isolated neck recurrence

42. RADIOTHERAPY
 External beam radiotherapy
o two-dimensional radiation therapy (2D-RT)
o three-dimensional conformal radiation therapy
(3D-CRT)
 Intensity-modulated radiation therapy (IMRT)
 Brachytherapy

43. EXTERNAL BEAM RADIOTHERAPY
 2 lateral fields: nasopharynx, skull base & upper
neck; sparing temporal lobe, pituitary & spinal cord.
 1 anterior field: lower neck; sparing spinal cord &
larynx

44. BRACHYTHERAPY
 Used for small tumor, residual or recurrent tumor

46. COMPLICATIONS
 U tái phát
 Khối u lành tính của hầu
 Cứng cơ khít hàm do bất thường khoang nhai
 Tổn thương thùy thái dương
 Hoại tử xương do xạ trị
 Các khối u do bức xạ kích thích

47. CHEMOTHERAPY
 Drug used: - Cisplatin
- 5-Fluorouracil
 Role of chemotherapy : radiation sensitization,
locoregional control
(locoregional means: limited to a localized area, as
contrasted with systemic or metastatic)
 Indications: - Radiation failure
- Palliation in distant metastasis

48. RESULT: 6% ABSOLUTE SURVIVAL BENEFIT AT
5 YEARS

49. TREATMENT
 T1 N0 M0:
 RT alone
 T2,T3,T4 or N+,M0
 ChemoRT
 Cisplatin based 3 weekly
 Metastatic
 Platinum based combination CR radical RT

51. OTHER
 Immunotherapy against E.B.V
 Vaccination against EBV: experimental

52. POSTTREATMENT FOLLOW-UP
Documentation of remission
 Clinical
 Endoscopic
 Imaging
3 months
 MRI scan of the skull base and neck
 CT head &neck
 PET-CT

53. FOLLOW UP
 3 monthly follow up for 2 years
 4-6 monthly for 3-5 years
 Annually after 5 years
11/3/2016 53

54. PROGNOSIS

55. PROGNOSIS