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Cancer of the nasopharynx

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cancer of nasopharynx,
By : Dr , Ibrahim Habib Barakat. M.D.(otorhinolaryngology).
salamatuall@yahoo.com
/www.facebook.com/Dr.Ibrahim.Barakat

Published in: Health & Medicine

Cancer of the nasopharynx

  1. 1. Cancer of thenasopharynx<br />BY<br />Dr , Ibrahim HabibBarakat<br />M.D.<br />( E.N.T.)<br />salamatuall@yahoo.com<br />www.facebook.com/Dr.Ibrahim.Barakat<br />
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  4. 4. Epidemiology of nasopharyngeal ca.<br />Incidence : Rare o.6 per 100,000 l yr in U S A<br />Southern China is 50 times > U S A ِ<br />Age : 4TH to 5th decade<br />Sex : male : female 2 to 3 : 1<br />Etiology : Multifactorial : <br />Viral , dietry , occupational , cigarette smoking<br />
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  6. 6. Viruses & human malignancies<br />
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  8. 8. Anatomy of the nasopharynx<br />Anterior : post. Nasal choana , nasal septum<br />Post : 2 cervical vertebrae , prevertebral and buccopharyngeal fascia<br />Sup: basisephenoid , basioccipt<br />Inf : sup . Surface of soft palate<br />Lateral : maxilloph. Space , pterigoid plate, paraph. Space<br />
  9. 9. pharynx<br />
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  11. 11. Fossa of Rosenmuller<br />Eustachian tube opens in lateral wall of the nasopharynex , surrounded by torus tubarius ( cartilagenous elevation ) . <br />A recess behind torus tubarius is called Rosenmuller fossa . <br />Clinical importance : location for cancer to arise . <br />
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  13. 13. Blood supply of nasopharynx<br />Arterial : branches from E.C.A.<br />Venous : pharyangeal plexus to I.J.V.<br />
  14. 14. Nerve supply of nasopharynx<br />Branches from cranial nerve V2 , IX , X .<br />Sympathetic n.<br />
  15. 15. Lymphatic drainage of the nasopharynx<br />Retropharyngeal .<br />Parapharyngeal .<br />Jugular chain .<br />L . N . Of spinal accesory chain in posterior triangle.<br />Supraclavicular L . N .<br />Contralateral neck.<br />
  16. 16. Epithelial lining of nasopharynx<br />60% of nasopharynx is lined with <br />Stratified squamous epithelium<br />
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  18. 18. Spread of nasopharyngeal ca.<br />Ant : nasal cavity , paranasal sinuses , pterigopalatine fossa, orbital apex .<br />Inferiorly : oropharynx.<br />Superiorly : skull base , sphenoid body & sinus.<br />Laterally : paraph. , pterigoid structures.<br />
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  21. 21. Pathology of tumors of nasopharynx<br />Epithelial benign<br />Epithelial malignant<br />Papilloma<br />Pleomorphic adenoma<br />Oncocytoma<br />Basal cell adenoma<br />Ectopic pituitary adenoma<br />Nasopharyngeal carcinoma.<br />1- Squamous cell ca. <br />2- Non keatinizing ca. <br />3- Undifferentiated ca.<br />Adenocarcinoma.<br />Papillary adenocarcinoma.<br />Mucoepidermoid carcinoma.<br />Adenoid cyctic ca.<br />Polymorph low grade adeno ca. <br />
  22. 22. Pathology of tumors of nasopharynx<br />Non epithelial Benign<br />Non epithelial malignant<br />Angiofibroma.<br />Fibroma.<br />Haemangioma.<br />Osteoma.<br />Haemangioma.<br />Haemangiopericytoma.<br />Paraganglioma.<br />Meningioma.<br />Craniopharyngioma.<br />Angiosarcoma.<br />Kaposi sarcoma.<br />Malignant haemagiopericytoma.<br />Fibrosarcoma.<br />Rabdomyosarcoma.<br />Osteosarcoma.<br />Malignant nerve sheath tumor.<br />Chondrosarcoma.<br />Chordoma.<br />Malignant melanoma.<br />Malignant lymphoma.<br />2ry tumors<br />
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  24. 24. Tumour like lesions<br />1- Cyst.<br />2-Heterotopic pituitary tissue.<br />3- Menengocele , meningoencephalocele.<br />4- fibroinflammatory pseudotumour,<br />5- infective granuloma.<br />6- wegner,s granuloma.<br />7- Pseudoepthliomatous hyperplasia.<br />8- granuloma pyogenicum.<br />9- lymphoid hyperplasia.<br />10- oncocytic metaplasia.<br />
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  31. 31. Symptoms of nasopharyngeal ca<br />Neck mass <br />, blood tinged mucus .Epistaxis<br />Nasal obstruction<br />Change of voice<br />Pain – Ozona - otalgia – headache<br />Decreased hearing <br />Cranial neuropathies<br />
  32. 32. Hallmark of terminal disease<br />Severe pain & headache ((skull base erosion<br />
  33. 33. Cranial neuropathies in N.PH.ca<br />Cn VI most frequently affected .<br />Cn ( II toVI ) Jacod’s syndrome due to cavernus sinus invasion .<br />Cn ( IX – XII ) & sympathetic n. Villaret’s syndrome retropharyngeal invasion<br />
  34. 34. 5years boy presented with neck mass . On examination he had nasopharyngeal mass on the same side ( left )<br />
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  38. 38. Nasopharyngeal lymphepithelioma<br />
  39. 39. Symptoms of advanced disease<br />Trismus<br />Dysphagia<br />Proptosis<br />Lung , bone , liver metastasis<br />
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  41. 41. examination<br />Complete examination of head & neck.<br />Examination of nasopharynx with endoscopy<br />Flexible or rigid<br />Biopsy<br />
  42. 42. Nasal cavity<br />
  43. 43. Posterior nasal cavity<br />
  44. 44. nasopharynx<br />
  45. 45. Nasopharyngeal carcinoma<br />
  46. 46. oropharynx<br />
  47. 47. Upper hypopharynx<br />
  48. 48. Lower hypopharynx<br />
  49. 49. larynx<br />
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  52. 52. investigation<br />laboratory<br />radiological<br />.c.b.c. ca , PO4 , alkaline phosphate. <br />Urin analysis<br />Liver function<br />Kidney function<br />Serum IgA<br />E.B.V. caspid antigen<br />EBV DNA<br />X- ray chest<br />C.T. scan<br />M R I<br />P .E .T.<br />Bone scintigraphy<br />
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  60. 60. PET scan<br />
  61. 61. Staging system for n.ph.caT stage <br />TX : primary tumor can’t be assessed .<br />TO : no evidence of primary tumor .<br />Tis : carcinoma in situ .<br />
  62. 62. Staging systems for N . Ph . Ca.<br />T stage( 1ry tumour extent)<br />T1 confined to nasopharynx<br />T2 extend to oropharynx or nasal cavity<br />a without parapharyngeal extention<br />B with parapharyngeal extention<br />T3 invade bones or PNS<br />T4 involvement of cranial nerves , intracranial content , infratemporal fossa , hypopharynx , orbit<br />
  63. 63. N stage lymph node disease<br />N0 No L . N . Metastasis .<br />N1 unilateral L . N (s) < or = 6 cm<br />N2 bilateral L . N (s) < or = 6 cm<br />N3<br />3a L . N (s) > 6 cm<br />3b with extension to supraclavicular fossa<br />
  64. 64. M stage distant metastasis<br />M0 abscent<br />M1 present<br />
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  67. 67. Management of nasopharyngeal ca<br />Non surgical treatment<br />Surgical teatment<br />Surgical treatment<br />Biopsy <br />neck dissection <br />nasopharyngectomy<br />Non surgical treatment<br />Effective radiotherapy<br />Intracavitary brachytherapy<br />Newer technologies :<br /><ul><li>Steriostatic radiosurgery
  68. 68. Intensity modulated radiotherapy.</li></ul>chemotherapy<br />
  69. 69. Acute side effects of R. T.<br />Skin reaction<br />altered taste<br />Weight loss<br /> fatigue<br /> mucositis<br />Xerostomia <br />
  70. 70. Chronic side effects of R. T.<br />Hypothyroidism<br />Chronic S . O . M .<br />
  71. 71. Serious side effects of R . T .<br />Severe trismus<br />Osteoradionecrosis<br />Pituitary dysfunction<br />Carotid artery stenosis<br />Brain necrosis<br />Cranial neuropathy<br />Spinal myelitis<br />R.T. induce 2nd malignant salivary g. , skin , thyroid sarcoma <br />
  72. 72. Surgical approaches to nasopharynx<br />1- transnasal – maxillary .<br />A- lat. Rhinotomy .<br />B- LeFort I osteotomy .<br />c- extended subtotal maxillectomy .<br />2- transpalatal .<br />3- sublabial midfacial degloving approach .<br />4- transfacial – maxillary swing .<br />5-transmandibular & mandibular swing .<br />6- infratemporal approach .<br />7- others<br />A- lateral transtemporal sphenoidal .<br />B- transpharyngeal .<br />C- transcervical .<br />
  73. 73. Intracavitary brachytherapy<br />
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  75. 75. PROGNOSIS<br />Well differentiated n. ph. Ca. has poorer local control rates.<br />Advanced undifferentiated n. ph. Ca. has higher distant metastasis .<br />.Accepted 5 years survival rate is ( 40 %– 50 %)<br />Better result in female patient under age of 40<br />Very poor prognosis in pregnancy concurrent within 1st year of treatment.<br />Relapse and distant failure occurs within the 1st 2 or 3 years<br />
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  77. 77. Thank you<br />

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