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- 1. Nasopharyngeal cancer Department of Radiology, Thammasat University R1 Kittipong Poolketkit
- 2. Outline • Etiology • Anatomy landmark • TMN staging • Treatment • Follow up • Complication
- 3. Etiology • Nasopharyngeal carcinoma accounts for ~70% of all primary malignancies of the nasopharynx • Most common malignancies encountered in asia. • Males are more commonly affected, with a male to female ratio of 3:1. • Age 15-25 , 50-60 yrs • Risk factor • EBV infection • Environmental factor : Salted f ish, Fermented vegetables, Tobacco smoking • Genetic factor
- 5. Pathology • WHO Classi f ication • WHO type I: Keratinizing Squamous Cell Carcinoma • WHO type II: Non-Keratinizing Squamous Cell Carcinoma (NK-SCCA) • M/C and associated with EBV infection • WHO type IIA: NK-SCCA, differentiated • WHO type IIB: NK-SCCA, undifferentiated • WHO type III: Basaloid Squamous Cell Carcinoma
- 6. Boundaries • Anterior: posterior to nasal cavity • Inferior: soft palate 2 • Superior: base of skull • Posterior: C1 and C2 • Laterally : • Eustain tube opening • Torus tubarius • Fossa of Rossenmuller ◦ 1
- 11. Clinical presentation Early nasal obstruction, epistaxis, or conductive hearing loss due to Eustachian tube obstruction and the development of a middle ear effusion. Delayed nodal masses in the neck (most common), cranial nerve palsies, tinnitus, headache, or even diplopia and proptosis
- 12. Imaging • CT / MRI • Chest X-ray evaluated lung metastasis • US for upper abdomen for evaluated liver metastasis • Bone scan for evaluated bone metastasis • PET scan (optional) foe evaluted metastasis
- 13. CT scan
- 14. MRI
- 16. • T1
- 17. • T2 parapharyngeal extension Note normal levator palatini muscle (red arrow) tensor palatini muscle (blue arrow) pharyngobasilar fascia (black arrow) fat space (yellow arrow) on normal right side
- 18. • T3
- 19. T4
- 20. Lymphatic drainage • Medial • Lymph vessels from the roof and posterior wall drain into the median retropharyngeal lymph nodes. • Lateral • Lymph vessels trasverse the superior constrictor muscle and drain into lateral retropharyngeal, deep cervical and posterior triangle lymph nodes.
- 21. Lymph node size Measured in short axis Retropharyngeal node > 5 mm Cervical node > 1 cm Group IIa >1.1 cm Borderline sized node : a cluster > 3 nodes Tiffany Y. So,et al.Essential imaging of the nasopharyngeal space with special focus on nasopharyngeal carcinoma Operative Techniques in Otolaryngology , Volume 32, Issue 1, Pages 8-14
- 23. Deep cervical lymph node
- 24. • N1 • Retropharyngeal LN
- 25. • N2 • Cervical lymp node level IIB
- 26. • N3 • Left leve IIB size 8x4 cm • Leftlevel IV (supraclavicular lymph node) size 1.2 cm
- 28. Treatment
- 32. Radiotherapy Preparation • Audiogram • Dental evaluation : 2 wk before RT and 2 year after RT -> avoid risk of osteoradionecrosis • Nutritional evaluation
- 33. Radiotherapy • Position and Immobilization head-shoulder thermoplastic mask
- 34. Radiotherapy • MRI simulation with treatment planning CT
- 35. Radiotherapy • Intensity-Modulated Radiation Therapy (IMRT) 3D-CRT IMRT
- 36. Follow up
- 37. Complication RT • Acute complication • Anorexia , change of taste sensation • oral mucositis • dysphagia • xerostomia • Reversible 2 wk-1 month after radiotherapy. • Xerostomia: 6 month -2 years to producing saliva again.
- 38. Complication RT • Late complication • Chronic xerostomia • Neck f ibrosis, trimus (masticator muscles effected of radiation) • Visual f ield , dry eye • Hypothyroid
- 40. Complication RT Temporal lobe radionecrosis