Nasopharyngeal cancer

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

7. Torus
tubarius
Resenmuller fossa
Opening
eustacian
tube

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

15. Staging
Bone>lung>liver

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

29. Early stage
Advance stage

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

39. Complication RT
Osteoradionecrosis

40. Complication RT
Temporal lobe radionecrosis

41. Complication RT
Radiation-Induced Tumors