H&N Evaluation and Management of Nasopharyngeal Carcinoma Flashcards
What are the primary risk factors associated with
nasopharyngeal carcinoma?
● EBV
● Genetics (including ethnicity and gender)
● High intake of preserve foods (nitrosamines)
People of what ethnicity are most commonly
affected by nasopharyngeal carcinoma?
Chinese. It is endemic in Southern China and Southeast
Asia.
What food confers an increased risk for nasopharyngeal carcinoma?
Salted fish. Thought to be related to the volatile nitros-
amines released in steam while cooking salt-cured foods
and early exposure to these foods in childhood
What genetic factors have been associated with
nasopharyngeal carcinoma?
● Family history (especially first-degree relatives)
● Haplotype human leukocyte antigen (HLA) alleles
● Genetic polymorphisms in CYP2A6 (nitrosamine metabolizing gene)
● Male sex 3:1 ratio
Describe the basic structure of the herpes virus
that represents a major risk factor for developing
nasopharyngeal carcinoma.
Epstein-Barr virus (EBV): ● Nuclear core early antigens (Ea) ● Double-stranded DNA ● Viral capsid antigen (VCA) ● Lytic membrane proteins (LMP): LMP-1, -2, -3 ● EBV nuclear antigens (EBNA): 1–6 ● EBV encoded ribonucleic acids (EBER)
What is the primary mode of transmission of EBV
infection?
Saliva
In which nasopharyngeal cell type is EBV infection
a risk factor for the development of malignancy?
Pseudostratified columnar respiratory epithelium. It is
carried for life by the infected person.
What is the most common nasopharyngeal
malignancy?
Nasopharyngeal carcinoma
How does the WHO classify nasopharyngeal
carcinoma?
● Type 1 (I): Squamous cell carcinoma
● Type 2a (II): Keratinizing undifferentiated carcinoma
● Type 2b (III): Nonkeratinizing undifferentiated carcinoma
In lymphoepitheliomas, does the lymphoid infil-
trate give prognostic information?
No
In lymphoepitheliomas, what characterizes a
Regaud pattern?
Tumor cells growing in well-defined aggregates admixed
with a lymphoid infiltrate
What is the most common clinical manifestation
for nasopharyngeal carcinoma?
Lymphadenopathy (60%)
In addition to cervical lymphadenopathy, what
initial symptoms are common in nasopharyngeal
carcinoma?
● Blood tinged/stained saliva/sputum; more common than
epistaxis
● Conductive hearing loss, serous otitis media
● Epistaxis
● Nasal obstruction
● Tinnitus
● Cranial nerve palsy
A patient with nasopharyngeal carcinoma has
headache and cranial nerve deficits. What do these
symptoms most likely indicate?
Intracranial extension
What syndrome is defined by tumor invasion of
the base of skull with involvement of CN III–VI
resulting in facial pain and diplopia?
Petrosphenoidal syndrome
What notochord remnant presents as a benign
cystic nasopharyngeal mass?
Thornwaldt cyst
A patient has an ulcerative nasopharyngeal mass,
bulky unilateral adenopathy, V1/V2 numbness,
and ophthalmoplegia. This process has most likely
invaded what structure?
Cavernous sinus
A middle-aged immigrant from the Guangdong
province in Southern China presents with a
unilateral middle ear effusion. What is the most
important diagnostic maneuver?
Nasopharyngoscopy
A patient with locally advanced nasopharyngeal
cancer complains of ipsilateral dry eye. Which
nerve is most likely affected?
Vidian nerve
A patient with locally advanced nasopharyngeal
cancer has a unilateral true vocal-fold paralysis,
winged scapula, and uvular deviation. What is the
name of this syndrome?
Vernet syndrome
A patient with locally advanced nasopharyngeal
cancer has an ipsilateral constricted pupil and
ptosis. What structure has been invaded?
Cervical sympathetic trunk
What blood test predicts survival in EBV-related
nasopharyngeal carcinoma?
Polymerase chain reaction (PCR) of EBV DNA
What serologic test allows for screening and
monitoring response to therapy in EBV-related
nasopharyngeal carcinoma?
Anti-EBV viral capsid antigen (VCA) and early antigen (EA) immunoglobulin A (IgA)
What characterizes WHO type 1 nasopharyngeal
carcinoma?
Keratinization
Which of the WHO subtypes for nasopharyngeal
carcinoma is nonkeratinizing and undifferentiated?
WHO type 3
How do WHO type 3 tumors tend to fail treat-
ment?
Distant metastases
Where do WHO type 1 tumors tend to fail
treatment?
Locoregional recurrence is most common.
How often does nasopharyngeal carcinoma in-
volve the skull base at the time of diagnosis?
35%
A nasopharyngeal malignancy extends into the
nasal cavity but not the parapharynx. What is the
AJCC T stage?
T1
A nasopharyngeal malignancy extends into the
sphenoid sinus. What is the AJCC T stage?
T3
A nasopharyngeal malignancy causes a lateral
rectus palsy. What is the AJCC T stage?
T4
A patient with nasopharyngeal carcinoma has a
palpable 2-cm supraclavicular fossa lymph node.
What is the AJCC N stage?
N3b
A patient with nasopharyngeal carcinoma has 3-
cm bilateral retropharyngeal lymph nodes evident
on MRI. What is the AJCC N stage?
N1
Which is more important prognostically in nasopharyngeal carcinoma: low nodes or bilateral nodes?
Low (supraclavicular fossa) nodes
How is the supraclavicular fossa defined for N
staging nasopharyngeal carcinoma?
A triangle is bound by three points: the superior margin of
the medial end of the clavicle, the superior margin of the
lateral end of the clavicle, and the point where the neck
meets the shoulder.
A patient with nasopharyngeal carcinoma has a 5-
cm ipsilateral level II lymph node. What is the AJCC
N stage?
N1
What is the least common WHO subtype of
nasopharyngeal cancer in the Far East?
WHO type 1
Compared with its incidence in the Far East, is
WHO type 1 nasopharyngeal carcinoma more or
less common in North America?
More
What features of the primary tumor in nasopha-
rygenal carcinoma predict poor outcomes?
cranial neuropathy, bone erosion, and extensive para-
pharyngeal space involvement
Does upper cranial neuropathy give a worse prognosis than lower cranial neuropathy in nasopharyngeal carcinoma?
No
What is the strongest predictor of regional failure
in nasopharyngeal carcinoma?
Nodal stage
What predicts a worse prognosis in nasopharyn-
geal cancer: prestyloid or poststyloid parapha-
ryngeal extension?
Prestyloid
What is the strongest predictor of overall survival in nasopharyngeal carcinoma?
M stage
What is the best treatment for stage III–IV
nasopharyngeal carcinoma?
Concurrent chemoradiation therapy
What is the best treatment for stage I nasopharyngeal carcinoma?
External-beam radiation to the primary and bilateral necks
What doses are used to treat the nasopharynx in
nasopharyngeal carcinoma?
~ 70 Gy
What is the best surgical treatment for regionally
recurrent nasopharyngeal carcinoma?
Modified radical neck dissection
Local recurrence of nasopharyngeal carcinoma
involving the lateral nasopharyngeal wall, with
extension across the midline, is best suited for
what salvage surgical approach?
Anterolateral, or maxillary swing, approach
What is the most sensitive imaging test for
detecting nasopharyngeal carcinoma recurrence?
PET scan
What are treatment options for locally recurrent or
residual nasopharyngeal carcinoma?
Nasopharyngeal carcinoma is unique in the head and neck
in that reirradiation shortly after treatment is often used for
residual or recurrent disease. Other options include
stereotactic radiation therapy, brachytherapy, photody-
namic therapy, endoscopic or open resection, chemo-
therapy, or combined regimens.
What are common acute side effects of external
beam radiation for nasopharyngeal carcinoma?
Mucositis, xerostomia, cutaneous erythema, malaise
A patient is having seizures 4 years after primary
radiation therapy for nasopharyngeal carcinoma.
What is the likely cause?
Temporal lobe necrosis
Fatigue and amenorrhea 6 years after radiation
therapy are likely due to what late complication?
Hypopituitarism
A patient develops hearing loss with normal
immittance after treatment for nasopharyngeal
carcinoma. What is the most common audiologic
pattern?
Downsloping sensorineural hearing loss
A patient develops hypernasal speech after an
anterior approach surgical salvage of locally recurrent nasopharyngeal carcinoma. What is the most likely cause?
Palatal fistula
What feature of tumor recurrence contraindicates
nasopharyngectomy?
Cranial neuropathy
