Nasopharyngeal Carcinoma Flashcards

1
Q

Risk factors of NPC

A
  • EBV infection
  • Nitrosamines in salt preserved food
  • First degree relative
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2
Q

Epidemiology of NPC

A

Gender: 3/4 male
Race: majority Chinese
Age: 30-60 years old
- significant socio-economic impact

15-34 yo: 2nd most common cancer
35-64 yo: 3rd most common cancer

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3
Q

WHO histological classification of NPC

A

Type 1: squamous cell carcinoma
Type 2: undifferentiated squamous cell carcinoma
2a: keratinising undifferentiated SCC
2b: non-keratinising undifferentiated SCC** (most common)

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4
Q

Clinical presentations of NPC

A

1st most common:
Big, bulky, bilateral neck lumps (DDx: lymphoma) in level II, V
- Mets to cervical LNs
- Firm
- Enlarge –> Central necrosis and abscess formation if left for long time

2nd most common:
Persistent blood stained oral secretions (sputum/saliva)
- Tumour is at post-nasal space so blood from tumour tend to drop down and mix with saliva and sputum
- NO epistaxis/ profuse bleeding

3rd most common:
Unilateral conductive hearing loss or sensation of blocked ears
- Eustachian tube dysfunction
- NPC compresses eustachian tube causing airway pressure changes –> Otitis Media with Effusion —> Unilateral CHL or aural fullness

Other presentations of NPC
4. Nasal obstruction
5 Unilateral tinnitus
6. CN palsies
- In decreasing order of frequency:
CN 6 –> 5 –> 12 –> 9/10 (patient will be on NGT)

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5
Q

Clinical examination for NPC

A
  1. Rigid nasopharyngoscope with Post-nasal biopsy
    - Identify superficial mucosal irregularities
    - Other hand freed up for manipulation purposes like suctioning, indirect palpation and biopsies
    - Camera-mounted system so others can see
    - Performed under LA with nasal spray
  2. Otoscope
  3. Oral cavity PE (Salivary glands)
  4. CN PE
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6
Q

Normal post-nasal space

A
  • Mucosal walls smooth
  • No asymmetry
  • Eustachian tube orifices not obstructed
  • Fossa of Rosenmuller well defined bilaterally
    *posterolateral outpouching from each side of the nasopharynx that lies posterior to the eustachian tube
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7
Q

Describe an NPC seen

A
  • Exophytic mass that is located at postnasal space posterior to the Eustachian tube orifices
  • Ulcerated
  • Contact bleeding
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8
Q

Submucosal NPC

A

Mucosa only slightly irregular
- Small area of heaped up mucosa or
- mucosa of ↑ vascularity which can look normal

*asymptomatic
*incidental finding

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9
Q

Investigations for NPC

A

Imaging
- for staging purposes

  1. CT (MRI costly)
    - assess nasopharynx, neck lymph nodes
  2. FDG PET-CT
    - assess for distant metastasis, augment MRI
    - bone scan: bone mets
    - cxr: lung mets
    - ultrasound liver: liver mets

Others
1. Audiogram and tympanogram (type B)
- check baseline levels as radiation and chemotherapy can cause sensorineural hearing loss

  1. EBV serology titres
    - IgA VCA (Viral capsid antigen) is sensitive
    - IgA Ea (Early antigen) is specific
    - IgA VCA ≥ 1:40 and IgA Ea ≥ 1:10 is significant
  2. Plasma EBV DNA
    - levels should drop after treatment
    - used to trace recurrence during post-treatment surveillance
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10
Q

Most common order of distant metastasis from NPC

A

Bone > Lungs > Liver

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11
Q

GOLD standard for NPC diagnosis

A

Postnasal space biopsy (done with rigid nasopharyngoscope)
- done under direct visualisation using rigid endoscopy under LA

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12
Q

TMN staging epidemiology for NPC

A
  • Majority T1
  • Majority N positive
  • 2/3 of patients will be stage III/IV when they present
  • stage I-III have good outcomes
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13
Q

T staging for NPC

A

T0: no primary tumour
T1: confined to nasopharynx
T2a: extends to nasal cavity and oropharynx
T2b: extends to parapharyngeal space
T3: extends to sinuses, orbit, skull base, hypopharynx or bony erosions
T4: intracranial involvement, CN palsy

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14
Q

N staging for NPC

A

N0: no nodal involvement
N1: nodes confined to ipsilateral neck, not > 3cm
N2: ipsilateral nodes > 3cm but not > 6cm, bilateral nodes or contralateral nodes
N3: ipsilateral nodes > 6cm, supraclavicular nodes

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15
Q

M staging for NPC

A

M0: no distant metastasis
M1: distant metastasis (includes mediastinal nodes)

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16
Q

TMN staging for NPC

A

Stage 1: T1 N0 M0
Stage 2: T2 N0 M0, T1 N1 M0, T2 N1 M0
Stage 3: T3 N0 M0, T3 N1 M0, T1 N2 M0, T2 N2 M0
Stage 4: T4 N0 M0, any T N3 M0, any T any N M1

17
Q

Pre-treatment planning

A
  • Audiological inv
  • Dental clearance (ensure oral hygiene is maintained as radiation field will affect oral cavity)
  • Hematological and biochemical Ix (CrCl too) for chemotherapy
18
Q

Treatment for NPC

A

Stage 1: radiotherapy
Stage 2: radiotherapy or chemo-radiotherapy
Stage 3: chemo-radiotherapy
Stage 4: neoadjuvant chemo, followed by chemo-radiotherapy

*Chemotherapy: Cisplatin, 5-fluorouracil

19
Q

Early S/E of radiation

A

Xerostomia*
Mucositis*
Skin burn
Dermatitis
Dysphagia

20
Q

Late S/E of radiation

A

Crusting
Trismus
- jaw muscles become so tight mouth cannot be opened
- muscle spasms in your temporomandibular joint
Hearing loss (Sensineural/C)
OME (Don’t drain!! Just continue RT and it’ll resolve)
*Cranial nerve palsy
*Carotid blowout syndrome

Aspiration
Pseudoaneurysm/ stenosis
CSOM
Eustachian tube dysfunction
- Valsalva to clear the ear fullness
- Ballooning
Transverse myelitis
Temporal lobe necrosis
Endocrinopathies
Lhermitte’s
Blindness

21
Q

S/E of cisplatin

A

Sensorineural hearing loss
Peripheral neuropathy

22
Q

Most common recurrence of NPC

A

Distant metastasis

*local and regional recurrences are uncommon

23
Q

Treatment for recurrent local and regional disease

A

Surgery:
- Nasopharyngectomy
1. Maxillotomy
- Lateral rhinotomy
- Facial de-gloving
2. Endoscopic
3. Maxillary swing
4. Combined transnasal-transoral

Radiation

Radial neck dissection

24
Q

Type of tympanogram seen in NPC

A

Type B