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nasopharynx Flashcards

1
Q

most common country where nasopharynx cancer is?

A

china, north africa and inuit

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2
Q

gender for nasopharynx cncer

A

M:F 2:1

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3
Q

What causes nasopharynx cancer?

A 
Epstein Barr Virus is a very strong association 
HLA-A2
NOT related to smoking and drinking 
diet ( salted, cured and smoked meats)
exposure ( formaldehyde, dust and fumes)
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4
Q

subsides of nasopharynx cancer

A

Posterosuperior and lateral pharyngeal wall
Eustachian tube orifice
Adenoids

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5
Q

nasopharynx lies on a line between ________and ________ and extends inferiorly to __________.

A

between zygomatic arch and External Auditory Meatus

extends inferiorly to mastoid tip

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6
Q

nasopharynx lies behind _____. and above_____.

A

lies behind nasal cavity and above the soft palate

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7
Q

what cranial nerves are most commonly involved in nasopharynx cancer

A

3rd and mist commonly the 6th nerve because it is close to the base of the brain

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8
Q

_______is commonly involved in nasopharynx cancer

A

cranial nerves

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9
Q

the ___to _____cranial nerves can be affected by enlargement of the retropharyngeal nodes, as can the external carotid artery

A

9th to 12th

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10
Q

nasopharynx cancer often invades what ____wall?

A

the lateral wall

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11
Q

local spread in nasopharynx

sup, inf, ant, post and lat

A

SUP: via the foramen lacerum into the cavernous sinus with involvement of the cranial nerves II & VI and erosion of the skull
INF: oropharyngeal wall and soft palate
ANT: infratemporal fossa and foramen ovale to involve the mandibular division of nerve V
POST: prevertebral musculature
LAT: medial ostium of Eustachian tube (blockage produces deafness)

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12
Q

how common is palpable LN nasopharynx cancer?what does this mean for treatment?

A

70-85% have palpable LN at presentation

this means we always treat the LN

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13
Q

What LN are always treated in nasopharynx cancer?l

A

jugulodigastric and retropharyngeal Ln

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14
Q

most common spread in nasopharynx cancer?

A 
direct extension 
extends to: Nose
Orbit
Eustachian tube
Cavernous sinus
Cribriform plate 
Pterygoid muscles 
Parapharyngeal space
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15
Q

dose nasopharynx present early ornate and why?

A

late due to nasopharynx symptoms being cold like

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16
Q

what is involved in advanced stage nasopharynx cancer?

A

tumour may involve oropharynx, particularly the lateral or post wall

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17
Q

most common distant sites for nasopharynx cancer

A

most common is bone then lung and liver

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18
Q

what do nasopharynx cancer symptoms present like?

A

like a cold

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19
Q

local nasopharynx signs and symptoms

A 
Epistaxis (nosebleed)
Nasal obstruction
Headache
Hearing deficit
Otalgia (ear pain) 
Nasal discharge 
Loss of smell
Symptoms related to cranial neuropathies ex. Double vision
Occasionally, nasal twang in voice
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20
Q

regional nasopharynx signs and symptoms

A

Neck mass MOST COMMON
Neck pain
Hemorrhage
Proptosis (bulging of eye anteriorly out of orbit) may occur if extended into the orbit
Cranial nerves III through VI are involved by extension of tumour up through the foramen lacerum to the cavernous sinus
Nerves I, VII and VIII are rarely involved

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21
Q

signs and symptoms of metastatic nasopharynx cancer

A

Bone pain COMMON
Abdominal pain COMMON
Cough
SOB

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22
Q

diagnostic methods of nasopharynx cancer

A

Complete history
Nasopharyngoscopy: thin tube with an eyepiece on the end to evaluate the nasopharynx
Extent of neck node mets must be assessed and search made for distant mets
Biopsies must be done of the nasopharynx and adjacent suspicious areas

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23
Q

most common histopathology of nasopharynx cancerr

A

SCC

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24
Q

WHO grade 1 histopathology nasopharynx cancer

A

keratinizing SCC (20%cases)

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25
WHO grade 2 histopathology nasopharynx cancer
differentiating non keratinizing SCC (10%cases)
26
WHO grade 3 histopathology nasopharynx cancer
undifferentiated carcinoma LYMPHOEPITHELIOMA (poorly differentiated carcinoma 70% cases)
27
grades for nasopharynx cancer
``` n.b. that the staging is different for nasopharynx than other H&N cancer stage1- T1 N0 M0 stage 2- T1 N1 M0 T2 N0 M0 T2 N1 M0 stage 3 T1-T2 N2 M0 T3 N0-N2 M0 Stage 4, T4, N0-N2, M0 any T any N M1 any T N3, M0 ```
28
TNM nasopharynx
T1- tumour confined to the nasopharynx T2- extends to soft tissue of oropharynx a)without any parapharyngeal extension b)with parapharyngeal extension T3-invades bony structure or paranasal sinuses T4-invades cranial nerves,hypo pharynx, orbit or infra temporal fossa N1-unilateral mets <6cm above supraclavicular fossa N2-bilateral mets in LN <6cm above supraclavicular fossa N3-mets in a LN with LN extension to the supraclavicular fossa
29
prognostic indicators nasopharynx
age <50 LN involvement is worse cranial nerve involvement is worse
30
general management of nasopharynx cancer
surgery is generally not achievable due to the proximity of the base of the skull chemorads therefore is often the treatment of choice for nasopharyngeal cancer
31
use of chemotherapy in nasopharynx cancer
used primarily with concurrent chemo and used adjuvantly on advanced stages
32
chemo agents used in nasopharynx cancer
concurrent with chemo the agent is cisplatinum | adjuvant chemo is 5FU (3cycles) +cisplatinum
33
treatment for XRT for stage 1 vs stage 2,3,4
stage 1 is treated with XRT alone | stage 2,3,4 primary is XRT +CONCURRENT chemo then followed by adjuvant chemo (3 cycles 5FU +cisplatinum)
34
conventional technique XRT nasopharynx
6MV 3-4fields lat POP with ant split
35
lat POP its ant split borders nasopharynx
SUP: level of lateral orbital margin INF: C4-C6 intervertebral space, not over larynx or VCs, gross disease/involved l/n, scar or through chin/shoulder ANT: variable depending on extent of disease (include 2cm margin to disease/involved l/n) POST: 2cm post to l/n disease
36
what is shielded in a conventional nasopharynx technique
Base of brain, orbits, salivary glands, oral cavity, mucosa After ~45 Gy, post border brought anteriorly to shield the spinal cord 22-27 Gy then given with the shielding
37
the ant split borders for the nasopharynx
SUP: junction with inf border of lat POP INF: inf aspect of clavicle heads LAT: includes ⅔ of clavicles
38
dose for conventional nasopharynx
50Gy/25fx
39
energy used for IMRT of the nasopharynx
6MV
40
Difference between the borders for IMRT in nasopharynx than other H&N cancers
the sup border is more superior than other H&N cancers
41
Boost to the nasopharynx T1-T2 and T3-T4
the tumour should be boosted to 65Gy for T1-T2 lesions and boosted to 75Gy for T3-T4 lesions
42
CTV1 for nasopharynx
this is the high risk CTV | Includes GTV +1cm margin
43
CTV2 for nasopharynx
CTV2- CTV1+ 5mm margin for T3/T4 tumours it extends into the sphenoid sinus, for T1/T2 extends to the floor of the sphenoid sinus laterally extends to the mandibular rams extends inferiorly to the sternoclavicular joint
44
CTV3 nasopharynx
low risk volume includes contralateral uninvolved disease includes nodal level V excludes level 1B (optionally) inferior margin is 2cm above the sternoclavicular joint inclydes medial retropharyngeal nodes to the hyoid bone
45
ENDEMIC AREA NPC is associated with what
EBV & immunoglobulin A
46
what causes NPC in china?
may have genetic predisposition - p16 tumour supressor gene - HLA-A2 - dietary factors- (salted and cured meats & fish)
47
environmental factors
diet: salted and cured meats and fish | exposure to dust- fomaldehyde and fumes
48
what causes NPC in America WHO type 1?
associated with smoking and alcohol
49
what LN are always tx XRT
RP or JD LN
50
What is the most common site of distant mets
Bone
51
NPC most commonly arises where
in lateral walls or rosenmuller fossa
52
Most NPC cancer presents in what stage
with palpable LN 70-85% | AND 1/2 have bilateral disease at dx
53
Local NPC cancer presents with?
cold like symptoms
54
most common regional NPC presentation?
neck massq
55
most common metastatic presentation
bone and abdominal pain
56
what cranial nerves are most commonly involved
3-6
57
wht WHO type is most common in north america
Type1- keratinizing SCC
58
What WHO type is most common in endemic areas
Type3- undifferentiated SCC
59
What staging systems are used
tnm AND WHO
60
what age has better survival
<50 y.o
61
what WHO grade is better or worse
WHO III is better than WHO I | undifferentiated is better than non-keratinizing SCC
62
Tx of choice for NPC
XRT as surgery is unresectable
63
what type of tumour is chemo and radiosensitive
WHO grade 2-3
64
LN doses
subclinical LN disease-50gy for LN <3cm 66Gy for LN >3cm 70Gy
65
what dose for T1, T2-4?
66Gy T1 | T2-4 70Gy
66
what LN are usually tx in NPC cancer
post cervical
67
is surgery done for NPC
NO because these tumours are unreseactable as they are close to base of skull
68
margins for IMRT
1-1.5cm
69
Stage 2-4 treatment
chemorads is primary treatment 70Gy with concurrent cisplatinum followed by adjuvant cx 3 cycles of cisplatinum +5fu

Skin Radiation therapy (40 decks)

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