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Skin Radiation therapy > nasopharynx > Flashcards

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
Q

WHO grade 2 histopathology nasopharynx cancer

A

differentiating non keratinizing SCC (10%cases)

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26
Q

WHO grade 3 histopathology nasopharynx cancer

A

undifferentiated carcinoma LYMPHOEPITHELIOMA (poorly differentiated carcinoma 70% cases)

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27
Q

grades for nasopharynx cancer

A 
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
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28
Q

TNM nasopharynx

A

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
Q

prognostic indicators nasopharynx

A

age <50
LN involvement is worse
cranial nerve involvement is worse

30
Q

general management of nasopharynx cancer

A

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
Q

use of chemotherapy in nasopharynx cancer

A

used primarily with concurrent chemo and used adjuvantly on advanced stages

32
Q

chemo agents used in nasopharynx cancer

A

concurrent with chemo the agent is cisplatinum

adjuvant chemo is 5FU (3cycles) +cisplatinum

33
Q

treatment for XRT for stage 1 vs stage 2,3,4

A

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
Q

conventional technique XRT nasopharynx

A

6MV
3-4fields
lat POP with ant split

35
Q

lat POP its ant split borders nasopharynx

A

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
Q

what is shielded in a conventional nasopharynx technique

A

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
Q

the ant split borders for the nasopharynx

A

SUP: junction with inf border of lat POP
INF: inf aspect of clavicle heads
LAT: includes ⅔ of clavicles

38
Q

dose for conventional nasopharynx

A

50Gy/25fx

39
Q

energy used for IMRT of the nasopharynx

A

6MV

40
Q

Difference between the borders for IMRT in nasopharynx than other H&N cancers

A

the sup border is more superior than other H&N cancers

41
Q

Boost to the nasopharynx T1-T2 and T3-T4

A

the tumour should be boosted to 65Gy for T1-T2 lesions and boosted to 75Gy for T3-T4 lesions

42
Q

CTV1 for nasopharynx

A

this is the high risk CTV

Includes GTV +1cm margin

43
Q

CTV2 for nasopharynx

A

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
Q

CTV3 nasopharynx

A

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
Q

ENDEMIC AREA NPC is associated with what

A

EBV & immunoglobulin A

46
Q

what causes NPC in china?

A

may have genetic predisposition

  • p16 tumour supressor gene
  • HLA-A2
  • dietary factors- (salted and cured meats & fish)
47
Q

environmental factors

A

diet: salted and cured meats and fish

exposure to dust- fomaldehyde and fumes

48
Q

what causes NPC in America WHO type 1?

A

associated with smoking and alcohol

49
Q

what LN are always tx XRT

A

RP or JD LN

50
Q

What is the most common site of distant mets

A

Bone

51
Q

NPC most commonly arises where

A

in lateral walls or rosenmuller fossa

52
Q

Most NPC cancer presents in what stage

A

with palpable LN 70-85%

AND 1/2 have bilateral disease at dx

53
Q

Local NPC cancer presents with?

A

cold like symptoms

54
Q

most common regional NPC presentation?

A

neck massq

55
Q

most common metastatic presentation

A

bone and abdominal pain

56
Q

what cranial nerves are most commonly involved

A

3-6

57
Q

wht WHO type is most common in north america

A

Type1- keratinizing SCC

58
Q

What WHO type is most common in endemic areas

A

Type3- undifferentiated SCC

59
Q

What staging systems are used

A

tnm AND WHO

60
Q

what age has better survival

A

<50 y.o

61
Q

what WHO grade is better or worse

A

WHO III is better than WHO I

undifferentiated is better than non-keratinizing SCC

62
Q

Tx of choice for NPC

A

XRT as surgery is unresectable

63
Q

what type of tumour is chemo and radiosensitive

A

WHO grade 2-3

64
Q

LN doses

A

subclinical LN disease-50gy
for LN <3cm 66Gy
for LN >3cm 70Gy

65
Q

what dose for T1, T2-4?

A

66Gy T1

T2-4 70Gy

66
Q

what LN are usually tx in NPC cancer

A

post cervical

67
Q

is surgery done for NPC

A

NO because these tumours are unreseactable as they are close to base of skull

68
Q

margins for IMRT

A

1-1.5cm

69
Q

Stage 2-4 treatment

A

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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