Carcinoma Of The Nasopharynx2
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CARCINOMA OF THE NASOPHARYNX
BY DR. BELLO ABUBAKAR MOHAMMED SENIOR REGISTRAR DEPARTMENT OF RADIATION ONCOLOGY NATIONAL HOSPITAL, ABUJA.
ANATOMY INCIDENCE ETIOLOGY CLINICAL PRESENTATION STANDARD TREATMENT OPTIONS PROGNOSIS FOLLOW UP
ANATOMY OF NASOPHARYNX
CUBOIDAL SHAPE LATERAL WALLS – FORMED BY THE EUSTACHIAN TUBE AND FOSSA OF ROSENMULLER INFERIOR BOUNDARY – ( FLOOR )HARD AND SOFT PALATE SUPERIOR BORDER – ( ROOF ) BASE OF THE SKULL POSTERIOR BORDER - ARCH OF THE ATLAS WITH 1st 2 CERVICAL VERTEBRAE ANTERIORLY – POSTERIOR CHOANAE AND NASAL CAVITY
INCIDENCE OF NASOPHARYNGEAL CANCER
WIDE VARIATION THROUGHOUT THE WORLD HIGHEST INCIDENCE REGIONS ARE • SOUTH CHINA 120/100,000 PER YEAR IN MALES AGED 45 – 55 YRS. • SOUTH EAST ASIA (HONG KONG, SINGAPORE, MALAYSIA, VIETNAM, LAOS AND NORTH THAILAND ) WITH AVERAGE INCIDENCE OF 20 – 30/100,000 PER YEAR. • ESKIMOS – PREVALENCE SIMILAR TO THE CANTONESE
INCIDENCE OF NASOPHARYNGEAL CANCER
INTERMEDIATE INCIDENCE REGIONS • MAGHREBIAN ARABS (ALGERIA, TUNISIA, MOROCCO, LIBYA AND SUDAN ) 1.5 – 9/100,000 PER ANNUM
INCIDENCE OF NASOPHARYNGEAL CANCER
INCIDENCE IN NIGERIA IS NOT WELL DOCUMENTED,
AETIOLOGY
EPSTEIN-BARR VIRUS (EBV) EXPOSURE GENETIC SUSCEPTIBILITY – MAJOR HISTOCOMPATABILITY COMPLEX PROFILE, H2, BW46, B17 ANTIGENS DIETARY – SALTY FISH – CONTAIN NITROSAMINES CHINESE HERBAL MEDICINE CONTAINS ESTERS – TUMOUR PROMOTERS, REACTIVATE EBV INFECTION
AETIOLOGY
LACK OF DIETARY VITAMIN C EBV COPIES INSIDE MALIGNANT CELLS URBANIZATION – FOR UNKNOWN REASONS, CERTAIN URBAN OCCUPATIONS SUCH AS FOOD SERVICE, MECHANICS AND CARPENTRY ARE ASSOCIATED WITH HIGH INCIDENCE OF NPC
PATHOLOGY
THE WHO DIVIDED NPC INTO THREE TYPES • TYPE 1 : KERATINIZING SQUAMOUS CARCINOMA • TYPE 2 :NON KERATINIZING CARCINOMA (TRANSITIONAL CELL CARCINOMA ) • TYPE 3 :UNDIFFERENTIATED (LYMPHOEPITHELIOMA –SCHMINKE TUMOUR)
THE PRESENCE OF KERATIN HAS BEEN ASSOC. WITH REDUCED LOCAL CONTROL AND SURVIVAL
PRESENTATION -PAINLESS, ENLARGED LYMPH NODES IN THE NECK ( PRESENT IN APPROXIMATELY 75% OF PTS. OFTEN BILATERAL AND POSTERIOR ) -NASAL OBSTRUCTION, EPISTAXIS -DIMINISHED HEARING, TINNITUS, RECURRENT OTITIS MEDIA -CRANIAL NERVE DYSFUNCTION (USUALLY II –VI OR IX – XII ) -SORE THROAT AND HEADACHE
PRESENTATION
LOSS OF MOVEMENT OF THE SOFT PALATE ON THE AFFECTED SIDE DUE TO INFILTRATION BY THE TUMOUR PROPTOSIS DUE TO LATERAL EXTENSION OF THE TUMOUR INTO THE ORBIT
MODE OF SPREAD
DIRECT SPREAD
POSTERIOR PART OF THE NOSE (NASAL OBSTRUCTION, BLEEDING ) EUSTACHIAN TUBE (DEAFNESS ) UPPER CERVICAL VERTEBRAE ( PAIN ) BASE OF SKULL (DOUBLE VISION ) PARAPHARYNGEAL SPACE ( FROM LATERAL WALL OR DUE TO INVOLVEMENT OF THE NODE OF ROUVIERE)
LYMPHATIC SPREAD JUGULODIGASTRIC (NODE JUST BELOW THE EAR ) POSTERIOR CERVICAL CHAIN LOW CERVICAL AND SUPRACLAVICULAR NODES
MODE OF SPREAD
DISTANT SPREAD • BONE (WITH SCLEROTIC METASTASIS ) • LUNGS • LIVER
CRANIAL NERVE SYNDROMES TWO PRINCIPAL SYNDROMES - RETROPAROTIDIAN SYNDROMES – INVOLVING THE 9th, 10th, 11th AND 12th CRANIAL NERVES - PETROSPHENOIDAL SYNDROMES – INVOLVING THE 3rd, 4th, 5th AND 6th CRANIAL NERVES (OCCASIONALLY 2nd VIA EXTENSION THROUGH THE FORAMEN LACERUM INTO THE MIDDLE CRANIAL FOSSA )
DIAGNOSTIC WORKUP
DETAILED MEDICAL HISTORY THOROUGH PHYSICAL EXAMINATION MIRROR EXAMINATION OF THE NASOPHARYNX EUA AND BIOPSY FULL BLOOD COUNT AND CHEMISTRY SOFT TISSUE LATERAL FACE FILM CHEST RADIOGRAPH ABDOMINAL AND PELVIC SCAN
DIAGNOSTIC WORKUP
CT SCAN MAGNETIC RESONANCE IMAGING (MRI ) BONE SCAN
TNM STAGING
STAGING
T1 TUMOUR LTD TO ONE SUBSITE OF THE NASOPHARYNX T2 TUMOUR INVOLVING MORE THAN ONE SUBSITE T3 TUMOUR INVADES NASAL CAVITY T4 TUMOUR INVADES SKULL AND/OR CRANIAL NERVES N0 - NO REGIONAL LYMPH NODES N1 – SINGLE IPSILATERAL NODE <3cms N2a – SINGLE IPSILATERAL NODE >3cms N2b – MULTIPLE IPSILATERAL NODES >3cms BUT <6cms N2c – BILATERAL OR CONTRALATERAL NODES ALL < 6cms • N3 – ANY NODE >6cms • • • • • • • • •
STAGING
Ho STAGING SCHEME (1989)
T1 TUMOUR CONFINED TO NASOPHARYNX T2n NASAL INVOLVEMENT WITHOUT PARAPHARYNGEAL SPACE INVOLVEMENT OR T3 FEATURES T2O OROPHARYNGEAL INVOLVEMENT WITHOUT T3 FEAT. T2p PARAPHARYNGEAL INVOLVEMENT WITHOUT T3 FEAT. T3q PARAPHARYNGEAL INVOLVEMENT WITH T3 FEATURE T3a BONE INVOLV. BELOW BASE OF SKULL INCLUDING FLOOR OF SPHENOID SINUS T3b INVOLV. OF BASE OF SKULL T3c CRANIAL NERVE INVOLVEMENT T3d INVOLV. OF ORBIT, LARYNGOPHARYNX OR INFRATEMPORAL FOSSA
STAGING Ho STAGING SCHEME (1989) CONT. N0 N1
NO CERVICAL LN PALPABLE NODES WHOLLY ABOVE THE SKIN CREASE EXTENDING LATERALLY AND BACKWARDS FROM JUST BELOW THE THYROID NOTCH N2 NODES PALPABLE BETWEEN THE SKIN CREASE AND SUPRACLAVICULAR FOSSA N3 NODES PALPABLE IN THE SUPRACLAVICULAR FOSSA OR SKIN INVOLVEMENT
STAGING
GROUPINGS STAGE I T1 N0 STAGE II T2 AND/OR N1 STAGE III T3 AND/OR N2 STAGE IV N3 INVOLVEMENT IRRESPECTIVE OF T STAGE STAGE V HAEMATOLOGOUS SPREAD OR NODAL INVOLVEMENT BELOW CLAVICLES
TREATMENT
SURGERY – QUITE IMPRACTICAL, RESERVED FOR RESIDUAL NODES RADICAL RADIOTHERAPY • EXTERNAL BEAM IRRADIATION IS THE MAINSTAY OF TREATMENT • BRACHYTHERAPY IS CONSIDERED FOR DISEASE THAT HAS RECURRED AFTER EXTERNAL BEAM IRRADIATION • CHEMORADIOTHERAPY
TREATMENT
STAGE I NPC ( T1 N0 ) HIGH DOSE RADIATION THERAPY TO THE PRIMARY TUMOUR SITE AND PROPHYLACTIC RADIATION THERAPY TO THE NODAL DRAINAGE STAGE II NPC ( T2 AND/OR N1 ) HIGH DOSE RADIATION THERAPY TO THE PRIMARY TUMOUR SITE AND PROPHYLACTIC RADIATION THERAPY TO THE NODAL DRAINAGE CHEMORADIATION
TREATMENT STAGE III NPC ( T3, N2 ) CHEMORADIATION HIGH DOSE OR SUPERFRACTIONATED RADIATION THERAPY TO THE PRIMARY TUMOUR SITE AND BILATERAL NECK NODES THAT ARE CLINICALLY POSITIVE. NECK DISSECTION FOR PERSISTENT OR RECURRENT NODES IF PRIMARY TUMOUR SITE IS CONTROLLED.
TREATMENT
STAGE IV NPC ( ANY T, N3, MO ) CHEMORADIATION. HIGH DOSE OR SUPERFRACTIONATED RADIATION THERAPY TO THE PRIMARY TUMOUR SITE AND BILATERAL LYMPH NODES THAT ARE CLINICALLY POSITIVE. NECK DISSECTION FOR PERSISTENT OR RECURRENT NODES. STAGE V ( ANY T, ANY N, M1 ) ALL ABOVE + CHEMOTHERAPY
TREATMENT
RADIOTHERAPHY LOCALIZATION PT. IS TREATED IN SUPINE POSITION WITH THE NECK EXTENDED TO ELEVATE THE CHIN, BUT TO KEEP THE SPINE STRAIGHT. NODAL MASSES IN THE NECK, AND THE LATERAL ORBITAL MARGINS ARE MARKED.
TREATMENT
FIELD ARRANGEMENTS
LARGE OPPOSING LATERAL FIELDS COVERING THE ENTIRE TARGET VOLUME, INCLUDING THE SPINAL CORD, TO A DOSE NOT EXCEEDING 40Gy GIVEN IN 4 WEEKS DLY FRACTIONATION. THE BRAINSTEM, OPTIC CHIASM AND ANTERIOR HALF OF THE ORBIT ARE SHIELDED. LOW CERVICAL NODES ARE TREATED WITH ANTERIOR FIELDS BECAUSE OF THE POSITION OF THE SHOULDERS. JUNCTIONS SHOULD NOT OVERLIE A PALPABLE DISEASE.
LATERAL FIELD WILL INCLUDE THE NASOPHARYNX, PARAPHARYNGEAL SPACE, BASE OF THE SKULL AND POSTERIOR HALF OF THE ORBIT, INCLUDING ANY EXTENSION ANTERIORLY TO THE NASAL FOSSA OR INFERIORLY TO THE OROPHARYNX. DOSE TO THE OPTIC NERVES SHOULD BE LIMITED TO 55Gy UNLESS THERE IS INVASION OF THE POSTERIOR ORBIT.
DOSE AND ENERGY PATIENTS WITH LYMPHADENOPATHY ( 6MV) LARGE LATERAL FIELDS 40Gy in 20#s/4W NASOPHARYNGEAL FIELDS 26Gy in 13#s/2.5 NECK FIELDS 26Gy in 13#s/2.5W TOTAL DOSE TO THE WHOLE VOLUME IS 66Gy in 33#s/ 6.5 WEEKS
DOSE AND ENERGY PATIENTS WITHOUT LYMPHADENOPATHY NASOPHARYNGEAL AND NECK FIELDS 56Gy in 28#s/ 5.5WKS NASOPHARYNX ALONE 10 – 14Gy in 5-8#s/1-1.5WKS TOTAL DOSE TO PRIMARY TUMOUR IS 66 – 70Gy in 33 -36#s/6.5 -7WKS
SIDE EFFECT OF XRT TREATMENT
DYSPHAGIA ( DUE TO MUCOSITIS ) DRYNESS OF MOUTH ( DUE TO TOTAL INHIBITION OF SECRETION OF BOTH PAROTID GLANDS SECRETORY OTITIS MEDIA (DUE TO FIBROSIS OF EUSTACHIAN TUBE ) DAMAGE TO SPINAL CORD, BRAINSTEM OR OPTIC NERVES IS RARE WITH CAREFUL PLANNING CATARACT (DUE TO DOSE TO LENS ) HYPOPITUITARISM HYPOTHYROIDISM
CHEMOTHERAPY
NEOADJUVANT – SHRINKS TUMOUR,RENDERING THEM MORE TREATABLE WITH RADIATION ADJUVANT – GIVEN AFTER OR DURING DEFINITIVE TREATMENT WITH RADIATON CISPLATINUM, EPIRUBICIN & BLEOMYCIN CISPLATINUM AND 5-FU ABOUT 20% COMPLETE RESPONSE
PROGNOSIS
5- YEAR SURVIVAL • STAGE • STAGE • STAGE • STAGE
I II III IV
80% >50% >50% 20%
FOLLOW UP
MONTHLY FOR THE 1ST YEAR, THEN 3MONTHLY FOR 2YRS, THEN 6MONTHLY FOR ANOTHER 2YRS, THEN ANNUALLY ROUTINE EVALUATION - FBC, U& E, LFTs, CHEST X-RAY, OPTIONAL EVALUATION – MRI, CT SCAN, TECHNETIUM-99m BONE SCAN THYROID FUNCTION TEST
THE FUTURE
DEVELOPMENT OF EBV VACCINE CONFORMAL RADIOTHERAPHY TO REDUCE DOSAGE TO NORMAL TISSUE ACCELERATED HYPERFRACTIONATED RADIOTHERAPHY COMBINED RADIATION AND CHEMOTHERAPHY
TAKE HOME TIPS
NPC REPRESENTS 0.1% OF ALL CANCERS AND OF CANCER DEATHS MAJORITY ARE SQUAMOUS CARCINOMAS MODE OF SPREAD IS IMPORTANT AND ACCOUNTS FOR GREAT VARIETY OF PRESENTING SYMPTOMS EXTERNAL BEAM RADIATION IS THE TREATMENT OF CHOICE FOR RECURRENCE, CHEMOTHERAPY AND INTERFERON SHOULD BE CONSIDERED
NA GODE • E SE GON
DA LO • THANK U!!!!!
BY DR. BELLO ABUBAKAR MOHAMMED SENIOR REGISTRAR DEPARTMENT OF RADIATION ONCOLOGY NATIONAL HOSPITAL, ABUJA.
ANATOMY INCIDENCE ETIOLOGY CLINICAL PRESENTATION STANDARD TREATMENT OPTIONS PROGNOSIS FOLLOW UP
ANATOMY OF NASOPHARYNX
CUBOIDAL SHAPE LATERAL WALLS – FORMED BY THE EUSTACHIAN TUBE AND FOSSA OF ROSENMULLER INFERIOR BOUNDARY – ( FLOOR )HARD AND SOFT PALATE SUPERIOR BORDER – ( ROOF ) BASE OF THE SKULL POSTERIOR BORDER - ARCH OF THE ATLAS WITH 1st 2 CERVICAL VERTEBRAE ANTERIORLY – POSTERIOR CHOANAE AND NASAL CAVITY
INCIDENCE OF NASOPHARYNGEAL CANCER
WIDE VARIATION THROUGHOUT THE WORLD HIGHEST INCIDENCE REGIONS ARE • SOUTH CHINA 120/100,000 PER YEAR IN MALES AGED 45 – 55 YRS. • SOUTH EAST ASIA (HONG KONG, SINGAPORE, MALAYSIA, VIETNAM, LAOS AND NORTH THAILAND ) WITH AVERAGE INCIDENCE OF 20 – 30/100,000 PER YEAR. • ESKIMOS – PREVALENCE SIMILAR TO THE CANTONESE
INCIDENCE OF NASOPHARYNGEAL CANCER
INTERMEDIATE INCIDENCE REGIONS • MAGHREBIAN ARABS (ALGERIA, TUNISIA, MOROCCO, LIBYA AND SUDAN ) 1.5 – 9/100,000 PER ANNUM
INCIDENCE OF NASOPHARYNGEAL CANCER
INCIDENCE IN NIGERIA IS NOT WELL DOCUMENTED,
AETIOLOGY
EPSTEIN-BARR VIRUS (EBV) EXPOSURE GENETIC SUSCEPTIBILITY – MAJOR HISTOCOMPATABILITY COMPLEX PROFILE, H2, BW46, B17 ANTIGENS DIETARY – SALTY FISH – CONTAIN NITROSAMINES CHINESE HERBAL MEDICINE CONTAINS ESTERS – TUMOUR PROMOTERS, REACTIVATE EBV INFECTION
AETIOLOGY
LACK OF DIETARY VITAMIN C EBV COPIES INSIDE MALIGNANT CELLS URBANIZATION – FOR UNKNOWN REASONS, CERTAIN URBAN OCCUPATIONS SUCH AS FOOD SERVICE, MECHANICS AND CARPENTRY ARE ASSOCIATED WITH HIGH INCIDENCE OF NPC
PATHOLOGY
THE WHO DIVIDED NPC INTO THREE TYPES • TYPE 1 : KERATINIZING SQUAMOUS CARCINOMA • TYPE 2 :NON KERATINIZING CARCINOMA (TRANSITIONAL CELL CARCINOMA ) • TYPE 3 :UNDIFFERENTIATED (LYMPHOEPITHELIOMA –SCHMINKE TUMOUR)
THE PRESENCE OF KERATIN HAS BEEN ASSOC. WITH REDUCED LOCAL CONTROL AND SURVIVAL
PRESENTATION -PAINLESS, ENLARGED LYMPH NODES IN THE NECK ( PRESENT IN APPROXIMATELY 75% OF PTS. OFTEN BILATERAL AND POSTERIOR ) -NASAL OBSTRUCTION, EPISTAXIS -DIMINISHED HEARING, TINNITUS, RECURRENT OTITIS MEDIA -CRANIAL NERVE DYSFUNCTION (USUALLY II –VI OR IX – XII ) -SORE THROAT AND HEADACHE
PRESENTATION
LOSS OF MOVEMENT OF THE SOFT PALATE ON THE AFFECTED SIDE DUE TO INFILTRATION BY THE TUMOUR PROPTOSIS DUE TO LATERAL EXTENSION OF THE TUMOUR INTO THE ORBIT
MODE OF SPREAD
DIRECT SPREAD
POSTERIOR PART OF THE NOSE (NASAL OBSTRUCTION, BLEEDING ) EUSTACHIAN TUBE (DEAFNESS ) UPPER CERVICAL VERTEBRAE ( PAIN ) BASE OF SKULL (DOUBLE VISION ) PARAPHARYNGEAL SPACE ( FROM LATERAL WALL OR DUE TO INVOLVEMENT OF THE NODE OF ROUVIERE)
LYMPHATIC SPREAD JUGULODIGASTRIC (NODE JUST BELOW THE EAR ) POSTERIOR CERVICAL CHAIN LOW CERVICAL AND SUPRACLAVICULAR NODES
MODE OF SPREAD
DISTANT SPREAD • BONE (WITH SCLEROTIC METASTASIS ) • LUNGS • LIVER
CRANIAL NERVE SYNDROMES TWO PRINCIPAL SYNDROMES - RETROPAROTIDIAN SYNDROMES – INVOLVING THE 9th, 10th, 11th AND 12th CRANIAL NERVES - PETROSPHENOIDAL SYNDROMES – INVOLVING THE 3rd, 4th, 5th AND 6th CRANIAL NERVES (OCCASIONALLY 2nd VIA EXTENSION THROUGH THE FORAMEN LACERUM INTO THE MIDDLE CRANIAL FOSSA )
DIAGNOSTIC WORKUP
DETAILED MEDICAL HISTORY THOROUGH PHYSICAL EXAMINATION MIRROR EXAMINATION OF THE NASOPHARYNX EUA AND BIOPSY FULL BLOOD COUNT AND CHEMISTRY SOFT TISSUE LATERAL FACE FILM CHEST RADIOGRAPH ABDOMINAL AND PELVIC SCAN
DIAGNOSTIC WORKUP
CT SCAN MAGNETIC RESONANCE IMAGING (MRI ) BONE SCAN
TNM STAGING
STAGING
T1 TUMOUR LTD TO ONE SUBSITE OF THE NASOPHARYNX T2 TUMOUR INVOLVING MORE THAN ONE SUBSITE T3 TUMOUR INVADES NASAL CAVITY T4 TUMOUR INVADES SKULL AND/OR CRANIAL NERVES N0 - NO REGIONAL LYMPH NODES N1 – SINGLE IPSILATERAL NODE <3cms N2a – SINGLE IPSILATERAL NODE >3cms N2b – MULTIPLE IPSILATERAL NODES >3cms BUT <6cms N2c – BILATERAL OR CONTRALATERAL NODES ALL < 6cms • N3 – ANY NODE >6cms • • • • • • • • •
STAGING
Ho STAGING SCHEME (1989)
T1 TUMOUR CONFINED TO NASOPHARYNX T2n NASAL INVOLVEMENT WITHOUT PARAPHARYNGEAL SPACE INVOLVEMENT OR T3 FEATURES T2O OROPHARYNGEAL INVOLVEMENT WITHOUT T3 FEAT. T2p PARAPHARYNGEAL INVOLVEMENT WITHOUT T3 FEAT. T3q PARAPHARYNGEAL INVOLVEMENT WITH T3 FEATURE T3a BONE INVOLV. BELOW BASE OF SKULL INCLUDING FLOOR OF SPHENOID SINUS T3b INVOLV. OF BASE OF SKULL T3c CRANIAL NERVE INVOLVEMENT T3d INVOLV. OF ORBIT, LARYNGOPHARYNX OR INFRATEMPORAL FOSSA
STAGING Ho STAGING SCHEME (1989) CONT. N0 N1
NO CERVICAL LN PALPABLE NODES WHOLLY ABOVE THE SKIN CREASE EXTENDING LATERALLY AND BACKWARDS FROM JUST BELOW THE THYROID NOTCH N2 NODES PALPABLE BETWEEN THE SKIN CREASE AND SUPRACLAVICULAR FOSSA N3 NODES PALPABLE IN THE SUPRACLAVICULAR FOSSA OR SKIN INVOLVEMENT
STAGING
GROUPINGS STAGE I T1 N0 STAGE II T2 AND/OR N1 STAGE III T3 AND/OR N2 STAGE IV N3 INVOLVEMENT IRRESPECTIVE OF T STAGE STAGE V HAEMATOLOGOUS SPREAD OR NODAL INVOLVEMENT BELOW CLAVICLES
TREATMENT
SURGERY – QUITE IMPRACTICAL, RESERVED FOR RESIDUAL NODES RADICAL RADIOTHERAPY • EXTERNAL BEAM IRRADIATION IS THE MAINSTAY OF TREATMENT • BRACHYTHERAPY IS CONSIDERED FOR DISEASE THAT HAS RECURRED AFTER EXTERNAL BEAM IRRADIATION • CHEMORADIOTHERAPY
TREATMENT
STAGE I NPC ( T1 N0 ) HIGH DOSE RADIATION THERAPY TO THE PRIMARY TUMOUR SITE AND PROPHYLACTIC RADIATION THERAPY TO THE NODAL DRAINAGE STAGE II NPC ( T2 AND/OR N1 ) HIGH DOSE RADIATION THERAPY TO THE PRIMARY TUMOUR SITE AND PROPHYLACTIC RADIATION THERAPY TO THE NODAL DRAINAGE CHEMORADIATION
TREATMENT STAGE III NPC ( T3, N2 ) CHEMORADIATION HIGH DOSE OR SUPERFRACTIONATED RADIATION THERAPY TO THE PRIMARY TUMOUR SITE AND BILATERAL NECK NODES THAT ARE CLINICALLY POSITIVE. NECK DISSECTION FOR PERSISTENT OR RECURRENT NODES IF PRIMARY TUMOUR SITE IS CONTROLLED.
TREATMENT
STAGE IV NPC ( ANY T, N3, MO ) CHEMORADIATION. HIGH DOSE OR SUPERFRACTIONATED RADIATION THERAPY TO THE PRIMARY TUMOUR SITE AND BILATERAL LYMPH NODES THAT ARE CLINICALLY POSITIVE. NECK DISSECTION FOR PERSISTENT OR RECURRENT NODES. STAGE V ( ANY T, ANY N, M1 ) ALL ABOVE + CHEMOTHERAPY
TREATMENT
RADIOTHERAPHY LOCALIZATION PT. IS TREATED IN SUPINE POSITION WITH THE NECK EXTENDED TO ELEVATE THE CHIN, BUT TO KEEP THE SPINE STRAIGHT. NODAL MASSES IN THE NECK, AND THE LATERAL ORBITAL MARGINS ARE MARKED.
TREATMENT
FIELD ARRANGEMENTS
LARGE OPPOSING LATERAL FIELDS COVERING THE ENTIRE TARGET VOLUME, INCLUDING THE SPINAL CORD, TO A DOSE NOT EXCEEDING 40Gy GIVEN IN 4 WEEKS DLY FRACTIONATION. THE BRAINSTEM, OPTIC CHIASM AND ANTERIOR HALF OF THE ORBIT ARE SHIELDED. LOW CERVICAL NODES ARE TREATED WITH ANTERIOR FIELDS BECAUSE OF THE POSITION OF THE SHOULDERS. JUNCTIONS SHOULD NOT OVERLIE A PALPABLE DISEASE.
LATERAL FIELD WILL INCLUDE THE NASOPHARYNX, PARAPHARYNGEAL SPACE, BASE OF THE SKULL AND POSTERIOR HALF OF THE ORBIT, INCLUDING ANY EXTENSION ANTERIORLY TO THE NASAL FOSSA OR INFERIORLY TO THE OROPHARYNX. DOSE TO THE OPTIC NERVES SHOULD BE LIMITED TO 55Gy UNLESS THERE IS INVASION OF THE POSTERIOR ORBIT.
DOSE AND ENERGY PATIENTS WITH LYMPHADENOPATHY ( 6MV) LARGE LATERAL FIELDS 40Gy in 20#s/4W NASOPHARYNGEAL FIELDS 26Gy in 13#s/2.5 NECK FIELDS 26Gy in 13#s/2.5W TOTAL DOSE TO THE WHOLE VOLUME IS 66Gy in 33#s/ 6.5 WEEKS
DOSE AND ENERGY PATIENTS WITHOUT LYMPHADENOPATHY NASOPHARYNGEAL AND NECK FIELDS 56Gy in 28#s/ 5.5WKS NASOPHARYNX ALONE 10 – 14Gy in 5-8#s/1-1.5WKS TOTAL DOSE TO PRIMARY TUMOUR IS 66 – 70Gy in 33 -36#s/6.5 -7WKS
SIDE EFFECT OF XRT TREATMENT
DYSPHAGIA ( DUE TO MUCOSITIS ) DRYNESS OF MOUTH ( DUE TO TOTAL INHIBITION OF SECRETION OF BOTH PAROTID GLANDS SECRETORY OTITIS MEDIA (DUE TO FIBROSIS OF EUSTACHIAN TUBE ) DAMAGE TO SPINAL CORD, BRAINSTEM OR OPTIC NERVES IS RARE WITH CAREFUL PLANNING CATARACT (DUE TO DOSE TO LENS ) HYPOPITUITARISM HYPOTHYROIDISM
CHEMOTHERAPY
NEOADJUVANT – SHRINKS TUMOUR,RENDERING THEM MORE TREATABLE WITH RADIATION ADJUVANT – GIVEN AFTER OR DURING DEFINITIVE TREATMENT WITH RADIATON CISPLATINUM, EPIRUBICIN & BLEOMYCIN CISPLATINUM AND 5-FU ABOUT 20% COMPLETE RESPONSE
PROGNOSIS
5- YEAR SURVIVAL • STAGE • STAGE • STAGE • STAGE
I II III IV
80% >50% >50% 20%
FOLLOW UP
MONTHLY FOR THE 1ST YEAR, THEN 3MONTHLY FOR 2YRS, THEN 6MONTHLY FOR ANOTHER 2YRS, THEN ANNUALLY ROUTINE EVALUATION - FBC, U& E, LFTs, CHEST X-RAY, OPTIONAL EVALUATION – MRI, CT SCAN, TECHNETIUM-99m BONE SCAN THYROID FUNCTION TEST
THE FUTURE
DEVELOPMENT OF EBV VACCINE CONFORMAL RADIOTHERAPHY TO REDUCE DOSAGE TO NORMAL TISSUE ACCELERATED HYPERFRACTIONATED RADIOTHERAPHY COMBINED RADIATION AND CHEMOTHERAPHY
TAKE HOME TIPS
NPC REPRESENTS 0.1% OF ALL CANCERS AND OF CANCER DEATHS MAJORITY ARE SQUAMOUS CARCINOMAS MODE OF SPREAD IS IMPORTANT AND ACCOUNTS FOR GREAT VARIETY OF PRESENTING SYMPTOMS EXTERNAL BEAM RADIATION IS THE TREATMENT OF CHOICE FOR RECURRENCE, CHEMOTHERAPY AND INTERFERON SHOULD BE CONSIDERED
NA GODE • E SE GON
DA LO • THANK U!!!!!
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