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Nasopharyngeal Cancer Treatment (PDQ®): Treatment - Health Professional Information [NCI] - General Information About Nasopharyngeal Cancer

Anatomy

The nasopharynx has a cuboidal shape. The lateral walls are formed by the eustachian tube and the fossa of Rosenmuller. The roof, sloping downward from anterior to posterior, is bordered by the pharyngeal hypophysis, pharyngeal tonsil, and pharyngeal bursa with the base of the skull above. Anteriorly, the nasopharynx abuts the posterior choanae and nasal cavity, and the posterior boundary is formed by the muscles of the posterior pharyngeal wall. Inferiorly, the nasopharynx ends at an imaginary horizontal line formed by the upper surface of the soft palate and the posterior pharyngeal wall.

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Risk Factors

Unlike other squamous cell cancers of the head and neck, nasopharyngeal cancer does not appear to be linked to excess use of tobacco or moderate alcohol intake (up to 15 drinks a week). Factors thought to predispose to this tumor include the following:

  • Chinese (or Asian) ancestry.[1]
  • Epstein-Barr virus (EBV) exposure.
  • Unknown factors that result in very rare familial clusters.[2]
  • Heavy alcohol intake.[3]

Signs and Symptoms

Symptoms and signs at presentation include the following:

  • Painless, enlarged lymph nodes in the neck (present in approximately 75% of patients and often bilateral and posterior).
  • Nasal obstruction.
  • Epistaxis.
  • Diminished hearing.
  • Tinnitus.
  • Recurrent otitis media.
  • Cranial nerve dysfunction (usually II–VI or IX–XII).
  • Sore throat.
  • Headache.

In the patient who presents with only cervical adenopathy, the finding of EBV genomic material in the tissue after amplification of DNA with the polymerase chain reaction lends strong evidence for a nasopharyngeal primary tumor, and a concerted search should be conducted in that area.[4]

Diagnostic Tests

Diagnosis is made by biopsy of the nasopharyngeal mass. Workup includes the following:[5]

  • Careful visual examination (by fiberoptic endoscopic examination or examination under anesthesia [EUA]).
  • Documentation of the size and location of the tumor and neck nodes.
  • Evaluation of cranial nerve function including neuro-ophthalmological evaluation and audiological evaluation.
  • Computed tomographic (CT) scan or positron emission tomography (PET)-CT scan.
  • Magnetic resonance imaging (MRI) to evaluate skull base invasion.
  • Hemogram.
  • Chemistry panel.
  • Epstein-Barr virus titers.

Any clinical or laboratory suggestion of distant metastasis may prompt further evaluation of other sites. Careful dental and oral hygiene evaluation and therapy is particularly important prior to initiation of radiation treatment. MRI is often more helpful than CT scans in assessing skull base involvement and in defining the extent of abnormalities detected.[5,6,7]

Prognosis

Major prognostic factors adversely influencing outcome of treatment include the following:[8]

  • Large tumor size.[9][Level of evidence: 3iiiA]
  • A higher tumor (T) stage.
  • The presence of involved neck nodes.

Other factors linked to diminished survival that were present in some, but not all, studies include the following:

  • Age.
  • World Health Organization (WHO) grade I.
  • Long interval between biopsy and initiation of radiation therapy.
  • Diminished immune function at diagnosis.
  • Incomplete excision of involved neck nodes.
  • Pregnancy during treatment.
  • Locoregional relapse.
  • Certain EBV antibody titer patterns.
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