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2 most common presentations of NPC
- 70% neck mass
- 50% unilateral serous otitis media
Describe T staging for NPC
- T1: confined to the nasopharynx, or tumor extends to oropharynx and/or nasal cavity without parapharyngeal extension (eg, without posterolateral infiltration of tumor)
- T2: parapharyngeal extension (posterolateral infiltration of tumor)
- T3: involves bony structures of skull base and/or paranasal sinuses
- T4: with intracranial extension and/or involvement of cranial nerves, hypopharynx, or orbit, or with extension to the infratemporal fossa/masticator space
Describe NPC nodal staging.
- N1 Unilateral metastasis in cervical lymph nodes ≤6cm in greatest dimension, above the supraclavicular fossa, and/or unilateral or bilateral retropharyngeal lymph nodes ≤6 cm in greatest dimension (midline nodes are considered ipsilateral nodes)
- N2Bilateral metastasis in cervical lymph nodes ≤6cm in greatest dimension, above the supraclavicular fossa
- N3Metastasis in a lymph node >6cm and/or to the supraclavicular fossa
- N3a>6cm in dimension
- N3bExtension to the supraclavicular fossa
Describe the different WHO classifications of NPC.
- WHO criteria
- Type 1 Differentiated (keratinizing) squamous cell carcinoma (worse prognosis, poorly radiosensitive)
- Type 2 Nonkeratinizing carcinoma (assoc with EBV, better prognosis, radiosensitive)
- Type 3 Undifferentiated carcinoma (assoc with EBV, better prognosis, radiosensitivite)
Management of stage I and II NPC
Radiotherapy to primary site and bilateral necks
Management of stage III and IV NPC
Based on Intergroup study 0099, concurrent chemoRT (cisplatin 5-fu) followed by adjuvant chemo
Risk factors for hypopharyngeal SCC.
- Plummer Vinson syndrome
- Reflux/Barretts Esophagus
Subsites of hypopharyngeal CA. Which is most common? What are the rates of regional metastases?
- Piriform sinus: most common subsite, 75%. 75% regional mets.
- Posterior pharyngeal wall, 25%. 60% regional mets.
- post cricoid, <5%. 40% regional mets. Assoc with Plummer-Vinson
T classification of hypopharyngeal SCC.
- T1: The tumor is limited to one subsite of the hypopharynx and is 2 cm or less at its greatest dimension.
- T2: The tumor involves more than one subsite of the hypopharynx or an adjacent site or is larger than 2 cm but not larger than 4 cm at its greatest diameter without fixation of the hemilarynx.
- T3: The tumor is larger than 4 cm at its greatest dimension or involves fixation of the hemilarynx.
- T4a – The tumor invades the thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophagus, or central compartment soft tissues, including prelaryngeal strap muscles and subcutaneous fat.
- T4b - The tumor invades the prevertebral fascia, encases the carotid artery, or involves mediastinal structures.
Nodal staging of hypopharyngeal SCC.
- N1: Metastasis is found in a single ipsilateral node (≤ 3 cm at its greatest dimension).
- N2: Metastasis is found in a single ipsilateral lymph node (>3 cm but < 6 cm in greatest dimension) or in multiple ipsilateral lymph nodes (none >6 cm at greatest dimension).
- N2a - Metastasis in a single ipsilateral lymph node (>3 cm but < 6 cm at its greatest dimension)
- N2b - Metastasis in multiple ipsilateral lymph nodes (none >6 cm at greatest dimension)
- N2c - Metastasis in bilateral or contralateral lymph nodes (none >6 cm at greatest dimension)
- N3: Metastasis is found in a lymph node larger than 6 cm at its greatest dimension.
Management options for stage I or II hypopharyngeal SCC
- Radiotherapy alone (commonly 66-70 Gy) including bilateral neckssurgery including ipsilateral neck dissection unless primary disease crosses midline, then B/L necks. Possibly with postoperative irradiation, depending on the pathology findings.
- Larynx preservation therapy is typically possible and is strongly favored.
Treatment of late stage (III or IV) hypopharyngeal SCC.
- concurrent chemoRT with surgical salvage for poor responders (first choice)
- Partial or total laryngopharyngectomy, neck dissection, postoperative radiotherapy
- Address bilateral necks
Rate of nodal disease at presentation of hypopharyngeal CA
Advanced disease, 40-70% have nodal disease.
Hypopharyngeal ca with esophageal involvement excision may require gastric pull-up reconstruction. What is the risk of anastomotic salivary leak?
Why do you worry about hypocalcemia after gastric pull-up?
Secondary to poor absorption from decreased gastric acidity, decreased transit time due to truncal vagotomy, and disruption of vascular supply to parathyroids.
Two antigens used for NPC screening and prognosis?
- Early antigen (EA)
- Viral capsule antigen (VCA): late antigen, most specific for NPC
- Low titers of IgA EA and IgA VCA predict poorer prognosis. High titers predict better prognosis.
Most common site of tumor in the nasopharynx
- Fossa of Rosenmuller: slitlike region medial to the medial crura of the eustachian tube orifice
Anterior border of the oropharynx
circumvallate papillae, junction of hard and soft palate
Most common site of oropharyngeal ca? How common is neck disease at this site?
- Tonsil/lateral pharyngeal wall
- 65-75% with neck disease at presentation
- lymphoma and lymphoepitheloma is more common here than elsewhere in OP
Describe the clinical nature of base of tongue tumors
- more aggressive than oral tongue
- >60% rate of cervical mets
- 20% B/L cervical mets
- 65% five year survival for all stages
T classification for oropharyngeal ca?
- T1 <2cm
- T2 2-4cm
- T3 >4cm
- T4a invades larynx, extrinsic muscles of tongue, medial pterygoid, hard palate, or mandible
- T4b invades lateral pterygoid, pterygoid plates, lateral nasopharynx, skull base, or encases carotid
What is a lymphoepithelioma?
- subgroup of poorly diffferentiated carcinoma
- may present in the tonsil
Treatment of the neck in oropharyngeal ca?
- N0: elective B/L ND vs RT
- N1-3: MRND
What are the indications for adjuvant RT in oropharyngeal ca?
- aggressive disease (eg tongue base ca)
- close or positive margins
- multiple positive nodes
- extracapsular ext
- perineural or intravascular spread
- invasion of bone, cartilage, soft tissue
Anatomic boundaries of the oropharynx
- Anteriorly at hard palate/soft palate junction and circumvillate papillae
- superiorly at hard palate
- inferiorly at superior surface of hyoid
most common site of oropharyngeal cancer
tonsil/lateral pharyngeal wall. Usually p/w neck disease (65-75%). Higher incidence of lymphoma and lymphoepithelioma at this site.
In BOT tumor, what is the rate of bilateral cervical mets? Approximate 5 year survival for all stages?
- 20% B/L neck disease
- 65% 5-year survival