Nasopharyngeal carcinoma is a non lymphomatous squamous-cell carcinoma that occurs in the epithelial lining of the nasopharynx. It frequently arises from the pharyngeal recess (fossa of Rosenmuller) posteromedial to the medial crura of the eustachian tube opening in the nasopharynx

1. Nasopharyngeal
Carcinoma
Dr. Krishna Koirala
2022-08-08

2. Introduction
• Non lymphomatous squamous-cell carcinoma
that occurs in the epithelial lining of the
nasopharynx
• Frequently arises from the pharyngeal recess
(fossa of Rosenmüller) posteromedial to the
medial crura of the eustachian tube opening in
the nasopharynx

3. Fossa of Rosenmuller

4. Epidemiology
• Accounts for 85% adult nasopharyngeal malignancies
and 30% pediatric nasopharyngeal malignancies
• Common in Chinese and North African people
• Male preponderance of 3:1
• Bimodal age presentation with small peak at 15-25
yrs and a large peak at 55-65 yrs

5. Etiology
• Genetic
– Commonest in Southern Chinese ( Mongoloid race)
– HLA association
• Viral : Epstein-Barr Virus
• Environmental
– Exposure to nitrosamines (dry salted fish),
polycyclic hydrocarbons (smoke of incense / wood)
– Smoking , chronic nasal infection, poor ventilation
of nasopharynx

6. W.H.O. Classification (Histological)
• Type 1 :
− Keratinizing squamous cell carcinoma (common
in the older adult population)
• Type 2:
− Non-keratinizing (transitional) carcinoma
• Type 3:
− Undifferentiated carcinoma ( common in
childhood and adolescents , associated with high
EBV Ab titre)

7. Clinical Features
1. Neck swelling (60%)
• Lateral retropharyngeal LN of Rouviere
• B/L, enlarged jugulodigastric, upper & middle deep
cervical nodes and posterior triangle nodes
2. Nasal (40%)
• Blood stained nasal mucus, epistaxis, nose block,
foul smelling nasal discharge
3. Otologic (30%) : Conductive deafness, tinnitus

8. 4. Ophthalmologic (20%)
• Diplopia & ophthalmoplegia (involvement of CN III,
IV, VI), Proptosis (orbit invasion) & blindness
(involvement of CN II)
5. Neurologic (20 %)
• Jugular foramen syndrome: CN IX, X, XI involved by
lateral retropharyngeal lymph node
• Horner's syndrome: sympathetic chain involvement

9. 6. Severe Headache
• Skull base erosion
7. Trotter's triad
– Conductive deafness: Eustachian Tube block
– Ipsilateral temporo -parietal neuralgia: Trigeminal
nerve involvement
– Ipsilateral palatal paralysis: Vagus nerve involved
8. Distant metastasis
• Bone, lungs & liver

11. Investigations
1. Nasopharyngoscopy and Diagnostic Nasal Endoscopy
– Mass seen in nasopharynx at fossa of
Rosenmüller
2. Nasopharyngeal tumor biopsy: blind /under vision
3. F.N.A.C. of neck node
4. C.T. scan head and neck : Tumor extent, skull base
erosion, Cervical lymph node metastasis

12. 5. M.R.I. head & neck: for intracranial extension
6. Tests for metastases
− C.T. chest and abdomen, bone scan, P.E.T. scan,
liver function tests
7. Serologic tests
– Immuno-fluorescence for IgA antibodies to Viral
Capsid Antigen, Ig G antibodies to Early Antigen

13. Diagnostic Nasal Endoscopy
• Gross
–Proliferative
–Ulcerative
–Infiltrative

14. Computerized Tomogram Scan

15. Magnetic Resonance Imaging

16. Endoscopic Biopsy

17. Whole body bone scan

18. Positron Emission Tomography

19. T.N.M. staging
• T1 : confined to nasopharynx
• T2 : soft tissue involvement in oropharynx or nasal
cavity or Parapharyngeal space
• T3 : invasion of bony structures or P.N.S.
• T4 : intracranial, involvement of orbit, cranial nerves,
infratemporal fossa, hypopharynx

20. N0 : no evidence of regional lymph node involvement
N1 : unilateral
N2 : bilateral (above supraclavicular fossa, < 6 cm)
N3 : > 6 cm or in supraclavicular fossa
M 0 : no evidence of distant metastasis
M 1 : distant metastasis present

21. • Stage I : T1 N0 M0
• Stage II : T2 or N1 M0
• Stage III : T3 or N2 M0
• Stage IV : T4 or N3 or M1

22. Treatment modalities
1. Teletherapy or External beam radiotherapy
2. Brachytherapy
3. Chemotherapy
4. Surgery
5. Immunotherapy against E.B.V.
6. Vaccination against EBV: experimental

23. External beam irradiation
2 lateral fields: nasopharynx, skull base and upper neck
sparing temporal lobe, pituitary and spinal cord
1 anterior field: lower neck; sparing spinal cord & larynx

24. Brachytherapy
• Treatment of cancer by the insertion of radioactive implants
directly into the tissue
• Used for small tumor, residual or recurrent tumor
– Interstitial: Radioactive source (Radium, Iridium, Iodine,
Gold) inserted into tumor tissue
– Intracavitary: Radioactive source placed inside the
catheter or moulds & inserted into nasopharynx
– High dose rate (HDR): High intensity radiation delivered
with precision under computer guidance

25. Interstitial Brachytherapy

26. Intracavitary Brachytherapy

27. High Dose Rate Brachytherapy

28. Chemotherapy
• Drugs used
−Cisplatin
−5-Fluorouracil
• Indications
–Radiation failure
–Palliation in distant metastasis

29. Surgery
1. Nasopharyngectomy, Cryosurgery : for residual or
recurrent tumor
2. Radical neck dissection : for radio-resistant neck
node metastasis
3. Palliative debulking : for T4 tumors
4. Myringotomy & grommet insertion : for persistent
otitis media with effusion

30. Radical neck dissection & Interstitial
Brachytherapy

31. Treatment Protocol
T1 : External Radiotherapy (6500 c Gy)
T2 : External Radiotherapy (7000 c Gy)
T3 / T4 : Radiotherapy + Chemotherapy 
Brachytherapy / Salvage surgery if required
N0 : External Radiotherapy (5000 c Gy)
N+ : External Radiotherapy (6000 c Gy) +
Chemotherapy

32. Prognosis
• W.H.O. Type 2 and 3 carcinomas have good
response to radiotherapy and better survival rates
• Average 5 year survival rates for treated patients
Stage I : 95 – 100 %
Stage II : 60 – 80 %
Stage III : 30 – 60 %
Stage IV : 20 – 30 %

33. Follow up protocol for ca nasopharynx
• Final assessment (2–3 months after the end of treatment)
– Local and regional exam plus nasopharyngeal endoscopy, FDG-PET/CT
and/or MRI
• First two years
– Local and regional exam plus nasopharyngeal fibroscopy (every 3 to 4
months)
– Chest X-ray, thyroid function test, CT/MRI (yearly)
• Two to five years
– Local and regional exam plus nasopharyngeal fibroscopy
(every 6 months)
– Chest X-ray, thyroid function test, CT/MRI (yearly)