Pathology of nasopharyngeal cancer

2021-02-01 12:00 AM

The upper surface is the lower margin of the mantle and the base of the occipital bone. On this side, lymphatic organization is concentrated in clusters called Luschka tonsils

Outline

Nasopharyngeal cancer (NPC - Nasopharyngeal Carcinoma) in our country has a high rate, ranking first among head and neck cancers, and 5th among cancers in general. But atypical symptoms are mostly "borrowed" symptoms of neighbouring organs such as ears, nose, nerves, lymph nodes ... so the diagnosis is difficult. Need early detection, timely treatment to save the patient's life.

Nasopharyngeal surgery

Anatomical structure: the nasopharynx, also known as nasopharynx, belongs to the inner fetal leaf with a structure of a box of six sides.

The front is the back door.

The posterior surface is the pharyngeal mucosa and is around the pharynx, associated with the occipital bone, the cervical vertebrae 1, 2. 

The two sides are the eardrum speakers, about 1 cm from the lower nose, around the speaker there is a lymphatic organization called Gerlach tonsils. Above the posterior atrial edge is the Rosenmuller fossa. The upper surface is the lower margin of the mantle and the base of the occipital bone. On this side, lymphatic organization is concentrated in clusters called Luschka tonsils. When this organ is overgrowth it is called VA inflammation

The lower side is open to the throat.

Nourishing blood vessels: the female palate artery, which comes from the inner jaw artery (one of the two common branches of the external carotid artery).

Organology: The upper part is composed of a single cylindrical epithelium with shifting hair in the respiratory tract mucosa. Below is the paved epithelium of the lining of the digestive tract.

Research history of nasopharyngeal cancer

In the study of the mummies in Egypt, Elliot Smith discovered two human skulls with damage in the base of the skull such as lesions of throat cancer.

According to Fardel in 1837 in Europe, there were the first medical records of patients with throat cancer-like conditions.

In Vietnam, the late professor Tran Huu Tuoc studied 612 patients with nasopharyngeal cancer at Bach Mai Hospital (1955 - 1964).

Epidemiology

World: nasopharyngeal cancer appears in many China, Africa and some Southeast Asian countries, very rare in Europe and America. Especially, the Guangdong region (China) has a lot of problems with the rate: 30-45 patients / 100,000 people/year. They also call nasopharyngeal cancer "Guangdong U".

Vietnam: still does not have complete and accurate statistics. But according to the statistics of K-Hanoi Hospital (1998), throat cancer ranks 4th and 5th after lung cancer, ovarian uterine cancer, breast cancer, liver cancer and is the leading disease among regional cancers. head and neck with the rate of 9-11 patients / 100,000 people / year.

Gender is common in men, the ratio male / female: 2-3 / 1.

Age: the disease usually appears from 20 to 65 years old, after 65 years the rate of the disease gradually decreases.

Related factors

Environmental factors: including microclimate conditions, smog, pollution and eating habits (eating salted fish, soy sauce, tomato and moulds... because these contain carcinogenic nitrosamines) ).

Due to the Epstein Barr Virus (EBV): This is a human virus of the Herpes group that causes Burkitt's lymphoma in African children. In recent years, people talk about the association between oropharyngeal cancer with EBV, due to the detection of the EBV genome in nasopharyngeal tumour cells and in the serum of patients with oropharyngeal cancer, antibody titer. IgA anti-VCA-EBV is very high, while it is very low or absent in the serum of normal people or other cancers.

Genetic factors: recently there have been some authors suggesting that people of the same bloodline are more likely to develop throat cancer together. Genetics has found about 30 endogenous cancer genes. These genes are normally in a state that automatically closes and stays dormant, but if there is an induction mechanism, the oncogene will wake up and cause disorganized growth that causes cancer.

However, many authors believe that the cause of nasopharyngeal cancer is not alone but caused by many factors acting together. Therefore, the prevention of nasopharyngeal cancer must be done in many different stages and fields to bring results.

Histopathology

According to the classification of (WHO - 1978):

The most common is undifferentiated carcinoma (UCNT-Undifferentiated carcinoma nasopharyngeal type) accounting for 75% - 85%.

Differentiated type of carcinoma (CS-Carcinome spinocellulaire) accounts for 10% - 15%.

Associated cancer (Sarcoma) is rare about 5%.

Nodules of the neck during biopsy do pathological anatomy: consistent with the pathological anatomical results of the nasopharynx (primary).

Clinical

Early-stage

The symptoms are silent so it is difficult to detect. Headache is an early symptom, usually migraine, in episodes or dullness. Use less effective pain relievers.

Resident phase

Mechanical symptoms

Neurological symptoms: the most common is headache, migraine or deep pain in the eye sockets, temples and damage to the cranial nerves in the case of late patients such as: feeling numb in the mouth and face along with the headache caused by a pinched nerve.

Nasal sinus symptoms: stuffy nose on one side, along with headaches, infrequently stuffy at first after continuous stuffing. The most common are runny nose, can run purulent nose combination sinusitis, sometimes with bloody mucus leakage.

Ear symptoms (tumour stemming from the side of the throat, nose, mouthpiece): a feeling of pressure as if the earwax button is on the same side with a headache. Tinnitus, hearing loss can be done simply (due to blocked Eustachy tap). Lateral otitis may occur due to superinfection.

Symptoms of cervical and sub-jaw: most patients come to the examination because of the presence of cervical lymph nodes, often the cervical lymph node with the tumor. Easy to misdiagnose as primary lymphoma. Typical lymph nodes are usually seen at the posterior angle of the jaw, the upper carotid ganglion, lymph node enlargement initially, the lymph nodes are stiff, painless press, no peri-lymphadenitis, limited mobility. After fixing stick to muscle, skin.

Physical symptoms

The pre-nasal exam is nothing special.

A post-nasal examination can reveal a lumpy or infiltrated tumour on the roof of the dome or in the dome, on the edge of the Eustachy nozzle.

Touch the dome by hand or visit with a bloody cotton stick.

Stage is rampant

Systemic symptoms: reduced physical condition, poor appetite, insomnia, weight loss, anaemia, straw-coloured skin, or fever due to superinfection.

Physical and physical symptoms: depending on the direction of tumour spread, different symptoms will appear.

Spread out front 

Common tumours in the roof of the arch, the posterior nose.

Tumours spread into the nasal passages causing nasal congestion. Initially stuffy one side later, the tumour grows to fill the back of the nose causing congestion on both sides of the nose, nasal voice. Nasal discharge has a strong odour, often mixed with blood sparks, sometimes nosebleeds.

Nasal examination: found tumours, deep in the back of the nose, often with necrotic ulcers, easy to bleed.

Spread to two sides: the tumour in the speaker tap, spread along with the Eustachy tap to the middle ear.

Tinnitus marked unilateral hearing loss.

Pain in the ear spreads to the mastoid area.

Purulent discharge with blood, the smell of rotten, sometimes mixed with necrotic tissue.

Ear microscopy: the eardrum is punctured, there are tumours, necrosis, easy to bleed, the tumour can pass through the eardrum and spread to the outer ear canal.

Lan down 

Tumours spreading downwards push up the pharynx is affecting voice (nasal voice open), swallowing or choking.

The tumour can reach the mouth, usually behind the posterior pillar of the tonsils.

Trotter syndrome may be deafness, closed jaw, paralysis of the pharynx.

Spread upwards

Cancer spread to the base of the skull causes intracranial syndromes such as increased intracranial pressure and focal neurological syndromes:

Butterfly Slit Syndrome: paralysis of the nerves III, VI and the ocular branch of the V cord causes paralysis of the muscles of the eye, pain in the forehead and orbit.

Cliff syndrome: paralysis of nerves V, VI causes strabismus, tight jaw, half-face numbness

Rock-butterfly syndrome or Jacob syndrome: nerve paralysis II, III, IV, V, VI cause blindness, entire eyeball paralysis, chewing muscle paralysis, semi-facial anaesthesia.

Post-tear syndrome or Vernet syndrome: paralysis of the nerves IX, X, XI causes paralysis of the throat, paralysis of the pharynx, signs of tearing up the pharynx, double voice, paralysis of the thymus, trapezium.

Post-laceration-convex convex syndrome or Collet-Sicard syndrome: paralysis of the nerves IX, X, XI, XII and paralysis of the tongue.

Gracin syndrome: all 12 pairs of unilateral cranial nerves are paralyzed.

Diagnose

 Before a patient with the above symptoms, to suspect and be meticulously examination of the oropharynx: indirect arches in the mirror or dome with a bronchoscope (hard, soft). Through the dome can see a purulent, ulcerative or infiltrated organization that bleed easily.

Tumour biopsy

Diagnostic anatomy is the defining diagnostic factor.

Diagnostic cytology

Significantly oriented (cells in the nasopharynx or in the cervical lymph nodes).

Serum diagnosis

This method relies on EBV's association with oropharyngeal cancer and can be performed in a wide range of people to detect it as soon as the clinical symptoms are unknown. It is the indirect immunofluorescence assay, which determines the titre of IgA / VCA-EBV or IgA / EA. But also, does not have a definitive diagnostic value that must still be based on the results of pathological anatomy.

Diagnosis of X-ray

Hirtz posture.

CT Scan of the oropharynx, the base of the skull: assesses the spread and destruction of the tumour on the base of the skull.

Radiation diagnosis

It is possible to early diagnose the tumour size, diagnose the distal metastasis of the disease.

Stage diagnosis

Union Internationale Contre le Cancer (UICC) - 1987 ranked the UTVH stage.

TNM classification

T (Tumor): Primary tumour:

Tx: unknown tumour.

Tis: (insitu) Small tumour localized under the mucosa.

Enlargement: no tumour (no tumour on the dome).

T1: Tumor is localized in one anatomical site.

T2: The tumour has spread to 2 other locations.

T3: Tumor spread into the nasal passages, down the pharynx.

T4: The tumour has destroyed the base of the skull or damaged the cranial nerves.

N (Node): ancient node:

No: cervical lymph nodes are not palpable.

N1: a cervical lymph node, unilateral, mobile, KT <3 cm.

N2: cervical ganglia divided into 3 levels.

N2a: a cervical lymph node, unilateral, mobile, KT: 3 - 6 cm.

N2b: many cervical lymph nodes, parietal, mobile, KT <6 cm.

N2c: bilateral or opposite cervical lymph node, mobile, KT <6 cm.

N3: fixed cervical lymph node (including unilateral cervical lymph node) or KT> 6 cm.

M (Metastasis): distant metastasis:

Mo: Far metastasis has not appeared.

M1: has appeared distant metastasis (based on X-ray and ultrasound to diagnose).

Clinical staging classification

Stage I: T1NoMo.

Stage II: T2NoMo.

Stage III: T3NoMo, T1-3N1Mo.

Stage IV: T4No-1Mo, N2-3Mo and T.

M1 (T and Ns).

Differential diagnosis

Nasopharyngeal fibroids.

Postnasal polyps.

VA organizational residues

Evolution and prognosis

Early-stage

Locally, progressing slowly, having little effect on the whole body, usually lasting 1-2 years if diagnosed early and treated in time with the correct regimen that can cure the disease.

Stage is rampant

The effects on the body are clear, rapid progression often dies from the tumour spread to the base of the skull, from metastasis to organs such as lungs, liver, bones.

Treatment

Because the tumour is located in a deep cavity, near the base of the skull, treatment is difficult, results are limited, the prognosis is poor.

Radiotherapy

Co60 is the main treatment and gives good results if the patient arrives early, especially for undifferentiated carcinoma.

The primary tumour was radiated into the lateral neck, at a dose of 65-70Gy for 6 to 7 weeks.

Nodules of the neck or sub jaw are radiated at a dose of 50Gy for 6 to 7 weeks.

Acceleration.

Inserting the needle into the tumour and lymph nodes in case of external radiation enough dose but the tumor has not gone away.

Surgery

Surgery to remove cervical lymph nodes before or after radiation therapy.

Chemotherapy

Only applies to undifferentiated carcinoma or cervical lymphoma that has spread and has distant metastasis.

Immunotherapy

Resistance and supportive effect in radiation therapy.

Prevention of nasopharyngeal cancer

Currently, it is thought that: 70% of cancer cases are due to foreign factors, and 30% due to internal factors and genetic factors, so: must have a reasonable diet, reduce animal fat, less eat meat instead of vegetables and fruits high in Vitamin C, E.