CASE Bệnh nhân: Đặng Thanh T. Nam 41T Lý do vv: Hạch cổ Bệnh sử: Cách vào viện 3 tuần, BN thấy xuất

hiện hạch vùng cổ phải, không đau, to dần. Kèm đau nửa đầu bên phải, chảy máu cam số lượng ít vv

Tiền sử: VGB điều trị thuốc namThuốc lá 6 bao/năm

Thăm khám: Hạch ở đoạn 1/3 dưới sau cơ ức đòn chũm bên phải. Kích thước 2cm, bề mặt nhẵn, cứng, không đau, di động được.

CTM: HC: 4.21; Hb: 145; Hct: 0.411; BC: 10.24

Nội soi TMH: - Lần 1: Viêm họng amydal mạn tính-TD nang hố dưới lưỡi thành thiệt.

- Lần 2: Viêm họng-Amydal. Loét vòm. Siêu âm vùng cổ: Đa hạch vùng cổ phải,

Hạch lớn nhất kích thước 24.11mm. Nang nhỏ thùy phải tuyến giáp.

Mô bệnh học: Hạch di căn Carcinoma không biệt hóa.

Cần làm thêm những gì?? Điều trị như thế nào?? Tiên lượng ra sao?

NASOPHARYNGEAL CANCER

Tùng-Y4

OVERVIEW Introduction Anatomy Epidemiology Etiology Clinical presentation Classification Staging Treatment Prognosis

INTRODUCTION Nasopharyngeal cancer is a cancer that

starts in the nasopharynx, the upper part of the throat behind the nose and near the base of skull.

Nasopharyngeal carcinoma (NPC): 85%

Lymphomas: 10%

Adenocarcinoma

ANATOMY Anteriorly Roof Posteriorly Inferiorly Lateral wall

NASOPHARYNX

EPIDEMIOLOGY World wide:o 80,000 new cases/year o 50,000 deaths/year

Regional differenceso Endemic in southern China, Hong Kongo Rare in westo Intermediate in middle east

EPIDEMIOLOGY Incidence:

o Increases after 20 years and decreases after 60 years

o M:F 3:1

ETIOLOGY Multifactorial

Endemic

Virus

Diet Genetic

Non-endemi

c

Tobacco

Alcohol

VIRUS Epstein-Barr virus (EBV)o Normal nasopharyngeal epithelia lack EBVo EBV DNA and EBV gene were found in

precursor lesions and tumour cellso Patients also demonstrate specific serologic

responses to various gene products of EBV (Ig A against EBV)

Human papilloma virus (HPV)

DIET

CLINICAL PRESENTATION Patients may remain asymptomatic for a

prolonged period

Most presents with locally advanced disease

Painless neck mass 30-70 % /nodal metastasisHearing loss or ear drainage 25 % /ET tube involvement Nasal bleeding or obstruction

Nasal cavity

Cranial nerve deficitVI and V2(V2 most commonly)facial pain

Cavernous sinus involvement

headaches Intracranial extension Trismus pterygoid muscle invasionProptosis Orbit

neck discomfort. Retropharyngeal node involvement

9,10 ,11 CN Para pharyngeal space involvement

NECK MASS

LEFT PROPTOSIS

METASTATIC POTENTIAL Most common site

Cervical nodesUp to 90 %Bilateral in 50 % cases.

Distant metastasis o Bone (75%)o Lung, liver, and distant nodes

DIAGNOSTIC EVALUATION Diagnostic Nasal Endoscopy

Aural Examination

Head and Neck Examination

Cranial Nerve Examination

DIAGNOSTIC NASAL ENDOSCOPY

CT-SCAN

MRI

WHOLE BODY BONE SCAN

PET-CT

ENDOSCOPIC BIOPSY

CLASSIFICATION WHO classes: Keratinizing squamous cell carcinoma (type I) Non-keratinizing differentiated carcinoma

(type II) Undifferentiated carcinoma (type III)

STAGING 

29

30

31

32

33

34

35

36

38

39

TREATMENT Radiotherapy

Chemotherapy

Surgery

SURGERY Not indicated as a primary treatment

To obtain biopsy

Neck dissection Residual neck nodes following RTIsolated neck recurrence

RADIOTHERAPY External beam radiotherapyo two-dimensional radiation therapy (2D-RT)o three-dimensional conformal radiation

therapy (3D-CRT)

Intensity-modulated radiation therapy (IMRT)

Brachytherapy

EXTERNAL BEAM RADIOTHERAPY 2 lateral fields: nasopharynx, skull base & upper neck; sparing temporal lobe, pituitary & spinal cord. 1 anterior field: lower neck; sparing spinal cord & larynx

BRACHYTHERAPY Used for small tumor, residual or recurrent tumor

COMPLICATIONS U tái phát

Khối u lành tính của hầu

Cứng cơ khít hàm do bất thường khoang nhai

Tổn thương thùy thái dương

Hoại tử xương do xạ trị

Các khối u do bức xạ kích thích

CHEMOTHERAPY Drug used: - Cisplatin

- 5-Fluorouracil Role of chemotherapy : radiation

sensitization, locoregional control(locoregional means: limited to a localized area, as contrasted with systemic or metastatic) Indications: - Radiation failure

- Palliation in distant metastasis

RESULT: 6% ABSOLUTE SURVIVAL BENEFIT AT 5 YEARS

TREATMENT T1 N0 M0:

RT alone

T2,T3,T4 or N+,M0ChemoRTCisplatin based 3 weekly

Metastatic Platinum based combination CR radical RT

OTHER Immunotherapy against E.B.V

Vaccination against EBV: experimental

POSTTREATMENT FOLLOW-UPDocumentation of remission 

Clinical Endoscopic Imaging

3 months MRI scan of the skull base and neck CT head &neck PET-CT

FOLLOW UP

3 monthly follow up for 2 years

4-6 monthly for 3-5 years

Annually after 5 years

05/01/2023 53

PROGNOSIS

PROGNOSIS