| disease | Nasopharyngeal Carcinoma |
The incidence of nasopharyngeal carcinoma is higher in southern China, such as in Guangdong, Guangxi, and Hunan provinces, particularly in the central and western regions of Guangdong, including Zhaoqing, Foshan, and Guangzhou. It is reported that the incidence rate among males residing in central Guangdong and speaking local dialects is 30 to 50 per 100,000. Nationally, the incidence of nasopharyngeal carcinoma gradually decreases from south to north, with the northernmost regions having an incidence rate no higher than 2 to 3 per 100,000.
bubble_chart Etiology
Epidemiological investigations suggest that the disease cause of nasopharyngeal carcinoma may be related to the following factors: ①EB virus infection. ②Environment and diet: Environmental factors are also a cause of nasopharyngeal carcinoma. In Guangdong, investigations have found that the content of the trace element nickel in rice and water in high-incidence areas of nasopharyngeal carcinoma is higher than in low-incidence areas. The nickel content is also high in the hair of nasopharyngeal carcinoma patients. Animal experiments have shown that nickel can promote nitrosamine-induced nasopharyngeal carcinoma. There are also reports that consuming salted fish and preserved foods is a high-risk factor for nasopharyngeal carcinoma in southern China, and it is related to the age at which salted fish is consumed, the duration, amount, and cooking methods. ③Genetic factors: Nasopharyngeal carcinoma patients exhibit racial and familial clustering, such as the descendants of southern Chinese living in other countries still maintaining a high incidence of nasopharyngeal carcinoma, suggesting that nasopharyngeal carcinoma may be a genetic disease.
bubble_chart Pathological Changes
(1) Common Sites and Gross Morphology Nasopharyngeal carcinoma commonly occurs at the top of the posterior wall of the nasopharynx, followed by the lateral wall, while occurrences at the anterior and bottom walls are extremely rare. The gross morphology of nasopharyngeal carcinoma is divided into five types: nodular, cauliflower-like, submucosal, infiltrative, and ulcerative.
(2) Growth and Spread Patterns The spread of nasopharyngeal carcinoma follows certain patterns. In the early stages, nasopharyngeal carcinoma is confined to the nasopharynx and can be referred to as localized. As the tumor grows, it can directly spread to adjacent sinus cavities, spaces, and the skull base. Nodular or cauliflower-like tumors may protrude into the nasopharyngeal cavity, while infiltrative, submucosal, and ulcerative types often grow in the submucosal layer. The tumor can extend into the nasal cavity, oropharynx, and may spread to the parapharyngeal space, pterygopalatine fossa, or invade the orbit. The tumor can also extend upward, destroying the skull base and cranial nerves. Cervical metastasis of nasopharyngeal carcinoma occurs through the lymphatic drainage system, while distant metastasis can occur through the lymphatic system entering the bloodstream or by direct invasion of surrounding blood vessels, leading to distant organ metastasis.
(3) Histological Classification
1. Carcinoma in situ: The concept of carcinoma in situ implies that cancer cells have not yet breached the basement membrane, and nasopharyngeal carcinoma in situ is no exception. There must be an intact basement membrane beneath the cancer lesion. When carcinoma in situ cells proliferate, forming bud-like or peg-like projections into the subepithelial layer, a clear basement membrane still separates the cancer cells from the underlying mucosal lamina propria. The diagnosis of nasopharyngeal carcinoma in situ is primarily based on cytological criteria, with histological arrangement and structure considered secondarily. Therefore, the cytological criteria for diagnosing nasopharyngeal carcinoma in situ must be strictly adhered to, ensuring that the degree of anaplasia meets widely accepted standards. Compared to normal epithelial cells, carcinoma in situ cells have an increased nuclear-to-cytoplasmic ratio, meaning the nuclear area is significantly enlarged.
2. Invasive Carcinoma
(1) Microinvasive carcinoma: This refers to the destruction of the basement membrane by cancer cells, but the extent of invasion does not exceed one field of view under 400x magnification. The cell morphology is more atypical than carcinoma in situ, with invasive growth through the basement membrane.
(2) Squamous cell carcinoma: Although most nasopharyngeal carcinomas originate from columnar epithelium, the majority of nasopharyngeal carcinomas are squamous cell carcinomas. To diagnose squamous cell carcinoma, the histological section must exhibit features of squamous differentiation. Squamous differentiation refers to: ① keratin pearls; ② intracellular and extracellular keratinization; ③ intercellular bridges; ④ the arrangement of cells in cancer nests resembling squamous epithelium, with cells not appearing syncytial. Based on the degree of squamous differentiation, nasopharyngeal squamous cell carcinoma can be classified into well-differentiated, moderately differentiated (grade II), and poorly differentiated.
① Well-differentiated squamous cell carcinoma: This type is characterized by the presence of intercellular bridges or keratinization in most of the cancer tissue, also known as well-differentiated squamous cell carcinoma or keratinizing squamous cell carcinoma. Cancer nests generally do not have lymphocyte infiltration, although scattered lymphocytes may occasionally be seen. The boundaries of cancer nests are usually clear, sometimes with a complete membrane surrounding them. The stroma of this type is mostly fibrous tissue, with infiltration of neutrophils, lymphocytes, and plasma cells, although plasma cells are generally not abundant.
③Low-grade differentiated squamous cell carcinoma: Under the light microscope, a certain number of cancer cells can also be seen with intercellular bridges or intracellular keratinization, but the quantity is small. The nuclei of the cancer cells are deeply stained. The nucleoli are hypertrophic, often with some basophilic eosin staining. The boundary between the cancer nests and the stroma is relatively clear, but they can also be intermingled with the stroma. There are varying numbers of lymphocytes infiltrating the cancer nests, and the stroma can present in various types, such as lymphocyte-rich infiltration type, granulation tissue type, fibrotic type, and intrinsic tissue type, etc. Regardless of the type of stroma, there is always a varying number of plasma cells infiltrating.
(3) Adenocarcinoma: Nasopharyngeal adenocarcinoma is extremely rare compared to nasopharyngeal squamous cell carcinoma, especially in high-incidence areas of nasopharyngeal carcinoma. From a histogenetic perspective, adenocarcinoma must originate from glandular tissue.
① Highly differentiated adenocarcinoma: The boundary between the cancerous parenchyma and stroma is clear, and the cancer nests are relatively obvious. Some cancer cells are arranged in an acinar pattern; some are arranged in a tall columnar duct-like structure; some exhibit adenoid cystic carcinoma or cribriform carcinoma structures; and some are simple adenocarcinomas.
② Moderately differentiated adenocarcinoma: This refers to adenocarcinomas in which a certain number of clear glandular lumens are observed in the cancerous tissue, but are accompanied by partially undifferentiated cancerous structures. They are often the result of further anaplasia of the aforementioned highly differentiated adenocarcinomas, thus still retaining some traces of highly differentiated adenocarcinoma.
③ Poorly differentiated adenocarcinoma: Clear glandular lumen structures are visible in the cancerous tissue, but they are very few in number. Most of the cancerous tissue exhibits an undifferentiated carcinoma structure. The tumor cells have foamy cytoplasm and show weak positivity with Alcian blue staining.
(4) Vesicular nucleus cell carcinoma: Nasopharyngeal carcinoma in which most of the cancer cell nuclei exhibit vesicular changes can be termed vesicular nucleus cell carcinoma. Due to its relatively unique morphology and better prognosis after radiotherapy, it is classified as a distinct type. The so-called vesicular change of the nucleus refers to the nucleus being large and round or oval or spindle-shaped. The nuclear area is more than three times that of a lymphocyte nucleus. The chromatin within the nucleus is relatively sparse, giving the nucleus a vesicular appearance; the chromatin often adheres unevenly to the inner surface of the nuclear membrane, making it uneven in thickness, with thin areas even resembling nuclear membrane defects. To diagnose nasopharyngeal vesicular nucleus cell carcinoma, more than 75% of the cancer cell nuclei in the section must exhibit vesicular changes. The remaining less than 25% of the cancer cells can be poorly differentiated squamous cell carcinoma or undifferentiated carcinoma. The diagnostic criterion for vesicular nucleus cell carcinoma is set at more than 75% of the cancer cells exhibiting vesicular changes because only then can its unique biological characteristics, namely a better prognosis after radiotherapy, be demonstrated.
(5) Undifferentiated carcinoma: The cancer cells are distributed diffusely and often mixed with the stroma. The cells are medium-sized or slightly smaller, short spindle-shaped, oval, or irregular, with scant cytoplasm and slight basophilia. The nuclear chromatin is increased, granular or clumped, and nucleoli may sometimes be visible.
bubble_chart Clinical Manifestations
(1) Bleeding: Early symptoms may include bleeding, manifested as blood in the sputum after nasal suction or blood in the nasal discharge when blowing the nose. In the early stages, there may only be a small amount of blood streaks in the sputum or nasal discharge, which may come and go. In the advanced stage, bleeding may be more severe, possibly including nosebleeds.
(2) Tinnitus, hearing loss, and a feeling of ear blockage: When nasopharyngeal carcinoma occurs on the lateral wall of the nasopharynx, in the lateral fossa, or on the upper lip of the eustachian tube opening, the tumor pressing on the eustachian tube can cause unilateral tinnitus or hearing loss, and may also lead to catarrhal otitis media. Unilateral tinnitus or hearing loss and a feeling of ear blockage are among the early symptoms of nasopharyngeal carcinoma.
(3) Headache: A common symptom, accounting for 68.6%. It can be the first or only symptom. In the early stages, the location of the headache is not fixed and is intermittent. In the advanced stage, it becomes a persistent migraine with a fixed location. The cause in early-stage patients may be due to neurovascular reflexes or stimulation of the terminal branches of the trigeminal nerve's first branch. In advanced-stage patients, it is often caused by tumor destruction of the skull base and intracranial spread involving cranial nerves.
(4) Diplopia: Due to tumor invasion of the abducens nerve, it often causes double vision when looking outward. Invasion of the trochlear nerve often causes inward strabismus and diplopia, with diplopia accounting for 6.2-19%. It is often accompanied by damage to the trigeminal nerve.
(5) Facial numbness: Refers to a feeling of numbness in the facial skin, with clinical examination showing reduced or absent pain and touch sensation. Tumor invasion of the cavernous sinus often causes damage to the first or second branch of the trigeminal nerve; tumor invasion of the foramen ovale, pre-styloid region, or the third branch of the trigeminal nerve often causes numbness or abnormal sensation in the skin of the anterior auricle, temporal region, cheek, lower lip, and chin. Facial skin numbness accounts for 10-27.9%.
(6) Stuffy nose: A tumor blocking the posterior nasal cavity can cause a stuffy nose. When the tumor is small, the stuffy nose is mild, but as the tumor grows, the stuffy nose worsens, usually being unilateral. If the tumor blocks both posterior nasal cavities, bilateral stuffy nose can occur.
(7) Symptoms of cervical lymph node metastasis: Nasopharyngeal carcinoma is prone to cervical lymph node metastasis, about 60.3-86.1%, with half being bilateral metastasis. Cervical lymph node metastasis is often the first symptom of nasopharyngeal carcinoma (23.9-75%). In a few patients, the primary lesion cannot be found in the nasopharyngeal examination, and cervical lymph node metastasis is the only clinical manifestation. This may be related to the small size of the primary lesion of nasopharyngeal carcinoma and its spread into the submucosal tissue.
(8) Tongue muscle atrophy and tongue deviation: Nasopharyngeal carcinoma directly invades or metastasizes to the retro-styloid region or hypoglossal canal, causing damage to the hypoglossal nerve, leading to tongue deviation towards the affected side, accompanied by atrophy of the tongue muscle on the affected side.
(9) Ptosis and fixed eyeball: Related to damage to the oculomotor nerve. Reduced or lost vision is related to damage to the optic nerve or invasion of the orbital cone.
(10) Distant metastasis: The distant metastasis rate of nasopharyngeal carcinoma is between 4.8-27%. Distant metastasis is one of the main reasons for treatment failure in nasopharyngeal carcinoma. Common metastatic sites include bone, lung, liver, etc., with multi-organ simultaneous metastasis being common.
(11) Associated dermatomyositis: Dermatomyositis can also be associated with nasopharyngeal carcinoma, so patients with dermatomyositis, regardless of the presence of nasopharyngeal carcinoma symptoms, should have a thorough nasopharyngeal examination.
(12) Amenorrhea: As a first symptom of nasopharyngeal carcinoma, it is very rare and is related to the invasion of the sphenoid sinus and pituitary gland by nasopharyngeal carcinoma. {|111|}
In addition to paying attention to the above clinical manifestations, the following examinations should be performed:
(1) Anterior rhinoscopy: After the nasal mucosa contracts, the posterior nasal cavity and nasopharynx can be observed through anterior rhinoscopy, which can detect cancers invading or adjacent to the nasal cavity.
(2) Indirect nasopharyngoscopy: This method is simple and practical. The walls of the nasopharynx should be examined in sequence, paying attention to the posterior wall of the nasopharynx and the pharyngeal recesses on both sides. Corresponding areas on both sides should be compared. Any asymmetrical submucosal bulges or isolated nodules should be noted.
(3) Fiberoptic nasopharyngoscopy: Before performing fiberoptic nasopharyngoscopy, the nasal mucosa can be contracted with a 1% Ephedrine solution to dilate the nasal passages. Then, the nasal passages are anesthetized with a 1% Dicaine solution. The fiberoptic scope is inserted through the nasal cavity, observing as it advances until it reaches the nasopharyngeal cavity. This method is simple and the scope is well fixed, but the posterior nasal cavity and anterior wall are not well observed.
(4) Neck biopsy: For cases where nasopharyngeal biopsy has not confirmed the diagnosis, a neck mass biopsy can be performed. This is usually done under local anesthesia. The earliest appearing hard lymph node should be selected and the entire node with its capsule should be removed. If excision biopsy is difficult, a wedge biopsy can be performed on the mass. The tissue should be taken with sufficient depth and should not be squeezed. The surgical site should not be sutured too tightly or densely.
(5) Fine needle aspiration: This is a simple, safe, and efficient method for tumor diagnosis, which has been increasingly recommended in recent years. For suspected cervical lymph node metastasis, fine needle aspiration can be used first to obtain cells. The specific methods are as follows:
1. Nasopharyngeal mass aspiration: A 7-gauge long needle is attached to a syringe. After anesthetizing the oropharynx, the needle is inserted into the tumor under indirect nasopharyngoscopy. The syringe is pulled to create negative pressure, and the needle is moved back and forth twice within the tumor. The aspirate is then smeared on a slide for cytological examination.
2. Fine needle aspiration of neck mass: A 7-gauge or 9-gauge needle is attached to a 10ml syringe. After disinfecting the local skin, the puncture site is selected, and the needle is inserted along the long axis of the tumor. The syringe is aspirated, and the needle is moved back and forth 2-3 times within the mass. The aspirate is then subjected to cytological or pathological examination.
(6) EB virus serological testing: Currently, the most commonly used method is the immunoenzyme assay to detect the titers of EB virus IgA/VCA and IgA/EA antibodies. The former has higher sensitivity but lower accuracy, while the latter is the opposite. Therefore, for suspected nasopharyngeal carcinoma, both antibodies should be tested simultaneously, which is helpful for early diagnosis. For cases with IgA/VCA titer ≥1:40 and/or IgA/EA titer ≥1:5, even if the nasopharynx appears normal, exfoliated cells or biopsy should be taken from the common sites of nasopharyngeal carcinoma. If the diagnosis is still not confirmed, regular follow-up is necessary, and multiple biopsies may be required.
(7) Nasopharyngeal lateral view, skull base view, and CT scan: Every patient should routinely undergo nasopharyngeal lateral view and skull base view radiographs. If there is suspicion of invasion of the paranasal sinuses, middle ear, or other areas, corresponding radiographs should also be taken. If possible, a CT scan should be performed to understand the local extension, especially the infiltration range of the parapharyngeal space. This is crucial for determining the clinical stage and formulating a treatment plan.
(8) B-ultrasound examination: B-ultrasound has been widely used in the diagnosis and treatment of nasopharyngeal carcinoma. It is simple, non-invasive, and well-accepted by patients. In cases of nasopharyngeal carcinoma, it is mainly used to examine the liver, neck, retroperitoneum, and pelvic lymph nodes to determine the presence of liver metastasis, lymph node density, and whether there are cystic changes.
(9) Magnetic Resonance Imaging (MRI) Examination Since Magnetic Resonance Imaging (MRI) can clearly display various layers of the head, cerebral sulci, gyri, gray matter, white matter, ventricles, cerebrospinal fluid pathways, blood vessels, etc., the use of the SE method to display T1 and T2 prolonged high-intensity images can diagnose nasopharyngeal carcinoma, maxillary sinus cancer, etc., and show the relationship between the tumor and surrounding tissues.
bubble_chart Treatment Measures
(1) Radiotherapy
Radiotherapy has always been the preferred method for treating nasopharyngeal carcinoma. The reason is that most nasopharyngeal carcinomas are poorly differentiated cancers, which are highly sensitive to radiation, and the primary lesion and cervical lymph drainage area are easily included in the radiation field. Since the 1940s, deep X-ray radiotherapy for nasopharyngeal carcinoma has been carried out in our country. From the 1950s to the 1960s, external radiotherapy with 60Co was introduced, and the combined large-field irradiation of the nasopharynx and neck was changed to small-field irradiation, reducing radiotherapy reactions and improving survival rates. Currently, the most effective and definitive method is the use of a 60Co teletherapy machine.
1. Indications and contraindications for radiotherapy of nasopharyngeal carcinoma
(1) Indications for radical radiotherapy: ① Patients with moderate or better general condition; ② No obvious bone destruction at the skull base; ③ CT or MRI shows no or only mild, grade II infiltration in the paranasopharyngeal area; ④ The maximum diameter of cervical lymph nodes is less than 8cm, mobile, and not reaching the supraclavicular fossa; ⑤ No distant organ metastasis.
(2) Indications for palliative radiotherapy: ① KS score above 60; ② Severe headache, moderate or more bleeding in the nasopharynx; ③ Single distant metastasis or cervical lymph node metastasis larger than 10cm. If the general condition improves, symptoms disappear, and distant metastasis can be controlled after palliative radiotherapy, it can be changed to radical radiotherapy. (3) Contraindications for radiotherapy: ① KS score below 60; ② Extensive distant metastasis; ③ Concurrent acute infectious disease; ④ Radiation-induced brain or spinal cord injury. (4) Principles of re-radiotherapy for recurrence after radiotherapy: Re-radiotherapy is not suitable for the following conditions. ① Recurrence within the same target area (including nasopharyngeal and cervical target areas) less than one year after radiotherapy; ② Radiation-induced encephalopathy or myelopathy after radiotherapy; ③ The total course of radiotherapy for the nasopharyngeal target area should not exceed three courses, and for the cervical target area should not exceed two courses.
2. Selection of radiation and irradiation range
(1) Design of the irradiation field: The principle of designing the irradiation field is "small but not fistula disease". The areas involved by the tumor should be fully included in the irradiation field, but normal tissues within the irradiation field, especially those sensitive to radiotherapy, should be protected. The primary lesion in the nasopharynx is mainly treated with bilateral preauricular fields. If the nasal cavity and paranasopharyngeal space are involved, a nasal anterior field can be added. If the orbit is involved, a supraorbital or infraorbital field can be added, with attention to protecting the eyes with lead sheets to avoid radiation-induced internal visual obstruction. The irradiation range of the neck depends on the lymph node lesions. For those without palpable cervical lymph nodes, prophylactic irradiation of the bilateral upper cervical region is often performed. If there is cervical lymph node metastasis, in addition to irradiating the metastatic lesion, prophylactic irradiation of the drainage area below the metastasis is often performed.
3. Radiation dose and time
(1) Continuous radiotherapy: 5 times a week, 200cGY each time, total dose TD6000～7000cGY/6～7 weeks.
(2) Segmented radiotherapy: Generally, radiotherapy is divided into two segments, 5 times a week, 200cGY each time, each segment about 3.5 weeks. A four-week break between the two segments, total dose TD6500～7000cGY.
4. Afterloading intracavitary radiotherapy
(1) Indications:
① Small localized lesions in the nasopharynx (tumor thickness less than .cm), located at the top wall, anterior wall, or lateral wall;
② Residual lesions after external irradiation or surgical resection of nasopharyngeal carcinoma that meet the criteria of ①.
(2) Treatment method: Often combined with external and intracavitary irradiation, external irradiation dose 4500～6000cGY, followed by intracavitary irradiation 1～2 times after 1～2 weeks of external irradiation, with an interval of 7～10 days between each session, each dose point at 0.25cm below the mucous membrane, giving 1000～2000cGY/session.
5. Radiation reactions, sequelae, and their management
(1) Radiotherapy complications
① Systemic reactions: including lack of strength, dizziness, loss of appetite, nausea, vomiting, loss of taste or altered taste, insomnia or drowsiness, etc. Some patients may experience changes in blood counts, especially leukopenia. Although the severity varies, these symptoms can generally be managed with symptomatic treatment, allowing the completion of radiotherapy. If necessary, vitamin B1, B6, C, and metoclopramide can be taken. Radiotherapy should be temporarily suspended if the white blood cell count drops below 3×109/L.
② Local reactions: including skin, mucous membrane, and salivary gland reactions. Skin reactions manifest as dry dermatitis or even wet dermatitis, and 0.1% borneol talc powder or lanolin-based anti-inflammatory ointment can be used locally. Mucous membrane reactions manifest as congestion, edema, exudation, and secretion accumulation in the nasopharyngeal and oropharyngeal mucous membranes, and local use of gargles and lubricating anti-inflammatory agents can be applied. A few patients may experience parotid gland swelling after 2Gy irradiation, which gradually subsides in 2-3 days. When irradiated to 40Gy, salivary secretion significantly decreases, while oral mucous membrane secretion increases, with congestion and redness. Patients experience dry mouth and difficulty eating dry food. Therefore, excessive irradiation of the parotid gland should be avoided.
(2) Post-radiation complications: mainly include temporomandibular joint dysfunction, soft tissue atrophy and fibrosis, radiation-induced dental caries, radiation-induced osteomyelitis of the jaw, and radiation-induced myelopathy. There is currently no effective method for reversal, and symptomatic treatment and supportive methods are somewhat helpful. Strict avoidance of excessive irradiation of important tissues and organs is necessary.
(II) Surgical Treatment
1. Resection of the primary lesion of nasopharyngeal carcinoma
(1) Indications:
① Well-differentiated nasopharyngeal carcinoma, such as adenocarcinoma, squamous cell carcinoma grades I and II, and early cases of malignant mixed tumors.
② Local recurrence of nasopharyngeal carcinoma after radiotherapy, with the lesion limited to the posterior or anterior wall of the roof, or only involving the edge of the pharyngeal recess, without infiltration of other areas, no difficulty in opening the mouth, and good constitution.
③ After radiotherapy has delivered a radical dose, the primary lesion of the nasopharynx has not disappeared, or radiation resistance has appeared, and surgical resection can be performed after one month of rest.
(2) Contraindications:
① Patients with skull base bone destruction or nasopharyngeal infiltration, cranial nerve damage, or distant metastasis.
② Patients with poor liver and kidney function and poor general condition.
(3) Surgical method: First, perform a tracheostomy and intubation, and perform the surgery under general anesthesia. Make a horseshoe-shaped incision along the inner side of the upper jaw tooth root, at a distance of .cm from the alveolar ridge, cut the hard palate mucous membrane, and peel off the mucous membrane to the soft palate, removing part of the hard palate plate and vomer. Transversely cut the nasal floor mucous membrane at the junction of the hard and soft palate, exposing the roof, anterior part of the lateral walls, and the tumor of the nasopharyngeal cavity. Cut the nasopharyngeal mucous membrane along the posterior edge of the nasal septum and the upper edge of the posterior nasal aperture to the bone surface, perform blunt or sharp separation, cut along the junction of the roof and side of the nasopharynx, and transversely cut the mucous membrane at the junction of the oropharynx and nasopharyngeal posterior wall, and remove the entire posterior roof mucous membrane of the nasopharynx along with the cancer en bloc.
2. Neck lymph node dissection
(1) Indications: The primary cancer lesion of the nasopharynx has been controlled after radiotherapy or chemotherapy, the general condition is good, and only residual or recurrent lesions in the neck remain, with limited and mobile range, neck lymph node dissection can be considered.
(2) Contraindications:
① Residual or recurrent lesions in the neck that are adherent and fixed to deep neck tissues;
② Patients with distant metastasis or extensive skin infiltration;
③ Elderly and frail patients with incomplete heart, lung, liver, and kidney function that cannot be corrected.
(3) Scope of resection: En bloc resection of lymph nodes and adipose connective tissue within the area from the mastoid tip and the lower edge of the upper jaw bone to the upper edge of the clavicle, from the midline of the neck to the anterior edge of the trapezius muscle, along with the platysma, sternocleidomastoid muscle, internal and external jugular veins, omohyoid muscle, submandibular gland, root of the nose of the parotid gland, and accessory nerve.
3. Simple excision of neck lymph nodes
Simple excision can be performed for single neck lymph nodes that are not sensitive to radiotherapy or for isolated neck lymph node recurrence after radiotherapy. After local infiltration anesthesia, cut the skin and subcutaneous tissue over the metastatic lesion, and completely remove the metastatic lesion along with part of the surrounding normal tissue. The wound can be slightly pressure bandaged postoperatively.
(III) Chemotherapy
1. Indications for chemotherapy in nasopharyngeal carcinoma
(1) Stage IV patients and those with obvious lymph node metastasis in stage IV;
(2) Any patient suspected of having distant metastasis;
(3) Massive metastatic lymphadenopathy in the cervical region, undergoing induction chemotherapy prior to radiotherapy;
(4) Chemotherapy as a radiosensitizer before radiotherapy;
(5) Adjuvant chemotherapy after radiotherapy or surgical treatment.
2. Commonly used combination chemotherapy regimens
(1) CBF regimen: Cyclophosphamide 600-1000mg per dose, intravenous injection, administered on days 1 and 4. Bleomycin 15mg per dose, intramuscular injection, administered on days 1 and 5. 5-Fluorouracil 500mg, intravenous injection, administered on days 2 and 5. After the course, rest for 1 week, a total of 4 courses. The effective rate is 60.8%.
(2) PFA regimen: Cisplatin 20mg and 5-Fluorouracil 500mg, intravenous infusion for 5 days; Doxorubicin 40mg, intravenous injection on day 1 of the course. Repeat after 3-4 weeks, with significant tumor shrinkage effect.
(3) PF regimen: Cisplatin 20mg/m2 and 5-Fluorouracil 500mg/m2, intravenous infusion, used continuously for 5 days followed by 2 weeks rest, can be used for 2-3 courses. This regimen can be used to shrink tumors before radiotherapy or for cases of simple chemotherapy, with an effective rate of 93.7%.
3. Regional stirred pulse intubation perfusion chemotherapy
For ascending and locally recurrent nasopharyngeal carcinoma after radiotherapy, stirred pulse intubation chemotherapy can be used. The superficial temporal stirred pulse or facial stirred pulse retrograde intubation can be selected. A combination or sequential treatment of several chemotherapy drugs with strong potency and short action time is often chosen. Before administration, inject 2ml of 2% procaine to prevent stirred pulse spasm, then inject the anticancer drugs, and then fill the lumen with 2.5% sodium citrate solution and seal the tube end. If continuous medication is needed, use 100ml of heparin solution and 1500mg of 5% glucose saline with anticancer drugs for 24-hour continuous infusion.
The natural course of nasopharyngeal carcinoma varies significantly among patients, ranging from 3 months to 113 months from the onset of symptoms to death. Radiation therapy is the primary treatment for nasopharyngeal carcinoma. According to domestic and international reports, the 5-year survival rate after radiation therapy ranges from 8% to 62%. With the advancement of radiation therapy equipment and techniques, the 5-year survival rate for nasopharyngeal carcinoma after radiation therapy has been continuously improving. The Cancer Hospital of Shanghai Medical University reported that the 5-year survival rate was 8% before 1955 when deep X-ray therapy was used, and it increased to 54% by 1983. Local recurrence and distant metastasis after radiation therapy are the main causes of death in patients with nasopharyngeal carcinoma. Therefore, in addition to improving radiation therapy techniques and enhancing treatment efficacy, it is essential to study the biological characteristics of nasopharyngeal carcinoma, the patient's physical factors, and the interaction between the tumor and the patient's body. Based on the biological characteristics of nasopharyngeal carcinoma and the patient's physical condition, a comprehensive treatment plan should be considered, including radiation therapy, chemotherapy, surgical treatment, immunotherapy, Chinese medicine, and other therapeutic methods, to further improve treatment outcomes.
