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Ear, Nose and Throat (ENT), Head and Neck Surgery
Specialist Clinic
Nasopharyngeal   Cancer (NPC)
Where is the “nasopharynx” in your body ? : Nasopharynx is the small area located behind your nose and above the back of your throat. What is nasopharyngeal cancer (NPC) ?: NPC is cancer that occurs in the nasopharynx, an area located behind your nose and above the back of your throat. NPC   is   difficult   to   detect   early,   probably   because   the   nasopharynx   isn't   easy   to examine   (it   is   impossible   to   see   unless   an   endoscope   is   used   in   an   ENT   clinic) and   symptoms   of   NPC   mimic   those   of   many   other   conditions.   In   its   early stages, NPC may not even cause any symptoms ! Possible noticeable symptoms of NPC include: A lump in your neck caused by a swollen lymph node Bloody discharge from your nose Nasal congestion/blockage on one side of your nose Hearing loss in one ear -otitis media wth effusion Frequent ear infections Headaches Double vision Face and neck pain  
Nasopharyngeal cancer (NPC) 3-fold pamplet (English language)
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Nasopharyngeal cancer (NPC) 3-fold pamplet (Bahasa Malaysia/Malay language)
Nasopharyngeal cancer (NPC) 3-fold pamplet (Chinese language)
Kanser nasofarinks/hidung
This patient education is provided in good faith to help patients and their families learn more about their medical conditions, the options available to them and the possible consequences of their decisions. This information is not intended to be used for diagnosis, or treatment of any specific individual. Please consult with your ENT doctor regarding your particular circumstances.
Endoscopic view of the nasopharynx (back portion of the nose): Compare the normal on the left and large adenoids (non-cancerous growth) in the middle picture. In the right picture, the nasopharynx has a cancerous growth (partially covered by blood) ! © Vincent Tan ENT This is how nasopharyngeal carcinoma (NPC) looks like under the microscope. © Vincent Tan ENT
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Last update:  1/5/13 
What are the complications ? NPC   frequently   spreads   (metastasizes)   beyond   the   nasopharynx.   Many   people   with   NPC   have regional   metastases,   meaning   cancer   cells   from   the   initial   tumor   have   migrated   to   nearby areas,   such   as   lymph   nodes   in   the   neck,   causing   the   lymph   nodes   to   be   swollen.   Cancer   cells that   spread   beyond   the   head   and   neck   (distant   metastases)   most   commonly   travel   to   the bones   and   bone   marrow,   lungs   and   liver.   Just   like   any   cancers,   death   is   inevitable   in   advanced disease. What are the risk factors ? Researchers   have   identified   some   risk   factors   that   appear   to   increase   your   risk   of   developing NPC, including: Gender.   Men   have   about   double   the   risk   of   developing   cancer   of   the   nasopharnyx   as women do. Race   &   Genetics.   This   type   of   cancer   more   commonly   affects   people   in   Asia   and northern   Africa.   In   Malaysia,   the   Chinese   in   particular   has   a   higher   risk   of   NPC   and   in Sarawak, the Bidayuhs and Ibans. Age.   Most   cases   of   NPC   occur   in   people   between   the   ages   of   30   and   55.   However,   it can still occur outside this age group. Salt-cured   food.   Chemicals   released   in   steam   when   cooking   salt-cured   foods,   such   as fish,   preserved   vegetables   and   Chinese   herbs,   may   enter   the   nasal   cavity,      increasing the   risk   of   NPC.   In   China,   NPC   has   been   linked   to   high   consumption   of   salted   fish,   and as   people   in   Southeast   China   are   adopting   a   more   Western   diet,   their   rates   of   NPC have been declining. Preserved   meats .   Preserved   meats   contain   high   levels   of   nitrates,   contributing   to   the production of carcinogenic agent nitrosamine,  which may increase the risk of NPC. Infection   by   Epstein-Barr   virus   (EBV)    -virus   particles   of   EBV   has   been   found   in   many cases    of    NPC.    It    is    believed    that    EBV    infection    contributes    to    the    early    cancer transformation changes Family   history.    Having   a   family   member   with   NPC   increases   your   risk   of   the   disease, This could be due to genetic or environmental factors. How is NPC diagnosis made ? Diagnosing   NPC   usually   begins   with   a   general   examination   by   the   ENT   doctor. Your   doctor   will ask   questions   about   your   symptoms.   He   or   she   may   press   on   your   neck   to   feel   for   swelling   in your lymph nodes. Because    early    signs    and    symptoms    of    NPC    are    not    specific    to    the    disease,    the    initial symptoms may be ignored or diagnosis may be elusive. Your   doctor   will   also   use   the   endoscope   (an   endoscope   is   a   thin,   tube-like   instrument   with   a light   and   a   camera   lens   for   viewing)   to   examine   your   nose   and   nasopharynx.   Narrow   Band Imaging   (NBI)   endoscopy   also   offers   an   extra   advantage   in   the   early   detection   of   cancer   lesion.   Once a   suspicious   lesion   is   seen,    another   instrument   to   take   a   small   tissue   sample   (biopsy)   to   be tested   for   cancer.   Biopsy   refers   to   the   removal   of   cells   or   tissues   so   they   can   be   viewed   under a   microscope   in   a   laboratory   by   a   pathologist   to   check   for   signs   of   cancer. A   biopsy   is   the   only sure way to diagnose NPC beyond doubt ! Once the diagnosis is confirmed, your doctor orders other tests to determine the extent (stage) of the cancer. This may include chest X-ray, CT scan of the neck and ultrasound of the liver. Many    people    are    not    diagnosed    with    NPC    until    it    has    spread,    probably    because    the nasopharynx   is   not   easy   to   examine   and   symptoms   of   this   cancer   mimic   those   of   many   other conditions.   Even   a   nasal   polyp   can   sometimes   mimic   NPC.   However,   as   NPC   becomes   more advanced, it also becomes more difficult to treat successfully. So what is the treatment and chances of cure? Your   main   treatment   options   for   NPC   are   radiation   therapy/radiotherapy,   chemotherapy   or   a combination   of   the   two.   Radiotherapy   is   a   cancer   treatment   that   uses   high-energy   x-rays   or other   types   of   radiation   to   kill   cancer   cells   or   keep   them   from   growing.      Chemotherapy   is   a cancer   treatment   that   uses   drugs   to   stop   the   growth   of   cancer   cells,   either   by   killing   the   cells   or by stopping them from multiplying. Prognosis (chance of recovery) and treatment options depend on the following: The   stage   of   the   cancer   (whether   it   affects   part   of   the   nasopharynx,   involves   the   whole nasopharynx, or has spread to other places in the body). The type of NPC (WHO Type I, II or III). The size of the neck lymph nodes. The patient's age and general health. Surgery is not often used as a first-line treatment for NPC unless for: Recurrence of cancer in the neck. o Here, neck disssection can be performed to remove the diseased lymph nodes. o Prior   to   this,   FNAC   and   CT   or   preferably   PET-CT   scan   can   be   performed   to confirm that the disease has indeed spread to the lymphatic chain in the neck. Recurrence of cancer in the nasopharynx o Surgical   options   are   possible   in   the   form   of   nasopharyngectomy,   whether   done endoscopically or via open approach. o The   option   for   treatment   also   include   brachytherapy   (a   very   precise   form   of radiation   therapy   localised   to   the   nasopharynx   only,   limiting   the   radiation   dose and   damage   to   important   neighbouring   structures   eg.   eye,   brain)   or   other   forms of stereotactic radiosurgery Other concurrent conditions associated with NPC o Otitis     Media     with     Effusion     i.e     fluid     behind     the     ear     drum     -usually     a ventiilation/drainage tube (grommet) can be inserted onto the eardrum o Vocal   Cord   Paralysis    -   if   symptomatic   of   choking   on   fluid   intake,   corrective surgery   can   be   performed   to   mobilise   the   vocal   cords   into   a   particular   position   to overcome this problem. How do I prevent NPC ? Unfortunately,   NO   sure   way   exists   to   prevent   NPC.   However,   you   can   take   steps   to   reduce your   risk   of   the   disease.   For   instance,   cut   back   on   the   amount   of   salt-cured   foods   and preserved meats that you eat, or choose to avoid these foods altogether. Random   IgE   antibody   tumour   marker   screening   is   not   advisable   and   best   done   only   after taking    into    consideration    the    family    history    and    a    complete    physical    and    endoscopic examination. In   those   with   strong   family   history   (i.e   parents,   siblings   had   NPC   before),   regular   surveillance examination and endoscopy is advised to detect early onset of disease.
Neck swelling arising from the lymph nodes due to NPC Another case of neck swelling arising from the lymph nodes  Abnormal squint or asymmetry of the eye movements due to nerve damage   Incomplete closure of the vocal cords (black arrow) and stagnation of saliva (yellow arrow) due NPC nerve damage   Fluid and bubbles (red arrow) behind the ear drum due to Eustachian tube blockage causing hearing loss  © Vincent Tan ENT
© Vincent Tan ENT
A grommet in place (red arrow) on the ear drum.
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This is how Epstein-Barr virus (EBV) looks like under the electron microscope. (image source: Wikipedia)
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Heart  Disease No.1  Head & Neck Cancer in M’sia !
The   number   1   head   and   neck   cancer   in   Malaysia   is   nasopharyngeal   cancer   (NPC) .   Other   common cancers include oral cavity cancers (eg. tongue, floor of mouth, buccal region). Based    on    the    2006    Malaysian    National    Cancer    Registry    NCR    ( refer    to    graph    on    the    right ),    the commonest Head & Neck Cancers (by frequency) were: 1. Nasopharyngeal Cancer (NPC) (981 cases) 2. Thyroid Cancer (891) 3. Oral Cancer (428) 4. Laryngeal Cancer (216) 5. Salivary Gland Cancer (142) 6. Pharyngeal Cancer (113) 7. Sinonasal Cancer (113) In   2007,   there   were   900   NPC   cases   geal   cancer   diagnosed   in   2007   and   registered   at   NCR,   comprising of   685   males   and   255   females.   Based   on   2007   Malaysian   NCR   (the   latest   officially   published   registry report), NPC is the: 4th   commonest   cancer   among   Malaysian   (behind   cancers   of   the   breast,   colorectal   and      lung   in that sequence ) commonest cancer in the Head & Neck region 3rd commonest cancer among males in Malaysia. The   incidence   was   more   than   2   folds   higher   among   males   when   compared   to   females.   Chinese   were found   to   have   higher   incidence   rate   compared   to   Malay   and   Indian.   The   incidence   of   nasopharyngeal cancer   increases   with   age.   The   peak   of   Age-specific   Incidence   Rate   was   at   the   70-75   age   groups. Unfortunately,   the   majority   of   NPC   was   detected   at   the   late   stages   of   III   and   IV.   The   percentage   of   the cancer detected at the early stages of I and II was only 34%
unfortunately, most NPC cases are diagnosed late !
Reference: 1. Malaysia Cancer Registry 2006 and 2007
Top 10 cancers in Malaysia ! (source: NCR2007)
Top Head & Neck cancers in Malaysia ! (source: NCR2006)
Left picture showing a suspicious mass (the white arrow) seen under conventional white light. The right picture showing similar site using Narrow-Band Imaging (NBI) where irregular blood vesssels pattern is clearly seen depsite the copius secretion and mucus over the local site. “Can you see the tumour ?”
© Vincent Tan ENT
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D R. V INCENT T AN Consultant Ear, Nose and Throat, Head and Neck Surgeon, MD (UKM), MS ORL-HNS (UKM), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), Postgrad. Allergy (UK), A.M. (Mal), Fellowship in Rhinology (Singapore) Fellowship in Head and Neck Oncology & Surgery (Amsterdam)
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