What is nasopharyngeal cancer?

Dr Mark Torres-Holmes educates us on nasopharyngeal cancer, a rare head and neck cancer.

You can listen to this article below, or by using your favourite podcast player at pod.link/oncologybuddies

The nasopharynx is the top part of the throat behind the nose and though rare in SA, cancers can originate there. The type of cells from which cancer can develop in this area are surface lining cells (squamous epithelium) causing squamous cell carcinoma. 

There are many risk factors including smoking; the Epstein-Barr virus (EBV); having ancestry in South East Asia, North Africa, or the Arctic; having a family member with head and neck cancer; and following a diet high in salt-cured fish with nitrosamine. 

There seems to be a bimodal age distribution for patients getting nasopharyngeal cancer. The peaks are between 15 – 25 and 40 – 50 years. 

Symptoms of nasopharyngeal cancer

The eustachian tube connects the middle ear to the nasopharynx and so a blocked, painful or ringing ear is usually the earliest sign. A blocked nose usually on one side progressing to both sides, sometimes with nose bleeds is another common symptom. 

Sometimes there are no symptoms other than a neck lump which indicates that the cancer has already spread to lymph nodes. If the disease is particularly advanced, the tumour can invade into the skull base, brain, or eyes with symptoms associated with those structures.   

Diagnosis of nasopharyngeal cancer

The nasopharynx is a difficult area to examine for general clinicians because it requires specialised equipment, such as endoscopes. Because the symptoms can be vague and mimic many more common ear, nose and throat (ENT) conditions, if the primary care physician doesn’t have a high index of suspicion for nasopharyngeal cancer, it can easily be missed. 

ENT or head and neck surgeons are the best specialists to make the diagnosis. 

After seeing a mass in the nasopharynx, an imaging scan like a CT- or MRI scan is indicated. This helps for staging if it’s a cancer and to exclude other conditions as a cause of a nasopharynx mass. 

Biopsy under general anaesthesia is often necessary to make the histological diagnosis. This can sometimes also be achieved with ultrasound-guided needle biopsy of a neck node. 

Often another useful staging tool is a PET-CT scan to confirm whether the cancer has spread to the bloodstream (haematogenous metastasis) or not. 

Once all the tests have been performed to most accurately stage the cancer, recommendations regarding the optimum treatment should be made in a multi-disciplinary team. The goals are usually to get rid of the cancer, prevent recurrence, and maintain quality of life as high as possible. 

Treatment for nasopharyngeal cancer

Treatment mostly involves radiation both to the nasopharynx and neck nodes on both sides where the cancer has or will likely spread to, sometimes combined with chemotherapy, often a platinum-based one like cisplatin. 

This extra chemotherapy sensitises the tumour to the radiation to improve cure rates. Surgery is usually only considered if radiation hasn’t worked either in the primary site or neck nodes. 

The technology of the radiation machine is ever-improving and is able to decrease the adverse effects of the treatment. However, because the radiation field for this disease is big, these adverse effects need to be pre-emptively minimised. Radiation can damage teeth and a specialist dental team is necessary to assess the risk to the teeth. Swallow therapy and a dietitian can greatly increase resilience for the treatment.

Cure rates for this disease can be high and therefore it’s always worth fighting this fight. Surveillance after treatment requires intermittent scopes by the head and neck surgeon or ENT, along with radiology imaging. 

If the cancer was related to EBV, then newer tests can now monitor the EBV antibodies and DNA in the blood as a tumour marker. 

If cancer comes back in a small way, then surgery can be considered. However, if surgery can’t be performed, or haematogenous metastasis has occurred, chemotherapy is usually necessary. 

Newer medicines like immunotherapy which activate the patient’s own immune system to kill the cancer are showing promise and are currently being studied to improve outcomes in patients with advanced disease. 

Dr Reddy’s and Word For Word Media offer sincere condolences to the Torres-Holmes family on the sudden passing of Dr Mark Torres-Holmes. He was a valuable contributor who was always willing to assist.

Header image by Freepik