Nasopharyngeal cancer

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SYMPTOMS AND RISK FACTORS

Common:

• A lateral neck swelling, usually in the upper third of the neck. The swelling results from cancer spread to lymph nodes in the neck.

NPC may also present with:

• Persistent nasal obstruction on one side or both nasal passages.
• A blocked ear or hearing loss, resulting from Eustachian tube involvement.

Rare:

• Recurrent nose bleeds.

Advanced disease:

• Pain or nerve involvement, resulting in facial numbness or visual changes.

RISK FACTORS

• Previous infection with the common virus Epstein-Barr Virus (EBV). Infections are frequently asymptomatic. Most patients infected with EBV will not develop NPC.
• An association with human papillomavirus (HPV) has also been reported.
• NPC is more common in China and Asia.
• NPC in a relative increases your risk.
• Working with hard wood, processed foods, and smoking.

PRESENTATION

The rule of thumb is to seek referral to a doctor or specialist where any of the below persist for two weeks.

• A lateral neck swelling is often the first sign. Other symptoms, such as nasal obstruction or blocked ear, may be mild and unfortunately ignored for a long time.
• Facial numbness, pain, and nose bleeds are rare-presenting symptoms.
• May also present as simple snoring or obstructive sleep apnoea.

DIAGNOSTIC PROCESS

1. A lateral neck swelling may be quite obvious.
2. Clinical examination of the head and neck will usually identify tumour in the nasopharynx.
3. Nerve involvement may also be evident.
4. Fluid in the middle ear may also be present.
5. Special endoscopic equipment is required to accurately examine the nasopharynx.

TESTS

• A fine-needle aspiration (FNA) biopsy of a neck swelling (usually guided by ultrasound) often results in a conclusive diagnosis. This is quick, effective, and reduces delays in diagnosis and treatment.
• Open biopsy (incision biopsy) of a lateral neck lymph node is rarely required.
• A biopsy of the nasopharyngeal tumour is not required if the FNA is conclusive.
• Special staining for EBV in the FNA specimen is often positive.
• A CT scan may be required. However, when FNA is conclusive, a PET-CT may be the initial investigation as it’s required to assess the cancer staging and plan treatment.
• MRI may be indicated to assess nerve involvement and local spread beyond the nasopharynx.
• If no neck node involvement is found, then a biopsy of the tumour in the nasopharynx is required. This is usually performed under sedation or general anaesthetic.

TREATMENT

• Chemoradiation is the most common treatment. This is a full six-week course of intensity modulated radiation (IMRT) with chemotherapy.
• Surgery is rarely indicated.
• Occasionally persistent neck glands following IMRT may require surgery.
• Immunotherapy may be considered in recurrent disease or advanced cases.
• Management by a head and neck multi-disciplinary team (MDT) is recommended for patient-centred care and outcomes.

SURVIVAL

• NPC is highly-sensitive to chemoradiation with the majority of patients surviving even when the neck nodes are involved.
• Close follow-up is required. A PET-CT scan is usually performed four to six months after completion of treatment to confirm response.
• Recurrences usually present within 18 to 24 months of treatment.

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