鼻咽癌

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1 鼻咽癌 staging and NCCN guideline 馬偕紀念醫院耳鼻喉科資深主治醫師教育部定助理教授 / IRB 執行祕書 / 癌症中心執行祕書電子病歷委員會醫令工作組長呂宜興醫師

5 病因和危險因子鼻咽癌的致病因迄今未明確遺傳因素鼻咽癌家庭成員的罹患率為 14.5%, 血親越近罹患率越高鼻咽癌患者的一等親, 得鼻咽癌的機率高出常人 19.2 倍若 HLA 為 A 2 B 46 DR 9 者, 則其得鼻咽癌較正常人高 2.3 倍 EB 病毒感染飲食因素環境因素

6 鼻咽癌的臨床表現頸部淋巴腺腫大耳部症狀 : 耳鳴耳閉塞感聽力減退神經症狀 : 臉部麻木複視視力模糊鼻部症狀 : 鼻塞鼻出血惡臭分泌物頭痛 : 單側性頭痛

7 鼻咽癌的檢查流程 Sinoscope and biopsy Check anti-ebv antibody OPD to confirm diagnosis Arrange admission MRI,bone scan, abdominal echo Multidisciplinary consultation

8 病理組織學分類 WHO 於 1978 年分類 TYPE I:keratinizing squamous cell carcinoma TYPE II : nonkeratinizing carcinoma TYPE III : undifferentiated carcinoma 1991 年修訂之分類 TYPE I:keratinizing squamous cell carcinoma TYPE II : nonkeratinizing carcinoma II-a : differentiated II-b : undifferentiated Revised WHO Keratinizing squamous cell carcinima (SCC,WHO Type I) Nonkeratinizing carcinoma Differentiated (WHO Type II) Undifferentiated (WHO Type III) Basaloid squamous cell carcinoma

9 分期 T (Primary tumor) TX :Primary tumor cannot be assessed T0 :No evidence of primary tumor Tis :Carcinoma in situ AJCC 7 th ed

10 分期 T (Primary tumor) T1 : Tumor confined to the nasopharynx, or extends to oropharynx and/or nasal cavity without parapharyngeal extension* T2: Tumor with parapharyngeal extension* T3: Tumor involves bony structures of skull base and/or paranasal sinuses T4: Tumor with intracranial extension and/or involvement of involvement of cranial nerves, hypopharynx, orbit, or with extension to the infratemporal fossa/masticator space * Parapharyngeal extension denotes posterolateral infiltration of tumor. AJCC 7 th ed

11 分期 N (Regional lymph nodes) N0:No regional lymph node metastasis N1:Unilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa, and/or unilateral or bilateral, retropharyngeal lymph nodes, 6 cm or less, in greatest dimension* N2:Bilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa* N3:Metastasis in a lymph node(s)* >6 cm and/or extension to supraclavicular fossa N3a:Greater than 6 cm in dimension N3b: Extension to the supraclavicular fossa** AJCC 7 th ed

12 分期 N (Regional lymph nodes) * Midline nodes are considered ipsilateral nodes. **Supraclavicular zone or fossa is relevant to the staging of nasopharyngeal carcinoma and is the triangular region originally described by Ho. It is defined by three points: (1) the superior margin of the sternal end of the clavicle, (2) the superior margin of the lateral end of the clavicle, (3) the point where the neck meets the shoulder. Note that this would include caudal portions of Levels IV and VB. All cases with lymph nodes (whole or part) in the fossa are considered N3b. AJCC 7 th ed

13 分期 M (Distant metastasis) M0: No distant metastasis (no pathologic M0; use clinical M to complete stage group) M1: Distant metastasis AJCC 7 th ed

14 TNM Staging (NPC) AJCC 7 th ed

15 TNM 鼻咽癌分期 T1 T2 T3 T4 N0 Ⅰ Ⅱ Ⅲ Ⅳa N1 Ⅱ Ⅱ Ⅲ Ⅳa N2 Ⅲ Ⅲ Ⅲ Ⅳa N3 Ⅳb Ⅳb Ⅳb Ⅳb Any T Any N M1:Ⅳc

16 No. % 鼻咽癌分期的分布 (MMH) No. % I II a II b III IV a IV b IV c Stage 0

20 治療 Concurrent chemoradiation Chemotherapy CDDP 15mg/m2 24h-infusion on day 1-5 5FU 750mg/m2 24 h-infusion on day 1-5 x 2 courses Radiotherapy primary and gross nodal disease ( 70 Gy) Prophylactic neck ( 60 Gy)

21 治療 Adjuvant chemotherapy: CDDP, 75mg/ m2 24h-infusion on day 1, 5FU 1500mg/m2 24h-infusion on day 1-2, If partial remission, additional 2 courses.

22 鼻咽癌放射治療之副作用急性 : 慢性 : 晚期 : 口咽黏膜炎咽喉疼痛皮膚炎等口乾頸背纖維化慢性中耳炎併聽障 Temporal lobe necrosis Hypothalamic-pituitary dysfunction Skull base osteoradionecrosis Delayed bulbar palsy Radiation-induced second cancer

23 鼻咽癌化學治療之副作用常用藥物 : 5FU cisplatin cetuximab gemcitabine paclitaxel oxaliplatin carboplatin anthracyclines mitomycin C 血球降低粘膜發炎嘔吐聽力腎臟功能的影響

24 追蹤回診檢查項目容易復發的部位與治療前癌細胞散佈情況有關鼻咽頸部淋巴結骨骼肺臟肝臟常規檢查鼻後鏡或內視鏡 EB 病毒抗體之檢測 EBV EA IgA EBNA IgA EBV VCA IgA Plasma DNA copy Nasopharynx swab EBNA-1 LMP-1 RT-PCR MRI Bone scan Abdominal echo PET / PET CT

25 復發治療局部復發的鼻咽癌 Surgery Open surgery Endoscopic surgery Photodynamic therapy Brachytherapy Re-irradiation or Chemoradiation Chemotherapy (new trial or target therapy) 頸部殘留腫塊或復發施行頸部廓清術或放射線治療

26 台灣地區鼻咽癌標準化死亡率趨勢標準化死亡率標準化死亡率

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<4D6963726F736F667420576F7264202D20BBF3AB7CC0F9A9F1AE67AA76C0F8BDC3B1D0B3E6303530392E646F63> 認識鼻咽癌鼻咽癌的症狀因鼻咽位置的關係, 鼻咽癌的早期症狀都不太明顯, 所以鼻咽癌的早期診斷並不容易, 鼻咽癌有下列常見的症狀 : 單側耳鳴耳塞或有耳朵流水聲或聽力減損 : 這些乃是因腫瘤影響到耳咽管的肌肉, 造成耳咽管內