Nasopharyngeal Cancer Workup

  • Author: Arnold C Paulino, MD; Chief Editor: Robert J Arceci, MD, PhD   more...
 
Updated: Apr 26, 2012
 

Laboratory Studies

  • Perform routine blood work, including a complete blood count and chemistry profile. Liver function test results may be abnormal in those rare cases with hepatic metastases. Uric acid levels may be elevated in patients with rapidly growing tumors.
  • Epstein-Barr virus (EBV) titers, including immunoglobulin A (IgA) and immunoglobulin G (IgG) antibodies to the viral capsid antigen, early antigen, and nuclear antigen should be performed. These titers may correlate with tumor burden and decrease with treatment.[8, 9] New data has emerged that plasma EBV-DNA levels may be a helpful marker for pretreatment risk categorization, initial treatment response, and at the time of relapse.[10]
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Imaging Studies

  • CT scanning
    • CT scanning of the head and neck is used to determine tumor extent, base of skull erosion, and cervical lymphadenopathy.
    • CT scanning of the chest is used to search for distant metastases.
  • When intracranial extension is suspected, MRI of the head and skull base may better reveal the extent of the tumor.MRI of the head and neck in a patient with nasophaMRI of the head and neck in a patient with nasopharyngeal carcinoma showing the primary tumor and cervical lymph node metastases
  • Bone scans are used to search for distant bony metastatic disease.
  • Positron emission tomography (PET) imaging has been used to assess questionable neck nodes and evaluate for other sites of distant disease. Intensity modulated radiotherapy images for a patiIntensity modulated radiotherapy images for a patient with nasopharyngeal carcinoma
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Other Tests

  • A baseline audiogram is helpful prior to platinum-based chemotherapy and radiotherapy.
  • Creatinine clearance rates (24-hour collection or nuclear GFR testing) should be obtained at baseline and during treatment for those patients being treated with platinum-based chemotherapy because decreases in renal function, requiring dose modifications, have been reported.
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Procedures

  • A biopsy of the primary lesion or neck node is obtained for diagnosis.
  • Central line placement is recommended for those children receiving chemotherapy.
  • Because of severe oropharyngeal mucositis that can be seen with radiation therapy, strong consideration of gastrostomy tube placement should happen at diagnosis and/or prior to initiation of radiation therapy in order to sustain proper hydration and nutrition.
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Histologic Findings

  • The World Health Organization (WHO) has classified nasopharyngeal carcinoma into 3 categories.
    • WHO-1 is defined as well–to–moderately differentiated squamous or transitional cell carcinoma with keratin production.
    • WHO-2 is nonkeratinizing carcinoma.
    • WHO-3 is undifferentiated carcinoma, including lymphoepithelioma. This entity consists of malignant epithelial cells with lymphocytic infiltration.
  • The vast majority of children are found to have WHO-3 disease.[11, 12]
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Staging

Various staging schema have been proposed for nasopharyngeal carcinoma in children.[13] No single system has proven satisfactory in correlating disease extent to prognosis.

Currently, the Seventh Edition of the American Joint Committee on Cancer (AJCC) Staging is used to stage patients with nasopharyngeal cancer. The staging system takes into account the tumor (T), nodal (N) and metastatic (M) extent of the nasopharyngeal cancer.[14]

Table 1. AJCC Staging for Nasopharyngeal Cancer (Open Table in a new window)

StageTNM
0TisNoM0
IT1N0M0
IIT1N1M0
T2N0M0
T2N1M0
IIIT1N2M0
T2N2M0
T3N0M0
T3N1M0
T3N2M0
IVAT4N0M0
T4N1M0
T4N2M0
IVBAny TN3M0
IVCAny TAny NMI

Table 2. Tumor (T) Staging (Open Table in a new window)

TXPrimary tumor cannot be assessed
T0No evidence of primary tumor
TisCarcinoma in situ
T1Tumor confined to the nasopharynx or extends to oropharynx and/or nasal cavity without parapharyngeal extension
T2Tumor with parapharyngeal extension
T3Tumor involves bony structures of skull base and/or paranasal sinuses
T4Tumor with intracranial extension and/or involvement of cranial nerves, hypopharynx, orbit, or with extension to the infratemporal fossa/masticator space

Table 3. Nodal (N) Staging (Open Table in a new window)

NXRegional lymph nodes cannot be assessed
N0No regional lymph node metastasis
N1Unilateral metastasis in cervical lymph node(s), less than or equal to 6 cm in greatest dimension, above the supraclavicular fossa, and/or unilateral or bilateral retropharyngeal lymph nodes, less than or equal to 6 cm in greatest dimension
N2Bilateral metastasis in a cervical lymph node (s), less than or equal to 6 cm in greatest dimension, above the supraclavicular fossa
N3Metastasis in a lymph node(s) greater than 6 cm and/or to supraclavicular fossa
N3aGreater than 6 cm in dimension
N3bExtension to supraclavicular fossa

Table 4. Metastasis (M) Staging (Open Table in a new window)

M0No distant metastasis
M1Distant metastasis
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Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Arnold C Paulino, MD  Professor of Radiation Oncology, Methodist Hospital and Weill-Cornell Medical College; Associate Professor of Pediatrics, Baylor College of Medicine

Arnold C Paulino, MD is a member of the following medical societies: American Medical Association, American Radium Society, American Society for Therapeutic Radiology and Oncology, American Society of Clinical Oncology, Children's Oncology Group, International Society of Paediatric Oncology, and Radiological Society of North America

Disclosure: Nothing to disclose.

Coauthor(s)

Chrystal U Louis, MD, MPH  Assistant Professor, Texas Children's Cancer Center and Hematology Service, Center for Cell and Gene Therapy, Baylor College of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Samuel Gross, MD  Professor Emeritus, Department of Pediatrics, University of Florida; Clinical Professor, Department of Pediatrics, University of North Carolina; Adjunct Professor, Department of Pediatrics, Duke University

Samuel Gross, MD is a member of the following medical societies: American Association for Cancer Research, American Society for Blood and Marrow Transplantation, American Society of Clinical Oncology, American Society of Hematology, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Steven K Bergstrom, MD  Department of Pediatrics, Division of Hematology-Oncology, Kaiser Permanente Medical Center of Oakland

Steven K Bergstrom, MD is a member of the following medical societies: Alpha Omega Alpha, American Society of Clinical Oncology, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Children's Oncology Group, and International Society for Experimental Hematology

Disclosure: Nothing to disclose.

Helen SI Chan, MBBS, FRCP(C), FAAP  Associate Senior Scientist, Research Institute; Professor, Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto Faculty of Medicine, Canada

Helen SI Chan, MBBS, FRCP(C), FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American Society of Hematology, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Robert J Arceci, MD, PhD  King Fahd Professor of Pediatric Oncology, Professor of Pediatrics, Oncology and the Cellular and Molecular Medicine Graduate Program, Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine

Robert J Arceci, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Pediatric Society, American Society of Hematology, and American Society of Pediatric Hematology/Oncology

Disclosure: Nothing to disclose.

References

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MRI of the head and neck in a patient with nasopharyngeal carcinoma showing the primary tumor and cervical lymph node metastases
Intensity modulated radiotherapy images for a patient with nasopharyngeal carcinoma
Table 1. AJCC Staging for Nasopharyngeal Cancer
StageTNM
0TisNoM0
IT1N0M0
IIT1N1M0
T2N0M0
T2N1M0
IIIT1N2M0
T2N2M0
T3N0M0
T3N1M0
T3N2M0
IVAT4N0M0
T4N1M0
T4N2M0
IVBAny TN3M0
IVCAny TAny NMI
Table 2. Tumor (T) Staging
TXPrimary tumor cannot be assessed
T0No evidence of primary tumor
TisCarcinoma in situ
T1Tumor confined to the nasopharynx or extends to oropharynx and/or nasal cavity without parapharyngeal extension
T2Tumor with parapharyngeal extension
T3Tumor involves bony structures of skull base and/or paranasal sinuses
T4Tumor with intracranial extension and/or involvement of cranial nerves, hypopharynx, orbit, or with extension to the infratemporal fossa/masticator space
Table 3. Nodal (N) Staging
NXRegional lymph nodes cannot be assessed
N0No regional lymph node metastasis
N1Unilateral metastasis in cervical lymph node(s), less than or equal to 6 cm in greatest dimension, above the supraclavicular fossa, and/or unilateral or bilateral retropharyngeal lymph nodes, less than or equal to 6 cm in greatest dimension
N2Bilateral metastasis in a cervical lymph node (s), less than or equal to 6 cm in greatest dimension, above the supraclavicular fossa
N3Metastasis in a lymph node(s) greater than 6 cm and/or to supraclavicular fossa
N3aGreater than 6 cm in dimension
N3bExtension to supraclavicular fossa
Table 4. Metastasis (M) Staging
M0No distant metastasis
M1Distant metastasis
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