Nasopharyngeal carcinoma (NPC) is an epithelial malignant tumor originating from the nasopharyngeal mucosa, which mainly occurs in the top and side walls of the nasopharynx, especiallyPharyngeal recess。The causes of nasopharyngeal carcinoma includeEB virus infection, genetic and environmental factors, and some bad living habits, such as smoking heavily and eating pickled food, may also induce the occurrence of the disease,Enlargement of cervical lymph nodesIt is often the first symptom. South China and Southeast Asian countries are the high incidence areas. Every year, there are more than 60000 newly diagnosed cases of nasopharyngeal carcinoma in China.
In terms of symptoms, early nasopharyngeal carcinoma often does not cause obvious symptoms. In the advanced stage, there may be tinnitus, hearing loss, nasal congestion, blood in the nose, headache and other symptoms, as well as neck lumps and cranial nerve paralysis.There is no clear evidence of interpersonal transmission of nasopharyngeal carcinoma.
For treatment of nasopharyngeal carcinomaRadiotherapyMainly, cooperatechemotherapyandTargeted therapy。For patients with locally advanced nasopharyngeal carcinoma who cannot be completely eliminated by radiotherapy, induction chemotherapy can be carried out first and then synchronous chemotherapy can be carried out.Targeted therapy is a new therapeutic method in recent years, which can specifically block the growth process of tumor cells.In addition, some patients can be treated with traditional Chinese medicine for long-term recuperation and repair after treatment.
Nasopharyngeal carcinoma also has a history of discovery and naming in some communities and related research events, such as the discovery of the relationship between EB virus and nasopharyngeal carcinoma, which has brought the diagnosis and etiology of the disease to a new stage.At the same time, there are also some new studies in progress to further clarify the pathogenesis of the disease and its treatment, hoping to better improve the quality of life and survival rate of patients.
TCM disease name
Nasopharyngeal carcinoma
Foreign name
Nasopharyngeal carcinoma
Alias
NPC
Visiting department
Head and neck radiotherapy department, oncology department, otorhinolaryngology department
At present, it is believed that the occurrence of nasopharyngeal carcinoma is mainly related toEB virus infection, heredity and environment.At the same time, people's unhealthy lifestyle can also induce the occurrence of the disease, such as heavy smoking, eating pickled food, air pollution, etc.
Pathogenesis
EB virus infection
adoptMolecular hybridizationas well aspolymerase chain reaction, PCR It can be found that EB virus DNAmRNAOr gene expression products.EB virus mainly infects humanOral epithelial cellsandB cell, integrate into the host cell DNA, prevent the apoptosis of infected cells, activate their growth at the same time, and cause nasopharyngeal carcinoma.
Predisposing factors
Individual factors
Nasopharyngeal cancer can occur at any age, but it is most common in adults aged 40 to 50 years, and the incidence rate of men is higher than that of women.
environmental factor
Food and water in high incidence areas of nasopharyngeal carcinomanickelThe content is high. Animal experiments have confirmed that nickel can induce nasopharyngeal carcinoma.
Dietary factors
Salted fish, preserved meat and other pickled foods are high risk factors for nasopharyngeal carcinoma, and these foods will produce Class 2A carcinogens during the curing processnitriteTo induce nasopharyngeal carcinoma.The carcinogenesis experiment in rats found that nitrosamines could induce nasopharyngeal carcinoma.
Genetic factor
Nasopharyngeal cancer patients have obvious ethnic and familial clustering. For example, families with high incidence rate move overseas, and their descendants still have a high incidence rate.
symptom
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At an early stage, nasopharyngeal carcinoma may not cause any symptoms.As the disease progresses, the patient may have a series of symptoms such as tinnitus, hearing loss, nasal congestion, blood in the nose, headache, facial numbness, diplopia, and other related symptoms and signs such as cervical mass and cranial nerve paralysis.
early symptom
In the early stage, nasopharyngeal carcinoma may not cause any symptoms. When the symptoms are obvious, it has entered the advanced stage or advanced stage. Most patients have a tumor in the neck as the first symptom.In daily life, patients with bloody nose, tinnitus, nasal congestion and other symptoms are recommended to see a doctor for a detailed examination of the nasopharynx.
Typical symptoms
Nasal symptoms
In the early stage, sometimes there is blood in the nose. When the tumor increases, it can block the back nostril and cause nasal congestion, which starts from unilateral obstruction and then develops to bilateral obstruction.
Ear symptoms
Nasopharyngeal cancer patients who occur in the pharyngeal recess can compress or block the pharyngeal orifice of the eustachian tube in the early stage, causing tinnitus, ear closure, hearing loss and other symptoms.
Craniocerebral symptoms
Local late patients may be accompanied by headache or cranial nerve damage symptoms when diagnosed, such as facial numbness, diplopia, decreased vision, decreased or disappeared sense of smell, nervous deafness, ptosis, eyeball fixation, difficulty in swallowing, tongue deviation, hoarseness, etc.
About 70% of patients had cervical lymph node metastasis at the time of diagnosis.About 40% of the patients were diagnosed with cervical lymph node enlargement as the first symptom, most of them were painless masses.With the progress of the disease, the cervical lymph nodes can be progressively enlarged, hard, and poor mobility. At first, they are unilateral, and then they develop into bilateral. When combined with infection, there may be local redness, swelling, heat, and pain.In severe cases, the swollen lymph nodes may compress the neck vessels, causing head and neck pain on the affected side, sudden syncope, or even death.
A small number of patients with nasopharyngeal carcinoma are accompanied by dermatomyositis when they seek medical advice, and the skin of face, chest, back and limbs is more common.There is usually no need for special treatment. As the tumor disease is controlled, dermatomyositis will also improve.
Dermatomyositis is a serious connective tissue disease. The relationship between malignant tumor and dermatomyositis has not been clearly defined, but the incidence of malignant tumor in dermatomyositis patients is at least five times higher than that in normal people.Therefore, for patients with dermatomyositis, careful general examination should be carried out in order to find hidden malignant tumors.
Distant metastasis symptoms
More than half of the dead patients with nasopharyngeal carcinoma had distant metastasis, the common metastasis sites were bone, lung and liver, and brain metastasis was rare.Metastatic focus can cause tissue destruction or compression at the corresponding metastatic site, resulting in corresponding symptoms, such as bone pain, cough, abdominal pain, etc.
Medical treatment
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In case of ear tightness, ear blockage, hearing loss, blood in the nose, nasal congestion, diplopia, headache and other symptoms, or when you touch a painless lump in the neck, please go to the hospital in time.
Visiting department
Head and Neck Radiotherapy Department of Cancer Hospital, Oncology Department or Otolaryngology Department of General Hospital.
Relevant inspection
physical examination
A complete and orderly physical examination, especially the examination of twelve pairs of cranial nerves and cervical lymph nodes, is essential.According to the changes of symptoms and signs of patients during the treatment, the effectiveness of the treatment can be preliminarily judged.
Nasopharyngoscopy and biopsy
Indirect nasopharyngoscope and electronic nasopharyngoscope can be used for examination. Nasopharyngeal cancer is prone to occur in the front wall of the top of the nasopharynx and the pharyngeal recess. Nasopharyngoscope can observe small nodules or granulomatous protrusions at the lesion, rough surface, and easy to bleed.
Early pathological changes are not typical, and can be diagnosed by pathological biopsy of nasopharyngeal lesions.
EBV serological test
EBV is closely related to the occurrence of nasopharyngeal carcinoma and can be used as an auxiliary indicator for the diagnosis of nasopharyngeal carcinoma.EBV deoxyribonucleic acid in the plasma of patients with nasopharyngeal carcinoma exists in the form of free fragments, which is rarely detected in healthy people.
Magnetic resonance imaging (MRI) of nasopharynx and neck
The resolution of MRI for soft tissue is higher than that of CT, which can determine the location and scope of tumor and the invasion of adjacent structures, especially for brain tissue, parapharyngeal tissue and muscle tissue.It is suggested that all patients with conditions should undergo MRI examination to better determine the patient's stage, the choice of treatment plan and the delineation range of radiotherapy target area.
Chest CT
It is suggested that patients over 50 years old or who have smoked for a long time should take plain chest CT scan instead of chest X-ray to determine whether there is intrapulmonary metastasis or mediastinal lymph node metastasis.
Abdominal B-ultrasound
Further clarify whether the patient has abdominal metastasis.
Positron emission computed tomography (PET/CT)
For patients with advanced nasopharyngeal carcinoma, especially those with large cervical lymph nodes or with supraclavicular lymph nodes, systemic PET/CT can be directly performed to determine whether there is distant metastasis.
Also known as nasopharyngeal angiofibroma, it is a common benign tumor in the nasopharynx, which contains rich blood vessels and is easy to bleed.The main differential points between nasopharyngeal carcinoma and nasopharyngeal carcinoma were the lesion site and the history of multiple epistaxis.
It is a nonspecific inflammation.The pathogenic bacteria of lymphadenitis can come from oropharyngeal inflammation and subcutaneous suppurative infection.Compared with nasopharyngeal carcinoma, lymphadenitis is characterized by bilateral multiple lymph nodes enlargement. Lymph nodes enlargement occurs in adjacent tissues during acute attack, and there is no obvious pathological change in lymph nodes that have been enlarged for a long time.After inflammation subsides, lymph nodes can shrink.
It is the general name of a group of malignant tumors originating from the lymphohematopoietic system, which is more common in young adults.Lymphoma involves a wide range, often involving the nasal cavity and oropharynx.Common bilateral cervical or systemic lymph nodes are generally swollen, with elastic texture and a rubber ball feel.If the mucosal line is seen on the surface of the mass, it is necessary to pay attention to the possibility of lymphoma, which can be used as a differentiation point from nasopharyngeal carcinoma.
Tuberculosis of nasopharynx
Most patients have a history of pulmonary tuberculosis. In addition to nasal obstruction and bloody discharge, they also have low fever, night sweats, emaciation, and other symptoms. Examination showed nasal ulcer, edema, and pale color.
In addition, X-ray chest film often indicates active pulmonary tuberculosis.
Proliferative lesion
Single or multiple nodules can be seen on the top wall, back wall or top side wall of the nasopharynx. The bulge is like a mound with a size of 0.5cm~1cm. The surface of the mucosal surface of the nodules is smooth and light red.It mostly occurs on the basis of nasopharyngeal mucosa or adenoid body, and can also occur after the squamous mucosa epithelium. Keratification epithelium retention forms the change of epidermoid cyst, and part of it is the retention cyst formed by the strong secretion of mucosal glands.
When the mucosa on the surface of the nodule is rough, erosive, ulcerative or bleeding, the possibility of canceration should be considered, and biopsy should be performed to make a clear diagnosis.
treatment
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Adopting a multidisciplinary and comprehensive treatment model, and formulating individualized comprehensive treatment plans in a planned and reasonable manner will help to improve the treatment effect and the quality of life of nasopharyngeal carcinoma patients.Radiotherapy is the only radical treatment for nasopharyngeal carcinoma. The addition of chemotherapy and targeted therapy can further improve the therapeutic effect of nasopharyngeal carcinoma.
radiotherapy
Nasopharyngeal cancer YesradiotherapyIt is very sensitive, and radiotherapy is the first choice for its radical treatment.Early nasopharyngeal carcinoma can be cured by radiotherapy alone, while intermediate and advanced nasopharyngeal carcinoma usually needs to choose a comprehensive treatment mode of radiotherapy combined with chemotherapy to achieve better results.
In recent years, with the continuous improvement of radiotherapy technology, more and more medical units have begun to use intensity modulated radiotherapy (IMRT) technology, which can maximize the radiation dose in the tumor target area, and effectively kill tumor cells while reducing damage to adjacent tissues.
In addition, with thechemotherapy、Targeted therapyWith the addition of other comprehensive treatment modes, the overall curative effect of nasopharyngeal carcinoma has been greatly improved, especially in the local control rate. The 5-year overall survival rate is as high as 80%.However, some patients still face the risk of recurrence or metastasis, which is also an urgent problem to be solved in the treatment of nasopharyngeal carcinoma.
chemotherapy
Chemotherapy is a systemic chemical therapy, which mainly kills cancer cells through chemicals.According to the different sequential methods of radiotherapy, it can be divided into induction chemotherapy, synchronous chemotherapy and adjuvant chemotherapy.
Induced chemotherapy
For patients with locally advanced nasopharyngeal carcinoma, due to the large tumor at the time of treatment, direct concurrent radiotherapy and chemotherapy may not be able to completely eliminate the tumor, and the damage to the surrounding normal tissue is greater.Therefore, concurrent chemoradiotherapy can be performed after 2-3 cycles of induction chemotherapy evaluation.Induction chemotherapy scheme usually selects platinum based combination chemotherapy:
In addition to early patients who can be cured by radiotherapy alone, other patients with advanced nasopharyngeal carcinoma should usually use chemotherapy in combination with radiotherapy when there is no contraindication to chemotherapy.Chemotherapy programs usually choose platinum based single drug chemotherapy: cisplatin, carboplatin, etc;For patients with large local lesions and poor regression after induction chemotherapy, platinum based dual drug synchronous chemotherapy or combined targeted therapy can be used under close observation.
adjuvant chemotherapy
For some patients with advanced stage, 2~3 cycles of adjuvant chemotherapy can be continued after the end of radiotherapy to consolidate the therapeutic effect. The scheme is the same as that of induction chemotherapy.However, it is still controversial which kind of patients can benefit from adjuvant chemotherapy.Existing research shows that adjuvant chemotherapy may bring benefits to patients with residual focus after radiotherapy and EBV-DNA not reduced to normal.In addition, oral single drug capecitabine maintenance consolidation chemotherapy (rhythmic chemotherapy) may also be an option for adjuvant chemotherapy.
surgical treatment
Surgical treatment is not the main treatment method for nasopharyngeal carcinoma, but only in a few cases, for example, it can be used as a choice for treatment of local radiotherapy failure or local recurrence of nasopharyngeal carcinoma.There are many surgical methods, including traditional open surgery and increasingly mature nasal endoscopic technology.
Traditional surgery
The traditional open surgical methods used in the past include resection through the jaw approach, resection through the nasal side incision approach, resection through the maxillary overturning approach, and resection through the cervical side approach.There are many shortcomings such as long route, narrow field of vision, poor exposure, many damaged structures, and great trauma, which can lead to major complications such as maxillary necrosis, palate fistula, facial numbness, facial scars, and seriously affect the quality of life of patients.
Nasal endoscopic resection of nasopharyngeal carcinoma
At present, the commonly used endoscopic resection of nasopharyngeal carcinoma has the characteristics of direct surgical path, clear surgical field lighting, flexible perspective and minimally invasive.The curative effect is the same as that of traditional surgery, but the survival rate and quality of life of patients treated with this surgery are higher, and the complications are significantly less, especially the mortality related to late complications of patients can be reduced.
Surgical treatment of recurrent (residual) cervical lymph nodes
Salvage surgery is safe and effective for residual or recurrent lymph nodes after radiotherapy. Initial treatment, recurrence stage, and lymph node capsule invasion are related to survival and prognosis.The choice of surgical method should be based on the patient's condition to select modified or radical neck dissection.
TCM treatment
Nasopharyngeal cancer patients, on the one hand, suffer from serious damage in immunity and other aspects due to long-term tumor consumption; on the other hand, after a long period of radiotherapy, chemotherapy and targeted treatment, they often suffer from treatment related side effects such as dry mouth, nausea, vomiting, loss of appetite and poor appetite. Patients can go to the TCM clinic for long-term conditioning and repair during and after treatment.
Molecular targeted therapy can specifically block the signal transduction pathway of tumor cell growth process, and prevent tumor cell growth to achieve therapeutic purposes. It is a new tumor treatment mode.It is usually applied to patients with advanced stage or combined chemotherapy.At present, the commonly used targeted drug in nasopharyngeal carcinoma is EGFR monoclonal antibody, including cetuximab and nituzumab, which can further improve the curative effect for some patients with advanced stage or elderly patients who cannot tolerate chemotherapy.
In recent years, immunotherapy based on PD-1/PD-L1 immunocheckpoint inhibitor has gradually penetrated into the comprehensive treatment of various tumors, which also brings new hope for patients with nasopharyngeal carcinoma, especially those with recurrent and metastatic nasopharyngeal carcinoma.However, up to now, the application of immunotherapy in nasopharyngeal carcinoma is still in the clinical trial stage, and most of the clinical studies are aimed at the treatment of recurrent and metastatic nasopharyngeal carcinoma. The long-term clinical results need to be further verified.
prognosis
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Radiotherapy is a radical treatment for nasopharyngeal carcinoma. Early nasopharyngeal carcinoma can be cured by radiotherapy alone, while advanced nasopharyngeal carcinoma usually needs to choose a comprehensive treatment mode of radiotherapy combined with chemotherapy to achieve better results.
Targeted therapy, especially the monoclonal antibody against EGFR, can further improve the efficacy in some patients with advanced stage or elderly patients who cannot tolerate chemotherapy.
In recent years, due to the continuous improvement of radiotherapy technology, especially the extensive application of intensity modulated radiotherapy (IMRT), as well as the addition of chemotherapy and targeted treatment, the overall efficacy of nasopharyngeal carcinoma, especially in the local control rate, has been greatly improved, with the 5-year overall survival rate as high as 80%.However, some patients still face the risk of recurrence or metastasis, which is also an urgent problem in the treatment of nasopharyngeal carcinoma.
complication
Radioactive caries
After radiotherapy for nasopharyngeal carcinoma patients, their oral cavity and salivary glands are damaged to varying degrees by radiation, resulting in reduced salivary secretion and changes in the oral microenvironment, which is easy to induce dental caries.The extraction or seeding of teeth should be avoided as far as possible within 2 to 3 years after radiotherapy, otherwise it is easy to cause mandibular necrosis.
Therefore, all patients should undergo oral treatment before the start of radiotherapy, and the existing or possible caries should be extracted at least 2 weeks before the start of radiotherapy.Gargle frequently and pay attention to oral hygiene.If tooth extraction is required within 2 to 3 years after radiotherapy, contact the radiologist and stomatologist for comprehensive evaluation.
Radiation otitis media
Most parts of the ear structure are located in the radiation field during radiotherapy, which can cause ear symptoms such as hearing loss, otitis media, etc., and become a common complication of nasopharyngeal carcinoma after radiotherapy.Patients should be instructed to prevent colds, keep the ear circumference clean, and do not dig the ear canal at will.
Radiation brain injury
For patients with large nasopharyngeal tumors, especially those involving brain tissue before treatment, there is a high probability of brain injury after radiotherapy, which can occur within 2-3 years after radiotherapy.
Most of the early patients with radiation brain injury have no obvious symptoms. Active treatment can prevent further expansion of the scope of brain injury, and the treatment effect is good.
However, patients with advanced radiation brain injury usually have headache accompanied by nausea and vomiting, and even limb movement disorders. The range of brain injury is large, and surgery may be required. The overall effect is poor.
It is suggested that patients with nasopharyngeal carcinoma should have regular reexamination after radiotherapy, which can effectively detect early radiation brain injury and provide opportunities for active intervention.
Facial numbness
It is one of the common symptoms of nasopharyngeal carcinoma with cranial nerve damage, mainly trigeminal nerve damage, and about 20% of patients may have facial numbness.In some patients, the short-term compressed trigeminal nerve function recovered after the tumor retreated, and the facial numbness symptoms could be significantly alleviated or disappeared;In other patients, the trigeminal nerve is subjected to long-term compression or invasion of the tumor, resulting in irreversible damage. After treatment, the numbness symptoms will continue.
Double vision and eye symptoms
The patient has a large tumor, which may invade the optic nerve, oculomotor nerve, trochlear nerve and abducent nerve when it affects the intracranial cavernous sinus or the back of the eyeball, resulting in diplopia, vision loss, eyeball fixation and other ocular symptoms.The symptoms of some patients can be alleviated or disappeared after treatment, but if the irreversible damage is caused by long-term compression or invasion of nerves, the above symptoms may still persist after treatment.
matters needing attention
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Diet, living habits, environment, etc. are only some of the factors that may lead to illness, and patients with stage II symptoms of nasopharyngeal carcinoma are more likely to seek medical advice because of neck tumors or physical examination findings, rather than long-term headache;prognosisThe statement that "the survival period is two years in case of metastasis" is not accurate enough.
Related drugs
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On October 28, 2023, the bio pharmaceutical company Coherus BioSciences and Junshi Biological announced that the US Food and Drug Administration (FDA) approved its monoclonal antibody Loqtorzi (toripalimab, teriprimab) combined with gemcitabine/cisplatin as the first-line treatment for adult patients with advanced recurrent or metastatic nasopharyngeal carcinoma (NPC).Its single drug is also approved for second-line and above treatment of recurrent or metastatic nasopharyngeal carcinoma after platinum containing treatment.
