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Nose Cancer (NPC): a rare cancer in the West, but common in the East

Dear friends


TGIF!


We are back in Phase 2 COVID pandemic restrictions after the recent outbreak of the Delta variant in 2 large clusters: Jurong Port Fishery & the KTV cluster. So as you stay home and work from home, do have a look at our EUANSENT blogposts and let us know what topics would be of interest this Phase 2A!


This week, let's look at a condition that is RARE in the West, but common in the East.


Nose cancer (NPC) is a common cancer amongst the Southern Chinese, including those who have migrated to Singapore, Malaysia, Canada & beyond. For Singaporean Chinese males, it remains as one of the top 10 cancers we encounter in clinical practice.


Nasopharyngeal cancer is a disease in which malignant (cancer) cells form in the tissues of the nasopharynx. The nasopharynx is a silent area at the back of the nose, between the nose and the throat (see illustration below). Ethnic background and exposure to the Epstein-Barr virus (EBV) can affect your risk of nasopharyngeal cancer.


Common signs of nasopharyngeal cancer include neck lump, nosebleeds, blocked nose, muffled hearing or tinnitus (ringing in the ears). In more advanced cases, there may be headaches, loss of smell and other systemic signs eg bone pains.


Illustration to show where the Nasopharynx is located in the upper aero-digestive tract (shaded in purple) from WEB MD.COM


Some of you might ask : Who is at risk of getting NPC?


Well, you are at higher risk if you:

  • Are male

  • Eat a diet rich in salt-cured fish and meats; these items contain high levels of nitrosamines

  • Have a family history of nasopharyngeal cancer

  • Have certain genes linked to cancer development

  • Have come in contact with EBV

Some, but not all, studies have found a higher risk of nasopharyngeal cancer in people who:

  • Smoke

  • Drink a lot of alcohol

  • Work around wood dust or exposure to a chemical called formaldehyde

WHAT TO EXPECT?


Generally, your GP will alert you if your annual blood screening tests eg EBV serology titre is elevated, raising the suspicion of NPC. This is often before you develop any signs or symptoms eg neck lump , blocked nose, loss of smell, hearing loss , blocked ears or nosebleeds.


Many screening packages now include EBV serology tests for NPC.


Currently, Lucence Diagnostics offers a new (novel) liquid DNA test for NPC and it is called the NPC GOLD test. It is a blood test, and is highly sensitive and specific for NPC. It is available in most local hospitals in Singapore. You can ask your doctor about it.


here's an interesting article from Nature in 2016:

Vo, J.H., Nei, W.L., Hu, M. et al. Comparison of Circulating Tumour Cells and Circulating Cell-Free Epstein-Barr Virus DNA in Patients with Nasopharyngeal Carcinoma Undergoing Radiotherapy. Sci Rep6, 13 (2016). https://doi.org/10.1038/s41598-016-0006-3


When you see your ENT Specialist, we will take a detailed clinical history and perform a NASOENDOSCOPY to look into the back of your nose, in the nasopharynx, and to closely examine the hidden areas eg the Fossa of Rosenmuller which is a very small cleft near the Ear tube opening into the nasopharynx. It is said that NPC most commonly starts in this tiny cleft.

Illustration to show how a Naso-Endoscopy is performed in clinic (under topical anaesthesia ) courtesy of Euan's ENT Surgery & Clinic Pte Ltd.


Also, some of our clinics are equipped with Narrow Band Imaging (NBI) endoscopy systems which can detect early cancerous lesions.


If we discover any suspicious lesions / masses in the Post Nasal Space (PNS) or nasopharynx, we will usually take a small biopsy to send for histological examination. This report usually takes between 3 to 5 days to come back and we will then update you on the results.


STAGING OF NPC:


Once the diagnosis of NPC is confirmed, we will arrange a few STAGING scans to help decide how advanced the cancer is eg loco-regional or distant metastases to the lung or bone.


TNM staging system


One tool that doctors use to describe the stage of cancer is called the TNM system. Doctors use the results from your diagnostic tests and scans to answer these questions:

  • Tumor (T): How large is the primary tumour? Where is it located?

  • Node (N): Has the tumour spread to the lymph nodes? If so, where and how many?

  • Metastasis (M): Has the cancer spread to other parts of the body? If so, where and how much?

The results are combined to determine the stage of cancer for each person.


There are 5 stages of NPC: stage 0 (zero) and stages I through IV (1 through 4). The stage provides a common way of describing the cancer, so we doctors can work together to plan the best treatments.


TREATMENT MODALITIES for NPC:


We will work closely with the Medical Oncologist and Radiation Oncologist to plan your treatment, depending on the stage of the cancer, and your general health condition and any co-morbidities you may have eg liver or renal function etc.


Currently, the main stay of treatment of NPC is still CHEMO-IRRADIATION THERAPY. This treatment can be administered in various modes & schedules, and these are discussed and planned at our Head & Neck Tumour Inter-disciplinary Boards with the participation of many specialists, to ensure the best possible outcomes.


The good news is that the survival rates for early (Stage 1 & 2) NPC have improved remarkably, with the advent of more advanced irradiation technology / techniques and the advent of newer & less toxic chemo-therapeutic drugs.


FOLLOW UP for NPC:


Your follow up is for life! We will usually see you more frequently in the first year of treatment, then gradually space out your appointments eg 6 months to 1 year the longer you remain in remission.


The 5 year overall survival rate for Stage 1 & 2 NPC is high, between 92 to 94%. So this is good news!


For recurrent NPC, there is also the option of surgery eg Nasopharyngectomy and Neck dissection for nodal disease (to eradicate cancer that has spread to the lymph nodes in the neck region).


Oftentimes, the treatment for NPC affects the hearing either the middle ear, inner ear or even both. Nowadays, we are better equipped to deal with such post treatment hearing loss, be it with hearing aids or even hearing implants to restore your hearing. Do seek our help if you are so affected.


For more information on NPC cancer survival & prognosis, you can refer to this article from Taiwan:


Prognostic classification for patients with nasopharyngeal carcinoma based on American Joint Committee on cancer staging system T and N categories

Chung-Wen Jen1, Yu-Chen Tsai1, Jia-Shing Wu1, Pei-Lin Chen2, Jia-Hua Yen1, Wei-Kai Chuang1, Skye Hung-Chun Cheng1 1Department of Radiation Oncology, 2Department of Research, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan


So, dear friends, the important take home NPC message this TGIF is:


Get yourself screened, especially if you have a family history of NPC, or if you are of Southern Chinese extraction. See your GP annually, and check your cancer markers; if you are at risk, please see your ENT Specialist for a check Naso-endoscopy. Remember:


Early detection saves lives!

References:

1.Du T, Xiao J, Qiu Z, Wu K. The effectiveness of intensity-modulated radiation therapy versus 2D-RT for the treatment of nasopharyngeal carcinoma: A systematic review and meta-analysis. PLoS One. 2019;14(7):e0219611. [PMC free article] [PubMed]


2.Sun L, Wang Y, Shi J, Zhu W, Wang X. Association of Plasma Epstein-Barr Virus LMP1 and EBER1 with Circulating Tumor Cells and the Metastasis of Nasopharyngeal Carcinoma. Pathol Oncol Res. 2020 Jul;26(3):1893-1901. [PubMed]


3.Adoga AA, Kokong DD, Ma'an ND, Silas OA, Dauda AM, Yaro JP, Mugu JG, Mgbachi CJ, Yabak CJ. The epidemiology, treatment, and determinants of outcome of primary head and neck cancers at the Jos University Teaching Hospital. South Asian J Cancer. 2018 Jul-Sep;7(3):183-187. [PMC free article] [PubMed]


4.Cao SM, Simons MJ, Qian CN. The prevalence and prevention of nasopharyngeal carcinoma in China. Chin J Cancer. 2011 Feb;30(2):114-9. [PMC free article] [PubMed]


5.Peng G, Wang T, Yang KY, Zhang S, Zhang T, Li Q, Han J, Wu G. A prospective, randomized study comparing outcomes and toxicities of intensity-modulated radiotherapy vs. conventional two-dimensional radiotherapy for the treatment of nasopharyngeal carcinoma. Radiother Oncol. 2012 Sep;104(3):286-93. [PubMed]


6.Mo HY, Sun R, Sun J, Zhang Q, Huang WJ, Li YX, Yang J, Mai HQ. Prognostic value of pretreatment and recovery duration of cranial nerve palsy in nasopharyngeal carcinoma. Radiat Oncol. 2012 Sep 07;7:149. [PMC free article] [PubMed]


7.Batsakis JG, Solomon AR, Rice DH. The pathology of head and neck tumors: carcinoma of the nasopharynx, Part 11. Head Neck Surg. 1981 Jul-Aug;3(6):511-24. [PubMed]


8.Teoh JW, Yunus RM, Hassan F, Ghazali N, Abidin ZA. Nasopharyngeal carcinoma in dermatomyositis patients: A 10-year retrospective review in Hospital Selayang, Malaysia. Rep Pract Oncol Radiother. 2014 Sep;19(5):332-6. [PMC free article] [PubMed]


9.Blanchard P, Nguyen F, Moya-Plana A, Pignon JP, Even C, Bidault F, Temam S, Ruffier A, Tao Y. [New developments in the management of nasopharyngeal carcinoma]. Cancer Radiother. 2018 Oct;22(6-7):492-495. [PubMed]


10.Lee N, Harris J, Garden AS, Straube W, Glisson B, Xia P, Bosch W, Morrison WH, Quivey J, Thorstad W, Jones C, Ang KK. Intensity-modulated radiation therapy with or without chemotherapy for nasopharyngeal carcinoma: radiation therapy oncology group phase II trial 0225. J Clin Oncol. 2009 Aug 01;27(22):3684-90. [PMC free article] [PubMed]


11.Liu J, Yu H, Sun X, Wang D, Gu Y, Liu Q, Wang H, Han W, Fry A. Salvage endoscopic nasopharyngectomy for local recurrent or residual nasopharyngeal carcinoma: a 10-year experience. Int J Clin Oncol. 2017 Oct;22(5):834-842. [PubMed]


12.Hay A, Simo R, Hall G, Tharavai S, Oakley R, Fry A, Cascarini L, Lei M, Guerro-Urbano T, Jeannon JP. Outcomes of salvage surgery for the oropharynx and larynx: a contemporary experience in a UK Cancer Centre. Eur Arch Otorhinolaryngol. 2019 Apr;276(4):1153-1159. [PubMed]


13.Amin MB, Greene FL, Edge SB, Compton CC, Gershenwald JE, Brookland RK, Meyer L, Gress DM, Byrd DR, Winchester DP. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more "personalized" approach to cancer staging. CA Cancer J Clin. 2017 Mar;67(2):93-99. [PubMed]


14.Li J, Chen S, Peng S, Liu Y, Xing S, He X, Chen H. Prognostic nomogram for patients with Nasopharyngeal Carcinoma incorporating hematological biomarkers and clinical characteristics. Int J Biol Sci. 2018;14(5):549-556. [PMC free article] [PubMed]


15.Ho AC, Chan JY, Ng RW, Ho WK, Wei WI. The role of myringotomy and ventilation tube insertion in maxillary swing approach nasopharyngectomy: review of our 10-year experience. Laryngoscope. 2013 Feb;123(2):376-80. [PubMed]



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