Familial Nasopharyngeal Carcinoma 6

60 P-J. Lou, W-L. Hsu, Y-C. Chien et al.has abundant supply of regional lymphatic vessels,so metastasis is frequently found in NPC rather thanin other head-and-neck cancers. Any type of NPCmost commonly metastasizes to regional lymphnodes. Cervical lymphadenopathy is often the onlyclinical manifestation of NPC patients. The usualsites of distant metastasis are bone, lung, and liver.Metastasis to the brain, breast, or other parts of thebody is occasionally found.5.5.1Early SymptomsFor early diagnosis of NPC, it is important to recognizethe early symptoms of this disease. Discussionon symptoms from NPC and their implication to thediagnosis has been presented in the previous chapter.Therefore, only symptoms related to early diagnosisand screening is detailed here.The nasopharynx is situated at the skull base withclose proximity to the surrounding head and neckspaces. It is a clinical blind spot in many aspects.Tumors arising here may masquerade their symptomsto regions other than the primary site. Themarked invasive and metastatic powers of the NPCare responsible for the symptomatology. Most patientshave multiple symptoms which are insidious at theonset, and are sometimes disregarded by the patientsand doctors. This has often led to delayed diagnosisand treatment. However, in endemic areas, patientswith the following symptoms should be presumed tohave NPC, until proven otherwise.Blood-stained rhinorrhea or saliva. Blood-stainednasal mucus and/or saliva on hawking are frequentlyencountered as an early symptom of NPC. Epistaxis,on the other hand, is more commonly seen inadvanced NPC.Tinnitus and aural symptoms. Unilateral tinnitus,aural stuffiness, and mild hearing loss that are causedby serous otitis media are not an uncommon presentationof NPC. These symptoms are related to thedysfunctional Eustachian tube due to peritubal tumorinfiltration.Painless neck lumps. NPC has a tendency for earlylymphatic spread. Statistically, cervical lymphadenopathyis the most frequent presenting symptom ofNPC by many centers. The lateral retropharyngeallymph node (of Röuviere) is the first lymphatic filter,but is not palpable. The first common palpable nodeis the jugulodigastric node under the sternocleidomastoideusmuscle.Headache, neurological symptoms such as diplopiaand facial numbness are also clinical symptomsof NPC, but are considered as late symptoms of thedisease.5.5.2Nasopharyngeal ExaminationMirror examination is the quickest and most commonlyused method to assess the nasopharynx.However, it is restricted by the pharyngeal reflex,patient cooperation, and inability to open the mouth.With the introduction of transnasal fiberopticnasopharyngoscopes, close-up, end-on viewing ofthe nasopharynx becomes possible. Any tiny growthwhich escapes detection with routine mirror examinationcan be identified. Biopsy can also be performedunder direct visual guidance. Care must betaken that the tumors in the early stage may be indistinguishablefrom the surrounding nasopharyngeallymphoid tissues. This is especially true in youngsubjects whose adenoid tissues have not completelydegenerated (Fig. 5.1). In some cases, tumors in earlystage are so insignificant that they cannot even beidentified by the nasopharyngoscope. In such cases,the vascular pattern in the nasopharynx becomes animportant clue in assisting the diagnosis of NPC(Fig. 5.2). A gentle touch with a cotton stick may beFig. 5.1. Endoscopic view of a T1 tumor in the nasopharynx.Arrowheads indicate the normal adenoid tissue in thenasopharynx. Arrows indicate the tumor