How to identify the primary lesion in the MRI report of nasopharyngeal carcinoma?

The incidence rate of nasopharyngeal cancer is higher in southern China, such as Guangdong, Guangxi, Hunan and other provinces, especially in Zhaoqing, Foshan and Guangzhou in central and western Guangdong, with more men than women. . According to reports, the incidence rate among men living in central Guangdong Province and speaking Guangdong dialect is 30/100,000 to 50/100,000. Nationally speaking, the incidence rate of nasopharyngeal cancer gradually decreases from south to north. For example, the incidence rate in the far north is no higher than 2/100,000 to 3/100,000.

Malignant tumors that mostly occur in the nasopharyngeal mucosa. The age of onset is mostly middle-aged people, and adolescents are also affected. The cause is related to racial susceptibility (yellow people are more susceptible than white people), genetic factors and EB virus infection. Nasopharyngeal cancer is highly malignant and can cause cervical lymph node metastasis at an early stage. The clinical characteristics are 4 major symptoms: ① Nasal symptoms. One side of the nose is blocked and nose bleeds. In the early stage, there may be only bloody nasal discharge or bloody nasal discharge. ②Neck mass. More than half of the patients have lymph node metastasis when diagnosed, and many patients present with neck tumors as the first symptom. The tumors are mostly located on the upper side of the neck and are hard and have poor mobility. ③Cranial nerve symptoms. Tumors can invade into the skull along the base of the skull and invade multiple cranial nerves. Headaches on one side and diplopia may appear in the early stages of the disease. ④ Ear symptoms. One-sided ear fullness, deafness, or recurring ear blockage, etc. The location of the nasopharyngeal cavity is hidden, and early symptoms are vague. When patients experience nosebleeds on one side, bloody nasal discharge, ear tightness on one side, headache on one side, diplopia, and neck swelling, they should seek medical attention promptly and undergo repeated examinations. EB virus serological examination, X-ray photography, CT examination, MRI examination, etc. can assist in the diagnosis. The confirmed diagnosis must be confirmed by biopsy from the nasopharyngeal tumor and histopathological confirmation. Sometimes multiple biopsies are needed to confirm. After the diagnosis of nasopharyngeal cancer is established, radiotherapy should be carried out as soon as possible. Sufficient and uninterrupted radiotherapy combined with traditional Chinese medicine, leukocyte-raising drugs, etc. can enable more than half of the patients to survive for more than 5 years.

Etiology

Epidemiological surveys suggest that the cause of nasopharyngeal cancer may be related to the following factors: ①EB virus infection. ②Environment and diet: Environmental factors are also a cause of nasopharyngeal cancer. In Guangdong, a survey found that the trace element nickel content in rice and water in areas with a high incidence of nasopharyngeal cancer was higher than in areas with a lower incidence of nasopharyngeal cancer. Nickel content is also high in the hair of nasopharyngeal cancer patients. Animal experiments show that nickel can promote nitrosamine-induced nasopharyngeal cancer. It has also been reported that consumption of salted fish and pickled foods is a high-risk factor for nasopharyngeal cancer in southern China, and is related to the age of the salted fish eater, the duration, amount and cooking method of eating salted fish. ③ Genetic factors: Nasopharyngeal cancer patients have racial and family aggregation phenomena. For example, descendants of southern Chinese living in other countries still maintain a high incidence rate of nasopharyngeal cancer, which suggests that nasopharyngeal cancer may be a hereditary disease.

Pathological changes

(1) Prevalent site and general shape Nasopharyngeal cancer often occurs at the top of the posterior wall of the nasopharynx, followed by the lateral wall, and the anterior wall and bottom Walls are extremely rare. The general morphology of nasopharyngeal cancer is divided into five types, namely nodular type, cauliflower type, submucosal type, invasive type and ulcer type.

(2) Laws of growth and spread The spread of nasopharyngeal cancer has its own rules. Earlier nasopharyngeal cancer is limited to the nasopharynx and can be called localized type. As the tumor grows, it can spread directly to adjacent sinus cavities, spaces, and skull base. Nodular or cauliflower-type tumors can protrude into the nasopharyngeal cavity, while infiltrative, submucosal and ulcerative types mostly grow in the submucosa. Cancer can grow into the nasal cavity and oropharynx, and can expand into the parapharyngeal space, pterygopalatine fossa, or invade the orbit. Cancer can expand directly upward, destroying the skull base bones and cranial nerves. Neck metastasis of nasopharyngeal cancer occurs through the lymphatic drainage system, while distant metastasis can enter the blood circulation through the lymphatic system or cancer cells directly invade surrounding blood vessels, enter the blood circulation and metastasize to distant organs.

(3) Histological classification

1. Carcinoma in situ: The concept of carcinoma in situ means that the cancer cells have not yet broken through the basement membrane, and nasopharyngeal carcinoma in situ is no exception. There must be a complete basement membrane under the cancer focus. When cancer cells proliferate in situ and project under the epithelium in the form of buds or spikes, there is still a clear basement membrane separating the cancer cells from the underlying mucosal lamina propria. The diagnosis of nasopharyngeal carcinoma in situ is mainly based on cytological criteria, followed by consideration of histological arrangement and structure. Therefore, the cytological standards for diagnosing nasopharyngeal carcinoma in situ must be strictly controlled, that is, the anaplastic images must reach a level that is generally recognized. Compared with normal epithelial cells, cancer cells in situ have an increased nuclear-to-cytoplasmic ratio, that is, their nuclear area is significantly increased.

2. Invasive cancer

(1) Micro-invasive cancer: refers to the basement membrane being destroyed by cancer cells, but the scope of invasion does not exceed a field of view 400 times under a light microscope. The cell morphology is more atypical than that of carcinoma in situ and grows infiltratively through the basement membrane.

(2) Squamous cell carcinoma: Although most nasopharyngeal carcinomas originate from columnar epithelium, most nasopharyngeal carcinomas are squamous cell carcinomas. To diagnose squamous cell carcinoma, features of squamous differentiation must be present in the sections. The so-called squamous differentiation refers to: ① keratinized beads; ② intracellular and extracellular keratinization; ③ intercellular bridges; ④ The arrangement of cells in cancer cell nests is similar to squamous epithelium, and the cells are not syncytial. According to the degree of squamous differentiation of cancer cells, nasopharyngeal squamous cell carcinoma can be divided into three grades: highly differentiated, moderately differentiated and poorly differentiated.

① Highly differentiated squamous cell carcinoma: Those with intercellular bridges or keratinization visible in most cancer tissues are called well-differentiated squamous cell carcinoma, or keratinized squamous cell carcinoma. There is generally no lymphocyte infiltration in the cancer nest, and individual scattered lymphocytes can sometimes be seen. The boundaries of cancer nests are generally relatively clear, and sometimes they are surrounded by complete membranes. This type of cancer is mostly fibrous tissue type. It is accompanied by infiltration of neutrophils, lymphocytes, plasma cells, etc., but there are generally not too many plasma cells.

② Moderately differentiated squamous cell carcinoma: refers to nasopharyngeal carcinoma where clear intercellular bridges and/or keratinization are seen in the cancer tissue, not individually but in a certain number. The amount of either intracellular or extracellular keratinization is much less in highly differentiated squamous cell carcinomas. There are varying numbers of lymphocyte infiltrates in the cancer nests, varying numbers of plasma cells around the nests, and stromal changes similar to those of poorly differentiated squamous cell carcinomas, but different from those of highly differentiated squamous cell carcinomas.

③ Lowly differentiated squamous cell carcinoma: A certain number of cancer cells can also show intercellular bridges or intracellular keratinization under a light microscope, but the number is small. The nuclei of cancer cells are deeply stained. The nucleoli are enlarged and often stained with basophilic eosin. The boundary between cancer nests and stroma is relatively clear, but they can also be intertwined with the stroma. Every time there are varying numbers of lymphocytes infiltrating in the cancer nest, the stroma can be of various types, such as lymphocyte-rich infiltration type, granulation tissue type, fibrosis type, and inherent tissue type. No matter which type of stroma it is, it is always accompanied by varying numbers of plasma cell infiltrates.

(3) Adenocarcinoma: Nasopharyngeal adenocarcinoma is extremely rare compared with nasopharyngeal squamous cell carcinoma, especially in areas with high incidence of nasopharyngeal cancer. From a histogenesis point of view, adenocarcinoma must originate from glands.

① Highly differentiated adenocarcinoma: The boundaries between cancer parenchyma and stroma are clear, and the cancer nests are obvious. Some cancer cells are arranged in an alveolar shape; some are arranged in a tall columnar duct-like structure; some are adenoid cystic carcinoma or cribriform carcinoma; and some are simple adenocarcinomas.

② Moderately differentiated adenocarcinoma: refers to adenocarcinoma in which a certain number of clear glandular cavities are formed in the cancer tissue, but accompanied by some undifferentiated cancer structures. They are often the further development of the above-mentioned highly differentiated adenocarcinoma. As a result of anaplastic changes, some traces of highly differentiated adenocarcinoma remain.

③Poorly differentiated adenocarcinoma: Clear glandular cavity structures can be seen in the cancer tissue, and the number is very small. Most cancer tissues have the structure of undifferentiated cancer. The tumor cells were foamy and the Alcian blue staining was weakly negative.

(4) Alveolar nuclear cell carcinoma: Nasopharyngeal cancer in which most of the cancer cell nuclei are vacuolated can be called alveolar nuclear cell carcinoma. Because of its special shape and good prognosis after radiotherapy, it is classified as a type independently. The so-called vacuolation of the nucleus means that the nucleus is large and round or oval or fat and spindle-shaped. The nuclear area is more than three times the nuclear area of ??lymphocytes. The chromatin in the nucleus is relatively sparse, so the nucleus appears vacuolated; the chromatin adheres unevenly to the inner surface of the nuclear membrane, making it unevenly thick, and the thin areas even resemble nuclear membrane defects. To diagnose nasopharyngeal alveolar cell carcinoma, more than 75% of the cancer cell nuclei must be found to be vacuolated in the section. Less than 25% of the remaining cancer cells can be poorly differentiated squamous cell carcinoma or undifferentiated cancer. The criteria for diagnosing alveolar nuclear cell carcinoma are set to have more than 75% of cancer cells showing vacuolation. This is why Only then can it show its unique biological characteristics, that is, it has a better prognosis after radiotherapy.

(5) Undifferentiated cancer: The distribution of cancer cells is diffuse and often mixed with the stroma. The cells are medium or small in size, short spindle, oval or irregular, with less brain plasma and slightly basophilic. The nuclear chromatin is increased, granular or lumpy, and nucleoli are sometimes visible.

Clinical manifestations

(1) Respiratory bloody nasal discharge. There may be bleeding symptoms in the early stage, which are manifested as blood in the sputum after sucking the nose or blood in the nasal discharge when blowing the nose. In the early stage, there is only a small amount of blood in the phlegm or nasal discharge, which sometimes disappears. In the late stage, there is more bleeding and there may be nosebleeds.

(2) Tinnitus, hearing loss, and ear obstruction. When nasopharyngeal cancer occurs on the lateral wall of the nasopharynx, the lateral fossa, or the upper lip of the Eustachian tube opening, unilateral tinnitus may occur when the tumor compresses the Eustachian tube. Or hearing loss, catarrhal otitis media may also occur. Unilateral tinnitus or hearing loss, and a sense of blockage in the ear are one of the early symptoms of nasopharyngeal cancer.

(3) Headache is a common symptom, accounting for 68.6%. It can be the first symptom or the only symptom. In the early stages, the headache location is not fixed and is intermittent. In the late stage, there is persistent migraine with a fixed location. The reason may be caused by neurovascular reflex in early-stage patients or stimulation of the first terminal nerve of the trigeminal nerve. Late-stage patients are often caused by tumors destroying the skull base and spreading intracranially to involve cranial nerves.

(4) Diplopia: Due to tumor invasion of the abducens nerve, double vision often occurs when looking outward. Invasion of the trochlear nerve often causes inward strabismus and diplopia, which accounts for 6.2% to 19%. Often damaged at the same time as the trigeminal nerve.

(5) Facial numbness refers to the numbness of the facial skin, and clinical examination shows that the pain and touch sensation decrease or disappear. Tumors that invade the cavernous sinus often cause damage to the first or second branch of the trigeminal nerve; tumors that invade the foramen ovale, prestyloid area, and the third branch of the trigeminal nerve often cause damage to the front of the auricle, temporal region, cheek, lower lip, and Numbness or abnormal sensation of the chin skin. Facial skin numbness accounts for 10% to 27.9%.

(6) Nasal obstruction: Nasal obstruction may occur when a tumor blocks the posterior nares. When the tumor is small, the nasal obstruction is mild. As the tumor grows, the nasal obstruction worsens, and it is mostly unilateral nasal obstruction.

Bilateral nasal obstruction may occur if the tumor blocks both choanae.

(7) Symptoms of cervical lymph node metastasis Nasopharyngeal cancer is prone to cervical lymph node metastasis, about 60.3% to 86.1%, half of which are bilateral metastases. Cervical lymph node metastasis is often the first symptom of nasopharyngeal cancer (23.9% to 75%). In a small number of patients, the primary lesion cannot be found in nasopharyngeal examination, and cervical lymph node metastasis is the only clinical manifestation. This may be related to the small primary tumor of nasopharyngeal carcinoma and its expansion into the submucosal tissue.

(8) Glossary muscle atrophy and tongue extension deviation. Nasopharyngeal cancer directly invades or lymph nodes metastasize to the retrostyloid area or hypoglossal canal. The hypoglossal nerve is invaded, causing the tongue to stick out toward the diseased side, accompanied by atrophy of the tongue muscles on the diseased side.

(9) Eye ptosis and eyeball fixation are related to damage to the oculomotor nerve. Vision loss or loss is related to optic nerve damage or orbital cone invasion.

(10) Distant metastasis The distant metastasis rate of nasopharyngeal carcinoma is approximately 4.8% to 27%. Distant metastasis is one of the main reasons for treatment failure of nasopharyngeal carcinoma. Common metastasis sites are bones, lungs, liver, etc. Simultaneous metastasis to multiple organs is common.

(11) Dermatomyositis can also be accompanied by nasopharyngeal cancer. Therefore, patients with dermatomyositis should carefully examine the nasopharynx regardless of whether they have symptoms of nasopharyngeal cancer or not. .

(12) Menopause is very rare as the first symptom of nasopharyngeal cancer and is related to the invasion of sphenoid sinus and pituitary gland by nasopharyngeal cancer.

Diagnosis

In addition to paying attention to the above clinical manifestations, the following examinations should be performed:

(1) Anterior nostril examination After the nasal mucosa has converged, pass the anterior nostril endoscope The choana and nasopharynx can be seen, and cancers that invade or are adjacent to the nostril can be found.

(2) Indirect nasopharyngoscopy is a simple and practical method. Each wall of the nasopharynx should be examined in turn, paying attention to the posterior wall of the nasopharyngeal roof and the pharyngeal recesses on both sides. The corresponding parts on both sides should be compared and observed. Any asymmetric submucosal bulges or solitary nodules on both sides should be paid more attention to.

(3) Fiberoptic nasopharyngoscopy For fiberoptic nasopharyngoscopy, 1% ephedrine solution can be used to converge the nasal mucosa and expand the nasal passages. Then use 1% dicaine solution to superficially anesthetize the nasal passages, and then insert the fiberscope through the nasal cavity and advance it forward until it reaches the nasopharyngeal cavity while observing. This method is simple and the mirror is well fixed, but the observation of the posterior nares and the front wall is unsatisfactory.

(4) Neck biopsy: Neck mass biopsy can be performed in cases where the diagnosis cannot be confirmed by nasopharyngeal biopsy. Generally, it can be performed under local anesthesia. During the operation, the earliest hard lymph nodes that appear should be selected and the entire capsule should be removed. If excisional biopsy is indeed difficult, wedge-shaped incisional biopsy can be performed at the mass. The tissue must be cut with a certain depth and avoid squeezing. At the end of the operation, the surgical field should not be sutured too tightly.

(5) Fine-needle aspiration This is a simple, safe and efficient method for diagnosing tumors, which has been highly recommended in recent years. For patients with suspected cervical lymph node metastasis, fine needle aspiration can be used to obtain cells first. The specific methods are as follows:

1. Puncture of nasopharyngeal tumors: Use a No. 7 long needle attached to a syringe. After the oropharynx is anesthetized, the needle is inserted into the tumor parenchyma under an indirect nasopharyngoscope, and the syringe is withdrawn to create negative pressure. It can be moved back and forth in the tumor twice, and the aspirate is smeared on a glass slide for cytological examination.

2. Fine needle aspiration of neck masses: Use a No. 7 or No. 9 needle attached to a 10m1 syringe. After local skin disinfection, select the puncture point, insert the needle along the long axis of the tumor, aspirate the syringe and move the needle back and forth in the tumor 2 to 3 times. After taking out the aspirated material, perform cytological or pathological examination.

(6) EB virus serological detection Currently, the immunoenzyme method is commonly used to detect the IgA/VCA and IgA/EA antibody titers of EB virus. The former has higher sensitivity and lower accuracy; while the latter is just the opposite. Therefore, those with suspected nasopharyngeal cancer should be tested for both antibodies at the same time, which will be helpful for early diagnosis. For cases with IgA/VCA titer ≥1:40 and/or IgA/EA titer ≥1:5, even if no abnormality is found in the nasopharynx, exfoliated cells or biopsies should be taken from the site where nasopharyngeal cancer is common. If the diagnosis remains undiagnosed, regular follow-up should be carried out and multiple biopsies should be performed if necessary.

(7) Lateral nasopharyngeal radiographs, skull base radiographs and CT examinations Each patient should undergo routine nasopharyngeal lateral radiographs and skull base photographs. If there is suspected invasion of the paranasal sinuses, middle ear or other parts, corresponding radiographs should be taken at the same time. Units that have the conditions should conduct CT scans to understand the local expansion, especially the extent of infiltration in the parapharyngeal space. This is extremely important for determining clinical staging and formulating treatment plans.

(8) B-mode ultrasonic examination B-mode ultrasonic examination has been widely used in the diagnosis and treatment of nasopharyngeal carcinoma. The method is simple, non-invasive, and patients are willing to accept it. In cases of nasopharyngeal cancer, it is mainly used to examine the liver, neck, retroperitoneal and pelvic lymph nodes to understand whether there is liver metastasis, lymph node density, whether it is cystic, etc.

(9) Magnetic resonance imaging examination Magnetic resonance imaging (MRl) can clearly display all levels of the skull, sulci, gyri, gray matter, white matter, ventricles, and cerebrospinal fluid ducts , blood vessels, etc. Using the SE method to display T1 and T2 extended high-intensity images can diagnose nasopharyngeal cancer, superior frontal sinus cancer, etc., and show the relationship between the tumor and surrounding tissues.

Treatment measures

(1) Radiotherapy

Radiation therapy has always been the first choice method for the treatment of nasopharyngeal cancer. The reason is that most nasopharyngeal carcinomas are poorly differentiated cancers with high sensitivity to radiation, and the primary tumor and cervical lymphatic drainage area are easily included in the radiation field. Since the 1940s, deep X-ray radiotherapy for nasopharyngeal cancer has been carried out in my country. Since the 1950s and 1960s, 60Co external beam radiotherapy has been carried out, and combined large-field irradiation of the nasopharynx and neck has been changed to small-field irradiation, which has reduced radiotherapy reactions and improved survival rates. At present, the most effective and certain method is to use 60Co remote treatment machine.

1. Indications and contraindications for radiotherapy for nasopharyngeal carcinoma

(1) Indications for radical radiotherapy: ① Those with moderate or above general condition; ② No obvious bone at the skull base Those with mass destruction; ③ CT or MRI films show no or only mild or moderate infiltration in the paranasopharynx; ④ The maximum diameter of cervical lymph nodes is less than 8cm, mobile, and has not yet reached the supraclavicular fossa; ⑤ There is no distant organ metastasis.

(2) Indications for palliative radiotherapy: ① KS grade 60 or above; ② Severe headache, moderate or above nasopharyngeal bleeding; ③ Individual distant metastasis or cervical lymph node metastasis greater than 10cm . After palliative radiation, if the general condition improves, symptoms disappear, and distant metastases can be controlled, radical radiation therapy can be used. (3) Contraindications to radiotherapy: ① KS grade below 60 points; ② patients with extensive distant metastasis; ③ patients with acute infectious diseases; ④ patients with radiation-induced brain and spinal cord injury. (4) The principle of radiotherapy for recurrence after radiotherapy is that patients with the following conditions should not receive radiotherapy. ① The recurrence time after radiotherapy in the same target area (including nasopharynx and neck target areas) is less than one year; ② Radiation encephalopathy or radiation myelopathy occurs after radiotherapy; ③ The total treatment course of the nasopharyngeal target area should not exceed three courses, and the cervical cancer target area should not exceed three courses of treatment. The target area should not exceed two courses of treatment.

2. Selection of radiation and irradiation range

(1) Design of irradiation field: The principle of designing irradiation field is "small without leakage". All parts of the tumor involved should be included in the radiation field, but normal tissues in the radiation field, especially those sensitive to radiotherapy, should be protected. For primary lesions in the nasopharynx, the bilateral anterior auricular field is mainly used. If the nasal cavity and paranasopharyngeal space are involved, the anterior nasal field can be additionally photographed. If the orbit is involved, the supraorbital field or the infraorbital field can be additionally photographed. Pay attention to protecting the eyes with lead films to avoid the occurrence of the disease. Radiation cataracts. The irradiation range of the neck depends on the disease of the lymph nodes. For patients with no palpable cervical lymph nodes, preventive irradiation of the upper neck areas on both sides is often performed. If there is cervical lymph node metastasis, in addition to irradiating the metastatic lesions, preventive irradiation of the drainage area below the metastatic lesions is often performed.

3． Radiation dose and time

(1) Continuous radiotherapy: 5 times a week, 200cGY each time, total dose TD6000~7000cGY/6~7 weeks.

(2) Fractional radiotherapy: Generally, radiotherapy is divided into two sections, 5 times a week, 200cGY each time, each section is about 3.5 weeks. There is four weeks of rest between the two sessions, and the total dose is TD6500~7000cGY.

4． Post-loading intracavitary radiotherapy

(1) Indications:

① Small localized lesions in the nasopharynx (tumor thickness less than 0.5cm), located on the roof, anterior wall or Those on the side wall;

② Those who have residual lesions after external irradiation or surgical resection of nasopharyngeal carcinoma that meet ①.

(2) Treatment method: External irradiation is often combined with intracavitary irradiation, and the external irradiation dose is 4500 to 6000 cGY. After 1 to 2 weeks of external irradiation, intracavity radiation is added 1 to 2 times, with intervals between each time. For 7 to 10 days, each dose is taken at 0.25 cm under the mucosa as the dose point, and 1000 to 2000 cGY is administered per time.

5. Radiation reactions, recession syndrome and their treatment

(1) Complications of radiotherapy

① Systemic reactions: including fatigue, dizziness, anorexia, nausea, vomiting, tasteless or altered taste in the mouth, Insomnia or drowsiness, etc. Individual patients may experience blood changes, especially leukopenia. Although the degree varies, with symptomatic treatment, it can generally be overcome and radiation therapy can be completed. If necessary, you can take vitamins B1, B6, C, metoclopramide, etc. If the white blood cell count drops below 3×109, radiotherapy should be suspended.

②Local reactions: including reactions on the skin, mucous membranes, and salivary glands. If the skin reaction is dry dermatitis or even wet dermatitis, anti-inflammatory ointment with 0.1% borneol talcum powder or lanolin as the base can be used topically. Mucosal reactions manifest as congestion, edema, exudation, and accumulation of secretions in the nasopharyngeal and oropharyngeal mucosa. Gargles and lubricating anti-inflammatory agents can be used topically. Parotid gland swelling occurs in a few patients after irradiation of 2Gy to the parotid gland, and the swelling gradually subsides in 2 to 3 days. When irradiated with 40Gy, saliva secretion significantly decreased, while oral mucosal secretion increased, and the mucosa became congested, red, and swollen. The patient has dry mouth and difficulty eating dry food. Therefore, excessive irradiation of the parotid gland should be avoided.

(2) Radiotherapy regression syndrome: mainly include temporomandibular joint dysfunction and soft tissue atrophy and fibrosis, radiation-induced dental caries, radiation-induced osteomyelitis of the mandibular spine, and radiation-induced encephalomyelopathy. There is currently no proper way to reverse it, but symptomatic treatment and support methods can be helpful. Excessive exposure of important tissues and organs must be strictly avoided.

(2) Surgical treatment

1. Resection of primary tumor of nasopharyngeal carcinoma

(1) Indications:

① Highly differentiated nasopharyngeal carcinoma, such as adenocarcinoma, squamous cell carcinoma grade I and II, and early cases of malignant mixed tumors.

② Local recurrence in the nasopharynx after radiotherapy, the lesions are limited to the posterior or anterior parietal wall, or only involve the edge of the pharyngeal recess, without infiltration in other parts, no difficulty in opening the mouth, and good physical condition.

③If the radical dose of radiotherapy has been given, but the primary tumor in the nasopharynx has not disappeared, or there is resistance to radiation, surgical resection can be performed after one month's rest.

(2) Contraindications:

① Patients with skull base bone destruction or paranasopharyngeal infiltration, cranial nerve damage or distant metastasis.

②Those with poor liver and kidney function and poor general condition.

(3) Surgical method: First perform tracheotomy and intubation, and perform surgery under general anesthesia. A horseshoe-shaped incision was made along the inner side of the maxillary tooth root 0.5cm away from the alveolar, the hard hip bone mucosa was incised, and the soft palate was peeled off under the mucosa, and part of the hard hip bone plate and vomer bone were removed. The nasal floor mucosa was transected at the junction of the soft and hard palate to expose the roof wall of the nasopharyngeal cavity, the anterior divisions of both sides of the wall, and the tumor. Incise the nasopharyngeal mucosa from the posterior edge of the nasal septum and the upper edge of the choana to the bone surface, perform blunt or sharp dissection, incise along the junction of the top side of the nasopharynx, and cut transversely down to the junction of the oropharynx and the posterior wall of the nasopharynx Mucosa, the entire posterior mucosa of the nasopharyngeal roof together with the cancer was removed en bloc.

2． Cervical lymph node dissection

(1) Indications: The primary nasopharyngeal cancer lesions have been controlled after radiotherapy or chemotherapy, and the general condition is good. Only residual lesions or recurrences in the neck remain, which are limited in scope and mobile. , cervical lymph node dissection may be considered.

(2) Contraindications:

① Residual lesions or recurrent lesions in the neck are adherent and fixed to the deep tissues of the neck;

② Distant lesions appear Those with metastasis or extensive skin infiltration;

③ Those who are old and frail, with heart, lung, liver and kidney dysfunction that cannot be corrected.

(3) Excision range: starting from the mastoid tip, the lower edge of the upper skull, down to the upper edge of the clavicle, from the midline of the neck in the front, to the lymph nodes and fat connectives in the front edge of the trapezius muscle in the back The tissue was resected in large pieces together with the platysma muscle, sternocleidomastoid muscle, internal and external jugular veins, scaphohyoid muscle, submandibular gland, inferior pole of parotid gland and accessory nerve.

3． Simple resection of cervical lymph nodes

Simple resection can be performed for single lymph nodes in the neck that are insensitive to radiotherapy or for patients with solitary lymph node recurrence in the neck after radiotherapy. After local infiltration anesthesia, the surface skin and subcutaneous tissue of the metastasis are incised, and the metastasis and the surrounding normal tissue are completely removed. The wound can be bandaged with slight pressure after surgery.

(3) Chemotherapy

1. Indications for chemotherapy for nasopharyngeal carcinoma

(1) Stage IV patients and stage IV patients with obvious lymphatic metastasis;

(2) Any patient suspected of distant metastasis;

p>

(3) For large massive metastasis of regional lymph nodes in the neck, induction chemotherapy before radiotherapy;

(4) Chemotherapy as a sensitizing effect before radiotherapy;

(5) As adjuvant chemotherapy after radiotherapy or surgery.

2． Commonly used combination chemotherapy regimens

(1) PF regimen: cisplatin 20 mg/m2 and 5-fluorouracil 750 mg/m2, intravenous drip, use for 5 days and then rest for 2 weeks, and can be used for 2 to 3 courses. This solution can be used to shrink tumors before radiotherapy, or in cases of chemotherapy alone, with an effective rate ranging from 40% to 90%. The most commonly used chemotherapy regimen.

(2) PFA protocol: cisplatin 20 mg and 5-fluorouracil 500 mg, intravenously infused for 5 days; doxorubicin 40 mg, intravenously injected on the first day of treatment. Repeating it once after 3 to 4 weeks can significantly shrink the tumor. It is now rarely used.

(3)CBF protocol: cyclophosphamide 600-1000mg/time, intravenous injection, applied on the 1st and 4th day. Zingmimycin 15mg/time, intramuscular injection, applied on the 1st and 5th day. 5-Fluorouracil 500mg, intravenous injection, applied on the 2nd and 5th days, rest for 1 week after the course of treatment, and last 4 courses of treatment. The effective rate is 60.8%. It is now rarely used.

3． Regional intra-arterial intubation chemotherapy

Arterial infusion chemotherapy can be used for ascending nasopharyngeal carcinoma and local recurrence after radiotherapy. Retrograde cannulation of the superficial temporal artery or facial artery is an option. Combination or sequential treatment of several chemotherapy drugs with strong action and short action time is often chosen. Before administration, inject 2% procaine 2ml to prevent arterial spasm, then inject anti-cancer drugs, and then fill the tube cavity with 2.5% sodium citrate solution and seal the tube end. If continuous medication is required, 1500 mg of 5% glucose saline added with 100 ml of heparin solution and anticancer drugs can be used for continuous infusion for 24 hours.

Treatment of nasopharyngeal cancer with traditional Chinese medicine

Yew has long been recorded in Chinese medicine: "Compendium of Materia Medica" records the efficacy of yew in treating cholera, typhoid, and detoxification; in modern "Compendium of Materia Medica", There are further records in medical books such as "Dictionary of Traditional Chinese Medicine", "Records of Northeastern Medicinal Plants", "Jilin Chinese Herbal Medicine", and "Compendium of Materia Medica". Yew herbal medicine is generally effective in one course of treatment (twenty-eight days).

For cancer surgery patients, the best effect is to start taking it 10 to 15 days after surgery; for radiotherapy and chemotherapy patients, it can be taken at the same time as they are undergoing treatment, which has the effect of increasing efficiency and reducing toxicity. For ordinary patients, after 4 to 6 courses of treatment, all test indicators are normal, and they can change to a low-dose maintenance regimen under the guidance of a doctor to prevent spread and metastasis; for severe patients, the course of treatment should be increased under the guidance of the attending doctor according to the condition; rectal cancer If patients develop diarrhea symptoms after taking it, they should take a small dose first and continue taking it after the symptoms disappear.

Usage and dosage:

Take 5 to 10 grams of yew branches and leaves and place them in a casserole. Add one liter (about 2 pounds) of water to boil, simmer over low heat for ten to fifteen minutes, take it after meals and finish it within one day.

Notes:

Avoid fasting, spicy food, and alcohol; keep your mood stable and avoid getting angry. Some patients have increased bowel movements after taking it, which is a normal symptom and usually recovers within a week; some cancer patients experience leg soreness, fatigue and other symptoms after taking it, which is a sign that the disease is taking effect; some patients feel stomach discomfort after taking it, and they can reduce the weight appropriately. quantity. This product is not recommended for people who are critically ill or near death.

Strange willow treats nasopharyngeal cancer

Decoct 1 tael each of strange willow and Digupi in water, one dose per day. Trial treatment was given to 2 cases. After 68 days and 3 months respectively, the subjective symptoms were relieved and the original vegetations in the nasopharynx disappeared. The reexamination after half a year showed no recurrence of the vegetations. Excerpted from Dictionary of Traditional Chinese Medicine

Prognosis

The natural course of nasopharyngeal cancer varies greatly among patients. The natural course from onset of symptoms to death ranges from 3 to 113 months. Radiation therapy is the main treatment for nasopharyngeal cancer. According to domestic and foreign reports, the 5-year survival rate after radiotherapy is 8% to 62%. With the updating of radiotherapy equipment and improvements in radiotherapy technology, the 5-year survival rate after radiotherapy for nasopharyngeal cancer continues to improve. The Cancer Hospital of Shanghai Medical University reported that before 1955, when deep X-ray therapy was used, the 5-year survival rate was 8%. In 1983, the 5-year survival rate was 54%. Local recurrence and distant metastasis after radiotherapy for nasopharyngeal cancer are the main causes of patient death. Therefore, in addition to improving radiotherapy technology and improving radiotherapy effects, we must also study the biological characteristics of nasopharyngeal cancer and the factors affecting the body of nasopharyngeal cancer patients. and study factors such as the interaction between tumors and the patient's body. According to the biological characteristics of the patient's nasopharyngeal carcinoma, radiotherapy, chemotherapy, surgical treatment, immunotherapy, traditional Chinese medicine and other treatment methods are comprehensively considered in treatment, and an appropriate treatment plan is selected and formulated to further improve the efficacy.

Prevention of nasopharyngeal cancer

1. Reduce contact with risk factors, such as eating less or no pickled or moldy foods, such as salted fish, pickles, and cured meats Wait, don't smoke.

2. Eliminate potential risk factors, and actively treat severe inflammation of the glands and nasopharyngeal ulcers.