The nasopharynx is located behind the nose and is part of the upper portion of the pharynx. It connects the two nasal cavities with the oropharynx and with the ears, through the two Eustachian tubes during swallowing.  It may be extended to the nasopharyngeal and nasal passages, the sinuses, the soft palate up to the ethmoid, the anterior, and sometimes the medial cranial bones.

STAFF

At the IEO nasopharynx cancer is treated by a multidisciplinary team consisting of specialists in:

• Otolaryngology - Head and Neck Surgery
• Urogenital and Head and Neck Tumors Medical Treatment
• New Drugs and Early Drug Development for Innovative Therapies
• Department of Pathology and Laboratory Medicine
• Department of Medical Imaging and Radiation Sciences

These tumours are less frequently associated with known risk factors for head and neck cancers such as tobacco or alcohol. They are recognised as having a multifactorial aetiology, genetic, viral (presence of the Epstein Barr genome or EBV in the DNA of the tumour cells of patients), food (consumption of salted fish, or smoked meat). In the early stages there is no sign; in the later stages there may be signs and symptoms such as continuous nasal obstruction, frequent episodes of nasal bleeding, feeling of muffled ears (due to obstruction of the Eustachian tube), swelling in the neck due to the spread of the disease to the lymph nodes. Onset of constant and lateralised headache or visual disturbances such as double vision are indirect signs of the involvement of the skull base. 

Diagnosis is made by clinical and fibre-optic video examinations of the nasal cavity combined with an outpatient biopsy. For staging completion an ultrasound of the neck with possible fine-needle aspiration, magnetic resonance with contrast material, FDG-PET (or CT thorax and abdomen and bone scintigraphy) and quantitative evaluation of EBV DNA may be required before starting treatment.

Good standards for prevention

• Adopting a healthy lifestyle, not smoking and limiting alcohol intake.
• Adopting a few precautions in eating habits: eating fruit, vegetables, and foods rich in carotenoids, such as tomatoes, carrots, sweet and spicy peppers, pumpkins, apricots, herbs (probable evidence).
• Keeping a careful eye on oral hygiene.
• Not underestimating any injury of the mouth although small or painless (nodules, small ulcers, white or red patches, growths).
• After the age of 60 in subjects with risk factors, examination of the oral cavity and pharyngeal-laryngeal district is recommended.
• Undergoing regular visits, if already affected in the past by a carcinoma of the head and neck district.

The most common symptoms and signs are small ulcers of the lip or mouth, a white or red spot in the oral mucosa, frequent epistaxis (nosebleeds), nasal respiratory obstruction, hoarseness, persistent sore throat, feeling of closed ears, pain radiating to the ear, blood in sputum, difficulty chewing, swallowing or breathing, numbness of the tongue, painless and persistent swelling in the neck. The durability of these disorders should be considered as an alarm bell; if they have not resolved spontaneously or with treatment within 3 weeks, a specialist should be consulted.

The first approach to treatment is essential. Cure is the main goal, and is considered as important as the quality of life and functionality of the treated organs, such as the voice, language, swallowing, taste and breathing. IEO provides patients with a multidisciplinary team dedicated to diagnosis, treatment and rehabilitation

THE VALUE OF A MULTIDISCIPLINARY TEAM

Our multidisciplinary team is dedicated to the diagnosis, treatment and rehabilitation of patients with tumors of the head and neck, and to the study of these diseases. Our team includes over thirty oncology professionals with expertise in various specialties, such as ENT, maxillofacial surgery, emergency surgery, plastic-reconstructive surgery, radiotherapy, medical oncology, radiology, pathology, nuclear medicine, nutrition, physiotherapy, endocrinology, dentistry, voice therapy, speech therapy, psychology, and biology.

 The integration of various skills can address complex clinical problems, from diagnosis and treatment planning, to functional recovery (speech, breathing, swallowing) in order to achieve the best results with cancer and adequate quality of life. The team works in harmony and meets on a weekly basis to discuss cases of patients who trust in our structure. They develop comprehensive personalized care plans considering all aspects of treatment and rehabilitation, considering the different treatment options, taking into account the needs of individual patients in accordance with internal, national and international guidelines.

The team, in close collaboration with the Scientific and Health Management Board, monitors the results of treatment and the quality of the performances in real time in order to point out critical issues and identify areas for improvement and development. The multidisciplinary meetings are an opportunity for professional development based on the exchanges in the group, the evidence in the literature, and the critical review and update of guidelines as well as diagnostic and therapeutic approaches. The information obtained from the critical review of the clinical activities, from technological innovations, from the study of the evolution of the cancers treated, and from continuous updating are used to identify open issues and propose research activities. Thanks to this approach, clinical research activities and institutional research projects in collaboration with national and international institutions have been put in place.

Cancers of the nasopharynx

The treatment of nasopharyngeal cancer is solely radiotherapy in the early stages, and combined chemo-radiotherapy in more advanced stages. Surgery has a marginal role and is limited to the non-healed or relapsed lymph nodes in the neck, or to some cases of recurrent nasopharyngeal tumours refractory to further radiation treatment. 

Distant metastases of head and neck carcinoma

Distant metastases are defined as tumor spread to other organs. Lung, liver, and bone are the most common sites for hematogenous metastases of head and neck squamous cell carcinoma. The incidence of distant metastasis in head and neck squamous cell carcinoma is low for the general head and neck squamous cell carcinoma population: generally below 5% at presentation. Head and neck squamous cell carcinoma patients with distant metastases are generally candidates for palliative treatment scenarios only, because currently no systemic therapy has curative potential in head and neck squamous cell carcinoma patients with distant disease. Consequently, extensive locoregional treatment is usually considered futile in these patients. Particular attention is paid to our collaboration with CNAO, National Centre of Oncology Hadrontherapy) for Phase II, the clinical trial on radiotherapy boost, using protons (hadron therapy) for locally advanced tumours of the cervical-cephalic region.

Clinical nutrition

Stage and location of the disease, anatomical changes resulting from any surgical procedure, and the acute and late toxicity of chemo-radiotherapy are all factors that may contribute to the impairment of swallowing and create deficiency in the oral protein-calorie intake.

Artificial Nutrition (AN) is indicated in cases of cancers that cause a stenosis (narrowing), severe dysphagia (difficulty in eating that contraindicate oral feeding), or in the case of evident malnutrition or in the patient who, although feeding through the mouth, takes on a calorie-protein amount <50% of nutritional needs. AN must also be started when you expect a period of severe dysphagia longer than 7 days or inadequate intake (<60% of the nutritional requirements) for at least 10 days.

In patients with cancer of the cervical-facial district, Enteral Nutrition (EN) represents the primary route of choice when the gastrointestinal tract is accessible and functioning. It can be performed via nasogastric tube or via Percutaneous Endoscopic Gastrostomy (PEG) or Jejunostomy Nutrition, in case of expected duration of nutritional support greater than 3-4 weeks. EN is effective in containing the decline in body weight, preventing dehydration and interruptions of the radio-chemotherapy treatment, reducing the frequency and duration of hospitalisations, and improving the quality of life.

 Adequate nutritional support during radiotherapy treatment can reduce the impact and degree of morbidity (mucositis, odynophagia, dysphagia, xerostomia, dysgeusia, nausea, vomiting, and anorexia), minimise weight loss, preserve the nutritional status, improve the quality of life and optimise by speeding it up the recovery of the patient at the end of treatment.

The use of early and intensive nutritional counseling and oral caloric supplementation have been shown to increase the protein-calorie oral intake, reduce the extent of body weight loss, and reduce the interruptions of the cancer treatment.

In the presence of a sufficiently safe swallowing, oral feeding (using a diet modified in consistency) is the first choice.