Nasopharyngeal Carcinoma: Profile, Challenges and 5-Year Outcome in a Nigerian Tertiary Hospital

International Journal of Healthcare and Medical Sciences
ISSN(e): 2414-2999, ISSN(p): 2415-5233
Vol. 4, Issue. 2, pp: 25-30, 2018
URL: http://arpgweb.com/?ic=journal&journal=13&info=aims
Academic Research Publishing
Group
*Corresponding Author
25
Original Research Open Access
Nasopharyngeal Carcinoma: Profile, Challenges and 5-Year Outcome in a
Nigerian Tertiary Hospital
Eziyi Josephine Adetinuola Eniola*
ORL Unit, Department of Surgery, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
Department of Otolaryngology-Head and Neck Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
Amusa Yemisi Bola
ORL Unit, Department of Surgery, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
Olusoga-Peters Pelumi
Uchendu Dubem
Ikoko Mike
Okunola Babatunde
Abstract
BACKGROUND: Nasopharyngeal carcinoma is encountered regularly in otolaryngological practice in Nigeria.
However, it is often misdiagnosed due to varied presenting symptoms, hence the need to describe the pattern of
presentation and the challenges of treatment of the patients that presented to our centre with nasopharyngeal
carcinoma. METHODS: The pathology and clinical records were retrieved for all histologically confirmed cases of
nasopharyngeal carcinoma from the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) cancer
registry. The epidemiological data, symptoms and stage at presentation, type of treatment, outcome and challenges
encountered were obtained from the records. RESULTS: A total of 384 histologically confirmed head and neck
malignancies were seen over the review period, and nasopharyngeal carcinoma constituted 32 (8.33%). There were
24(75.0%) male and 8(25.0%) female. The age ranged from 17 - 80 years with a mean of 54.5 + 12.2 years. All the
patients presented with neck swelling, Nasal obstruction 14(43.75), Epistaxis 11(37.5%), Trismus 2(6.25%), and
proptosis 2(6.25%). Twenty-four (75%) presented with stage four tumour. Treatment was primarily radiotherapy.
Fifteen (46.88%) completed radiotherapy. Two (6.25%) patients had chemo-radiation and 15(46.88%) defaulted at
different stages of treatment mainly due to financial constraints, others include beliefs and breakdown of
radiotherapy machines. Prognosis was very poor with 1-year survival of 21.9% and five-year survival of 9.25%.
Conclusion: Neck swelling, Epistaxis and nasal blockade are the most common presenting symptoms. Patients
present late leading to poor prognosis. Financing treatment out of pocket is a major reason for presenting late and
defaulting during management.
Keywords: Nasopharyngeal; Neck swelling; Carcinoma; Nigerian.
CC BY: Creative Commons Attribution License 4.0
1. Introduction
Nasopharyngeal carcinoma (NPC) occurs worldwide with high incidence in the south east Asian countries such
as china, the Pacific Island and Mediterranean countries [1, 2]. It is a unique tumor of the head and neck region as a
result of its epidemiology, racial predisposition, distinctive immunogenetics as well as its association with Epstein
Barr (EB) virus [3, 4].
There is a male preponderance in the incidence of NPC with M: F ratio of 2-3:1 and a bimodal age incidence has
been described in endemic areas [5, 6]. The first peak age incidence is in the 2nd decade of life and this is commonly
seen in an endemic area while the 2nd peak is in the 5th
decade of life [7].
The aetiological factors associated with NPC are exposure to Epstein Barr (EB) virus infection. This is based on
the fact that the EB viral capsid antigen VCA, nuclear Antigen (EBNA) and early Antigen were demonstrated in the
tumor cells and EB viral antibody had been demonstrated in affected patients [8-11]. A genetic factor has also been
implicated based on the fact that it is commoner in the Chinese, and the Orientals in addition to the association with
the HLA A, B, CD, DR, BW6 2 and 17, 5, 6. SIN 2 + HZ (California) (Singapore).

26
Other factors implicated in the aetiology of NPC are food and cooking habits, it is found to be commoner in
people who consumed a lot of ungutted smoked fish, engage in religious activity with burning of incense, and the
use of Joss stick [12-16] .Also implicated are exposure to industrial fumes in certain occupations and to heavy metal
like Arsenic and several other factors [15, 16]. Tumors of the nasopharynx may masquerade their symptoms to
regions other than the primary site thereby presenting in many different ways [17-19]. Diagnosis is also often
difficult because of the non-specific nature of early clinical symptoms and the difficulty in visualizing the
nasopharynx leading to late diagnosis and this is associated with a poor prognosis.
This article describes the incidence, pattern of presentation and the challenges of treatment of nasopharyngeal
cancer in a tertiary health care facility in South-Western Nigeria.
2. Materials and Methods
This is a retrospective study of all histologically confirmed cases of nasopharyngeal carcinoma from the
Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) cancer registry over a fourteen year period
(2008-2012) with patients' entry points of NPC being mainly from the Otolaryngological unit. The hospital records
of the patients as well as the histopathology files of the hospital over the stated period were reviewed. The
demographic details, two major presenting complaints and their duration or complaints elicited during history taking
or principal clinical findings, stage of the disease at presentation, histological types based on WHO classification,
treatment modalities and outcome after 5 years were recorded. All the patients had panendoscopy and biopsy with
tissue specimens sent for histopathology. Staging of the disease was done using the TNM classification. The
absolute survival rates using the percentage of patients that are alive after one and five years of diagnosis were
calculated. The data were entered into a proforma and analyzed using descriptive statistics.
3. Results
The total number of Head and Neck malignancies seen over the review period was 384. The numbers of
histologically diagnosed NPC were 32. Nasopharyngeal carcinoma accounted for 8.33 % of all head and neck
malignancies in our hospital.
3.1. Age and Sex Distribution
There was a male preponderance with 24(75.0%) males and 8(25.0%) female. The Male: Female ratio is 3:1.
The age of the patients ranged from 17 - 80 years with a mean age of 54.5years +12.2years. Peak incidence is in the
51-60 age group (Table I).
3.2. Presenting Symptoms
Table II shows the presenting complaints with painless neck swelling being the most common presentation and
unilateral in 84.4% of patients, other symptoms include; epistaxis, nasal blockade, proptosis and trismus.
3.3. Staging of the Disease
Table III shows the clinical staging of the disease at presentation. Seventy five percent (24) of the patients
present with a stage IV disease while only 6.25% had stage I disease.
3.4. Histology
Keratinizing Squamous Cell Carcinoma was seen in 19 (59.38%), undifferentiated in 8 (25.00%) and non
keratinizing squamous cell carcinoma in 5(15.62%)
3.5. Treatment
All the patients were referred for Radiotherapy alone except two patients (6.25%) who was referred for chemo-
radiotherapy. however, only 15(46.88%) out of the 30 patients for radiotherapy alone completed it, the remaining
15(46.88%) could not complete the appropriate treatment modality due majorly to financial constraints. Two
(6.25%) patients for concomitant chemotherapy and radiotherapy also completed treatment.
3.6. Challenges
The challenges experienced during the course of management ranged from late presentation, financial
constraints, and lack of family support or support group to availability of few functioning radiotherapy centers at any
particular time (Table IV).
3.7. Prognosis
Prognosis was found to be very poor, only seven patients survived for one year after the commencement of
therapy. The overall one year survival was 21.9%. Five-year survival was 9.4% with no recurrence.
4. Discussion
Nasopharyngeal Carcinoma is a disease with a remarkable racial and geographical distribution. It is very rare in
most parts of the World except in Southern China in the Eskimos of the Arctic region, South East Asia, The Arabs of
Northern Africa and Kuwait [20]. In the present study Nasopharyngeal Carcinoma accounted for 8.3% of all head

27
and neck malignancies. This figure is quite high when compared with the reports from Europe and America that
found NPC to account for less than 2% of all head and neck cancers.
There was a male preponderance with a male to female ratio of 3:1. Obafunwa et al and Fong et al also found a
male preponderance with a male to female ratio of 2:1 and 2.5:1 respectively[21, 22]. The mean age of our patients
was 54.5years and peak age incidence was found to be in the 6th decade of life. The average age is similar with
findings by Carla et al that found a mean age of 53years and differs from the peak age incidence of 2nd and 4th -5th
decade of life found by Kitcher and Chu et al respectively [6, 23, 24]. However the bimodal peak age incidence was
not observed in this series.
The most common presentations include painless neck swelling, Epistaxis, and nasal blockade (Table III). These
features are similar to what had been documented in the literature [6, 25]. Other presentations include some degree
of hearing impairment usually associated with blockage of Eustachian tube, Tinnitus and cranial nerve palsies due to
extension into the base of the skull. All our patients (32,100%) presented with painless neck swelling which is more
than the documented 63-80% mostly because majority of them present late [26].
Late presentation is a common finding in these patients, the late presentation as seen in this work could be due
to the fact that the tumor could masquerade their symptoms to other regions other than the primary site, inadequate
diagnostic facilities, inadequate number of otolaryngologists and the endemic poverty in developing countries. Other
attributed causes of late presentation include inefficiency of referral system, delay in diagnosis by primary care
physicians and initial treatment by alternative medical practitioner [6, 27, 28].Keratinizing Squamous cell Carcinoma
(WHO type I) was the most commonhistopathological variant observed in this work, this was seen in over fifty
percent of the patients. Obafunwa in Northern part of Nigeria had 40% of his patients with WHO type I while WHO
type III was more common in Ghana. While the most common type of nasopharyngeal carcinoma among US-born
Chinese and Whites is WHO type I tumors, among Chinese who reside in Hong Kong, Taiwan, and Macao, WHO
type III tumors predominate. WHO type I has been said to be common in endemic regions [6, 21, 29].
Radiotherapy was the mainstay of management in our patients. Chemotherapy can also be combined with
radiotherapy as in two patients (6.3%). However 15 (46.9%) did not complete radiotherapy majorly due to socio-
economic constraints. This has also been documented in treatment of other cancers in developing Countries [30]. To
get placement for radiotherapy is also becoming difficult due to availability of the service in only few centres
necessitating long queues, incessant break down of machines and consequent ineffective radiotherapy at the hospital
they were referred to because of the large volume of patients using the same facility [30]. Delayed placement
worsens the prognosis even when patients present relatively early, they do not get to commence radiotherapy
immediately. Some Oncology centres however gives neoadjuvant chemotherapy while waiting for the radiotherapy.
The challenges encountered in our facility during management also include limited, unavailable or broken down
diagnostic and treatment facilities, the inability of the patients to afford the cost of investigations and treatment due
to high cost of services when available and poverty state of the patients [30-32]. All the patients treated were referred
to another tertiary hospital for radiotherapy +/- Chemotherapy and majority subsequently defaulted or are haphazard
in clinic appointments in our facility. They defaulted from our facility because of the distance they had to cover from
their homes to attend both hospitals appointment and the fact that the available fund was being kept for chemo-
radiotherapy bills such that when they develop complications either from the disease or treatment, the patients may
not present early leading to late treatment.
One-year survival was 7(21.9%) while 5 years survival was found to be 9.4%. This is low compared to Carla et
al who had a five year actuarial survival rate of 65.1% although 58% of his cases were WHO Type III and it is
known that WHO Types II and III also have a better prognosis than WHO type I tumours [3, 23, 33]. Early age of
diagnosis, localized stage at presentation (versus distant), radiation therapy (versus none), undifferentiated non-
keratinizing carcinoma (versus keratinizing squamous cell carcinoma) were associated with improved survival [34].
The 5-year survival rate is significantly better for non-keratinizing carcinoma than keratinizing squamous cell
carcinoma of the nasopharynx (51% versus 6%) [34]. In addition, non keratinizing carcinomas are generally
associated with EBV positivity and EBV positivity in turn has been shown to be associated with improved survival
[35]. Recent studies have demonstrated that concurrent chemotherapy and radiotherapy are effective in the treatment
of local and regionally advanced nasopharyngeal cancer [36, 37]. Similarly, neoadjuvant and adjuvant chemotherapy
in local and regionally advanced disease has resulted in consistently high response rates [38, 39]. Nevertheless,
distant metastases continue to impede improvement of survival rates for patients with nasopharyngeal cancer. The
prognosis in this series is poor. Delay in diagnosis leading to late presentation as well as the cancer type, financial
constraints, the long waiting period at the radiotherapy clinic could have been responsible for this poor outcome.
There is need to create awareness about this disease among clinicians so as to heighten their suspicion and to
encourage early referral. The government also need to attend to these challenges urgently by implementing policies
to equips the available cancer treating hospitals with state of art equipment, increase coverage of national health
insurance scheme to cover non- government workers or makes cancer treatment free of charge so that many more
patients will have access to diagnostic tests, treatment and therefore better prognosis and outcome [30].
5. Conclusion
Nasopharyngeal Carcinoma has an incidence of 8.3% of all head and neck malignancies at OAUTHC. Neck
swelling, Epistaxis and nasal blockade are the most common presenting symptoms. Financing treatment out of
pocket is a major reason for presenting late and defaulting during management thereby leading to poor prognosis.

28
Table-I. Age and Sex Distribution of Patients with NPC.
Age group Male (%) Female (%) Total (%)
0-10 0 (0.00) 0 (0.00) 0(0.00)
11-20 1(3.13) 0 (0.00) 1 (3.13)
21-30 0 (0.00) 1(3.13) 1(3.13)
31-40 3(9.38) 2 (6.25) 5 (15.63)
41-50 6(18.75) 0 (0.00) 6 (18.75)
51-60 6(18.75) 4 (12.50) 10 (31.25)
61-70 5(15.63) 1 (3.13) 6 (18.75)
71-80 3(9.38) 0 (0.00) 3 (9.38)
Total 24(75.00) 8 (25.00) 32 (100.00)
Mean age: 54.5 +12.2years
Table-2. The two prominent presenting complaints in patients with NPC.
Table-3. Staging of the disease at presentation.
Clinical staging Male Female Number (%)
Stage IV 17 7 24 (75.00)
Stage III 0 0 0 ( 0.00 )
Stage II 6 0 6 (18.75)
Stage I 1 1 2 ( 6.25)
Total 24 8 32 (100)
Table-4. Challenges experienced during management of Patients with NPC
1 Late Presentation to specialists
2 Lack of family support/Support group
3 Out of pocket payment/Poverty
4 Different radio-oncology Centres with different protocols of treatment
5 Few functional machine at any point in time/incessant breakdown of
machines for long periods
6 Long waiting time (queue)
7 Influence of spiritual undertones/Personal Beliefs concerning diseases
and treatment.
8 Distance covered to Oncology Centres
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