43598782 palliative treatment in nasopharyngeal carcinoma
TRANSCRIPT
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Cita Herawati Murjantyo
ENT DEPT DHARMAIS CANCER CENTRE HOSPITAL
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INTRODUCTION
:
INDONESIA
:
NPC ENT 1st ALL OF CANCER IVth
EARLY STAGE DIFFICULT !! - NO SPESIFIC SYMPTOM - PHYSICAL EXT. NOT VISIBLE
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NASOPHARYNX :THE TRANSITIONAL ZONE BETWEEN NASAL CAVITY & OROPHARYNX : ANATOMICAL BLIND SPOT
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MONGOLOID RACE :
SOUTHERN CHINESE, HONGKONG, VIETNAMESE, THAIS, MALAYS, INDONE SIANS.
INDONESIA :
RSCM RSHS UJUNG PANDANG PALEMBANG DENPASAR PADANG DHARMAIS HOSPITAL
100 NEW CASES / YEAR 60 25 25 15 11 70
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No.1
DIAGNOSABREAST
ICD-XC501 C509
JUMLAH1661
23
CERVIXBRONCHUS & LUNG
C530 C539C340 C349
708390
45 6 7 8
PHARYNXCOLORECTUM LYMPH NODES LEUKIMIA OVARY
C100 C148C180 C209 C770 C779 C420 C424 C569
380353 320 270 223
9
10
THYROID GLANDHEPAR
C739C220 C221
183170
Sumber : Instalasi Rekam Medis & Admission RSKD
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10 BESAR KANKER TERSERING RS KANKER DHARMAIS RAWAT JALAN (KASUS BARU) TAHUN 2005- 2007
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No.1
DIAGNOSABREAST
ICD-XC501 C509
JUMLAH227
23
PHARYNXCOLORECTUM
C100 C148C180 C209
264203
45 6 7 8
LYMPH NODESLEUKIMIA HEPAR ORAL CAVITY PROSTATE GLAND
C770 C779C420 C424 C220 C221 C000 C609 C619
191151 126 78 60
9
10
SKINSOFT TISSUE
C440 C449C490 C499
5855
Sumber : Instalasi Rekam Medis & Admission RSKD
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10 BESAR KANKER TERSERING RS KANKER DHARMAIS RAWAT JALAN (KASUS BARU) MALE TAHUN2005 - 2007
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EtiologyEpstein-Barr Virus (EBV)- 100% association with NPC - Elevated high titer of EBV-EA, VCA for early diagnosis
Enviromental factors- Salted fish, nitrosamine, N-nitrosodimethyamine - Herbal medicines: promoter and initiator in plants
Genetic factors- Somatic changes: activation of oncogenes and inactivation of tumor suppressorgenes - Heritable genetic changes: Susceptibility genes in high risk family (familial aggregation and immigration)
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Agent/FactorsEpstein-Barr virus
ImplicationRaised antibody Viral genome in tumor cells Cigarette smoking Chinese herbal medicine EBV activating properties/co-factors Salted fish Preserved vegetables, fermented food stuff Nitrosamines & nitro-precursors Tunisian preserved spice meatand stewing base
Chemical-Tobacco Drugs Plant Products Diet
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Agent/FactorsCooking Habits Religious Practice Occupation
ImplicationHousehold smoke and fumes
Incense and joss stick smoke Industrial fumes and chemicals Metal smelting Formaldehyde Wood dust
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1. EPISTAXIS & NASORESPIRATORY SYMPTOMS - BLOOD STAINED, NASAL MUCUS & SALIVA(POST NASAL DRIP) - EPISTAXIS / NOSE BLEEDING - NOSE BLOCKAGE 2. TINITUS & AURAL SYMPTOMS - OTITIS MEDIA WITH EFFUSION - TINNITUS - OTALGIA - DISCOMFORT EAR
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3. NEUROLOGICAL PALSIES - DOUBLE VISION (+ + +) N III, IV, VI, V (LACERUM FORM.)- TRIGEMINAL NEURALGIA - VOICE & SWALLOWING CAN BE AFFECTED (N. IX, X, XI, XII,JUGULARE FORM) 4. CERVICAL LYMPHADENOPATHY - EARLY LYMPHATIC SPREAD
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EARLY DIAGNOSIS : IMPORTANT !! EARLY SYMPTOMS :
BLOOD STAINED MUCUS EUSTC.TUBE BLOCKAGE
COLDS/SINUSITIS
OTHER SYMPTOMS MAY BE :A LUMP IN THE NECK NOSEBLEEDS MUFFLED HEARING RINGING IN THE EAR HEADACHE DOUBLEVISION
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Number of patients
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Symptoms / SignOthers Epistaxis Neck Mass9 27
9
Neck Mass + Epistaxis + Ear Disorder
6
18
Neck Mass + Ear Fullness / TinitusOthers = Diplopi / Cephalgi
Neck Mass + Epistaxis
4
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NASOPHARYNX
POST OR RHINOSCOPY POST OR RHINOSCOPY + CATHETER NASOENDOSCOPY/NASOPHARYNGOSCOPY
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LOCAL ANESTHETIA GENERAL ANESTHETIC (SPESIFIC CIRCUMTANCES)
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THE
GOLD STANDART WHO :Type I Type II Type III
- Squamous cell carcinoma - Non keratinizing carcinoma - Undifferentiated carcinoma
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CT Scan (MRI) USG distant metast Bone scans distant metast EBV serology
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IgA
anti VCA (viral carsid antigen) IgA anti EA (early antigen) IgA anti EBNA (nuclear antigen) Serological screening in endemic region Conjunction with nasoendoscopy & radiological evaluation
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NPC Diagram
Pretreatment staging 1. Nasoparyngeal tumor biopsy 2. Chest radiograph 3. Planeradiograph of skull and nasopharynx 4. CT scan of nasopharynx 5. Fibreoptic endoscopic examination 6. Clinical assesment for level and size of cervical lymph nodal metastases (if any) 7. Liver ultrasound 8. Bone 99m Tc-scintigram 9. Fine needle aspiration of doubtful cervical lymph nodes
Bulky cervical N1-N3 ( 4 cm in maximal diameter) Non-bulky cervical nodes N1N3 ( 5cm M Distant metastasis evident clinically M M0 No distantmetastasis M1 Clinically evident distant metastasis beyond cervical lymph nodeinvolvement
M-Stage
Stage Grouping
I TIN0 II T2 and/or N1 III T3 and/or N2 IV N3 (any T) V M1
I TsN0M0 (prymary soft tissue only) II TsN1M0 or TbN0-1M0 (any condition with N1and /or Tb) III TsN2M0 or TbN2M0 or TnN0-2M0 or TcN0-2M0 or TcN0-2M0 or TbnN0-2M0 or TbcN0-2M0 or TbncN0-2M0 (any condition involving N2 or Tn or TC or more combinations) IV M1 (any of the above conditions with distant metastasis evident clinically)
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Tabel. 3 Stage NPCStage classification Changsha (1983)T0 Subclinical T1 One wall or corner betwen 2 walls T2 2 walls T3 Nasal fossa, oropharynx (including parapharyngeal region) T4 2 features of T3
UICC (1987)T1 One wall NP T2 2 walls NP T3 Nasal cavity, oropharynx (including parapharyngeal region) T4 Skull base and /or cranial nerve
T-Stage
N-Stage
N0 No nodes N1 Mobile and /or < 3 cm above supraclavicular fossa N2 Fixed and/or(3-8) cm and above supraclavicular fossa N3 Supraclavicular and /or > 8cm N0 Nometastase M1 Distant metastaces
N0 No node N1 Single homolateral node 3cm N2 N2a single homolateral node > 3 - 6cm N2c bilateral or contralateral nodes 6cm N3 > 6cm node(s) N0 No metastase M1Distant metastaces
M-Stage
Stage Grouping
I TIN0 II T2N0; T0-2N1 III T3N0-1; T0-3N2 IV T4N0-2; T0-4N3; M1
I TIN0 II T2N0 III T3N0; T1-3N1 IV T4N0-1 N2-3 (any T); M1 (any T, any N)
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Alur DiagnosisAnamnesis :1. GEJALA HIDUNG : a. Ingus campur darah (sedikit) / epistaksis ringan unilateral b. Sumbatan hidung unilateralbilateral c. Post nasal drip 2. GEJALA TELINGA : a. Rasa penuh/gangguan pendengaran unilateral menetap b. Tinitus unilateral c. Otalgia/Otorea unilateral 3. GEJALA LEHER : a. Benjolan leher unilateral bilateral4. GEJALA MATA & SYARAF : a. Sakit kepala b. Diplopia (N3&6) c. Ptosis (N4) d.Trismus (N5) e. Parese lidah (N12) f. Parese Saraf Otak lain
PF
Penunjang
Penentuan Stadium
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Alur Diagnosis PemeriksaanPemeriksaan lengkap THT-Kepala Leher: 1. Pemeriksaan hidung & nasofaring (THT lengkap) : a. Rinoskopi anterior & posterior b. Nasoendoskopi/nasolaringoskopi kaku/fleksibel 2. Perhatian pada : a. OMS, Lesi Intrakranial, Limfadenopati Servikal 3. Pemeriksaan kelenjar leher:
Anamnesis
Penunjang
lokasi, ukuran, kekenyalan, mobilitas4. Pemeriksaan lesi intrakranial: a. Gangguan gerak bola mata (Diplopia N3&6) b.Ptosis (N4) c. Trismus (N5) d. Parese lidah (N12)
Penentuan Stadium
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Alur Diagnosis
Pemeriksaan Penunjang1. CT scan/MRI 2. Serologi: a) IgA VCA b) IgA EA c) EBNA total
Tentukan Stadium :1. Ro Toraks 2. Laboratorium: fungsi hati, ginjal, kimia drh 3. Konsul saraf danmata 4. USG abdm atas & bone scan 5. Audiogram
Anamnesis & PF
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GAMBARAN KLINIS
WORK UP CT scan NF Curiga (+)
PENEMUAN KNF(-) ulangi 3x/eksplorasi (-)bukan KNF Biopsi NF KNF (+)
Anamnesis : KGB leher >> Keluhan hidung,telinga, sakit kepala kronis PF
Kls curiga : CT scan NF Serologi
OM Serosa e.c. tidak jelas
Pe IgA
KGB leher curiga
FNAB
KSS/Ca undiff
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PENEMUAN
STAGINGStadium I
Hasil PA WHO Pemeriksaan 3 hr Stadium IIKNF (+) Staging persiapan terapi Stadium III
Stadium IV
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STAGING
TERAPI Radiasi ekst 60 Gy + brakiterapi 4-6 x 3 Gy PR : cisplatin + 5 FU TR : cisplatin + 5FU + Docetaxel + atau Carboplatin + Docetaxel + gemcitabin Rekurensi: < 1 thn Kemoterapi > 1 thn Kemoradiasi Radiasi ekst 60 Gy + brakiterapi 4-6 x3 Gy PR : cisplatin + 5 FU TR : cisplatin + 5FU + Docetaxel atau Carboplatin + Docetaxel + gemcitabin Rekurensi : < 1 thn Kemoterapi > 1 thn Kemoradiasi
FOLLOW UP Thn I : setiap 1-2 bln Thn II: setiap 2-3 bln Thn III: setiap 4-6 blnThn IV & V : setiap 12 bln Setiap follow up: Anamnesis & PF Nasofaringoskopi Setiap 6 bln ( th.I & II) Lab, R toraks, CT scan NF Seromarker, Bonescan USG abdomen
Stadium IT1 N0 M0
Stadium IIAT2a N0 M0
Biopsi ulang stlh 6 bln/thn 1Rehabilitasi minggu ke-2 stlh radiasi
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STAGING
TERAPI Radiasi ekst 60 Gy + brakiterapi 4-6 x 3 Gy + kemoterapi PR : cisplatin +5 FU TR : cisplatin + 5 FU + Docetaxel atau Carboplatin + Docetaxel + gemcitabin Rekurensi : < 1 thn Kemoterapi > 1 thn Kemoradiasi Neoadjuvan + kemoradiasi Reseksi KGB bl primer bersih Bila T3 CT scan u/ radiasi Bila N2 CT scan u/ boosterKGB 5-10 x 2 Gy
FOLLOW UP Thn I : setiap 1-2 bln Thn II: setiap 2-3 bln Thn III: setiap 4-6 blnThn IV & V : setiap 12 bln Setiap follow up: Anamnesis & PF Nasofaringoskopi Setiap 6 bln ( thn.I & II ) Lab, R toraks, CT scan NF Seromarker, Bonescan USG abdomen
Stadium IIBT1 N1 M0 T2a N1 M0 T2b N0-1 M0
Stadium IIIT1 N2 M0 T2a N2 M0 T2b N2 M0 T3 N0-2M0
Biopsi ulang stlh 6 bln/thn 1Rehabilitasi minggu ke-2 stlh radiasi
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STAGING Stadium IIIT1 N2 M0 T2a N2 M0 T2b N2 M0 T3 N0-2M0
TERAPI
FOLLOW UP Thn I : setiap 1-2 bln Thn II: setiap 2-3 bln Thn III: setiap 4-6 blnThn IV & V : setiap 12 bln Setiap follow up: Anamnesis & PF Nasofaringoskopi Setiap 6 bln ( th. I & II ) Lab, R toraks, CT scan NF Seromarker, Bonescan USG abdomen
Neoadjuvan + radiasi Reseksi KGB bl primer bersih Bila T3 CT scan u/ radiasi Bila N2 CT scan u/ booster KGB 510 x 2 GyNeoadjuvan + radiasi 60 Gy Bila penekanan saraf mata (+) Radioterapi cito
Stadium IVaT4 N0-3 M0 T berapa pun, N3, M0
Stadium IVbT berapa pun, N berapa pun, M1
Neoadjuvan + radiasi paliatif 40-60 Gy Untuk lokasi tumor pd weight bearing boneradioterapi dahulu
Biopsi ulang stlh 6 bln/thn 1
Rehabilitasi minggu ke-2 stlh radiasi
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