Cita Herawati Murjantyo
ENT DEPT
DHARMAIS CANCER
CENTRE HOSPITAL
INTRODUCTION :
INDONESIA :NPC – ENT 1st
ALL OF CANCER – IVth
EARLY STAGE DIFFICULT !!
- NO SPESIFIC SYMPTOM
- PHYSICAL EXT. NOT VISIBLE
- NASOPHARYNX :
THE TRANSITIONAL ZONE BETWEEN NASAL CAVITY & OROPHARYNX :
“ANATOMICAL BLIND SPOT”
1. LUMEN / NASOPHARYNX
CHAMBER
2. RETROPHRYNX
3. PARAPHARYNX
4. INTRACRANICAL
5. PARANASAL SINUS
6. DISTANT METASTATIC
12
3
4555
MONGOLOID RACE : SOUTHERN
CHINESE, HONGKONG, VIETNAMESE, THAIS, MALAYS, INDONESIANS.
INDONESIA : RSCM 100 NEW CASES / YEAR RSHS 60 UJUNG PANDANG 25 PALEMBANG 25 DENPASAR 15 PADANG 11 DHARMAIS HOSPITAL 70
Sumber : Instalasi Rekam Medis & Admission RSKD
No. DIAGNOSA ICD-X JUMLAH
1 BREAST C501 – C509 1661
2 CERVIX C530 – C539 708
3 BRONCHUS & LUNG C340 – C349 390
4 PHARYNX C100 – C148 380
5 COLORECTUM C180 –C209 353
6 LYMPH NODES C770 – C779 320
7 LEUKIMIA C420 – C424 270
8 OVARY C569 223
9 THYROID GLAND C739 183
10 HEPAR C220 – C221 170
10 BESAR KANKER TERSERING RS KANKER DHARMAIS
RAWAT JALAN (KASUS BARU) TAHUN 2005 - 2007
Sumber : Instalasi Rekam Medis & Admission RSKD
No. DIAGNOSA ICD-X JUMLAH
1 BREAST C501 – C509 227
2 PHARYNX C100 – C148 264
3 COLORECTUM C180 – C209 203
4 LYMPH NODES C770 – C779 191
5 LEUKIMIA C420 –C424 151
6 HEPAR C220 – C221 126
7 ORAL CAVITY C000 – C609 78
8 PROSTATE GLAND C619 60
9 SKIN C440 – C449 58
10 SOFT TISSUE C490 – C499 55
10 BESAR KANKER TERSERING RS KANKER DHARMAIS
RAWAT JALAN (KASUS BARU) MALE TAHUN 2005 - 2007
Etiology
Epstein-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 suppressor genes
- Heritable genetic changes:
Susceptibility genes in high risk family (familial aggregation and
immigration)
Agent/Factors Implication
Epstein-Barr virus
Chemical-Tobacco
Drugs
Plant Products
Diet
Raised 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 meat and stewing base
Agent/Factors ImplicationCooking Habits
Religious Practice
Occupation
Household smoke and fumes
Incense and joss stick smoke
Industrial fumes and chemicals
Metal smelting
Formaldehyde
Wood dust
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
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
EARLY DIAGNOSIS : IMPORTANT !!
EARLY SYMPTOMS :– BLOOD STAINED MUCUS– EUSTC.TUBE BLOCKAGE
• OTHER SYMPTOMS MAY BE :A LUMP IN THE NECKNOSEBLEEDSMUFFLED HEARINGRINGING IN THE EAR HEADACHEDOUBLE VISION
∞ COLDS/
SINUSITIS
Number of patients
27
9
9
6
18
4
Neck Mass
Symptoms / Sign
Neck Mass + Epistaxis
Others
Epistaxis
Neck Mass + Ear Fullness
/ Tinitus
Neck Mass + Epistaxis + Ear Disorder
Others = Diplopi / Cephalgi
NASOPHARYNX
POST OR RHINOSCOPY
POST OR RHINOSCOPY + CATHETER
NASOENDOSCOPY/NASOPHARYNGOSCOPY
LOCAL ANESTHETIA
GENERAL ANESTHETIC (SPESIFIC CIRCUMTANCES)
THE GOLD STANDART
WHO : Type I - Squamous cell carcinoma
Type II - Non keratinizing carcinoma
Type III - Undifferentiated carcinoma
• CT Scan (MRI)
• USG – distant metast
• Bone scans – distant metast
• EBV serology
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
Pretreatment staging
1. Nasoparyngeal
tumor biopsy
2. Chest radiograph
3. Plane radiograph
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
No
distans
metastasi
s (M0)
Distant metastasis (M1)
Bulky cervical
N1-N3 (≥ 4
cm in
maximal
diameter)
Negative
cervical
nodes N0
Parapharyngeal boost
Local
residual
disease for
T1 or T2n
Pretreatmen
t bulky
parapharyng
eal disease
(T2p and
T3p)ERT*
Neoadjuvant
chemotherap
y
ICT ⁺
Palliative treatment
Non-bulky
cervical
nodes N1-
N3 (<4 cm in
maximal
diameter)
NPC Diagram
Stg I T1 N0 M0
T2 N0 M0
External Rad.6000cgy(30x)
Brachyterapy4-6 x 300cgy+
Radiosentisizer- Cisplatin 20-25- Giemsar 200
Stg IIB T3 N0 M0
T1 N1 M0ChemoradStg III
Rad.ext 6000BrachyTx 4-6x300
Cisplatin 40mg/m2/mggDocetaxel 25mg/m2/mggPaclitaxel 90mg/m2/mgg
Stg IV T4 N0 M0 ChemoradRad.ext 6600 - 7000
Cisplatin 40mg/m2/mggDocetaxel 25mg/m2/mggPaclitaxel 90mg/m2/mgg
Stg IV T1-3 N3 M0 NeoAdjuvan
Taxotere 20-25mg/m2/mgg
Cisplatin 40mg/m2/mgg
5 FU 1000mg/m2/mgg
T4 N3 M0
every 3 weeks 4 cyclescontinue :
ChemoradExternal Rad. + BrachyTx
-Cisplatin 40mg/m2/mgg-5FU oral 100mg 1-2hour before
Stg IV T1-4 N3 M1 Full dose
Response Cisplatin + 5FU – 3 sesi
Response
Response continue until 6 cycles
Response 2nd line chemotx
2nd line : CarboplatinTaxan (docetaxel 75mg/m2/3mmg
Paclituxel 175.200mg/m2/3mmg)
Salvation Surgery
Reccurant local Hemimaxilectomy swing
Mid facial degloving
Transpalatal app
Regional lymphnodes : Neck dissection
DISTANT METASTASIS
FAILED OF CURED
TO RELIEVE SYMPTOMS & IMPROVE QUALITY
OF LIFE
TO LIVE LONGER & LIVE COMFORTABLY
NOT JUST MEAN PAINKILLERS & ANTI
SICKNESS DRUGS
CHEMOTHERAPY
RADIOTHERAPY
SURGICALCAN ALL BE USED
BENEFIT OF CHEMOTHERAPY
LOCOREGIONAL TUMOUR CONTROL
CONTROL OF PAIN
RESTORATION OF SWALLOWING & APPETITE
IMPROVEMENT OF WEIGHT LOSS & FATIGUE
INCREASED DISEASE – FREE SURVIVAL
PALLIATIVE RADIOTHERAPY
USEFUL FOR METASTASES IN BONE,BRAIN &
SKIN
RELIEVING BLEEDING
RELIEVING PRESSURE SYMPTOM SUCH AS PAIN
OR OBSTRUCTION CAUSEDTHE BULK OF
TUMOR
SURGERY FOR PALLIATION :
DEBULKING : LESION MUST BE RESECTABLE
MUST BE RECONSTRUCTIVE TO FUNCTION LEVEL
PATIENT MUST BE AGREE, FULL INFORMATION
LOSS OF FUNCTION
POTENTIAL MUTILATION/ COMPLICATION
CONTROL OF HEMORRHAGE
PAIN CONTROL :
INFRA TEMPORAL FOSSA : MANDIBULAR
NEURALGIA, TRISMUS, TEMPORAL PAIN
NEURALGIAS IN DISTRIBUTION OF N.X & XI
NUTRITIONAL PROBLEM :
DIFFICULTY IN MASTICATION : PAIN, DRY
MOUTH, XEROSTOMIA
POOR ORAL HYGIENE
PROGRESSIVE LOCAL DISEASE
CHRONIC NAUSEA
CHANGES IN TASTE
ASPIRATION
DYSPNEA :
UPPER AIRWAY OBSTRUCTION:
HUMIDIFIED AIR TO REDUCE STICKY
TRACHEOSTOMY
SUPERIOR VENA CAVA OBSTRUCTION :
RADIOTHERAPY
LUNG METASTASE : SYMPTOMATIC TREATMENT
PULMONARY EMBOLI
BRONCHOPNEUMONI
TX Primary tumor unable to be assessed
T0 No primary tumor detected
T1 Confined to nasopharynx
T2a Tumor extend to nasal cavity, oropharynx
T2b Tumor extend to parapharyngeal space
T3 Tumor involves sinuses, orbit, skull base, hypopharynx or bony erosion
T4 Intracranial involvement, cranial nerve palsy
N0 No nodal involvement
N1 Nodes confined to ipsilateral neck, not greater than 3cm
N2 Ipsilateral node greater than 3cm but not greater than 6cm, bilateral nodes or contra lateral nodes
N3 Ipsilateral node greater than 6cm, supraclavicular nodes
M0 No distant metastasis
M1 Distant metastasis (includes mediastinal nodes)
Stage I T1 N0 M0
Stage II T2 N0 M0, T1 N1 M0, T2 N0M0
Stage III T3 N0 M0, T3 N1 M0, T1 N2 M0, T2 N2 M0
Stage IV T4 N0 M0, any T N3 M0,any T any N M1
Sumber : Instalasi Rekam Medis & Admission RSKD
No. DIAGNOSA ICD-X JUMLAH
1 BREAST C501 – C509 1637
2 CERVIX UTERI C530 – C539 700
3 OVARY C569 221
4 COLORECTUM C180 – C209 147
5 THYROID GLAND C739 138
6 LYMPH NODES C770 – C779 127
7 LEUKIMIA C420 – C424 119
8 PHARYNX C100 – C148 114
9 BRONCHUS & LUNG C340 – C349 112
10 CORPUS UTERI C540 – C549 100
10 BESAR KANKER TERSERING RUMAH SAKIT
“DHARMAIS” RAWAT JALAN (KASUS BARU) FEMALE
TAHUN 2005 - 2007
History and Examination
Normal looking
NP
Other
Tretment
Repeat
Biopsy
(LA/GA
)
Treatment
Other
DiagnosisDiagnosis
Uncertain
NPC
Proven
Biopsy NP
(LA)
Obvious Tumour
Biopsy
NP
(GA)
Radiologicall
y Suspicious
Unexplaine
d SOM
Suspicious
Neck Node
Persistentl
y Raised
IgA
Clinically
SuspiciousClinicaly
not
Suspicious
FNA
Cytology
Biopsy NP (GA) +/-
PanendoscopyOther Treatment
Squamous Cell or
Undifferentiared Carcinoma
Other
Diagnosis
Treatment
SOM = Serous otitis
media LA = Local
anaesthesia
GA = General
anaesthesia
NP = Nasopharynx
FNA = Fine-needle
aspiration
Stage classification
Ho’s (1978) Huang’s (1985)
T-Stage T1 NP Only T2 T2n Nasal fossa
T20 Oropharynx T2p Parapharyngeal region
T3 T3a Bone involvement below the base of the skull including floor of the sphenoid sinus
T3b Base of the skull T3c Cranial nerve(s) palsy T3d Orbits, larygopharynx (hypopharynx) or
infratemporal fossa
T Ts Primary soft tissue tumour only Tb basal skull destruction evident on radiographs Tn cranical nerve involvement Tc direct invasion to the adjecent brain evident
on CT scan (newly added item)
N-Stage N0 No nodes N1 Node(s) above skin crease at laryngeal
cartilageN2 Node(s) below skin crease but above
supraclavicular fossa N3 Supraclavicular node(s)
N Cervival lymph node N0 No palpable node N1 Unilateral (ipsilateral) small lymph nodes with
total diameter ≤ 5cm N2 Bilateral (contralateral) large lymph nodes
with total diameter > 5cm
M-Stage N0 Nb distant metastase M1 Distant metastaces
M Distant metastasis evident clinically M M0 No distant metastasis
M1 Clinically evident distant metastasis beyond cervical lymph node involvement
Stage Grouping
I TIN0 II T2 and/or N1 III T3 and/or N2IV N3 (any T) V M1
I TsN0M0 (prymary soft tissue only) II TsN1M0 or TbN0-1M0 (any condition with N1
and /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)
Tabel. 3 Stage NPC
Stage classification
Changsha (1983) UICC (1987)
T-Stage 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
T1 One wall NP T2 ≥ 2 walls NP T3 Nasal cavity, oropharynx (including
parapharyngeal region) T4 Skull base and /or cranial nerve
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 No node N1 Single homolateral node ≤ 3cm N2 N2a single homolateral node
> 3 - ≤ 6cm N2c bilateral or contralateral nodes ≤ 6cm
N3 > 6cm node(s)
M-Stage N0 No metastase M1 Distant metastaces
N0 No metastase M1 Distant metastaces
Stage Grouping
I TIN0 II T2N0; T0-2N1 III T3N0-1; T0-3N2IV T4N0-2; T0-4N3; M1
I TIN0 II T2N0III T3N0; T1-3N1 IV T4N0-1
N2-3 (any T); M1 (any T, any N)
Tabel. 3 Stage NPC
Anamnesis :
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 bilateral
4. 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
Alur Diagnosis
Penentuan
Stadium
PF Penunjang
Pemeriksaan
Pemeriksaan 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:
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)
AnamnesisPenunjang
Penentuan
Stadium
Alur Diagnosis
Pemeriksaan Penunjang
1. 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 dan mata
4. USG abdm atas & bone scan
5. Audiogram
Anamnesis
& PF
Alur Diagnosis
Anamnesis :
KGB leher >>
Keluhan
hidung,telinga,
sakit kepala
kronis
PF
PENEMUAN
Kls curiga :
CT scan NF
Serologi
CT scan NF
Curiga (+)
OM Serosa
e.c. tidak
jelas
Pe IgA
KGB leher
curiga
Biopsi
NF
FNABKSS/Ca
undiff
KNF (+)
KNF(-)
ulangi
3x/eksplorasi
(-)bukan
KNF
GAMBARAN
KLINIS
WORK UP
KNF (+)
Hasil PA WHO
Pemeriksaan 3 hr
STAGING
Staging persiapan
terapi
Stadium I
Stadium II
Stadium III
Stadium IV
PENEMUAN
STAGING TERAPI FOLLOW UP
Stadium IT1 N0 M0
Stadium IIAT2a N0 M0
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
Thn I : setiap 1-2 bln
Thn II: setiap 2-3 bln
Thn III: setiap 4-6 bln
Thn IV & V : setiap 12 bln
Setiap follow up:
Anamnesis & PF
Nasofaringoskopi
Setiap 6 bln ( th.I & II)
Lab, Rö toraks, CT scan NF
Seromarker, Bonescan
USG abdomen
Biopsi ulang stlh 6 bln/thn 1
Rehabilitasi
minggu ke-2 stlh radiasi
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
Stadium IIBT1 N1 M0
T2a N1 M0
T2b N0-1 M0
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
Thn I : setiap 1-2 bln
Thn II: setiap 2-3 bln
Thn III: setiap 4-6 bln
Thn IV & V : setiap 12 bln
Setiap follow up:
Anamnesis & PF
Nasofaringoskopi
Setiap 6 bln ( thn.I & II )
Lab, Rö toraks, CT scan NF
Seromarker, Bonescan
USG abdomen
Biopsi ulang stlh 6 bln/thn 1
Rehabilitasi
minggu ke-2 stlh radiasi
Stadium IIIT1 N2 M0
T2a N2 M0
T2b N2 M0
T3 N0-2M0
Neoadjuvan + kemoradiasi
Reseksi KGB bl primer bersih
Bila T3 CT scan u/ radiasi
Bila N2 CT scan u/ booster KGB
5-10 x 2 Gy
STAGING TERAPI FOLLOW UP
STAGING
Stadium IIIT1 N2 M0
T2a N2 M0
T2b N2 M0
T3 N0-2M0
Stadium IVaT4 N0-3 M0
T berapa
pun, N3, M0
Stadium IVbT berapa pun,
N berapa
pun, M1
Thn I : setiap 1-2 bln
Thn II: setiap 2-3 bln
Thn III: setiap 4-6 bln
Thn IV & V : setiap 12 bln
Setiap follow up:
Anamnesis & PF
Nasofaringoskopi
Setiap 6 bln ( th. I & II )
Lab, Rö toraks, CT scan NF
Seromarker, Bonescan
USG abdomen
Biopsi ulang stlh 6 bln/thn 1
Rehabilitasi
minggu ke-2 stlh radiasi
TERAPI FOLLOW UP
Neoadjuvan + radiasi
Reseksi KGB bl primer bersih
Bila T3 CT scan u/ radiasi
Bila N2 CT scan u/ booster KGB 5-
10 x 2 Gy
Neoadjuvan + radiasi 60 Gy
Bila penekanan saraf mata (+)
Radioterapi cito
Neoadjuvan + radiasi paliatif
40-60 Gy
Untuk lokasi tumor pd weight bearing
boneradioterapi dahulu