43598782 Palliative Treatment in Nasopharyngeal Carcinoma

7/29/2019 43598782 Palliative Treatment in Nasopharyngeal Carcinoma

1/65

Cita Herawati Murjantyo

ENT DEPT DHARMAIS CANCER CENTRE HOSPITAL


2/65

INTRODUCTION

:

INDONESIA

:

NPC ENT 1st ALL OF CANCER IVth

EARLY STAGE DIFFICULT !! - NO SPESIFIC SYMPTOM - PHYSICAL EXT. NOT VISIBLE


3/65

-

NASOPHARYNX :THE TRANSITIONAL ZONE BETWEEN NASAL CAVITY & OROPHARYNX : ANATOMICAL BLIND SPOT


4/65


5/65


6/65

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


7/65

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


8/65

10 BESAR KANKER TERSERING RS KANKER DHARMAIS RAWAT JALAN (KASUS BARU) TAHUN 2005- 2007


9/65

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


10/65

10 BESAR KANKER TERSERING RS KANKER DHARMAIS RAWAT JALAN (KASUS BARU) MALE TAHUN2005 - 2007


11/65

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)


12/65

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


13/65

Agent/FactorsCooking Habits Religious Practice Occupation

ImplicationHousehold smoke and fumes

Incense and joss stick smoke Industrial fumes and chemicals Metal smelting Formaldehyde Wood dust


14/65

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


15/65

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


16/65

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


17/65

Number of patients


18/65

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


19/65


20/65

NASOPHARYNX

POST OR RHINOSCOPY POST OR RHINOSCOPY + CATHETER NASOENDOSCOPY/NASOPHARYNGOSCOPY


21/65


22/65

LOCAL ANESTHETIA GENERAL ANESTHETIC (SPESIFIC CIRCUMTANCES)


23/65

THE

GOLD STANDART WHO :Type I Type II Type III

- Squamous cell carcinoma - Non keratinizing carcinoma - Undifferentiated carcinoma


24/65

CT Scan (MRI) USG distant metast Bone scans distant metast EBV serology


25/65

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


26/65


27/65


28/65


29/65


30/65


31/65


32/65


33/65


34/65

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)


56/65

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)


57/65

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


58/65

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


59/65

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


60/65

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


61/65

PENEMUAN

STAGINGStadium I

Hasil PA WHO Pemeriksaan 3 hr Stadium IIKNF (+) Staging persiapan terapi Stadium III

Stadium IV


62/65

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


63/65

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


64/65

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


65/65

Documents

43598782 Palliative Treatment in Nasopharyngeal Carcinoma