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CHAPTER IREVIEW1.1 AnatomyNasopharynx is a space or a cube-shaped cavity that lies behind the nose. This cavity is very difficult to see, so in the past so-called "dead-end cavity or hidden cavity". The boundaries of nasopharyngeal cavity at the front is koana (posterior nares). Upper, which is also the roof is cranii base. The back is the mucosal tissue in front of the cervical vertebrae. The lower is the isthmus of the pharynx and soft palate.1

Figure 1.1. Nasal and Nasopharynx Side Anatomy

Figure 1.2. Nasopharyx Anatomy from the backImportant parts located in the nasopharynx are: 11. Adenoid or tonsil Lushka The building is only found in children aged less than 14 years. In adults this structure has undergone regression. 2. Nasopharyngeal FossaThis structure is a small indentation which is predilection of nasopharynx angiofibroma 3. Torus TubariusIt is a bulge where the estuary of the Eustachian tube (tubal ostia) .4. Fossa RosenmullerIt is a small dent in the rear of tubarius torus. This small dent passed down behind as a small groove called the sulcus salfingo-pharynx. Rosenmulleri fossa is the place where the replacement of columnar epithelium/cuboidal epithelium becomes squamous epitel. This interchange place is considered a predilection for the occurrence of nasopharyngeal malignancy. 1.2 DefinitionNasopharyngeal carcinoma (NPC) is a tumor arising from the epithelial cells that cover the surface and line the nasopharynx.2 It involves squamous cell carcinoma, non-keratinizing carcinoma (differentiated or undifferentiated) and basaloid squamous cell carcinoma. Adenocarcinoma and salivary gland-type carcinoma are excluded.31.3 EpidemiologyNasopharyngeal carcinoma is a malignant tumor of the head - neck which most are found in Indonesia. Nearly 60% of malignant tumors of the head and neck is a nasopharyngeal carcinoma, followed by malignant tumors of the nose and paranasal sinuses (18%), larynx (16%), and malignant tumors of the oral cavity, tonsils, hypopharynx in low percentage.4Cancer registration data in Indonesia based on histopathology of 2003 showed that the NPC ranks first of all primary malignant tumors in male and the 8th in female. Nasopharyngeal carcinoma can affect all ages, the incidence increases after age 30 years old and reached the peak at age 40-60 years old. During 2006-2008 found as many as 45 cases of nasopharyngeal carcinoma in West Sumatra. Most patients were men, that is 32 cases (71.1%). WHO subtype-2 and WHO-3 have the same lot number of cases, each 17 cases (37.8%). 51.4 Etiology and Risk FactorEpstein-Barr virus

The near constant association of EBV with NPC, irrespective of ethnic background, indicates a probable oncogenic role of the virus in the genesis of this tumour. The evidence is there is higher levels of antibodies, especially IgA, against EBV (most commonly viral capsid antigen and early antigen) in most patients with NPC compared with normal controls and patients with other cancer types.3Environmental factors

Diet

In high incidence regions, high levels of volatile nitrosamines in preserved food have been implicated as the putative carcinogen for NPC development. In the 1960s, it was proposed that the increased incidence of NPC among Hong Kong boat dwellers compared to house dwellers may have been due to their staple diet of salted fish.Several studies found that only the consumption of salted fish during childhood and weaning is significantly associated with NPC, while consumption during adulthood is not. Besides the age of consumption the manner of cooking and the type of fish may also be important, sea salted fish carried a higher risk than fresh-water fish, as well as steamed fish than fried, grilled or boiled salted fish.6Other environmental risk factors

Other purported risk factors include cigarette smoking, occupational exposure to smoke, chemical fumes and dusts, formaldehyde exposure, and prior radiation exposure.Busson Matched case-control study reported in Semarang vaporous formaldehyde exposure and inhalation of smoke that the most likely towards the NPC. Heavy smokers who smoke 2-4 times a day has more risk than non-smokers. High alcohol consumption showed no risk in Chinese society, although in the United States suggest a correlation.Genetic FactorsBased on the facts that there are significant differences in the frequency among some ethnic groups, namely the existence of an increased risk in families NPC patients. In ethnic Chinese, NPC connected with the discovery of HLA type A2 and Bw46. Research in Medan find that the potential gene as the cause of the onset of NPC susceptibility in Batak is HLA-DRB1.71.5 PathogenesisEBV plays a role in the pathogenesis of nasopharyngeal carcinoma, which was originally of infection from this virus causes changes in low-grade dysplasia cells in the nasopharynx. cell low-grade dysplasia has been caused by predisposing factors such as diet, genetic sueptibilitas and others. With the infection of EBV and the influence of chromosomal disorders develop into cancer invasif. Metastastasis of these tumors is influenced by the presence of p53 mutation and over-expression of kaderin.8

Figure 1.3. Pathogenesis of Nasopharyngeal Carcinoma9

Figure 1.4. The Microbiologic Changing in Nasopharyngeal Carcinoma91.6 Clinical ManifestationSymptoms or clinical manifestations of nasopharyngeal carcinoma can be divided into several groups, namely4:1. Nasal / Nasopharyngeal SymptomsNasopharyngeal carcinoma should be suspected when any of these symptoms: If the patient has a cold a long time, more than 1 month, especially patients aged over 40 years, currently there are abnormalities in the nasal examination. If the patient is cold and has thick discharge, foul-smelling, especially if there is a point or a line of bleeding without abnormalities in the nose or paranasal sinuses. In patients over the age of 40 years, frequent bleeding from the nose (epistaxis), while normal blood pressure and from nasal examination, there is no abnormalities.2. Ear SymptomsSymptoms in the ear are reduced hearing, the ear feels full as filled with water, or buzzing (tinnitus) and pain (otalgia). Hearing loss that occurs usually in the form of conductive deafness and occurs when there is an extension to the nasopharyngeal carcinoma tumor or around the tube, resulting in blockage.3. Neck Tumor SymptomsEnlarged neck or neck tumors is the nearest limphogenic spread of nasopharyngeal carcinoma. This deployment can be unilateral or bilateral. The specificity of tumor as metastasis of nasopharyngeal carcinoma neck is the location of the tumor which is at the end of the mastoid process, behind the angle of the mandible, in the sternocleidomastoid muscle, hard and not easily move. Suspicions grew when the examination of the oral cavity, tongue, pharynx, tonsils, hypopharynx and larynx found no abnormality.4. Eye SymptomsPatients will complain of reduced vision, but when asked carefully, people will explain that he saw something in half or double. Clear what is meant is diplopia. This occurs due to paralysis N.VI located above the foramen laserum lesions due to tumor expansion. Other circumstances that could give eye symptoms are due to paralysis N.III and N.IV, causing paralysis of the eye called the ophthalmoplegia. When the expansion of the tumor on the optic chiasm and N.II then the patient may experience blindness.5. Nerve Symptoms Prior to the cranial nerve paralysis is usually preceded by some subjective symptoms are perceived by patients as very disturbing headache or head was spinning, hipoestesia on the cheek and nose, and often complain of difficulty in swallowing (dysphagia). Are not uncommon symptoms of trigeminal neuralgia by a neurologist when there has been no significant complaints. Process of further carcinoma will make lesion of N.IX, X, XI, and XII when expand through the jugular foramen. This disorder is called the Jackson syndrome. When the entire cranial nerve have lesions, it called the unilateral syndrome. Can also be accompanied by the destruction of the skull and it becomes a worse prognosis.1.7 Classification Based on histopathologic pattern, nasopharyngeal carcinoma can be divided into three types according to the WHO. This division is based on examination by electron microscopy which nasopharyngeal carcinoma is one variant of epidermoid carcinoma. This division has supported by more than 70% pathologist and retained to this day3:a. WHO Type 1 These include squamous cell carcinoma (SCC). WHO Type 1 has a clear growth type on the surface of the nasopharyngeal mucosa, differentiated cancer cells well to moderate and produce quite a lot of keratin both inside and outside the cell.b. WHO Type 2 These include non-keratinizing carcinoma (NKC). WHO Type 2 is the most various type, some tumor has moderately differentiated and the other half has well differentiated, microscopic finding of this type is similar to transitional cell carcinoma. c. WHO Type 3 This type is a Undifferentiation Carcinoma (UDC). The picture of cancer cells most heterogeneous. The WHO Type 3 includes the formerly called limfoepitelioma, anaplastic carcinoma, clear cell carcinoma, and spindle variations.

Type without differentiation and without keratinization in the same nature, which are radiosensitive, while this type with keratinization not so radiosensitive.Figure 1.5. Squamous cell carcinoma, polymorphic nuclei, khromatin rugged, clear cell boundaries, cytoplasmic bluish (Barnes, 2005)

Figure 1.6. Classify undifferentiated epithelial cells, with a background of lymphocytes. Appearance of eosinophilic cytoplasm and prominent nuclei child (Barnes, 2005).

Figure 1.7. Keratinizing Squamous Cell Carcinoma (Barnes, 2005).

Figure 1.8. Non-keratinizing Squamous Cell Carcinoma. (Barnes, 2005)

Figure 1.9. Undifferentiated Carcinoma. (Barnes, 2005).1.8 Diagnostic Methods

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