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Nasopharyngeal Carcinoma Awareness for GPs and Nurses

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Text of Nasopharyngeal Carcinoma Awareness for GPs and Nurses

  • 1. dr. S R Indrasari, M.Kes., Sp.THT-KL(K) Yogyakarta, 15 Juli 1987 -1995 1999 - 2003 1999 2004 2009 - ..... 2009 2012Kedokteran Umum, UNS S2 Kedokteran Klinis, UGM Spesialis THT-KL, UGM Program Doktor FK.UGM Konsultan Onkologi Bedah Kepala Leher1996-1999 : Dokter PTT Puskesmas , Klaten 1999 : Staff di Sub Bag Onkologi-Bedah Kepala Leher IK.THT-KL FK UGM / RS. Dr. Sardjito 2006-2012 : Kodik Profesi Bag. IK.THT-KL 2013 : Sekretaris Program Studi PPDS IK.THT-KL Jl. Bogowonto 108B Klaten [email protected] ; [email protected]

2. KARSINOMA NASOFARINGS (KNF) NASOPHARYNGEAL CARCINOMA (NPC)SUB BAGIAN ONKOLOGI BAGIAN IK. THT-KL FAKULTAS KEDOKTERAN UGM / RS DR SARDJITO YOGYAKARTA 3. Why Cancer ?The burden of Cancer 4. MENGAPA KANKER ? Penyebab utama kematian tahun 2001 Percentage of Total Deaths, US31,0Heart Diseases Cancer23,2 6,8Cerebrovascular Diseases4,8Chronic Obstructive Lung Diseases Accidents4,2Pneumonia & Influenza3,9Diabetes Mellitus2,8Suicide1,3Nephritis1,1Cirrhosis of the Liver1,1 Adapted from Greenlee RT, et al. CA Cancer J Clin. 2001:51;15-36. 5. 10 besar keganasan di dunia RankMalesFemalesBoth Sexes1LungBreastLung2 3 4 5 6 7 8 9 10Stomach Colon/rectum Prostate Liver Mouth/pharynx Esophagus Bladder Leukemia NHL*Colon/rectum Cervix uteri Stomach Lung Ovary Corpus uteri Liver Mouth/pharynx EsophagusStomach Breast Colon/rectum Liver Prostate Cervix uteri Mouth/pharynx Esophagus Bladder*Non-Hodgkins lymphoma.Total New Cases 1,037,000 798,000 796,000 783,000 437,000 396,000 371,000 363,000 316,000 261,000Adapted from Parkin DM, et al. CA Cancer J Clin. 1999;49:39. 6. Why NPC ?The burden of NPC 7. Mengapa Karsinoma nasofarings ? Keganasan no. 4 di seluruh badan No.1 dari keganasan di Kepala-Leher Insidensi cukup tinggi di Indonesia Mengenai usia produktif Penderita datang pd stadium lanjut Mortalitas tinggi 8. PREVALENSI / INSIDENSCINA SELATAN 30-50 kasus*INDONESIA (NATIVE) 4.7/6.7 kasus*MALAYSIA MALAY 1.1 kasus CHINESE 40.1(14.9) kasusSINGAPURA CANTONESE 18.2/7.5 HOKKIEN 12.3/3.7 MALAY 4.3/1.5*per 100.000/tahunTHAILAND 4.1/1.6HONGKONG 28.5/11.2 9. Di RS Sardjito, Yogyakarta 2007-2009 Grafik Klasifikasi Tumor Kepala Leher Berdasarkan Letak Tumor Primer Tahun 2007-2009 Tumor Telinga 2%Tumor Laring 8% Tumor Orofaring 15% Tumor Nasofaring 50%Tumor Sinonasal 25%588 kasus 10. Grafik Klasifikasi Tumor Kepala Leher Berdasarkan Jenis Kelamin Tahun 2007-2009 Laki-lakiPerempuan19193 76 67 49 35402 Tumor NasofaringTumor SinonasalTumor OrofaringTumor Laring86Carcinoma Auricula 11. Grafik Tumor Kepala Leher Berdasarkan Umur Tahun 2007-2009 10758 51 40Tumor NasofaringTumor Sinonasal2018Tumor OrofaringTumor Laring3Tumor Telinga4 78-87168-77058-6738-47148-573 28-372 18-27211 4 77-89525-3712-2473-8351-61364-7611 40-50129-397-1781-9170-8059-6948-5837-4726-362518-283 15-254-1475-8465-7455-6445-546 35-4415-245-14225-34713112451-63201738-502762-723029242 12. What is NPC ? Definition Cause & Risk factors Symptoms & signs 13. Apa yg disebut dg KNF ? Stad awal : Tdk spesifik (tinnitus, blood stained discharge) Stad lanjut: metast, cranial nerves involvementsAdvanced stage 14. ETIOLOGI & FAKTOR RISIKO Epstein-Barr virus (smoke)(Immuno)genetic factorsDietNPC Environmental factorsGenderEthnicityHerbal Drugs/ oils 15. PATOLOGI ANATOMI WHO; 1978: Type 1: Keratinizing SCC Type 2: Non Keratinizing SCC Type 3: Undifferentiated 16. GEJALA & TANDA ---ANATOMI 17. Cefalgia Rasa penuh di telinga Tinnitus , OtalgiaDiplopia Ophtalmoplegia LagophtalmusTuli konduktif unilateral Perforasi , OMEGEJALA KLINIS Obstruksi hidung Sekret + darah Anosmia Blood stained discharge PNDLimfadenopati colli Trismus Disfagia Gangguan pengecap Atrofi palatum mole Parese parsial lidah 18. ALIRAN KGB LEHER 19. DIAGNOSIS Anamnesis Pemeriksaan Fisik THT Rinoskopi Anterior &Posterior Endoskopi: Rigid/ Fiber nasopharyngolaryngoscopy BIOPSI 20. Pemeriksaan Penunjang CT Scan: * Perluasan tumor * Superior: destruksi tulang, densitas jaringan lunakMRI: * Resolusi tinggi * Superior: residual/reccurent, inflamasi, fibrosis * Keterlibatan sum tul,perineural, intracranial 21. Primary Tumor TXPrimary tumor cannot be assessedT0No evidence of primary tumorTisCarcinoma in situT1Tumor confined to the nasopharynxT2Tumor extends to soft tissues T2a: Tumor extends to the oropharynx and/or nasal cavity without parapharyngeal extension* T2b: Any tumor with parapharyngeal extension*T3Tumor invades bony structures and/or paranasal sinusesT4Tumor with intracranial extension and/or involvement of cranial nerves, infratemporal fossa, hypopharynx, orbit, or masticator space 22. T1 Tumor terbatas pada nasofarings, menyebabkan penebalan / asimetri mukosa 23. T2a Perluasan ke orofarings atau kavum nasi 24. T2b Keterlibatan spasium para farings 25. T3 Keterlibatan sinus paranasal atau tulang 26. T4 Intrakranial, hipofarings, orbita 27. Lymph Node NxRegional lymph nodes cannot be assessedN0No regional lymph node metastasisN1Unilateral metastasis in lymph node(s), not more than 6 cm in greatest dimension, above the supraclavicular fossa*N2Bilateral metastasis in lymph node(s), not more than 6 cm in greatest dimension, above the supraclavicular fossa*N3Metastasis in a lymph node(s)* larger than 6 cm and/or to supraclavicular fossa N3a: Larger than 6 cm N3b: Extension to the supraclavicular fossa*** [Note: Midline nodes are considered ipsilateral nodes.] ** [Note: Supraclavicular zone or fossa is relevant to the staging of nasopharyngeal carcinoma and is the triangular region originally described in the Ho-stage classification for nasopharyngeal cancer. It is defined by three points: (1) the superior margin of the sternal end of the clavicle; (2) the superior margin of the lateral end of the clavicle; and, (3) the point where the neck meets the shoulder. Note that this would include caudal portions of Levels IV and V. All cases with lymph nodes (whole or part) in the fossa are considered N3b.] 28. AJCC Stage GroupingDistant Metastasis MXDistant metastasis cannot be assessedStage 0Tis, N0, M0M0No distant metastasisStage IT1, N0, M0M1Distant metastasisStage IIAT2a, N0, M0Stage IIBT1, N1, M0 T2, N1, M0 T2a, N1, M0 T2b, N0, M0 T2b, N1, M0Stage IIIT1, N2, M0 T2a, N2, M0 T2b, N2, M0 T3, N0, M0 T3, N1, M0 T3, N2, M0Stage IV AT4, N0, M0 T4, N1, M0 T4, N2, M0Stage IV BAny T, N3, M0Stage IV CAny T, any N, M1 29. Survival Rates StageRelative Survival Rates 5-year10-yearI78%62%II64%52%III60%46%IV47%37% 30. PENATALAKSANAANStadium I & IIRadioterapiStadium III, IVa & bKemoradiasiStadium IVcKemoterapi 31. N P CTHT Pemeriksaan klinis Endoskopi Biopsi nasofaringsRadiologi CT scan kepala coronal extended Foto thorak USG upper abdDIAGNOSISTHT Catat hasil PA Ambil darah utk serologi Brushing nasofarings Staging: Stad. awal / Stad.lanjutM A N A G E M E N TStad.awalStad.lanjut TERAPIRadioterapi Radiasi eksternal 70 Gy + BrachitherapyTHT Pemeriksaan klinis & endoskopiTHT Endoskopi Biopsi nasofarings CT scan kepala coronal extended Ambil darah utk serologi Brushing nasofarings THT Endoskopi Swab nasofarings / kp. biopsi Brushing nasofarings Ambil darah utk serologiTulip Kemoterapi Cisplatin & 5FU 3 siklusEVALUASITulip Pemeriksaan klinis Ambil darah utk serologiRadioterapi Pemeriksaan klinis Ambil darah utk serologiFOLLOW UP 32. Potentially DODiagnosisEarly stageAdvanced stageRadiotherapyChemotherapy 2 weeks12 weeksRadiotherapy 12 weeks Response Assessment Follow-up 33. KNF di RS Sardjito Kasus baru bertambah (1992= 48 ; 1993 = 59 ; 1994 = 63 ) Penderita KNF di THT (Mei 03 - Nov 06) = 446 penderita Th 2007=103, th 2008=73, th 2009=108 Laki : Wanita = 297:149 (2:1) Management: Protocol I ( 4 cycles CT + ERT) Protocol II ( 3 cycles CT + ERT + BT) Protocol III Concurrent Chemoradiation AreaAge Proportion50.00% 5%4%5%40.00% Luar Jawa Jawa Timur Jawa Barat Jawa Tengah86%30.00% Series120.00% 10.00% 0.00% 10-30 y.o31-50 y.o51-70 y.o>70 y.o 34. Sardjitos standard therapy protocols (Advanced stage)Protocol I: Chemotherapy : Neoadjuvant. CisPlatinum : 80 mgr/m2 body surface 5 Fu : 800 mgr/m2 body surface 4 cycles Radiotherapy : Cobalt 60 6600 7000 cGy 35. Protocol II: Chemotherapy : Neoadjuvant. CisPlatinum : 100 mgr/m2 body surface 5 Fu : 1000 mgr/m2 body surface 3 cycles. Radiotherapy : Cobalt 60 6600-7000 Cgy Brachytherapy: 1200 cGy/3 days Protocol III: Concurrent chemoradiotherapy 36. Protocol I vs Protocol II Survival analysislog rank=8,60; p=0,003 1.0 .9 .8 .7terapiLMP 2.6 .5Brachy (+) < 2.7=5:5.4Cencored 25 < 2.7-censored.3=24.2Brachy (-):14 >= 2.7=14 Censored 12.1>= 2.7-censored0.0=13 01020304050607080Follow-up (bulan)n=56, stad. III dan IV non metastasis 37. Protocol III n=23, Stad. III & IV non metastasis Overall Survival 1.0Overal Survival.8.6.4.2 Survival Function 0.0Censored 051015202530Time (months)Overall survival is 86.95% median follow up of 12 month 38. Photodynamic Therapy in Recurrent or Residual Disease of Nasopharyngeal Carcinoma After Standard Therapy in Sardjito Hospital Yogyakarta: 5-year Experience Sagung Rai Indrasari1, Camelia Herdini1, Bambang Hariwiyanto1, Tan IB2 39. Principle of Photodynamic therapy (PDT) administrationtherapy96 h12 9photosensitizer3 6photosensitizer + light + O2laserNon thermal illumination of target volumecell death 40. PDT Survival analysisn=25, rekurens/residu1.0 .92005-2008.8Cum Survival.7 .6 .5 .4 .3 .2 Survival Function.1 0.0Censored 0510152025303540Follow Up (Months)Event: Died and recurrence42 41. PDT, 2011 n=36 5 year overall survival: 65.5 42. Advanced stage diseases need longer treatment time potentially DO ! In advanced diseases, treatment results are poorImportant ! Diagnosis in early stageNO DELAY !! 43. Delay in the diagnosis & treatment of NPC: Patient delay Profesional delay: Gagal mengidentifikasi gejala & tanda kecurigaan kankerSystem delay: Waktu yg diperlukan utk mendpt pelay