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
4 2. RETROPHRYNX
5 5
5 3. PARAPHARYNX
2 1
3
4. INTRACRANICAL
5. PARANASAL SINUS
6. DISTANT METASTATIC
 MONGOLOID RACE :
 SOUTHERN
CHINESE, HONGKONG, VIETNAMESE, THAIS, MALAYS, INDONE
SIANS.

 INDONESIA :
 RSCM 100 NEW CASES / YEAR
 RSHS 60
 UJUNG PANDANG 25
 PALEMBANG 25
 DENPASAR 15
 PADANG 11
 DHARMAIS HOSPITAL 70
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

Sumber : Instalasi Rekam Medis & Admission RSKD

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

Sumber : Instalasi Rekam Medis & Admission RSKD

 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 Raised antibody
Viral genome in tumor cells
Chemical-Tobacco Cigarette smoking
Drugs Chinese herbal medicine
Plant Products EBV activating properties/co-factors
Diet Salted fish
Preserved vegetables, fermented
food stuff
Nitrosamines & nitro-precursors
Tunisian preserved spice meat and
stewing base
Agent/Factors Implication
Cooking Habits Household smoke and fumes
Religious Practice Incense and joss stick smoke
Occupation 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 : ∞ COLDS/

– BLOOD STAINED MUCUS SINUSITIS
– EUSTC.TUBE BLOCKAGE

• OTHER SYMPTOMS MAY BE :

A LUMP IN THE NECK
NOSEBLEEDS
MUFFLED HEARING
RINGING IN THE EAR
HEADACHE
DOUBLE VISION
Number of patients
 Symptoms / Sign
Others
27

Epistaxis Neck Mass

9

Neck Mass + Epistaxis +

6
Ear Disorder

18

Neck Mass + 4
Neck Mass + Epistaxis
Ear Fullness
/ Tinitus

Others = Diplopi / Cephalgi

NASOPHARYNX
 POST OR RHINOSCOPY
 POST OR RHINOSCOPY + CATHETER
 NASOENDOSCOPY/NASOPHARYNGOSCOPY
 LOCAL ANESTHETIA
 GENERAL ANESTHETIC (SPESIFIC

CIRCUMTANCES)
 THEGOLD 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
 NPC Diagram

Pretreatment staging Bulky cervical

N1-N3 (≥ 4 Neoadjuvant
cm in chemotherap
1. Nasoparyngeal maximal y
tumor biopsy diameter)
2. Chest radiograph Pretreatmen
3. Plane radiograph t bulky
No Non-bulky parapharyng Parapharyngeal boost
of skull and eal disease
distans cervical
nasopharynx nodes N1- (T2p and
metastasi
4. CT scan of s (M0) N3 (<4 cm in T3p)
ERT*
nasopharynx maximal
5. Fibreoptic diameter)
endoscopic Local
residual ICT ⁺
examination disease for
6. Clinical assesment Negative T1 or T2n
for level and size cervical
of cervical lymph nodes N0
nodal metastases
(if any)
7. Liver ultrasound
8. Bone 99m Distant metastasis (M1) Palliative treatment
Tc-scintigram
9. Fine needle
aspiration of
doubtful cervical
lymph nodes
Stg I T1 N0 M0 External Rad. Brachyterapy
T2 N0 M0 6000cgy(30x) + 4-6 x 300cgy

Radiosentisizer
- Cisplatin 20-25
- Giemsar 200

Rad.ext 6000
Stg IIB T3 N0 M0 BrachyTx 4-6x300
Stg III T1 N1 M0 Chemorad
Cisplatin 40mg/m2/mgg
Docetaxel 25mg/m2/mgg
Paclitaxel 90mg/m2/mgg
 Rad.ext 6600 - 7000
Stg IV T4 N0 M0 Chemorad
Cisplatin 40mg/m2/mgg
Docetaxel 25mg/m2/mgg
Paclitaxel 90mg/m2/mgg

Stg IV T1-3 N3 M0 Cisplatin 40mg/m2/mgg

NeoAdjuvan
T4 N3 M0 Taxotere 20-25mg/m2/mgg
5 FU 1000mg/m2/mgg
every 3 weeks 4 cycles
continue :
External Rad. + BrachyTx
Chemorad
-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 : Carboplatin

Taxan (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
CAN ALL BE USED
 SURGICAL
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
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

Sumber : Instalasi Rekam Medis & Admission RSKD

 10 BESAR KANKER TERSERING RUMAH SAKIT
“DHARMAIS” RAWAT JALAN (KASUS BARU) FEMALE
TAHUN 2005 - 2007
 History and Examination
Normal looking
Obvious Tumour NP
Clinically Clinicaly
Suspicious not
Suspicious

Biopsy NP Radiologicall Unexplaine Persistentl Suspicious

y Suspicious d SOM y Raised Neck Node
(LA)
IgA

NPC Other
Diagnosis Biopsy FNA
Proven Diagnosis
Uncertain NP Cytology
(GA)

Squamous Cell or Other

Repeat Diagnosis
Treatment Other Undifferentiared Carcinoma
Biopsy
Treatment Tretment
(LA/GA
)
Biopsy NP (GA) +/- Other Treatment
Panendoscopy

SOM = Serous otitis NP = Nasopharynx

media LA = Local FNA = Fine-needle
anaesthesia aspiration
GA = General
anaesthesia
 Tabel. 3 Stage NPC
Stage Ho’s (1978) Huang’s (1985)
classification
T-Stage T1 NP Only T Ts Primary soft tissue tumour only
T2 T2n Nasal fossa Tb basal skull destruction evident on radiographs
T20 Oropharynx Tn cranical nerve involvement
T2p Parapharyngeal region Tc direct invasion to the adjecent brain evident
T3 T3a Bone involvement below the base of the on CT scan (newly added item)
skull including floor of the sphenoid sinus
T3b Base of the skull
T3c Cranial nerve(s) palsy
T3d Orbits, larygopharynx (hypopharynx) or
infratemporal fossa
N-Stage N0 No nodes N Cervival lymph node
N1 Node(s) above skin crease at laryngeal N0 No palpable node
cartilage N1 Unilateral (ipsilateral) small lymph nodes with
N2 Node(s) below skin crease but above total diameter ≤ 5cm
supraclavicular fossa N2 Bilateral (contralateral) large lymph nodes
N3 Supraclavicular node(s) with total diameter > 5cm

M-Stage N0 Nb distant metastase M Distant metastasis evident clinically

M1 Distant metastaces M M0 No distant metastasis
M1 Clinically evident distant metastasis beyond
cervical lymph node involvement
Stage I TIN0 I TsN0M0 (prymary soft tissue only)
Grouping II T2 and/or N1 II TsN1M0 or TbN0-1M0 (any condition with N1
III T3 and/or N2 and /or Tb)
IV N3 (any T) III TsN2M0 or TbN2M0 or TnN0-2M0 or TcN0-2M0
V M1 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 Changsha (1983) UICC (1987)
classification
T-Stage T0 Subclinical T1 One wall NP
T1 One wall or corner betwen 2 walls T2 ≥ 2 walls NP
T2 ≥ 2 walls T3 Nasal cavity, oropharynx (including
T3 Nasal fossa, oropharynx (including parapharyngeal region)
parapharyngeal region) T4 Skull base and /or cranial nerve
T4 ≥ 2 features of T3

N-Stage N0 No nodes N0 No node

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
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 N0 No metastase

M1 Distant metastaces M1 Distant metastaces

Stage I TIN0 I TIN0

Grouping II T2N0; T0-2N1 II T2N0
III T3N0-1; T0-3N2 III T3N0; T1-3N1
IV T4N0-2; T0-4N3; M1 IV T4N0-1
N2-3 (any T);
M1 (any T, any N)
Alur Diagnosis
Anamnesis :

1. GEJALA HIDUNG :
a. Ingus campur darah (sedikit) / epistaksis ringan
unilateral
b. Sumbatan hidung unilateralbilateral
c. Post nasal drip
2. GEJALA TELINGA :
a. Rasa penuh/gangguan pendengaran unilateral
menetap
b. Tinitus unilateral PF Penunjang
c. Otalgia/Otorea unilateral
3. GEJALA LEHER :
a. Benjolan leher unilateral  bilateral
4. GEJALA MATA & SYARAF : Penentuan
a. Sakit kepala
b. Diplopia (N3&6)
Stadium
c. Ptosis (N4)
d. Trismus (N5)
e. Parese lidah (N12)
f. Parese Saraf Otak lain
Alur Diagnosis
Pemeriksaan

Pemeriksaan lengkap THT-Kepala Leher:

1. Pemeriksaan hidung & nasofaring (THT lengkap) :

a. Rinoskopi anterior & posterior
b. Nasoendoskopi/nasolaringoskopi kaku/fleksibel
Anamnesis 2. Perhatian pada : Penunjang
a. OMS, Lesi Intrakranial, Limfadenopati Servikal
3. Pemeriksaan kelenjar leher:
lokasi, ukuran, kekenyalan, mobilitas
4. Pemeriksaan lesi intrakranial:
a. Gangguan gerak bola mata (Diplopia N3&6) Penentuan
b. Ptosis (N4) Stadium
c. Trismus (N5)
d. Parese lidah (N12)
 Alur Diagnosis

Tentukan Stadium :
Pemeriksaan Penunjang

1. Ro Toraks
1. CT scan/MRI
Anamnesis 2. Laboratorium:
2. Serologi:
& PF fungsi hati, ginjal, kimia drh
a) IgA VCA
3. Konsul saraf dan mata
b) IgA EA
4. USG abdm atas & bone scan
c) EBNA total
5. Audiogram
GAMBARAN WORK UP PENEMUAN
KLINIS
KNF(-)
CT scan NF ulangi
Curiga (+) 3x/eksplorasi
(-)bukan
KNF
Anamnesis : OM Serosa
KGB leher >> e.c. tidak Biopsi
Kls curiga : NF
Keluhan jelas
CT scan NF
hidung,telinga, KNF (+)
Serologi
sakit kepala Pe IgA
kronis
PF
KGB leher KSS/Ca
curiga FNAB undiff
 PENEMUAN STAGING

Stadium I
Hasil PA WHO
Pemeriksaan 3 hr

Stadium II
KNF (+)

Stadium III
Staging persiapan
terapi

Stadium IV
 TERAPI
STAGING
Radiasi ekst 60 Gy + brakiterapi 4-6 x
3 Gy
PR : cisplatin + 5 FU
Stadium I
T1 N0 M0
TR : cisplatin + 5FU + Docetaxel +
atau Carboplatin + Docetaxel +
gemcitabin
Rekurensi : < 1 thn  Kemoterapi
> 1 thn  Kemoradiasi
Radiasi ekst 60 Gy + brakiterapi 4-6 x
3 Gy
Stadium IIA PR : cisplatin + 5 FU
T2a N0 M0 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 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
STAGING

Radiasi ekst 60 Gy + brakiterapi 4-6 x Thn I : setiap 1-2 bln

3 Gy + kemoterapi Thn II: setiap 2-3 bln
Stadium IIB Thn III: setiap 4-6 bln
T1 N1 M0 PR : cisplatin + 5 FU
Thn IV & V : setiap 12 bln
T2a N1 M0 TR : cisplatin + 5 FU + Docetaxel atau
T2b N0-1 M0 Carboplatin + Docetaxel + Setiap follow up:
gemcitabin Anamnesis & PF
Rekurensi : < 1 thn  Kemoterapi Nasofaringoskopi
> 1 thn  Kemoradiasi
Setiap 6 bln ( thn.I & II )
Lab, Rö toraks, CT scan NF
Stadium III Neoadjuvan + kemoradiasi Seromarker, Bonescan
T1 N2 M0 Reseksi KGB bl primer bersih USG abdomen
T2a N2 M0 Bila T3  CT scan u/ radiasi
T2b N2 M0 Biopsi ulang stlh 6 bln/thn 1
Bila N2  CT scan u/ booster KGB
T3 N0-2M0
5-10 x 2 Gy Rehabilitasi
minggu ke-2 stlh radiasi
 TERAPI FOLLOW UP
STAGING

Thn I : setiap 1-2 bln

Stadium III Neoadjuvan + radiasi Thn II: setiap 2-3 bln
T1 N2 M0 Reseksi KGB bl primer bersih Thn III: setiap 4-6 bln
Thn IV & V : setiap 12 bln
T2a N2 M0 Bila T3  CT scan u/ radiasi
T2b N2 M0 Bila N2  CT scan u/ booster KGB 5-
T3 N0-2M0 Setiap follow up:
10 x 2 Gy Anamnesis & PF
Nasofaringoskopi
Stadium IVa Neoadjuvan + radiasi 60 Gy
T4 N0-3 M0 Setiap 6 bln ( th. I & II )
Bila penekanan saraf mata (+)  Lab, Rö toraks, CT scan NF
T berapa
pun, N3, M0 Radioterapi cito Seromarker, Bonescan
USG abdomen

Stadium IVb Neoadjuvan + radiasi paliatif Biopsi ulang stlh 6 bln/thn 1

T berapa pun,
40-60 Gy
N berapa Rehabilitasi
pun, M1 Untuk lokasi tumor pd weight bearing
minggu ke-2 stlh radiasi
bone radioterapi dahulu