A R I E C A H YO N OE N T D E PA R T M E N T

D R . C I P TO M A N G U N K U S U M O G E N E R A L H O S P I TA LJA K A R TA

Detekasi Dini Karsinoma Nasofaring

PREVALENSI / INSIDENS

CINA SELATAN30-50 kasus*

INDONESIA (NATIVE)

4.7/6.7 kasus*

MALAYSIAMALAY 1.1 kasusCHINESE 40.1(14.9) kasus

SINGAPURACANTONESE 18.2/7.5

HOKKIEN 12.3/3.7MALAY 4.3/1.5

THAILAND4.1/1.6

HONGKONG28.5/11.2

*per 100.000/tahun

ETIOLOGI

Epstein-Barr virus

NPCEthnicity

Diet(smoke)

(Immuno)genetic factors

Gender

Herbal Drugs/

oils

Environmentalfactors

KNF 1996-2005

PATOLOGI ANATOMI

WHO; 1978:Type 1: Keratinizing SCCType 2: Non Keratinizing SCCType 3: Undifferentiated

WF: Working Formulation: degree of anaplasia and tumor cell1. High malignant degree SCC2. Type A: Anaplasia/obvious pleomorphic, Intermediate malignant

degree3. Type B: Anaplasia/ light pleomorphic, low malignant degree

Radiation response: Type B good, Type A: less

KLASIFIKASI PATOLOGI ANATOMI

Classical scheme WHO Scheme Cologne modification WHO

SCC, keratinising SCC Type I

SCC Non Keratinisingtransisional cellIntermediate cell

Lymphoepithelial Ca(Regaud Type)

Non Keratinising Ca

Non-keratinising Ca

Type IIa ( NKC with no lymphoid infiltration)

Type IIb ( NKC with lymphoid infliltration)

Undifferentiated ( anaplastic)

Clear Cell Ca

Lymphoepithelial Ca(Schmincke type)

Undifferentiated Ca Type IIIa (Undifferentiated)

Ca with no lymphoid infiltration

Type IIIb ( undifferentiated Ca with lymphoid infiltration)

ANATOMI

ANATOMI

ALIRAN KGB LEHER

GEJALA KLINIS

Cefalgia

DiplopiaOphtalmoplegiaLagophtalmus

Obstruksi hidungSekret + darah

AnosmiaEpistaksis

PND Trismus Disfagia

Gangguan pengecapAtrofi palatum mole Parese parsial lidah

Limfadenopaticollie

Rasa penuh di telingaTinitusOtalgia

Tuli konduktif unilateral Perforasi

OME

DIAGNOSIS

Anamnesis Pemeriksaan Fisik THT Rinoskopi Anterior & Posterior Endoskopi: Rigid/ Fiber

nasopharyngolaryngoscopy

BIOPSY

Serology EBV

Serology Jakarta Singapore HongkongIgA anti VCASensitivity %Specificity %

IgA anti EASensitivity %Specificity%

73,33%83,33%

98,67% 63,67%

95,00%80-90%

>95%

93,00%

76,00%

Diagnosis

CT Scan:* Perluasan tumor* Superior: destruksi tulang, densitas jaringan

lunak

MRI:* Resolusi tinggi* Superior: residual/reccurent, inflamasi, fibrosis* Keterlibatan sum tul,perineural, intracranial

Primary Tumor

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis Carcinoma in situ

T1 Tumor confined to the nasopharynx

T2 Tumor extends to soft tissuesT2a: Tumor extends to the oropharynxand/or nasal cavity without parapharyngealextension* T2b: Any tumor with parapharyngealextension*

T3 Tumor invades bony structures and/or paranasal sinuses

T4 Tumor with intracranial extension and/or involvement of cranial nerves, infratemporalfossa, hypopharynx, orbit, or masticator space

T1: confined to the nasopharynx,causing thickening and asymmetry

T2a: spread to the oropharynx or nasal cavity

T2b: Parapharyngeal space involvement

T3: paranasal sinus andbony involvement

Tumor eroding and widening right pterygopalatine fossa (thick arrow)

T4: Intracranial hypopharyngeal, orbital, maxillary sinus or cranial nerve involvement tumours

Lymph Node

Nx Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Unilateral metastasis in lymph node(s), not more than 6 cm in greatest dimension, above the supraclavicular fossa*

N2 Bilateral metastasis in lymph node(s), not more than 6 cm in greatest dimension, above the supraclavicular fossa*

N3 Metastasis in a lymph node(s)* larger than 6 cm and/or to supraclavicular fossa N3a: Larger than 6 cm N3b: Extension to the supraclavicularfossa**

* [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.]

Distant Metastasis

MX Distant metastasis cannot be assessed

M0 No distant metastasis

M1 Distant metastasis

AJCC Stage Grouping

Stage 0 Tis, N0, M0

Stage I T1, N0, M0

Stage IIA T2a, N0, M0

Stage IIB T1, N1, M0 T2, N1, M0 T2a, N1, M0 T2b, N0, M0 T2b, N1, M0

Stage III T1, N2, M0 T2a, N2, M0 T2b, N2, M0 T3, N0, M0 T3, N1, M0 T3, N2, M0

Stage IV A T4, N0, M0 T4, N1, M0 T4, N2, M0

Stage IV B Any T, N3, M0

Stage IV C Any T, any N, M1

Types of Nasopharyngeal Carcinoma

Three microscopic subtypes of NPC: Well-differentiated keratinizing (type 1) Moderately-differentiated nonkeratinizing (type 2) Undifferentiated (type 3), which typically contains large numbers

of non-cancerous lymphocytes (lymphoepithelioma)

Stage Relative Survival Rates

5-year 10-year

I 78% 62%

II 64% 52%

III 60% 46%

IV 47% 37%

Survival Rates

Stage Relative Survival Rates

5-year 10-year

I 78% 62%

II 64% 52%

III 60% 46%

IV 47% 37%

PENATALAKSANAAN

Sesuai dengan staging tumor yang telah dibuat:

RadioterapiStadium 1

KemoradiasiStadium 2 & 3

KemoradiasiStadium 4a & b

KemoterapiStadium 4 c

Pasien dengangejala dini

Dokter umum Tidak berobat Pengobatan Alternatif

Rujuk ke Spesialis THT setelah 6 mg keluhan

Misdiagnosis karenarendahnya pengetahuan

Pasien memasuki stadium lanjut KNF Tidak dapat diterapi

Pasien dengan KNF

Pasien dapatditerapi

Edukasi

Deteksi dan terapi dini akan menyelamatkanbanyak nyawa!

Angka ketahanan hidup 5 tahun:Stadium 1: 78%Stadium 4: 47%

Deteksi & terapi dini: angka keberhasilan

UPAYA PENCEGAHAN

Jaga daya tahan tubuh

Cegah ISPA

Skrining pasien risiko tinggi

Kurangi makanan dengan pengawet

Kurangi pemakaian alat rumah tangga yang mengandung karsinogen

Hindari rokok (aktif + pasif), terutama di sekitaranak-anak

KEYPOINTS

KNF kasus terbanyak di kepala leher

Stadium dini prognosis lebih baik

Skrining pasien risiko tinggi

Rekuren terjadi < 1 tahun

Follow up rutin: KEHARUSAN

Program kewaspadaan