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laporan kasus dan pembahasan nasopharyngeal cancer atau karsinoma nasofaring

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Nasopharyngeal carcinoma (NPC)

Nasopharyngeal carcinoma (NPC)Identitas PasienNama: Ibu THUmur: 48 tahunPekerjaan: -Pendidikan: -Tanggal Periksa: Poli THT RSUDSH Purworejo, 5 Desember 2013

AnamnesisKeluhan Utama:Pasien kontrol ke Poli RSUDSH tanggal 5 desember 2013 karena post biopsy 2 minggu sebelum periksa.Saat ini terdapat benjolan pada leher sebelah kanan ukuran 4x3x3 cm pada leher, keras, tidak mobile.Riwayat Penyakit SekarangPasien dilakukan biopsy 2 minggu sebelum periksaSaat ini hanya terdapat keluhan benjolan pada leher. Sesak (-), dysphagia (-). Sebelum biopsi OS merasakan sering pilek, cairan jernih, terkadang berdarah, terutama pada hidung kanan. Bersin (-), nasolalia (+), rhinalgia (-), foetor (+), hyposmia (+) Os juga terkadang merasakan berdenging pada telinga. Otorrhea (-/-), deafness (-/-), otalgia (-/-), itching (-/-)

Tidak ada keluhan penurunan berat badan, pengelihatan ganda, nyeri kepala, sulit menelan, kelumpuhan bahu, sulit bicara, serak, sesak, batuk darah. RPD: Riwayat penyakit serupa (-), riwayat pengobatan (+: obat warung), RPK: Riwayat keganasan keluarga (-), keluhan serupa (-)Riwayat Alergi: (-)Pemeriksaan FisikKeadaan Umum: Compos MentisVital Sign:Tensi: 100/70RR: 20x/mNadi: 74x/mSuhu: 36.7 CKepala: Conjunctiva anemis (-/-), Ikterik (-/-)Leher: Terdapat benjolan 4x3x3 cm pada Lnn Coli Dextra, keras, tidak mobile, batas tidak tegasParu: Tidak dilakukanJantung: Tidak dilakukanAnggota gerak: Tidak dilakukan

NoPemeriksaan TelingaTelinga KananTelinga Kiri1TragusNyeri Tekan (-), Edema (-)Nyeri Tekan (-), Edema (-)2Daun TelingaBentuk dan ukuran dbn, hematoma (-), nyeri tarik (-)Bentuk dan ukuran dbn, hematoma (-), nyeri tarik (-)3Liang TelingaSerumen (-), Hiperemis (-), furunkel (-), Edema (-), otorrhea (-)Serumen (-), Hiperemis (-), furunkel (-), Edema (-), otorrhea (-)4Membran TimpaniRetraksi (-), Bulging (-), hiperemis (-), edema (-), perforasi (-), cone of light (+)Retraksi (-), Bulging (-), hiperemis (-), edema (-), perforasi (-), cone of light (+)No.PemeriksaanTelingaTelingakananTelingakiri1.TragusNyeritekan(-),edema(-)Nyeritekan(-),edema(-)2.DauntelingaBentukdanukurandalambatasnormal, hematoma (-), nyeritarik aurikula (-)Bentuk dan ukuran dalam batasnormal, hematoma (-), nyeritarik aurikula (-)3.LiangtelingaSerumen(-),hiperemis(-),furunkel (-), edema (-), otorhea(-)Serumen (-), hiperemis (-),furunkel (-), edema (-), otorhea(-) Pemeriksaan hidungPemeriksaan hidungHidung KananHidung KiriHidung LuarBentuk normal, hiperemis (-). Nyeri tekan (-), deformitas (-)Bentuk normal, hiperemis (-). Nyeri tekan (-), deformitas (-)Rhinoskopi anteriorVestibulum nasiNormal, ulkus (-)Normal, ulkus (-)Cavum nasiBentuk normal, mukosa pucat (-), hiperemis (-)Bentuk normal, mukosa pucat (-), hiperemis (-)Meatus nasi mediaMukosa hiperemis, sekret (+), bening, massa (-)Mukosa hiperemis, sekret (+), bening, massa (-)Konka nasi inferiorEdema (-), mukosa hiperemis (-)Edema (-), mukosa hiperemis (-)Septum nasiDeviasi (-), perdarahan (-), ulkus (-)Deviasi (-), perdarahan (-), ulkus (-)

Pemeriksaan TenggorokanBibirMukosa bibir basah, pucatMulutMukosa mulut basah berwarna merah mudaLidahPermukaan lidah pink, saat dijulurkan simetrisGigiKaries (+), tambalan (-)UvulaSimetrisPalatum MoleSimetris, massa (-), bercak putih (-)FaringHiperemis (-)Tonsila PalatinaHipertrofi (-)NasopharynxDinding BelakangChoanaeMuara Tuba eustachiiTidak diperiksaAdenoidTumor

LaryngopharynxDinding BelakangParapharynxTidak diperiksaLarynxEpiglotisAritenoidPlica VocalisGerakan Plica vocalis Tidak diperiksaTumorSubglotisTracheaPemeriksaan PenunjangPemeriksaan Pathology AnatomyMakroskopik: Kiri: Jaringan pecah belah sebanyak 0.5 cc berwarna coklat kehitaman, semua cetak (A)Kanan: Jaringan pecah belah sebanyak 0.5 cc berwarna coklat kehitaman, semua cetak (B)MikroskopikA dan B kedua sediaan menunjukkan jaringan nasofaring dengan diantara haringan limfoid ditemukan sarang kecil karsinoma sel skuamosa tanpa keratinisasiKesimpulanNasofaring: Non Keratinizing Carcinoma (WHO tipe II)

DiagnosisNon Keratinizing Carcinoma of NasopharynxPlanRujuk RSUP dr Sardjito

Anatomy Anatomy

16The nasopharynx is a roughly cuboidal space, opening into the nasal cavity through the posterior choane anteriorly, and the oropharynx, inferiorly. The lateral and the posterior wall are bounded by the pharyngobasilar fascia, descending from the base of the skull. The roof contains abundant lymphomatous tissue special in children and the aggregate of lymphomatous tissue forms the pharyngeal tonsil in this age group. The Eustachian tube opens into the lateral wall of the nasopharynx, and the posterior cartilaginous edge of the same makes the bulge, which is known as the torus tubaris. Just posterior to this torus lies the fossa of Rosenmuller which is considered as the most common site for origin of nasopharyngeal carcinomas. This is the place where the nasopharynx is at its widest.Anatomy

Foramen lacerum

Foramen spinosumForamen ovaleForamen rotundum17This diagram shows the base of the skull from below, and the close relationship of the foramen lacerum to the nasopharynx is immediately apparent. Since the foramen lacerum opens directly into the middle cranial fossa, It forms an important route by which nasopharyngeal cancers can spread into this area. In addition to this important foramen, other foramina in close relationship, include the foramen rotundum, which transmits the maxillary division of the trigeminal nerve, foramen ovale which transmits the mandible division of the trigeminal nerve, foramen spinosum, which transmits the middle meningeal vessels and the recurrent branch of the mandibular nerve. In addition to this the hypoglossal canal and jugular foramen are in close relationship posteriorly and serve as potential pathways of spread to the cranial nerves, particularly 9th, 10th, 11th and 12th .CT anatomy

18Anasopharyngeal carcinoma (NPC)isthe most commonprimary malignancy of the nasopharynx. It is of squamous cell origin andsome types of which are strongly associated withEpstein Barr virus (EBV).EpidemiologyNasopharyngeal carcinomas account for approximately 70% of all primary malignancies of the nasopharynx.Although it is rare in western populations, it is one of the most common malignancies encountered in Asia, especially China.Department of Radiotherapy, PGIMER, ChandigarhIncidence

Incidence: Sex

EtiologyNormal EpitheliumLow Grade DysplasiaHigh Grade DysplasiaInvasive CarcinomaMetastatic CarcinomaP53 MutationGain Chromosome 12Deletion 11 and 13Deletion of Chromosomes 3p and 9pInactivation of Chromosome p14, 15 and 16EBV infection23Inactivation of the tumor suppressor genes namely the Chromosomes 14, 15 and 16 are considered central steps in the pathogenesis of high grade dysplasia.RiskEnvironmentalVirusesEBV- well documented viral fingerprints in tumor cells and also anti-EBV serologies with WHO type II and III NPCHPV - possible factor in WHO type I lesionsNitrosamines - salted fishOthers - polycyclic hydrocarbons, chronic nasal infection, poor hygiene, poor ventilation

Clinical ManifestationClinical presentation, and often only when the tumor has grown significantly in size and has invaded adjacent structures.Actual presentation is often delayed until more sinister signs are evident including nodal masses in the neck (most common), cranial nerve palsies, tinnitus, headache or even diplopia and proptosis.Cervical adenopathy 60%Epistaxis & Nasorespiratory symptomsAudiological symptoms 30%Neurological symptoms 20%Cervical adenopathyNPC has a tendency for early lymphatic spread.Retropharyngeal node of Rouviere is the first echelon node.Commonest first palpable node is the J.D. node and the apical node under sternomastoid muscle.27Contralateral node involvement is also common. The parotid gland and lymph nodes can be involved if the parapharyngeal space is breached.Epistaxis & Nasal symptomsCommonly seen in advanced NPCs.Complete nasal obstruction is a late presentation.Ozaena occurs as a result of tumour necrosis.

28If complete nasal obstruction occur at an early stage of the disease, it is often due to superimposed infection.Tinnitus & Aural symptomsSerous otitis media is commonAcute otitis media Aural blockTinnitus29Adult Chinese patients with unresolving serous otitis media have to be presumed to have NPC until proven otherwise.Nerve palsiesAll cranial nerves can be affectedFrequently involved are iv, v, vi, ix, & x.Nerves ix & x are invariably involved together.Nerves of the ocular muscles are the next commonly affected.Pain & HeadacheThis is an ominous symptomSevere pain is hallmark of terminal disease.Signifies tumour erosion into skull base.If accompanied by trismus,the disease is very advanced and has extended into pterygopalatine fossa.31Sepsis, particularly sphenoidal sinusitis produces intense headache. Atypical facial pain or unexplained headache in the absence of obvious clinical findings in the nasopharynx may be a presenting symptom of NPC.MetastasisTumors arising from fossa of Rosenmuller frequently extend to paranasopharyngeal space, then along trigeminal nerveOften metastasizes to regional nodes; common presentation is unilateral cervical lymphadenopathy; 25% have bilateral nodal metastasesMay have distant metastases to bonesAfter radiation therapy, risk of 0.4% of subsequent carcinoma in nasal cavity of nasopharynx; differentiate from recurrence based on > 5 year delay, different histology, EBV negativeLocal SpreadNasal cavity & PNSOrbital invasionBase of Skull, ClivusSphenoid sinusCavernous Sinus Lateral Parapharyngeal spaceMiddle ear cavityOropharynx (tonsillar pillars)C1 vertebraeNodal Spread

34Lymph nodes are involved at presentation in 89%. There is unilateral involvement in 39% and bilateral involvement in 51%. Low-grade squamous cell carcinomas produce fewer metasta