dr. S R Indrasari, M.Kes., Sp.THT-KL(K)
Yogyakarta, 15 Juli
1987 -1995
1999 - 2003
1999 – 2004
2009 - .....
2009 – 2012
K...
KARSINOMA NASOFARINGS (KNF)
NASOPHARYNGEAL CARCINOMA (NPC)
SUB BAGIAN ONKOLOGI BAGIAN IK. THT-KL
FAKULTAS KEDOKTERAN UGM ...
Why Cancer ?
The burden of Cancer
MENGAPA KANKER ?
Penyebab utama kematian tahun 2001
Percentage of Total Deaths, US
31,0
Heart Diseases
Cancer
23,2
6,8
...
10 besar keganasan di dunia
Rank
Males
Females
Both Sexes
1
Lung
Breast
Lung
2
3
4
5
6
7
8
9
10
Stomach
Colon/rec...
Why NPC ?
The burden of NPC
Mengapa Karsinoma nasofarings ?
Keganasan no. 4 di seluruh badan
No.1 dari keganasan di Kepala-Leher
Insidensi cukup tingg...
PREVALENSI / INSIDENS
CINA SELATAN
30-50 kasus*
INDONESIA
(NATIVE)
4.7/6.7 kasus*
MALAYSIA
MALAY 1.1 kasus
CHINESE 40.1...
Di RS Sardjito, Yogyakarta 2007-2009
Grafik Klasifikasi Tumor Kepala Leher
Berdasarkan Letak Tumor Primer Tahun 2007-2009
...
Grafik Klasifikasi Tumor Kepala Leher
Berdasarkan Jenis Kelamin Tahun 2007-2009
Laki-laki
Perempuan
191
93
76
67
49
35
...
Grafik Tumor Kepala Leher Berdasarkan Umur
Tahun 2007-2009
107
58
51
40
Tumor Nasofaring
Tumor Sinonasal
20
18
Tumor...
What is NPC ?
Definition
Cause & Risk factors
Symptoms & signs
Apa yg disebut dg KNF ?
Stad awal : Tdk spesifik (tinnitus, blood stained
discharge)
Stad lanjut: metast, cranial nerves i...
ETIOLOGI & FAKTOR RISIKO
Epstein-Barr virus
(“smoke”)
(Immuno)genetic
factors
Diet
NPC
Environmental
factors
Gender
E...
PATOLOGI ANATOMI
WHO; 1978:
Type 1: Keratinizing SCC
Type 2: Non Keratinizing SCC
Type 3: Undifferentiated
GEJALA & TANDA ---ANATOMI
Cefalgia
Rasa penuh di telinga
Tinnitus , Otalgia
Diplopia
Ophtalmoplegia
Lagophtalmus
Tuli konduktif unilateral
Perfora...
ALIRAN KGB LEHER
DIAGNOSIS
 Anamnesis
 Pemeriksaan Fisik THT
 Rinoskopi Anterior &
Posterior
 Endoskopi: Rigid/ Fiber
nasopharyngolary...
Pemeriksaan Penunjang
CT Scan:
* Perluasan tumor
* Superior: destruksi tulang, densitas jaringan
lunak
MRI:
* Resolusi ti...
Primary Tumor
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
T1
Tumor co...
T1
Tumor terbatas pada nasofarings, menyebabkan
penebalan / asimetri mukosa
T2a
Perluasan ke orofarings atau kavum nasi
T2b
Keterlibatan spasium para farings
T3
Keterlibatan sinus paranasal atau tulang
T4
Intrakranial, hipofarings, orbita
Lymph Node
Nx
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Unilateral metastasis i...
AJCC Stage Grouping
Distant Metastasis
MX
Distant metastasis cannot be assessed
Stage 0
Tis, N0, M0
M0
No distant me...
Survival Rates
Stage
Relative Survival Rates
5-year
10-year
I
78%
62%
II
64%
52%
III
60%
46%
IV
47%
37%
PENATALAKSANAAN
Stadium I & II
•Radioterapi
Stadium III, IVa & b
•Kemoradiasi
Stadium IVc
•Kemoterapi
N
P
C
THT
Pemeriksaan klinis
Endoskopi
Biopsi nasofarings
Radiologi
CT scan kepala coronal extended
Foto thorak
USG uppe...
Potentially DO
Diagnosis
Early
stage
Advanced
stage
Radiotherapy
Chemotherapy
2
weeks
12 weeks
Radiotherapy
12
week...
KNF di RS Sardjito
Kasus baru bertambah (1992= 48 ; 1993 = 59 ; 1994 = 63 )
Penderita KNF di THT (Mei ‘03 - Nov ’06) = 446...
Sardjito’s standard therapy protocols
(Advanced stage)
Protocol I:
Chemotherapy :
Neoadjuvant.
CisPlatinum : 80 mgr/m2 bo...
Protocol II:
Chemotherapy :
–Neoadjuvant.
–CisPlatinum : 100 mgr/m2 body
surface
–5 Fu : 1000 mgr/m2 body surface
3 cycles...
Protocol I vs Protocol II
Survival analysis
log rank=8,60; p=0,003
1.0
.9
.8
.7
terapi
LMP 2
.6
.5
Brachy (+)
< 2.7=5...
Protocol III
n=23, Stad. III & IV non metastasis
Overall Survival
1.0
Overal Survival
.8
.6
.4
.2
Survival Function
0...
Photodynamic Therapy in Recurrent or
Residual Disease of Nasopharyngeal
Carcinoma After Standard Therapy in Sardjito
Hospi...
Principle of Photodynamic therapy (PDT)
administration
therapy
96 h
12
9
photosensitizer
3
6
photosensitizer + light...
PDT
Survival analysis
n=25, rekurens/residu
1.0
.9
2005-2008
.8
Cum Survival
.7
.6
.5
.4
.3
.2
Survival Function
.1...
PDT, 2011 n=36
5 –year overall survival: 65.5
 Advanced stage diseases need longer treatment
time  potentially DO !
 In advanced diseases, treatment results are poor...
Delay in the diagnosis & treatment of NPC:
Patient delay
Profesional delay:
Gagal mengidentifikasi gejala & tanda kecuriga...
EARLY DIAGNOSIS
AWARENESS
(of symptoms and
signs)
Stadium dini
Stadium lanjut
KNF
vs
Clinical Symptom
Cefalgia
Rasa penuh di telinga
Tinnitus Otalgia
Diplopia
Ophtalmoplegia
Lagophtalmus
Tuli konduktif
unilateral Perforasi...
Peran Serologi EBV pd KNF ?
Serology
Indonesia Singapore
Hongkong
IgA anti VCA
Sensitivity %
Specificity %
73,33% 95,0...
Early diagnosis- “difficult”
Tumor
: non specific symptoms
sub mucosal
Medical expert : low index of suspiciousness
techn...
Deteksi dini pada penderita dg faktor
risiko
 Annual physical examination
 Special attention to upper aerodigestive
tra...
Skreening penderita dengan risiko
Pd umumnya tdk berhasil krn:
 Rendahnya tingkat partisipasi penderita
berisiko dlm pr...
UPAYA PENCEGAHAN
Jaga daya tahan tubuh
Cegah ISPA
Skrining pasien risiko tinggi
Kurangi makanan dengan pengawet
Kurangi p...
KEYPOINTS
• KNF  kasus terbanyak di kepala leher
• Stadium dini  prognosis lebih baik
• Skrining pasien risiko tinggi
•...
Nasopharyngeal Carcinoma Awareness for GPs and Nurses
Nasopharyngeal Carcinoma Awareness for GPs and Nurses
Nasopharyngeal Carcinoma Awareness for GPs and Nurses
Nasopharyngeal Carcinoma Awareness for GPs and Nurses
Nasopharyngeal Carcinoma Awareness for GPs and Nurses
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Nasopharyngeal Carcinoma Awareness for GPs and Nurses

Published on: Mar 3, 2016
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Transcripts - 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 – 2012 Kedokteran Umum, UNS S2 Kedokteran Klinis, UGM Spesialis THT-KL, UGM Program Doktor FK.UGM Konsultan Onkologi Bedah Kepala Leher 1996-1999 : 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 srindrasari@invosa.com ; srindrasari123@gmail.com
  • 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, US 31,0 Heart Diseases Cancer 23,2 6,8 Cerebrovascular Diseases 4,8 Chronic Obstructive Lung Diseases Accidents 4,2 Pneumonia & Influenza 3,9 Diabetes Mellitus 2,8 Suicide 1,3 Nephritis 1,1 Cirrhosis of the Liver 1,1 Adapted from Greenlee RT, et al. CA Cancer J Clin. 2001:51;15-36.
  • 5. 10 besar keganasan di dunia Rank Males Females Both Sexes 1 Lung Breast Lung 2 3 4 5 6 7 8 9 10 Stomach Colon/rectum Prostate Liver Mouth/pharynx Esophagus Bladder Leukemia NHL* Colon/rectum Cervix uteri Stomach Lung Ovary Corpus uteri Liver Mouth/pharynx Esophagus Stomach Breast Colon/rectum Liver Prostate Cervix uteri Mouth/pharynx Esophagus Bladder *Non-Hodgkin’s lymphoma. Total New Cases 1,037,000 798,000 796,000 783,000 437,000 396,000 371,000 363,000 316,000 261,000 Adapted 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 / INSIDENS CINA SELATAN 30-50 kasus* INDONESIA (NATIVE) 4.7/6.7 kasus* MALAYSIA MALAY 1.1 kasus CHINESE 40.1(14.9) kasus SINGAPURA CANTONESE 18.2/7.5 HOKKIEN 12.3/3.7 MALAY 4.3/1.5 *per 100.000/tahun THAILAND 4.1/1.6 HONGKONG 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-laki Perempuan 191 93 76 67 49 35 40 2 Tumor Nasofaring Tumor Sinonasal Tumor Orofaring Tumor Laring 8 6 Carcinoma Auricula
  • 11. Grafik Tumor Kepala Leher Berdasarkan Umur Tahun 2007-2009 107 58 51 40 Tumor Nasofaring Tumor Sinonasal 20 18 Tumor Orofaring Tumor Laring 3 Tumor Telinga 4 78-87 1 68-77 0 58-67 38-47 1 48-57 3 28-37 2 18-27 2 11 4 77-89 5 25-37 12-24 73-83 51-61 3 64-76 11 40-50 1 29-39 7-17 81-91 70-80 59-69 48-58 37-47 26-36 2 5 18-28 3 15-25 4-14 75-84 65-74 55-64 45-54 6 35-44 15-24 5-14 2 25-34 7 13 11 24 51-63 20 17 38-50 27 62-72 30 29 24 2
  • 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 involvements Advanced stage
  • 14. ETIOLOGI & FAKTOR RISIKO Epstein-Barr virus (“smoke”) (Immuno)genetic factors Diet NPC Environmental factors Gender Ethnicity Herbal 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 , Otalgia Diplopia Ophtalmoplegia Lagophtalmus Tuli konduktif unilateral Perforasi , OME GEJALA KLINIS Obstruksi hidung Sekret + darah Anosmia Blood stained discharge PND Limfadenopati 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 lunak MRI: * Resolusi tinggi * Superior: residual/reccurent, inflamasi, fibrosis * Keterlibatan sum tul,perineural, intracranial
  • 21. 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 tissues T2a: Tumor extends to the oropharynx and/or nasal cavity without parapharyngeal extension* T2b: Any tumor with parapharyngeal extension* T3 Tumor invades bony structures and/or paranasal sinuses T4 Tumor 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 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 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 Grouping Distant Metastasis MX Distant metastasis cannot be assessed Stage 0 Tis, N0, M0 M0 No distant metastasis Stage I T1, N0, M0 M1 Distant metastasis 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
  • 29. Survival Rates Stage Relative Survival Rates 5-year 10-year I 78% 62% II 64% 52% III 60% 46% IV 47% 37%
  • 30. PENATALAKSANAAN Stadium I & II •Radioterapi Stadium III, IVa & b •Kemoradiasi Stadium IVc •Kemoterapi
  • 31. N P C THT Pemeriksaan klinis Endoskopi Biopsi nasofarings Radiologi CT scan kepala coronal extended Foto thorak USG upper abd DIAGNOSIS THT Catat hasil PA Ambil darah utk serologi Brushing nasofarings Staging: Stad. awal / Stad.lanjut M A N A G E M E N T Stad.awal Stad.lanjut TERAPI Radioterapi Radiasi eksternal 70 Gy + Brachitherapy THT Pemeriksaan klinis & endoskopi THT 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 serologi Tulip Kemoterapi Cisplatin & 5FU 3 siklus EVALUASI Tulip Pemeriksaan klinis Ambil darah utk serologi Radioterapi Pemeriksaan klinis Ambil darah utk serologi FOLLOW UP
  • 32. Potentially DO Diagnosis Early stage Advanced stage Radiotherapy Chemotherapy 2 weeks 12 weeks Radiotherapy 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 Area Age Proportion 50.00% 5% 4% 5% 40.00% Luar Jawa Jawa Timur Jawa Barat Jawa Tengah 86% 30.00% Series1 20.00% 10.00% 0.00% 10-30 y.o 31-50 y.o 51-70 y.o >70 y.o
  • 34. Sardjito’s 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 analysis log rank=8,60; p=0,003 1.0 .9 .8 .7 terapi LMP 2 .6 .5 Brachy (+) < 2.7=5:5 .4 Cencored 25 < 2.7-censored .3 =24 .2 Brachy (-):14 >= 2.7=14 Censored 12 .1 >= 2.7-censored 0.0 =13 0 10 20 30 40 50 60 70 80 Follow-up (bulan) n=56, stad. III dan IV non metastasis
  • 37. Protocol III n=23, Stad. III & IV non metastasis Overall Survival 1.0 Overal Survival .8 .6 .4 .2 Survival Function 0.0 Censored 0 5 10 15 20 25 30 Time (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) administration therapy 96 h 12 9 photosensitizer 3 6 photosensitizer + light + O2 laser Non thermal illumination of target volume cell death
  • 40. PDT Survival analysis n=25, rekurens/residu 1.0 .9 2005-2008 .8 Cum Survival .7 .6 .5 .4 .3 .2 Survival Function .1 0.0 Censored 0 5 10 15 20 25 30 35 40 Follow Up (Months) Event: Died and recurrence 42
  • 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 poor Important ! Diagnosis in early stage NO DELAY !!
  • 43. Delay in the diagnosis & treatment of NPC: Patient delay Profesional delay: Gagal mengidentifikasi gejala & tanda kecurigaan kanker System delay: Waktu yg diperlukan utk mendpt pelayanan kesehatan primer / RS Waktu yg diperlukan utk referal ke pelayanan tertier
  • 44. EARLY DIAGNOSIS AWARENESS (of symptoms and signs)
  • 45. Stadium dini Stadium lanjut
  • 46. KNF vs Clinical Symptom
  • 47. Cefalgia Rasa penuh di telinga Tinnitus Otalgia Diplopia Ophtalmoplegia Lagophtalmus Tuli konduktif unilateral Perforasi OME GEJALA KLINIS Obstruksi hidung Sekret + darah Anosmia Blood stained discharge PND Limfadenopati collie Trismus Disfagia Gangguan pengecap Atrofi palatum mole Parese parsial lidah
  • 48. Peran Serologi EBV pd KNF ? Serology Indonesia Singapore Hongkong IgA anti VCA Sensitivity % Specificity % 73,33% 95,00% 83,33% 80-90% 93,00% IgA anti EA Sensitivity % Specificity% 98,67% 63,67% 76,00% >95% Skreening faktor risiko, bukan diagnosis !!!
  • 49. Early diagnosis- “difficult” Tumor : non specific symptoms sub mucosal Medical expert : low index of suspiciousness technical exam of nasopharynx
  • 50. Deteksi dini pada penderita dg faktor risiko  Annual physical examination  Special attention to upper aerodigestive tract and neck with digital examination of oral cavity  Referral for evaluation of unexplained symptoms  Follow-up for patient with risk factor Stupp R, Vokes EE. Current Cancer Therapeutics. 3rd ed. 1998;165.
  • 51. Skreening penderita dengan risiko Pd umumnya tdk berhasil krn:  Rendahnya tingkat partisipasi penderita berisiko dlm program skreening  Kondisi subklinis/tanpa gejala yg lama  Faktor waktu dan perlu edukasi di seting di pelayanan kesehatan primer Schantz SP, et al. Cancer: Principles & Practice of Oncology. 6th ed. 2001;797-860.
  • 52. 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 sekitar anak-anak
  • 53. 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