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Anamnesis

Pemeriksaan Penunjang

Diagnosis

Pemeriksaan fisik

Pemeriksaan nasofaring

Neck swelling Social history Nasal sx

Family history

Aural sx

Anamnesis

Risk factors

Neurological sx

Constitutional sx Metastatic sx

Oropharyngeal sx

Pemeriksaan Fisik
General condition, LOC, Vital signs Anterior rhinoscopy & Posterior rhinoscopy

Throat Examination & Indirect Laryngoscopy


Otoscopy Cranial nerve examination

Nasopharyngoscopy

This elderly woman presented with epistaxis. On nasal endoscopy, a fleshy globular nasopharyngeal tumor is noted. The tumor is friable, easily bleeding and hangs from the vault of the nasopharynx. Histologic diagnosis: squamous cell carcinoma.

Pemeriksaan Laboratorium

Pemeriksaan Penunjang

Imaging

Histopatologi

Pemeriksaan Laboratorium
Full blood count

Liver function test

Renal profile

Serology: Specific EBV antigen


Histopathology

Histopathology
FNAC

FNAC to cervical lymph nodes

Tissue Biopsy Biopsy can be done via nasal or oral route. Pinch of tissue from the tumor is sent for histopathological studies.

Imaging
CT Scan MRI Chest X-ray
Staging, Submucosal tumor, Local extension, Bony erosion Soft tissue involvement Nerve compression

To rule out (TRO) lung metastasis

USG Bone scintigraphy

TRO liver, spleen and kidney metastasis

TRO bone metastasis

CT Scan of NPC

TNM Staging
Sistem TNM menurut UICC (Union for International Cancer Control) Tabel 1. T = Tumor, menggambarkan keadaan tumor primer, besar dan perluasannya T T0 T1 T2 Tumor primer Tidak tampak tumor Tumor terbatas di nasofaring Tumor meluas ke jaringan lunak T2A Perluasan tumor ke orofaring dan/atau rongga hidung tanpa perluasan ke parafaring T2B disertai perluasan ke parafaring Tumor menginvasi struktur tulang dan/atau sinus paranasal Tumor dengan perluasan intrakranial dan/atau terdapat keterlibatan saraf kranial, fossa infratemporal, hipofaring, orbita atau ruang mastikator

T3 T4

Tabel 2. N = Nodul, menggambarkan keadaan kelenjar limfe regional

Tabel 3. M = Metastase, menggambarkan metastase jauh

Stadium
Stadium 0 T1 N0 M0

Stadium I
Stadium IIa Stadium IIb

T1
T2a T1 T2a T2b

N0
N0 N1 N1 N0, N1 N2 N2 N2 N0, N1, N2 N3 Semua N

M0
M0 M0 M0 M0 M0 M0 M0 M0 M0 M1

Stadium III

T1 T2a, T2b T3

Stadium IVa Stadium IVb Stadium IVc

T4 Semua T Semua T

Treatment
Stages 0 and I : Radiation therapy Stages II, III, IVA and IVB : Chemoradiation Stage IVC
Chemotherapy (cisplatin and 5-FU). If no sign of cancer after chemotherapy, radiotherapy to nasopharynx & lymph nodes in the neck @ chemoradiation is given to kill remaining cancer cells. If there are still signs of cancer after the initial chemotherapy, another chemotherapy regimen may be tried. Chemotherapy plus targeted therapy cetuximab (Erbitux) may be another option.

American Cancer Society

Complication
Petrosphenoid syndrome Tumors grow upwards towards the base of the skull through the foramen laserum to cavernous sinus compressing N. III, N. IV. N.VI and also N. II & N.V which manifest as: Trigeminal neuralgia (N. V)
Unilateral facial pain limited to the area of distribution of the trigeminal nerve.

Lid ptosis (N. III) Ophthalmoplegia (N. III, IV N., N. VI)

Retroparidean syndrome
Tumor grows forward to nasal cavity and infiltrate the surrounding. It can also grow laterally and backward to retropharynx, parapharynx and lymph nodes. This tumor will compress N. IX, N. X, N.XI, N. XII to the manifestation of symptoms such as:
N. IX: difficulty swallowing as superior constrictor muscle hemiparesis and disturbance of taste in the posterior 1/3 of the tongue. NX: hiper / hipoanestesia of mucosal soft palate, pharynx and larynx with impaired respiration and saliva. N. XI: paralysis / atrophy of the trapezius muscle, sternocleidomastoid muscle and soft palate hemiparese. N. XII: hemiparalisis and atrophy of the tongue side.

Prognosis
Overall survival rates for people with undifferentiated nasopharyngeal cancer are better than the keratinizing type. This is because the undifferentiated type responds better to radiotherapy and chemotherapy Poor outcome of NPC:

Advance stage Types of nasopharyngeal cancer Age > 40 years old Male gender Chinese mongoloid race Cervical lymph node metastasis Paralysis of cranial nerve & skull damage Distant Metastasis

Prognosis
Stage 5 years survival rate (%)

I II
III IV

70% 65%
60% 40%

American Cancer Society

Prevention
Education Lifestyle modification

Vaccintion against EBV for high risk group.

Screening: serology, genetic studies

No sure way exists to prevent nasopharyngeal carcinoma.