Dr. Asti Widuri Sp. THT -KL, M.

Kes
 Leading cancers worldwide

Total New
Rank Males Females Both Sexes Cases

1 Lung Breast Lung 1,037,000

2 Stomach Colon/rectum Stomach 798,000
3 Colon/rectum Cervix uteri Breast 796,000
4 Prostate Stomach Colon/rectum 783,000
5 Liver Lung Liver 437,000
6 Mouth/pharynx Ovary Prostate 396,000
7 Esophagus Corpus uteri Cervix uteri 371,000
8 Bladder Liver Mouth/pharynx 363,000
9 Leukemia Mouth/pharynx Esophagus 316,000
10 NHL* Esophagus Bladder 261,000

*Non-Hodgkins lymphoma. Adapted from Parkin DM, et al. CA Cancer J Clin. 1999;49:39.
 Leading causes of death in 2001

Percentage of Total Deaths, US

Heart Diseases 31.0
Cancer 23.2
Cerebrovascular Diseases 6.8
Chronic Obstructive Lung Diseases 4.8
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.

HEAD & NECK CANCER
Worldwide incidence and mortality (estimated)

Males (thousands) Females (thousands)

Cases (thousands)

Cases (thousands)
141 160
160
120
120 70
66 77 80
80 40 50 34
24 40 18 11 17 12
40
0 0
Mouth Nasopharynx Other Pharynx Mouth Nasopharynx Other Pharynx

Incidence Mortality Incidence Mortality

Parkin DM, et al. CA Cancer J Clin. 1999;49:33-64.

Kepala dan leher
Rongga mulut: termasuk bibir, bagian depan lidah,
langit-langit keras, dasar mulut, bagian dari garis gusi
dan lapisan dalam pipi.
Nasofaring: daerah faring di belakang hidung dan
perbatasan belakang hidung.
Oropharynx: daerah pharynx di belakang mulut,
langit-langit lunak, amandel, dan pangkal lidah
Hypopharynx: mencakup daerah faring bawah
oropharynx ke kerongkongan
Kepala dan leher
Laring: termasuk pita suara (laring), yang terletak tepat di
bawah faring, dan katup tenggorok, yang merupakan
lipatan jaringan yang mencegah air liur dan makanan
masuk trakea ketika salah satu menelan
Sinus (frontal, ethmoid, berkenaan dgn rahang atas,
sphenoid)
Kelenjar ludah (kelenjar mayor dan minor)
Bagian-bagian telinga (kanal auditori eksternal, tengah dan
telinga dalam)
Leher (kelenjar getah bening, dll)
 Risk factors
Tobacco
Alcohol
Male gender, Age> 50yrs
Poor orodental care
Genetic susceptibility
Occupational exposure
Malnutrition
Mechanical irritation
Chronic viral infection
Apa penyebab kanker kepala dan leher, dan
faktor risikonya?
80-90% kanker kepala dan leher disebabkan oleh
penggunaan tembakau dan alkohol.
Tembakau rokok, cerutu, pipa, dan tembakau
tanpa asap (mengunyah, dip, tembakau, dan sirih).
Pengguna tembakau 20-40 kali lebih mungkin
mengalami kanker kepala dan leher dari non-
pengguna, tergantung pada jumlah penggunaan,
serta usia, jenis kelamin dan ras pengguna.
Apa tanda-tanda kepala & leher kanker?
Rongga mulut: bercak putih atau luka tak sembuh-
sembuh, atau mulut sakit
Nasopharyngeal atau sinus: sinus infeksi yang tidak
membaik dengan terapi antibiotik, nyeri di rahang
atas, hidung berdarah, sesak napas, sakit atau
berdering di telinga
Pharyngeal: kesulitan menelan, sakit tenggorokan,
atau suara serak
Pemeriksaan fisik
TUMOR PALATUM
Tumor tonsil
Ca sinonasal
Early detection in patients at risk
Annual physical examination
Special attention to upper aerodigestive
tract and neck with digital examination
of oral cavity
Referral for evaluation of unexplained symptoms
Biopsy/follow-up for leukoplakia
Systematic work-up
History, clinical signs
ENT investigation
FNAC
Imaging
Examination under general anesthesia
Pathological examination of the fine needle
aspirate and biopsies with ancillary techniques like
Immuno-histochemistry and Molecular biology
History
Painless often slowly growing mass in level II/III
Adult male population
Asian or Mediterranean descent
Alcohol abuse and heavy smoking
Radiation exposure in the past
Curative treatment in the past for other
malignancy
Clinical Signs
Local pain or referred pain to the ear
Hoarseness
Bloodstained discharge form the nose
Hearing loss
Foetor
Speech and swallowing disorders
Airway obstruction (nose or larynx)
Trismus
ENT investigation
Inspection of mucosa
Bimanual examination of oral cavity
Palpation of neck
Biopsy of leukoplakia, erythroplakia,
erythroleukoplakia
Indirect laryngoscopy
Endoscopic examination
Direct laryngoscopy, Esophagoscopy,
Bronchoscopy
ENT investigation
At least two experienced ENT surgeons
Flexible nasopharyngoscope for inspection
nasopharynx and oro/hypopharynx
Bi-manual palpation
Fine needle aspiration cytology
/FNAC
ultrasound guidance if necessary
Imaging

X ray of the chest

CT scan head and neck
MRI (CT no signs for primary or not conclusive,
contra-indication for contrast fluid)
(PET)
NPC
Tumor ganas yg berasal dari epitel mukosa yang
terdapat pada nasofaring atau kelenjar yang
terdapat di nasofaring ( Batsakis, 1974; Rao-
Levitt, 1985).
Tumor ganas yang tumbuh di daerah nasofaring
dengan predileksi di fossa rossenmuller dan atap
nasofaring.(Roezin, 2001)
Sign & Symptoms
Early stage : not specifics
Nose obstruction.
Rinorrhoe.
Epistaxis / Nose blood.
Tinitus.
Deafness.
Late stage ;
Lump of the neck .
Strabismus.
Exopthalmus.
Headache.
Difficulty of swallowing
Gejala
Gejala dini (tumor masih terbatas pd nasofaring) :
Telinga : Oklusi tuba Eustachius rasa penuh
ditelinga, berdengung. Gangguan pendengaran
Otitis media serosa sampai perforasi dg
gangguan pendengaran.
Hidung : Epistaksis (berulang-ulang, jumlah sedikit
bercampur ingus, warnanya merah jambu)
Sumbatan hidung, pilek kronis, gangguan
penciuman, ingus kental
Gejala lanjut :
Limfadenopati servical
Gejala akibat perluasan tumor ke jaringan sekitar
Gejala akibat metastase jauh
Diagnose
Complete ENT Examination
Rhinscopy anterior.
Rhinoscopy posterior.
Nasopharyngoscopy.
Biopsy.
CT Scan
Serology
 Histo Pathology
WHO I : Keratinizing Carcinoma ( 0 % )
WHO II : Non Keratinizing Carcinoma (20.55%)
WHO III : Undifferentiated Carcinoma ( 79,45%)
Staging
UICC 1997
Tumor
T1 : Tumor confined to nasopharynx
T2 : Tumor Extends to orophaynx and /or nasal fossa.
(T2a : without parapharyngeal extension. )
T3 : Tumor invaded to bony structures.
T4 : Tumor with intracranial extension
 N0 : No regional lymph node metastasis.
N1 : Unilateral metastasis in lymph node (s), 6 cm or
less .
N2 :Bilateral metastasis in lymph node(s), 6 cm or less.
N3 : Metastasis in lymph node(s)
a : greater than 6 cm
b : in supra clavicular fossa.
MO : No distant metastasis.
M1 : Positive distant metastasis
 Stage :
I : T1 No Mo
IIA : T2a No Mo
IIB : T1 N1 Mo / T2a N1 Mo / T2b No-1 Mo
III : T1-2 N2 Mo / T3 N0-2 Mo
IVA : T4 No-2 Mo
IVB : All T, N3 Mo
IVC : All T. all N, M1
Treatment
Stage I & II : External Radiotherapy.(followed with
brachytherapy).
Stage III & IV : Chemotherapy followed with external
radiotherapy.
Chemotherapy :
Cis-platinum
5 Flurouracil
 Recurrent :
Local :
Brachytherapy
Photo Dynamic therapy
Regional.
Surgery : Neck Dissection.
>> no. 4 Ca KL DIAGNOSIS
Lokasi tumor, PA Anamnesis keluhan
Std AJCC Pemeriksaan fisik
1997 Ca Laring Pemeriksaan penunjang
ETIOLOGI Laringoskopi : - direk
Rokok - indirek
Polusi Biopsi
karsinogenik
Genetik
HPV
TERAPI
KOMPLIKASI
PREDISPOSISI
Laringektomy Fistula faringo-
Umur
cutaneus
Sex
sepsis
Pekerjaan Radioterapi aspirasi pneumoni
Std
hipokalsemi
PA Kemoterapi dehisensi
Px pre op : TT,
NGT, Lab, Ab
Laryngoscopy direct tumor glottis
CA LARYNX PASKA TRACKHEOSTOMI
UICC STAGING
OF CARCINOMA OF THE LARYNX 1997

TNM STAGE :
I : T1 N0 M0
II : T2 N0 M0
III: T3 N0 M0
T1/2/3 N1 M0
IV : T4 N0/1 M0
T0-4 N2/3 M0
T0-4 N0-3 M1
Supraglottis
T1: Tumor limited to one subsite of
the supraglottis with normal vocal
cord mobility
T2: Tumor invades mucosa of
more than one adjacent subsite of
the supraglottis or glottis or region
outside the supraglottis (eg,
mucosa of the base of tongue,
valleculae, medial wall of pyriform
sinus) without fixation of the larynx
T3: Tumor limited to the larynx
with vocal cord fixation and/or
invades any of the following:
postcricoid area, preepiglottic UICC STAGING OF
tissues CARCINOMA OF
T4: Tumor invades through the THE LARYNX 1997
thyroid cartilage, and/or extends
into the soft tissues of the neck,
thyroid and/or esophagus
Glottis
T1: Tumor limited to the vocal cord(s)
(may involve anterior or posterior
commissure) with normal vocal cord
mobility
T1A: Tumor limited to one vocal cord
T1B: Tumor involves both vocal cords
T2: Tumor extends to the supraglottis
and/or subglottis, and/or with impaired
vocal cord mobility
T3: Tumor limited to the larynx with
vocal cord fixation
T4: Tumor invades through the thyroid
cartilage and/or extends to other
tissues beyond the larynx (eg, trachea,
soft tissues of the neck, including UICC STAGING OF CARCINOMA
thyroid, pharynx) OF THE LARYNX 1997
Subglottis
T1: Tumor limited to the subglottis
T2: Tumor extends to the vocal
cord(s) with normal or impaired
mobility
T3: Tumor limited to the larynx with
vocal cord fixation
T4: Tumor invades through the
cricoid or thyroid cartilage and/or
extends to other tissues beyond the
larynx (eg, trachea, soft tissues of
the neck, including thyroid,
esophagus)

UICC STAGING OF CARCINOMA OF THE LARYNX 1997

Lymph node
N0: No regional lymph node metastasis
N1: Ipsilateral lymph node metastasis =
3 cm
N2: Lymph node metastasis in a single
ipsilateral lymph node > 3 cm and = 6
cm, or in multiple lymph nodes none
more than 6 cm including bilateral nodal
metastasis)
N2A: Lymph node metastasis in single
UICC STAGING
ipsilateral lymph node > 3 cm and = 6 cm OF
N2B: Lymph node metastasis in multiple CARCINOMA
ipsilateral lymph nodes all = 6 cm OF THE
N2C: Lymph node metastasis in bilateral LARYNX 1997
or contralateral lymph nodes all = 6 cm
N3: Lymph node metastasis > 6 cm

Metastase
M0 : no metast
M1 : Advanced metast
Flow chart Penanganan Ca Laring
Laringoskopi
Suara indirek dg Endoskopi /
serak cermin Laringoskopi
indirek
ANAMNESIS : BIOPSI DIAGNOSIS
gejala, riwayat Ca Laring
Ro,CT scan
T1 Eksisi, RTx
T2 Hemilaringektomi, STADIUM
Laringektomi parsial, RTx
T3/4 laringektomi total,
RTx, Kemoterapi TERAPI
Bagaimana kanker kepala dan leher dirawat?

Tim perawatan kanker multidisipliner, ahli bedah,

otorhinolaryngologists (THT), ahli patologi, ahli onkologi
medis dan radiasi, dokter gigi, ahli bedah plastik, ahli
diet, pekerja sosial, perawat, terapis fisik dan terapi
wicara.
Pendekatan tim ini sangat penting untuk suksesnya
pengobatan dan untuk membantu pasien menjaga
kualitas hidup.
Secara umum, tahap I dan II kanker diobati dengan
operasi dan / atau terapi radiasi, sedangkan tahap III
dan IV multi-mode memerlukan pengobatan (operasi,
radiasi, dan kemoterapi).