Bab III. Hasil dan Diskusi
3.7. Algoritma Diagnosis dan Tata Laksana
Nasofaring&curiga&tumor Klinis&curiga Nasofaring&tampak&normal
Serologi&EBV&(C)&
9"
Daftar Pustaka
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BAB IV
SIMPULAN DAN REKOMENDASI
Karsinoma Nasofaring (KNF) merupakan keganasan yang muncul pada daerah nasofaring (area di atas tenggorok dan di belakang hidung).
Karsinoma ini terbanyak merupakan keganasan tipe sel skuamosa.
Diagnosis pasti berdasarkan pemeriksaan PA dari biopsi nasofaring, bukan dari Biopsi Aspirasi Jarum Halus (BAJH) atau biopsi insisional/eksisional kelenjar getah bening leher.
Terapi kanker nasofaring dapat mencakup radiasi, kemoterapi, kombinasi keduanya, dan didukung dengan terapi simptomatik sesuai dengan gejala.
Koordinasi antara bagian THT, Radioterapi, dan Onkologi Medik merupakan hal penting yang harus dikerjakan sejak awal.
Teknik radiasi yang dapat diberikan adalah teknik 2D, 3D, IMRT. Teknik IMRT di dunia telah menjadi standar namun teknik lain dapat diterima asalkan spesifikasi dosis dan batasan dosis terpenuhi. (Rekomendasi A)
Penggunaan teknik IMRT telah menunjukkan penurunan dari toksisitas kronis pada kasus karsinoma orofaring, sinus paranasal, dan nasofaring dengan adanya penurunan dosis pada kelenjar-kelenjar ludah, lobus temporal, struktur pendengaran (termasuk koklea), dan struktur optic.
(Rekomendasi A)
Terapi sistemik pada Karsinoma Nasofaring adalah dengan kemoradiasi dilanjutkan dengan kemoterapi adjuvant, yaitu Cisplatin + RT diikuti dengan Cisplatin/5-FU atau Carboplatin/5-FU. (Rekomendasi A)
Syarat pasien kanker yang membutuhkan tatalaksana nutrisi: (Rekomendasi A)
!! Skrining gizi dilakukan untuk mendeteksi gangguan nutrisi, gangguan asupan nutrisi, serta penurunan BB dan IMT sedini mungkin
!! Skrining gizi dimulai sejak pasien didiagnosis kanker dan diulang sesuai dengan kondisi klinis pasien
!! Pada pasien dengan hasil skrining abnormal, perlu dilakukan penilaian objektif dan kuantitatif asupan nutrisi, kapasitas fungsional, dan derajat inflamasi sistemik.
Direkomendasikan bahwa selama radioterapi pada kanker kepala-leher, saluran cerna bagian atas dan bawah, serta thoraks, harus dipastikan asupan nutrisi adekuat, melalui edukasi dan terapi gizi individual dan/atau dengan menggunakan ONS, untuk mencegah gangguan nutrisi, mempertahankan asupan adekuat, dan menghindari interupsi RT. (Rekomendasi A)
Disarankan untuk melakukan skrining rutin pada semua pasien kanker lanjut, baik yang menerima maupun tidak menerima terapi antikanker, untuk menilai asupan nutrisi yang tidak adekuat, penurunan BB dan IMT yang rendah, dan apabila berisiko, maka dilanjutkan dengan assessmen gizi.
(Rekomendasi A)
Kebutuhan energi total pasien kanker, jika tidak diukur secara individual, diasumsikan menjadi agak mirip dengan subyek sehat dan berkisar antara 25−30 kkal/ kg BB/hari. (Rekomendasi A)
Pasien sebaiknya diberi informasi dan instruksi tentang nyeri dan penanganan serta didorong berperan aktif dalam penanganan nyeri(Rekomendasi B)
Prinsip program pengontrolan nyeri WHO sebaiknya digunakan ketika mengobati pasien kanker (Rekomendasi D). Pengobatan pasien nyeri kanker sebaiknya dimulai pada tangga WHO sesuai dengan tingkat nyeri pasien (Rekomendasi B). Rekomendasi terbaik : penanganan optimal pasien nyeri kanker memerlukan pendekatan multidisiplin
Program latihan pencegahan dan edukasi manuver posisi menelan dapat mengurangi hendaya, menjaga fungsi, dan mempercepat pemulihan.
(Rekomendasi D)
Pasien kanker kepala dan leher dengan disfagia sebaiknya mendapatkan terapi bicara dan bahasa yang tepat untuk mengoptimalkan fungsi menelan yang masih ada dan mengurangi risiko aspirasi. (Rekomendasi C)
Semua pasien dengan kemoradiasi sebaiknya mendapatkan akses terapi bicara dan bahasa baik sebelum, selama, dan sesudah kemoradiasi.
(Rekomendasi C)
Lampiran 1. Prinsip Kemoterapi
Prinsip'Kemoterapi'(1)' '
Adapun'regimen'kemoterapi'yang'dapat'diberikan'adalah'' 1.'Cisplatin'Mingguan9Radioterapi''
2.'Docetaxel9Cisplatin959Fluorouracil'' 3.'59Fluorouracil9Cisplatin''
4.'Methotrexate'' 5.'Paclitaxel9Cisplatin'' 6.'Capecitabine''
7.'Cisplatin9Radioterapi'+'Ajuvan'Cisplatin9Fluorouracil'' 8.'Gemcitabine9Cisplatin''
' '
Obat3obatan'Simptomatik'
1.'Keluhan'yang'biasa'timbul'saat'sedang'diradiasi'terutama'adalah'akibat'reaksi'akut'pada'mukosa'mulut,'berupa'nyeri'untuk'mengunyah' dan'menelan.'
2.'Keluhan'ini'dapat'dikurangi'dengan'obat'kumur'yang'mengandung'tanda'septik'dan'adstringent,'(diberikan'3'–'4'sehari).'Bila'ada' tandatanda'moniliasis,'dapat'diberikan'antimikotik.'
3.'Pemberian'obat9obat'yang'mengandung'anestesi'lokal'dapat'mengurangi'keluhan'nyeri'menelan.'
4.'Sedangkan'untuk'keluhan'umum,'misalnya'nausea,'anoreksia'dan'sebagainya'dapat'diberikan'terapi'simptomatik.' 5.'Radioterapi'juga'diberikan'pada'kasus'metastasis'untuk'tulang,'paru,'hati,'dan'otak.'
Prinsip'Kemoterapi'(2)' '
A.'Nama'regimen' CISPLATIN'mingguan3RADIOTERAPI'' Jenis'kanker' Kanker'kepala'dan'leher'stadium'lokal'
lanjut!
Tujuan'kuratif'
'
Regimen'Kemoterapi''
Regimen'cisplatin'mingguan'+'radioterapi'–'salah'satu'regimen'kanker'kepala'an'leher'yang'efektif'dengan'efek' samping'yang'relatif'rendah.'
Penggunaan'Rasional '
Untuk'kanker'kepala'dan'leher,'stadium'lokal'lanjut'yang'tidak'dapat'direseksi.'' B.'Efek'samping'
'
Efek'samping'yang'paling'sering'terjadi '
•' Mual'muntah' '
•' Nefrotoksiksisitas' '
•' Neurotoksiksistas'dan'ototoksiksisitas' '
•' Myelosupresi'dan'infeksi' '
•' Stomatitis' '
•' Fatigue' '
C.'Hal3hal'yang'harus'diperhatikan' '
Koordinasi'dengan'bagian'radioterapi'merupakan'hal'penting'yang'harus'dikerjakan'sebelum'memulai'program' terapi'dengan'regimen'ini.'Selain'itu,'selama'terapi'sangat'penting'untuk'mengedukasi'penderita'agar'
mempertahankan'asupan'makanan'dan'cairan'cukup'untuk'mengurangi'risiko'terjadinya'mukositis'yang'berat.' Pemasangan'selang'nasogastrik'sejak'awal'perlu'dipertimbangkan'untuk'mempertahankan'asupan'makanan'dan' minuman.'Guna'menghindari'infeksi'fokal'dari'gigi'dan'mulut,'perlu'dilakukan'konsultasi'perawatan'kesehatan'gigi' mulut'sebelum'dimulai'terapi'kemoradiasi.'Selain'itu'selama'menjalani'kemoradiasi,'higiene'oral'perlu'dijaga' dengan'cara'menggunakan'obat'kumur'secara'teratur.'Jenis'obat'kumur'yang'dapat'digunakan'adalah'obat'kumur' yang'mengandung'salin,'fluoride,'dan'larutan'analgetik.'Sukralfat'topikal,'dan'nystatin'topikal'juga'dapat'dipakai' untuk'mengurangi'derajat'mukositis.'Penderita'disarankan'untuk'banyak'mengunyah'permen'karet'tanpa'gula'guna' mengurangi'beratnya'xerostomia'kronik'pasca'radiasi.''
'
D.'Catatan'
'
Meskipun' regimen' ini' relatif' aman' digunakan,' efek' samping' yang' berat' tetap' mungkin' terjadi' terutama' pada' penderita'dengan'status'performa'yang'kurang'baik'(ECOG'2,'lihat'Lampiran'1).'Penderita'dengan'status'performa' kurang' baik' atau' penderita' yang' status' performanya' menurun' selama' pengobatan,' sebaiknya' disarankan' rawat' inap'agar'dapat'dilakukan'monitor'ketat'untuk'mencegah'timbulnya'efek'samping'yang'berat.'Penggunaan'masker' pelindung'khusus'selama'radiasi'sangat'diperlukan'untuk'mengurangi'beratnya'efek'samping.'Selain'efek'samping'
akut'juga'sering'dijumpai'efek'samping'kronik'terutama'berupa'xerostomia'yang'sering'dikeluhkan'penderita'karena' akan' berpengaruh' terhadap' nafsu' makan' dan' pada' akhirnya' akan' menyebabkan' penurunan' kualitas' hidup.' Efek' samping' kronik' lain' yang' sering' terjadi' adalah' osteoradikulonekrosis' yang' menyebabkan' tanggalnya' gigi.' Pemeriksaan'gigi'dan'mulut'sebelum'pengobatan'akan'menurunkan'risiko'timbulnya'efek'samping'ini''
Prinsip'Kemoterapi'(3)' '
A.'Nama'regimen' DOCETAXEL3CISPLATIN353FLUOROURACIL'' Jenis'kanker' Kanker'kepala'dan'leher'stadium'lokal'
lanjut!
Induksi'/'neoajuvan' Tujuan'kuratif' '
Regimen'Kemoterapi''
Regimen'docetaxel9cisplatin95FU:'sering'disebut'dengan'regimen'TPF,'merupakan'regimen'standar'baru'yang' mulai'banyak'digunakan'di'beberapa'pusat'onkologi'di'dunia.''
'
Penggunaan'Rasional '
Terapi'induksi/neoajuvan'kanker'kepala'dan'leher,'stadium'lokal'lanjut'yang'tidak'dapat'direseksi.'' B.'Efek'samping'
'
Regimen' 5FU' bolus' memiliki' efek' myelosupresi' dan' gastrointestinal' lebih' besar' namun' lebih' sedikit' hand&foot!
syndrome,'dibanding'infus'kontinyu.' Efek'samping'yang'paling'sering'terjadi '
•' Myelosupresi'
•' Mual'muntah' '
•' Demam,'reaksi'hipersensitivitas'
•' Retensi'cairan'
•' Neuropati'(ototoksisitas)'
•' Stomatitis'
•' Nefrotoksisitas'
•' Hand&foot!syndrome' '
C.'Catatan'
'
Regimen'TPF'sekarang'ini'banyak'digunakan'sebagai'terapi'induksi/neoadjuvan'standar'kanker'kepala'dan'leher' stadium'lokal'lanjut'yang'tidak'dapat'direseksi'menggantikan'regimen'klasik'PF'(cisplatin95FU),'karena'efikasinya' yang'lebih'baik'serta'profil'efek'sampingnya'yang'lebih'ditoleransi'oleh'penderita.'Regimen'TPF'diberikan'sebanyak' 4' siklus' dan' dalam' 497' minggu' sesudah' kemoterapi' selesai,' terapi' dilanjutkan' dengan' radioterapi' atau' kemoradioterapi' konkuren.' Median' OS' kombinasi' TPF' +' radioterapi' adalah' 18,8' bulan,' sedangkan' median' OS' untuk'kombinasi'TPF'+'konkuren'kemoradioterapi'adalah'71'bulan.''
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Prinsip'Kemoterapi'(4)' '
A.'Nama'regimen' 53FLUOROURACIL3CISPLATIN' Jenis'kanker' Kanker' kepala' dan' leher' stadium'
lanjut'(metastasis'atau'rekuren)!
Tujuan'paliatif'
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Regimen'Kemoterapi''
Regimen'59FU9cisplatin:'sering'disebut'regimen'klasik'karena'paling'lama'dan'paling'luas'digunakan'sebagai'terapi' standar'kanker'kepala'dan'leher'stadium'lanjut.'
Penggunaan'Rasional '
Terapi'induksi'untuk'penderita'kanker'kepala'dan'leher'rekuren'dan/atau'metastasis.'' B.'Efek'samping'
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Regimen' bolus' 5FU' memiliki' efek' myelosupresi' dan' gastrointestinal' lebih' besar' namun' lebih' sedikit' handfoot!
syndrome,'dibanding'infus'kontinyu'5FU.' Efek'samping'yang'paling'sering'terjadi '
•' Mual'muntah' '
•' Nefrotoksiksisitas' '
•' Neuropati'(ototoksisitas)'
•' Myelosupresi'
•' Stomatitis'
•' Hand&foot!syndrome' '
C.'Pemberian'obat'dan'hal3hal'yang'perlu'diperhatikan' '
Cisplatin!'
Efek'samping'utama'cisplatin'adalah'nefrotoksik'yang'sangat'berkaitan'dengan'fungsi'ginjal'sebelum'terapi,' sehingga'penting'untuk'selalu'memonitor'fungsi'ginjal'sebelum,'selama'dan'sesudah'terapi.'Hidrasi'yang'adekuat' adalah'kunci'utama'untuk'mereduksi'kemungkinan'terjadinya'gagal'ginjal.'
'' 5FU!'
5FU'dapat'dilarutkan'dalam'NaCl'0,9%'ataupun'D5%.'5FU'yang'sudah'dilarutkan'dalam'NS'atau'D5%'stabil'dalam' 96'jam'pada'suhu'kamar.''
D.'Catatan'
'
Regimen' 5FU9cisplatin' sering' menyebabkan' efek' samping' grade' 3/4' berupa' trombositopenia,' nausea,' vomitus,' stomatitis' dan' penurunan' pendengaran.' Mortalitas' yang' berhubungan' dengan' toksisitas' obat' terjadi' pada' kurang' lebih' 5%' penderita.' Beratnya' efek' samping' dari' regimen' ini' merupakan' salah' satu' faktor' yang' menyebabkan' penderita' putus' berobat.' Beberapa' cara' dilakukan' untuk' menurunkan' toksisitas' regimen' ini' antara' lain' yaitu:'
mengurangi' dosis' cisplatin' maupun' dosis' 5FU' atau' memberikan' cisplatin' dalam' dosis' terbagi' selama' beberapa' hari.' Di' beberapa' pusat' onkologi,' kedudukan' regimen' 5FU9cisplatin' sebagai' terapi' standar' telah' diganti' dengan' regimen'TPF.''
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Prinsip'Kemoterapi'(5)' '
A.'Nama'regimen' METHOTREXATE'
Jenis'kanker' Kanker' kepala' dan' leher' stadium' lanjut'(metastasis'atau'rekuren)!
Tujuan'paliatif'
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Regimen'Kemoterapi''
Regimen'methotrexate:'merupakan'salah'stau'regimen'klasik'yang'digunakan'di'banyak'pusat'onkologi.' Penggunaan'Rasional '
Terapi'untuk'penderita'kanker'kepala'dan'leher'rekuren'dan/atau'metastasis,'biasanya'digunakan'sebagai'terapi'lini' kedua'bagi'mereka'yang'gagal'dengan'dengan'regimen'berbasis'platinum'atau'terapi'lini'pertama'pada'penderita' yang'tidak'dapat'mentoleransi'terapi'kombinasi'cisplatin95FU.''
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B.'Efek'samping'
'
Efek'samping'yang'paling'sering'terjadi '
•' Mual'muntah' '
•' Myelosupresi'
•' Stomatitis'
•' Diare'
•' Toksisitas'paru'(jarang)'
•' Radiation'recall'reaction'(jarang)'
•' Nefrotoksisitas'(jarang)'
•' Hepatotoksisitas'(jarang)' '
C.'Pemberian'obat'dan'hal'yang'perlu'diperhatikan' '
Beberapa'efek'samping'methotrexate'yang'jarang'terjadi'(frekuensi'1%910%)'tetapi'dapat'bersifat'berat'adalah'
Beberapa'efek'samping'methotrexate'yang'jarang'terjadi'(frekuensi'1%910%)'tetapi'dapat'bersifat'berat'adalah'