SISTEM ALIRAN LIMF LEHER

Penting o/k hampir semua bentuk radang ,keganasan

bermanifetasi ke kelenjar limf leher

Setiap sisi leher 75 kelenjar limf

- >> rangkaian jugularis int & spinal asesorius

Rangkaian kel limf jugularis interna (profunda)

- clavicula dasar tengkorak
- Selalu terlibat metastasis tumor
Kelompok kelenjar limf :
 Jugularis prof. superior.
 Jugularis prof. medius
 Jugularis prof. inferior
 Submentalis
 Submandibula
 Servikal superfisial
 Retrofaringeal
 Paratrakeal
 Spinal asesorius
 Skalenius anterior
Nodus jugularis profunda superior
Palatum molle, tonsil, arkus ant/post, dasar lidah,
posterior lidah, sinus piriformis, supraglottik,
nodus retrofaring, spinal asesorius, parotis, servikalis
superfisialis, submandibula
Nodus jugularis profunda medius
Subglottik laring, sinus piriformis bgn inferior,
krikoid posterior.
Nodus jug.prof.sup, retrofaring bgn inferior
Nodus jugularis profunda inferior
Kel.tiroid, trakea, esofagus pars sevikalis.
Nodus jug.prof. med, paratrakea
Nodus submental
Dagu, bibir bawah bgn tengah, cavum oris ant,
vestibulum nasi.
Eferen : nodus submandibula, jug.prof. superior

Nodus submandibula
Area submentalis, kel.liur submandibula,
bibir atas, lateral bibir bawah, rongga hidung,
kavum oris anterior, 2/3 ant. lidah

Nodus retrofaring
Nasofaring, cav.nasi post, telinga tengah,
tuba eustachius, orofaring, hipofaring, sinus
paranasalis
Nodus spinal asesorius
Kulit kepala bagian parietal, leher belakang,
Nodus retrofaring
Nodus servikalis superfisialis
Parotis, oksipitalis, retroaurikuker, terdapat vena
jugularis eksterna
Nodus paratrakea
Hipofaring, esofagus servikalis, trakea bgn atas, tiroid
Nodus supraklavikula
Paru, hepar, nodus spinal asesorius
 What is head and neck cancer?

Head and Neck

Cancer is a group
of cancers that
includes tumors
in several areas
above the collar
bone.
Head and Neck Cancer has three major
subdivisions:

 Oral Cancer
 Laryngeal Cancer
 Nasopharyngeal Cancer.
Head and Neck Cancer

Squamous cell carcinoma

of the head and neck
(SCCHN) occurs in
50,000 new cases
annually in the US,
resulting in over 13,000
deaths each year
 Risk Factors for
Head and Neck Cancer
Tobacco Products:
 Smoking Tobacco
Chemicals:
 Cigarettes
 Asbestos
 Cigars
 Chromium
 Pipes  Nickel
 Chewing Tobacco  Arsenic
 Snuff  Formaldehyde

Ethanol Products Other Factors:

 Ionizing Radiation
 Plummer-Vinson Syndrome
 Epstein-Barr Virus
 Human Papilloma Virus
Possible Occupational Risks
for Head and Neck Cancer

 Woodworking
 Leather manufacturing
 Nickel refining
 Textile industry
 Radium dial painting
Warning Signs of Head and Neck Cancer

 Hoarseness  Serous otitis media

 Erythroplasia
 Referred otalgia
 Persistent sore throat
 Epistaxis
 Nasal obstruction
 Neck mass
 Non-healing ulcer
 Dysphagia
 Submucosal mass

Not all cancers present with symptoms at early stages!

Factors Delaying the Diagnosis of
Head and Neck Cancers

 Patient procrastination in seeking medical

attention
 Physician delay in diagnosis
 Patient remains asymptomatic for a prolonged
period
Anatomy
 Generally, T stage
 Depends on anatomical location, complicate
 General concept of T stage
 T1, T2: confined, not invade adjacent tissue
 T3: larger, may invade adjacent tissue

 T4: deeply invade adjacent tissue/organ

 4a, 4b: depends on extend of invasion

 Critical structure: skull base, pre-veterbral
fascia, internal carotid artery, mediastinum
 T stage of oropharyngeal cancer
T1 T2 T3

T4a T4b Invade to adjacent tissue,

more extensive

Invade to adjacent tissue,

less extensive
 N1 Single ipsilateral, < 3cm

Single,<
3 cm

Ipsilateral Contralateral
 N2a Single ipsilateral, 3-6cm

Single,
3-6 cm

Ipsilateral Contralateral
 N2b Multiple ipsilateral, < 6cm

< 6 cm

Ipsilateral Contralateral
 N2c Bilateral or contralateral, < 6cm

< 6 cm

Ipsilateral Contralateral
 N3 Any LN > 6cm

> 6 cm

Ipsilateral Contralateral
 Staging
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
Stage IVa T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
Stage IVb T4b Any N M0
Any T N3 M0
Stage IVc Any T Any N M1
 Resectability
 Depends on T stage
 T1, T2: resectable
 T3: may be resectable
 T4: mostly unresectable

 Depends on surgical team

 Wide excision  reconstruction
 ENT surgeon  plastic surgeon

 Depends on patients
 Organ preservation
 Definitive local therapy

 Historically
 Resectable: surgery +/- RT
 Primary tumor: margin positive or close, perineural
invasion, vascular embolism
 LN: multiple, extracapsular extension

 Unresectable: RT alone
Incorporation of chemotherapy
 Before definitive treatment:
 Induction/neoadjuvant chemotherapy

 After definitive treatment

 Adjuvant/consolidation chemotherapy

 Concurrent with radiotherapy

 Concurrent chemoradiotherapy
 KARSINOMA NASOFARING

KNF : Tumor ganas THT terbanyak

Urutan V di Indonesia

EPIDEMIOLOGI
Cina Selatan ( Guang Dong, Guang Xi)
- 38,84 / 100.000 penduduk
Asia Tenggara
- Ras Mongoloid
Eskimo
Sex Incidence Pria : Wanita ( Makassar 2,8 : 1 )
Age Incidence : 30 – 50 thn (44%)
ETIOLOGI

Multifaktor :
Genetik : HLA-A2, HLA-B.sin
Virus : Epstein Barr
- DNA pada epitel sel tumor
- Antibodi Anti EBV
Environment
- Nitrosamin
- Asap kayu bakar
- Herbal tea
- Higiena buruk
- Ventilasi buruk
HISTOPATOLOGI

KNF adalah tumor asal epidermoid

Kriteria WHO :

Tipe 1 : Keratinizing squamous cell carcinoma

(Karsinoma sel skuamosa berkeratin)
Tipe 2a : Non-keratinizing squamous cell carcinoma
(Karsinoma sel skuamosa tidak berkeratin)
Tipe 2b : Undifferentiated carcinoma
(Karsinoma tidak berdiffrensiasi)
GEJALA KLINIK

Lokasi pertumbuhan di fossa Rossenmuleri

Stadium dini tidak khas
Diagnosis dini sulit ok :
- nasofaring tersembunyi
- creeping tumor
Tergantung lokasi tumor
Nasofaring : obstruksi nasi, epistaksis
Telinga : oklusi tuba, gangguan pendengaran,
otalgi, tinnitus
Mata dan syaraf : diplopia (N.VI) , parestesi muka (N.V)
Kadang ke N.III dan IV,
lebih lanjut dapat mengenai N.IX, X, XI,
sefalgia/hemisefalgia

Leher : Tumor koli lateral (nodus jug.prof.sup disebelah

bawah belakang m. sternokleidomastoideus)

Metastasis jauh : hepar, paru, tulang

DIAGNOSIS

Gejala klinis : 2 gejala curiga KNF

3 gejala klinis KNF
Nasofaringoskopi
Peningkatan titer viral capsid Ag (VCA Epstein - Barr)
Biopsi Nasofaring dignosis pasti

TERAPI

Radioterapi Pengobatan utama ( 6000 rad )

Kemoterapi Adjuvan terapi (kemo-radioterapi)
Diseksi leher
PROGNOSIS
5-YEAR SURVIVAL RATE
STADIUM I : 76,9 %
STADIUM II : 56,0 %
STADIUM III : 36,4 %
STADIUM IV : 16,4 %
 ANGIOFIBROMA NASOFARING
( Angiofibroma nasasofaring juvenile )
- Tumor jinak jarang
- Mendapat perhatian gambaran klinis ganas
- Ekspansif
- Mudah berdarah

ETIOLOGI
Belum jelas, diduga faktor hormonal akibat gangguan
keseimbangan estrogen dan androgen
INSIDEN
- Anak atau dewasa muda ( 10-25 thn )
- Pria : Wanita = 10 : 1
HISTOPATOLOGI
- Angioma td tunika intima, tanpa muskular
- Fibroma
- Makro : soliter atau multipel, warna merah kebiruan ;
pucat
GEJALA
- Epistaksis banyak, sukar dihentikan
bila sering ANEMIA
- Obstruksi nasi
- FROG FACE : Prluasan ke arah wajah
- Mudah berdarah bila disentuh
Sebaiknya tidak dilakukan biopsi
PEMERIKSAAN
- Rinoskopi anterior / posterior
- CT- Scan
- Angiografi

TERAPI
1. Operasi Pendekatan transpalatal dan
Rinotomi lateral
1. Diperlukan darah yang cukup ( > 1 liter )
2. Radioterapi
3. Hormonal
PROGNOSIS
Umumnya baik
 TUMOR GANAS SINUS MAKSILARIS
Tumor ganas sinus paranasalis paling sering
INSIDEN :
- Umur 50 – 59 tahun
- Pria : Wanita= 2 : 1
ETIOLOGI
- Belum diketahui
- Paling banyak menegenai pekerja kayu, tambang
- Thoratrast
- Sinusitis kronik
HISTOPATOLOGI
- Carsinoma Planoselulare paling sering
- Adenocarsinoma, Papillary carsinoma
- Silendroma
GEJALA KLINIK
 Pd stad awal jarang bergejala/tdk jelas o/k sin.maksilla
merupakan rongga tertutup
 Blood stain rhinorrhoe
 Stad lanjut :
- Hidung : obstruksi nasi progresif,
rinore campur darah, foetor nasi
- Muka : pembengkakan pipi, parestesia pipi
- Rongga mulut : benjolan pd palatum, alveolus,
gigi goyah, trismus
- Mata : epifora, proptosis, diplopia, optalmoplegia
- Saraf : sefalgia
- Telinga : oklusi tuba
- Matastasis regional
DIAGNOSIS
- Pemeriksaan Fisis : Rinoskopi anterior dan posterior
- Foto polos
- Ct-Scan perluasan tumor
- Biopsi

TERAPI
Maksilektomi merupakan terapi pilihan untuk tumor
ganas sinus maksila
- Radikal maksilektomi dengan eksentrasio orbita
- Partial maksilektomi biasanya untuk tumor jinak
-Inferior partial maksilektomi
-Superior partial maksilektomi
 TUMOR GANAS OROFARINGEAL
ETIOLOGI
- Belum jelas, diduga berhubungan dengan alkohol, tembakau

HISTOPATOLOGI
- Squamous cell carcinoma (paling sering)
- Lymfoma
GEJALA
- Disfagi, odinofagi, referred otalgia
- Sakit tenggorok, rasa benda asing
- Hot potato voice
- Trismus
- Hematemesis
 Pada pemeriksaan ditemukan :
- Tonsil tampak membesar paling sering unilateral,
permukaan tidak rata, ulserasi
- Infiltrasi ke ruang parafaring trismus
- Pembesaran kel. Limf jugularis profunda superior
(Cepat mengadakan metastasis regional )
 Many of the oral lesions may have had an initial
lesion that were potentially curable.

 The cure could be predicted if the lesion is

diagnosed early and the appropriate therapy is
given before the disease reaches advance stages to
become incurable
Glandular epithelium
1- Adenocarcinoma
2- Mucoepidermoid
carcinoma
3- Adenoid cystic
carcinoma
4- Acinic cell
carcinoma
5- Undifferentiated
carcinoma
Mesenchymal tissues
1. Sarcoma
 Fibrosarcoma
 Rhadomyosarcoma
 Osteogenic sarcoma
 Chondrosarcoma
 Neurogenic sarcoma
 Angiosarcoma
 Synovial cell sarcoma
2. Hodgkin’s & non-
Hodgkin’s lymphomas
3. Plasmacytoma & multiple
myeloma
4. Leukaemia
Metastatic carcinoma, sarcoma
Assessment
 Complaint:
 Vary widely and is often unreliable
 Painless lump which persisted for a varying
period of time
 Persistent ulceration
 Difficulty of wearing denture
 Later Symptoms:
 Pain locally or referred to the jaw or ear
 Difficulty with chewing food and swallowing
 Altered speech and respiratory difficulty
 Asymptomatic and noticed during routine
dental examination
 TUMOR LARING
JINAK :
- tidak banyak, sekitar 5 % dari tumor laring
- histopatologis : papilloma laring, adenoma,
kondroma, hemangioma, lipoma, neurofibroma
Papiloma Laring
 paling sering
 terdapat 2 jenis :
1. Papiloma laring juvenilis
- pada anak-anak
- multipel
- dapat mengalami regresi pd usia dewasa
- analog dengan verucca (o/k virus)
 2. Pada orang dewasa
-Bentuk soliter
-Tidak mengalami regresi
- pre kanker
 Makroskopis :
Seperti buah murbei, warna putih kelabu, rapuh,
tidak mudah berdarah

 Gejala
- Disfonia
- Batuk
- Sesak
 Terapi :
- Bedah laring mikroskopis ( BLM )
- Sinar laser
- Anti virus
- Radioterapi (tdk dianjurkan)
TUMOR GANAS LARING
 tidak jarang
 Etiologi :
- Risiko tinggi perokok, peminum alkohol
- Virus herpes
- Polusi udara
 Patologi : 95 % Karsinoma sel skuamosa
 Insidens :
- Luar negeri, Ca laring peringkat I
- Indonesia, Ca laring peringkat III (setelah tumor
nasofaring dan hidung/sinus paranasalis
 Pria : Wanita = 7 : 1
 Umur 51 – 60 tahun
KLASIFIKASI LETAK TUMOR
- Supraglotik : tepi bebas epiglotis sampai
plika ventrikularis
- Glotik : plika vocalis
- Infraglotik : > 1 cm dibawah plika vokalis sampai
tepi bawah krikoid

DIAGNOSIS
Gejala : suara serak, sesak napas, batuk (hemoptisis), BB
Pem. Fisis : Laringoskopi indirek/direk
Radiologik : X-Foto toraks/leher, CT-scan
Histopatologi : Ca. sel skuamosa (terbanyak)
Stadium tumor : Klasifikasi UICC
TERAPI
 Pembedahan : Laringektomi total/parsial
 Radioterapi : tergantung stadium dan KU
 Sitostatik
 Rehabilitasi suara :
- Esophageal speech
- Speech therapy