Professional Documents
Culture Documents
In Partial Fulfillment
Of the Course Requirement
In NCM 104
Submitted By:
Mario Mandilag
Patricia Xyrille Cariño
Nysell delos Reyes
Dianne Criselle Nuñez
Rachelle Anne Villafranca
BSN IV A
Group IV
Submitted to:
Mrs. May Mesina-Veridiano RN, MAN
Clinical Instructor/Dean of the College of Nursing
Anatomy
Nasopharynx
The buccopharyngeal fascia extends posterolaterally from the free edge of the
medial pterygoid plate to the lateral border of the carotid artery. This fascia separates the
nasopharynx from the parapharyngeal (paranasopharyngeal) space. A line joining the free
edge of the medial pterygoid plate posterolaterally to the styloid process divides the
paranasopharyngeal space into the prestyloid space anteriorly and the retrostyloid space
(containing the carotid sheath and the cranial nerves) posteriorly.
Neck
The supraclavicular fossa described as a triangular region defined by 3 points: the
sternal end of the clavicle, the lateral end of the clavicle, and the point where the neck
meets the shoulder. This area is clinically significant in that any nodal involvement within
this triangle is, by definition, an N3 lesion and, therefore, stage IV cancer.
Nasopharyngeal carcinoma
Nasopharyngeal carcinoma
Classification and external resources
Causes
Viral DNA in nasopharyngeal carcinoma has revealed that Epstein-Barr virus (EBV) can
infect epithelial cells and is associated with their transformation to cancer.
Risk factors:
Sex
Classification
Nasopharyngeal carcinoma, commonly known as nasopharyngeal cancer, is classified as:
• a malignant neoplasm
• cancer
Arise from the mucosal epithelium of the nasopharynx, most often within the lateral
nasopharyngeal recess or fossa of Rosenmüller.
• The most common physical finding is a neck mass, which is observed in 80% of
patients. Painless firm lymph node enlargement is present.
• Neck involvement is often bilateral; the most common nodes involved are the
jugulodigastric and upper and middle jugular nodes in the anterior cervical chain.
• Cranial nerve palsy at initial presentation is observed in 25% of patients.
• On nasopharyngoscopy, a mass arising in the nasopharynx is often visible. The
most frequent site is the fossa of Rosenmüller.
• A paraneoplastic osteoarthropathy has been described in patients with widespread
or recurrent disease.
Laboratory Studies
• Perform routine blood work, including a CBC count and chemistry profile. Liver
function test results may be abnormal in those rare cases with hepatic metastases.
• Epstein-Barr virus (EBV) titers, including immunoglobulin A (IgA) and
immunoglobulin G (IgG) antibodies to the viral capsid antigen, should be
performed. These titers correlate with tumor burden and decrease with
treatment.5,6
• If invasion through the base of the skull has occurred, a cerebrospinal fluid
examination is performed to detect tumor seeding.
Imaging Studies
• CT scanning
o CT scanning of the head and neck is used to determine tumor extent, base
of skull erosion, and cervical lymphadenopathy.
o CT scanning of the chest and bone imaging are used to search for distant
metastases.
• When intracranial extension is suspected, MRI may reveal the extent of the tumor.
• Positron emission tomography (PET) imaging has been used to assess
questionable neck nodes.
Other Tests
Procedures
Staging
Treatment
Medical Care
• Radiotherapy is administered to the primary tumor and level II-V neck nodes.
Care should be taken to include the skull base in the initial field because
nasopharyngeal cancer can travel via the foramen lacerum. Traditionally, the
initial radiotherapy fields are often treated with 2 parallel opposed lateral fields
that encompass the nasopharynx and upper cervical nodes. The lower cervical
nodes are treated with an anterior field, which abuts the upper lateral fields
superiorly. These patients are now commonly treated with 3-dimensional
treatment, conformal radiotherapy, or intensity modulated radiation therapy
(IMRT).
• Avoid overdose to the spinal cord at this junction by using a spinal cord block at
the upper lateral fields or lower anterior supraclavicular field. Treatments are
administered at 1.8-2 Gy/d for 5 days a week until a dose of 40-44 Gy has been
administered. Thereafter, additional radiation is administered to the posterior neck
nodes using electron beam to avoid radiation myelitis. A dose of 50 Gy to the
neck is desirable; bulky neck masses may need higher doses of 66-70 Gy.
• Nasopharyngeal tumors and anterior neck tumors continue to be treated with
parallel opposed fields to a dose of at least 50 Gy. The primary site then receives
a boost, delivering a dose of 50-70 Gy. Three-dimensional (conformal)
radiotherapy may be used to spare more critical structures next to the
nasopharynx, such as the brain, pituitary gland, optic chiasm, optic nerve, and
spinal cord. Data show that lower doses of radiotherapy may suffice when the
response to neoadjuvant chemotherapy is excellent.16 However, a multi-
institutional study showed that doses of at least 66 Gy are needed for optimal
local control.17
• Parotid sparing techniques are also available in some centers with 3-dimensional
treatment capability or IMRT.18 Data using IMRT reveal equivalent or better
locoregional control compared with conventional radiotherapy and sparing of the
parotid glands from high doses of radiation therapy.19
• During the course of radiotherapy, several immediate effects may occur, usually
after the first 2 weeks of treatment. Confluent mucositis usually occurs, especially
in children receiving both radiotherapy and 5-fluorouracil. Dry mouth and thick
saliva are also likely secondary to irradiation of the salivary glands. Redness,
itching, and peeling of the treated skin can occur towards the end of radiotherapy
and may need to be treated with topical antibiotics and Silvadene. Because of this
oropharyngeal mucositis, consideration of placement of a gastrostomy tube prior
to initiation of radiotherapy. If a gastrostomy tube is not placed, poor nutrition
and dehydration are quite common, and intravenous fluids may need to be
administered.
• Some centers use amifostine, a radioprotective agent, to help reduce radiation-
related xerostomia. Possible side effects of amifostine such as flulike symptoms,
nausea and hypotension have limit its widespread use in the oncologic
community.
Surgical Care
Surgical therapy for these patients is often limited to a biopsy for tissue diagnosis. Nearly
all tumors are unresectable at diagnosis because of tumor location.
Consultations
Consultation with an endocrinologist may be required in the future if the child shows
signs of growth retardation or hypothyroidism secondary to radiotherapy. Occasionally,
children develop panhypopituitarism.
Consultation with a dentist familiar with radiation effects should be performed prior to
initiation of radiotherapy to minimize risk of osteoradionecrosis. Patients also need to be
followed after treatment as xerostomia and change in salivary consistency may
predispose the patient to dental caries.
Diet
Many patients experience severe mucositis during radiotherapy. Certain foods may
irritate irradiated mucosa, causing pain or difficulty swallowing or chewing. Soft foods
such as milkshakes, mashed potatoes, and pureed meats are advisable during the course
of radiotherapy. Citrus fruits, spicy foods, salty foods, and coarse foods can make the
irritated mucosa worse. Gastrostomy tube placement allows adequate hydration and
calorie intake during radiotherapy.
Activity
Medication
Medical therapy consists of radiation therapy and chemotherapy. Concurrent treatment
with cisplatin, 5-fluorouracil, and radiotherapy has been shown to improve survival rates.
Other studies have used neoadjuvant chemotherapy followed by radiation therapy with
improvement in local control or progression-free survival rates.
Anesthetic lozenges and sprays may be helpful during the course of radiotherapy to
minimize oral or throat pain.
Antineoplastic agents
Chemotherapy is used to decrease the bulk of disease and to limit the risk of recurrence.
Cancer chemotherapy is based on an understanding of tumor cell growth and how drugs
affect this growth. After cells divide, they enter a period of growth (ie, phase G1),
followed by DNA synthesis (ie, phase S). The next phase is a premitotic phase (ie, G2);
then, finally a mitotic cell division (ie, phase M) occurs.
Cell division rate varies for different tumors. Most common cancers increase very slowly
in size compared to normal tissues, and the rate may decrease further in large tumors.
This difference allows normal cells to recover more quickly than malignant ones from
chemotherapy and is the rationale behind current cyclic dosage schedules. Dosage cycles
are determined by cancer stage and tolerance of adverse effects.
Antineoplastic agents interfere with cell reproduction. Some agents are cell cycle
specific, whereas others (eg, alkylating agents, anthracyclines, cisplatin) are not. Cellular
apoptosis (ie, programmed cell death) is also a potential mechanism of many
antineoplastic agents.
Cisplatin (Platinol)
Inhibits DNA synthesis and, thus, cell proliferation by causing DNA crosslinks and
denaturation of double helix.
• Dosing
• Interactions
• Contraindications
• Precautions
Adult
Pediatric
80-100 mg/m2 per cycle IV on day 1 of cycle; alternatively 200 mg/m2 per cycle IV
divided over 5 d (ie, 40 mg/m2/d for 5 d)
• Dosing
• Interactions
• Contraindications
• Precautions
• Dosing
• Interactions
• Contraindications
• Precautions
• Dosing
• Interactions
• Contraindications
• Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
• Dosing
• Interactions
• Contraindications
• Precautions
Adult
Pediatric
• Dosing
• Interactions
• Contraindications
• Precautions
• Dosing
• Interactions
• Contraindications
• Precautions
• Dosing
• Interactions
• Contraindications
• Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Nausea, oral and GI ulcers, depression of immune system, and hemopoiesis failure (bone
marrow suppression) may occur; adjust dosage in renal impairment
Antiemetic agents
Antineoplastic agents may cause nausea and vomiting so intolerable that patients may
refuse further treatment. Some antineoplastic agents are more emetogenic than others.
Prophylaxis with antiemetic agents prior to and following cancer treatment is often
essential to ensure administration of the entire chemotherapy regimen.
Ondansetron (Zofran)
Selective 5-HT3-receptor antagonist that blocks serotonin both peripherally and centrally.
Prevents nausea and vomiting associated with emetogenic cancer chemotherapy (eg,
high-dose cisplatin) and complete body radiotherapy.
• Dosing
• Interactions
• Contraindications
• Precautions
Adult
Pediatric
Oral:
4-12 years: 4 mg PO 30 min prior to chemotherapy, repeat q4h for 2 doses, then q8h for
1-2 d
>12 years: 8 mg PO 30 min prior to chemotherapy, repeat once in 8 h, then q12h for 1-2
d
Intravenous: O.45 mg/kg/d IV divided q8h or administered as a single daily dose
• Dosing
• Interactions
• Contraindications
• Precautions
• Dosing
• Interactions
• Contraindications
• Precautions
Documented hypersensitivity
• Dosing
• Interactions
• Contraindications
• Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans;
may use if benefits outweigh risk to fetus
Precautions
More effective when administered for prevention of nausea and vomiting than as rescue;
may cause headache
Colony-stimulating factors
These agents act as a hematopoietic growth factor that stimulates the development of
granulocytes. They are used to treat or prevent neutropenia in patients receiving
myelosuppressive cancer chemotherapy and to reduce the period of neutropenia
associated with bone marrow transplantation. They are also used to mobilize autologous
peripheral blood progenitor cells for bone marrow transplantation and in the management
of chronic neutropenia.
• Dosing
• Interactions
• Contraindications
• Precautions
Adult
Pediatric
Complications
Q and A
Madalas gulay at isda, minsan lang ako kumain ng karne mga isang beses lang sa isang
buwan.
Noong 2006 hanggang 2009, nagtrabaho ako sa pabrika ng tela sa Calamba. Kapag
wala ang aking amo, tinatanggal ko ang mask ko kasi hindi ako makahinga. Yung mga
tela na yun ay galing sa abroad ay matapang ang amoy kaya tinitiis ko na lang kaysa
hindi ako makahinga ng maayos. Tapos mayroon kaming babuyan, ako ang naglilininis
at nagapapakain ng mga baboy.
Oo, mula nung una akong nagpatingin, dalawang beses sa isang taon ako ngpapa X-ray.
4. Did you have any relatives that were also diagnosed of having cancer?
2008 ko naramdaman yung maliit na bukol sa may kaliwa kong leeg. Hindi ko pinansin
kasi hindi naman sya masakit.
6. What manifestations did you experience hat made you decide to consult to
the specialist?
Madalas sumasakit ang ulo ko akala ko migraine lang. Tatlong beses sa isang araw
dumudugo ang ilong ko, hindi ko masukat kung gaano karami sinisinga ko din dahil may
buo buong dugo.
7. Did you consult for second opinion?
8. What are the procedures that were done when you were diagnose that
disease?
X-ray, ok naman daw wala naman daw problema. Kasi minsan yung dugo sa bibig ko na
lumalabas.
Biopsy, kumuha sila ng tissue sa tumor sa leeg ko. Noong una ayaw pang sabihin ng
doctor sa akin ang resulta dahil mag-isa lang ako baka hindi ko daw kayanin. Pero
pinilit ko sila na sabihin na sa akin.
CT Scan, nahilo nga ako eh, kasi 12 hours ako hindi kumain bago yung procedure.
Nasal endoscopy, ditto nakita na sa ilong sya nagsimula nagddraine daw sa may leeg.
Kaya daw lumalaki yung sa leeg ko.
9. What medications your doctor prescribed for the disease? Did you comply
with this medication?
10. Did you take any medications aside for the prescribed medication given by
your doctor?
Herbal, yung malunggay at luyang dilaw. Lactulose, kapag dalawang araw na hindi pa
ako nakakadumi.
Inisip ko na lang na maging positive, dahil kapag daw puro negative ay lalong lalala
yung sakit ko,
Mas natakot sila sa kondisyon ko, pero ako tanggap ko na kasi kung hanggang saan na
lang ako. Pero ramdam ko na magtatagal pa ako kasi malakas pa ako. Yung mga anak
ko lagi silang nagdadasal na pagalingin na ako.
13. What is the effect of this disease to your relationship with God?
Mas tumibay ang pananalig ko sa kanya, sya na lang kasi ang pinanghahawakan ko.
15. Did the doctor told you how long you will live from the time you were
diagnosed of this disease?
Hindi ako binigyan ng taning, pero kung sakaling bibigyan ako hindi rin ako maniniwala
kasi Diyos lang naman ang magsasabi kung hanggang saan ako.