Medical and Health Information by Shaman

A. Primary Therapy

1. radiotherapy
Until recently, radiotherapy still plays an important role in the management of nasopharyngeal carcinoma. Management of nasopharyngeal carcinoma is the first to radiotherapy with or without chemotherapy.
2. chemotherapy
Chemotherapy as an adjunct therapy in nasopharyngeal carcinoma was found to improve therapeutic outcomes. Especially, given the advanced stage or on the state of relapse.
Various combinations are developed, the best to date is combined with Cis-platinum as the core
Giving chemotherapy anjuvan Cis-platinum, bleomycin and 5-fluororacil with interim results that are satisfactory. Similarly, studies have been conducted of chemotherapy praradiasi with epirubicin and cis-platinum, although there are side effects severe enough, but it gives hope of a better cure.
3. operation
Surgery in patients with nasopharyngeal carcinoma are, radical neck dissection and nasopharyngectomy. Neck dissection is performed if there is still residual gland after radiation or a recurrence of the gland with the proviso that the primary tumor has been cleared as evidenced by radiological examination and serology. Nasopharyngectomy is a palliative operation is performed in relapse cases or the presence of residues that are not successful in the nasopharynx treated by other ways.
4. immunotherapy
By knowing the possible causes of nasopharyngeal carcinoma is the Epstein-Barr virus, So patients can be administered immunotherapy.

Radiotherapy
Radiotherapy is a method of treatment of malignant diseases using lawyer-ion beam, aiming to kill tumor cells as much as possible and maintain the healthy tissue around the tumor so as not to suffer the damage is too severe. Nasopharyngeal carcinoma is radioresponsif that radiotherapy remains an important therapy.
Radiation on tissue, can cause ionization of water and electrolytes from the body fluids both intra-and extra-cellular, so that the resulting very reactive H + and OH-. Ions that can react with a molecule of DNA in the chromosomes, so
can occur:
1. DNA double chain break
2. Changes in cross-linkage in the DNA chain
3. Base changes that cause degeneration or cell death.
Lethal dose and the ability to repair damage to cancer cells is lower than normal cells, so the effect of radiation, the cancer cells more likely to die and remain damaged compared with normal cells.
The cells that still survive, will hold its DNA damage repair on their own. DNA repair ability of normal cells better and faster than the cancer cells. This situation is used as a basis for radiotherapy in cancer.
At the VIII International Congress of Radiology in 1953, set RAD (radiation absorbed Dose) as the amount of energy absorbed per unit of tissue. Currently the International System units (SI) of dose on absorption has been changed to Gray (Gy) and the unit often used is the unit of centi gray
(cGy).
1 Gy = 100 rad
1 rad = 1 cGy = 10-2 Gy.,
Treatment outcomes are expressed in numbers in response to irradiation is highly dependent on tumor stage. The more advanced tumor stage, the less response. For stage I and II, obtained a complete response 80% - 100% with radiation therapy. Whereas stage III and IV, found the numbers
failure of local response and distant metastases is high, namely 50% - 80%. Survival rate of patients with nasopharyngeal carcinoma depends on several factors, foremost among which is the stage of disease.
a.    Preparation / planning prior to radiotherapy
Before, were given radiation therapy, clinical staging was made, histopathologic diagnosis, as well as determined the purpose of radiation, curative or palliative. Patients also prepared mentally and physically. To the patient, if necessary, the family also provided information regarding the necessity of this action, the purpose of treatment, side effects that may arise during the treatment period.
Physical examination and laboratory before starting radiation is absolute. Patients with poor general condition, malnutrition or fever are not allowed to radiation, except in patients with life-threatening circumstances, such as track digestivum obstruction, massive bleeding from the tumor, radiation still starts while improving the general state of the patient. As a benchmark, Hb levels should not be less than 10 g%, the number of leukocytes can not be less than 3000 per mm3 and platelets 100,000 per uL.
b. Determination of the limits of the radiation field
This action is one of the most important step to ensure the success of the radiotherapy. Radiation field included the primary tumor and the surrounding area / potential to continue spreading and lymph-regional lymph nodes.For tumor stage I and II, the following areas should be illuminated:
1. The entire nasopharynx
2. The entire base of the sphenoid and occiput
3. cavernosal sinuses
4. Cranial base, a minimum width 7 cm 2 covering the foramen ovale, carotid canal and jugular foramen laterally.
5. Rear half of nasal cavity
6. Posterior Etmoid sinus
7. 1 / 3 posterior orbit
8. 1 / 3 posterior maxillary sinus
9. fossa pterygoidea
10. Lateral and posterior pharyngeal wall as high as midtonsilar fossa
11. gland retrofaringeal
12. Bilateral cervical glands including the posterior jugular, spinal accessory and supraclavicular
If there is an extension to the nasal cavity or oropharynx (T3) the entire cavity and oropharynx nasal should be included in the radiation field. If the extension through the skull base has reached the cranial cavity, the upper limit of the radiation field is located above the pituitary fossa. If the spread of tumor to the maxillary sinus and Etmoid or orbit, around the sinuses or the orbit should be irradiated. Submental and occipital lymph nodes are not routinely included, unless a massive cervical lymphadenopathy was found or if there is metastasis to the sub-maxillary glands.
irradiation field boundaries are:
- Superior: covering the cranial base, sella tursika included in the radiation field.
- Anterior: located behind the eyeball and choana
- Posterior: right behind the external acoustic meatus, except when there is enlargement of the gland the rear boundary should be located 1 cm beyond the palpable glands.
- Inferior: located on the top edge of thyroid cartilage, these limits change when obtained enlarged neck glands, which is 1 cm lower than the gland is palpable. This field of radiation received from the left and right of the patient.
In patients with neck glands are very large so that the radiation in the above methods can not be done, then the radiation field is given by the front and rear.
The upper limit includes all the cranial base. The lower limit is the bottom edge of the clavicle, the left and right limits are 2 / 3 of the distal clavicle, or follow the magnitude of the gland.
Gland supra clavicle and lower neck received radiation from the field in front, the upper limit of the radiation field is coincident with the lower limit of the radiation field to the primary tumor.
c.    Rays to radiotherapy
Rays used for radiotherapy are:
1. Alpha rays
Alpha rays are corpuscular rays or particles from the nucleus. The nucleus consists of protons and neutrons. This light can not penetrate the skin and are not widely used in radiotherapy.
2. Beta rays
Beta rays is the electron ray. These rays emitted by radioactive substances that have low energy. Power breakdown of the skin is limited, 3-5 mm. Used for the treatment of superficial lesions.
3. Gamma rays
Gamma rays are electromagnetic rays or photons. These rays can penetrate the body. Depending on the power breakdown of the energy that causes the beam. The higher energy or higher voltagenya, the bigger and more power breakdown in the location of the maximum dose.
d.     radioisotopes
1. Caecium137! gamma rays
2. Cobalt60! gamma rays
3. Radium226! alpha rays, beta, gamma.
e. Radiotherapy technique
There are three main ways of radiotherapy, namely:
1. External radiation / teletherapy
Ray sources in the form of X-ray apparatus or a radioisotope which is placed outside the body. Beam is directed into the tumor to be given radiation. Much energy is absorbed by a tumor depends on:
a. The amount of energy emitted by energy source
b. The distance between the source of energy and the tumor
c. Density of the tumor mass.
Teletherapy fractional generally administered at a dose of 150-250 rad per time, in 2-3 series. Among the series 1-2 or 2-3 given 1-2 weeks to break the person's condition so that recovery takes 4-6 weeks of radiotherapy.
e.    2. International Radiation / Brachytherapy
Energy source is placed inside the tumor or adjacent to the tumor in the body cavity. There are several types of internal radiation:
a. interstitial
Radioisotopes in the form of needle inserted into the tumor, for example, radium needles or needle irridium.
b. Intracavitair
The provision of radiation can be done by:
- After loading
An empty applicator is inserted into the body cavity to
the tumor. After the applicator is located right, enter new
radioisotope into the applicator.
- Installation
Radioisotope solution injected into the body cavity, for example:
pleura or peritoneum.
3. intravenous
Radioisotope solution injected into a vein. For example, I131 is injected IV will be absorbed by the thyroid to treat thyroid cancer.
f.    radiation dose
There are two types of radiation, namely:
1. Curative radiation
Awarded to all levels of disease, except in patients with distant metastases. Target of radiation is the primary tumor, lymph nodes of the neck and supra clavicle. Total radiation dose given was 6600-7000 rad to 200 rad fractions, 5 x delivery per week. After a dose of 4000 rad to the spinal cord in the block and after 5000 rad irradiation supraclavicular field were excluded.
2. Palliative radiation
Given for metastatic tumors in bone and local recurrence. The dose of radiation to bone metastases with 3000 rad 300 rad fractions, 5 x per week. For local recurrence, radiation field is limited to local relapse.
g. radiation response
After the radiation is given, then the evaluation of response to radiation. Assessed the response of cervical lymph node reduction and downsizing of the primary tumor in the nasopharynx. Assessment of radiation response based on WHO criteria:
- Complete Response: remove all the lymph nodes are large.
- Partial Response: downsizing of the lymph nodes to 50% or more.
- No Change: the size of lymph nodes that persist.
- Progressive Disease: size of enlarged lymph nodes of 25% or
more.
h. complications of radiotherapy
Complications of radiotherapy can be:
1. early complications
Usually occur during or several weeks after radiotherapy, such as:
- Xerostomia - Nausea, vomiting
- Mukositis - anorexia
- dermatitis
- Erythema
2. further complication
Usually occurs after 1 year of radiotherapy, such as:
- Contractures
- Impaired growth
- etc.

B. Palliative care
Palliative care is any active measures to ease the burden of cancer patients especially those that can not be cured. Said to be mainly on the unlikely cure because these actions are not only performed on patients who can not be cured but it worked well in patients who still have hope of recovery together - together with the action - the action or curative treatment, with a view to alleviate or eliminate symptoms - symptoms that disrupt or even aggravate the suffering of patients.

Active measures in question are, among others, relieve pain and complaints - other complaints, improvements in aspects of psychology, social and spiritual. All this aims to improve the quality of life is maximized, for patients and families.
The first attention should be given to patients with radiation treatment. Mouth dryness is caused by damage to major or minor salivary glands during irradiation. Not much can be done in addition to advise patients to eat with lots of sauce, bring drinks to go anywhere and try to eat and chew the material so that the sour taste stimulates saliva. Other disorders of the oral cavity is mukositis because mushrooms, stiffness in the neck because fibrotic tissue caused by irradiation, headache, loss of appetite and sometimes vomiting or nausea.

Difficulties arising in the care of patients post-treatment where the tumor remains incomplete (residual) or relapse (residif). Can also arise post-treatment metastatic far as to bone, lung, liver, brain. In the second condition mentioned above is not much action that can be given medical treatment other than simtimatis to improve the quality of life of patients. The patient eventually died of poor general condition, bleeding from the nose and nasopharynx that can not be stopped and the undermining of vital equipment due to tumor metastasis.