International Journal of Nasopharyngeal Carcinoma (IJNPC) Vol. 03, No.

02, June 2021 | 54-56

International Journal of
NASOPHARYNGEAL CARCINOMA
Journal homepage: https://talenta.usu.ac.id/IJNPC

Radiotherapy Management of Nasopharyngeal Carcinoma Patient in General Hospital Haji

Adam Malik Medan: A Case Report
Wan Andre Nugraha Baros1*, Farhat Farhat1, Elvita Rahmi Daulay2
1
Departement of Otorhinolaryngology Head and Neck Surgery, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
2
Departement of Radiology, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia

Abstract Article Info

Introduction: Nasopharyngeal carcinoma (NPC) is a head and neck malignancy with a high incidence Article history:
especially in Asian region. NPC has highly prevalence in head and neck cancer with most of the type is Received: 7th June 2021
squamous cell type with three different histologic subtypes, namely squamous cell carcinoma, Received in revised form: 16th June 2021
nonkeratinizing carcinoma, and undifferentiated carcinoma. Principle of management NPC is radiotherapy Accepted: 17th June 2021
because of this kind of carcinoma highly radiosensitive and is the mainstay of treatment for all stages.
Case report: A 33-year-old woman came to the ENT-Head and Neck Surgery Outpatient clinic of General Keywords:
Hospital Haji Adam Malik Medan on March, 2021. The patient was diagnosed with Nasopharynx carcinoma, Nasopharyngeal carcinoma, radiotherapy,
with complaints of nose bleeds and, nasal congestion. History of consuming salted fish was found. History chemotherapy
of cooking food with flavoring was found. The patient then performed a non-contrast-enhanced
nasopharyngeal MSCT scan on February 17th, 2021 with the result: Left nasopharyngeal mass that extends *Corresponding author:
to the left torus tobarius, left rossenmuller fossa crossing to the right nasopharyngeal midline (T1N0M0). Address: Jl. Dr. Mansyur No.5, Padang Bulan,
The histopathological results were carried out at the Vina Estetika Hospital: Keratinizing Squamous Cell Kec. Medan Baru, Kota Medan, Sumatera Utara
Carcinoma. The patient then performed a contrast-enhanced nasopharyngeal MSCT scan on March 3rd 2021
20155, Indonesia
with the result: a left-sided nasopharyngeal mass with a rosenmuller fossa and an obliterated Tobarius torus
was seen. Nasopharyngeal mass (T1N0M0). The patient was given 70 gy of Radiotherapy on March 18th e-mail: andre2301baros@gmail.com
2021. After radiation 35 times on May 18th 2021, the patient was evaluated on the next 8 weeks.
Conclusion: Using radiotherapy alone in this patient is the best therapy for this patient. Beside that, early
diagnosis in NPC was giving better result of this management. Post radiotherapy condition of this patient
was good. The patient will be evaluated on the next 8 weeks.

1. CASE REPORT to 35% of nasopharyngeal malignancies in children. The difficulty of the

33-year-old woman came to the ENT-Head and Neck Surgery
Outpatient clinic of General Hospital Haji Adam Malik Medan on March,
2021. The referral patient from the Royal Prima Hospital was diagnosed
with Nasopharynx carcinoma, with complaints of nose bleeds and, nasal
congestion. Previous history of tinnitus in the ears was denied. History of
habitual smoking was denied. History of consuming alcohol was denied.
History of consuming salted fish was found. History of cooking food with
flavoring was found. There was no lump in the neck. There was history of
epistaxis. The patient then performed a non-contrast-enhanced
nasopharyngeal MSCT scan on February 17th, 2021 with the result: Left
nasopharyngeal mass that extends to the left torus tobarius, left rossenmuller
fossa crossing to the right nasopharyngeal midline, enlarged lymph nodes
(-). The histopathological results were carried out at the Vina Estetika
Hospital: Keratinizing Squamous Cell Carcinoma. The patient was given 70
gy of Radiotherapy on March 18th 2021. The patient then performed a
contrast-enhanced nasopharyngeal MSCT scan on March 3rd 2021 with the
result: a left-sided nasopharyngeal mass with a rosenmuller fossa and an
obliterated Tobarius torus was seen. Nasopharyngeal mass (T1N0M0). After
radiation 35 times on May 18th 2021, the patient will be evaluated on the
next 8 weeks.
2. DISCUSSION
Nasopharyngeal carcinoma (NPC) is a head and neck malignancy with
excessive prevalence in Asian region. Also, in a developing country like
Indonesia, NPC has exceedingly incidence in head and neck cancers with
the most case is squamous cell type with 3 special histologic subtypes,
specifically squamous cell carcinoma, nonkeratinizing carcinoma, and
undifferentiated carcinoma [1].
Nasopharyngeal carcinoma is an extraordinary tumor that arises
within side the epithelium of nasopharynx. Nasopharyngeal carcinoma
estimated more than 95% of nasopharyngeal malignancies in adults and 20
nasopharyngeal examination, making it frequently misdiagnosed early due
to the vagueness of the presenting symptoms [2]. Nasopharyngeal
carcinoma is a malignancy that affects the nasopharynx, that's the wall area
at the back of nose. Nasopharyngeal carcinoma is a malignant tumor that
grows in the nasopharynx with a predilection for the Rossen muller fossa
and the roof of the nasopharynx [2].
NPC discovered in lots of Mongoloid races. In Indonesia, there are
about 6.2 cases per 100,000 population or around 12,000 new cases every
year. While the highest case in 2012 turned into in South China achieving
20-40 per 100,000 population, in Malaysia 9.1 per 100,000 population and
in Singapore 15 per 100,000 population [3]
Consumption of salted fish has clearly increased the incidence of NPC
case. According to the carcinogenic compound in salted fish, Nitrosamine,
is one of the etiologic factors most frequently mentioned (4). Cigarette
smoking also has tremendous danger aspect for inflicting most cancers
especially in nasopharynx due to the additives of cigarette contents have
carcinogenic potential such as nitrosamines and formaldehyde (1). In Hasan
Sadikin Bandung General risk factors that increase the prevelance of NPC
consists of a history of smoking (50.7%), use of mosquito coils (43.2%),
history of consuming salted fish (39.7%), alcohol consumption (14.1%), and
a family history of cancer (7%) [5].
The role of the Epstein Barr virus in carcinogenesis causes the
histopathological features of NPC (WHO types 1, 2 and 3) to differ from
those of squamous cell carcinoma which is often found in malignancies in
the head and neck area [6].
NPC regularly present with one or more symptoms of four groups of
symptoms. They are consist of: 1. Nasal symptoms consisting of epistaxis,
nasal obstruction and discharge (those symptoms are associated with the
presence of tumor mass within the nasopharynx; 2. Otologic symptoms
consisting of deafness and tinnitus, associated with the Eustachian tube
disorder because of the lateroposterior extension of the tumor to the para-
nasopharyngeal space; 3. Cranial nerve palsies, commonly fifth and sixth
cranial nerves, that's related to the superior extension of the tumor leading
to cranium base erosion (the person would possibly complaints in a
headache, diplopia, facial pain, and numbness); and four. Neck masses,

Copyright © International Journal of Nasopharyngeal Carcinoma Published by Talenta Publisher, ISSN: 2656-9027 e-ISSN: 2656-9035 DOI: 10.32734/ijnpc.v3i02.6324 54
International Journal of Nasopharyngeal Carcinoma (IJNPC) Vol. 03, No. 02, June 2021 | 54-56

commonly seem withinside the upper neck. Primary tumors are not easy to
visualise and are frequently minimum or asymptomatic [7]. In this case, the Conventionally, early stage NPC (T1, T2) is given radiation at a dose
patient had chief complaint of nasal congestion accompanied by nosebleeds. of 200 - 220 cGy per fraction, given 5 times a week without rest until it
There is no otologic symptom, cranial nerve palsy, and mass on the neck. reaches a total dose of 6000 - 7000 cGy in 6 weeks. Whereas for NPC with
Three categories of Nasopharyngeal Carcinoma histologic that was larger tumor sizes (T3 and T4), a higher total dose of radiation to the primary
categorized by World Health Organization (WHO) are: first, keratinizing tumor in the nasopharynx was given, namely 7000-7500 cGy (6).
squamous cell carcinoma, second, non-keratinizing carcinoma, and third, If there is no metastasis in the neck lymph nodes (N0), prophylactic
undifferentiated carcinoma. There had been 2 classes of WHO for radiation is given at a dose of about 4000 - 5000 cGy in four or four and a half
nasopharyngeal carcinoma in 1991, including squamous cell carcinoma weeks, whereas if there is enlarged lymph nodes in the neck, radiation is given
(keratinizing squamous cell carcinoma), and non-keratinizing carcinoma the same dose as the primary tumor (6000-7500 cGy). After undergoing a total
(which is the non-keratinizing and undifferentiated become the same dose of external radiation, tumor evaluated by CT scan [16].
category). Non keratinizing carcinoma then divided into undifferentiated
and differentiated carcinomas. Non keratinizing carcinoma has been 3. CONCLUSION
confirmed to have a prognostic importance and more relevant for research
which is epidemiological. Nasopharyngeal carcinoma with undifferentiated Using radiotherapy alone in this patient is the best therapy for this
class has larger control rate for local tumor with therapy and more patient. Besides that, early diagnosis in NPC was giving better result of this
occurrence of metastasis cancer than the nasopharyngeal carcinoma with management. Post radiotherapy condition of this patient was good. The
differentiated class [8, 9]. Nasopharyngeal carcinoma with keratinizing patient will be evaluated on the next 8 weeks.
squamous cell carcinoma class turned into mentioned about 25% of
nasopharyngeal carcinoma cases in the North America, when in endemic REFERENCES
regions, it is only 1%. The nasopharyngeal carcinoma with undifferentiated
class turned into mentioned about 95% of all patients in the endemic regions, [1] Nuaba IG, Nalle TS, Weta IW. Correlation of Cigarette Smoking and
when 60% from patients in the North America [10]. In this case, the
Salted Fish Consumption with Nasopharyngeal Carcinoma and Its
histopathological result was keratinizing squamous cell carcinoma. In
general, research from non-endemic regions have constantly proven that Clinical Stage in ORL-HNS Outpatient, Sanglah General Hospital.
patients with keratinized carcinoma have a worse prognosis than patients
International Journal Of Nasopharyngeal Carcinoma. 2020 Dec
with non-keratinized or undifferentiated carcinomas. Keratinized squamous
cell nasopharyngeal carcinoma has greater local tumor growth than non- 20;2(04):103-7. DOI: https://doi.org/10.32734/ijnpc.v2i04.4806
keratinized and undifferentiated squamous cell carcinoma, where in
lymphatic and haematogenous metastases is more common on this type [11]. [2] Jeyakumar A, Brickman TM, Jeyakumar A, Doerr T. Review of
Radiological examination of suspect NPC is an important diagnostic nasopharyngeal carcinoma. Ear, nose & throat journal. 2006
investigation. The main objective of the radiological examination is: a)
Mar;85(3):168-84. DOI: https://doi.org/10.1177/014556130608500313
provide a more definite diagnosis of suspected tumor in the nasopharynx; b)
determine the more precise location of the tumor; c) determine tumor size; [3] Adham M, Kurniawan AN, Muhtadi AI, Roezin A, Hermani B,
d) find and determine the extent of the spread of the tumor to the surrounding
Gondhowiardjo S, Tan IB, Middeldorp JM. Nasopharyngeal
tissue. Nasopharyngeal carcinoma uses the imaging of CT Scan (Computed
Tomography) with contrast and MRI (Magnetic Resonance Imaging) for carcinoma in Indonesia: epidemiology, incidence, signs, and
staging the disease. CT Scan has long been used for identification of skull
symptoms at presentation. Chinese journal of cancer. 2012
base tumor involvement with sclerotic or lytic lesion. Magnetic resonance
imaging (MRI) is basically been used for number one and nodal staging. Apr;31(4):185. DOI: https://doi.org/10.5732/cjc.011.10328
However, computed tomography (CT) continues to be used for radiotherapy
[4] Tobing IN. Early-Stage Nasopharyngeal Carcinoma: A Case Report.
planning [12].
Staging of nasopharyngeal carcinoma is according to the eighth International Journal Of Nasopharyngeal Carcinoma. 2019 Sep
edition of the American Joint Committee on Cancer (AJCC) and
17;1(02):75-7. DOI: https://doi.org/10.32734/ijnpc.v1i2.1133
International Union Against Cancer (UICC) TNM staging system, that relies
on evaluation of the primary tumor (T category), the lymph node [5] Hardianti RA, Dewi YA, Utami RD. Risk Factor Of Nasopharyngeal
involvement (N category), and the presence of distant metastasis (M
Carcinoma Dr. Hasan Sadikin General Hospital Bandung.
category). Regional infiltration of the tumor, neck adenopathies and the
metastasis are the most valuable elements, which are all encountered in International Journal Of Nasopharyngeal Carcinoma. 2019 Dec
TNM system [13].
19;1(03):110-1. DOI: https://doi.org/10.32734/ijnpc.v1i03.2065
In this case, radiological examination with contrast CT SCAN results
was: A left-sided nasopharyngeal mass with fossa rosen muller and an [6] Kentjono, W.A. Perkembangan Terkini Penatalaksanaan Karsinoma
obliterated Tobarius torus was seen. Nasopharyngeal mass (T1N0M0).
Nasofaring. Majalah Kedokteran Tropis Indonesia. 14(2), July 2003.
According on this case, this patient was giving Radiotherapy (RT)
alone for 35 times. Principle of management NPC is radiotherapy because [7] Wei WI, Kwong DL. Current management strategy of nasopharyngeal
of this kind of carcinoma highly radiosensitive and is the mainstay of
carcinoma. Clinical and experimental otorhinolaryngology. 2010
treatment for all stages. The radiation given is expected to improve the
quality of life and prolong the survival of patients: NPC is included in the Mar;3(1):1. DOI: https://doi.org/10.3342/ceo.2010.3.1.1
class of cancer that can be cured by radiation (radiocurable), especially if it
[8] Petersson BF, Bell D, El-Mofty SK, Gillison M, Lewis JS, Nadal A, et
is still in early stage (stage I and II) (6). According to Setiani et al
retrospective studies performed with the aid of using evaluating radiation al. Nasopharyngeal carcinoma. In: El-Naggar AK, Chan JKC, Grandis
doses, they discovered that the radiation dose given >60 Gy 5-year disease
JR, Takata T, Slootweg PJ, editors. WHO Classification of Head and
free survival rate charge turned into reached to 70% in T1-T2 sufferers in
comparison to just 20% in T3-T4 [14]. Neck Tumours. 4th ed. Lyon: IARC. 2017: 65-9.
[9] Tabuchi K, Nakayama M, Nishimura B, Hayashi K, Hara A. Early
Table 1. Management of NPC [15]
detection of nasopharyngeal carcinoma. International journal of
Stage NCCN (2018) EHNS-ESMO-ESTRO(2012)
I RT Alone RT Alone otolaryngology. 2011 Jan 1;2011. DOI: https://10.1155/2011/638058
II RT + C : Concurent + Adjuvan RT + C : Concurent (1B)
(2A),Concurent (2B) [10] Chen YP, Chan AT, Le QT, Blanchard P, Sun Y, Ma J. Nasopharyngeal
Or Induction + Concurent (2B)
III RT + C : Concurent + Adjuvan RT + C : Concurent ± Adjuvant 1A carcinoma. The Lancet. 2019 Jul 6;394(10192):64-80. DOI:
(2A),Concurent (2B)
Or Induction + Concurent (2B) https://doi.org/10.1016/S0140-6736(19)30956-0
IVA RT + C : Concurent + Adjuvan RT + C : Concurent ± Adjuvant 1A
(2A),Concurent (2B) or Induction + Concurrent (2B) [11] Wei WI, Chua DTT. Nasopharyngeal Carcinoma. In: Johnson JT,
Or Induction + Concurent (2B)
IVB Chemotherapy or Rosen CA, editors. Bailey’s Head and Neck Surgery Otolaryngology.
RT + C

55
International Journal of Nasopharyngeal Carcinoma (IJNPC) Vol. 03, No. 02, June 2021 | 54-56

5th ed. Philadelphia: Lippincott Williams & Wilkins. 2014: 1875-97.

DOI: https://doi.org/10.1016/S0140-6736(05)66698-6
[12] Ch Chen YP, Chan AT, Le QT, Blanchard P, Sun Y, Ma J.
Nasopharyngeal carcinoma. The Lancet. 2019 Jul 6;394(10192):64-
80. DOI: https://doi.org/10.1016/S0140-6736(19)30956-0
[13] Razek AA, King A. MRI and CT of nasopharyngeal carcinoma.
American Journal of Roentgenology. 2012 Jan;198(1):11-8. DOI:
https://doi.org/10.2214/AJR.11.6954.
[14] Wani SQ, Khan T, Wani SY, Mir LR, Lone MM, Malik TR, Najmi AM,
Afroz F, Teli MA, Khan NA. Nasopharyngeal carcinoma: a 15-year
study with respect to clinicodemography and survival analysis. Indian
Journal of Otolaryngology and Head & Neck Surgery. 2016
Dec;68(4):511-21. DOI: https://doi.org/10.1007/s12070-016-1018-9.
[15] Setiani L, Kurnia B, Karnita Y. Characteristics Of Nasopharyngeal
Carsinoma In Children And Adolescents In Dr. Zainoel Abidin
General Hospital Banda Aceh. International Journal Of
Nasopharyngeal Carcinoma. 2019 Dec 17;1(03):93-6. DOI:
https://doi.org/10.32734/ijnpc.v1i03.2062
[16] Lee VH, Lam KO, Chang AT, Lam TC, Chiang CL, So TH, Choi CW,
Lee AW. Management of nasopharyngeal carcinoma: is adjuvant
therapy needed?. Journal of oncology practice. 2018 Oct;14(10):594-
602. DOI: https://doi.org/10.1200/JOP.18.00219

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