PELAYANAN TERPADU RETINOBLASTOMA

PELAYANAN TERPADU RETINOBLASTOMAMONITORING EFEK SAMPING KEMOTERAPI

PMN RS MATA CICENDO BANDUNG

LATAR BELAKANG

• Pelayanan terpadu Retinoblastoma (RB) merupakan layanan baru

RSMC

• Layanan Unggulan 2015−2019

• Setiap tenaga medis terpapar montoring efek samping kemoterapi

• Efek samping setiap anak berbeda dengan pemberian obat

kemoterapi yang sama

ALUR PASIEN

• Emergensi atau non emergensi

• Tentukan apakah pasien layak diberikan kemoterapi atau tidak

• Penyakit penyerta yang lain

• Penggunaan HCR/HCU

•MULTIDISIPLIN

Approach to a Child with Leucocoria.Vijay Kumarmes. DOS Times - Vol. 19, No. 8 February, 2014

International Intraocular Retinoblastoma Classification

Murphree AL. Intraocular Retinoblastoma: the Case for a New Group Classification. Ophthalmol Clin N Am. 2005

Kemoterapi±fokal

Kemoterapi±fokal

Enukleasi+ ±fokal

kemoterapi

Kemoterapi±fokal

Fokal+kemoterapi

TENTUKAN LETAK TUMOR DAN UKUR DIAMETER TERBESAR

Even though this is the smallestcircle, its diameter representsthe largest chord length in thedrawing. This region containsthe optic disc, where the opticnerve passes through the sclera,as well as the macula (whichsurrounds the fovea) which isthe region of greatest opticalacuity found at the posteriorpole of the eye.

FIG. 1. The anatomy of the right eye in a transverse cut relates

to the fundus view diagram. Two tumors labeled A and B

located on a transverse great circle are shown in both views.

The next largest circle represents the circumference in the coronal plane at the ora serrata, which is thepoint at which the retina terminates at the cilliary body. The region contained between this circle and theequator represents a band on the inside surface of the eye from the equator to the ora serrata. Theoutermost circle in the fundus diagram is the circumference in the coronal plane at the limbus, which isthe point at which the sclera terminates at the cornea. This circle, although apparently the largest on thediagram, actually represents the smallest diameter of the three.

As the central point of the diagram represents the posterior pole of the eye, any radial displacement fromthis point represents a shift in the anterior direction along a retinal meridian, so that the most anteriorposition of the diagram is reached at the outermost circle. The clock position of the tumor also givesgeographic information with respect to the coronal plane of the patient, so that 12 o'clock is superior, 6o'clock is inferior, 3 o'clock is to the patient's left, and 9 o'clock is to the patient's right. The location of theoptic nerve is indicated by a small solid circle along the 3 to 9 o'clock line (90* meridian). As the opticnerve lies medially to the macula, the position of this solid circle identifies the right or left eye. In theupper half of Fig. 1 the eye is shown containing two tumors labeled A and B and their correspondingpositions in the fundus diagram are also shown. As tumor A lies in the posterior hemisphere on the rightside, it is contained entirely in the smallest concentric circle of the fundus diagram. Tumor B lies on the

left of the optic axis between the equator and the ora seratta, thus it is located between the smallest and

MAKULA

EKUATOR

ORA

Ekuator

ORBITAL RB

B Scan

Approach to a Child with Leucocoria.Vijay Kumarmes. DOS Times - Vol. 19, No. 8 February, 2014

Kalsifikasi

High Internal reflectivity and spikes

CT scan dan MRI

Approach to a Child with Leucocoria.Vijay Kumarmes. DOS Times - Vol. 19, No. 8 February, 2014

Keterlibatannervus opticus

Kalsifikasi

DPJP Tergantung Dari Tindakan

• Enukleasi→ ROO

• Kemoterapi→ IK Anak

• TTT → Vitreoretina

• EUA → PO

• Enukleasi, TTT, EUA → Tindakan yang paling tinggi pembiayaan (ROO)

PPK DAN CP (PO, ROO, RETINA, IK ANAK)

FARMASI

Kelengkapan obatsitostatika

RUANGAN KEMOTERAPI

RUANGAN KEMOTERAPI

SKENARIO PASIEN

• Pasien gelombang 1 sebanyak 2 orang skrining persiapan kemoterapi hariSenin

• Permintaan obat ke Farmasi• Senin sore pasien masuk ke ruangan• Selasa pagi diberikan kemoterapi hari I • Rabu pagi diberikan kemoterapi hari II• Rabu siang pasien pulang• Penjadwalan kemoterapi berikutnya 3 minggu yang akan datang

• Pasien masuk kembali (gelombang 2 sebanyak 2 orang)Rabu siang/sore untuk mulai kemoterapi Kamis

TOTAL: 2 gelombang @2 orang= 4 pasien/minggu

Mengapa Diperlukan PengetahuanEfek Samping Kemoterapi?

To Err is Human

EFEK SAMPINGKEMOTERAPI• Mual dan muntah

• Diare

• Konstipasi

• Nyeri → skala nyeri

• Mukositis

• Kehilangan berat badan

• Body image changes

• Rontok/ alopecia

• Perubahan warna kulit

VINCRISTINE

• Neurotoksisitas (neuropati perifer, disfungsi sistem sarafotonom, parese saraf kranialis, ataksia, buta kortikal, nyeri tulang, punggung, ekstremitas, rahang, kelenjar parotid)

• Konstipasi, nyeri perut, ileus paralitik (mual, muntah, diare lebih jarang)

• Alopecia, ruam kulit, demam

• Ekstravasasi menimbulkan nekrosis jaringan lokal

• Mielosupresi

• Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

• Reaksi hipersensitivitas

• Azoospermia dan amenorea

CATATAN KHUSUS VINCRISTINE

• Pengurangan dosis pada anak dengan disfungsi hepar

• Bolus/drip

• Ekstravasasi→ infus hentikan, kompres es ke arah ekstravasasi, elevasi ekstremitas yang terkena

• Hati-hati kontaminasi pada mata

• Diet tinggi serat→ Gizi

• Lakukan pemeriksaan neurologis sebelum dimulainya kemoterapi

ETOPOSIDE

• Mielosupresi (leukopenia dapat terjadi 10−14 hari setelahterapi dengan pemulihan hari ke 21)

• Mual dan muntah

• Anoreksia

• Alopesia

• Mukositis dan diare

• Reaksi hipersensitivitas (menggigil, demam, bronkospasme, takikardia, bengkak wajah, hipotensi→ 2%)

• Sensasi pengecapan seperti rasa logam

• Reaksi inflamasi lokal pada tempat suntikan

CATATAN KHUSUS ETOPOSIDE

• Hati-hati pada pasien disfungsi ginjal dan disfungsi hepar(penyesuaian dosis)

• Kecepatan dikurangi bila terjadi hipotensi

• Reaksi anafilaksis

• Pantau tanda flebitis

CARBOPLATIN

• Mielosupresi (trombositopenia dengan titik nadir tercapai pada harike 21)

• Mual dan muntah

• Nefrotoksik (lebih toksik cisplatin)

• Neuropati perifer (<10% pasien terutama dengan keluhan yang samasebelumnya)

• Peningkatan enzim hepar

• Reaksi alergi

• Jarang alopesia

CATATAN KHUSUS CARBOPLATIN

• Hati-hati pada gangguan fungsi ginjal

• Tidak bersifat emetogenik namun premedikasi antiemetik sangatdisarankan

• Pre hidrasi dan post hidrasi tidak diperlukan

• Reaksi hipersensitivitas meningkat dari 1% menjadi 27% pada pasienyang telah menerima regimen >7 kali regimen berbasis carboplatin

THE CARE OF RETINOBLASTOMA PATIENTS IS NOT THE RESULT OF A SINGLE CLINICIAN, BUT IT IS A CONSORTIUM OF MULTIPLE SUBSPECIALTIES

Aparna Ramasubranian

Carol L. Shields

TERIMA KASIH