The Role of Thoracic Surgery in Lung Cancer Managementat Dr.H.A.Rotinsulu Lung Hospital

Bandung

ACHMAD PETER SYARIEF

Thoracic Surgery Department - Dr.H.A.Rotinsulu Lung Hospital

Bandung

World Cancer Day 2016, Harris Hotel Festival Citylink - Bandung, 6 – 7 Februari 2016“Penatalaksanaan Kanker Paru di Era JKN Pada Semua Lini Pelayanan”

Sejarah Singkat

Menegakkan Diagnosis Tumor Paru

• Sasaranpenyaringan

• Langkahpenyaringan

• Tindakandiagnostik

• Penentuanmodalitas terapi

• Evaluasi

Lung Cancer Screening - How, Who,

What Happens Next ?

• Background and rationale for lung cancer screening

– Current guidelines and recommendations

– Insurance coverage and reimbursement

• Components of a successful lung cancer screening program

– Fundamentals and logistics

– Challenges

• The future

Betty C. Tong, MD, MHS, Division of Cardiovascular and Thoracic Surgery Co-Director, Lung

Cancer Screening Program, Duke University Medical Center

95th AATS Annual Meeting 2015, April 25th-29th 2015, Seattle, WA, USA

http://seer.cancer.gov/statfacts/html/lungb.html

Sasaran Penyaringan

•Laki – laki usia > 40 tahun

•Perokok berat / PekerjaIndustri

•Batuk > 2 minggu, disertaibatuk darah

•Berat badan turun > 4 kg / 6bulan

Summary of Current Guidelines

CMS

Primary Criteria

• 55 – 79 years• > 30 pack-yrs

• 55 – 74 years• > 30 pack-yrs• Current smoker

or quit < 15 yrs• Asymptomatic

• 55 – 80 years• > 30 pack-yrs• Current smoker

or quit < 15 yrs• Asymptomatic

• 55 – 77 years• > 30 pack-yrs• Current smoker

or quit < 15 yrs• Asymptomatic

Secondary Criteria

• Lung cancersurvivor

• > 50 years• > 20 pack-yrs

ANDAdded >5% risk of lung CA within 5

years

• > 50 years• > 20 pack-yrs• At least one

other risk factor (not second-hand smoke)

None None

Grade BRecommendation

Tindakan Diagnostik

• Sitologi sputum

• Toraks foto

• Endoskopi Bronkoskopi

• CT Scan / PET Scan

• Biopsi (Percutaneus TransthoracicNeedle Biopsy)

• Mediastinoskopi

• VATS

• Imunologi

• Biochemical Marker ( CEA )

Langkah Penyaringan

Sitologi SputumNegatif Positif

Foto Dada Negatif A CPositif B D

A : Penyaringan setiap 6 bulan

B, C : Tegakkan diagnosis lebih lanjut

D : Tindakan diagnostik (menentukan derajat tumor )

NLSTLung Cancer Cases

Lung Cancer Diagnoses: CT (n = 1060)

649 from positive screens

44 after negative screens

367 in those who missed screens or after trial completed

Lung Cancer Diagnoses: CXR (n = 941)

279 from positive screens

137 after negative screens

535 in those who missed screens or after trial completed

61.8% 29.6%

Pembagian Kanker Paru

• Non Small Cell Lung Ca (NSCLC)

• Small Cell Lung Ca (SCLC)

Stage Ia T1 N0 M0

Stage Ib T2 N0 M0

Stage IIa T1 N1 M0

Stage IIbT2

T3

N1

N0

M0

M0

TNM Staging of NSCLC

T=primary tumor; N=nodal involvement; M,=distant metastasis.

Stage IIIaT1-3

T3

N2

N1

M0

M0

Stage IIIbT4

Any T

Any N

N3

M0

M0

Stage IV Any T Any N M1

TNM Staging of NSCLC

Stage I Non-Small Cell Lung Cancer

• Cancer is found only in the lung

• Surgical removal recommended

• Radiation therapy and/or chemotherapy may also be used

Stage II Non-Small Cell Lung Cancer

• The cancer has spread to lymph nodes in the lung

• Treatment is surgery to remove the tumor and nearby lymph nodes

• Chemotherapy recommended; radiation therapy sometimes given after chemotherapy

Type of resection :

- wedge resection in 1649 ( 18.1% )

- segmentectomy in 394 ( 4,4% )

- lobectomy in 6042 ( 67,0% )

- bilobectomy in 357 ( 4,0% )

- pneumonectomy in 591 ( 6,5% )

Data from The Society of Thoracic Surgeons

General Thoracic Surgery database:

The Surgical management of primary lung tumorsBoffa DJ, Allen MS, Grab JD, et alJ Thorac Cardiovasc Surg 2008;135: 247-554

Pengalaman Instalasi Bedah

RS Paru H.A. Rotinsulu

(Single Institution Experience)

Diagnosis Operasi (2009-2014)RS Paru H.A. Rotinsulu

n = 159

Jumlah Operasi Per TahunRS Paru H.A. Rotinsulu

Hasil Operasi Kanker Paru (2009-2015)RS Paru H.A. Rotinsulu

No Pasien Diagnosis Stage Jenis operasi

1. Laki, 57 th NSCLC, Squamous T3N1M0, IIIA Lobektomi, 2012

2. Laki, 36 th Tumor paru, jenis ? T4N1M0, IIIA Lobektomi NSCLC, 2012

3. Laki, 66 th NSCLC, Squamous T3N0M0, IIB Lobektomi, 2013

4. Wanita, 57 th NSCLC, Adeno T3N0M0, IIB Lobektomi, 2013

5. Laki, 57 th Tumor paru, jenis ? T4N0M0, IIIA Biopsi tumor NSCLC, 2013

6. Laki, 47 th Tumor paru, jenis ? T2N0M0, IB Lobektomi Carcinoid , 2013

7. Wanita, 63 th NSCLC, Adeno T1N0M0, IA Lobektomi, 2014

8. Laki, 59 th Tumor paru, Neuroendokrin T2N0M0, IB Lobektomi Abses paru nonspesifik, 2015

9. Laki, 56 th Tumor paru, jenis ? T3N0M0, IIB Debulking Large cell, 2015

10. Laki, 45 th NSCLC, Adeno T3N0M0, IIB Bilobektomi, 2015

11. Wanita, 32 th NSCLC, Squamous T3N0M0, IIB Lobektomi, 2015

Evaluasi / Follow up

No Pasien F.u. lanjutan Hasil Ket.

1. Laki, 57 th Kemoradiasi Meninggal, 2014

2. Laki, 36 th Kemoradiasi Loss to f.u DO

3. Laki, 66 th Kemoterapi Loss to f.u DO

4. Wanita, 57 th Kemoterapi Follow up (+)

5. Laki, 57 th Kemoradiasi Loss to f.u DO

6. Laki, 47 th ?? Loss to f.u DO

7. Wanita, 63 th Observasi Follow up (+)

8. Laki, 59 th Konservatif

9. Laki, 56 th Kemoradiasi Follow up (+)

10. Laki, 45 th Kemoterapi Follow up (+)

11. Wanita, 32 th Kemoterapi Follow up (+)

Evaluasi / Follow up

StageNumber

of pts5-year

survival (%)

I T1N0 (IA) 245 75

T2N0 (IB) 291 57

II T1N1 (IIA) 66 52

T2N1 (IIB) 153 38

T3N0 (IIB) 106 33

IIIA T3N1 (IIIA) 85 39

T1-3N2 (IIIA) 368 15

T1-3N3 (IIIB) 55 0

T4 any N (IIIB) 104 0

IV TN any M 293 7Naruke T et al, Prognosis and survival in resected lung cancer based on the new

international staging system. J Thorac cardiovasc surg 96:440. 1988

TERIMA KASIH