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Dr.dr. Tahan P.H.,SpP.DTCE,MARS

FK UWK Surabaya

Januari 2014

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- Located inside the chest- Part of the respiratory system

(also includes nose, throat, trachea)- Responsible for the breathing in (inhalation) and

breathing out (exhalation) of air-Right lung divided into three lobes (upper, midle,

lower); Left into two lobes (upper, lower)-Each lung covered by a thin sheet of protective tissue

visceral pleura

-Protected by the ribs in front of the chest and spine inback.- Lung separated from each other by space

mediastinum (in the middle of the chest, containsseveral organs: the heart,trachea and lymph nodes)

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-Lungs allow us to inhale air that contains O2, isgas needed for cell to survive. All of the cells in the

body use O2 to produce energy so they canfunction.

- When O2 is used by the cells, another gas CO2isproduced.

- Lungs control the amount of O2 and CO2 in ourbody

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Istilah yg sering menimbulkan kerancuan:

tumor, tumor jinak, tumor ganas serta kankerTumor:

Hasil perkembang biakan suatu sel tubuh yg tdk terkontol.(Normal: perkembangbiakan sel hanya akan terjadi apabila dibutuhkan

tubuh).

Tumor Jinak Tumor Ganas = Kanker

Sel tumor yg berkembangbiak secaratdk terkontrol,

tetapi TIDAK melakukan INVASI ke

jaringan sekitar(walaupun mampu mendesak, namuntidak tumbuh masuk ke jaringan

lain/TIDAK MENYEBAR ke bagiantubuh lain).

Biasanya tdk mengancam jiwa, bisa di

operasi dan jarang timbul kembali.

Sel tumor berkembang biak secaraTIDAK TERKONTROL

dan

men INVASI jaringan sekitarsertabisa MENYEBAR (=METASTASE) ke

bagian tubuh lain

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Primary malignanttumor

Part of the body

BloodLymph

Carries:Dead cells, abnormal

and cancer cellsthrough

lymphatic vesselsto

Lymph nodes(filter unwanted substances)

If too many cancer cells :

Lymph nodes cannot remove all,some may travel in the lymph to

other parts of the body(Lung cancer, spread to bone,

brain, liver, adrenal gland)My also break away from

primary tumor and form newtumor in some or opposite lung)

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Ada dua jenis utama kanker paru:Small Cell Lung Cancer(SCLC = KPKSK) ---

Kanker Paru Jenis Karsinoma Sel KecilNon-Small Cell Carcinoma(NSCLC = KPKBSK) ---

Kanker Paru Jenis Karsinoma Bukan Sel Kecil,yaitu terdiri dari: adenokarsinoma, squamous cell dan large cell.

NSCLC adalah tipe yang paling umum dari kanker paru.MenurutAmerican Cancer Society, pada tahun 2008 sekitar 85 - 90%dari semua kasus kanker paru adalah dari jenis NSCLC.Membedakan antara NSCLC and SCLC sangatlah penting karena

kedua jenis kanker ini memerlukan terapi yang berbeda.

Apa itu Kanker Paru?

Kanker paru adalah pertumbuhan sel kanker yang tidakterkendali dalam jaringan paru, biasanya pada sel-sel tempat

mengalirnya udara.

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Proses terjadinya belum diketahui dengan pastiDiduga ada faktor exogen dan endogen (dari dalam-kerentananbawaan/genetik)

PATOGENESIS

Eksogen: Paparan Karsinogen RokokEndogen:Kepekaan Faktor HostGenetik a.l. p53 Tumor Supresor

Gene80-90% Ca ParuPerokok

Faktor Eksogen Kanker ParuTobacco (inhaled carcinogen) : 85-87%Second-Hand Passive Smoker: 5-7%Others : 5-7%

Asbestos, Uranium,Marijuana, Beryllium, Airpollutant, diesel, Tar, arsenik,

nikel, kromScar/Fibrosis : 1-2%

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SMOKING - number one couseCigarette smoke contains at least 43 different carcinogens,

accociated with various cancers :

lung; oesophagus; mouth; stomach; pancreas and liver

Smoking accounts for 30% all cancer-related deaths

and 87% of lung cancer deaths

50% new lung cancers diagnosed in former smokers

Risk of lung cancer increases with an increase in the total

number of cigarettes smoked

The use pipe tobacco also increase the risk

Second-hand smoke also contains carcinogens

(USA 5.000 10.000 dignosed lung cancer resulting from

breathing second-hand smoke)

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Quitting smokingdecreases risk of developing

10 years after quittingrisk decrease 50%

Quit smoking during cancer tretmentlive longer than who

continue to smoke during treatment

Some people with lung cancer who have never smoked

Factor contribute to lung cancer:- Exposure to chemicals in the air, asbestos and radon

- Lung diseases that can block airflow to lungs, COPD or TB

- Genetics

- Age, occurs more often in people over 65 years of age

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Two main catagories:Small-cell lung cancer (SCLC) 20%

Non Small cell lung cancer (NSCLC) 80%

1. Adeno Ca

30-35% of all NSCLCusually develop at the edges of the lung, but some times occurtoward the center of the chest

Often slow growing and dont typically cause symptoms in earlystagesOften found and diagnosed at more advanced stagesThe most common subtype of the lung Ca in women and in nonsmokers

Divide into subcatagories such as Bronchoalveolar Carcinoma.

NSCLC

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NSCLC

2. Squamous cell Ca- account about 30% of all NSCLC

- unlike Adeno Ca, this type strongly associated with

smoking

- usually foundin the larger airway tubes and toward

the center of the chest

3. Large cell Ca

- account about 10-20% of all NSCLC

- more difficult to diagnose

- grow at the edges of the lung- tend to grow fast and spread to other areas of the

body (metastasize)

- like Sq Cell Ca, are associated with smoking

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1. Cough(over 50% of people with lung Ca)tumor irritates the lung and airway tissue, resulting cough.

2. Chest Pain; shortness of breath (dyspnea) and wheezing3. Hemoptysis(30% of people with lung Ca) call the doctor

immediately

Important to perform Physical Examination and know medical history.Consider for Age; smoking history; disease or conditions may have;

have been exposed to any harmful chemicals

Some are similar to other common illnesses

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4. If the tumor grows larger, it can press nearby organs andbones.

may include bone pain; chest pain; hoarseness; cough;swelling of the face or arms; and/or build upof fluid around the

outside of the lungs (pleural effusion)5. Symptom from lung Ca metastases: depend on where the Cahas spread. Brain and spinal cord: headaches, nausea,vomiting, weakness, tiredness. Bone: bone pain. Liver: right-sided abdominal pain and Jaundice.

6. Some general symptoms like weight loss, fatique, and loss ofappetite.

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Early Dx is difficult because symptoms do not usually occuruntil disease is more advanced.Have signs or symptoms of lung Ca during a routinePhysical examination

Test used to help detect lung Ca:1.Chest X-Ray2,Computed Tomography (CT) Scan3.Magnetic Resonance Imaging (MRI)4.Positron Emission Tomography (PET) Scan5.Sputum Cytology6.Biopsy

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Chest X-Ray CT-Scan MRI SputumCytology

Biopsy

Common testused

Uses small ofradiation

Compare oldchest X-rays

withrecent ones

to see iftumor is

growing orshrinking

Is anothertest used toHelpdiagnoselung caSimilar toCXR butgives a moredetailedpicture of the

lungCan detectextremelysmall tumors

-Similar toCT scan-Clearimagesinternal bodypart,includingtissue,muscle,nerves, and

bones.- used todetect thepresence oftumor

-Sputum iscollected tolook forcancer cells.- mostaccurateto collect

and analyzeearly-morning

mucus forthree days

- A simplecells be takenfrom thetumors.- Can beobtained inseveraldifferentwaysdepending

on thelocation andsize of atumors.

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Bronchoscopy

Transthoracic Needle

Aspiration

FineNeedle

Aspiration

CervicalMediasti

noscopy

EndoscopicLymph

NodeBiopsy

VideoAssisted

Thoracoscopy

Exploratory

Thoracotomy

To see theinside of thelungs andairways.Theres small

camera onthe end ofthe bronchoscope thattakespictures .Theres also asmall toolthats used toremove asample of thetissue fromthe tumors.

Inserts aneedle intochest walland uses theneedle to

make asample oftissue- Is used fortumors closerto the chestwall

-Using a CTscan forguidance, anincision ismade in the

skin so aneedle can beinserted intothe tumor toremove asample ofcells.- May beused tobiopsytheprimarytumor ormetastases

- Thistechnique isoften used tobiopsylymph nodes

around thelungs

-Small tubepassedthroughmouth intothe

esophagus.- small toolpassed thetube, it cantake tissuesample ofnearbylymph nodes

- Tubecontaining asmalltelevisioncamera,

insertedbetweenribsafter makinga smallincisionthrough theskin, can seethe tumor.

- This is asurgicalprosedurewhere opensthe chest to

visuallyexamine andremove thetumor.

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Tujuan pemeriksaan diagnosis utk menentukan jenis histopatologi

kanker, lokasi tumor serta penderajatannya yg selanjutnya diperlukan

utk menetapkan kebijakan pengobatan

Deteksi Dini

Prosedur Diagnosis:Gambaran Klinis- Gambaran Radiologis

Pemeriksaan LainPenderajatan (Staging)

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Dekeksi Dini:

-Keluhan dan GX penyakit tdk spesifik,-Batuk darah, Batuk kronis, BB menurun dan Gx lain, jugadapat ditemui pd penyakit paru lain

- Penemuan dini berdasarkan keluhan saja jarang terjadi

-Biasanya keluhan ringan terjadi pada mereka yg telahmasuk stadium II dan III

-Sasaran utk deteksi dini terutama ditujukan pada subyekdengan resiko tinggi :

* Laki-laki, usia > 40 tahun, perokok* Paparan industri tertentu+ satu @ lebih gejala: batuk darah, batuk kronis, sesak

napas, nyeri dada, BB menurun

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Deteksi Dini Kanker Paru(Skrining)

Golongan Resiko Tinggi(GRT)

Bukan GRT dengan gejala batukkronis, sesak napas, batuk darah,

BB turun

Foto thoraks dan Sitologi Sputum Diagnostik dan terapi penyakit paru

non kankerSemua hasil (-)

Ada hasil yg (+)(a,b,c dlm skema) Curiga Kanker Paru

Re-skrining 4-6bulan

Teruskan prosedurdiagnostik kanker

paru

Teruskan prosedurdiagnostik kanker paru

Foto thoraksSitologi sputum ( + ) ( - )

( + ) a b

( - ) c d

Skema

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Dilakukan utk mendapatkan gambaran penyakit yang akurat serta

objektif guna pemilihan option penanganan

T (tumor) Ukuran dan lokasi / akibat langsung tumor

N (Node) Kelenjar limfe: zone kelenjar limfe yg mengalami penyebaran

M(Metastase)

Ada / tidak penyebaran ke organ lain

Dinilai 3 Hal T N M Staging

Stage I Kanker ukuran kecil masih terbatas pada paru saja

Stage II Telah ada penyebaran ke kel.limfe atau invasi ke dinding dada

Stage III Penyebaran ke kel.limfe yang lebih jauh

Stage IV Merupakan tahapan tertinggi, telah menyebar ke organ lain

diluar paru.

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Penderajatan utk NSCLC ditentukan menurut International Staging System ForLung Cancer berdasarkan sistem TNM

Pengertian T tumor yg dikatagorikan atas TX,T0 s/dT4.N utk keterlibatan KGB yg dikatagorikan atas NX,N0 s/d N3.

M adalah menunjukkan ada-tidaknya metastase jauh (M0 s/d M1)

Stage TNM

Occult Ca TX,N0,M0

0 Tis,N0,M0

IA T1,N0,M0

IB T2,N0,M0

IIA T1,N1,M0

IIB T2,N1,M0; T3,N0,M0

IIIA T1,N2,M0; T2,N2,M0; T3,N2,M0

IIIB Sembarang T,N3,MoT4, sembarang N, M0

IV Sembarang T, sembarang N, M1

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Kanker Paru umumnya hanya 1-3

Mis. NSCLC:Bila masih terbatas (localized)pembedahan

Bila sdh lebih meluas (Regional tumor)kemoterapi & @ radiasi,Bisa ditindak lanjuti dgn pembedahan

Bila sdh advancedkemoterapi (paliatif)

Dikenal 5 modalitas terapi:

1. Pembedahan2. Radioterapi3. Kemoterapi

4. Hormonal5. Immunologik

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T N M STAGING NSCLC

N-0 N-1 N-2 N-3

T-1 IA IIA IIIA IIIB

T-2 IB IIB IIIA IIIB

T-3 IIB IIIA IIIA IIIB

T-4 IIIB IIIB IIIB IIIB

All M-1 = IV

OPERABLE

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Anti Angiogenesis Tx disigned to stop thecancer by nullifying a tumors ability

to obtain O2 and nutrients for growth.Angiogenesis is the formation of new bloodvessels.

Tumor targeted cryoblastion / cryosargery, is aminimally invasive surgeryTreatment that uses extreme cold to destroy, orablate, diseased tissue , including

Cancer cells.

Cytocin Induced Killer Cell Imunotherapy, NonMHC

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NSCLC (Non Small Cell Lung Cancer)Dr.Chandra P.Belani (Penn State Cancer Institute, Hershey Pennsylvania, USA) (Medical Tribune July

2009):

Maintenance therapy with PEMETREXED offer new paradigm forpatients who have advanced lung cancer, because it has a low toxicity

and can be given on an ongoing basis over a prolonged period of time

to extend patients` live,.