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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,.
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