Dr.dr. Tahan P.H., SpP.DTCE,MARS FK UWK Surabaya Agustus 2011 Lung TUMORS Dr.dr. Tahan P.H., SpP.DTCE,MARS FK UWK Surabaya Agustus 2011

LungS and how do they work? - 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 in back. - Lung separated from each other by space “mediastinum” (in the middle of the chest, contains several organs: the heart,trachea and lymph nodes)

LungS and how do they work? Lungs allow us to inhale air that contains O2, is gas needed for cell to survive. All of the cells in the body use O2 to produce energy so they can function. - When O2 is used by the cells, another gas CO2is produced. - Lungs control the amount of O2 and CO2 in our body

What is cancer ? Istilah yg sering menimbulkan kerancuan: tumor, tumor jinak, tumor ganas serta kanker Tumor: 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 secara tdk terkontrol, tetapi TIDAK melakukan INVASI ke jaringan sekitar (walaupun mampu mendesak, namun tidak tumbuh masuk ke jaringan lain/TIDAK MENYEBAR ke bagian tubuh lain). Biasanya tdk mengancam jiwa, bisa di operasi dan jarang timbul kembali. Sel tumor berkembang biak secara TIDAK TERKONTROL dan men INVASI jaringan sekitar serta bisa MENYEBAR (=METASTASE) ke bagian tubuh lain

How do cancer cell spread to other parts of body? Primary malignant tumor Lymph Blood Carries: Dead cells, abnormal and cancer cells through lymphatic vessels to 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 new tumor in some or opposite lung) Part of the body

WHAT IS LUNG CANCER ? Malignant tumor, grows in one or both of the lung Usually form from cells that line the airways and nearby glands that contact with the air we breathe, which my contain carcinogens Lung cancer: changing of normal cells into carcenous cells usually happens over a period of years USA (2004) 173.770 ( male: 93.110, females: 80.660) – second most common. (Number one : males – prostate cancer; females: breast cancer)

Apa itu Kanker Paru? Kanker paru adalah pertumbuhan sel kanker yang tidak terkendali dalam jaringan paru, biasanya pada sel-sel tempat mengalirnya udara. Ada dua jenis utama kanker paru: Small Cell Lung Cancer (SCLC = KPKSK) --- Kanker Paru Jenis Karsinoma Sel Kecil Non-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. Menurut American 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. 

Faktor Eksogen Kanker Paru Penyebab LUNG CANCER Proses terjadinya belum diketahui dengan pasti Diduga ada faktor exogen dan endogen (dari dalam-kerentanan bawaan/genetik) PATOGENESIS Eksogen : Paparan Karsinogen  Rokok Endogen: Kepekaan Faktor Host  Genetik a.l. p53 Tumor Supresor Gene 80-90% Ca Paru  Perokok Faktor Eksogen Kanker Paru Tobacco (inhaled carcinogen) : 85-87% Second-Hand Passive Smoker: 5-7% Others : 5-7% Asbestos, Uranium, Marijuana, Beryllium, Air pollutant, diesel, Tar, arsenik, nikel, krom Scar/Fibrosis : 1-2% :

WHAT CAUSES LUNG CANCER ? SMOKING - number one couse Cigarette 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)

WHAT CAUSES LUNG CANCER ? Quitting smoking  decreases risk of developing 10 years after quitting  risk decrease 50% Quit smoking during cancer tretment  live 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

WHAT ARE THE DIFFERENT KINDS OF LUNG CANCER ? Two main catagories: Small-cell lung cancer (SCLC) – 20% Non Small cell lung cancer (NSCLC) – 80% NSCLC Adeno Ca 30-35% of all NSCLC usually develop at the edges of the lung, but some times occur toward the center of the chest Often slow growing and don’t typically cause symptoms in early stages Often found and diagnosed at more advanced stages The most common subtype of the lung Ca in women and in non smokers Divide into subcatagories such as Bronchoalveolar Carcinoma.

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 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

WHAT ARE THE SYMPTOMS OF LUNG CANCER ? Some are similar to other common illnesses 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 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 wheezing 3. Hemoptysis (30% of people with lung Ca)  call the doctor immediately

WHAT ARE THE SYMPTOMS OF LUNG CANCER ? 4. If the tumor grows larger, it can press nearby organs and bones. 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 Ca has 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 of appetite.

HOW LUNG CANCER DIAGNOSED ? Early Dx is difficult because symptoms do not usually occur until disease is more advanced. Have signs or symptoms of lung Ca during a routine Physical examination Test used to help detect lung Ca: 1.Chest X-Ray 2,Computed Tomography (CT) Scan 3.Magnetic Resonance Imaging (MRI) 4.Positron Emission Tomography (PET) Scan 5.Sputum Cytology 6.Biopsy

HOW LUNG CANCER DIAGNOSED ? Chest X-Ray CT-Scan MRI Sputum Cytology Biopsy Common test used Uses small of radiation Compare old chest X-rays with recent ones to see if tumor is growing or shrinking Is another test used to Help diagnose lung ca Similar to CXR but gives a more detailed picture of the lung Can detect extremely small tumors -Similar to CT scan Clear images internal body part, including tissue, muscle, nerves, and bones. used to detect the presence of tumor Sputum is collected to look for cancer cells. most accurate to collect and analyze early-morning mucus for three days - A simple cells be taken from the tumors. - Can be obtained in several different ways depending on the location and size of a tumors.

Procedures for Biopsy Bronchos copy Transthora cic Needle Aspiration Fine Needle Aspiration Cervical Mediasti noscopy Endoscopic Lymph Node Biopsy Video Assisted Thoracos Explora tory Thoracotomy To see the inside of the lungs and airways. There’s small camera on the end of the bronchos cope that takes pictures . There’s also a small tool that’s used to remove a sample of the tissue from the tumors. Inserts a needle into chest wall and uses the needle to make a sample of tissue - Is used for tumors closer to the chest wall Using a CT scan for guidance, an incision is made in the skin so a needle can be inserted into the tumor to remove a sample of cells. May be used to biopsy theprimary tumor or metastases - This technique is often used to biopsy lymph nodes around the lungs Small tube passed through mouth into the esophagus. small tool passed the tube, it can take tissue sample of nearby lymph nodes - Tube containing a small television camera, inserted betweenribs after making a small incision through the skin, can see the tumor. - This is a surgical prosedure where opens the chest to visually examine and remove the tumor.

DIAGNOSIS dan PENDERAJATAN 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 Lain Penderajatan (Staging)

Keluhan dan GX penyakit tdk spesifik, Dekeksi Dini: Keluhan dan GX penyakit tdk spesifik, Batuk darah, Batuk kronis, BB menurun dan Gx lain, juga dapat ditemui pd penyakit paru lain Penemuan dini berdasarkan keluhan saja jarang terjadi Biasanya keluhan ringan terjadi pada mereka yg telah masuk stadium II dan III Sasaran utk deteksi dini terutama ditujukan pada subyek dengan resiko tinggi : * Laki-laki, usia > 40 tahun, perokok * Paparan industri tertentu + satu @ lebih gejala: batuk darah, batuk kronis, sesak napas, nyeri dada, BB menurun

Alur Deteksi Dini Kanker Paru (Skrining) Golongan Resiko Tinggi (GRT) Bukan GRT dengan gejala batuk kronis, sesak napas, batuk darah, BB turun Foto thoraks dan Sitologi Sputum Diagnostik dan terapi penyakit paru non kanker Semua hasil (-) Ada hasil yg (+) (a,b,c dlm skema) Curiga Kanker Paru Teruskan prosedur diagnostik kanker paru Re-skrining 4-6 bulan Teruskan prosedur diagnostik kanker paru Foto thoraks Sitologi sputum ( + ) ( - ) ( + ) a b c d Skema

Penderajatan (Staging) Kanker Paru Dinilai 3 Hal  T N M Staging Dilakukan utk mendapatkan gambaran penyakit yang akurat serta objektif guna pemilihan option penanganan Dinilai 3 Hal  T N M Staging 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 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.

Penderajatan (Staging) Kanker Paru Penderajatan utk NSCLC ditentukan menurut International Staging System For Lung 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 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,Mo T4, sembarang N, M0 IV Sembarang T, sembarang N, M1

Pengobatan Kanker Paru Dikenal 5 modalitas terapi: 1. Pembedahan 2. Radioterapi 3. Kemoterapi 4. Hormonal 5. Immunologik 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 advanced  kemoterapi (paliatif)

T N M STAGING NSCLC OPERABLE N-0 N-1 N-2 N-3 T-1 IA IIA IIIA IIIB T-2 All M-1 = IV OPERABLE

Anti Angiogenesis Tx disigned to stop the cancer by nullifying a tumor’s ability to obtain O2 and nutrients for growth. Angiogenesis is the formation of new blood vessels. Tumor targeted cryoblastion / cryosargery, is a minimally invasive surgery Treatment that uses extreme cold to destroy, or ablate, diseased tissue , including Cancer cells. Cytocin Induced Killer Cell Imunotherapy, Non MHC

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 for patients 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,”.

KEBERHASILAN YANG TERTUNDA SEKIAN KEGAGALAN NO BUT KEBERHASILAN YANG TERTUNDA