Lung and Mediastinal cancer

Dr.dr. Tahan P.H.,
SpP.DTCE,MARS
FK UWK Surabaya
Agustus 2011
- 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
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
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
Primary malignant
tumor
Lymph
Carries:
Dead cells, abnormal
and cancer cells
through
lymphatic vessels
to
Lymph nodes
(filter unwanted substances)
Blood
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
1. Malignant tumor, grows in one or both of the lung
2. Usually form from cells that line the airways and
nearby glands that contact with the air we breathe,
which my contain carcinogens
3. Lung cancer: changing of normal cells into carcenous
cells usually happens over a period of years
4. 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.
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%
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)
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
Two main catagories:
Small-cell lung cancer (SCLC) – 20%
Non Small cell lung cancer (NSCLC) – 80%
NSCLC
1. 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
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
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
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: rightsided abdominal pain and Jaundice.
6. Some general symptoms like weight loss, fatique, and loss of
appetite.
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
Chest X-Ray
CT-Scan
MRI
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
Cytology
-Sputum is
collected to
look for
cancer cells.
- most
accurate
to collect
and analyze
earlymorning
mucus for
three days
Biopsy
- A simple
cells be taken
from the
tumors.
- Can be
obtained in
several
different
ways
depending
on the
location and
size of a
tumors.
Bronchos
copy
Transthora
cic Needle
Aspiration
Fine
Needle
Aspiration
Cervical
Mediasti
noscopy
Endoscopic
Lymph
Node
Biopsy
Video
Assisted
Thoracos
copy
Explora
tory
Thoracoto
my
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.
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)
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
Deteksi Dini Kanker Paru
(Skrining)
Bukan GRT dengan gejala batuk
kronis, sesak napas, batuk darah,
BB turun
Golongan Resiko Tinggi
(GRT)
Foto thoraks dan Sitologi Sputum
Semua hasil (-)
Ada hasil yg (+)
(a,b,c dlm skema)
Re-skrining 4-6
bulan
Teruskan prosedur
diagnostik kanker
paru
Diagnostik dan terapi penyakit paru
non kanker
Curiga Kanker Paru
Teruskan prosedur
diagnostik kanker paru
Foto thoraks
Skema
Sitologi sputum
(+)
( - )
( + )
a
b
( - )
c
d
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 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
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,Mo
T4, sembarang N, M0
IV
Sembarang T, sembarang N, M1
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
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
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,”.