Download - Ukdw CA Paru
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1KANKER PARUKANKER PARU--TUMOR MEDIASTINUMTUMOR MEDIASTINUM
ISWANTO
SMF PARU RS BETHESDA-FK UKDW
YOGYAKARTA
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CA PARU-ROKOK.
Rokok dapat meningkatkan resiko CA
Paru, dan hal tersebut berhubungan
dengan:
Jumlah rokok yang dihisap
Cara menghisap rokok.
Lama merokok
Genetik.
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HIPOTESA ROKOK-CAPARU
Tar pada rokok
Peningkatan oxidative stress
Ketidakseimbangan oksidan antioksidans menyebabkan kerusakan jaringan paru
Inflamasi peribronkial
Kerusakan struktur dan fungsi epitel
Fibrosis
Mitosis
CA Paru
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Divided into two types:
nonsmall cell lung cancer (NSCLC)
small cell lung cancer (SCLC)
Smallcell lung cancer (SCLC) (2025% of lung cancers), both limited and extensive stage disease, systemic
chemotherapy plays a pivotal role
Nonsmall cell lung cancer (NSCLC) (adenocarcinoma, squamous cell carcinoma, and largecell carcinoma)
surgery, chemotherapy, radiotherapy
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PROSEDUR DIAGNOSTIKPROSEDUR DIAGNOSTIK
Konfirmasi :
1. Pemeriksaan sitologik
- sputum dari batuk spontan
- induksi sputum
- bronchial washing, brushing, aspiration
- sputum collecting paska FOB
3 hari berturutan, fiksasi dengan alkohol 70%
2. Pemeriksaan radiologik
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PROSEDUR
2. Pemeriksaan Radiologik :
1. Foto toraks PA & lateral
- tumor > 1 cm
- komplikasi
- perburukan penyakit non-kanker
2. CT-Scan toraks kontras
- evaluasi KGB
- deteksi tumor < 1 cm
3. USG
4. Positron Emission Tomography (PET)
- deteksi KGB < 1 cm
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PROSEDUR
3. Pemeriksaan khusus :
a. Bronkoskopi
- evaluasi mukosa, massa intraluminal
- brushing, washing, lavas, biopsi
b. Fine needle aspiration biopsy (FNAB)
c. Transbronchial needle aspiration (TBNA)
d. Transbronchial lung biopsy (TBLB)
e. Transthoracal needle aspiration (TTNA)
f. Transthoracal biopsy (TTB)
g. Fine needle aspiration (FNA)
h. Biopsi KGB
i. Torakoskopi, Mediastinoskopi, VATS
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PROSEDUR
4. Pemeriksaan lain :
a. Tumor marker
- Carcino embryonic antigen (CEA)
- Cyfra 21, SCC, Ca 19-9, Ca 125 II
- Non specific enolase (NSE)
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Performance scale of lung cancer patients(Karnofsky & WHO)
Karnofsky Scale
WHO Scale
Keterangan
90 -100 0 Normal beraktivitas
70 - 80 1 Ada keluhan tapi masih aktif & dapat mengurus diri sendiri
50 - 60 2 Cukup aktif tapi kadang memerlukan bantuan
30 - 40 3 Kurang aktif, perlu perawatan
10 - 20 4 Tak dapat meninggalkan tempat tidur, perlu MRS
0 - 10 - Tidak sadar
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PENGOBATAN KANKER PARUPENGOBATAN KANKER PARU
Pengobatan kanker paru saat ini :
- Bedah
- Kemoterapi
- Radioterapi
- Target terapi
Pengobatan tergantung pada stadium penyakit.
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Combined modality therapy
Landasan terapi kanker paru :
1. Staging (penderajatan)
a. TNM b. G (gradasi histopatologis)
GX Tak dapat ditentukanG1 Well differentiatedG2 Moderately differentiatedG3 Poorly differentiatedG4 Undifferentiated
2. HistopatologiNSCLC atau SCLC
3. Status Performance
PengobatanPengobatan
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Modalitas terapi kanker paru
1. Pembedahan
- Reseksi lengkap + KGB intrapulmonal
Lobektomi, pneumonektomi
- Histo PA : NSCLC
- Stage I & II, Stage III
- Kegawatan paru
- Syarat : VC kontralateral baik
FEV1 > 60%
Pengobatan
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Pengobatan
2. Radioterapi
- Kuratif, paliatif- Dosis : 200 cGy, 5x /minggu
5.000 - 6.000 cGy- Syarat :
- Hb >10 g% - Trombosit > 100.000 /mL - Leukosit > 3000 /mL
- Radiasi paliatif :- Performance < 70- BB > 5% dalam 2 bulan- Faal paru jelek
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Pengobatan
3. Kemoterapi
Prinsip :a. Platinum base chemotherapyb. Respon obyektif 1 obat 15%c. Toksisitas obat grade III skala WHOd. Stop/ganti bila 3 siklus tumor progresif
Syarat :a. KS > 70-80b. Hb > 10 g%c. Granulosit > 1.500 /mLd. Trombosit > 100.000 /mLe. LFT & RFT baik
(Cl creatinin > 70 mL/min)
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Pengobatan
3. Kemoterapi
Truthful information
Autonomy (do everything) vs Medical judgement
Autonomy & Justifiability
* do not give false hope * do not destroy hope* the right to information concerning
themselves * obligation to preserve both
physical & emotional well being
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Pengobatan
4. Imunoterapi
- ImunomodulatorKeladi tikus, buah merah, thymus dll.
- Sitokin : IL-2, anti VEGF
5. Terapi hormonal
6. Terapi gen
5 & 6 masih dalam penelitian
Terapi paliatif bebas nyeri Stadium III B - IV
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Management of NSCLC
TNM STAGE < II B TNM STAGE III A TNM STAGE III B TNM STAGE IV
Segmentectomy /Lobectomy
Neoadjuvant ChTx
ChTx 2x RaTx 40Gy
KS > 70 KS < 70 KS > 70 KS < 70
Surgery (+)
Surgery ( - ) Re Staging
Adjuvant ChTx Improved Not improved
Surgical Tx
Continue ChTx, RaTx
ChTx, RaTx
ChRaTx Palliative
ChTx
RaTx
BSC
ChTx
RaTx
Palliative
BSC
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Limited disease Extensive disease
KS 70 KS 70KS < 70
Best Supportive
Care
ChTxRaTx
CR PR
Prophylactic
Cranial
Irradiation
Change
ChemoTx ChangeChemoTx
ChemoTx
2x
Response (+) Continue ChTx ~ 6x
Response (-)
Histo-PA
Reevaluation CR
PR
Management of SCLC
KS < 70
Best Supportive
Care
Prophylactic Cranial Irradiation
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Curative Palliative
Mode of chemotherapy
Induction, Adjuvant,
Neo-adjuvant
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Evaluation after 2 cycles
Stop if :
no partial response
Continue if :
palliation +, no progression
Adverse effects
May be severe
Must be minimal
Intent Intent to cure Palliation intent :
DO NO HARM
Curative vc Palliative chemotherapy
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1. Kemoterapi kuratif :
Induction ChemoTx
Kemoterapi primer tanpa alternatif modalitas
terapi lain untuk mencapai Complete / Partial
response
Adjuvant ChemoTx
Kemoterapi yang diberikan setelah tumor
primernya diterapi dengan modalitas terapi lain,
untuk mengatasi mikro metastasis tersisa,
tumor burden, efektivitas kemoterapi
Jenis kemoterapi
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Neo-adjuvant Chemotx
Pengobatan initial untuk memungkinkan
modalitas lain bekerja lebih efektif
Karena vaskularisasi intak suplai obat baik
ukuran tumor preservasi organ
Kerugian: penundaan modalitas terapi lain
2. Kemoterapi paliatif
Mengurangi keluhan dan gejala
tanpa menyembuhkan
Jenis kemoterapi
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Pilihan pengobatan yang terbatas pada Pilihan pengobatan yang terbatas pada
stadium lanjut kanker parustadium lanjut kanker paru
Kemoterapi pada kanker paru dasarnya
bersifat paliatif.
Bila jenis kemoterapi ditambah maka efek
samping/toksik >>>
Kemoterapi kanker paru kurang memberikan
hasil
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Tumor MediastinumTumor Mediastinum
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Rosenberg ClassificationNeurogenic
Arising from peripheral nerves
Neurofibroma
Neurilemoma/Schwannoma
Neurosarcoma
Arising from sympathetic ganglia
Ganglioneuroma
Ganglioneuroblastoma
Neuroblastoma
Arising from paraganglionic tissue
Pheochromocytoma
Chemodectoma/paraganglioma
Germ cell tumor
Seminoma
Nonseminomatous tumors
Pure embryonal cell
Mixed embryonal cell with
seminomatous elements
trophoblastic elements
teratoid elements
entodermal sinus elements/yolk sac tumor
Teratoma benign
Aneurysms
Thymic
Thymoma
Carcinoid
Thymolipoma
Mesenchymal tumors
Fibroma, fibrosarcoma
Lipoma, liposarcoma
Myxoma
Myxoma
Mesothelioma
Leiomyoma, leiomyosarcoma
Rhabdomyosarcoma
Xanthogranuloma
Mesenchymoma
Hemangioma
Hemangioendothelioma
Hemangiopericytoma
Lymphangioma
Lymphangiopericytoma
Cysts
Pericardial
Bronchogenic
Enteric
Thymic
Thoracic duct
Meningoceles
Lymphadenopathy
Inflammatory
Granulomatous
Sarcoid
Hernias: Hiatal, Morgagni
Endocrine tumors: Thyroid, Parathyroid
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Mediastinal contentheart, great artery & vein, nerves, trachea, thymus,lymph nodes & vessels, esophagus, connective tissue
Compartment of the mediastinumM superior:
Thoracic inlet- VTh V & lower part of sternumM anterior:
Superior mediastnal border-diaphragm infront of the heart
M posterior: Superior mediastinal border -diaphragm behind the heart
M medius: Superior mediastinal border-diaphragm between anterior & posterior mediastinal
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Clinical features
Symptoms & signs* Asymptomatic* Dry Cough, dyspnea, stridor, dysphagia,
VCSS, hoarseness, chest pain
Physical examination
Radiologic procedureChest X-ray, Tomography, CT-Scan, MRI,
Fluoroscopy, Echocardiography, Angiography, Esophagoscopy, USG, Nuclear medicine
Endoscopic procedureBronchoscopy, Mediastinoscopy, Thoracoscopy
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Clinical features
Pathologic procedureCytology:
FNAB, Pleural effusion, Brushing, Washing, Transthoracal biopsy
Histological examinationLymph node biopsy, Daniels biopsyMediastinal biopsy, Excisional biopsy, VATS
LabCBC, ESR, Tuberculin skin test, Thyroid study, -FP, -HCG, EMG
Surgical procedure
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Staging of timic tumor (Masaoka)
Stage & description TreatmentI Macroscopic: capsulated
No microscopic capsul invasion
Extended thymo thymectomy (ETT)
II Macroscopic invasion to fat tissue surrounding mediastinal pleura or microscopic capsul invasion
ETT, continued with radiation
III Macroscopic invasion to surrounding organ
ETT and extended resection, then radiation and chemotherapy
IVA Pleural /pericardial spreading Debulking, then chemotherapy and radiotherapy
IV B Lymphogenic / hematogenic spreading
Chemotherapy and radiotherapy then debulking
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Germ Cell Tumor
SeminomaRadiation & chemotherapy sensitiveNo surgical interventionChemo after radiation or Chemoradiation Platinum based chemotherapy
Non seminomatous mediastinal tumorRadioresistant tumor6 cycles Chemotherapy
-HCG, -FP, Chest X-ray evaluation
Benign teratomaSurgical intervention
Malignant teratomaMultimodality therapy
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Neurogenic Tumor
Surgical intervention except neuroblastoma
NeuroblastomaRadiosensitive Combination Radio & chemotherapy
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Management of VCSS
Dx & Tx
As it
caused
Diagnostic Procedures
forLung/
Mediastinal
tumor
Improved Stable Continue
Diagnostic
Procedure
Primary
tumor
mngment
Continue
Diagnostic
Procedures
Consider
Surgical
Procedure
Tumor (-) Tumor (+)
CT-Scan Thorax
No tumor/mass
clearly detected
Chest X-ray ( PA & Lateral )
Radiation 1 x 8 Gy
General performance
Poor/Dyspnea
Lung/Mediastinal tumor
Good
General performance
PA (+) PA (-)
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Management of mediastinal tumor
Mediastinal tumor Benign
Malignant Surgical
Lymphoma
Non-Lymphoma
Hodgkin
Non-Hodgkin
Thymoma
Thymic tumor
Germ Cell
Tumor
Neurogenic
tumor
Mesengial tumor
Endocrine tumor