Kuliah kanker paru bronchogenic carcinoma
• A focus of metastatic
carcinoma from breast is
seen on the pleural surface
of the lung. Such pleural
metastases may lead to
pleural effusions, including
hemorrhagic effusions, and
pleural fluid cytology can
often reveal the malignant
cells.
•
The dense white encircling tumor mass is
arising from the visceral pleura and is a
mesothelioma. These are big bulky tumors
that can fill the chest cavity.The risk factor
for mesothelioma is asbestos exposure.
However, mesothelioma is rare even in
persons with asbestos exposure.
Asbestosis more commonly predisposes to
bronchogenic carcinomas, increasing the
risk by a factor of five. Smoking increases
the risk for lung cancer by a factor of ten.
Thus, smokers with a history of asbestos
exposure have a risk 50 fold greater
likelihood of for developing lung cancer.
• Mesotheliomas have
either spindle cells or
plump rounded cells
forming gland-like
configurations, as seen
here at high power
microscopically. They
are very difficult to
diagnose cytologically.
TNM staging
T: Tumor (size, extension
to surrounding organsim)
N: lymph node (hilar,
mediastinal, supraclavicular)
M: distant metastasis
(multiple organ,
Thoracic CT scanning for staging
Multicenter, Jakarta
2007-2008
Staging,
nonsmall cell
lung cancer
IIIA
IIB
IIA
IB
IA
IIIB
IB IIA
IA
IIIA
IV
www.kankerparu.org
RS Persahabatan
2004-2006
IIB
IV
IIIB
Treatment modalities for lung cancer
• Scalpel: surgery
• Beam: radiotherapy
• Drugs: chemotherapy,
new targeted therapy
• Combined/multimodality
General approach NSCLC
NEJM 2004
Surgery
5(1,3%)
Chemoradioth/
(17.2%)
Chemoradio
Chemotherapy 35,26%
10,4%
Untreated 35,1%
Radioth/
No medical
Treatment
39(10,5%)
131(35,1%)
Surgery 1,42%
% Others 27,3%
Chemoth/)
95
( 25.5%)
Others
39(10,5%
)
RS Persahabatan
(n = 373)
Untreat ed 17,6%
targted th 0,9%
Radioth 7,3%/
Multicenter, Jakarta
Treatment: Nonsmall cell Lung Cancer
WWW.KANKERPARU.ORG
. Journal of Thoracic Oncology 2007 ; 2(suppl) : S657
Survival rate
Angka tahan hidup
1.00
Stg IA&IIA
0.75
p=0,0000
0.50
Stg IB
0.25
Stg IIIB
Stg IIB
0.00
0
20
Stg IV
Stage IB
Stage IIB
Stage IIIB
Lama hidup
(bulan)
40
Stg IIIA
60
Stage
Stage
Stage
Stage
80
IASurvival
IIA
IIIA
IV
time
Survival of lung cancer after surgery
in Persahabatan
Hospital
Survival of lung cancer after surgery
in Persahabatan Hospital
Angka tahan hidup
1.00
• t
0.75
p=0,0002
0.50
0.25
0.00
0
Resection+
adjuvant
Lama hidup
(bulan)
20
Neoadjuvant+resection
40
60
Adjuvan
Resection only
Pembedahan saja
NotTanpa
resected
pembedahan
Neoadjuvan
. Journal of Thoracic Oncology 2007 ; 2(suppl) : S657
80
New targeted therapy
for lung cancer
Cancer cells may have receptor for EGF, which then sends
signals to the nucleus, causing
cells to proliferate, invade the
surroundings, metastasize,
and make new blood vessels.
EGFR inhibitors drugs can
block this process, resulting
in clinical improvement and
better prognosis
The role clinical laboratory examination
• As support to treatment: hematology,
organ function (especially liver, blood,
kidney)
• Tumor markers: CEA, SCC, Cyfra 21.1,
NSE may indicate treatment failure,
recurrent or metastasis
• As support to diagnosis, but not decisive.
What We Need to Be Aware of
Mangunnegoro:
43% of lung cancer patients were
previously diagnosed as pulmonaryTb
Taufik:
38% of lung cancer patients have
been treated as pulmonary Tb when
the diagnosis of lung cancer was
established.
What We Need to Be Aware of
A male smoker patient in
cancer age, diagnosed as
pneumonia or smear negative pulmonary TB,
Not responding to an
adequate treatment
within 1-2 weeks
should be evaluated for the
possibility of lung ca ncer
•
What We Need to Be Aware of
The esponse to treatment in a smer negative Tb ptnt must be
assessed clinically in the 1st 2 weeks
Anamnesis
is very important to detect improvement
*is the
patient feeling better?
* is
fever subsiding*
*is appetite reappearing? Is cough decreasing?
Adequate verbal contact is mandatory,
just drug prescribingdrugs is not enough
If the patient complains of no improvement
do not feel offended,
continue assessment towards lung cancer
What We Need to Be Aware of
frequently neglected symptoms & signs
Beware!
persistent pain
in the shoulder and/or arm
Male, 44 yrs
Persistent pain
on rgt shoulder,
treated as tb for
>2 months,
not improved.
Biopsy: adeno
carcinoma
23/5/2008
After chemothrp I
& radiotherapy 10x
110608
After chemothrp II
& radiotherapy 20x
230308
080508
Before therapy
Male, 44 yrs
Persistent pain
on rgt shoulder,
treated as tb for
>2 months,
not improved.
Biopsy: adeno
carcinoma
23/5/2008
After chemothrp I
& radiotherapy 10x
110608
After chemothrp II
& radiotherapy 20x
What We Need to Be Aware of
frequently neglected symptoms & signs
Beware!
Netter FH, et al
persisten pain in the shoulder
and/arm plus a lesion on the apex
of the lung
Look for signs:
paresthesia, paresis
myosis, ptosis,
enophtalmos
(brachial plexsus syndrome.
What We Need
to Be Aware of
frequently neglected
symptoms & signs
Netter FH, et al
What We Need to Be Aware of
frequently neglected symptoms &
•
signs
Severe
headache or signs of stroke
may indicate
cerebral metastasis from lung cancer
• Chest x-ray film must be made
before brain surgery.
• Lung cancer is often found after extirpat-ion of brain lesion
suspected for tumor.
Prevention: risk factors for lung cancer
Yayasan Jantung Indonesia
REPUBLIKA
Further reading & acknowledgment
1. Rukmini Mangunkusumo, Pidato Pengukuhan Guru Besar FKUI , 2004
2. Netter FH, Divertie MB, Brass E (eds): the Ciba Collection of Medical Illustration
vol 7 Ciba 1979
3. Sun S, Schiller JH, Gazdar AF. Lung cancer in never smokers a different disease.Nature Rev Cancer.2007; 7:778-90
4. Subramanian J, Govindan R. Molecular genetics of lung cancer
in people
who have never smoked. Lancet Oncol.2008;9:676-82
5. Jusuf A: Pidato Pengukuhan Guru Besar FKUI , 2004
6. Kanker Paru: Pedoman Dignosis&Pengobatan PDPI & POI, 2005
7. Sjahruddin E. Journal of Thoracic Oncol 2007;2 (suppl):657
8. www.kankerparu.org
9. Files, Departmnt of Respiratory Medicine, FKUI-RS Persahabatan
Sun S, Schiller JH, Gazdar AF.
Lung
cancer in never smokersa different disease.Nature Rev
Cancer.2007;7:778-90
carcinoma from breast is
seen on the pleural surface
of the lung. Such pleural
metastases may lead to
pleural effusions, including
hemorrhagic effusions, and
pleural fluid cytology can
often reveal the malignant
cells.
•
The dense white encircling tumor mass is
arising from the visceral pleura and is a
mesothelioma. These are big bulky tumors
that can fill the chest cavity.The risk factor
for mesothelioma is asbestos exposure.
However, mesothelioma is rare even in
persons with asbestos exposure.
Asbestosis more commonly predisposes to
bronchogenic carcinomas, increasing the
risk by a factor of five. Smoking increases
the risk for lung cancer by a factor of ten.
Thus, smokers with a history of asbestos
exposure have a risk 50 fold greater
likelihood of for developing lung cancer.
• Mesotheliomas have
either spindle cells or
plump rounded cells
forming gland-like
configurations, as seen
here at high power
microscopically. They
are very difficult to
diagnose cytologically.
TNM staging
T: Tumor (size, extension
to surrounding organsim)
N: lymph node (hilar,
mediastinal, supraclavicular)
M: distant metastasis
(multiple organ,
Thoracic CT scanning for staging
Multicenter, Jakarta
2007-2008
Staging,
nonsmall cell
lung cancer
IIIA
IIB
IIA
IB
IA
IIIB
IB IIA
IA
IIIA
IV
www.kankerparu.org
RS Persahabatan
2004-2006
IIB
IV
IIIB
Treatment modalities for lung cancer
• Scalpel: surgery
• Beam: radiotherapy
• Drugs: chemotherapy,
new targeted therapy
• Combined/multimodality
General approach NSCLC
NEJM 2004
Surgery
5(1,3%)
Chemoradioth/
(17.2%)
Chemoradio
Chemotherapy 35,26%
10,4%
Untreated 35,1%
Radioth/
No medical
Treatment
39(10,5%)
131(35,1%)
Surgery 1,42%
% Others 27,3%
Chemoth/)
95
( 25.5%)
Others
39(10,5%
)
RS Persahabatan
(n = 373)
Untreat ed 17,6%
targted th 0,9%
Radioth 7,3%/
Multicenter, Jakarta
Treatment: Nonsmall cell Lung Cancer
WWW.KANKERPARU.ORG
. Journal of Thoracic Oncology 2007 ; 2(suppl) : S657
Survival rate
Angka tahan hidup
1.00
Stg IA&IIA
0.75
p=0,0000
0.50
Stg IB
0.25
Stg IIIB
Stg IIB
0.00
0
20
Stg IV
Stage IB
Stage IIB
Stage IIIB
Lama hidup
(bulan)
40
Stg IIIA
60
Stage
Stage
Stage
Stage
80
IASurvival
IIA
IIIA
IV
time
Survival of lung cancer after surgery
in Persahabatan
Hospital
Survival of lung cancer after surgery
in Persahabatan Hospital
Angka tahan hidup
1.00
• t
0.75
p=0,0002
0.50
0.25
0.00
0
Resection+
adjuvant
Lama hidup
(bulan)
20
Neoadjuvant+resection
40
60
Adjuvan
Resection only
Pembedahan saja
NotTanpa
resected
pembedahan
Neoadjuvan
. Journal of Thoracic Oncology 2007 ; 2(suppl) : S657
80
New targeted therapy
for lung cancer
Cancer cells may have receptor for EGF, which then sends
signals to the nucleus, causing
cells to proliferate, invade the
surroundings, metastasize,
and make new blood vessels.
EGFR inhibitors drugs can
block this process, resulting
in clinical improvement and
better prognosis
The role clinical laboratory examination
• As support to treatment: hematology,
organ function (especially liver, blood,
kidney)
• Tumor markers: CEA, SCC, Cyfra 21.1,
NSE may indicate treatment failure,
recurrent or metastasis
• As support to diagnosis, but not decisive.
What We Need to Be Aware of
Mangunnegoro:
43% of lung cancer patients were
previously diagnosed as pulmonaryTb
Taufik:
38% of lung cancer patients have
been treated as pulmonary Tb when
the diagnosis of lung cancer was
established.
What We Need to Be Aware of
A male smoker patient in
cancer age, diagnosed as
pneumonia or smear negative pulmonary TB,
Not responding to an
adequate treatment
within 1-2 weeks
should be evaluated for the
possibility of lung ca ncer
•
What We Need to Be Aware of
The esponse to treatment in a smer negative Tb ptnt must be
assessed clinically in the 1st 2 weeks
Anamnesis
is very important to detect improvement
*is the
patient feeling better?
* is
fever subsiding*
*is appetite reappearing? Is cough decreasing?
Adequate verbal contact is mandatory,
just drug prescribingdrugs is not enough
If the patient complains of no improvement
do not feel offended,
continue assessment towards lung cancer
What We Need to Be Aware of
frequently neglected symptoms & signs
Beware!
persistent pain
in the shoulder and/or arm
Male, 44 yrs
Persistent pain
on rgt shoulder,
treated as tb for
>2 months,
not improved.
Biopsy: adeno
carcinoma
23/5/2008
After chemothrp I
& radiotherapy 10x
110608
After chemothrp II
& radiotherapy 20x
230308
080508
Before therapy
Male, 44 yrs
Persistent pain
on rgt shoulder,
treated as tb for
>2 months,
not improved.
Biopsy: adeno
carcinoma
23/5/2008
After chemothrp I
& radiotherapy 10x
110608
After chemothrp II
& radiotherapy 20x
What We Need to Be Aware of
frequently neglected symptoms & signs
Beware!
Netter FH, et al
persisten pain in the shoulder
and/arm plus a lesion on the apex
of the lung
Look for signs:
paresthesia, paresis
myosis, ptosis,
enophtalmos
(brachial plexsus syndrome.
What We Need
to Be Aware of
frequently neglected
symptoms & signs
Netter FH, et al
What We Need to Be Aware of
frequently neglected symptoms &
•
signs
Severe
headache or signs of stroke
may indicate
cerebral metastasis from lung cancer
• Chest x-ray film must be made
before brain surgery.
• Lung cancer is often found after extirpat-ion of brain lesion
suspected for tumor.
Prevention: risk factors for lung cancer
Yayasan Jantung Indonesia
REPUBLIKA
Further reading & acknowledgment
1. Rukmini Mangunkusumo, Pidato Pengukuhan Guru Besar FKUI , 2004
2. Netter FH, Divertie MB, Brass E (eds): the Ciba Collection of Medical Illustration
vol 7 Ciba 1979
3. Sun S, Schiller JH, Gazdar AF. Lung cancer in never smokers a different disease.Nature Rev Cancer.2007; 7:778-90
4. Subramanian J, Govindan R. Molecular genetics of lung cancer
in people
who have never smoked. Lancet Oncol.2008;9:676-82
5. Jusuf A: Pidato Pengukuhan Guru Besar FKUI , 2004
6. Kanker Paru: Pedoman Dignosis&Pengobatan PDPI & POI, 2005
7. Sjahruddin E. Journal of Thoracic Oncol 2007;2 (suppl):657
8. www.kankerparu.org
9. Files, Departmnt of Respiratory Medicine, FKUI-RS Persahabatan
Sun S, Schiller JH, Gazdar AF.
Lung
cancer in never smokersa different disease.Nature Rev
Cancer.2007;7:778-90