Lung And Mediastinal Tumor

  

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 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?

HOW DO CANCER CELL SPREAD TO OTHER

  Primary malignant tumor Primary malignant tumor

  Part of the body

  

Part of the body

  Blood Blood

  Lymph Lymph

  Carries: Dead cells, abnormal and cancer cells through lymphatic vessels to

  Lymph nodes (filter unwanted substances)

  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) 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)

WHAT IS LUNG CANCER ?

WHAT IS LUNG CANCER ?

  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)

  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. 

  

Penyebab LUNG CANCER

Penyebab LUNG CANCER

  Proses terjadinya belum diketahui dengan pasti Diduga ada faktor exogen dan endogen (dari dalam- kerentanan bawaan/genetik)

  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

  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%

  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 ?

  

WHAT CAUSES LUNG CANCER ?

• number one couse

  Cigarette smoke contains at least 43 diferent

  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

SMOKING

• number one couse

  Cigarette smoke contains at least 43 diferent

  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

  SMOKING

  

Second-hand smoke also contains carcinogens

(USA 5.000 – 10.000 dignosed lung cancer

resulting from breathing second-hand smoke)

  Second-hand smoke also contains carcinogens

(USA 5.000 – 10.000 dignosed lung cancer

resulting from breathing second-hand smoke)

WHAT CAUSES LUNG CANCER ?

  

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

  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

• Exposure to chemicals in the air, asbestos and radon

• Lung diseases that can block airfow to lungs, COPD or

  TB

• Lung diseases that can block airfow to lungs, COPD or

  TB

• Genetics

  -

  Age, occurs more often in people over 65 years of age

• Genetics

  -

  Age, occurs more often in people over 65 years of age

  Some people with lung cancer who have never smoked

  Factor contribute to lung cancer:

  

CANCER ?

  1. Adeno Ca

  Divide into subcatagories such as Bronchoalveolar Carcinoma.

  and in non smokers

  Often found and diagnosed at more advanced stages The most common subtype of the lung Ca in women

  symptoms in early stages

  Often slow growing and don’t typically cause

  30-35% of all NSCLC usually develop at the edges of the lung, but some times occur toward the center of the chest

  Divide into subcatagories such as Bronchoalveolar Carcinoma.

  

CANCER ?

Two main catagories:

Small-cell lung cancer (SCLC) – 20%

  and in non smokers

  Often found and diagnosed at more advanced stages The most common subtype of the lung Ca in women

  symptoms in early stages

  Often slow growing and don’t typically cause

  30-35% of all NSCLC usually develop at the edges of the lung, but some times occur toward the center of the chest

  1. Adeno Ca

  

Non Small cell lung cancer (NSCLC) –

80%

  NSCLC NSCLC NSCLC NSCLC

  2. Squamous cell Ca

  2. Squamous cell Ca

• account about 30% of all NSCLC
• unlike Adeno Ca, this type strongly
• account about 30% of all NSCLC
• unlike Adeno Ca, this type strongly

  associated with smoking

  associated with smoking

• usually foundin the larger airway tubes and toward the center of the chest

• - usually foundin the larger airway tubes

  and toward the center of the chest

  3. Large cell Ca

  3. Large cell Ca

• account about 10-20% of all NSCLC
• more difcult 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<
• account about 10-20% of all NSCLC
• more difcult 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 ?

  

WHAT ARE THE SYMPTOMS OF LUNG CANCER ?

  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

  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

  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

  

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

  

WHAT ARE THE SYMPTOMS OF LUNG CANCER ?

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 efusion )

  

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.

HOW LUNG CANCER DIAGNOSED ?

  

HOW LUNG CANCER DIAGNOSED ?

  

Early Dx is difcult 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

Early Dx is difcult 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 ?

HOW LUNG CANCER DIAGNOSED ?

  Chest X- Ray

CT-Scan MRI Sputum

Cytology

Biopsy

  Common test used

  Is another test used to Help diagnose lung ca Similar to CXR but

• Similar to CT scan
>A simple cells be taken from the tumors.
• Can be obtained in several diferent ways depending on the location and size of a tumors.<
• Sputum is collected to look for cancer cells.
• Clear images internal body part, including tissue, muscle, nerves, and bones.

  Uses small of radiation

• most accurate to collect and analyze early- morning mucus for three days

  Compare old chest X- rays with recent ones to see if tumor is growing or shrinking

  gives a more detailed picture of the lung

• used to detect the presence of tumor

  Can detect extremely small tumors

  Bronchos copy Transtho ra cic Needle Aspiratio n Fine Needle Aspiratio n

Cervical

Mediasti

noscopy

Endosco pic Lymph Node Biopsy Video Assisted Thoracos copy Explora tory Thoracot omy

  

Procedures for Biopsy

Procedures for Biopsy

  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

• 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.
• 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 betweenrib s 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.<
• Is used for tumors closer to the chest wall
• May be used to biopsy theprimary tumor or metastases
• This technique is often used to biopsy lymph nodes around the lungs
Tujuan pemeriksaan diagnosis utk menentukan jenis histopatologi kanker, lokasi tumor serta penderajatannya yg selanjutnya diperlukan utk menetapkan kebijakan pengobatan

  

Deteksi Dini

Prosedur Diagnosis:

  

DIAGNOSIS dan PENDERAJATAN

DIAGNOSIS dan PENDERAJATAN

• – Gambaran Klinis

  - Gambaran Radiologis

  Pemeriksaan Lain

  Penderajatan (Staging)

  Dekeksi Dini:

• Keluhan dan GX penyakit tdk spesifik,
• Keluhan dan GX penyakit tdk spesifik,

• Batuk darah, Batuk kronis, BB menurun dan Gx lain,

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

• + satu @ lebih gejala: batuk darah, batuk kronis,

  sesak napas, nyeri dada, BB menurun

  Dekeksi Dini:

Alur Deteksi Dini Kanker Paru

  Curiga Kanker Paru Re-skrining 4- 6 bulan

  Skema

  ( + ) a b ( - ) c d

  Foto thoraks Sitologi sputum ( + ) ( - )

  Teruskan prosedur diagnostik kanker paru

  Teruskan prosedur diagnostik kanker paru

  Teruskan prosedur diagnostik kanker paru

  Teruskan prosedur diagnostik kanker paru

  

Alur Deteksi Dini Kanker Paru

  Deteksi Dini Kanker Paru (Skrining)

  (+) (a,b,c dlm skema)

  (a,b,c dlm skema) Ada hasil yg

  Ada hasil yg (+)

  Semua hasil (-)

  Foto thoraks dan Sitologi Sputum Diagnostik dan terapi penyakit paru non kanker

  Bukan GRT dengan gejala batuk kronis, sesak napas, batuk darah, BB turun

  Golongan Resiko Tinggi (GRT)

  Curiga Kanker Paru

Penderajatan (Staging) Kanker Paru

Penderajatan (Staging) Kanker Paru

  Dilakukan utk mendapatkan gambaran penyakit yang akurat Dilakukan utk mendapatkan gambaran penyakit yang akurat serta objektif guna pemilihan option penanganan 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 Ada / tidak penyebaran ke organ lain (Metastase )

  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 (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

Pengobatan Kanker Paru

  Dikenal 5 modalitas terapi:

  1. Pembedahan

  2. Radioterapi

  3. Kemoterapi

  4. Hormonal

  5. Immunologik Kanker Paru umumnya hanya 1-3

  Kanker Paru umumnya hanya 1-3

  Mis. NSCLC:

  Mis. NSCLC:

  Bila masih terbatas (localized)  pembedahan

  Bila masih terbatas (localized)  pembedahan

  Bila sdh lebih meluas (Regional tumor) kemoterapi &amp; @

  Bila sdh lebih meluas (Regional tumor) kemoterapi &amp; @

  radiasi,

  radiasi,

  Bisa ditindak lanjuti dgn pembedahan

  Bisa ditindak lanjuti dgn pembedahan

  Bila sdh advanced  kemoterapi (paliatif)

  Bila sdh advanced  kemoterapi (paliatif)

T N M STAGING NSCLC

  IIIA

  OPERABLE

  IIIB All M-1 = IV

  IIIB

  IIIB

  IIIB

  IIIB T-4

  IIIA

  N-0 N-1 N-2 N-3 T-1

  IA

  IIIB T-3

  IIIA

  IIB

  IB

  IIIB T-2

  IIIA

  IIA

  IIB

  

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.

  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

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,”.

  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,”.

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