Lung And Mediastinal Tumor

(1)

LUNG

TUMORS

Dr.dr. Tahan P.H.,

SpP.DTCE,MARS

(2)

(3)

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

(4)



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

(5)

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

(6)

HOW DO CANCER CELL SPREAD TO OTHER

PARTS OF BODY?

HOW DO CANCER CELL SPREAD TO OTHER

PARTS OF BODY?

Dead cells, abnormal and cancer cells

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

(7)

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.

(8)

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.

Apa itu Kanker Paru?

Kanker paru adalah pertumbuhan sel kanker yang tidak terkendali dalam jaringan paru, biasanya pada sel-sel

(9)

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

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%

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

(10)

WHAT CAUSES LUNG CANCER ?

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 Second-hand smoke also contains carcinogens

(USA 5.000 – 10.000 dignosed lung cancer resulting from breathing second-hand smoke)

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 Second-hand smoke also contains carcinogens

(11)

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

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

TB

- _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:

- _{Exposure to chemicals in the air, asbestos and radon}

-_{Lung diseases that can block airfow to lungs, COPD or}

TB

- Genetics

(12)

WHAT ARE THE DIFFERENT KINDS OF LUNG

CANCER ?

WHAT ARE THE DIFFERENT KINDS OF LUNG

CANCER ?

Two main catagories:

Small-cell lung cancer (SCLC) – 20% Non Small cell lung cancer (NSCLC) –

80%

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.

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

(13)

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 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

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 difcult to diagnose

- grow at the edges of the lung

- tend to grow fast and spread to other areas

of the

body (metastasize)

(14)

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

(15)

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:

sided abdominal pain and Jaundice.

6. Some general symptoms

like weight loss,

(16)

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

(17)

HOW LUNG CANCER DIAGNOSED ?

Chest

X-Ray CT-Scan MRI CytologySputum Biopsy

(18)

(19)

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

(20)

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

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

(21)

Alur Deteksi Dini Kanker Paru

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

skema) Curiga Kanker _Paru

(22)

Penderajatan (Staging) Kanker Paru

Dilakukan utk mendapatkan gambaran penyakit yang akurat serta objektif guna pemilihan option penanganan

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

Dinilai 3 Hal  T N M Staging

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

(23)

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

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

(24)

Pengobatan Kanker Paru

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)

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)

Dikenal 5 modalitas terapi:

1. Pembedahan 2. Radioterapi 3. Kemoterapi

(25)

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

(26)

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

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.

(27)

(28)

(29)

(30)

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):