LBM 5 SGD 16 STEP 1 Facial Anhidrosis - Tidak dapat berkeringat pada sebagian wajah Ptosis - Turunnya kelopak mata

akibat gangguan nervus ketiga atau akibat innervasi simpatetik Miosis - Pupil yang mengecil Fever - Suatu keadaan dimana suhu tubuh meningkat diatas 36,5 0,4 derajat celcius Puffy face - Terjadinya pembengkakan pada wajah karena terjadi gangguan pada vaskularisasi pada wajah. Horners syndrome - Suatu sindrom yang terdiri dari kelainan berupa ptosis, miosis, anhidrosis pada wajah akibat paralisis saraf simpatis servikal. Hoarse voice - Perubahan kualitas suara menjadi kasar atau menghilang akibat n. Laryngeus reccurens terdesak oleh suatu massa.

STEP 2 1. 2. 3. 4. 5. Definisi Patogenesis Etiologi Faktor resiko Manifestasi klinis

6. DD 7. Diagnosis 8. Komplikasi 9. Terapi 10. Prognosis

STEP 3 1. Definisi Ca ada 2 : - Benigna

BENIGN NEOPLASM OF THE LUNG The benign neoplasms of the lung, representing < 5% of all primary tumors, include : bronchial adenomas and hamartomas (90% of such lesions) a group of very uncommon benign neoplasms (epithelial tumors such as bronchial papillomas, broepithelial polyps; mesenchymal tumors such as chondromas, bromas, lipomas, hemangiomas, leiomyomas, pseudolymphomas; tumors of mixed origin such as teratomas; and other diseases such as endometriosis). BRONCHIAL ADENOMAS Bronchial adenomas (80%are central) are slowgrowing, endobronchial lesions. Adenomas present in patients 15 to 60 years old (average age, 45) Patients may have a chronic cough, recurrent hemoptysis, or obstruction with atelectasis, lobar collapse, or pneumonitis and abscess formation. Hamartomas Pulmonary hamartomas have a peak incidence at age 60 and are more frequent in men than in women. Histologically, they contain normal pulmonary tissue components (smooth muscle and collagen) in a disorganized fashion. They are usually peripheral, clinically silent, and benign in their behavior

- Maligna Lung malignancy : cenderung selalu ganas Lung malignancy

Klasifikasi

Several histologic variants of each type of lung cancer are described : Adenocarcinoma (males 37%, females 47%) Squamous cell carcinoma (males 32%, females 25%) Small cell carcinoma (males 14%, females 18%) Large cell carcinoma (males 18%, females 10%) For common clinical use, however, the various histologic types of lung cancer can be clustered into two groups on the basis of likelihood of metastases and response to available therapies: small cell carcinomas (almost always metastatic, high initial response to chemotherapy) non-small cell carcinomas (less often metastatic, less responsive). Ex : squamous cell carcinoma, adenocarcinoma, and large cell carcinoma. The strongest relationship to smoking is with squamous cell and small cell carcinoma. Small Cell Carcinorma fast-growing type of lung cancer, small cell carcinoma usually spreads faster than non-small cell lung cancer. small cell carcinoma accounts for about 15 percent of all lung cancer cases Small cell lung cancer usually starts in or near the lungs bronchi. The cells can quickly grow into large tumors that can rapidly spread to the brain, liver, bones, and other parts of the body More common in men than women, small cell carcinoma is almost always caused by smoking and is rare among those who have never smoked. Heavy exposure to second-hand smoke or to asbestos or radon also can cause small cell carcinoma. Symptoms include coughing, bloody sputum, shortness of breath, wheezing, chest pain, loss of appetite, and weight loss. The tumor cells cause increased secretion of adrenocorticotropic hormone (a hormone from the adrenal gland), causing Cushings disease, which is characterized by a puffy face, weightgain, hump on the lower neck, or elevated blood sugarlevels. Antidiuretic hormone, also secreted by these tumor cells, lead to water retention and low sodium, which can cause confusion. Small cell carcinoma antibodies also can cause weakness by the tumorproducing antibodies against normal tissues (autoanti-bodies). Gambar

Diagnosis Physical examination complete blood count chest x ray CT, MRI, PET scan to better determine the nature, position, or extent of a mass biopsy to gathers cell samples from the suspicious area for the pathologist to examine Treatment 1. Staging : limited or extensive

Limited small cell carcinoma is confined inside the chest, and extensive small cell carcinoma has spread outside the chest. 2. Because most cases of small cell carcinoma have advanced to the extensive stage, physicians usually recommend combined chemotherapy and radiation therapy to increase the chances of remission. Chemotherapy delivers drugs throughout the body, slows the cancers progression, and reduces pain. Radiation therapy uses pinpointed high-energy beams to shrink localized tumors or cancer cells. This treatment is also used to relieve the symptoms of advanced lung cancer or to slow its spread. 3. Surgery is rarely used to treat small cell carcinoma because the disease has usually spread by the time it is diagnosed Because small cell carcinoma is a very aggressive type of cancer with a high chance of recurring after remission. LUNG ADENOCARCINOMA (including bronchoalveolar) Adenocarcinoma: A type of cancerous, or malignant, tumor that forms glandular structures. Lung adenocarcinoma is the most common kind of lung cancer, both in smokers and non-smokers and in people under age 45. This type of non-small cell lung cancer usually develops in the peripheral portion of the lungs. Lung adenocarcinoma cells form recognizable glandular patterns. Slow growing, lung adenocarcinoma can take years to develop from a confined tumor tometastatic cancer. Symptoms develop slowly as well. They include coughing, shortness of breath, wheezing, chest pain, and bloody sputum Gambar

Diagnosis Physical examination complete blood count chest x ray CT, MRI, PET scan to better determine the nature, position, or extent of a mass biopsy to gathers cell samples from the suspicious area for the pathologist to examine Treatment If the cancer is located only in the lungs, surgery is generally recommended. Common lung cancer surgical procedures include thoractomy (opening the chest wall) or median sternoctomy (cutting through the breastbone) during which lung tissue, one lobe, or an entire lung will be removed, depending on the size of the tumor. Another method is video-assisted thoracic surgery (VATS) enables surgeons to remove tissue through smaller incisions For aggressive and widespread tumors, physicians recommend chemotherapy and radiation therapy. SQUAMOUS CELL CARCINOMA

 Squamous cell lung carcinoma is a type of non-small cell lung cancer formed from reserve cells round cells that replaced injured or damaged cells in the lining of the bronchi, the lungs major air-ways. Squamous cell tumors usually occur in the lungs central portions or in one of the main airway branches. These tumors can form cavities in the lung if they grow to a large size. Paraneoplastic syndrome : hypercalcemia Making up between 25 and 40 percent of all lung cancers, squamous cell carcinoma can spread to bones, adrenal glands, the liver, small intestine, or brain. Slow growing, this type of cancer can take years to develop from a confined tumor to invasive cancer. Symptoms develop slowly as well. They include coughing, shortness of breath, wheezing, chest pain, and bloody sputum. Gambar Squamous cell carcinoma

Gambar sel paru normal

Diagnosis

Physical examination complete blood count chest x ray CT, MRI, PET scan to better determine the nature, position, or extent of a mass biopsy to gathers cell samples from the suspicious area for the pathologist to examine Treatment If the cancer is located only in the lungs, surgery is generally recommended. Common lung cancer surgical procedures include thoractomy (opening the chest wall) or median sternoctomy (cutting through the breastbone) during which lung tissue, one lobe, or an entire lung will be removed, depending on the size of the tumor. Another method is video-assisted thoracic surgery (VATS) enables surgeons to remove tissue through smaller incisions For aggressive and widespread tumors, physicians recommend chemotherapy and radiation therapy. Large Cell Carcinoma ( also called large cell anaplastic) This is an undifferentiated malignant epithelial tumor that lacks the cytologic features of small-cell carcinoma and glandular or squamous differentiation. The cells typically have large nuclei, prominent nucleoli, and a moderate amount of cytoplasm.

2. Patogenesis
Pathogenesis Individual carcinomas of the lung have multiple genetic alterations that are likely be to the result of a stepwise progression from a normal cell toward a malignant tumor. Carcinogenic products in tobacco are clearly involved in this process. Some of the more common genetic alterations associated with lung carcinoma are as follows:

K-ras oncogene: Mutations in this oncogene are found in adenocarcinomas (25%), large cell tumors (20%), and less commonly in squamous cell carcinoma (5%). The mutations correlate with smoking and a poor prognosis. Myc oncogene: Overexpression of this gene occurs in 10% to 40% of small cell carcinomas but is rare in other types. Bcl-2: This antiapoptotic protooncogene is expressed in 25% of squamous cell carcinomas and 10% of adenocarcinomas. Rband p53: Mutations in both of these important tumor suppressor genes are found in 80% of small cell carcinomas. Both genes are somewhat less frequently mutated in nonsmall cell tumors (50% and 25%, respectively).

Deletions in the short arm of chromosome 3 (3p): Such deletions are frequently found in all types of lung cancers.

Terjadinya kanker paru didasari teori

1. 2.

3.

4.

Perubahan tampilan gen supresor tumor dalam genom (onkogen) Adanya inisiator mengubah gen supresor tumor dengan cara menghilangkan (Delesi) atau penyisipan (insersi) sebagian susunan pasangan basanya (basa pain) Tampilanya gen ErB-1 berperan dalam anti apoptosis (mekanisme sel untuk mati secara alamiah atau programmed cell death) Perubahan tampilan gen kasus ini menyebabkan sel sasaran berubah sel kanker dengan sifat pertumbuhan otonom

3. Etiologi
Etologi karsinoma paru sampai sekarang masih belum jelas. Namun Terdapat beberapa factor yg berperan dalam terjadinya Karsinoma Paru yaitu :
Faktor merokok : Terutama pada perokok berat (lebih dari 20 batrang / hari) Faktor pencermaran udara : Udara dicemari oleh bahan Lung Carcinogen (Asbestos, arsen, nikel, kromat, besi, asap arang batu, uranium,radium, uap minyak) Faktor penyakit paru yg sdh diderita sebelumnya : Jaringan parut pada paru akibat menderita penyakit paru sebelumnya dapat mengalami perubahan keganasan. Penyakit2 paru tsb antara lain : Infark paru, TB Paru lama, Granuloma pada paru, Asbesitos, Bronkitis Kronik, Fibrosis intersisial Kronik Faktor perkembangan sel aberrant dalam paru : Karsinoma paru terjadi dari perkembaganan sel aberrant dalam paru yg mempunyai potensi keganasan Faktor2 lain

(Buku Ajar Ilmu Penyakit Paru Jilid 2 Prof. Pasiyan)

Seperti kanker pada umumnya penyebab pasti belum diketahui, tetapi paparan / inhalasi berkepanjangan zat karsinogenik merupakan penyebab utamanya selain faktor genetik, kekebalan tubuh. Zambarg (1928) Etiologi kanker paru sangat berhubungan dengan kebiasaan MEROKOK

4. Faktor resiko
a. b. c. d. e. f. merokok bahaya industri polusi udara makanan familial adanya jaringan parut (sisa penyembuhan penyakit paru sebelumnya) Sumber: Buku Patofisiologi Vol. 2 Ed. 6

Bahan Karsinogen (c), kokarsinogenik (cc), tumor promoter (TP), mutagen (M) hal 2255 ( tabel 1 ) - Asbestos - Radiasi ion pekerja tambang uranium - Radon , arsen, kromium, nikel, polisiklik hidrokarbon - Polutan - Genetis - Diet : rendah betakaroten, selenium, vitamin A

5. Manifestasi klinis

Manifestasi klinik Central or endobronchial growth of the primary tumor may cause cough, hemoptysis, wheeze and stridor, dyspnea, and postobstructive pneumonitis (fever and productive cough). Peripheral growth of the primary tumor may cause pain from pleural or chest wall involvement, cough, dyspnea on a restrictive basis, and symptoms of lung abscess resulting from tumor cavitation. Regional spread of tumor in the thorax (by contiguous growth or by metastasis to regional lymph nodes) may cause tracheal obstruction, esophageal compression with dysphagia, recurrent laryngeal nerve paralysis with hoarseness, phrenic nerve paralysis with elevation of the hemidiaphragm and dyspnea, and sympathetic nerve paralysis with Horners syndrome (enophthalmos, ptosis,miosis, and ipsilateral loss of sweating) Malignant pleural effusion often leads to dyspnea. Pancoasts (or superior sulcus tumor) syndrome results from local extension of a tumor growing in the apex of the lung with involvement of the eighth cervical and rst and second thoracic nerves, with shoulder pain that characteristically radiates in the ulnar distribution of the arm, often with radiologic destruction of the rst and second ribs. Often Horners syndrome and Pancoasts syndrome coexist.

Staging

Gambaran TNM Status Tumor Primer (T) T0 Tx Tis T1 T2

Definisi Tdk terbukti adanya tumor primer Kanker yang tersembunyi, terlihat pada sitologi bilasan bronkus, tetapi tidak terlihat pada radiogram atau bronkoskopi Karsinoma insitu Tumor berdiameter 3 cm dikelilingi paru atau pleura viseralis yang normal Tumor berdiameter 3 cm atau ukuran berapa pun yang sudah menyerang pleura viseralis atau mengakibatkan atelektasis yang meluas ke hilus; harus berjarak > 2 cm distal dari karina. Tumor ukuran berapa pun dengan perluasan langsung pada dinding dada, diafragma, pleura mediastinalis, atau pericardium tanpa mengenai jantung, vaso besar, trachea, esofagus, atau korpus vertebra; atau dalam jarak 2 cm dari karina, tapi tidak mengenai karina. Tumor berukuran berapa pun yang sudah menyerang mediastinum atau mengenai jantung, vaso besar, trakea, esofagus, korpus vertebra, atau karina; atau adanya efusi pleura yang maligna.

T3

T4

Keterlibatan Kelenjar Getah Bening Regional (N) N0 Tidak dapat terlihat metastasis pada kelenjar getah bening regional N1 Metastasis pada peribronkial dan/atau kelenjar2 hilus ipsilateral N2 Metastasis pada mediastinal ipsilateral atau kelenjar getah bening subkarina N3 Metastasis pada mediastinal atau kelenjar2 getah bening hilus kontralateral; kelenjar2 getah bening skalenus atau

supraklavikular ipsilateral atau kontralateral Metastasisi Jauh (M) M0 M1 Kelompok Stadium Karsinoma tersembunyi

Tidak diketahui adanya metastasi jauh Metastasi jauh terdapat pada tempat tertentu (mis. Otak)

Tx,N0,M0

Stadium 0 Stadium IA

Tis,N0,M0 T1,N0,M0

Stadium IB

T2,N0,M0

Stadium IIA

T1,N1,M0

Stadium IIB

T2,N1,M0 T3,N0,M0

Stadium IIIA

T1-T3, N1, N2, M0

Stadium IIIB

T berapa pun, N3, M0 T4, N berapa pun, M0

Stadium IV

T berapa pun, N berapa pun, M1

Sputum mengandung sel2 ganas tetapi tidak dapat dibuktikan adanya tumor primer atau metastasis. Karsinoma in situ Tumor trmsk T1 tanpa adanya bukti metastasis pada kelenjar getah bening regional atau tempat2 yang jauh. Tumor trmsk T2 dengan bukti metastasis pada kelenjar getah bening regional atau tempat2 yang jauh. Tumor temasuk klasifikasi T1 dengan bukti hanya terdapat metastasis ke peribronkial ipsilateral atau hilus kelenjar limfe; tidak ada metastasis ke tempat yang jauh Tumor termasuk klasifikasi T2 atau T3 dengan atau tanpa bukti metastasis ke peribronkial ipsilateral atau hilus kelenjar limfe; tidak ada metastasis ke tempat yang jauh Tumor termasuk klasifikasi T1, T2, atau T3 dengan atau tanpa bukti metastasis ke peribronkial ipsilateral atau hilus kelenjar limfe; tidak ada metastasis ke tempat yang jauh Setiap klasifikasi tumor dengan metastasis hilus kontralateral atau kelenjar getah bening mediastinum atau ke skalenus atau kelenjar limfe supraklavikular; atau setiap tumor yang diklasifikasikan sebagai T4 dengan atau tanpa metastasis ke kelenjar getah bening regional; tidak ada metastasis ke tempat yang jauh Setiap tumor dengan metastasis jauh

Sumber: Buku Patofisiologi Vol. 2 Ed. 6

Pada fase awal, kebanyakan kanker paru tidak menunjukkan gejala klinis, bila sudah menampakkan gejala berarti pasien dalam stadium lanjut. Gejala dapat bersifat :
1.

Lokal (tumor tumbuh setempat)

-

batuk baru atau batuk lebih hebat dari batuk kronis hemoptisis (batuk darah) mengi (wheezing, stidor) atelektasis kavitas seperti abses paru

2.

Invasi Lokal :
nyeri dada Dispnea karena efusi pleura invasi ke Perikardium tamponade sindrom vena cava superior sindrom Horner ( facial anhidrosis, ptosis, miosis ) sindrom Pancoast ( invasi pleksus brakialis dan saraf simpatis servikalis )

3.

Gejala Penyakit Matastasis

- pada otak,tulang, hati, adrenal - limfadenopati servikal dan supraklavikula

4.

Sindroma Para Neoplastik dengan gejala :

sistemik = penurun BB, anoreksia, demam hematologi : leukositosis, anemia, hiperkoagulasi hipertrofi osteoartropati Neurologik : dementia, ataksia, neuropati perifer Neuromiopati endokrin : hiperkalsemia dematologik :eritema multiform, hiperkeratosis, jari tabuh - renal : gagal ginjal akut

5.

Asimptomatik dengan kelainan Radiologik

- Sering pada PPOK dan Perokok - Kelainan berupa nodul soliter

6. DD 7. Diagnosis

Anamnesis lengkap dan periksa hasil teliti cermat Bila tumor < 1 cm sulit terdeteksi

Cara lain : Bronkoskopi sputum ( sitopatologi )

Foto Rontgen secara PA dan lateral MRI / CT Scan paru

Lebih sensitif PET (Positron Emission Tromography) membedah tumor jinak dan ganas
Bone scanning deteksi metastasis ke tulang Histopatologi dengan biopsi melalui bronkoskopi sebagai Gold standart Diagnosis

8. Komplikasi 9. Terapi
a. Pembedahan i. NSCLC stadium I, II, dan sebagian IIIa. ii. Dapat berupa pengankatan paru2 parietal atau total b. Radiasi

iii. Lesi2 stadium I & II jika terjadi kontraindikasi pembedahan. iv. Lesi2 stadium III jika penyakit terbatas pada hemitoraks & kelenjar getah bening supraklavikular ipsilateral. v. Dapat juga diberikan pada daerah2 lokal pada NSCLC yang tersebar untuk tujuan paliatif. c. Kemoterapi (dengan atau tanpa terapi radiasi) vi. Dasar dari pasien SCLC vii. Kemoterapi + radioterapi dapat diberikan pada stadium penyakit yang terbatas. viii. Kombinasi kemoterapi yang dipakai: 1. siklofosfamid 2. doksorubisin (adriamycin) 3. vinkristin (CAV) 4. siklofosfamid 5. doksorubisin 6. otoposid (CAE) Sumber: Buku Patofisiologi Vol. 2 Ed. 6

1.

2. 3.

4.

Kuratif : menyembuhkan / memperpanjang masa bebas penyakit dan meningkatkan angka kehidupan hidup pasien Paliatif : megurangi dampak kanker, meningkatkan kualitas hidup Rawat rumah (hospice care) pada kasus terminal : menurunkan dampak fisik / psikologi bagi pasien dan keluarga Suportif : Nutrisi, transfusi darah / komponen darah, anti nyeri / anti infeksi

10. Prognosis buruk

STEP 4
COUGH, SHORTNESS, WEIGHT LOSS RISK FACTOR

DIAGNOSTIC EXAMINATION

ANAMNESIS AND PHYSICAL EXAMINATION

LUNG MALIGNANCY/ TUMORS

COMPLICATION

CLASSIFICATION

STAGING

MANAGEMENT

PROGNOSIS