Coughing UP BLOOD RAPID WEIGHT GAIN LOSS eith STEP 1 1.

Horner syndrome: Is the combine from miosis, ptosis and anhidrosis

2. Anhidrosis Is a condition the body can not sweat product 3. Miosis Is the pupil contraction smaller diameter (<2mm) 4. Ptosis Is eyelid down condition and can not open normally

STEP 2 1. Why this man appereances puffy face? 2. Why you sometimes cough with Phlegm with hoarse voices, shortnessof breath, pain in the lower chest and chest tightness when breathing? 3. Why he Decreased appetite therefore he perceived weight loss and fever? 4. Why the cough and shortness again when he runs out the medicine? 5. What are the relationship between physical examination (facial anhidrosis, miosis and ptosis) and sensitivity of the right lung? 6. Why examination of PA opaque mass defined thoracic radiograhph? 7. The etiology of the disease? 8. Pathogenesis of the disease? 9. Risk factors from the scenario? 10. What the other diagnostic examination from this patient? 11. DD? 12. Therapy from the diagnostic?

STEP 3 1. Why this man appereances puffy face? (Enlargement of the lymph nodes) In patient with carcinoma enlargement lymfe nodes than suround the neck and it make a puffy face

2. Why you sometimes cough with Phlegm with hoarse voices, shortnessof breath, pain in the lower chest and chest tightness when breathing? Cause of CA enlargment compress the n. Laryngeus recurrens so that with hoarse voice, and then Inhalation cause smooking and polution in respiratory track in bronchus

Cause of abnormality lungs hyperplasia is becaus polution in respiratory system chest wall pleura reach the chest wall pressing

l sympathetic

Because of the mataplasia carcinoma and hyperplasia of it the make Decrease the lung compliance he can not breath normally

Exposure of materials - materials such as cigarette smoke, pollutants (carcinogenic) in long term respiratory ere will be changes - changes such as damaged cilia and changes metaplasia (transformation of bronchial epithelium) gh receptors coughing up blood

The main symptoms of cough Patients who suffer from chronic bronchitis paru2 cancer is often noticed that cough gets worse Sputum may contain blood cause bleeding

Sources: Arif N. Coughing up blood in the pulmonology clinic. Part pulmonology FKUI; York: 1992, 179-183 and www.medicastore.com

 complained of chest pain is usually on the side of the tumor is unilateral, localized pain is not as sharp, it lasts from minutes to hours, and usually do not last long. The cause of pain is not so clear, and does not indicate a metastasis to the pleura. Chest pain not related to the onset of cough, or infection. Shoulder pain can be due to tumor Pancoast tumor involving a piece of stale or tumors invading the diaphragm, the central part of the nerve irritation phrenicus. Receptors pain in the thorax is limited to the parietal pleura, mediastinum, and the possibility of the large blood vessels. Parietal pleura is supplied by afferent fibers from the sympathetic nerves and nerve intercostalis. Many nerve fibers, free nerve endings, and some tactile corpuscle in the parietal pleura and the tissue subpleura that cause the perception of pain and the pressure. Although the lung parenchyma is not sensitive to pain, bronchi and nerves peribronkial can increase pain via the vagus. Pain that persist in patients with bronchial carcinoma may indicate tumor involvement. (Clinical manifestations of lung cancer, Leroy charles hyde and hyde chest l 1974)

Chest tightness when breathing Since the occurrence of hyperplasia and metaplasia of the cell - abnormal cells in the lungs pulmonary lung mass formed at are normally filled only on inspiration, but because of the mass so it is not just a moment of inspiration recess filled lungs but also in ordinary circumstances so that when breathing will be heavier. And the presence of such disorders as inflammation and constriction of bronchial mucus hypersecretion and airway tract interfere would make the weight when breathing. Soepaman, Sarwono Waspadji. , 2001. Medicine in Volume II, Issue 3. Jakarta: Center Publisher FKUI

3. Why he Decreased appetite (appetite) therefore he perceived weight loss and fever?

- Decreased appetite: Because of the inflamation hypotalamus can make-Decrease appetite. - Weight loss: Because the energy from in the body used for the metabolism of carcinoma cells - Fever: Because inflamation reaction (endogenous or exogenous pyrogens)

Decreased appetite dysphagia (press esophagus), and superior vena cava syndrome (pressing the superior vena cava). (Amin M, Alsagaff H. Introduction pulmonary disease. Surabaya: Airlangga University Press; 1989). The cause of fever other than infection is a state of toxemia, the malignancy or due to drug reactions (Gelfand, et al, 1998). While disruption in the center of the central temperature regulation can cause temperature elevation as occurs in brain hemorrhage, coma or other central disorders. At the time of the reabsorption of internal bleeding blood can also cause elevated temperatures (Andreoli, et al, 1993).

Febrile (fever) is an abnormal increase in body temperature (Child Nursing 2001). Febris (fever) of increased body temperature through the normal limit of more than 38 C (Fadjari In Nakita 2003).

SIGNS AND SYMPTOMS Fever Temperature increases> 380 C. Chills. Fatigue, anxiety and irritable and have trouble sleeping. Sweating, red face and watery eyes. appetite down.

Sources: www.repository.usu.ac.id

Levels of human body temperature is divided into: 1. Hypothermia: body temperature below 36O C 2. Normotermi: 36-37o C 3. Subfebris: 37 to 37.8 o C 4. Fever (Febris): above 37.8 o C

Quoted from Gelfand JA, Dinarello CA: alteration in Body Temperature,

, 1998. dr. Amran Arsjad (http://leukosit.wordpress.com/2009/08/23/demam/)

4. Why the cough and shortness again when he runs out the medicine? - There's damage in the lung and chronic disease in the lung damage procces damage. - Because the medicine is just for relieve the symptoms not stop the growth for the Ca cell he run out the medicine, he will Suffer it again.

Treatment of cough there are 2 ways: Specific Treatment That is to cure the underlying disease, such as antibiotics for lung infections, tuberculosis, etc..

That is to relieve the symptoms of the disease, for example by pressing cough, divided into 3: antitusive (suppress cough), mucolytics (thin phlegm), ekspetoran (issued by the increased volume of sputum bronchial secret). Drugs - drugs that are only symptomatic, that is to reduce the symptoms - the symptoms and also to reduce the inflammatory process continues to progress, but no effect to stop the growth or development of abnormal cells - her cells, so that when the drug was discharged the symptoms will was again due to the medicine only be palitatif / temporary. Treatment should also be tailored to the type of tumor or cancer cells that attack.

Soepaman, Sarwono Waspadji. , 2001. Medicine in Volume II, Issue 3. Jakarta: Center Publisher FKUI

5. What are the relationship between physical examination (facial anhidrosis, miosis and ptosis) and sensitivity of the right lung?

- Facial anhidrosis: cell Ca compressed the cervical sympathetic nerve serous glands can not produce the sweat - Meiosis: cell Ca compressed the cervical sympathetic nerve (nerve of C III-IV) - Ptosis:

6. Why examination of PA opaque mass defined thoracic radiograhph - Because the mass is solid tumor - Another DD opaque mass of tumor except: atelectasis, pleural effusion, pneumonia, tuberculosis. 7. The etiology of the disease? - Inhalation - Smooker - Polution - Genetic

Until now remains unclear Prof. dr. H. Pasiyan Rachmatullah. Pulmonary Medicine (Pulmonology) vol 1. FK Undip. - Prolonged exposure or inhalation of a substance that is carcinogenic: o Asbestos benign mesothelioma associated with exposure to asbestos. O o Radon, arsenic (eg insecticide), chromium, nickel, polycyclic hydrocarbons, vinyl chloride - The habit of smoking (active or passive) - Air pollution - Genetic suppressor gene, Gene encoding enzyme) - Diet Textbook IPD IV Volume II ed. FK UI. ung cancer (Proto oncogen, Tumor

8. Pathogenesis of the disease?

- The lower chest and chest tightness when breathing? Cause of CA enlargment compress the n. Laryngeus recurrens so that with hoarse voice, and then Inhalation cause smooking and polution in respiratory track in bronchus

Cause of abnormality lungs hyperplasia is becaus polution in respiratory system comprees it damage the cervical sympathetic

Because of the mataplasia carcinoma and hyperplasia of it the make Decrease the lung compliance he can not breath normally 9. Risk factors from the scenario? - Smooker - Chamical inhalation - Radiation - Lifestyle Factors affecting: Smoking (both active smokers and passive smokers) Dangers industry

Workers at risk 10 times higher than the general society. Benign mesothelioma local / diffuse malignant pleural is a rare tumor of the specifics associated with exposure to asbestos.

Air pollution Other factors: food & familial tendency ancerous lung.

Sylvia A. Price & Lorraine M. Wilson. Pathophysiology 6th ed vol 2. EGC 10. What the other diagnostic examination from this patient? - CT scan - Biopsy - Bronchoscopy If someone (especially smokers) had a cough that persists or worsens or symptoms of other lung, there is the possibility of lung cancer. Sometimes finding clues originally a shadow on a chest x-ray of someone who did not show symptoms. Chest X-rays can find most of the lung tumors, although not all the shadows that look is a cancer.

Usually the microscopic examination of tissue samples, which sometimes comes from the sputum of patients (sputum cytology). To obtain the necessary network, performed bronchoscopy. CT scans can show a little shadow that is not visible on chest x-rays and may reveal enlarged lymph nodes. To determine the spread to the liver, adrenal gland or brain, a CT scan of the abdomen and brain. The spread to the bone can be seen through the bones skening. Sometimes a bone marrow biopsy, because of small cell carcinoma tends to spread to the bone marrow

Classification (stage) of cancer is based on: - The size of the tumor - Spread to nearby lymph nodes - Spread to other organs. This stage is used to determine the type of treatment to be performed and the prediction of disease in patients.

A thorough history and physical examination focused on the clinical manifestations may indicate the possibility of carcinoma.

PHYSICAL EXAMINATION On physical examination,

thoracic wall and appear in the form of the protrusion. s in the neck and axilla is a manifestation of metastatic carcinoma of the lung, and in certain circumstances is key for tumor diagnostics. ymptom of the carcinoma. In later stages, more severe clinical symptoms: hoarseness, Homer's syndrome, vena cava syndrome, Pancoast syndrome and neurologic symptoms.

Radiology Examination of lung fluoroscopy or photo is a diagnostic tool to determine. Perselubungan in frequent misdiagnosis of pulmonary tuberculosis with specific processes. When specific treatment for 4-8 weeks did not bring improvement, you should think about the possibility of lung carcinoma. Perselubungan with calcification caused more benign abnormalities. In case of doubt it is recommended for a CT Scan. BRONKHOSKOPI Tumors were located in the bronchi is an indication for bronkhoskopi. By using a set of tools bronkhoskop fiberoptik, bronchus mucosal changes can be evaluated in the form of a lump or lumps of meat. At the same time do brush cytology and biopsy the tumor mass pads for diagnosis and identification of the type of carcinoma. Tumors were located in large or medium caliber bronchi, examination bronkhoskopi not many find it difficult. However, if the tumor is located in the peripheral end bronkhoskop difficult to reach the tumor mass, in such cases, the alternative is Balk transthoracic fine needle aspiration biopsy. ASPIRATION BIOPSY transthoracic Transthoracic aspiration biopsy method is one alternative for the diagnosis of lung carcinoma that is located mainly in the periphery. Procedures and simple technique with high diagnostic accuracy. With tires fluoroskopposisi host tumordalam chest cavity can be determined and the insertion needle is not hard to do. Technological advances radiology, enabling easier aspiration biopsy with guidance fluoroskopTV. In the case of a risky, often preceded and then examination Cf Scan needle insertion can be done to reach the right targets. In such cases there is good cooperation between the radiologist and patologist. If on palpation of lymph nodes palpable nodules smaller besaratau supraklavikuler, aspiration biopsy is useful for determining the possibility of metastatic carcinoma of the lung. In certain cases, where bronkhoskopi or biopsy

difficult transthoracic aspiration, lymph node aspiration biopsy is a diagnostic key. MEDIASTINOSTOMI AND thoracotomy Both methods are performed to biopsy the tumor mass, if bronkhoskopi or aspiration biopsy failed to obtain a specimen.

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11. DD? - Lung Cancer

Lung Ca

1. DEFINITION Growth of primary malignant lung tissue. Undergo malignant lung tissue: Bronchial mucosa: Epithelial cells Tues basal membrane bronchial gland cells Bronchial mucosa Tues alveoli Other lung tissue Prof. dr. H. Pasiyan Rachmatullah. Pulmonary Medicine (Pulmonology) vol 1. FK Undip. Bronkogenik carcinoma is a malignant tumor derived from primary lung airways. (Al sagaff Hood et al 1993) Lung cancer is a dangerous tumor that grows in the lungs, lung most cancers originate from cells in the lungs but can also come from other parts of the body affected by cancer. (Zerich 150 105 Weblog, by Erich)

12. Therapy from the diagnostic? - What are the clinical symptoms of lung cancer - Clasification based on TNM - Prognosis of lung cancer CLASSIFICATION In pathology, to determine treatment: a) small cell lung cancer (small cell lung cancer, SCLC) Histologist typical picture: small sel2 dominated almost all filled mucus handling it fine distribution of chromatin without nucleoli. It is also called "oat cell carcinoma" because of its shape like a grain of wheat. These cells tend to congregate around the delicate blood vessels resembling pseudoroset. Sel2 bermitosis who once found so many picture of necrosis. DNA that regardless myebabkan dark color around the blood vessels. b) small cell lung cancer (non-small cell lung cancer, NSCLC) Included are epidermoid, adenocarcinoma, large cell types / mix of all three. Squamous cell sqamos distinctively kreatinisasi process and the formation of "bridge" intracellular. In cytology significant change from the Ca situ squamous dysplasia. The diagnosis of localized, treated with surgical resection. Textbook IPD IV Volume II ed. FK UI. DIFFERENCES SCLC NSCLC Histology little cytoplasm; hiperkromatik small nucleus with fine chromatin pattern; nucleolus is unclear; lembaran2 that many diffuse cytoplasm; pleomorphic nuclei with coarse chromatin pattern; nucleolus often striking; architecture of glandular or squamous Neuroendocrine markers (eg, dense-core granules on electron microscopy; kromogranin expression, neuron specific enolase, sinaptofisin) Usually there are usually no Epithelial markers (epithelial membrane antigen, karsinoembrionik antigen and cytokeratin intermediate filaments) There There Musin No Yes adenocarcinoma Formation of peptide hormone Hormone adenokorteks, antidiuretic hormone, gastrin releasing peptide, calcitonin parathyroid hormone-related peptide (PTH-rp)

Abnormalities of tumor suppressor genes - 3p Deletions - RB Mutation - Mutation p16/CDKN2A - TP53 Mutations

-> 90% - About 90% - About 10%

-> 90%

-> 80% - About 20% -> 50%

-> 50% Dominant oncogene abnormalities - K-RAS Mutation - Excessive family MYC expression - <1% -> 50% - Approximately 30% (adeno Ca) -> 50% Response to chemotherapy and radiotherapy often complete response response seldom completely Robbins Kumar. Textbook of Pathology 7th ed vol 2. EGC.

In histology: Squamous cell carcinoma (epidermoid) (30%) Most commonly found; derived from bronchial epithelial surface. Epithelial changes including metaplasia / dysplasia caused by long-term smoking, typically precedes the onset of tumors. ng into the major bronchi.

nodes, chest wall and mediastinum. cough and hemoptysis due to irritation / ulceration, pneumonia, and abscess formation due to obstruction and secondary infection.

Adenocarcinoma Cellular arrangement shows such as bronchial glands and may contain mucus. Section arise peripheral bronchial segments and kadang2 be associated with localized pulmonary scarring and chronic interstitial fibrosis. Lesions often extends into the blood and lymph vessels in the early stages and often metastasize long before the primary lesion causing gejala2. Bronchial alveolar carcinoma cells Rarely found, originating from the terminal bronchioles and alveolar epithelium. Onset is generally not significant, with tanda2 resembling pneumonia. Macroscopic: neoplasms is similar consolidation lobaris uniform pneumonia. Microscopic: looks kelompok2 alveolar sel2 clearly bounded by producing mucus and there are a lot of mucoid sputum. Prognosis: poor; unless they do exhaust lobes are affected when the disease is still early. Large cell carcinoma Malignant cells are large and very poorly differentiated with a large cytoplasm and nucleus size assortment. Tend to occur in the peripheral lung tissue, grows quickly with extensive and rapid deployment to a remote tempat2. Small cell carcinoma As the squamous cell type is usually located around the middle of the main branching bronchi.

Unlike other lung cancers, this type of tumor arising from sel2 kulchitsky, the normal component of the bronchial epithelium. Microscopic: sel2 formed from small (about 2x the size of lymphocytes) with a dense nucleus and cytoplasm hiperkromatik bit. Sel2 often resemble oat seed, so called oat cell carcinomas. Prognosis: worst than others. (Small cell division had the fastest time). Sylvia A. Price & Lorraine M. Wilson. Pathophysiology 6th ed vol 2. EGC.

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