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KANKER PARUPARU-TUMOR MEDIASTINUM

ISWANTO

SMF PARU RS BETHESDA-FK UKDW


YOGYAKARTA
1

CA PARU-ROKOK.
Rokok dapat meningkatkan resiko CA
Paru, dan hal tersebut berhubungan
dengan:
Jumlah
Cara

rokok yang dihisap

menghisap rokok.

Lama

merokok

Genetik.

HIPOTESA ROKOK-CAPARU

Tar pada rokok

Peningkatan oxidative stress

Ketidakseimbangan oksidan antioksidans


menyebabkan kerusakan jaringan paru

Inflamasi peribronkial

Kerusakan struktur dan fungsi epitel

Fibrosis

Mitosis

CA Paru

Divided into two types:

nonsmall cell lung cancer (NSCLC)

small cell lung cancer (SCLC)

Smallcell lung cancer (SCLC) (2025% of lung cancers),

both limited and extensive stage disease, systemic


chemotherapy plays a pivotal role

Nonsmall cell lung cancer (NSCLC) (adenocarcinoma,


squamous cell carcinoma, and largecell carcinoma)
surgery, chemotherapy, radiotherapy

PROSEDUR DIAGNOSTIK
Konfirmasi :
1. Pemeriksaan sitologik
- sputum dari batuk spontan

- induksi sputum
- bronchial washing, brushing, aspiration
- sputum collecting paska FOB
3 hari berturutan, fiksasi dengan alkohol 70%
2. Pemeriksaan radiologik

PROSEDUR
2. Pemeriksaan Radiologik :
1. Foto toraks PA & lateral
- tumor > 1 cm
- komplikasi
- perburukan penyakit non-kanker
2. CT-Scan toraks kontras
- evaluasi KGB
- deteksi tumor < 1 cm

3. USG
4. Positron Emission Tomography (PET)
- deteksi KGB < 1 cm

PROSEDUR
3. Pemeriksaan khusus :
a. Bronkoskopi
- evaluasi mukosa, massa intraluminal
- brushing, washing, lavas, biopsi

b.
c.
d.
e.
f.
g.
h.
i.

Fine needle aspiration biopsy (FNAB)


Transbronchial needle aspiration (TBNA)
Transbronchial lung biopsy (TBLB)
Transthoracal needle aspiration (TTNA)
Transthoracal biopsy (TTB)
Fine needle aspiration (FNA)
Biopsi KGB
Torakoskopi, Mediastinoskopi, VATS

PROSEDUR
4. Pemeriksaan lain :
a. Tumor marker
- Carcino embryonic antigen (CEA)
- Cyfra 21, SCC, Ca 19-9, Ca 125 II
- Non specific enolase (NSE)

Performance scale of lung cancer patients


(Karnofsky & WHO)
Karnofsky
Scale
90 -100
70 - 80

WHO
Scale
0
1

50 - 60

30 - 40
10 - 20

3
4

0 - 10

Keterangan
Normal beraktivitas
Ada keluhan tapi masih aktif &
dapat mengurus diri sendiri
Cukup aktif tapi kadang
memerlukan bantuan
Kurang aktif, perlu perawatan
Tak dapat meninggalkan
tempat tidur, perlu MRS
Tidak sadar

PENGOBATAN KANKER PARU

Pengobatan kanker paru saat ini :


- Bedah
- Kemoterapi
- Radioterapi
- Target terapi

Pengobatan tergantung pada stadium


penyakit.
21

Pengobatan
Combined modality therapy
Landasan terapi kanker paru :
1. Staging (penderajatan)
a. TNM
b. G (gradasi histopatologis)
GX
G1
G2
G3
G4

Tak dapat ditentukan

Well differentiated
Moderately differentiated
Poorly differentiated
Undifferentiated

2. Histopatologi
NSCLC atau SCLC
3. Status Performance

Pengobatan
Modalitas terapi kanker paru
1. Pembedahan
- Reseksi lengkap + KGB intrapulmonal
Lobektomi, pneumonektomi
- Histo PA : NSCLC
- Stage I & II, Stage III
- Kegawatan paru
- Syarat : VC kontralateral baik
FEV1 > 60%

Pengobatan
2. Radioterapi
- Kuratif, paliatif
- Dosis : 200 cGy, 5x /minggu
5.000 - 6.000 cGy
- Syarat :
- Hb >10 g%
- Trombosit > 100.000 /mL
- Leukosit > 3000 /mL
- Radiasi paliatif :
- Performance < 70
- BB > 5% dalam 2 bulan
- Faal paru jelek

Pengobatan
3. Kemoterapi
Prinsip :
a. Platinum base chemotherapy
b. Respon obyektif 1 obat 15%
c. Toksisitas obat grade III skala WHO
d. Stop/ganti bila 3 siklus tumor progresif
Syarat :
a. KS > 70-80
b. Hb > 10 g%
c. Granulosit > 1.500 /mL
d. Trombosit > 100.000 /mL
e. LFT & RFT baik
(Cl creatinin > 70 mL/min)

Pengobatan
3. Kemoterapi
Truthful information
Autonomy (do everything) vs Medical
judgement
Autonomy & Justifiability
* do not give false hope
* do not destroy hope
* the right to information concerning
themselves
* obligation to preserve both
physical & emotional well being

Pengobatan
4. Imunoterapi

- Imunomodulator
Keladi tikus, buah merah, thymus dll.
- Sitokin : IL-2, anti VEGF
5. Terapi hormonal
6. Terapi gen

5 & 6 masih dalam penelitian


Terapi paliatif bebas nyeri Stadium III B - IV

Management of NSCLC
TNM STAGE < II B

TNM STAGE III A

Segmentectomy /
Lobectomy

Neoadjuvant
ChTx
ChTx 2x
RaTx 40Gy

Surgery
(+)
Adjuvant
ChTx

Surgery
(-)

TNM STAGE III B

KS > 70

KS < 70

KS > 70

KS < 70

ChRaTx

Palliative
ChTx
RaTx
BSC

ChTx
RaTx

Palliative
BSC

Re Staging

Improved

Not improved

Surgical Tx

ChTx, RaTx

Continue
ChTx, RaTx

TNM STAGE IV

Management of SCLC
Limited disease

Extensive disease

KS < 70

KS 70

KS 70

KS < 70

Best
Supportive
Care

ChTxRaTx

ChemoTx
2x

Best
Supportive
Care

CR

PR

Response (-)

Prophylactic
Cranial
Irradiation

Change
ChemoTx

Histo-PA
Reevaluation

Response (+)
Continue
ChTx ~ 6x
CR
Prophylactic
Cranial Irradiation

PR
Change
ChemoTx

Curative vc Palliative chemotherapy

Curative
Mode of
chemothera
py
Evaluation
after 2
cycles

Adverse
effects
Intent

Palliative

Induction,
--Adjuvant,
Neo-adjuvant
Stop if :
Continue if :
no partial
palliation +, no
response
progression
May be
Must be minimal
severe
Intent to cure Palliation intent
:

Jenis kemoterapi
1. Kemoterapi kuratif :
Induction ChemoTx
Kemoterapi primer tanpa alternatif modalitas
terapi lain untuk mencapai Complete / Partial
response
Adjuvant ChemoTx
Kemoterapi yang diberikan setelah tumor
primernya diterapi dengan modalitas terapi lain,
untuk mengatasi mikro metastasis tersisa,
tumor burden, efektivitas kemoterapi

Jenis kemoterapi
Neo-adjuvant Chemotx
Pengobatan initial untuk memungkinkan
modalitas lain bekerja lebih efektif
Karena vaskularisasi intak suplai obat baik
ukuran tumor preservasi organ
Kerugian: penundaan modalitas terapi lain
2. Kemoterapi paliatif
Mengurangi keluhan dan gejala
tanpa menyembuhkan

Pilihan pengobatan yang terbatas pada


stadium lanjut kanker paru

Kemoterapi pada kanker paru dasarnya


bersifat paliatif.

Bila jenis kemoterapi ditambah maka efek


samping/toksik >>>

Kemoterapi kanker paru kurang memberikan


hasil
38

Tumor Mediastinum

Rosenberg Classification
Neurogenic
Arising from peripheral nerves
Neurofibroma
Neurilemoma/Schwannoma
Neurosarcoma
Arising from sympathetic ganglia
Ganglioneuroma
Ganglioneuroblastoma
Neuroblastoma
Arising from paraganglionic tissue
Pheochromocytoma
Chemodectoma/paraganglioma
Germ cell tumor
Seminoma
Nonseminomatous tumors
Pure embryonal cell
Mixed embryonal cell with
seminomatous elements
trophoblastic elements
teratoid elements
entodermal sinus elements/yolk sac tumor
Teratoma benign
Aneurysms
Thymic
Thymoma
Carcinoid
Thymolipoma

Mesenchymal tumors
Fibroma, fibrosarcoma
Lipoma, liposarcoma
Myxoma
Myxoma
Mesothelioma
Leiomyoma, leiomyosarcoma
Rhabdomyosarcoma
Xanthogranuloma
Mesenchymoma
Hemangioma
Hemangioendothelioma
Hemangiopericytoma
Lymphangioma
Lymphangiopericytoma
Cysts
Pericardial
Bronchogenic
Enteric
Thymic
Thoracic duct
Meningoceles
Lymphadenopathy
Inflammatory
Granulomatous
Sarcoid
Hernias: Hiatal, Morgagni
Endocrine tumors: Thyroid, Parathyroid

Mediastinal content
heart, great artery & vein, nerves, trachea, thymus,
lymph nodes & vessels, esophagus, connective tissue
Compartment of the mediastinum
M superior:
Thoracic inlet- VTh V & lower part of sternum
M anterior:
Superior mediastnal border-diaphragm infront of
the heart
M posterior:
Superior mediastinal border -diaphragm
behind the heart
M medius:
Superior mediastinal border-diaphragm
between anterior & posterior mediastinal

Clinical features
Symptoms & signs
* Asymptomatic
* Dry Cough, dyspnea, stridor, dysphagia,
VCSS, hoarseness, chest pain

Physical examination
Radiologic procedure
Chest X-ray, Tomography, CT-Scan, MRI,
Fluoroscopy, Echocardiography, Angiography,
Esophagoscopy, USG, Nuclear medicine

Endoscopic procedure
Bronchoscopy, Mediastinoscopy,
Thoracoscopy

Clinical features
Pathologic procedure
Cytology:
FNAB, Pleural effusion, Brushing, Washing,
Transthoracal biopsy
Histological examination
Lymph node biopsy, Daniels biopsy
Mediastinal biopsy, Excisional biopsy, VATS
Lab
CBC, ESR, Tuberculin skin test,
Thyroid study, -FP, -HCG, EMG
Surgical procedure

Staging of timic tumor (Masaoka)


Stage & description

Treatment

Macroscopic: capsulated
No microscopic capsul invasion

Extended thymo thymectomy


(ETT)

II

Macroscopic invasion to fat


tissue surrounding mediastinal
pleura or microscopic capsul
invasion

ETT, continued with radiation

III

Macroscopic invasion to
surrounding organ

ETT and extended resection,


then radiation and chemotherapy

IVA

Pleural /pericardial spreading

Debulking, then chemotherapy


and radiotherapy

IV B Lymphogenic / hematogenic
spreading

Chemotherapy and radiotherapy


then debulking

Germ Cell Tumor


Seminoma
Radiation & chemotherapy sensitive
No surgical intervention
Chemo after radiation or Chemoradiation
Platinum based chemotherapy

Non seminomatous mediastinal tumor


Radioresistant tumor
6 cycles Chemotherapy
-HCG, -FP, Chest X-ray evaluation
Benign teratoma
Surgical intervention
Malignant teratoma
Multimodality therapy

Neurogenic Tumor
Surgical intervention except neuroblastoma
Neuroblastoma
Radiosensitive
Combination Radio & chemotherapy

Management of VCSS
Chest X-ray ( PA & Lateral )

No tumor/mass
clearly detected

CT-Scan Thorax

Tumor (-)

Tumor (+)

Dx & Tx
As it
caused

Diagnostic
Procedures
for
Lung/
Mediastin
al
tumor

Lung/Mediastinal tumor
General
performance
Poor/Dyspnea
Radiation 1 x 8 Gy

Improved

Stable

Continue
Diagnostic
Procedures

Consider
Surgical
Procedure

Good
General performance

PA (+)

PA (-)

Continue
Diagnostic
Procedure

Primary
tumor
mngment

Management of mediastinal tumor

Hodgkin

Mediastinal tumor

Benign

Malignant

Surgical

Lymphoma
Non-Hodgkin

Thymoma
Thymic tumor

Non-Lymphoma

Germ Cell
Tumor

Mesengial tumor
Endocrine tumor

Neurogenic
tumor