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LBM 6

STEP 1

- Puffy face : swealling on the face . there is udema on the face because of destroy of
vascularitation
- Hoarse voices : changes of the voice become to rough or lost because of presure of
nervus laryngeus reccurens by tumor
- Horner’s syndrom : a syndrom can decrease work of nervus sympatics cerervical from
cervical 8 until thoracal 1 , the manifestation facial anhidrosis , ptosis , miosis ,
endoftalmopati

- Ptosis : is the medical term for dropping eye lid that caused by paralisis of sympatics
nervush
- Miosis : condition when diameter of pupil < 2 mm because of decrease of nervus
sympatis
- Facial anhidrosis : a condition in ability to sweat normally same name with
hipohidrosis its means no sweat

STEP 2

1. Why the man appreance puffy face ?
2. Why he has hoarse voices ?
3. Why he feel decrease appetite ?
4. Explain about horner syndrom / bernard syndrom ?
5. Why he get pain in the lower chest and tightness when breathing ?
6. Why the patient cough with blood ?
7. Why the relation between aktif smoker with the desease ?
8. Why the patient perceived weight loss and fever ?
9. Why when he runout of medicine he suffered from cough and shortness again
?
10. What are the etiologys from the scenario ?
11. What are the risk factor from the scenario ?
12. What are the DD and Diagnose from the scenario ?
13. What are the treatments from diagnose ?
STEP 3

1. Why the man appreance puffy face ?
A puffy face, neck, and eyelids, coupled with dilated veins of the neck,
shoulder, thorax, and upper arm (i.e., superior vena cava syndrome) may
constitute the first clinical evidence of obstruction of the superior vena cava by
a neoplasm of the lung. Although the causes of superior vena cava syndrome
are many and diverse, at least 80 percent are attributable to a primary
carcinoma of the lung . In the patient in whom an eoplasm has evoked acute

Why he has hoarse voices ? In a patient with lung cancer.[1] Causes of Horner syndrome include the following:  Lesion of the primary neuron  Brainstem stroke or tumor or syrinx of the preganglionic neuron – In one study. unilateral vocal cord dysfunction results in hoarseness. ptosis. Why he feel decrease appetite ? 4. Horner’s syndrome. The nerve passes around the ligamen-tumarteriosumand “recurs “ along the left tracheoesophageal groove. signs andsymptomsof increased systemic venous pressure that progresses rapidly (e. The term Horner syndrome is commonly used in English-speaking countries. and marked decrease in the effectiveness of cough and the ability to clear secretions. anhidrosis). miosis. early diagnosis and prompt treatment of the neoplasm can be lifesaving. Fisman 3. The presence of Horner’s syndrome—unilateral ptosis. and atrophy of hand muscles. Fishman Horner syndrome (Horner’s syndrome) results from an interruption of the sympathetic nerve supply to the eye and is characterized by the classic triad of miosis (ie. and loss of hemifacial sweating (ie. an increased risk of aspiration.to laryngeal edema). Patologi robin This unusual location of a carcinoma of the lung was originally described by Pancoast in 1932 as characterized by pain along the distribution of the eighth cervical and the first and second thoracic nerves. 33% of patients with brainstem lesions demonstrated Horner syndrome[2] . the recurrent laryngeal nerves are vulnerable to injury because of either direct invasion by malignancy or injury during surgical dissection. 99-8). partial ptosis. constricted pupil). miosis. whereas the term Bernard- Horner syndrome is common in France..g. local destruction of bone by the tumor. If either nerve is injured. and anhidrosis—in a patient with a carcinoma of the lung suggests a pulmonary sulcus tumor with involvement of the ipsilateral sympathetic pathway within the thorax Fishman 2. and anhidrosis). The left vagus nerve is at greater risk than the right because of its course from the neck down into the left aspect of the mediastinum and across the aortic arch before giving off the left recurrent laryngeal nerve at the level of the inferior border of the aortic arch (Fig. Explain about horner syndrom / bernard syndrom ? neoplasms may invade the brachial or cervical sympathetic plexus to cause severe pain in the distribution of the ulnar nerve or to produce Horner syndrome (ipsilateral enophthalmos. Von Passow syndrome is an association of Horner syndrome with iris heterochromia (heterochromia iridis).

No age. Clinical manifestations Horner syndrome is caused by a lesion of the sympathetic pathway supplying the head.com/medlinkcontent. Miosis. Certain genetic polymorphisms of the P450 enzyme system. which remained isolated in half the cases (32/65)[3]  Carotid artery ischemia  Migraine  Middle cranial fossa neoplasm Horner syndrome is uncommon. therefore. and neck. http://www. The anisocoria of a Horner syndrome is generally small. The prognosis and the complications to be expected depend on the underlying cause of the syndrome. What are the relations between aktive smoker with the desease ? Exposure to environmental carcinogens. because of . the patient may or may not complain of decreased sweating on 1 side.medlink. The contribution of carcinogens on transformation is modulated by polymorphic variations in genes that affect aspects of carcinogen metabolism. specifically CYP1A1. sexual. about 1.asp 5. The miosis (smaller pupil) results from a lack of an active pupillodilator due to an oculosympathetic defect. However. or racial predilections are known to exist. 44% (65/146) of patients with internal extracranial carotid artery dissections had painful Horner syndrome. induce or facilitate the transformation from bronchoepithelial cells to the malignant phenotype. facial anhidrosis does not occur significantly with postganglionic Horner syndrome. Because the sympathetic plexus accompanying the internal carotid artery innervates sweat glands only to the medial forehead (Salvesen 2001). These genetic variations occur at relatively high frequency in the population but their contribution to an individual's lung cancer risk is generally low. such as those found in tobacco smoke.0 mm or less. Why he get pain in the lower chest and tightness when breathing ? 6. Why the patient cough with blood ? 7. or chromosome fragility are associated with the development of lung cancer. eye. Trauma to the brachial plexus  Tumors (eg. Among patients with central and preganglionic Horner syndrome. in which there is loss of the vasomotor sympathetic fibers to the face. There is both upper and lower lid ptosis due to loss of sympathetic innervation to the superior and inferior tarsal muscles. Ptosis. the anisocoria is greater in darkness than in room light. Pancoast) or infection of the lung apex  Lesion of the postganglionic neuron  Dissecting carotid aneurysm – In one study. as does treatment. Anhidrosis.

likely affect specific genes by deregulating important pathways to enable the cancer phenotype. their population frequency. These data suggest that specific genes and/or genetic variants may contribute to susceptibility to lung cancer. First-degree relatives of lung cancer probands have a two. TB paru Lesi dengan kalsifikasi : TB paru lama. 15q25(CHRNA5-CHRNA-3 nicotinic acetylcholine receptor subunits). Adanya bayangan suatu massa dengan kavitas : Neoplasma TB paru Abses paru c. d. very few such genes have yet been identified. Adanya efusi pleura maligna : Karsinoma/tumor primer di pleura (jarang) . the overall impact on lung cancer risk could be high. tumor benigna. Harisson’s Principle of Internal Medicine 18th edition 8. including 5p15 (TERT-CLPTM1L). Three genetic loci for lung cancer risk have been identified by genomewide association studies. A rare germline mutation (T790M) involving the epidermal growth factor receptor (EGFR) maybe be linked to lung cancer susceptibility in never smokers. Why when he runout of medicine he suffered from cough and shortness again ? 10. tetapi tanpa garis2 radier : umumnya gambaran metastasis tumor pada paru. Why the patient perceived weight loss and fever ? 9. Adanya gambaran lesi inflamasi akut : Pneumoni Abses paru TB paru Tumor paru benigna Infark paru b. no molecular criteria are used to select patients for more intense screening regimens or for specific chemopreventive strategies. Individuals with inherited mutations in RB (patients with retinoblastoma living to adulthood) and p53 (Li-Fraumeni syndrome) genes may develop lung cancer. However. environmental factors. and 6p21 (BAT3-MSH5). however. dengan garis2 radierkarsinoma paru primer Bayangan dengan batas tidak tegas. In addition. Adanya bayangan bulat di daerah perifer paru : Bayangan dengan batas tegas : tumor benigna. Currently. many of which are not smoking-related. What are the DD and Diagnose from the scenario ? Beberapa DD dari bayangan abnormal foto Rontgen dada: a.to threefold excess risk of lung cancer and other cancers. kista hidatidosa Bayangan dengan batas tidak tegas. as modified by inherited modulators.

several other factors have been implicated. Tingkat risiko utamanya diperngaruhi oleh lamanya seseorang merokok 2. sementaara yang terekspos asap rokok di lingkungan kerja resikonya meningkat 17%. Herbal Penyembuhan Gangguan Sistem Pernapasan. Usia lebih dari 40 tahun 4. although generally even long-term former smokers have higher risks of lung cancer than those who never smoked. A deep sequencing study suggested that one genetic mutation is induced for every 15 cigarettes smoked. Joko. What are the risk factor from the scenario ? Faktor risiko kanker paru paru Beberapa faktor risiko seseorang menderita adalah sebagai berikut: 1. What are the etiologys from the scenario ? 12. Cigarette smoking increases the risk of all the major lung cancer cell types. Pulmonologi. Pasiyan R. 2010. Polusi udara di luar ruangan Sumber : Suroyo. Dr. although none to the extent of tobacco. dsb. tumor primernya : o Karsinoma bronkus (paling sering) o Karsinoma di luar dada : mamme. FK UNDIP 11. .PD. gaster. Sejarah keluarga yang terkena kanker paru-paru 7. Metastasis keganasan pada pleura. former smokers have a ninefold increased risk of developing lung cancer compared to men who have never smoked versus the twentyfold excess in those who continue to smoke. The risk from ETS is less than from active smoking. Prof. Sakit yyang dialami sebelumnya (mis: TB) 6. Paparan asbes dan gas radon 5. Yogyakarta: B First Risk Factors While the large majority (80–90%) of lung cancers is caused by cigarette smoking. 3. Cigarette smokers have a tenfold or greater increase in risk of this cancer compared to those who have never smoked. Sp. Environmental tobacco smoke (ETS) or secondhand smoke is also an established cause of lung cancer. with a 20–30% increase in lung cancer observed among never smokers married for many years to smokers. pancreas. Menghirup asap rokok (perokok pasif). Perokok pasif juga merupakan faktor risiko dengan 25% peningkatan risiko terkena kanker paru paru jika pasangannya merokok. in comparison to the 2000% increase among continuing active smokers. Merokok (perokok aktif). 9 dari 10 kasus kanker paru paru disebabkan oleh rokok. The size of the risk reduction increases with the length of time the person has quit smoking. uterus. The risk of lung cancer is lower among persons who quit smoking than among those who continue smoking.

an nicotinic acetylcholine receptor partial agonist). nickel (as in certain nickel- refining processes). smoking cessation can even be beneficial in individuals with an established diagnosis of lung cancer. Food and Drug Administration (FDA) as first-line treatments for nicotine dependence.. Consequently. However. it is important to promote smoking cessation even after the diagnosis of lung cancer is established. might have chemopreventive effects for lung cancer. Stopping tobacco use before middle age avoids more than 90% of the lung cancer risk attributable to tobacco. little health benefit is derived from just "cutting back. emphysema. even well into middle age. Self-help strategies alone only marginally affect quit rates. The risk of lung cancer appears higher among individuals with low fruit and vegetable intake during adulthood. This observation led to hypotheses that specific nutrients. . In fact.g. Physicians need to understand the essential elements of smoking cessation therapy. Prior lung diseases such as chronic bronchitis. Smoking Cessation Given the undeniable link between cigarette smoking and lung cancer (not even addressing other tobacco-related illnesses).S. are approved by the U. raising the possibility that the scarring and inflammation produced by this fibrotic nonmalignant lung disease may in many cases (though likely not in all) be the trigger for asbestos-induced lung cancer. bupropion) or nicotine replacement therapy (varenicline. However. mustard gas. fewer side effects from therapy. Therapy with an antidepressant (e." Importantly. Physicians also must help their patients who smoke to stop smoking. most convincingly demonstrated from studies showing increased rates of lung cancer among survivors of the atom bombs dropped on Hiroshima and Nagasaki and large excesses among workers exposed to alpha irradiation from radon in underground uranium mining. including occupational exposures to asbestos. Prolonged exposure to low-level radon in homes might impart a risk of lung cancer equal or greater than that of ETS. bischloromethyl ether. the risk of lung cancer among asbestos-exposed workers is increased primarily among those with underlying asbestosis. The individual must want to stop smoking and must be willing to work hard to achieve the goal of smoking abstinence. as it is associated with improved survival. Smoking cessation. and an overall improvement in quality of life. Occupational studies also have provided insight into possible mechanisms of lung cancer induction. hexavalent chromium. potentially adversely altering the toxicities and therapeutic benefits of the agents. smoking can alter the metabolism of many chemotherapy drugs.While cigarette smoking is the dominant cause of lung cancer. and tuberculosis have been linked to increased risks of lung cancer as well. in particular retinoids and carotenoids. physicians must promote tobacco abstinence. Several other occupational exposures have been associated with increased rates of lung cancer. several other risk factors have been identified. can minimize an individual's subsequent risk of lung cancer. whereas individual and combined pharmacotherapies in combination with counseling can significantly increase rates of cessation. randomized trials failed to validate this hypothesis. arsenic. Moreover. For example. but the causal nature of the association is not as clear. Ionizing radiation is also an established lung carcinogen. studies found the incidence of lung cancer was increased among smokers with supplementation. and polycyclic aromatic hydrocarbons.

Prolonged use of varenicline beyond the initial induction phase proved useful in maintaining smoking abstinence. many of which are not smoking-related. induce or facilitate the transformation from bronchoepithelial cells to the malignant phenotype. 15q25(CHRNA5-CHRNA-3 nicotinic acetylcholine receptor subunits). varenicline was more efficacious than bupropion or placebo. Three genetic loci for lung cancer risk have been identified by genomewide association studies. . and 6p21 (BAT3-MSH5). There is great variability in the use of liquid nitrogen for cryotherapy and significant transatlantic variations in practice. In addition.to threefold excess risk of lung cancer and other cancers. environmental factors. In a randomized trial. both drugs have been reported to increase suicidal ideation and must be used with caution. However. Certain genetic polymorphisms of the P450 enzyme system. however. Individuals with inherited mutations in RB (patients with retinoblastoma living to adulthood) and p53 (Li-Fraumeni syndrome) genes may develop lung cancer. However. For this reason caution should be exercised in the use of cryotherapy for SCC although it may be an appropriate technique for selected cases in specialised centres Cryosurgery is not appropriate for locally recurrent disease or high risk tumours. These genetic variations occur at relatively high frequency in the population but their contribution to an individual's lung cancer risk is generally low. First-degree relatives of lung cancer probands have a two. including 5p15 (TERT-CLPTM1L). What are the treatments from diagnose ? depend of etilogy Cryosurgery Good short term cure rates have been reported for small histologically confirmed SCC treated by cryosurgery in experienced hands. However. Inherited Predisposition to Lung Cancer Exposure to environmental carcinogens. Prior biopsy is necessary to establish the diagnosis histologically. no molecular criteria are used to select patients for more intense screening regimens or for specific chemopreventive strategies. because of their population frequency. or chromosome fragility are associated with the development of lung cancer. the overall impact on lung cancer risk could be high. such as those found in tobacco smoke. A rare germline mutation (T790M) involving the epidermal growth factor receptor (EGFR) maybe be linked to lung cancer susceptibility in never smokers. likely affect specific genes by deregulating important pathways to enable the cancer phenotype. These data suggest that specific genes and/or genetic variants may contribute to susceptibility to lung cancer. 395). The contribution of carcinogens on transformation is modulated by polymorphic variations in genes that affect aspects of carcinogen metabolism. very few such genes have yet been identified. Currently. Harisson’s Principle of Internal Medicine 18th edition 13. specifically CYP1A1. as modified by inherited modulators. Clonidine and nortriptyline are recommended as second-line treatments (Chap.

Surgical Excision Surgical excision is the treatment of choice for the majority of cutaneous SCC. the tip of the nose and in some cases the ear. and photodynamic therapy. intralesional Interferon Alpha. intralesional 5-Fluorouracil. It allows full characterisation of the tumour and a guide to the adequacy of treatment through histological examination of the margins of the excised tissue. Other Treatments Other reported treatments include: topical Imiquimod. the lip. the lower eyelid.Radiotherapy Radiotherapy is generally contraindicated in the younger patient because the scar from surgery is usually less noticeable than the pallor and telangiectases which develop as a late effect in irradiated skin. Multi-professional Guidelines for the Management of the Patient with Primary Cutaneous Squamous Cell Carcinoma R J Motley. P W Preston. In some circumstances radiotherapy will give a better cosmetic effect. Quality of Evidence IV).Evidence for the role of these treatments is lacking and limited to isolated case reports (Strength of Recommendation C. For example. Choice of radiotherapy modality (electrons or photons) dose and technique require experience and the involvement of a qualified clinical oncologist. the inner canthus of the eye. SCC can be cured by radiotherapy in more than 90% of cases. C M Lawrence . particularly where loss of tissue is likely to cause cosmetic or functional impairment.