BLOK GANGGUAN

PERTUMBUHAN/Ca
PARU

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What
What is
is cancer
cancer ??
Cancer :  abnormal cell growth in a tissue
 escape from normal control
 invasive, metastases

How
How does
does cancer
cancer occur
occur ??
 Proliferation Apoptosis
 
Tumor Degenerative disease
Malignancy Autoimmune disease
 Cells premalignant

PROMOTION PROMOTION

Cells still Expansion of

have normal premalignant
phenotype clone
Multistage
Multistage
INITIATION Progression
Progression
PROGRESSIO
N
to Malignancy
to Malignancy
Cells
malignant

Further genetic
Expansion of
changes
malignant
clone
METASTASES
What
What is
is the
the cause
cause of
of cancer
cancer ??
External factors Internal factors

 Chemicals  Repair failure

 Radiations  Error
 Ultraviolet rearrangement
 Carcinogens

PERSISTENT GENE ABNORMALITY

Viruses
Viruses and
and Cancer
Cancer
Viruses
Viruses Associated
Associated with
with Human
Human
Cancers
Cancers
Virus Associated tumors

DNA viruses Burkitt’s lymphoma

Epstein-Barr Nasopharyngeal
cancer/LUNG CANCER
Hepatitis B Liver cancer
Papilloma virus Benign warts
Cervical cancer
RNA viruses
Human immunodeficiency virus (HIV-1) Kaposi’s sarcoma
Human T-cell leukemia virus Type I Adult T-cell leukemia
(HTLV-1)
HTLV-2 Hairy cell leukemia
HTLV-5 Cutaneous T-cell leukemia
Lung Cancer

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 Lung
Lung Cancer:
Cancer: Defined
Defined

 Uncontrolled
Uncontrolled growth
growth of
of malignant
malignant cells
cells in
in one
one
or
or both
both lungs
lungs and
and tracheo-bronchial
tracheo-bronchial treetree
 AA result
result of
of repeated
repeated carcinogenic
carcinogenic irritation
irritation
causing
causing increased
increased rates
rates of
of cell
cell replication
replication
 Proliferation
Proliferation of
of abnormal
abnormal cells
cells leads
leads to
to
hyperplasia,
hyperplasia, dysplasia
dysplasia or
or carcinoma
carcinoma in
in situ
situ

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 Angiogenesis is essential for
tumour growth
Premalignant Malignant Tumour Vascular Micro- Metastatic
tumour tumour growth invasion metastases growth
Angiogenic
switch

Stages at which angiogenesis plays a role in tumour progression

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Adapted from Poon, et al. JCO 2001
Pengertian

 Semua keganasan yang mengenai paru,

baik yang primer maupun yang sekunder
karena metastase ke paru
  tumor ganas yang berasal dari epitel
bronkus atau bronchogenic carsinoma

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 Structure & Function of
the Pulmonary System

Sel tmbh tak trkontrol,

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Iritasi terus zat carc.genik,proliferasi abnormal,hiperplasi,dis trophy
Deteksi dini
 Keluhan dan gejala tidak spesifik
 Biasanya dideteksi sudah dalam stage yang
lanjut
 Deteksi dini:
 Laki-laki, > 40 th, perokok  perempuan perokok
pasif
 Paparan industri tertentu
 Dengan salah satu gejala: batuk darah, batuk kronik,
sesak nafas, nyeri dada dan berat badan menurun
 Riwayat keluarga ada yang terkena kanker paru

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12
Keterangan skema bagan

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Diagnosis

 Anamnesis
 Pemeriksaan fisik
 Pemeriksaan radiologis
 Pemeriksaan khusus

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Anamnesis
 Keluhan utama: batuk dengan/ tanpa dahak
 Batuk darah
 Sesak nafas
 Suara serak
 Nyeri dada
 Sulit menelan
 Benjolan di pangkal leher
 Sembab muka dan leher kadang disertai sembab lengan
unilateral dg nyeri yang hebat
 BB menurun
 Demam hilang timbul
 Sindroma paraneoplastik

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Pemeriksaan Fisik
 Tumor kecil yang terletak di perifer  tidak
menampakkan kelainan
 Tumor berukuran besar dengan atelektasis,
efusi pleura, atau penekanan vena kava
superior  pemeriksaan lebih jelas
 Mencari metastase ke tempat lain: hepar, otak
(tanda-tanda peningkatan tekanna intra
kranial), tulang (fraktur)

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 Etiology
 Cigarette
Cigarette smoking
smoking isis the
the most
most important
important risk
risk factor
factor in
in the
the
development
development ofof lung
lung cancer.
cancer.

 75%
75% of
of Lung
Lung CA’s
CA’s related
related to
to smoking.
smoking.

 Other
Other environmental
environmental factors
factors that
that may
may predispose
predispose to
to lung
lung
cancer
cancer include
include industrial
industrial substances
substances such
such as
as asbestos,
asbestos,
arsenic,
arsenic, chromium,
chromium, oror nickel,
nickel, organic
organic chemicals,
chemicals, radon,
radon,
or
or iatrogenic
iatrogenic radiation
radiation exposure,
exposure, air
air pollution,
pollution, and
and other
other
environmental
environmental (secondary)
(secondary) smoke
smoke in in nonsmokers
nonsmokers..

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 Indonesia - 3 Besar Negara
Pengkonsumsi Rokok

 Jumlah perokok no. 3 di dunia

Negara Jumlah % Pria & no. 1 di ASEAN
Perokok Perokok
(Sumber: (Sumber:  70% perokok mulai merokok
WHO) WHO)
sebelum usia 19 tahun dan 12,77
% sudah merokok sejak SD
China 350,000,000 53.4%
 Penkonsumsi tembakau no. 5
India 120,000,000 29.4%
di dunia (215 miliar
batang/tahun)

Indonesi 62,800,00 69.0%

a 0

Source:
1.http://bola.okezone.com/index.php/ReadStory/2008/05/02/50/105935/50/beijing-mulai-perangi-perokok 2. WHO 2002 3. Mpower WHO Report on Tobacco Global Epidemic, 2008 4. .
http://jawaban.com/news/news/detail.php?id_news=071205093706&offx=0 5.http://www.pdpersi.co.id/?show=detailnews&kode=957&tbl=artikel 6. http://www.depkes.go.id/index.php?
option=news&task=viewarticle&sid=476&Itemid=2 7. http://www.republika.co.id/koran_detail.asp?id=319017&kat_id=3 8.

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.http://www.tempointeraktif.com/hg/nasional/2007/05/30/brk,20070530-100967,id.html 9. http://www.eramuslim.com/berita/int/8218114311-satu-juta-orang-india-meninggal-dalam-satu-
tahun-akibat-rokok.htm?prev
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 Smoking
Smoking Facts
Facts
 Tobacco use is the leading
cause of lung cancer
 87% of lung cancers are
related to smoking
 Risk related to:
 age of smoking onset
 amount smoked
 gender
 product smoked
 depth of inhalation

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Karbon Monoksida Hidrogen sianida

Ammonia Toluidine

Naftilamin Urethane

Aseton Arsenik

Metanol Butana

Benzena Plumbum

Turpentin Kadmium

Metoprena Formaldehid

Benzopirena Propilena Glikol

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 Perbandingan Bahan dalam
Asap Aliran Utama dan Asap Aliran
Sisi

Asap Aliran Utama vs Asap Aliran Sisi

Dadah nikotin 2 kali lipat/ganda

Aseton 2-5 kali ganda
Tar 3 kali ganda
Hidrogen sianid 4-6 kali ganda
Karbon monoksida 5 kali ganda
Toluen 6-8 kali ganda
Benzen 10 kali ganda
Anilin 30 kali ganda
Nitrosamin (bahan karsinogen) 50 kali lipat/ganda
Merokok Mengakibatkan
Penyakit Jantung, Strok
dan Kanker.
Merokok menyebabkan kanser larink, mulut dan
esofagus.

Merokok boleh menyumbatkan saluran darah

mengakibatkan serangan jantung dan strok.

Merokok akan mengurangkan penyaluran oksigen

menyebabkan jantung perlu bekerja lebih keras.

Merokok mengakibatkan kanser pundi kencing,

buah pinggang, pankreas dan perut.

Kanser organ peranakan didapati lebih kerap

dikalangan wanita yang hisap rokok atau yang
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mempunyai rekan hidup yang hisap rokok.
 Perokok Baru

 Setiap hari:

 14,000 hingga 15,000 golongan muda

dari negara berpendapatan tinggi
menjadi perokok

 68,000 hingga 84,000 golongan muda

dari negara berpendapatan rendah dan

Source:A World Bank Publication

sederhana menjadi perokok

World Bank Report, 1999

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 Lung Cancer: Diagnosis
 History and Physical exam
 Diagnostic tests
• Chest x-ray
• Biopsy (bronchoscopy, needle biopsy,
surgery)
 Staging tests
• CT chest/abdomen
• Bone scan
• Bone marrow aspiration
• PET scan

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Lung Cancer: Cell Types

 Non Small Cell Lung Cancer

(NSCLC)

 Small Cell Lung Cancer (SCLC)

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 Non Small Cell Lung
Cancer (NSCLC)

• 80% of all lung cancers

• Better survival rates when found in

early stages

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 Principles of therapy
Lung ca

Non Small
small cell cell
(NSCLC) (SCLC)
(> 85 %)

www.themegallery.com 29
Principles of therapy : NSCLC

www.themegallery.com 30
 NSCLC: Treatment
• Surgery
– Mediastinoscopy
– Video-assisted Thoracoscopy (VAT)
– Thoracotomy: Lobectomy. Pneumonectomy

• Radiation
– External Beam
– Brachytherapy

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 NSCLC:
NSCLC: Treatment
Treatment
 Chemotherapy
 Standard
 Cisplatin,
 Carboplatin
 Newer agents: Gemcitabine, Paclitaxel/Taxol,

Docetaxel, Vinorelbine, Irinotecan used alone
and in combination

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: early and continued effects OF TREATMENT

EARLY EFFECTS CONTINUED EFFECTS

1 Regression of existing tumour 3 Inhibition of new tumour

microvasculature vasculature
2 Normalisation of remaining
tumour vasculature

Baluk, et al. Curr Opin Genet Dev 2005; Inai, et al. Am J Pathol 2004; Erber, et al. FASEB J 2004

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Tong, et al. Cancer Res 2004; Jain. Nat Med 2001; Jain. Science 2005; Lee, et al. Cancer Res 2000
Gerber, et al. Cancer Res 2005; Warren, et al. J Clin Invest 1995
 NSCLC: Treatment by Stage
Stage Description Treatment Options

Tumor of any size is found

Stage I a/b Surgery
only in the lung
Tumor has spread to lymph
Stage II a/b nodes associated with the Surgery
lung

Tumor has spread to the

Chemotherapy
lymph nodes in the tracheal
Stage III a followed by radiation
area, including chest wall
or surgery
and diaphragm

Tumor has spread to the Combination of

Stage III b lymph nodes on the chemotherapy and
opposite lung or in the neck radiation

Chemotherapy and/or
Tumor has spread beyond
Stage IV palliative (maintenance) 34
the chest
care
NSCLC: Treatment Outcomes

Stage 5-Year Survival

I 60-80%
II 40-50%
IIIa 25-30%
IIIb 5-10%
IV <1%

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Chemoradiotherapy Approaches

• Sequential CT→ RT
• Concurrent CT/RT
• Sequential & Concurrent CT→ CT/RT
CT/RT → CT

CT: chemotherapy
RT: radiation therapy

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 SUMMARY FOR TREATMENT
OF NON-SMALL CELL LUNG CANCER

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Small Cell Lung Cancer (SCLC)

 Most aggressive lung cancer

 Responsive to chemotherapy and

radiation but recurrence rate is high
even in early stage

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 SCLC: Staging
 Limited Stage
Defined as tumor involvement of one lung, the
mediastinum and ipsilateral and/or contralateral
supraclavicular lymph nodes or disease that can be
encompassed in a single radiotherapy port.
 Extensive Stage
Defined as tumor that has spread beyond one lung,
mediastinum, and supraclavicular lymph nodes.
Common distant sites of metastases are the
adrenals, bone, liver, bone marrow, and brain.

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 SCLC: Treatment
• Limited Disease
– Chemotherapy
– Concomitant Radiation
– Prophylactic Cranial Irradiation

• Extensive Disease
– Chemotherapy
– Palliative radiation

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SCLC: Treatment Outcomes

• Limited Disease
– median survival 18 - 20 months
– 5-year survival 10%

• Extensive Disease
– median survival 10 - 12 months
– 5-year survival 1 - 2%

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 Chemotherapy:
• ALL patients with reasonable/layak performance status will
be given chemotherapy.
• Standard: platinum-etoposide.
• Response is rapid at 80%.
• Radiation:
– Curative intent: in patients with limited-stage disease, given
concurrently with chemotherapy.

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PROGNOSIS OF SMALLCELL
LUNG CANCER

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 Radiation therapy:

 Symptoms improvement:
 Airway compression
 Esophageal compression
 SVCO syndrome
 Bone or brain metastases.

 For non-chemotherapy candidate.

 Pain and symptom management or
palliative care.
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 WORK-UP FOR LUNG
CANCER
 􀂄 Staging of lung cancer: small-cell
lung cancer
 􀂄 CT scan of chest/abdomen
 􀂄 CT brain
 􀂄 Bone scan
 􀂄 PFT.
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 Lung
Lung Cancer:
Cancer: Conclusions
Conclusions
 Smoking cessation is essential for prevention
of lung cancer.
 New screening tools offer promise for
detection of early lung tumors.
 Clinical trials are testing promising new
treatments.
 New treatments offer improved efficacy and
fewer side effects.
 Treatment can palliate symptoms and improve
quality of life.
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