Cancer

CASE
Ny. N/P/62 Thn/1140827
dx. Ca mamma dextra + DM Tipe 2 terkontrol + Hipoalbuminemia +
Anemia
Pro. MRM

S: Benjolan di payudara kanan sejak 10 tahun yang lalu, ± 1 thn yang

lalu benjolan pecah dan menjadi luka borok.
R/DM (+) sejak 3 tahun yang lalu
HT (-)
Operasi sebelumnya (-)
Pemeriksaan fisik
Sens : CM TD : 130/70 Nadi: 99 x/m RR: 18 x/m SpO2: 98%
• Kepala : Konjungtiva anemis (+/+), sklera ikterik (-/-), Refleks cahaya (+/+)
• Thoraks : Vesikuler (+), Ronki (-/-), Wheezing(-/-) ; Bunyi jantung I/II reguler,
murmur (-), gallop (-)
• Abdomen : datar, lemas, shifting dullness (+), bising usus (+).
• Ekstremitas : Edema pretibia (+/+)
• Lab (21/9/)
DR 8,6/24/15160/711000
Ur 24 Cr 0,83 Na 134 K 4,0 Albumin 1,9

• EKG Normal sinus rhytm

• Ro thorax Tak tampak kelainan radiologis
Albumin
Albumin is the most abundant plasma protein and is principally
responsible for maintaining plasma osmotic pressure.
In addition, albumin is important as a transporter of plasma-bound
substances often including exogenously administered drugs.

Barbiturates have a duration of action that is determined by

redistribution and hepatic metabolism and may have prolonged effects
in patients with liver disease.
Hypoalbuminemia, as seen in patients with altered liver function, may
reduce protein binding and increases the free active fraction of these
drugs. Therefore, barbiturates must be titrated carefully in patients
with liver disease.
Benzodiazepines and opioids are metabolized primarily by the liver
and have significantly increased half-lives in patients with liver disease.
Additionally, they have increased potency in cases of hypoalbuminemia
as these drugs, which are usually protein bound, are now free in the
plasma resulting in higher drug levels. This issue may confound the
clinical picture of hepatic encephalopathy and should be titrated
carefully.
Mechanism
results from an accumulation of genetic mutations that causes
dysregulation of cellular proliferation.
• Genes are involved in carcinogenesis by virtue of inherited traits that
predispose to cancer (e.g., altered metabolism of potentially
carcinogenic compounds),
• mutation of a normal gene into an oncogene that promotes the
conversion of normal cells into cancer cells, or
• inactivation of a tumor suppressor gene that allows a tumor to
undergo malignant transformation.
Paraneoplastic syndrome
• Paraneoplastic syndromes are rare disorders that are triggered by an
altered immune system response to a neoplasm. They are defined as
clinical syndromes involving nonmetastatic systemic effects that
accompany malignant disease.
• these syndromes are collections of symptoms that result from substances
produced by the tumor, and they occur remotely from the tumor itself.
1. Fever and Cachexia
2. Neurologic Abnormalities
3. Endocrine Abnormalities
4. Renal Abnormalities
5. Dermatologic and Rheumatologic Abnormalites
6. Hematologic Abnormalities
Fever and Cachexia
• Fever may reflect tumor necrosis, inflammation, release of toxic products by
cancer cells, or production of endogenous pyrogens.

• Cancer cachexia is a frequent occurrence in cancer patients.

In addition to the psychological effects of cancer on appetite, cancer cells
compete with normal tissues for nutrients and may eventually cause nutritive
death of normal cells.
Tumor factors such as proteolysis-inducing factor and host response factors such
as tumor necrosis factor (TNF)-α, IFN-γ, and IL-6 also contribute to muscle
atrophy and lipolysis.
Neurologic abnormalities
Paraneoplastic neurologic syndromes are the result of antibody- mediated damage
to the nervous system. Antibodies produced by the host in response to tumor-
associated antigens cross-react with elements of the nervous system, which leads
to neurologic dysfunction.
The vast majority of paraneoplastic neurologic syndromes (80%) manifest before
the diagnosis of cancer. They can affect both the central and peripheral nervous
systems. They are relatively rare—occurring in about 1% of cancer patients—but
are seen disproportionately in those with small cell lung cancer (SCLC), lymphoma,
and myeloma.
Examples are limbic encephalitis, paraneoplastic cerebellar degeneration, Lambert-
Eaton myasthenia syndrome, and myasthenia gravis.
• Lambert-Eaton syndrome is caused by antibodies to voltage-gated calcium
channel receptors and is commonly associated with SCLC.
• Myasthenia gravis is caused by antibodies to the acetylcholine receptor and is
often present in patients with thymoma. Potentiation of neuromuscular blocking
agents may be observed in these myasthenic disorders.
These paraneoplastic neurologic syndromes often present a diagnostic challenge
because symptoms are nonspecific and the underlying cancer diagnosis is usually
unknown.
Endocrine abnormalities
Paraneoplastic endocrine syndromes arise from hormone or peptide production
within tumor cells

1. SIADH
SIADH affects approximately 1%–2% of cancer patients, with most cases related
to SCLC. Headache and nausea are early symptoms that may progress to
confusion, ataxia, lethargy, and seizures. Symptoms depend on the degree of
hyponatremia and the rapidity with which it develops. SIADH resolves with
treatment of the underlying tumor.
Vasopressin receptor antagonists (tolvaptan and conivaptan) and
demeclocycline (a tetracycline drug that produces a reversible form of
nephrogenic diabetes insipidus) are the pharmacologic therapies available if
symptoms are severe.
2. Hypercalcemia
The most common is secretion of a parathyroid hormone–like protein by tumor
cells that binds to parathyroid hormone receptors in the bone and kidney. This
occurs commonly with squamous cell cancers of the kidneys, lungs, pancreas, and
ovaries.
Hypercalcemia can also be caused by local osteolytic activity associated with bone
metastases, especially from breast cancer, multiple myeloma, and some
lymphomas. Occasionally tumors secrete vitamin D.
The rapid onset of hypercalcemia that occurs in patients with cancer may present
as lethargy or coma. Polyuria accompanies hypercalcemia and may lead to
dehydration. Treatment includes hydration with normal saline. Intravenous (IV)
bisphosphonates or calcitonin may also be indicated.
3. Cushing Syndrome
Cushing syndrome is most commonly associated with neuroendocrine tumors of
the lung, such as SCLC and carcinoid. It is caused by tumor secretion of either
adrenocorticotropic hormone (ACTH) or corticotropin-releasing factor (CRF).
Clinical symptoms include hypertension, weight gain, central obesity, and edema.
The diagnosis can be confirmed by measuring serum concentrations of ACTH or CRF
and by performing a dexamethasone suppression test, which involves
administration of dexamethasone followed by measurement of urinary cortisol
levels.
Treatment includes agents that block steroid production (e.g., ketoconazole,
mitotane). Antihypertensives and diuretics may also be needed for symptom
management.
4. Hypoglycemia
Intermittent hypoglycemic episodes can occur with insulin producing islet cell
tumors in the pancreas or with non–islet cell tumors outside the pancreas that
secrete insulin like growth factor (IGF)-2. Patients with islet cell tumors
demonstrate a high serum insulin level.
In contrast, those with non–islet cell tumors that secrete insulin-like substances
demonstrate a low serum insulin level and an elevated level of IGF-2.
Renal Abnormalities
Paraneoplastic glomerulopathies occur in a variety of different forms, including
membranous glomerulonephritis, nephrotic syndrome, and amyloidosis. Many
involve renal deposition of immunoglobulins or immune complexes containing
tumor antigens with host antibodies. Amyloidosis is marked by deposition of a
unique protein called amyloid and is most often associated with renal cell
carcinoma.

Glomerulopathies are relatively common in lymphoma and leukemia.

Dermatologic and Rheumatologic
Abnormalities
Paraneoplastic dermatologic and rheumatologic conditions an occur without overt evidence of
malignancy, but their appearance should initiate screening for an underlying cancer.
• Acanthosis nigricans is a skin pigmentation disorder recognized by dark patches of skin with a
thick velvety texture usually occurring in the axilla or neck. This skin disorder is most commonly
related to insulin resistance or other non–cancer related conditions. However, when found on the
palms (tripe palm), it is almost always associated with cancer, most often of GI origin.

• Dermatomyositis is an inflammatory condition that causes proximal muscle weakness as well as

characteristic skin changes, including a rash on the eyelids and hands. It can be seen with
ovarian, breast, lung, prostate, and colorectal cancers.

• Hypertrophic osteoarthropathy—commonly known as clubbing—involves subperiosteal bone

deposition that causes a characteristic remodeling of the phalangeal shafts. It is classically
associated with intrathoracic tumors or metastases to the lungs.
Hematologic Abnormalities
Paraneoplastic eosinophilia is related to production of specific interleukins that
promote eosinophilic differentiation and is most often seen in leukemia and
lymphoma.
Eosinophilia can sometimes cause wheezing or occasionally end-organ damage
resulting from eosinophilic infiltration.
Granulocytosis usually occurs with solid tumors, particularly large cell lung cancer.
Pure red cell aplasia is commonly associated with thymoma but also occurs with
leukemia and lymphoma.
Underlying malignancy is the diagnosis in about a third of patients with
thrombocytosis (platelet count > 400,000/mm3). It appears to be caused by tumor-
released cytokines such as IL-6.
Local effects of cancer and metastases
Superior Vena Cava Syndrome/Superior Mediastinal Syndrome
Obstruction of the superior vena cava is caused by spread of cancer into the mediastinum
or directly into the caval wall and is most often associated with lung cancer. Veins above
the level of the heart, particularly the jugular veins and veins in the arms, become
engorged. Edema of the face and upper extremities is usually prominent. Increased
intracranial pressure manifests as nausea, seizures, and decreased levels of consciousness
and is most likely due to an increase in cerebral venous pressure. Compression of the great
vessels may cause syncope.

Superior mediastinal syndrome is the combination of superior vena cava syndrome and
tracheal compression. Hoarseness, dyspnea, and airway obstruction may be present
because of tracheal compression. Treatment consists of prompt radiation therapy or
chemotherapy for symptomatic relief.
Spinal cord compression
Spinal cord compression results from the presence of metastatic lesions in the
epidural space, most often breast, lung, or prostate cancer or lymphoma.
Symptoms include pain, skeletal muscle weakness, sensory loss, and autonomic
dysfunction.

CT and MRI can visualize the limits of compression.

Corticosteroids are often administered to minimize the inflammation and edema

that can result from radiation directed at tumors in the epidural space. Once total
paralysis has developed, the results of surgical laminectomy or radiation treatment
to decompress the spinal cord are poor.
Increased Intracranial Pressure
Metastatic brain tumors, most often from lung and breast cancer,
present initially as mental deterioration, focal neurologic deficits, or
seizures.
Treatment of an acute increase in intracranial pressure caused by a
metastatic lesion includes corticosteroids, diuretics, and mannitol.
Radiation therapy is the usual palliative treatment, but surgery can be
considered for patients with only a single metastatic lesion. Intrathecal
administrationof chemotherapeutic drugs is usually necessary when
the tumor involves the meninges.
Breast Cancer
Women in the United States have a 12% lifetime risk of developing breast cancer.
The risk of death from breast cancer is approximately 3%.

Risk Factors
• The principal risk factors for development of breast cancer are increasing age
(75% of cases occur in patients > age 50 years) and family history (a first-degree
relative diagnosed with breast cancer before age 50 increases the risk threefold
to fourfold).
• Reproductive risk factors that increase the risk of breast cancer include early
menarche, late menopause, late first pregnancy, and nulliparity, all of which are
presumed to prolong exposure of the breasts to estrogen.
• Two breast cancer susceptibility genes (BRCA1 and BRCA2) are mutations that are
inherited as autosomal dominant traits.
Chemotherapy
Kemoterapi adalah istilah yang digunakan pada penggunaan obat obat
kimia yang ditujukan untuk mengobati kanker dengan cara
menghancurkan sel ganas di tubuh.
Chemotherapy
• Adjuvant chemotherapy is useful in patients with tumors larger than 0.5 cm,
pathologically involved lymph nodes, and those with high tumor grade.
• For patients with HER2-negative tumors, commonly used treatments include
doxorubicin and cyclophosphamide followed by paclitaxel in 2-week cycles.
• For those with HER2-positive lesions, trastuzumab, lapatinib, or pertuzumab (all
monoclonal antibodies directed against HER2) are added to the regimen.
• Chemotherapy for breast cancer has adverse effects such as nausea and
vomiting, hair loss, and bone marrow suppression that typically resolve following
treatment.
The most serious late sequelae of chemotherapy are leukemia and
doxorubicin induced cardiac impairment.
• Patients with symptoms of cardiac disease or congestive heart failure
should be evaluated with an ECG and echocardiography. Cardiac
toxicity is also a side effect of the monoclonal antibodies, especially
when used in conjunction with doxorubicin.
• Myelodysplastic syndromes or acute myeloid leukemia can occur after
chemotherapy, but the incidence is low (0.2%–1%).
• High-dose radiation therapy may be associated with brachial
plexopathy or nerve damage, pneumonitis, and/or pulmonary
fibrosis.
Obat Mekanisme
Agen alkylating Melemahkan fungsi sel dengan
membentuk ikatan di molekul
penting di protein, DNA, RNA
Antimetabolit Mengikat DNA atau RNA atau
mengikat tempat katalitik di enzim
penting
Antibiotik antitumor Menyatu dengan DNA pada
sekuensi spesifik, menghasilkan
radikal bebas strand hancur
Topoisomerase inhibitor Uncoiling DNA selama replikasi
Tubulin-binding drugs Mengikat tubulin dan mencegah
pembentukan mikrotubuler yang
berguna selama mitosis
Signal transduction Mengganggu interaksi growth
modifiers factor normal yang menyebabkan
proliferasi sel
Jenis obat
Cisplatin, carboplatin, chlorambucil,
cyclophosphamide, ifosfamide
5-Fluorouracil, methotrexate, pemetrexed,
mercaptopurine, gemcitabine
Bleomycin, anthracyclines (doxo- rubicin,
epirubicin)
Topoisomerase I—irinotecan, topotecan
Topoisomerase II—etoposide
Vinca alkaloids—vincristine, vinorelbine
Taxoids—docetaxel, paclitaxel
Antiestrogens—tamoxifen, toremifene,
raloxifene
Antiandrogens—flutamide, bicalutamide,
nilutamide Monoclonal antibodies—
rituximab, trastuzumab Aromatase
inhibitors—aminoglutethimide, anastrazole,
letrozole
Gonadotropin-releasing drugs— leuprolide,
buserelin
Progestins—megestrol acetate
Management of Anesthesia
Preoperative :
• evaluation includes a review of potential adverse effects related to chemotherapy.
• Placement of IV catheters in the arm at risk of lymphedema is avoided because of the potential to
exacerbate lymphedema and the susceptibility to infection. It is also necessary to protect that
arm from compression (as from a blood pressure cuff) and heat exposure.

Intraoperative :
• The presence of bone pain and pathologic fractures is noted when considering regional
anesthesia and when positioning the patient during surgery.
• Selection of anesthetic drugs, techniques, and special monitoring is influenced more by the
planned surgical procedure than by the presence of breast cancer.