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Ukdw CA Paru
Ukdw CA Paru
Ukdw CA Paru
ISWANTO
CA PARU-ROKOK.
Rokok dapat meningkatkan resiko CA
Paru, dan hal tersebut berhubungan
dengan:
Jumlah
Cara
menghisap rokok.
Lama
merokok
Genetik.
HIPOTESA ROKOK-CAPARU
Inflamasi peribronkial
Fibrosis
Mitosis
CA Paru
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.
PROSEDUR
4. Pemeriksaan lain :
a. Tumor marker
- Carcino embryonic antigen (CEA)
- Cyfra 21, SCC, Ca 19-9, Ca 125 II
- Non specific enolase (NSE)
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
Combined modality therapy
Landasan terapi kanker paru :
1. Staging (penderajatan)
a. TNM
b. G (gradasi histopatologis)
GX
G1
G2
G3
G4
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
Management of NSCLC
TNM STAGE < II B
Segmentectomy /
Lobectomy
Neoadjuvant
ChTx
ChTx 2x
RaTx 40Gy
Surgery
(+)
Adjuvant
ChTx
Surgery
(-)
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
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
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
Treatment
Macroscopic: capsulated
No microscopic capsul invasion
II
III
Macroscopic invasion to
surrounding organ
IVA
IV B Lymphogenic / hematogenic
spreading
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
Hodgkin
Mediastinal tumor
Benign
Malignant
Surgical
Lymphoma
Non-Hodgkin
Thymoma
Thymic tumor
Non-Lymphoma
Germ Cell
Tumor
Mesengial tumor
Endocrine tumor
Neurogenic
tumor