Arly Ung Ancer: Kks Bagian Pulmonologi Rsu. Dr. Pirngadi Medan 2006

Early Lung
Cancer
INTRODUCTION
Lung Cancer is a disease in which certain lung cells don't
function right, divide very fast, and produce too much tissue forming a
Lung Tumor. The lungs, a pair of sponge-like, cone-shaped organs,
are part of the body's respiratory system. When we breathe in, the
lungs take in oxygen, which our cells need to live and carry out their
normal functions. When we breathe out, the lungs get rid of carbon
dioxide, which is a waste product of the body's cells. Lung Cancers
that begin in the lungs are divided into the following two major types:
Non-small cell lung cancer
Small cell lung cancer

The type is determined by the way the cells look under a
microscope. Each type of lung cancer grows and spreads in different

ways and is treated differently. Another type of lung cancer is
Adenocarcinoma.1, 3,9
KKS BAGIAN PULMONOLOGI

RSU. DR. PIRNGADI MEDAN 2006
Lung Cancer Causes

Cigarette smoking is the most significant cause of lung cancer.
Research as far back as the 1950s clearly established this relationship.
Cigarette smoke contains more than 4000 chemicals, many of

which have been identified as causing cancer.
A person who smokes more than 1 pack of cigarettes per day has
a risk of developing lung cancer 20-25 times greater than
someone who has never smoked.
Once a person quits smoking, his or her risk for lung cancer
gradually decreases. About 15 years after quitting, the risk for
lung cancer decreases to the level of someone who never
smoked.
Cigar and pipe smoking increases the risk of lung cancer but not
as much as smoking cigarettes does.
About 85% of lung cancers occur in a smoker or former smoker. The

risk of developing lung cancer is related to the following factors:
The number of cigarettes smoked

The age at which a person started smoking
How long a person has smoked (or had smoked before quitting)
Other causes of lung cancer include the following:
Passive smoking, or sidestream smoke, presents another risk for

lung cancer. A person living with a smoker has twice the risk of
lung cancer of someone not regularly exposed to smoke.
Air pollution from motor vehicles, factories, and other sources

may increase the risk for lung cancer, but the degree of increase
has not been established accurately.
Asbestos exposure increases the risk of lung cancer by 9 times. A

combination
of
asbestos
exposure
and
cigarette
smoking
compounds the risk by as much as 50 times.
Lung diseases, such as tuberculosis (TB) and chronic obstructive

pulmonary disease (COPD), also create a risk for lung cancer. A
person with COPD has a 4-6 times greater risk of lung cancer
even when the effect of cigarette smoking is excluded.
Radon exposure poses another risk.

o
Radon is a by-product of naturally occurring radium, which

is a product of uranium.
Radon is present in indoor and outdoor air.
The risk for lung cancer increases with significant longterm exposure, although no one knows the exact risk.
Certain occupations where exposure to arsenic, chromium,

nickel, aromatic hydrocarbons, and ethers occurs may increase
the risk of lung cancer.
A person who has had lung cancer is more likely to develop a

second lung cancer than the average person is to develop a first
lung cancer.1,2,3,4,5

What Are Early Symptoms Of Lung Cancer

Early symptoms of lung cancer are often mistaken for less
serious diseases. That means it's more likely the early symptoms of
lung cancer has already spread through the lungs and to other parts of
the body before it's diagnosed.
Early symptoms of lung cancer often do not appear until the
disease is advanced. For this reason, only about 15 percent of lung
cancers cases are found in the early symptoms stages, before lung
cancer has spread to nearby lymph nodes or elsewhere.
Many lung cancers or Mesothelioma are diagnosed incidentally,
meaning they are found as a result of tests done for an unrelated
medical condition. For example, a diagnosis may be made when tests
are performed to investigate other conditions like heart disease,
pneumonia or other conditions.
It is hard to detect lung cancer in its starting stages. Chest Xrays and analysis of this cells in the sputum are usually done first if
there is a suspicion of cancers. These tests are not used without
symptoms. Fiber optic examination (looking through a flexible scope
into the lungs) , and biopsy helps to confirm the diagnosis.
Far and away, the most common symptoms of a primary tumor is
a cough. The tumor takes up space in the lungs and causes an
irritation that an individual senses and tries to cough up. Because the
vast majority of cancer patients are cigarette smokers, they often
delude themselves into thinking their cough is merely an extension of
their previous smokers cough.
Lung Cancer Symptoms
A cough that doesn't go away and gets worse over time
Constant chest pain
Coughing up blood
Shortness of breath, wheezing, or hoarseness
Repeated problems with pneumonia or bronchitis
Swelling of the neck and face
Loss of appetite or weight loss
Fatigue
These lung cancer symptoms may be caused by lung cancer or by

other conditions. It is important to check with a doctor.
To help find the cause of lung cancer symptoms, the doctor
evaluates a person's medical history, smoking history, exposure to
environmental and occupational substances such as asbestos, and
family history of cancer. The doctor also performs a physical exam and
may order a chest x-ray and other tests. If lung cancer is suspected,
sputum cytology (the microscopic examination of cells obtained from a
deep-cough sample of mucus in the lungs) is a simple test that may be
useful in detecting lung cancer. To confirm the presence of lung cancer,
the doctor must examine tissue from the lung. The removal of a small
sample of tissue for examination under a microscope by a pathologist
can show whether a person has lung cancer. A number of procedures
may be used to obtain this tissue:
Bronchoscopy. The doctor puts a bronchoscope (a thin, lighted

tube) into the mouth or nose and down through the windpipe to
look into the breathing passages. Through this tube, the doctor
can collect cells or small samples of tissue.
Needle aspiration. A needle is inserted through the chest into the

lung cancer tumor to remove a sample of tissue.

Thoracentesis. Using a needle, the doctor removes a sample of

the fluid that surrounds the lungs to check for cancer cells.
Thoracoscopy. Surgery to open the chest is sometimes needed to

diagnose lung cancer.
These symptoms may be caused by lung cancer or by other conditions.

It is important to check with a doctor if you have lung cancer
symptoms because only a doctor can make a diagnosis. Don't wait to
feel pain. Early cancer usually doesn't cause pain.
To find out if lung cancer may be present, the doctor evaluates a

person's
medical
history,
smoking
history,
their
exposure
to
environmental and occupational substances, and family history of

cancer. The doctor also performs a physical exam and may order a
chest x-ray or other tests. Seeing a spot on a chest x-ray is usually how
a doctor first suspects that lung cancer may be present.

Summary of lung cancer symptoms :
Constant cough, coughing up blood, hemoptysis. A change in a

cough you have had for a long time. An ache or pain when
breathing or coughing.
Shortness of breath, wheezing, or hoarseness
Chest pain.
Swelling of the neck and face.
Loss of appetite and weight loss.
Repeated problems with pneumonia or bronchitis.
Other lung cancer symptoms include:
Weakness, fatigue.
Skin paleness or bluish discoloration.
Difficulty swallowing
Muscle contractions or atrophy (shrinkage).
Joint pain or swelling.
Pain or discomfort under your ribs on your right side (from the
liver).
Facial swelling or paralysis.
Eyelid drooping.

Bone pain/tenderness.
Breast swelling in men.
These symptoms are rarely caused by lung cancer. But they can be. So
it is important you tell your doctor about any new symptoms you have
noticed. They may be nothing to do with your cancer and so your mind
can be put at rest.
4,7
Exams and Tests

Upon hearing about the symptoms, a health care provider,
whether a primary care provider or emergency department clinician,
will formulate a list of possible diagnoses. He or she will ask questions
about the symptoms; medical and surgical history; smoking and work
history; and other questions about lifestyle, overall health, and the
medications taken.1,4
Unless severe hemoptysis is occurring, a chest x-ray will most likely be
performed first to look for a cause of the respiratory symptoms.
The x-ray film may or may not show an abnormality.
Types of abnormalities seen in lung cancer include a small nodule

or nodules or a large mass.
Not all abnormalities are cancers. For example, some people

develop scarring and calcium deposition in their lungs that may
look like tumors on a chest x-ray film.
In most cases, a CT scan or MRI of the chest will further define the
problem.
If symptoms are severe, the x-ray may be skipped and a CT scan

or MRI is performed right away.

The advantages of CT scan and MRI are that they show much
greater detail than x-ray film and are in 3 dimensions.1,2,4,6
These tests help determine the stage of the cancer by showing

the size of the tumor or tumors.
They can also help identify spread of the cancer into regional
lymph nodes or certain other organs.
If a person's chest x-ray film or scan suggests that a tumor is present,

he or she will undergo a procedure for diagnosis.
This procedure involves removal of a small piece of the tumor

tissue (biopsy) or a small volume of fluid from the sac around the
lung.
The retrieved cells are reviewed under a microscope by a doctor

who specializes in diagnosing diseases by looking at cell and
tissue types (a pathologist).
Several different ways exist to obtain these cells.

Sputum testing: This is a simple test that is sometimes performed to

detect cancer in the lungs.
Sputum is thick mucus that may be produced during a cough.
Cells in the sputum can be examined to see if they are

cancerous. This is called cytologic review.
This is not a completely reliable test. If negative, the findings

usually need to be confirmed by further testing.
Bronchoscopy: This is an endoscopic test, meaning that a thin, flexible,

lighted tube with a tiny camera on the end is used to view organs
inside the body.
Bronchoscopy is endoscopy of the lungs. The bronchoscope is

inserted through the mouth or nose and down the windpipe.
From there, the tube can be inserted into the airways (bronchi) of
the lungs.
The tiny camera transmits images back to a video monitor.
The physician operating the bronchoscope can look for tumors

and collect samples of any suspected tumors.
Bronchoscopy can usually be used to determine the extent of the

tumor.
The
procedure
is
uncomfortable.
local
anesthetic
is
administered to the mouth and throat as well as sedation to

make bronchoscopy tolerable.
Bronchoscopy has some risks and requires a specialist proficient

in performing the procedure.

10
Needle biopsy: If a tumor is on the periphery of the lung, it usually

cannot be seen with bronchoscopy. Instead, a biopsy is taken through a
needle inserted through the chest wall and into the tumor.
Typically, a chest x-ray or CT scanning is used to guide the

needle.
This procedure is safe and effective in obtaining sufficient tissue

for diagnosis. After the chest surface is cleaned and prepared,
the skin and the chest wall are numbed.
The most serious risk with this procedure is that the needle
puncture may cause an air leak from the lung (pneumothorax).
This air leak occurs in as many as 3-5% of cases. Although this
condition can be dangerous, it is almost always recognized and
treated without serious consequences.
Thoracentesis: Lung cancers, both primary and metastatic, can cause

fluid to collect in the sac surrounding the lung. This is called pleural
effusion.
The fluid usually contains cells from the cancer.
Sampling this fluid can confirm the presence of cancer in the

lungs.
The fluid sample is removed by a needle in a procedure similar to

needle biopsy.
Thoracentesis can be important for both staging and diagnosis of

the condition.
Thoracotomy: Sometimes a lung cancer tumor cannot be reached by

bronchoscopy or needle procedures.

11
In these cases, the only way to obtain a biopsy is by performing

an operation.
The chest is opened (thoracotomy), and as much of the tumor as

possible is removed surgically. A biopsy is taken from the
removed tumor.
Unfortunately, this operation may not be successful in removing

all tumor cells if the tumor is large or has spread to the lymph
nodes outside of the lungs.
Thoracotomy is a major operation that is performed in a hospital.
Mediastinoscopy: This is another endoscopic procedure. It is performed

to determine the extent that the cancer has spread into the area of the
chest between the lungs (the mediastinum).
A small incision is made into the lower part of the neck, above
the breastbone (sternum). A variation is to make the incision in
the chest.
A mediastinoscope is inserted behind the breastbone.
Samples of the lymph nodes are taken to evaluate for cancer

cells.
Mediastinoscopy is a very important step to determine whether

the tumor can be surgically removed or not.
Other tests: Other tests are performed to stage the tumor and to
assess a person's ability to withstand surgery and other treatment.
Pulmonary function tests assess breathing capacity.
Blood tests are performed to identify any chemical imbalances,

blood disorders, or other problems that might complicate
treatment.

12
CT scans or MRIs may be performed on the most common areas

of spread to check for metastatic disease. These tests are
generally performed only if symptoms occur that suggest
metastatic disease. Certain treatment protocols require that
these tests be performed.
A bone scan can determine whether the cancer has spread to the
bones.
Staging: Staging is a method of classifying the tumor for purposes of

treatment planning.
Staging is based on size of the tumor, location of the tumor, and

degree of metastasis of the tumor (if any).
The treatment will be individually tailored to the tumor stage.
Tumor stage implies the outlook for cure and survival (prognosis).
The higher the tumor stage, the less likely the disease will be
cured.1,2,4,5
Lung Cancer Treatment

The best treatment of lung cancer depends on whether SCLC or
NSCLC is present. It also depends on tumor stage, particularly in
NSCLC.
person's general
physical
condition
is also taken
into
account.
The most widely used therapies for lung cancer are surgery,
chemotherapy, and radiation therapy.1,2,3,4,5
Surgery

13
Surgery is the preferred treatment for patients with early stage NSCLC.
Unfortunately, 60-80% of all patients who have advanced or metastatic
disease are not suitable for surgery.
People who have NSCLC that has not spread can tolerate surgery
provided they have adequate lung function.
A portion of a lobe, a full lobe, or an entire lung may be removed.

The extent of removal depends on the size of the tumor, its
location, and how far it has spread.
A technique called cryosurgery is sometimes used for NSCLC. In

cryosurgery, the tumor is frozen, which destroys it. This
treatment is mainly for relief of symptoms.
Cure rates for small peripheral cancers are around 80%.
Despite complete surgical removal, a large proportion of patients

with early stage cancer have recurrence of cancer and die from
it.
Surgery is not widely used in SCLC. Because SCLC spreads widely and
rapidly through the body, removing it all by surgery is usually
impossible.
An operation for lung cancer is major surgery. Many people experience
pain, weakness, fatigue, and shortness of breath after surgery. Most
have problems moving around, coughing, and breathing deeply. The
recovery period can be several weeks or even months.1,2,3,4
Follow-up
Following surgery for any operable lung cancer, a risk of developing a
second primary lung cancer is present. Following any treatment is the
risk that the original tumor will come back.

14
Many lung cancers come back within the first 2 years after
treatment.
Regular testing should be performed so that any recurrence can

be identified as early as possible.
A person who has undergone surgery should be checked every 34 months for the first 2 years and every 6-12 months
thereafter.1,4
Palliative and terminal care

Palliative care or hospice care refers to medical or nursing care to
reduce symptoms and suffering without attempting to cure the
underlying disease. Because only a small number of people with lung
cancer are cured, relief from suffering becomes the primary goal for
many.
The patient, his or her family, and the doctor will probably
recognize when the patient has reached this point.
Whenever possible, the transition to palliative care should be

planned in advance.
Planning should begin with a 3-way conversation between the

patient, someone representing the patient (if he or she is too ill
to participate), and the health care provider.
During these meetings likely outcomes, medical issues, and any

fears or uncertainties can be discussed.
Palliative care may be given at home, in a hospital if home care
is not possible, or in a special hospice. Palliative care consists mainly of

treatments to relieve shortness of breath and pain.

15
Breathlessness will be treated with oxygen and medications such

as opioids, which are narcotic drugs such as opium, morphine,
codeine, methadone, and heroin.
Pain management includes anti-inflammatory medications and

opioids. The patient is encouraged to participate in determining
doses of the pain medication, because how much is needed to
block pain will vary from day to day.
Other symptoms, such as anxiety, lack of sleep, and depression,

are treated with appropriate medications and, in some cases,
complementary therapies.1,2,4
DAFTAR RUJUKAN

16
1. SEATON A, Seaton D, Leitch A.G. Crofton AND Douglass

Respitory Disease II. Fifth Edition.
2. Hansen H. H. Textbook Of Lung Cancer. Martin Dunitz Ltd. 2000
3. Lung
Cancer
from
URL.
http://www.
Info
For
Your
Health.com
4. Lung Cancer : from URL. http://www. emedicine.com
5. Lung cancer. from URL. http://www. Wikipedia.com
6. Lung
Cancer
Symptoms.
from
URL.
http://www.
Cancer
homepage.com
7. Early Symptoms of Lung Cancer. from URL http://www.
goggle.com
8. Lung cancer, lateral chest X-ray. from URL. http://www. Medical
encylopedia.com
9. Smoker lung picture. availale at. http://www. Hope.com

17

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Early Lung

Non-small cell lung cancer

Small cell lung cancer

microscope. Each type of lung cancer grows and spreads in different

KKS BAGIAN PULMONOLOGI

Lung Cancer Causes

Cigarette smoke contains more than 4000 chemicals, many of

About 85% of lung cancers occur in a smoker or former smoker. The

The number of cigarettes smoked

KKS BAGIAN PULMONOLOGI

The age at which a person started smoking

Other causes of lung cancer include the following:

Passive smoking, or sidestream smoke, presents another risk for

Air pollution from motor vehicles, factories, and other sources

Asbestos exposure increases the risk of lung cancer by 9 times. A

compounds the risk by as much as 50 times.

Lung diseases, such as tuberculosis (TB) and chronic obstructive

Radon exposure poses another risk.

Radon is a by-product of naturally occurring radium, which

Radon is present in indoor and outdoor air.

Certain occupations where exposure to arsenic, chromium,

A person who has had lung cancer is more likely to develop a

KKS BAGIAN PULMONOLOGI

What Are Early Symptoms Of Lung Cancer

A cough that doesn't go away and gets worse over time

Constant chest pain

Shortness of breath, wheezing, or hoarseness

Repeated problems with pneumonia or bronchitis

Swelling of the neck and face

Loss of appetite or weight loss

These lung cancer symptoms may be caused by lung cancer or by

Bronchoscopy. The doctor puts a bronchoscope (a thin, lighted

Needle aspiration. A needle is inserted through the chest into the

KKS BAGIAN PULMONOLOGI

Thoracentesis. Using a needle, the doctor removes a sample of

Thoracoscopy. Surgery to open the chest is sometimes needed to

These symptoms may be caused by lung cancer or by other conditions.

To find out if lung cancer may be present, the doctor evaluates a

environmental and occupational substances, and family history of

KKS BAGIAN PULMONOLOGI

Summary of lung cancer symptoms :

Constant cough, coughing up blood, hemoptysis. A change in a

Shortness of breath, wheezing, or hoarseness

Swelling of the neck and face.

Loss of appetite and weight loss.

Repeated problems with pneumonia or bronchitis.

Other lung cancer symptoms include:

Skin paleness or bluish discoloration.

Muscle contractions or atrophy (shrinkage).

Joint pain or swelling.

Facial swelling or paralysis.

KKS BAGIAN PULMONOLOGI

Breast swelling in men.

Exams and Tests

The x-ray film may or may not show an abnormality.

Types of abnormalities seen in lung cancer include a small nodule

Not all abnormalities are cancers. For example, some people

If symptoms are severe, the x-ray may be skipped and a CT scan

KKS BAGIAN PULMONOLOGI

These tests help determine the stage of the cancer by showing

If a person's chest x-ray film or scan suggests that a tumor is present,

This procedure involves removal of a small piece of the tumor