1.

LUNG CANCER
 Leading cause of cancer-death  RISK FACTOR
 Poor prognosis - Smoking
- Passive smoking
 Dibedakan jadi 2 yaitu Non-Smaller Lung
- Radon gas -> radioactive gas produced by
Cancer & Small Cell Lung Cancer
the natural breakdown of uranium in soil,
 DEFINITION : pertumbuhan sel abnormal yang
rock and water
tiak terkontrol di paru
- Air pollution
 ETIOLOGY : over expression dari oncogene/ - Arsenic
inactivation dari tumor supressor gene - Tar
 Small Cell Lung Carcinoma - Asbestos
- sering terjadi pada perokok berat - Nickle
- less common (15%) - Family & genetic risk factor
- spreads faster
- >60% metastasis presentation (penyebaran
kanker ke tempat lain)
- Poor prognosis
- Small Carcinoma: Tumbuh dekat/
disekitaran hilum dan melibatkan
endokrin sel.
- Endokrin sel akan mengalami mutasi dan
memproduksi hormon, hormon ini akan
mentrigger Paraneoplastic Syndrome
 Non – Smaller Cell Lung Cancer
- Most common type (85%)
- include squamous cell carcinoma,
adenocarcinoma (most common) and
large cell carcinoma.
- Adenocarcinoma (38%), terjadi di
peripheral lung tissue (jauh dari  PATHOPHYSIOLOGY
hilum), involve gland. Normal epithelium mengalami hiperplasia, metaplasia
- Small Cell Carcinoma (20%), terjadi dekat karena p53 mutation/ k-ras mutation -> PCNA
dengan main bronchus dan dapat mengubah sel menjadi mild dysplasia -> sel
menyebabkan obstruksi di airway. Disebut berproliferasi -> severe dysplasia -> carcinoma in situ
squamous soalnya epithelial cell di airway -> invasif dan metastasis
bermutasi dari columnar cuboidal ->
squamous A. Mediastinal involvement (associated with lung
- Large Cell Carcinoma (5%), tumbuh cancer growth):
dengan cepat sama kayak small cell - Pancoast Tumor : tumbuh di apical lung
carcinoma, dan terjadi di periphery/ surface (on the top), sehingga dapat
peripheral lung tissue memblock brachial plexus. Dapat
 SIGN & SYMPTOMS menyebabkan :
- Cough a. shoulder arm pain
- Weight loss b.weakness/atrophy of epsilateral side,
- Hemoptysis c. horner syndrome = memblock sympathetic
- Dyspnea nerve (Jalur saraf terganggu di satu sisi
- Chest pain dari otak ke wajah dan mata)
- Clubbing finger - Pleural effusion
- Wheezing a. Dyspnea
- Stridor b. chest pain
- Fever - Pericardial Effusion
- Weakness - Obstruction of superior vena cava -> back flow
- Bone pain
- Obstruction A. Airway Involvement (bronchi, bronchioles), cancer
- Lymphadenopathy masuk ke airway dapat menyebabkan obstruksi ->
- Hepatomegaly menghambat airflow -> dypsnea
- Hoarse voice
 - Ketika airway obstruksi -> mengirim sinyal
sensory ke brain (tepatnya di medula) ->
cough reflex
- Cancer dan tumor -> menstimulate
angiogenesis (blood vessel growth) ->
vesselnya bisa bocor dan menjadi lambat ->
hemoptysis.
B. Blood involvement (di blood vessel yg contain
RBC dan WBC) :
- Anemia : fatique, dyspnea
- Leukocytosis (15% cases)
- Thrombocytosis (15% cases)
- Hypercoagulable disorder (rare)
C. Cancer dapat bermetastasis ke jantung. Dari
jantung sel tumor di pumped out ke -> brain,
upper limb, down to abdomen area, liver, adrenal
gland, bone (frequently asymptomatic)
D. Paraneoplastic Syndrome, occurs in Small lung
cancer.
- Syndromes that occur not related to invasion,
obstruction or metastasis of the primary
tumor
- Ectopic Cushing Syndrome, ketika hormon
release by cancer cell, dimana dia
menstimulate adrenal glands untuk
memproduksi cortisol. ADH stimulates up
secreted endocrine sel -> menstimulasi
kidney untuk retain water
- Meningkatkan Parathyroid hormone ->
menstimulate bone to break down mineral
dan release calcium into plasma ->
increasing blood calcium level ->
hypercalcemia
- Hypercalcemia paraneoplastic syndrome ->
hyperpulmonary osteopathy -> clubbing &
periosteal proliferation of tubular bone
- Inflammatory myopathies -> leads to muscle
weakness
 STAGING
A. STAGE OF NON SMALL CELL LUNG
CANCER
a. Stage 0 (carcinoma in situ or
adenocarcinoma in situ) : ditemukan di
lining of the airway atau di air sacs of lung.
b. Stage IA : tumor 3 cm or smaller
- Stage IA 1 : 1 cm or smaller
- Stage IA 2 : larger than 1 cm but no more
than 2 cm
- Stage IA 3 : largen than 2 cm but no more
than 3 cm
c. Stage IB : larger than 3 cm tapi gak lebih
dari 4 cm
- Grow di main airway tapi ga didaerah
dimana windpipe terbagi menjadi left and
right bronchi
- Grow di vischeral pleura
- Membuat collapse lung karena bronchus
ke block dan memnyebabkan inflamasi di
lung tissuenya
d. Stage IIA : tumor 5-7cm atau <5cm dan
ada cancer cell yg dekat dengan lymph
nodes/ lebih dari 4 cm tapi not more than 5
cm
- Grow di main airway tapi ga didaerah
dimana windpipe terbagi menjadi left
and right bronchi
- Grow di vischeral pleura
- Membuat collapse lung karena bronchus
ke block dan memnyebabkan inflamasi
di lung tissuenya
e. Stage IIB :
- tumor 5 cm or smaller tapi udah spread
ke lymph nodes yang deket sama bronchi
atau,
- tumor lebih dari 5 cm tapi not more than
7cm, tumor tumbuh di parietal pleura,
chest wall, phrenic nerve (nerve di
diafragma), atau di parietal pericardium.
- Ada 2 tumor yang sama pada kedua
lungs
f. Stage IIIA α : <7cm + lymph node in
mediastinum dan affecting one surounding
tissue
g. Stage IIIA ß : any size + nearby lymph
node dan affecting one surrounding tissue
h. Stage IIIB α : any size + in mediastinal
lymph node and cancer growth affects
surrounding structure
i. Stage IIIB ß : any size + has spread to
lymph node on opposite side and cancer
growth affects surrounding structure
j. Stage IV : tumor in both lungs or
metastasis
- Stage 4A : spread to other lungs, spread
to pleura or pericardium, extra fluid within
the pleura or pericardium (called
effusion), has spread dan 1 new tumor
growing outside the chest
- Stage 4B : has spread and 2 or more
tumors growing outside the chest
k. Recurrent : cancernya muncul lagi setelah
sudah di treat.
- Local recurrence : ditempat yg sama
- Regional recurrence : kalau muncul di
tissue atau lymph nodes yang dekat
dengan lokasi pertama kali kena
- Distant metastasis/ distant recurrence :
terjadi di another part of body
B. STAGE OF SMALL CELL LUNG CANCER
a. Limited stage :
- Found only on one side of the chest
- Have spread to lymph nodes on the same
side of the tumor
 - Treated with radiation
b. Exensive Stage :
- Spread widely in the lung to other lung, lymph
nodes on the other side of chest or other part
of bodies
- Kebanyakan orang udah kena stage ini,
soalnya cancernya udh nyebar duluan
sebelum symptoms nya muncul
 INVESTIGATIONS (d,e,f,c = u/ biopsy)
a. Chest X-ray : dapat dilihat massa tumor
kalau lebih dari 1cm
Common clinical findings :
- Hilam enlargement
- Pulmonary opacity
- Rib bone lesion
- Pleural effusion
- Lung colapse
- Metastasis intrapulmoner
b. Lab test : HT, ALP, SGOT, SGPT, ureum
cratinin
c. CT-SCAN : Should be perfomed early to
determine stage and management of
cancer. Mendeteksi tumor dengan ukuran
kecil/ kurang dari 1cm
d. Bronchoscopy : primary lung tumor
visualized and sample taken. untuk dapat
mengambil jaringan atau bahan agar dapat
dipastikan ada tidaknya sel ganas.
e. CT – Guided Fine Needle Biopsy : more
reliable to obtain a histological diagnosis
f. Needle Aspiration : needle insert to lump
or lymph node
g. Thorococentesis : fluid collection from
pleural cavity used for sampling
h. Tumor marker : CEA, Cyto 21-1, NSE 5,
Immunochemistry
 MANAGEMENT
a. Surgical Treatment : removal tumor for
stage I & stage II
Syarat untuk reseksi paru :
- Resiko ringan untuk Pneumonektomi, bila
KVP paru kontralateral baik, VEP1>60%
- Risiko sedang pneumonektomi, bila
KVP paru kontralateral > 35%, VEP1 >
60%
- Wedge or segmental resection removes
the lung tumour along with a margin of
healthy tissue around the tumour.  chemoreceptor trigger zone thus preventing
- Lobectomy removes a lobe of the lung
that has the tumour. A bilobectomy is a
type of lobectomy that removes 2 of the 3
lobes of the right lung.
- Pneumonectomy removes the whole
lung.
- Extended pulmonary
resection : removes the muscles, nerves,
blood vessels and other tissues near the
lung to take out as much of the cancer as
possible.
- Chest wall resection removes the
muscles, bones and other tissues of the
chest wall.
- Sleeve resection removes a tumour from
the large airway of the lung (bronchus)
along with a margin of healthy tissue
around the tumour.
b. Radiotherapy : less effective than surgery,
radiotherapy + chemotherapy for NSCLC
stage III A. Dipakai kalau tumornya gabisa
diangkat pake surgery
- Dosis radiasi yang diberikan secara
umum adalah 5000 – 6000 cGy, dengan
cara pemberian 200 cGy/x, 5 hari
perminggu.
- Syarat standar sebelum penderita
diradiasi adalah :
1. Hb > 10 g%
2. Trombosit > 100.000/mm3
3. Leukosit > 3000/dl
- Radiasi paliatif diberikan pada
unfavourable group, yakni :
1. PS < 70.
2. Penurunan BB > 5% dalam 2 bulan.
3. Fungsi paru buruk.
- External beam radiation therapy :
usually combined with chemotherapy =
chemoradiation
a. 3-D conformal radiation therapy (3-D
CRT)
b. intensity-modulated radiation therapy
(IMRT)
c. stereotactic body radiotherapy (SBRT)
d. hypofractionated radiation therapy
- Brachytherapy : internal radiation
therapy. A radioactive material
(radioactive isotope) is placed right into
the tumour or very close to it. The
radiation kills the cancer cells over time.
c. Chemotherapy : increase survival up to 1
year, side effect = nausea & vomit,
managed by 5 – HT 3 receptor antagonist
because these drugs will target the
vomit dan nausea
- Prinsip pemilihan jenis antikanker dan
pemberian sebuah regimen kemoterapi
adalah:
1. Platinum based therapy ( sisplatin atau
karboplatin)
 2. Respons obyektif satu obat antikanker s
15%
3. Toksisiti obat tidak melebihi grade 3
skala WHO
4. harus dihentikan atau diganti bila setelah
pemberian 2 sikius pada penilaian
terjadi tumor progresif.
- Regimen untuk NSCLC adalah :
1. Platinum based therapy ( sisplatin atau
karboplatin)
2. PE (sisplatin atau karboplatin +
etoposid)
3. Paklitaksel + sisplatin atau karboplatin
4. Gemsitabin + sisplatin atau karboplatin
5. Dosetaksel + sisplatin atau karboplatin
d. Laser Therapy and Stenting : airway
obstruction causing serious symptoms can be
managed using laser treatment (removed it)
and airflow can return normal
e. Immunotherapy : used for advanced or
metastatic non–small cell lung cancer after it
has stopped responding to chemotherapy or
targeted therapy. drugs include
pembrolizumab (Keytruda) and nivolumab
(Opdivo).
f. Hormonetherapy
g. Targeted therapy :
- used for non–small cell lung cancer that
has spread to the lymph nodes or other
parts of the body or has come back after
chemotherapy treatments.
- depends on what type of gene changes
(mutations) are found in the cancer cells
during molecular tissue tests
- drugs include gefitinib (Iressa), afatinib
(Giotrif), erlotinib (Tarceva), crizotinib
(Xalkori) and dabrafenib (Tafinlar) with
trametinib (Mekinist).
h. Positron Emission Tomography (PET)
 PEMERIKSAAN FISIK
a. Inspeksi : simetris/ asimetris
b. Perkusi : peka di lokasi massa
c. Palpasi : tactile fremitus normal/ meningkat
d. Auskultasi : decrease breath sound,
wheezing, stridor
 PREVENTION
a. Don’t smoke
b. Stop smoking
c. Avoid smoke
d. Test your home for radon
e. Avoid carcinogens at work
f. Eat a diet full of fruits and vegetable
g. Exercise
 JENIS HISTOLOGIS
1. Karsinoma skuamosa (karsinoma epidermoid)
2. Karsinoma sel kecil (small cell carcinoma)
3. Adenokarsinoma (adenocarcinoma)
4. Karsinoma sel besar (large Cell carcinoma)
 PROGNOSIS
Lung cancer survival rate is lower than
other types of cancer. Use “five year survival
rate” as a marker of prognosis.
Factor yang mempengaruhi prognosis :
a. stage of lung cancer
b. type of lung cancer -> NSCLC stage 0 dan 1
lebih bagus prognosis nya daripada stage
2,3,4. SCLC mempunyai prognosis yg lebih
bagus daripaDA NSCLC.
c. treatment and the patients response
d. location of the cancer
e. general health
f. metastasis
g. weight loss – orag yg udh mengalami
penurunan BB sebanyak 5% atau lebih
sebelum pengobatan punya prognosis yg
lebih jelek
h. performance status – orang yang masih bisa
beraktifitas sehari-hari punya prognosis yg
lebih bagus
i. sex –wanita punya prognosis yg sedikit lebih
bagus daripada laki-laki
j. lung problems – collapse, pneumonia,
pleural effusion
2. INDICATION OF OXYGEN THERAPY
Any individual with one or more of the following:
 peri and post cardiac or respiratory arrest
 hypoxia - diminished blood oxygen levels
(oxygen saturation levels of <92%)
 acute and chronic hypoxemia (PaO 2 <
65mmHg, SaO2 < 92%)
 signs and symptoms of shock
 low cardiac output and metabolic acidosis
(HCO3 < 18mmol/l)
 chronic type two respiratory failure (hypoxia
and hypercapnia)
  Despite a lack of supportive data, oxygen is
also administered in the following conditions:
 dyspnoea without hypoxemia
 post-operatively, dependent on instruction
from surgical team
 treatment of pneumothorax
3. HOW IMPORTANT THE CIGARETTE SMOKE
CAUSING LUNG CANCER
 Ada banyak chemicals di rokok yang bersifat
carcinogenic : cell di lungs berubah menjadi
lung cancer
 Tobacco smoke is a toxic mix of more than
7,000 chemicals.
 People who smoke cigarettes are 15 to 30
times more likely to get lung cancer or die
from lung cancer than people who do not
smoke.
 How does smoking cause cancer?
a. Direct damage DNA
Carcinogen di rokok menyebabkan
DNA lung cell mengalami mutasi dan other
changes. Ada chemical seperti chromium
yang menyebabkan carcinogen nempel ke
DNA kyk lem, dan increasing of damage.
b. Lack of DNA Repair
Apabila DNA rusak akan dibenerin
sama Tumor Supressor Gene atau sel yg
abnormal jadi mati. Bahan di rokok kyk
arsenik dan nikel mengganggu gene ini untuk
memperbaiki DNA yg rusak.
c. Inflamasi
Ketika sel terus membelah bisa terjadi
kesalahan dalam penyalinan kode genetik.
Ketika sel di rusak sama tobacco smoke, sel
akan terus membelah untuk mengganti sel
yg rusak, pada saat kejadian membelah ini
dapat terjadi kesalahan dalam penyalinan
kode genetik. Dan ada banyak senyawa
dalam asap tembakau yg membuat inflamasi.
d. Damage to silia
Silia berupa rambut kecil yang
melapisi airways. Silia berfungsi untuk
menangkap racun dan mendorongnya
keluar. Racun di rokok seperti Formaldehida
dapat merusak silia. Silianya jadi lengket dan
ga mau gerak, sehingga racunnya bisa
nempel di airways.
e. Immune Function
Sel- sel imun berfungsi untuk
mendeteksi dan menghancurkan sel- sel
abnormal kyk sel kanker. Tapi ketika sistem
kekebalan tubuh ga berfungsi dengan baik,
sel cancernya bisa escape. Beberapa racun
dalam rokok dapat menggangu sistem imun.
 Biasanya orang yg smoke = squamous cell lung
cancer. Non Smokers = adenocarcinoma
 Orang yang ada genetic BRCA2 mutation punya
risk yg tinggi
4. MEDIASTINAL TUMOR
Anterior mediastinal tumors include:
 Germ cell tumors (neoplasms) - benign in
about two-thirds of cases.
 Lymphoma including Hodgkin's and non
-Hodgkin's disease.
 Thymoma and thymic cysts – cysts that
develop in the thymus, a butterfly-shaped
gland at the base of the neck.
 Thyroid mass mediastinal – a benign growth
such as a goiter. These masses may develop
into cancer.
Middle mediastinal tumors include:
 Bronchogenic cysts - a disease in the
respiratory system.
 Lymphadenopathy mediastinal - disease in the
lymph nodes.
 Pericardial cysts which include growths that
start in the lining of the heart.
 Tracheal tumors.
Posterior mediastinal tumors include:
 Lymphadenopathy mediastinal - disease of the
lymph nodes.
 Neurogenic neoplasm mediastinal tumors -
cells that grow outside of the normal cell area
and are not part of the surrounding tissue.
 Extramedullary hematopoiesis - a rare mass
formed from bone marrow.
 Neuroenteric cyst mediastinal - sacs with pus
that develop outside of the normal tissue.
5. PNEUMOCONIOSIS
 Interstitial lung disease caused by breathing in
certain kinds of dust particles that damage your
lungs.
 Because you are likely to encounter these dusts
only in the workplace, pneumoconiosis is
called an occupational lung disease.
 usually take years to develop
 Black lung disease/ Miner’s lung : breathing
debu batu bara
 Brown lung : dust from cotton and fibers
 Silica & Asbestos
 Popcorn lung : Diacetyl, the compound used to
give movie popcorn its buttery flavor