Dr.dr. Tahan P.H.

,
SpP.DTCE,MARS
FK UWK Surabaya
Januari 2014
 - Located inside the chest
- Part of the respiratory system
(also includes nose, throat, trachea)
- Responsible for the breathing in (inhalation) and
breathing out (exhalation) of air
-Right lung divided into three lobes (upper, midle,
lower); Left into two lobes (upper, lower)
-Each lung covered by a thin sheet of protective tissue
visceral pleura
-Protected by the ribs in front of the chest and spine in
back.
- Lung separated from each other by space
mediastinum (in the middle of the chest, contains
several organs: the heart,trachea and lymph nodes)
 -Lungs allow us to inhale air that contains O2, is
gas needed for cell to survive. All of the cells in the
body use O2 to produce energy so they can
function.
- When O2 is used by the cells, another gas CO2is
produced.
- Lungs control the amount of O2 and CO2 in our
body
 Istilah yg sering menimbulkan kerancuan:
tumor, tumor jinak, tumor ganas serta kanker
Tumor:
Hasil perkembang biakan suatu sel tubuh yg tdk terkontol.
(Normal: perkembangbiakan sel hanya akan terjadi apabila dibutuhkan
tubuh).
Tumor Jinak Tumor Ganas = Kanker
Sel tumor yg berkembangbiak secara Sel tumor berkembang biak secara
tdk terkontrol, TIDAK TERKONTROL
tetapi TIDAK melakukan INVASI ke dan
jaringan sekitar men INVASI jaringan sekitar
(walaupun mampu mendesak, namun serta
tidak tumbuh masuk ke jaringan bisa MENYEBAR (=METASTASE) ke
lain/TIDAK MENYEBAR ke bagian bagian tubuh lain
tubuh lain).
Biasanya tdk mengancam jiwa, bisa di
operasi dan jarang timbul kembali.
 Primary malignant
tumor

Lymph Blood

If too many cancer cells :

Carries: Lymph nodes cannot remove all,
Dead cells, abnormal some may travel in the lymph to
and cancer cells other parts of the body
through (Lung cancer, spread to bone,
lymphatic vessels brain, liver, adrenal gland)
to My also break away from
Lymph nodes primary tumor and form new
(filter unwanted substances) tumor in some or opposite lung)

Part of the body

1. Malignant tumor, grows in one or both of the lung
2. Usually form from cells that line the airways and
nearby glands that contact with the air we breathe,
which my contain carcinogens
3. Lung cancer: changing of normal cells into carcenous
cells usually happens over a period of years
4. USA (2004) 173.770 ( male: 93.110, females: 80.660)
second most common.
(Number one : males prostate cancer; females:
breast cancer)
 Apa itu Kanker Paru?

Kanker paru adalah pertumbuhan sel kanker yang tidak

terkendali dalam jaringan paru, biasanya pada sel-sel tempat
mengalirnya udara.

Ada dua jenis utama kanker paru:

Small Cell Lung Cancer (SCLC = KPKSK) ---
Kanker Paru Jenis Karsinoma Sel Kecil
Non-Small Cell Carcinoma (NSCLC = KPKBSK) ---
Kanker Paru Jenis Karsinoma Bukan Sel Kecil,
yaitu terdiri dari: adenokarsinoma, squamous cell dan large cell.

NSCLC adalah tipe yang paling umum dari kanker paru.

Menurut American Cancer Society, pada tahun 2008 sekitar 85 - 90%
dari semua kasus kanker paru adalah dari jenis NSCLC.
Membedakan antara NSCLC and SCLC sangatlah penting karena
kedua jenis kanker ini memerlukan terapi yang berbeda.
 Proses terjadinya belum diketahui dengan pasti
Diduga ada faktor exogen dan endogen (dari dalam-kerentanan
bawaan/genetik)

PATOGENESIS
Eksogen : Paparan Karsinogen Rokok
Endogen: Kepekaan Faktor Host Genetik a.l. p53 Tumor Supresor
Gene
80-90% Ca Paru Perokok

Faktor Eksogen Kanker Paru

Tobacco (inhaled carcinogen) : 85-87%
Second-Hand Passive Smoker: 5-7%
Others : 5-7%
Asbestos, Uranium,
Marijuana, Beryllium, Air
pollutant, diesel, Tar, arsenik,
nikel, krom
Scar/Fibrosis : 1-2%
 SMOKING - number one couse
Cigarette smoke contains at least 43 different carcinogens,
accociated with various cancers :
lung; oesophagus; mouth; stomach; pancreas and liver
Smoking accounts for 30% all cancer-related deaths
and 87% of lung cancer deaths
50% new lung cancers diagnosed in former smokers
Risk of lung cancer increases with an increase in the total
number of cigarettes smoked
The use pipe tobacco also increase the risk
Second-hand smoke also contains carcinogens
(USA 5.000 10.000 dignosed lung cancer resulting from
breathing second-hand smoke)
 Quitting smoking decreases risk of developing
10 years after quitting risk decrease 50%

Quit smoking during cancer tretment live longer than who

continue to smoke during treatment

Some people with lung cancer who have never smoked

Factor contribute to lung cancer:

- Exposure to chemicals in the air, asbestos and radon
- Lung diseases that can block airflow to lungs, COPD or TB
- Genetics
- Age, occurs more often in people over 65 years of age
 Two main catagories:
Small-cell lung cancer (SCLC) 20%
Non Small cell lung cancer (NSCLC) 80%

NSCLC
1. Adeno Ca
30-35% of all NSCLC
usually develop at the edges of the lung, but some times occur
toward the center of the chest
Often slow growing and dont typically cause symptoms in early
stages
Often found and diagnosed at more advanced stages
The most common subtype of the lung Ca in women and in non
smokers
Divide into subcatagories such as Bronchoalveolar Carcinoma.
 NSCLC

2. Squamous cell Ca
- account about 30% of all NSCLC
- unlike Adeno Ca, this type strongly associated with
smoking
- usually foundin the larger airway tubes and toward
the center of the chest
3. Large cell Ca
- account about 10-20% of all NSCLC
- more difficult to diagnose
- grow at the edges of the lung
- tend to grow fast and spread to other areas of the
body (metastasize)
- like Sq Cell Ca, are associated with smoking
 Some are similar to other common illnesses

Important to perform Physical Examination and know medical history.

Consider for Age; smoking history; disease or conditions may have;
have been exposed to any harmful chemicals

1. Cough (over 50% of people with lung Ca)

tumor irritates the lung and airway tissue, resulting cough.
2. Chest Pain; shortness of breath (dyspnea) and wheezing
3. Hemoptysis (30% of people with lung Ca) call the doctor
immediately
4. If the tumor grows larger, it can press nearby organs and
bones. may include bone pain; chest pain; hoarseness; cough;
swelling of the face or arms; and/or build upof fluid around the
outside of the lungs (pleural effusion)
5. Symptom from lung Ca metastases: depend on where the Ca
has spread. Brain and spinal cord: headaches, nausea,
vomiting, weakness, tiredness. Bone: bone pain. Liver: right-
sided abdominal pain and Jaundice.
6. Some general symptoms like weight loss, fatique, and loss of
appetite.
Early Dx is difficult because symptoms do not usually occur
until disease is more advanced.
Have signs or symptoms of lung Ca during a routine
Physical examination
Test used to help detect lung Ca:
1.Chest X-Ray
2,Computed Tomography (CT) Scan
3.Magnetic Resonance Imaging (MRI)
4.Positron Emission Tomography (PET) Scan
5.Sputum Cytology
6.Biopsy
Chest X-Ray CT-Scan MRI Sputum Biopsy
Cytology
Common test Is another -Similar to -Sputum is - A simple
used test used to CT scan collected to cells be taken
Uses small of Help -Clear look for from the
radiation diagnose images cancer cells. tumors.
Compare old lung ca internal body - most - Can be
chest X-rays Similar to part, accurate obtained in
with CXR but including to collect several
recent ones gives a more tissue, and analyze different
to see if detailed muscle, early- ways
tumor is picture of the nerves, and morning depending
growing or lung bones. mucus for on the
shrinking Can detect - used to three days location and
extremely detect the size of a
small tumors presence of tumors.
tumor
 Bronchos Transthora Fine Cervical Endoscopic Video Explora
copy cic Needle Needle Mediasti Lymph Assisted tory
Aspiration Aspiration noscopy Node Thoracos Thoracoto
Biopsy copy my
To see the Inserts a -Using a CT - This -Small tube - Tube - This is a
inside of the needle into scan for technique is passed containing a surgical
lungs and chest wall guidance, an often used to through small prosedure
airways. and uses the incision is biopsy mouth into television where opens
Theres small needle to made in the lymph nodes the camera, the chest to
camera on make a skin so a around the esophagus. inserted visually
the end of sample of needle can be lungs - small tool betweenribs examine and
the bronchos tissue inserted into passed the after making remove the
cope that - Is used for the tumor to tube, it can a small tumor.
takes tumors closer remove a take tissue incision
pictures . to the chest sample of sample of through the
Theres also a wall cells. nearby skin, can see
small tool - May be lymph nodes the tumor.
thats used to used to
remove a biopsy
sample of the theprimary
tissue from tumor or
the tumors. metastases
 Tujuan pemeriksaan diagnosis utk menentukan jenis
histopatologi kanker, lokasi tumor serta penderajatannya yg
selanjutnya diperlukan utk menetapkan kebijakan pengobatan

Deteksi Dini
Prosedur Diagnosis:
Gambaran Klinis
- Gambaran Radiologis
Pemeriksaan Lain
Penderajatan (Staging)
 Dekeksi Dini:

-Keluhan dan GX penyakit tdk spesifik,

-Batuk darah, Batuk kronis, BB menurun dan Gx lain, juga
dapat ditemui pd penyakit paru lain
- Penemuan dini berdasarkan keluhan saja jarang terjadi
-Biasanya keluhan ringan terjadi pada mereka yg telah
masuk stadium II dan III
-Sasaran utk deteksi dini terutama ditujukan pada subyek
dengan resiko tinggi :
* Laki-laki, usia > 40 tahun, perokok
* Paparan industri tertentu
+ satu @ lebih gejala: batuk darah, batuk kronis, sesak
napas, nyeri dada, BB menurun
 Deteksi Dini Kanker Paru
(Skrining)

Golongan Resiko Tinggi Bukan GRT dengan gejala batuk

(GRT) kronis, sesak napas, batuk darah,
BB turun
Foto thoraks dan Sitologi Sputum Diagnostik dan terapi penyakit paru
non kanker
Ada hasil yg (+)
Semua hasil (-)
(a,b,c dlm skema) Curiga Kanker Paru
Re-skrining 4-6 Teruskan prosedur
diagnostik kanker Teruskan prosedur
bulan
paru diagnostik kanker paru

Foto thoraks
Sitologi sputum (+) ( - )
Skema ( + ) a b

( - ) c d
 Dilakukan utk mendapatkan gambaran penyakit yang akurat serta
objektif guna pemilihan option penanganan

Dinilai 3 Hal T N M Staging

T (tumor) Ukuran dan lokasi / akibat langsung tumor
N (Node) Kelenjar limfe: zone kelenjar limfe yg mengalami penyebaran
M Ada / tidak penyebaran ke organ lain
(Metastase)

Stage I Kanker ukuran kecil masih terbatas pada paru saja

Stage II Telah ada penyebaran ke kel.limfe atau invasi ke dinding dada
Stage III Penyebaran ke kel.limfe yang lebih jauh
Stage IV Merupakan tahapan tertinggi, telah menyebar ke organ lain
diluar paru.
Penderajatan utk NSCLC ditentukan menurut International Staging System For
Lung Cancer berdasarkan sistem TNM
Pengertian T tumor yg dikatagorikan atas TX,T0 s/dT4.
N utk keterlibatan KGB yg dikatagorikan atas NX,N0 s/d N3.
M adalah menunjukkan ada-tidaknya metastase jauh (M0 s/d M1)
Stage TNM
Occult Ca TX,N0,M0
0 Tis,N0,M0
IA T1,N0,M0
IB T2,N0,M0
IIA T1,N1,M0
IIB T2,N1,M0; T3,N0,M0
IIIA T1,N2,M0; T2,N2,M0; T3,N2,M0
IIIB Sembarang T,N3,Mo
T4, sembarang N, M0
IV Sembarang T, sembarang N, M1
 Dikenal 5 modalitas terapi:
1. Pembedahan
2. Radioterapi
3. Kemoterapi
4. Hormonal
5. Immunologik

Kanker Paru umumnya hanya 1-3

Mis. NSCLC:
Bila masih terbatas (localized) pembedahan
Bila sdh lebih meluas (Regional tumor) kemoterapi & @ radiasi,
Bisa ditindak lanjuti dgn pembedahan
Bila sdh advanced kemoterapi (paliatif)
 T N M STAGING NSCLC
N-0 N-1 N-2 N-3

T-1 IA IIA IIIA IIIB

T-2 IB IIB IIIA IIIB

T-3 IIB IIIA IIIA IIIB

T-4 IIIB IIIB IIIB IIIB

All M-1 = IV

OPERABLE
Anti Angiogenesis Tx disigned to stop the
cancer by nullifying a tumors ability
to obtain O2 and nutrients for growth.
Angiogenesis is the formation of new blood
vessels.

Tumor targeted cryoblastion / cryosargery, is a

minimally invasive surgery
Treatment that uses extreme cold to destroy, or
ablate, diseased tissue , including
Cancer cells.

Cytocin Induced Killer Cell Imunotherapy, Non

MHC
 NSCLC (Non Small Cell Lung Cancer)
Dr.Chandra P.Belani (Penn State Cancer Institute, Hershey Pennsylvania, USA) (Medical Tribune July
2009):

Maintenance therapy with PEMETREXED offer new paradigm for

patients who have advanced lung cancer, because it has a low toxicity
and can be given on an ongoing basis over a prolonged period of time
to extend patients` live,.