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1 KANKER PARU KANKER PARU-TUMOR MEDIASTINUM TUMOR MEDIASTINUM ISWANTO SMF PARU RS BETHESDA-FK UKDW YOGYAKARTA

Ukdw CA Paru

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  • 1KANKER PARUKANKER PARU--TUMOR MEDIASTINUMTUMOR MEDIASTINUM

    ISWANTO

    SMF PARU RS BETHESDA-FK UKDW

    YOGYAKARTA

  • CA PARU-ROKOK.

    Rokok dapat meningkatkan resiko CA

    Paru, dan hal tersebut berhubungan

    dengan:

    Jumlah rokok yang dihisap

    Cara menghisap rokok.

    Lama merokok

    Genetik.

  • HIPOTESA ROKOK-CAPARU

    Tar pada rokok

    Peningkatan oxidative stress

    Ketidakseimbangan oksidan antioksidans menyebabkan kerusakan jaringan paru

    Inflamasi peribronkial

    Kerusakan struktur dan fungsi epitel

    Fibrosis

    Mitosis

    CA Paru

  • Divided into two types:

    nonsmall cell lung cancer (NSCLC)

    small cell lung cancer (SCLC)

    Smallcell lung cancer (SCLC) (2025% of lung cancers), both limited and extensive stage disease, systemic

    chemotherapy plays a pivotal role

    Nonsmall cell lung cancer (NSCLC) (adenocarcinoma, squamous cell carcinoma, and largecell carcinoma)

    surgery, chemotherapy, radiotherapy

  • PROSEDUR DIAGNOSTIKPROSEDUR 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. Fine needle aspiration biopsy (FNAB)

    c. Transbronchial needle aspiration (TBNA)

    d. Transbronchial lung biopsy (TBLB)

    e. Transthoracal needle aspiration (TTNA)

    f. Transthoracal biopsy (TTB)

    g. Fine needle aspiration (FNA)

    h. Biopsi KGB

    i. Torakoskopi, Mediastinoskopi, VATS

  • PROSEDUR

    4. Pemeriksaan lain :

    a. Tumor marker

    - Carcino embryonic antigen (CEA)

    - Cyfra 21, SCC, Ca 19-9, Ca 125 II

    - Non specific enolase (NSE)

  • Performance scale of lung cancer patients(Karnofsky & WHO)

    Karnofsky Scale

    WHO Scale

    Keterangan

    90 -100 0 Normal beraktivitas

    70 - 80 1 Ada keluhan tapi masih aktif & dapat mengurus diri sendiri

    50 - 60 2 Cukup aktif tapi kadang memerlukan bantuan

    30 - 40 3 Kurang aktif, perlu perawatan

    10 - 20 4 Tak dapat meninggalkan tempat tidur, perlu MRS

    0 - 10 - Tidak sadar

  • 21

    PENGOBATAN KANKER PARUPENGOBATAN KANKER PARU

    Pengobatan kanker paru saat ini :

    - Bedah

    - Kemoterapi

    - Radioterapi

    - Target terapi

    Pengobatan tergantung pada stadium penyakit.

  • Combined modality therapy

    Landasan terapi kanker paru :

    1. Staging (penderajatan)

    a. TNM b. G (gradasi histopatologis)

    GX Tak dapat ditentukanG1 Well differentiatedG2 Moderately differentiatedG3 Poorly differentiatedG4 Undifferentiated

    2. HistopatologiNSCLC atau SCLC

    3. Status Performance

    PengobatanPengobatan

  • 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

  • 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 chemotherapyb. Respon obyektif 1 obat 15%c. Toksisitas obat grade III skala WHOd. Stop/ganti bila 3 siklus tumor progresif

    Syarat :a. KS > 70-80b. Hb > 10 g%c. Granulosit > 1.500 /mLd. Trombosit > 100.000 /mLe. 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

    - ImunomodulatorKeladi tikus, buah merah, thymus dll.

    - Sitokin : IL-2, anti VEGF

    5. Terapi hormonal

    6. Terapi gen

    5 & 6 masih dalam penelitian

    Terapi paliatif bebas nyeri Stadium III B - IV

  • Management of NSCLC

    TNM STAGE < II B TNM STAGE III A TNM STAGE III B TNM STAGE IV

    Segmentectomy /Lobectomy

    Neoadjuvant ChTx

    ChTx 2x RaTx 40Gy

    KS > 70 KS < 70 KS > 70 KS < 70

    Surgery (+)

    Surgery ( - ) Re Staging

    Adjuvant ChTx Improved Not improved

    Surgical Tx

    Continue ChTx, RaTx

    ChTx, RaTx

    ChRaTx Palliative

    ChTx

    RaTx

    BSC

    ChTx

    RaTx

    Palliative

    BSC

  • Limited disease Extensive disease

    KS 70 KS 70KS < 70

    Best Supportive

    Care

    ChTxRaTx

    CR PR

    Prophylactic

    Cranial

    Irradiation

    Change

    ChemoTx ChangeChemoTx

    ChemoTx

    2x

    Response (+) Continue ChTx ~ 6x

    Response (-)

    Histo-PA

    Reevaluation CR

    PR

    Management of SCLC

    KS < 70

    Best Supportive

    Care

    Prophylactic Cranial Irradiation

  • Curative Palliative

    Mode of chemotherapy

    Induction, Adjuvant,

    Neo-adjuvant

    ---

    Evaluation after 2 cycles

    Stop if :

    no partial response

    Continue if :

    palliation +, no progression

    Adverse effects

    May be severe

    Must be minimal

    Intent Intent to cure Palliation intent :

    DO NO HARM

    Curative vc Palliative chemotherapy

  • 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

    Jenis kemoterapi

  • 38

    Pilihan pengobatan yang terbatas pada Pilihan pengobatan yang terbatas pada

    stadium lanjut kanker parustadium lanjut kanker paru

    Kemoterapi pada kanker paru dasarnya

    bersifat paliatif.

    Bila jenis kemoterapi ditambah maka efek

    samping/toksik >>>

    Kemoterapi kanker paru kurang memberikan

    hasil

  • Tumor MediastinumTumor Mediastinum

  • Rosenberg ClassificationNeurogenic

    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 contentheart, great artery & vein, nerves, trachea, thymus,lymph nodes & vessels, esophagus, connective tissue

    Compartment of the mediastinumM superior:

    Thoracic inlet- VTh V & lower part of sternumM 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 procedureChest X-ray, Tomography, CT-Scan, MRI,

    Fluoroscopy, Echocardiography, Angiography, Esophagoscopy, USG, Nuclear medicine

    Endoscopic procedureBronchoscopy, Mediastinoscopy, Thoracoscopy

  • Clinical features

    Pathologic procedureCytology:

    FNAB, Pleural effusion, Brushing, Washing, Transthoracal biopsy

    Histological examinationLymph node biopsy, Daniels biopsyMediastinal biopsy, Excisional biopsy, VATS

    LabCBC, ESR, Tuberculin skin test, Thyroid study, -FP, -HCG, EMG

    Surgical procedure

  • Staging of timic tumor (Masaoka)

    Stage & description TreatmentI Macroscopic: capsulated

    No microscopic capsul invasion

    Extended thymo thymectomy (ETT)

    II Macroscopic invasion to fat tissue surrounding mediastinal pleura or microscopic capsul invasion

    ETT, continued with radiation

    III Macroscopic invasion to surrounding organ

    ETT and extended resection, then radiation and chemotherapy

    IVA Pleural /pericardial spreading Debulking, then chemotherapy and radiotherapy

    IV B Lymphogenic / hematogenic spreading

    Chemotherapy and radiotherapy then debulking

  • Germ Cell Tumor

    SeminomaRadiation & chemotherapy sensitiveNo surgical interventionChemo after radiation or Chemoradiation Platinum based chemotherapy

    Non seminomatous mediastinal tumorRadioresistant tumor6 cycles Chemotherapy

    -HCG, -FP, Chest X-ray evaluation

    Benign teratomaSurgical intervention

    Malignant teratomaMultimodality therapy

  • Neurogenic Tumor

    Surgical intervention except neuroblastoma

    NeuroblastomaRadiosensitive Combination Radio & chemotherapy

  • Management of VCSS

    Dx & Tx

    As it

    caused

    Diagnostic Procedures

    forLung/

    Mediastinal

    tumor

    Improved Stable Continue

    Diagnostic

    Procedure

    Primary

    tumor

    mngment

    Continue

    Diagnostic

    Procedures

    Consider

    Surgical

    Procedure

    Tumor (-) Tumor (+)

    CT-Scan Thorax

    No tumor/mass

    clearly detected

    Chest X-ray ( PA & Lateral )

    Radiation 1 x 8 Gy

    General performance

    Poor/Dyspnea

    Lung/Mediastinal tumor

    Good

    General performance

    PA (+) PA (-)

  • Management of mediastinal tumor

    Mediastinal tumor Benign

    Malignant Surgical

    Lymphoma

    Non-Lymphoma

    Hodgkin

    Non-Hodgkin

    Thymoma

    Thymic tumor

    Germ Cell

    Tumor

    Neurogenic

    tumor

    Mesengial tumor

    Endocrine tumor