CA Paru BARU
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TUMOR PARU
A.A Ngurah Surya Pranata07700008
Pembimbing : dr.Suharsono, Sp.P
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Jenis Tumor paru
Tumor PARUSMALL CELL CARCINOMA (SCC)
NON SMALL CELL CARCINOMA (NSCC)
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Jenis Histo Patologi Anatomi
1. Karsinoma Sel Kecil ( Small cell Carcinoma )
2. Karsinoma Squamosa ( Epidermoid / Squamous Cell Ca )
3. Karsinoma Kelenjar ( Adeno Carcinoma )4. Karsinoma sel Besar ( Large Cell
Carcinoma )
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Etiologi
Rokok Polusi udara Genetik Diet
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Gambaran klinis
Lokal• batuk
• hemoptosis• Mengi
• Abses paru• Atelektasis
Invasi Lokal• Nyeri dada
• Aritmia• Dispnea• Sindrom
horner• Suara serak
Gejala penyakit
metastasis• Pada otak, tulang, hati,
adrenal• Limfadenopat
i servikal dan supraklavikul
a
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Sindrom Paraneoplastik• ↓ BB, anoreksia, demam
• Hematologi (leukositosis, anemia, hiperkoagulasi)
• Neurologik (dementia, ataksia, tremor, neuropati
perifer )• Endokrin ( hiperkalsemia)• Dermatologik (eritema multiform, hiperkeratosis,
jari tabuh)• Renal (SIADH)
Asimtomatik dgn kelainan radiologis • Perokok dgn PPOK
yg terdeteksi secara radiologis• Nodul soliter
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Staging kanker paruTNMStage IA T1N0M0
Stage IB T2N0M0
Stage IIA T1N1Mo
Stage IIB T2N1M0
Stage IIIA T1-3N2M0T3N1M0
Stage IIIB T4 Any NM0Any TN3M0
Stage IV Any T Any NM1
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Small Cell Carcinoma (SCC) Limitied → Tumor dijumpai terbatas pada
satu sisi hemitoraks.
Extensive → Tumor dijumpai pada lebih dari satu sisi hemitoraks.
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Terapi Ca Bronkogenik ( Small Cell Ca )
*Staging Small Cell Carcinoma ,terbagi atas: Limited à Tumor dijumpai pada 1 sisi hemitoraks Extensive à Tumor dijumpai pada > 1 sisi hemitoraks• Modalitas Terapi Small Cell Ca : Sitostatika dan
Radioterapi• Small cell carcinoma, sering ditemukan dalam
keadaan sudah metastase jauh.
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Tumor ganas Paru primer, yang berasal
dari epitel bronkhus .
Batasan Ca Bronkogenik
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Etiologi Ca Bronkogenik1.Faktor genetik , adanya enzim AHH ( Aryl Hydrocarbon Hydroxilase ).2. Paparan Karsinogen ( Asap rokok, Paparan Industri, misalnya: Asbes, Nikel, Arsenikum, Kromium ) 3. Pengaruh Penyakit : Fibrosis bekas penyakit TBC paru yang sudah sembuh mengadakan hiperplasi & metaplasi, sering disebut: Scar Tissue Tumor.
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Manifestasi Klinik Ca Bronkogenik
IntrapulmonerEkstrapulmonal Intratoraksis
Ekstratoraksis Non Metastase
Ekstratoraksis Metastase
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Akibat adanya Tumor di ParuBatuk, Batuk darah, sesak napas, suara serak, nyeri dada, sulit menelan, benjolan di leher, sembab muka dan leher.
Manifestasi Intrapulmoner
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Tumor menyebar ke Mediastinum, sehingga menekan :
N. Phrenicus à Paralise diafragmaN. reccurent à Paralise Corda VocalisNN. Simpaticus à Horner syndroma ( APEM )Esophageus à disfagia ( sulit menelan )V. Cava Sup à bendungan vena ( VCSS )Trakhea / Bronkhus à atelektasis ( sesak napas 0Jantung à Efusi pericard, Tamponade jantung
Manifestasi Ekstrapulmonal Intratoraksis
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Syndroma Paraneoplastik a. Neuromuskularb. Endokrin Metabolik c. Jaringan ikat & Tulangd. Vaskuler & Hematologi
Manifestasi Ekstratoraksis Non Metastase
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Gejala Neuropatia Karsinomatosa à
• Miopati• Neuropati Perifer• Ensefalomiopati• Mielopati Nekrotik • Degenerasi Cerebelar Sub akut
Syndroma Paraneoplastik
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Endokrin Metabolik
Sindroma CushingSindroma CarcinoidHyperparatiroid dg HypercalcemiaSIADH dg HypernatremiaSekresi Insulin dg HypoglikemiaSekresi Gonadotropin dg
GynaecomastiSekresi MSH dg Hyperpigmentasi
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Gangguan pd Jaringan Ikat & Tulang
Akibat Peningkatan kadar HCGTerjadi: Hypertrophy Pulmonary
Osteoarthropathy / terbentuk subperiosteal pada jari – jari .
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Gangguan Vaskuler & Hematologi
Trombophlebitis Migrans
PurpuraAnemia
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Manifestasi Ekstratoraksis Metastase
Sel kanker menyebar ke sirkulasi darah à keseluruh organ tubuh.
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Manifestasi Sistemik
Batuk Penurunan Berat Badan
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Diagnosis Ca Bronkogenik
Diagnosis ditujukan untuk menentukan :a. Histopatologi Anatomi Tumorb. Lokasi Tumor serta Penderajadan / Stadium Tumorc. Status Penampilan ( Karnofsky / WHO )
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Pemeriksaan Penunjang Ca Bronkogenik
•Foto dada dan CT Scan Thoraks•Sitologi : sputum atau bahan lain ( cairan pleura, cairan pericard )
- Petanda Tumor: CEA, Cyfra 21-1, NSE- Pemeriksaan Biologi Molekuler : Protein p53,bcl2
•Bronkhoskopi: biopsi aspirasi, forcep biopsi, washing,brushing
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Pemeriksaan Penunjang Ca Bronko..................
•Biopsi : Kelenjar limfe, Fine Nedlee Aspiration (FNA) paru trans torakal, maupun kelenjar limfa
•Mengetahui adanya metastase: CT Scan kepala, Bone scan, USG abdomen
-Bedah Eksplorasi
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Pemeriksaan Penunjang Ca Bronko...............
Marker Ca Paru ( Chorio Embryonic Agent / CEA )CEA < 2,5 : Curiga Ca Paru à Pro evaluasi setelah 6 bulan. CEA 2,5 – 6,5 : Pasti Ca, namun diteliti ulang.CEA 6,5 - 15 : Pasti Ca à Pembedahan masih bermanfaat (belum metastase) CEA > 15 : Pasti Ca à Pembedahan tidak bermanfaat ( sudah metastase )
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Jenis Histo Patologi Anatomi
1. Karsinoma Sel Kecil ( Small cell Carcinoma )
2. Karsinoma Squamosa ( Epidermoid / Squamous Cell Ca )
3. Karsinoma Kelenjar ( Adeno Carcinoma )4. Karsinoma sel Besar ( Large Cell
Carcinoma )
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Histo Patologi Anatomi penentu jenis terapi Ca Bronkogenik
1.Karsinoma Sel Kecil ( Small cell Carcinoma )2.Karsinoma Bukan Sel Kecil (Non Small Cell Carcinoma)
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Diagnose Banding Ca Bronkogenik
1. Benda Asing 2. Tuberkuloma ( TB Paru )3. Hamartoma ( Tumor Pembuluh darah )4. Tumor Metastase5. Jamur Paru6. Penyakit Autoimun
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Small Cell Carcinoma ............
Small Cell Carcinoma
Limited disease Extensive disease
Kemoterapi - Kemoterapi +
Terapi SuportifKemoradioterapi
Respon Sebagian
Radioterapi ProfilaksisJenis Kemoterapidiganti
Respon Komplit
Kemoterapi -Kemoterapi +
Terapi SuportifKemoterapi 2X
Respon ada Respon tak ada
Kemoterapi s/d 6X
Evaluasi hasil PA
Respon Komplit
Respon Sebagian
Radioterapi Profilaksis Jenis Kemoterapi diganti
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Terapi Ca Bronkogenik ( Non Small Cell Ca )
•Modalitas terapi tergantung: - Stadium TNM dan Skala Penampilan Penderita- Stadium l A s/d II B à Operable ( pembedahan )- Stadium III A s/d IV à Non Operable / Paliatif - Tujuan Kuratif à Kemoterapi Induksi- Kasus Non Operable à Kemo & Radio terapi Paliatif- Mengecilkan Tumor ( Non Operable à Operable ) dengan Kemoterapi Neoajuvant.
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Non Small Cell Carcinoma ( NSSC ).............
Non Small Cell Carcinoma
Stadium < IIBStadium < IIB Stadium III A Stadium IIIB Stadium IV
Segmentegtomi / Lobektomi
Kemoterapi NeoajuvanKemo 2X ( 4000 cGy )
PS > 70 PS < 70 PS > 70 PS< 70
Surgical N (-) Surgical N (+)
Kemoterapi Ajuvan
Restaging
Staging Turun
StagingTetap
KemoterapiRadioterapi
Bedah KemoterapiRadioterapi
KemoterapiRadioterapi
Paliatif
KemoterapiRadioterapi
Paliatif
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Terapi Ca Bronkogenik dengan Kemoterapi
Prinsip Pemilihan Regimen Kemoterapi:• Berbasis Platinum• Respon Obyektif satu macam obat anti
kanker > 15%• Toksisitas Obat tidak lebih dari grade 3
( Skala WHO )• Kemoterapi harus dihentikan, apabila setelah
pemberian 2 siklus Respon Tumor Progresif
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Terapi Ca Bronkogenik dengan Kemoterapi .........
Evaluasi dilakukan terhadap:• Respon Subyektif ( Penurunan Keluhan )• Respon Semi Subyektif ( Perbaikan
Skala Karnofsky / Skala WHO ) dan Peningkatan Berat Badan
• Respon Obyektif ( Respon Komplit, Parsial, Menetap, Progresif )
• Efek Samping Obat
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Penderajatan Tumor Paru ( NSSC )
Stage TNM0IAIBIIAIIBIIIA
IIIBIV
Tis, No, MoT1, No, MoT2, No, MoT1, N1, MoT2, N1, Mo / T3, No, MoT1, N2, Mo / T2, N2, Mo / T3, N1, Mo / T3, N1, Mo.Semua T, N3, Mo / T4, Semua N, MoSemua T. semua N, M1
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Status Penampilan Penderita
Nilai SkalaKarnofsky
Nilai SkalaWHO
Keterangan
90 – 10070 – 8050 – 6030 – 4010 – 200 - 10
012345
Aktifitas NormalMengurus diri sendiriKadang perlu bantuanMemerlukan bantuianPerawatan di RSTidak sadar
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Kategori Sistim TNM – NSCLC
T : Tumor Primer T0 : Tumor Primer tak terlihat Tx : Sel tumor ditemukan pada sputum / cairan pleura,
namun tak terlihat pada foto dada / bronkoskopi.Tis : Carcinoma In SituT1 : Tumor Ø < 3 cm dikelilingi jar. Paru/pleura, bila ada invasi tak sampai ke bagian proximal bronkhus lobus
/ invasi hanya pada dinding bronkhus saja.
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Kategori Sistim TNM ..........
T2 : Tumor Ø >3 cm, menjalar sampai > 2 cm distal carina
bronkhus, invasi ke pleura visceralis, atelektasis
lobus paru.T3 : Tumor invasi ke dinding dada, diafragma, pleura
mediastinalis, menjalar s/d < 2 cm dari distal carina
bronkhusT4 : Tumor invasi jantung, Aorta, trakhea, esofageus,
vertebrae, menjalar s/d carina bronkhus.
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T1 T1
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T2
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T3
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T4
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Kategori Sistim TNM ..............
N : Kelenjar Getah Bening regional ( KGB )Nx : KGB tak dapat dinilai.N0 : KGB tak terlibat/ tak ada teraba N1 : Metastase ke KGB Peribronkhial/ Hilus paru Ipsilateral Tumor N2 : Metastase Ke KGB Mediastinal Ipsilateral Tumor / KGB Subcarina BronkhusN3 : Metastase ke KGB Hilus, Mediastinal, Scalenus, Supraclaviculae, Ipsilateral / Kontralateral
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N1
NNN
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N2
N2
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Pembesaran kelenjar mediastinal
Kontralateral & ipsilateral
Pembesaran kelenjarColli kontralateral & ipilateral
Pembesaran kelenjar Paratrakheal Kontralateral & ipsilateral
N3
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Kategori Sistim TNM ...........
M : Metastase jauh à penyebaran diluar organ paru / adanya Efusi PleuraMx : Metastase tak dapat dinilaiM0 : Tak ditemukan Metastase jauhM1 : Ditemukan metastase jauh / metastase nodule pd Ipsilateral tumor diluar lobus.
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Carcinoma Bronkogenik
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Pencegahan Carcinoma Bronkogenik
•Berhenti merokok•Deteksi dini terhadap Sasaran Penyaringan, seperti:Laki – laki usia > 40 tahunPerokok berat / Pekerja IndustriBatuk > 2 minggu, disertai batuk darahBerat badan turun > 4 kg / 6 bulan
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Pencegahan Carcinoma Bronkogenik ( Deteksi Dini )
Langkah penyaringan
Sitologi SputumNegatif Positif
Foto Dada
Negatif A CPositif B D
A : Penyaringan setiap 6 bulanB, C : Tegakkan diagnose lebih lanjutD : Penderajatan Tumor
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Prognose Carcinoma Bronkogenik
Stadium Stadium Klinis Stadium BedahNSCLC : 5 years survival I A (T1N0M0)IB ( T2N0M0)IIA ( T1N1M0)IIB ( T2N1M0, T3N0M0 )IIIAIIIBIVStadiumSCLC : 2 years survivalLimitedExtensive
( setelah Reseksi )60 %38 %34 %23 %9 – 13 %3 – 7 %1 %Stadium Klinis( setelah Kemoterapi )15 – 20 %< 3 %
74 %61 %55 %39 %22 %
Stadium Bedah
14 – 20 bulan8 – 13 bulan
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Terima kasihSukses Selalu