Metastatic Bone Disease (Dekstruksi Throcal IX) by Same
Transcript of Metastatic Bone Disease (Dekstruksi Throcal IX) by Same
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METASTATIC BONE DISEASEDestruction vertebrae thoracal IX
PERSENTASE KASUS BESARPRAKTEK KERJA PROFESI APOTEKER
RS. Dr. WAHIDIN SUDIROHUSODOPERIODE MARET – APRIL 2012
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Bone is a very common site for cancer metastasis
Bone metastasis is frequently seen in patients with breast cancer and prostate cancer with up to two-thirds to three-fourths of the patients developing bone metastasis
15–30% of patients with lung, bladder, uterine, rectal, thyroid or renal cancer developing bone metastasis during the course of their disease
INTRODUCTION
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Carcinomas that most likely to metastazise to bone:
1. Breast2. Prostate3. Lung4. Kidney5. Thyroid
Other: gastrointestinal tract, 10% unknown origin
ORIGIN
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Metastatic bone disease:1. Destroys the skeleton in older
patients2. Children < 6 years old renal
neuroblastoma3. Most vertebral lesion in adults are
metastases, myelomas, hemangiomas
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Penyebaran tumor ganas ke tulang adalah melalui aliran darah (hematogenic spread
Deposit sel tumor terdapat pada sumsum tulang, sedangkan pada diafise tulang deposit tumor didapatkan terutama pada arteri nutrisia.
PATOLOGI
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Penderita dengan metastasis tulang selalu mengeluh nyeri, kadang-kadang nyeri begitu hebat sehingga mengakibatkan penderita berhari-hari tidak bisa tidur.
Nyeri akan disertai dengan tidak berfungsinya anggota gerak apabila metastasis mengenai tulang belakang karena timbulnya fraktur yang patologik.
Penderita dengan metastasis ke tulang belakang disamping mengeluh nyeri, paraplegia inferior, bisa juga mengalami incontinentia urinae et alvi.
GEJALA KLINIK
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Tulang belakang 80% Femur 40% Iga-iga dan sternum 25 % Tengkorak dan pelvis 20% Kaput humeri 7% Tulang ekstremitas 1—2%
DISTRIBUSI METASTASIS PADA TULANG MENURUT BESCHAN
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ROUTE VIA BATSON VERTEBRAL VEIN PLEXUS
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Anatomy review
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Paraplegia loss of motor and/or sensory
function in thoracic, lumbar or sacral segments of SC (arm function is spared)
Quadriplegia loss of motor and / or sensory
function in the cervical segments of SC
TERMINOLOGY
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Pembedahan Radioterapi Kemoterapi Pain control
PENATALAKSANAAN
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KASUS BESARPROFIL
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Nama : Tn. KUmur : 63 tahunBB : -Alamat : Jl. Maccini Raya Lr. Merdeka IICara bayar : JamkesmasNo. RM : 5xxxxxMRS : 12 Februari 2012KRS : Belum KRS
PROFIL PASIEN
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Keluhan utama : Nyeri dan tidak bisa menggerakkan kedua kaki
Riwayat penyakit : Penurunan BB (+) dalam 4 bulan terakhir dengan jumlah tidak diketahui, riwayat trauma (-), riwayat batuk lama disangkal, riwayat minum obat 6 bulan disangkal, riwayat batuk darah (-)
PROFIL PENGOBATAN
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Autoanamnesis : Tidak bisa menggerakkan kedua kaki / tungkai bawah yang dialami sejak 2 minggu terakahir, awalnya pasien merasakan nyeri pada tulang belakang sejak 2 bulan lalu, dirasakan makin memberat sampai 1 bulan lalu pasien mulai merasakan kelemahan pada kedua tungkai, saat ini pasien tidak bisa sama sekali menggerakkannya dan merasakan kesemutan
Diagnosa : Dekstruksi vertebrae thoracal IX due to metastasis bone disease
PROFIL PENGOBATAN
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DATA KLINIK (FEBRUARI)
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DATA KLINIK (MARET)
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DATA KLINIK (MARET)
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DATA KLINIK (APRIL)
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DATA LABORATORIUM (MARET - APRIL)
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DATA LABORATORIUM (MARET - APRIL)
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DATA LABORATORIUM (MARET - APRIL)
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Hasil USG Abdomen ( Tgl 21 Februari 2012)Kesan : - Massa intrahepatik, suspek metastatis ke
hepar- Efusi pleura kiri
Hasil Radiologi (Tgl 02 Maret 2012)Kesan : - Susp. Metastatis pada hepar
- Efusi pleura bilateral- Susp. Primary bone tumor CV Th 9- Kista thyroid kiri
DATA PENUNJANG LAINNYA
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Hasil MRI ThoracolumbalKesan : Fraktur kompressi dan dekstruksi CV T9
disertai tanda-tanda fraktur pada CV T8 dan T10 dengan paravertebral abses yang sudah mendesak dan infiltrasi ke spinal cord yang menyebabkan stenosis totalis canalis
Hasil Patologi Anatomi (Tgl 02 April 2012)Kesimpulan :Metastase malignant tumor pada vertebrae
DATA PENUNJANG LAINNYA
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Hasil Pemeriksaan elektrolit
DATA PENUNJANG LAINNYA
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PROFIL PENGOBATAN (FEBRUARI 2012)
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PROFIL PENGOBATAN (MARET 2012)
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PROFIL PENGOBATAN (MARET 2012)
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PROFIL PENGOBATAN (APRIL 2012)
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RASIONALITAS PENGOBATAN
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ASSESMENT AND PLAN
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PM : DemamTerapi : Paracetamol (dimetabolisme di hati)DRPs : Pengaturan dosis obat yang dimetabolisme
dihati terhadap pasien dengan fungsi hati yang abnormal
Rekomendasi :Penggunaan Child-Pugh Score dalam penentuan dosis obatMonitoring :Kadar albumin, bilirubin, PT, asites, hepatik ensefalopatik
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Determination of Child-Pugh Scores
• No single laboratory test to assess the liver function (not like CLCr
to measure renal function)
• The most common way to estimate the ability of the liver to
metabolize drug is to determine the Child-Pugh score for a patient.
• The Child-Pugh score consists of five laboratory tests or clinical
symptoms. The five areas are serum albumin, total bilirubin,
prothrombin time, ascites, and hepatic encephalopathy
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Determination of Child-Pugh Scores
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Determination of Child-Pugh Scores
• Each of the symptom is given a score of 1 (normal) to 3
(severely abnormal), and the scores for the five areas are
summed.
• The Child-Pugh score for a patient with normal liver function
is 5, whereas for abnormal (hepatic damage) is 15
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Determination of Child-Pugh Scores
• A Child-Pugh score equal to 8–9 is grounds for a moderate
decrease (~25%) in initial daily drug dose for agents that are
primarily (≥60%) hepatically metabolized,
• A score of 10 or greater indicates that a significant decrease in
initial daily dose (~50%) is required for drugs that are mostly
liver metabolized.
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PM : DemamTerapi : ParacetamolDRPs : Tidak tepat penderitaRekomendasi :• Paracetamol dapat menambah kerusakan hati pada pasien sehingga
dapat diganti dengan sediaan ibuprofen atau sistenol• Penggunaan anti-piretik dapat pula dihindari karena temperatur tubuh
hingga 41°C relatif tidak berbahaya kecuali pada anak kecil dan ibu hamil sehingga penatalaksanaanya dapat dikompres dengan air hangat kuku
Monitoring :Demam
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3PM : NyeriTerapi : KetorolakDRPs : Lama pengobatanRekomendasi :• Durasi maksimum penggunaan ketorolak melalui terapi parenteral selama 2 hari
dan untuk penggunaan oral selama 7 hari• Penggunaan ketorolak secara IV digunakan selama 2 hari kemudian dilanjutkan
dengan penggunaan NSAIDs Celecoxib secara oral dengan pengaturan dosis 400 mg untuk hari pertama kemudian diikuti dengan 200 mg 2 x sehari
• Celecoxib memiliki indikasi sebagai inhibitor angiogenesis pada sel kanker
Monitoring :Nyeri pada pasien, hipersensitifitas
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Angiogenic Therapy
• A new form of cancer treatment using drugs called 'angiogenesis inhibitors'
that specifically halt new blood vessel growth and starve a tumor by cutting
off its blood supply.
• A substance in the body called Vascular Endothelial Growth Factor (VEGF) is
responsible for the growth of new blood vessels. It promotes this growth by
stimulating the endothelial cells, which form the walls of the vessels and
transport nutrients and oxygen to the tissues.
• Anti-Angiogenic drugs prevent the VEGF from binding with the receptors on
the surface of the endothelial cells.
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Celecoxib
• Is one of the “rediscovered” drugs
• It is better known as Celebrex, a non-steroidal, anti-inflammatory drug
• Celecoxib is a COX-2 inhibitor :
1. Overexpression of COX-2 in cancer cells induces the production of VEGF,
PDGF, bFGF and TGF-beta.
2. Through these angiogenesis mediators and their receptors on the
endothelial cells, COX-2 increased vascular permeability and induced
endothelial cell proliferation and migration.
3. COX enzymes are essential for maintenance of the migration and
attachment of endothelial cells through integrin pathways
• Therefore a COX-2 inhibitor will block new vessel formation
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American Association for Cancer Research
POTENTIAL ANTI-ANGIOGENESIS
Combination Therapy :
• Anti-angiogenic + Chemotherapeutic drug
• Inhibit vascularization + Cytotoxic agent
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PM : Red Blood CellTerapi : Transfusi PRCDRPs : Lama PengobatanRekomendasi :• Transfusi PRC terlalu cepat dihentikan sementara nilai RBC
pasien masih tidak normal. Untuk itu perlu ditambah kembali pemberiannya.
• Dapat pula diberikan SF untuk membantu meningkatkan RBCMonitoring :Red Blood Cell
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PM : AlbuminTerapi : Transfusi AlbuminDRPs : Lama PengobatanRekomendasi :• Penggunaan albumin hanya 2 hari (24-25 Maret’12) sementara
kadar albumin pasien masih rendah pada hasil laboratorium tanggal 04 April’12
• Sebagai alternatif dapat diberikan VIP Albumin / Pujimin® kapsul untuk membantu meningkatkan kadar albumin pasien
• Monitoring :Kadar Albumin
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PM : LemahTerapi : -DRPs : Ada indikasi, tidak ada terapiRekomendasi :• Melakukan pemeriksaan glukosa darah pasien (GDS, GDP,
HbA1c)• Pemberian vitamin seperti Neurodex• Monitoring :Kondisi pasien, glukosa darah
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PM : HepatitisTerapi : -DRPs : Ada indikasi, tidak ada terapiRekomendasi :• Pemberian obat antivirus• Pemberian hepatoprotektor HP ProMonitoring :Kondisi pasien, albumin, bilirubin, SGPT, SGOT, PT
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SEKIAN &TERIMA KASIH
PERSENTASE KASUS BESARPRAKTEK KERJA PROFESI APOTEKER
RS. Dr. WAHIDIN SUDIROHUSODOPERIODE MARET – APRIL 2012