kanker paru deteksi dini
DESCRIPTION
penyakit paruTRANSCRIPT
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FAKULTAS KEDOKTERANUNIVERSITAS TRISAKTIDr. Abdul Rohman, SpP
KANKER PARU
K 1
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DEFINISI Semua penyakit keganasan di paru,
mencakup baik yang berasal dari paru sendiri maupun dari luar paru
Kanker paru primer : tumor ganas yang berasal dari epitel bronkus atau karsinoma bronkus (bronchogenic carcinoma)
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Etiologi Etiologi
Rokok : Rokok : 80-90 % pasien Ca paru adalah perokok 80-90 % pasien Ca paru adalah perokok aktif, resiko juga meningkat pada perokok pasif aktif, resiko juga meningkat pada perokok pasif
Polusi udara :Polusi udara : asbestosis, debu arsen, nikel, asbestosis, debu arsen, nikel, chrom, batubara, tar, aldehida, semua asapchrom, batubara, tar, aldehida, semua asap
TB paru yang lama + Asap ROKOKTB paru yang lama + Asap ROKOK Radiasi ionRadiasi ion Predisposisi genetikaPredisposisi genetika
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Kanker Paru
Penyakit keganasan paru Tumor primer Tumor metastasis Angka kematian karena kanker
menurut SKRT 1972 : 1.02% meningkat menjadi 4.5% pada tahun 1990
Prognosis penyakit buruk
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Primer Primer metastase ke otak/tulang/hati metastase ke otak/tulang/hati Sekunder Sekunder berasal dari Ca mammae/ berasal dari Ca mammae/
cervix & korpus uteri/testis/hati/usus/tulang/ cervix & korpus uteri/testis/hati/usus/tulang/ tiroidtiroid
Klasifikasi & EpidemiologiKlasifikasi & Epidemiologi
Terbanyak pada pria (pria : wanita = 4 : 1 9 : 1)Penyebab kematian tertinggi
Konsumsi rokok Usia > 45 tahun Stadium lanjut
Dekade 1980 : Kampanye anti rokok giat kekerapan ↓ Indonesia cenderung meningkat
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Pajanan zat karsinogenik
Paparan polusi
genetik
ETIOLOGI
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FAKTOR RESIKO
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Konsep Masa Kini
Kanker adalah penyakit gen Ketidak seimbangan fungsi
onkogen dengan gen tumor supresor
Mutasi gen Multistep karsinogenesis Onkogen yang berperan dalam
karsinogenesis gen myc, gen k-ras
Gen tumor supressor: p53, gen rb
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Klasifikasi (1)Klasifikasi (1)Lama:Lama: Ca paru epidermoid (squamous cell lung cancer): Ca paru epidermoid (squamous cell lung cancer):
sel kanker mirip epitel saluran penapasan sel kanker mirip epitel saluran penapasan atasatas
Ca paru adeno-karsinoma (adeno-carcinoma of the lung): Ca paru adeno-karsinoma (adeno-carcinoma of the lung):
sel kanker mirip sel kelenjar mukus parusel kanker mirip sel kelenjar mukus paru Ca paru dengan sel-sel berdiferensiasi rendahCa paru dengan sel-sel berdiferensiasi rendah
- Ca paru dengan sel-sel besar (large cell lung cancer)- Ca paru dengan sel-sel besar (large cell lung cancer)
- Ca paru dengan sel-sel kecil (small cell lung cancer)- Ca paru dengan sel-sel kecil (small cell lung cancer)
Baru:Baru: Ca Paru jenis Sel Kecil (=Small Cell Lung Cancer / SCLC)Ca Paru jenis Sel Kecil (=Small Cell Lung Cancer / SCLC) Ca Paru Bukan Sel Kecil (=Non Small Cell Lung Ca/NSCLC)Ca Paru Bukan Sel Kecil (=Non Small Cell Lung Ca/NSCLC)
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Klasifikasi (2)Klasifikasi (2)
Kanker paru yang khasKanker paru yang khas Carsinoma insitu = Ca yg msh terbatas pd Carsinoma insitu = Ca yg msh terbatas pd
mukosa bronkus, blm menembus mukosa bronkus, blm menembus membrana basalismembrana basalis
Pancoast’s Tumor = Semua Ca di apex paru Pancoast’s Tumor = Semua Ca di apex paru d/s:d/s:- nyeri bahu - nyeri bahu lengan ipsilateral lengan ipsilateral
- invasi kejaringan sekitar (iga, plexus - invasi kejaringan sekitar (iga, plexus brakhialis,brakhialis,
kel getah bening, tr. symphaticus)kel getah bening, tr. symphaticus)
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JENIS TUMOR
Small Cell Lung Cancer
Adeno Carcinoma
Non Small Cell Lung Cancer
Carcinoma Bronkoalveolar
Carcinoma Sel Besar
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Kanker Paru NSCLC SCLC
Staging pada NSCLC TNM SCLC extensive dan limited disease
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Deteksi Dini Kanker Paru Keluhan dan gejala penyakit tidak
spesifik Penemuan dini berdasarkan
keluhan jarang terjadi Keluhan yang ringan bila stage II
atau stage III Negara berkembang : diagnosis
ditegakkan sudah advanced stage
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Sasaran Deteksi Dini
Usia> 40 tahun Perokok Paparan industri Gejala klinik: batuk
darah, batuk kronik sesak nafas, nyeri dada dan berat badan menurun
Riwayat keluarga
Perokok pasif Batuk darah, batuk
kronik, sakit dada, penurunan berat badan tanpa penyakit yang jelas
Riwayat keluarga
Laki-laki Perempuan
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Prosedur diagnostikGAMBARAN KLINIKA. ANAMNESISa. Keluhan Utama Batuk, dengan/tanpa dahak (putih/purulen) Batuk darah Sesak nafas suara serak Sakit dada Sulit / sulit menelan Benjolan di pangkal leher Sembab muka & leher, kdg disertai sembab lengan
+ nyeri yang hebat
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b. Keluhan akibat metastase di luar paru
- Kompresi hebat di otak - Pembesaran hepar - Patah tulang
c. Gejala & keluhan tidak khas Berat badan menurun Nafsu makan hilang Demam hilang timbul Sindroma paraneoplastik : - hypertrophic pulmonary
osteoarthropathy- trombosis vena perifer- neuropatia
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B. PEMERIKSAAN JASMANI:
Kecil dan Perifer normal
Besar - atelektasis ok kompresi bronkus - efusi pleura - penekanan vena kava
Staging penyakit : - pembesaran KGB- tumor luar paru
- metastasis hepar otak
tulang
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Jenis Pemeriksaan untuk Deteksi Dini Kanker Paru
GRT (Golongan Resiko Tinggi)
Foto toraks PA/Lateral Sputum sitologi induksi CT SCAN Toraks
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WASPADA CARCINOMA
Golongan risiko tinggi dengan follow up yang teliti
Pengobatan pnemonia tidak ada perbaikan
OAT 1 bulan tidak membaik/memburuk
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SITOLOGI SPUTUM Paling mudah & murah Kekurangan : - tumor perifer (Adeno Ca)
- batuk kering - tehnik & cara ambil sputum
Bantuan inhalasi NaCl 3 % ke + an
Cairan fiksasi (-) PA (sito/histologi) (+) dgn alkohol absolut/90 % :
sediaan apus Jaringan fiksasi formalin 4 %
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Gambaran radiologis (Foto Toraks)
PA/Lateral : tumor > 1 cm Tanda ganas : - tepi iregular +
- identasi pleura, - tumor satelit, dll
Juga : invasi dinding dada, efusi pleura,
efusi perikard & metastase intrapulmo
Keterlibatan KGB – tentukan N agak sulit
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Lung Cancer RLung Cancer Radiographyadiography
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Skema Foto Toraks dan Sitologi Sputum.
CXR sputum
( + )
( - )
( + ) a
b
( - ) c
d
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Deteksi dini kanker paru (skrining)
Golongan Resiko Tinggi (GRT)
Bukan GRT
Foto toraks & sitologis sputum
Dx & Tx penyakit paru
non kanker
Semua hasil (-)
Teruskan prosedur Dx ca
paru
Re – skrining 4-6 bulan
Curiga ca paruAda hasil (+)
(b,c,atau d, lihat skema)
Teruskan prosedur Dx ca
paru
ALUR DETEKSI DINI
KANKER PARU
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Diagnosis Cepat Kanker Paru
Memerlukan penanganan dan tindakan cepat dan terarah
Ketrampilan dan sarana Multidisiplin ilmu kedokteran Pulmonologi, radiologi diagnostik,
patologi anatomi, radio terapi, bedah toraks, rehabmedik, psikologi dsbnya
Staging dini kualitas hidup baik tidak menyembuhkan
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1. Toraks foto2. CT-scan3. Pemeriksaan radiologi lain :
brain-CT, bone scan / bone survey, USG abdomen (untuk mendeteksi metastasis)
Gambaran Radiologis
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1. Bronkoskopi2. Biopsi aspirasi jarum3. Transbronchial middle aspiration
(TBNA)4. Transbronchial Lung Biopsy (TBLB)5. Biopsi trans thorakal (Transthoraxic,
TTB)6. Torakoskopi medik7. Sitologi sputum
Pemeriksaan khusus
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Torakoskopi mediastinoskopi, torakotomi eksplorasi biopsi paru terbuka
Pemeriksaan lainCEA, Cyfra 21-1, NSEBiologi molekuler
Pemeriksaan invasif lain
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Histopatologi kanker Staging T N M Tampilan (Performance status)
Penatalaksanaan Terapi
Diagnosis dan Penderajatan
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CT Scan Toraks
Mendeteksi tumor < 1 cm Tanda tanda proses keganasan Penekanan thd bronkus,tumor
intra bronkial,atelektasis,efusi pleura minimal,invasi ke mediastinum atau dinding dada.
KGB
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Klasifikasi histologis WHO 1999 Untuk keperluan klinis cukup :
Karsinoma skuamosa/epidermoid Karsinoma sel kecil Adenokarsinoma Karsinoma sel besar
Kanker Paru Jenis Karsinoma Sel Kecil (KPKSK)=SCLC
Kanker Paru Jenis Ka. Bukan Sel Kecil (KBKBSK)=NSCLC
Jenis Histologis
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Kanker Paru
NSCLC SCLC
Staging pd NSCLC TNM SCLC extensive dan limited disease
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Penderajatan Kanker Paru
NSCLC international staging system for
Lung Cancer 1997 TNM system T: Tx, To – T4 N: Nx, N1 – N3 M: Mo – M1
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Penentuan STADIUM Penentuan STADIUM NSCLCNSCLC
Stage 0: Ca in situStage 0: Ca in situ Stage 1A: TStage 1A: T11NN00MM00
Stage 1B: TStage 1B: T22NN00MM00
Stage 2A: TStage 2A: T11NN11MM00
Stage 2B: TStage 2B: T22NN11MM0 0 / T/ T33NN00MM00
Stage 3A: TStage 3A: T33NN11MM00 / T / T11NN22MM00 / T / T22NN22MM00 / T / T33NN22MM00
Stage 3B: TStage 3B: T44NN00MM00 / T / T11NN22MM00 / T / T22NN22MM00 / T / T33NN22MM00
Stage 4: MStage 4: M11 with any T or N with any T or N
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Penderajatan Internasional Kanker Paru Berdasarkan Sistem TNM
Stage TNM
Occult Carcinoma
0IAIBIIAIIBIIIA
IIIB
IV
TX N0 M0
Tis N0 M0T1 N0 M0T2 N0 M0T1 N1 M0T2 N1 M0T3 N0 M0T1 N2 M0T2 N2 M0T3 N1 M0T3 N2 M0Sembarang T N3 M0T4 Sembarang N M0Sembarang T Sembarang N M1
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Tampilan
Keluhan subjektif dan objektif yang dinilai
Skala tampilan Karnofsky (Indonesia)
Skala tampilan WHO Pertimbangan terapi – kemo radio
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Tampilan Menurut Skala Karnofsky & WHO
Nilai Skala :Karnofsky
Nilai Skala :WHO
Keterangan :
90-100
70-80
50-60
30-40
10-20
0-10
0
1
2
3
4
5
Aktif Normal
Ada keluhan ttp msh aktif & dpt mengurus diri sendiri
Cukup aktif, namun kadang memerlukan bantuan
Kurang aktif, perlu rawatan
Tidak dpt menginggalkan tempat tidur, perlu rawat di rumah sakit
Tidak sadar
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KPKBSK = NSCLCCombined modality
Pembedahan Kemoterapi Radioterapi Imunoterapi Hormon terapi Terapi genPenatalaksanaan: adjuvant,
neoadjuvant, sekwensial
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Lobektomi
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KPKSK = SCLC Limited disease: kemoterapi,
radioterapi, PCI Extensive disease: kemoterapi dan
radioterapi SCLC = non operable
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Evaluasi Pengobatan Complete response/no evidence of disease
Partial response No Change/Stable disease Progressive disease
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PrognosisPrognosis
NSCLC:NSCLC: Stage 1: 80-90% 5 year survivalStage 1: 80-90% 5 year survival Stage 2: 40-50% 5 year survivalStage 2: 40-50% 5 year survival Stage 3a: 30-40% 5 year survivalStage 3a: 30-40% 5 year survival Stage 3b: 9-12% 5 year survivalStage 3b: 9-12% 5 year survival Stage 4: 6-9 months median survivalStage 4: 6-9 months median survival
SCLC: SCLC: jelek!jelek!
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Kanker Paru Pada Keadaan Khusus
Efusi pleura ganas ( EPG ) Sindrom Vena Kava Superior Obstruksi bronkus Invasi dinding toraks Hemoptisis Kompresi esofagus Metastasis
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Kemoterapi
Standard: etoposide, cyclophosphamide, cisplatin, carboplatin, doxurubicin
Novel: paclitaxel, gemcitabine, docetaxel, veneralbine,
Alimta, Iressa
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Penutup Pencatatan kanker
paru Data epidemiologi Data upaya
diagnostik Data
histologi/sitologi
Alur tindakan diagnosis kanker paru
Alur penatalaksanaan NSCLC+SCLC
EPG SVKS
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Bronchogenic carcinoma
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Terimakasih
Terimakasih
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Gejala klinisGejala klinis K.U.: kemunduran progresif K.U.: kemunduran progresif
(nafsu makan<, BB <, 9L, pucat)(nafsu makan<, BB <, 9L, pucat) Paru: spt TB paru ttp jauh lebih cepat Paru: spt TB paru ttp jauh lebih cepat (batuk ringan(batuk ringanberat/b.d./nyeri dada ipsilat/sesak*)berat/b.d./nyeri dada ipsilat/sesak*)
F.D.: tanda2 massa padat unilat/bilat F.D.: tanda2 massa padat unilat/bilat (tertinggal pd(tertinggal pd
pernapasan, fremitus <<, pekak, suara napas << pernapasan, fremitus <<, pekak, suara napas << -) -)
Lymphadenopathy leher/axilla (single/multipel)Lymphadenopathy leher/axilla (single/multipel) Manifestasi Ca primer ATAU Manifestasi Ca paruManifestasi Ca primer ATAU Manifestasi Ca paru ((fraktur patologis, fraktur patologis, benjolan di tlg dg/tanpa nyeri, benjolan di tlg dg/tanpa nyeri,
ikterus, kelainan neurologis, dll)ikterus, kelainan neurologis, dll)
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Alur Deteksi Dini Kanker Paru
Deteksi dini CA Paru
GRT BUKAN GRT
CXR+SPUTUM D/+Th/ non CA
Suspect CA
Protap D/
Hasil (+)
Protap D/
Hasil (-)
Reskrining 4-6 bulan
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DiagnosisDiagnosis
KlinisKlinis Foto Ro Paru Foto Ro Paru
(PA/lateral/lordotik)(PA/lateral/lordotik) CT scan dg kontrasCT scan dg kontras Sitologi sputumSitologi sputum Tumor markers:Tumor markers: - NSE - NSE SCLC SCLC - Cyfra-21 - Cyfra-21 NSCLC NSCLC Whole body
scintigraphy
Biopsi transtorakalBiopsi transtorakal Bronkoskopi Bronkoskopi
dengan dengan biopsi/sitologi biopsi/sitologi sikatan dan bilasan sikatan dan bilasan bronkusbronkus
Biopsi kelenjarBiopsi kelenjar
Non-invasif Invasif
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Gambaran Radiologis Foto toraks P/A
dan lateral Massa > 1 cm Tidak bisa
menentukan KGB Efusi pleura
Golongan risiko tinggi dengan follow up yang teliti
Pengobatan pnemonia tidak ada perbaikan
OAT 1 bulan tidak membaik/memburuk
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Lung Cancer Radiography
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Pemeriksaan Radiologik Lain
Menilai metastasis jauh Brain –CT Bone scan Bone survey USG abdomen
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LUNG CANCERLUNG CANCERBone scintigraphyBone scintigraphy
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Pemeriksaan Khusus
Bronkoskopi Biopsi aspirasi jarum TBNA TBLB PET Scan Biopsi lain Torakoskopi medik Sitologi sputum
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Pemeriksaan Invasif
Torakoskopi Mediastinoskopi Torakotomi eksplorasi Biopsi paru terbuka
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Pemeriksaan Lain
Petanda tumor: CEA, cyfra 21-1, NSE bukan sebagai diagnosis tetapi evaluasi terapi
Biologi molekuler: menilai ekspressi beberapa gen atau produk gen yang terkait dengan kanker paru
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NON-SMALL CELL LUNG CANCERStage I 2 cm
N0: no lymph node involvementN0: no lymph node involvementM0: no distant metastasisM0: no distant metastasis
No lobarbronchusinvolvement
T 3 cm
IaIaT1T1 N0N0 M0M0
IbIbT2T2 N0N0 M0M0
T >3 cm
T + visceral pleuralinvolvement
T + distal atelectasis
Any of the following:
T= main bronchial involvement
2 cm distal to carina
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LUNG CANCERBronchoscopy