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WILM"S TUMOR DAN PENATALAKSANAANNYA / Nephroblastoma

Wilm's tumor (Nephroblastoma)

A. INTRODUCTION

            Wilms tumor is the most malignancies and is the fifth most common renal tumor at the age of the children. These tumors most Appear at the age of three years and is rare after the age of 8 years. There are 250 cases of Wilms tumor ever reported. However, the preoperative diagnosis of Wilms' tumor in the adult is quite difficult. These tumors usually Appear as a solid renal mass with or without accompanied by hematuria. This solid mass may be accompanied by cystic part by focal necrosis and degeneration process. Sometimes radiological picture may resemble renal cysts hemorhagik. These tumors arise in one or two kidneys. (1) (7)

            Diabdomen large masses, especially in children aged 1-5 years should arouse suspicion Wilm tumors. This neoplasm is aggressive and metastasizes to various organs, but to respond to combination therapy. Wilms tumor when Diagnosed and receive NAMAs therapy has a cure rate is quite high, reaching 90%. (1) (7)

            The development of diagnostic imaging lately also play an important role in enhancing the efficacy and accuracy of the diagnosis of Wilms tumor and this is very important in designing the best combination therapy in children. (1) (7)

B. Epidemiology

            Wilms Tumour incidence was 0.8 cases per 100,000 people. There are 500 new cases each year in the United States, and as much as 6% of it involves both kidneys. Risks incident to hit Wilm tumor is 1 in 10,000 births. Wilms tumor Occurs primarily in children under the age of 5 years. The incidence is highest between the ages of 1-3 years. It is estimated that these tumors in 7 Occurred between 1 million children in the United States and much of the African-American race. The ratio of female Patients and the male is almost balanced. (7)

Krukernberg TUMOR DIAGNOSIS

Krukernberg is a malignant tumor of the ovary is a classic will do GIT.  Althougt tract metastases to the pila can arise in other tissues such as the breast. Adenocarcinoma of the stomach, especially in the area of the pylorus, a major source   of the most frequent tumor . Kreukenberg (over 80%) are found on both ovaries, consistent with the nature of these metastases.

Krukenberg tumors can be seen in all age groups, with an average age of 45 years . in united State, cancer that has metastasized to the ovary is only about 1 to 2% of cancers in Japan ovarium. but an increase in the occurrence of Krukenberg tumors is due to an increase in the prevalence of gastric cancer.

In people who have a malignancy nongynecologi, approximately 20% of adnexal masses were malignant, and 60% of them Krukenberg tumors.

TUMOR MARKER TERKINI / CURRENT TUMOR MARKER

CURRENT TUMOR MARKER

Advances in science and technology in the development of immunology, bringing a process in the early detection of cancer. As well as detection diagnosis, monitoring cancer progression, and determination of prognosis. Identification of the content of the tumor can help predict the diagnosis and cause of diseases.

With the advancement of technology development and advancement of biotechnology labratorium, now can be a marker mendeketksi kegananasan. Not only from the surrounding tissue to cancer can also detect up parts of the cell.

Because the clinical symptoms of the cancer started from uncontrolled growth sell, referred to as the disease of cancer cells or tissues with the hallmark of uncontrolled growth which can infiltrate surrounding tissues and organs, but now approved cancer is caused by the accumulation of mutations in several genes. Serological tumor markers is defined as the product of a tumor of the blood which shows the reflection of the tumor mass in the body.

TUMOR GANAS PADA ANAK / CANCER IN CHILDREN

INTRODUCTION

At first, the incidence of colon and rectal malignancies are not taken into account prior to 1900. However, since economic progress and growing industry, this increased incidence of malignancy. At this time, colorectal cancer is the third leading cause of death of men and women from cancer in the United States.

The incidence of colorectal cancer in Indonesia is quite high, so the 2002 figures kematiannya.Pada colorectal cancer ranks second in cancer cases are found in men, whereas in women colorectal cancer ranks third of all cases kanker.Meskipun no definitive data, but of various reports in Indonesia there are increasing number of cases, data from the Ministry of Health found 1.8 per 100,000 population numbers. ^1.4

In most cases of cancer, there is geographic variation in incidence were found, reflecting differences in socioeconomic and population density, particularly between developed and developing countries. Similarly, between the West and Indonesia, there is a difference in the frequency of colorectal cancers are found. In Indonesia, the frequency of colorectal cancer were found comparable between men and women; numerous in the young person; and approximately 75% of cancers found in the rectosigmoid colon, whereas in Western countries the frequency of colorectal cancers are found in men than women; numerous in the older person; and of cancer that is found only about 50% are located in the rectosigmoid colon. ²

Location of colorectal cancer is most often found in colon colorectal cancer patients rektosigmoid.Keluhan depending on the size and location of the tumor. Complaints of colonic lesions erada on the right can be a feeling of fullness in abdominal, symptomatic anemia and bleeding, while complaints from lesions in the left colon may be changes in the pattern of defecation, bleeding, constipation until the obstruction.

The division is based on the classification stages of the Duke is a complete blood test, digital rectal, barium enema, sigmoidoscopy, colonoscopy. Therapy consisted of curative and paliatif.Pengobatan curative therapy is surgery. Palliative therapy with chemotherapy and radiation. ⁵

CHAPTER II

LITERATURE REVIEW

II. 1. Wilms tumor

Wilms tumor is a malignant tumor derived from embryonic kidney metanefros. . Wilms tumor is a malignant tumor of the kidney that is most in infants and children. Approximately 80% of these tumors occurring in children under 6 years, with a peak incidence at 2-4 years of age. Wilms tumor can also be found in Wilms neonatus.Tumor counted 6% of all malignant disease in children. The incidence of the disease is almost the same in every country, because there is no distinction of race, climate and environment, which is an estimated 8 per 1 million children under the age of 15 years. Comparison of the incidence of men and women almost equally. Location of the tumor is usually unilateral, more often on the left, could also bilateral (approximately 5%). ⁶

Figure 1. Wilm's Tumor

Wilms tumor is derived from the pathological proliferation of blastema metanefron due to the absence of normal stimulation of duct metanefron to produce tubules and glomeruli of the renal blastema baik.Perkembangan differentiate to form the structure of the kidney occurs at 8-34 weeks gestation. So that primitive blastema is expected that the ability to pave the way for the formation of Wilms tumor, whether as a germ or somatic mutations, it occurs at 8-34 weeks gestation. ^6,7,8

Approximately 1.5% of patients have relatives or other family members who also suffer from Wilms tumor. Nearly all cases of unilateral descent is not different with the case of bilateral tumors. Approximately 7-10% of cases of Wilms tumor inherited autosomal dominant. Genetic mechanisms associated with this disease, is not yet fully known. In patients with WAGR syndrome (Wilms tumor, aniridia, genital malformations and mental retadasi) showed the presence of cytogenetic deletion in chromosome 11, region p13. In some patients, found WT1 gene on the short arm of chromosome 11, region p13. WT1 gene expression specifically in the kidney and is known as a transcription factor that is thought to be responsible for the development of Wilms tumor. ⁷

Pathology

Wilms tumor is composed of a network of primitive blastema metanefrik. Besides, these tumors   often contain tissues that are not normally found in normal metanefron, eg bone tissue, cartilage and squamous epithelium. highly diverse histological picture is characteristic of a Wilms tumor. Classical picture of Wilms tumor is triphasic, including epithelial cells and stromal blastema. Based on histological and clinical correlations, Wilms tumor histopathological picture can be classified into three groups, namely low-risk tumors ( favorable ), moderate-risk tumors and high-risk tumors ( unfavorable ). ⁷

Stadium

The National Wilms Tumor Study (NWTS) divides 5 Wilms tumor stage, namely:

Stage I: Tumor confined to the kidney tissue without penetrating the capsule. These tumors can be in with a complete resection.

Stage II: Tumor penetrates the capsule and extends into the surrounding renal tissue and perirenal tissues, namely kidney, the renal hilum, the renal vein and para-aortal lymph nodes. Tumors can be resected completely still.

Stage III : The tumor spread to the abdominal cavity (perkontinuitatum), for example, to the liver, peritoneum and others.

Stage IV : The tumor hematogenous spread to the abdominal cavity, lungs, brain and bone.

Clinical manifestations

Hematuria (macroscopic) present in approximately 25% of cases, due to tumor infiltration into the system Calix. Hypertension was found in about 60% of cases, presumably due to suppression of tumor or hematoma on the blood vessels that supply blood to the kidneys, resulting in tissue ischemia which will stimulate the release of renin, or tumors themselves secrete renin. Other symptoms such as anemia, weight loss, urinary tract infections, fever, malaise and anorexia. match In some patients who are colicky abdominal pain, due to a blood clot in the urinary tract. Wilms tumors are not infrequently found with other congenital anomalies, such as aniridia, hemihypertrophy, urinary tract or genital anomalies and mental retardation. ^7.8

Diagnosis

Wilms tumor diagnosis based on:

·          Clinical symptoms

·          radiological examination (IVP and ultrasound), laboratory LDH 

·          confirmed by histopathological examination of tumor tissue

With IVP examination seemed distortion pielokalises system (changes shape pielokalises system) and once this examination is useful to determine kidney function. Ultrasound is non-invasive inspection can differentiate solid tumors with tumor-containing fluids. With ultrasound, Wilms tumor appears as a solid tumor in the kidney area. Results of laboratory tests essential that support for Wilms tumor is the concentration of lactic dehydrogenase (LDH) elevated and Vinyl mandelic acid (VMA) in the normal range. ⁷

 Therapy

Wilms tumor treatment modality consists of, operation (surgery), chemotherapy and radiotherapy. In stage I and II tumors with cell type favorable , surgery with dactinomycin and vincristine combination chemotherapy without radiation of the abdomen. With stage III tumor cell types favorable given surgical treatment with a combination daktinomisin, vincristine and doxorubicin with abdominal radiation. For stage IV tumors with cell type favorable , given the combination daktinomisin, vincristine and doxorubicin. Patients also received abdominal radiation and lungs when it is no spread to the lung tissue. In cases with stage II to IV anaplastic cell types ( unfavorable ) are given surgical treatment with a combination daktinomisin, vincristine and doxorubicin plus siklofospamid. In these patients also received abdominal radiation and lung. ^6,7,8

Prognosis

Several factors determine the prognosis, the tumor size, histopathologic picture, the age of the patient and the stage or degree of tumor dissemination. Those who have a good prognosis are patients who have tumor size was small, the high degree of cell differentiation in histopathologic, still early stage or no metastasis and patient age under two years.

II. II. RHABDOMIOSARKOMA

Rhabdomiosarkoma (RMS) This word comes from the Greek, (rhabdo, which means striated shapes, and myo meaning muscle). Rhabdomyosarcoma is a malignant tumor that originates from the soft tissue (soft tissue) of the body, including here is muscle tissue, tendons and connective tissue. Rhabdomyosarcoma is a malignancy that is often found in children anak.Respon treatment and prognosis of the disease is highly dependent on the location and histological features of the tumor itself. The rate was slightly higher incidence in boys and white children. These tumors can occur in any location but most frequently in the head and neck 40%, 20% genitorius tract, limb 20%, weight 10%.

Predisposition Factor

• Congenital abnormalities.
• Rare syndromes such as Beckwith-Wiedemann Syndrome and Recklinghausensyndrome.
• Abnormalities in the formation of tumor-derived (autosomal dominant, chromosome 17).
• Li-Fraumeni Syndrome
• Neurofibromatosis type 1 (NF 1)
• Costello syndrome.

Classification

Intergroup Rhabdomyosarcoma Study (IRS) made a classification of laboratory and surgery for rhabdomyosarcoma, namely:

a.       Group I:

Only local disease, regional lymph nodes are not involved, complete resectable

1)       Confined to muscle or organ original

2)       Infiltration out muscle or organ original

b.       Group II:

1)       widely resectable tumors with microscopic residual (lymph node negative)

2)       regional disease, complete resectable (positive or negative lymph nodes)

3)       Reginal disease involving lymph nodes can be resected widely but with microscopic residual

c.        Group III:

Incomplete resection or biopsy only with sufficiently large residual disease

d.       Group IV:

There has been a metastasis is diagnosed when

Staging TNM (tumor, nodes and metastases)

Tumors:

T0: no palpable tumor

T1: tumor <5 cm

T2: tumor> 5cm

T3: the tumor has invaded the bone, blood vessels and nerves

Nodules:

No: not found regional node involvement

N1: regional node involvement is found

Metastasis:

Mo: there are no distant metastases

M1: There is distant metastasis

Rhabdomyosarcoma Staging System:

Stage 1: the location of the orbit, and head or neck (not Parameningeal) extends to the urinary tract (bladder or prostate instead)

Stage 2: other locations, No or Nx

Satge 3: other locations, N1 if tumor <5 cm or No or Nx if tumor> 5 cm

Stage 4: any location and there are distant metastases

Based on histological examination, it can be determined the degree of severity (grading):

a.        G1: well differentiated (good)

b.       G2: moderately differentiated (moderate)

c.        G3: poorly differentiated (bad)

Determination of specific histiotipe need for therapy and prognosis. There are four types of known subhistologi namely:

a.        embryonal type

Embryonal rhabdomyosarcoma is the type most commonly found in children, approximately 60% of all cases rabdomiosarkoma.Tumor can occur anywhere, but most often on the genitourinary, head or leher.Pada histology histology of this type have a high variability, which illustrates some levels of muscle morphogenesis skeletal.Merupakan neoplasms with high differentiation consisting of rabdomioblas with eosinophilic cytoplasm. Desmin and actin were found in the muscles used for diagnosing rhabdomyosarcoma

b.       Alveolar Type

Alveolar tumors that cause approximately 15% of cases, is characterized by the chromosomal translocation T (2; 13). Tumor cells tend to grow in the nucleus (core), which often have a slit-like spaces that resemble alveolar alveoli.Tumor most often occurs in the body and limbs and have the worst prognosis.

c.        Botrioid type,

It is a variant form of embryonal tumor and stromal cells which are swollen protruding into the cavity of the body like a bunch of grapes, causing 6% of cases and most often appear in the vagina, uterus, bladder, nasopharyngeal and middle ear.

d.       pleomorphic type (adult form)

Pleomorphic type (adult form) is rare in children (1% of cases). Approximately 20% of patients are estimated to have undifferentiated sarcoma. This type is very rare in patients over 45 years the other three in 90% of cases occur before the age of 20 years. Pleomorphic variant has atypical tumor cells were large, some showing cytoplasm with corakan berlurik much typical for skeletal muscle differentiation.

Histopathologic Classification TNM After Unresectable

pT0: There is no tumor on histological examination.

PT1: Limited on the organ of origin. Excision perfect.

Pt2: The invasion into surrounding organs, excision perfect.

PT3: Invasion into surrounding organs, excision is not perfect.

         a. Remaining visible microscopically

         b. The rest can be seen as a macroscopic

         c. Tumor can not be resected.

Nopt 4

pN0: No lymph nodes affected

PN1: lymph nodes affected

pM0: No metastasis to distant sites

PM1: There is metastasis to distant sites

Stages

- Stage I (16% of cases)

Cancer is only found in the initial site of cancer arise On microscopic examination, there are no cancer cells in the tissue after the tumor is removed.

- Stage II (28% of cases)

Divided into II A, II B, and II C

1. IIA: Cancer can be lifted, but microscopically, there are remaining cancer cells in the tissue. No lymph nodes were affected.

2. IIB: The cancer is localized, it can be removed, ith or without lymph node involvement

3. C II: The cancer has spread to lymph nodes. Cancer and lymph nodes still can be removed surgically, but still terapat remaining cancer cells are microscopic.

- Stage III (36% of cases)

Cancers can be removed surgically, but still there are remaining cancer can be seen without mikroskop.Kanker has not spread to distant sites.

- Stage IV (20% of cases)

Cancer has spread to distant sites.

Other variants are basically small tumors primitive blue cell, poorly differentiated have a focal skeletal muscle differentiation (rabdomioblas with eosinophilic cytoplasm and corakan striated).

Differentiation rabdomioblastik may only appear with electron microscopic or immunohistochemical techniques (ribosome-myosin complex or positive imunoperoksidase to desmis / myoglobin). Variance alveolar characterized by translocation 2; 13 chromosomal).

Pathology

Rhabdomiosarkoma thought to arise from the same embryonic mesenchymal skeletal muscle denngan attack latitude. Definitive diagnostic test requires menggnakan histokimiawi with antibodies   against skeletal bibs (desmin) and electron microscopy to distinguish typical image. Histological typing of need for therapy and prognosis. Subhistologi there are four types are known. embryonal type, causing 60% of all cases with moderate prognosis. botrioid type, a variant form of embryonal tumor and stromal cells which are swollen protruding into the body cavity like a bunch of grapes, resulting in 6% of cases and most often appear in the vagina, uterus, bladder, nasopharynx, and middle ear. Alveolar tumors that cause approximately 15% of cases. Palling alveolar tumors often occur on the limbs of the body and have the worst prognosis. pleomorphic type is rare in childhood 1% of cases. approximately 20% of patients with undifferentiated sarcoma estimated possessed.

CASE SOFT TISSUE TUMOR

CASE SOFT TISSUE TUMOR

1.1 PATIENT IDENTITY

·         Name                     : Tn. A

·         Sex                        : Male

·         Age                       : 27 yo

·         Address                 : depok

·         Job                         : Construction laborers

·         Marital Satus         : Married

·         Dates                     : July 12, 2013

1.2 ANAMNESA (AUTOANAMNESA dated 14 Juliy 2013)
A. Main complaints: lump on the right forearm and the left and on the left thigh.

B. History of Present

Patients come to Arjawinangun hospital with complaints lump on right forearm, left forearm and left thigh since 2 years. At first the patient know that there are bumps in the sudden emergence of left forearm due to the size of a mosquito bite like bumps, bump color resembling skin color around, not itchy, no pain, no red, well defined, smooth, soft palpable, not interfere with movement and activity and can be shaken. The lump is felt constantly popping up in other parts of the body. Not long after, a similar lump appeared in the right forearm and left thigh. The longer, the lump is felt enlarged, lump in right forearm-sized fruit like wild Cerri, a lump in the left forearm is slightly smaller than the lump in the right forearm, left thigh lump the size of a green pea.

Complaints of fever and headache denied. A history of high blood pressure and diabetes denied. Riwaya trauma and exposure to chemicals denied. On May 7, 2013, has performed the surgical removal of the lump on the right forearm and left forearm patient. Cerri obtained mass of fruit on the left forearm and arm of a pea on the bottom right side, pale yellow, and chewy.

BENIGN BONE TUMOR and handling / TUMOR JINAK PADA TULANG

BENIGN TUMOR BONE and handling

            Definition of tumor or neoplasm is an umbrella term used to describe the growth of mass (solid / solid) or abnormal tissue in the body. This mass arises as a result of an imbalance of growth and regeneration of cells or tumor is a collection of abnormal cells formed by cells that grow continuously are not limited to, not coordinated with the surrounding tissue and are not useful for the body.

            The incidence of some neoplasms bekaitan bone with age. Anatomic locations also have specificity, ie the most common occurring in long metaphysical areas, namely the distal femur, proximal tibia and proximal humerus. Based on the research found that the biggest trigger the occurrence of bone tumors are genetic factors. The initial symptoms are common in the form of prolonged pain in the bones. This pain may arise as a result of trauma impact, but could not. Not infrequently found patients initially it did not feel pain, but swelling of the bone. Interestingly, this tumor potential attack patients under the age of 20 years.

            Classification of bone tumors, namely primary and secondary (metastatic). Primary bone tumors are divided into benign tumors (benign) and malignant tumors (malignant). In Indonesia alone, the term refers to a tumor over benign tumors.   tumors are benign, does not always mean 'harmless', although most are usually harmless. A benign tumor (benign tumor) can still evolving, and could cause damage to the tissues, nerves or organs nearby. Depending on the location and magnitude, the tumor can still be a serious illness and life-threatening, such as brain tumors.

            Benign neoplasms of bone ditatalaksanai with excision or curettage. Bone defect was closed with bone grafts. When you disturb the surrounding tissue, the doctor may suggest surgical removal (surgery). Currently surgical techniques have been developed rapidly, even involving laser surgery technology, or cryosurgery (freezing) tumors.

CHAPTER II

Anatomy and physiology BONE

Anatomy and physiology SYSTEM MUSKULOSKLETAL (BONE)

            Muskuloskletal system is supporting the body shape and take care of the movement. The main component of connective tissue system is muskuloskletal. This system consists of bones, joints, skeletal muscles, tendons, ligaments, Ø exchanges, and a dedicated network that connects these structures. 

Aspects of male and female infertility / INFERTILITAS ASPEK PRIA DAN WANITA

Aspects of male and female infertility

 many infertile couples  can be calculated from the number of women who never marry, nor have children who are still alive, then according to the census there were 12% in both rural and urban, or think - about 3 million infertile couples in the whole of Indonesia.

In present-day medical science has managed to help infertile couples have 50% of their children. That means the other half are forced to live without children, adopt a child (adoption, polygamy, or even divorced.

Truly for the health of family planning is never complete without penganggulan infertility problems. In terms of health, family planning should include the prevention and treatment of infertility, especially if it happened before before couples have children - children she wanted. Moreover penganggulan alongside infertility family planning services that make the latter more easily acceptable, because it obviously takes into account programs such as happiness and well-being of the family. ²

Since some twenty years ago has been a lot of investigation that links fertility with husband semen analysis, especially spermatozoanya concentration. MacLeod & Gold in 1951 have reported the results of their investigation to the husband that his wife was 1.000 checkups. At that time there were only 5% with a concentration of less than 20 million spermatozoa / ml, whereas 44% of more than 100 million / ml. Twenty-four years later, Rehan et al reported the results of their investigation to the husband who will divasektomi 1300. Apparently, the 7% concentration spermatozoanya less than 20 million / ml, but only 24% are more than 100 million / ml. Zukermaan et al, 4122 investigated a husband who will divasektomi, there is a 12% concentration of less than 10 million spermatozoa / ml. Thus, the results of recent investigations differ from results obtained by MacLeod & Gold.

Such changes can only be explained by a decrease in fertility minimum standards due to rising fertility potential husband and wife. The wife is not ovulating can always fertilized egg cell, for example due to luteal phase defect, short luteal phase or ignorance when - when fertile in order to make pregnancy intercourse. More advanced treatment of the disorders - disorders in the wife's menstrual cycle and lighting - lighting that adds to the knowledge partner for intercourse at the time - if desired fertile time pregnancy, has increased the fertility potential of the wife so that only the required concentration of spermatozoa is not too high to make the pregnancy. ¹

                                                

                                                             

Definition

Fertility is the ability of a wife to become pregnant and give birth to a child who is able to live by husband menghamilkannya. So fertility is a function of the partner who could make pregnancy and live birth. ¹ Sterility is the term used for someone who is absolutely not possible to get offspring for example, women with genital aplasia or male without testes. Infertility is the diminished fertility. A so-called infertile couples when the wife is not pregnant within 12 months (1 year) after mating without practicing contraception (intentional).

According to Whitelaw 56.5% of healthy couples become pregnant in the first month and 78.9% in the first 6 months. Infertility is divided in two, there is primary infertility and secondary infertility. ²

The definition of primary infertility is if the wife had never been pregnant though copulate and faced with the possibility of pregnancy for 12 months. Called secondary infertility when his wife was pregnant, but then does not happen again though copulate pregnancy and faced with the possibility of pregnancy for 12 months. ¹

Etiology

LUNG CANCER / KANKER PARU

INTRODUCTION

            The high rates of smoking  will make lung cancer as one of the problems of health in Indonesia, such as the problems of other malignancies. Increased morbidity of malignant disease, such as cancer can be seen from the Household Health Survey (Survey)  shows the death rate due to cancer is still around 1.01% to 4.5% in 19901. data made ​​by WHO showed that lung cancer is a type of disease malignancy was the cause of death in the group of death from malignancy, not only in men but also in women. The poor prognosis of this disease may be closely related to the scarcity of patients come to the doctor when the disease is still in the early stages of the disease. The results of the study on postoperative lung cancer patients showed that, the average 5-year survival rate stage I very much different from those after stage II surgery, especially when compared with untreated advanced staging is 9 months.    Lung cancer is one type of lung disease require handling and swift and focused action. Diagnosis of this disease requires skills and tools that are not simple and requires a multidisciplinary approach medicine. This disease requires close cooperation between experts and integrated pulmonary diagnostic radiologist, pathologist, radiologist therapy and thoracic surgeons, medical rehabilitation specialists and other experts. Disease treatment or containment procedures is highly dependent on the dexterity of lung experts to get a definite diagnosis. The discovery of lung cancer at an early stage will help the patient, and the discovery of the diagnosis in a faster time allowing patients gain a better quality of life in the course of the disease although it can not cure it. The choice of therapy should be immediately carried out, given the poor response to various types of lung cancer treatment. Even in some cases of lung cancer patients require a handler as soon as possible, although a definite diagnosis can not be enforced.

             Lung cancer in its broadest sense is any disease in lung malignancies, including lung malignancy originating from outside itself and the malignancy of the lung (metastatic tumors in the lungs). In this management guidelines are intended to lung cancer is of primary lung cancer, the malignant tumor derived from bronchial epithelium or bronchial carcinoma (bronchogenic carcinoma). According to the present concept of cancer is a disease of genes. A normal cell can become cancerous cells by a variety of causes occurs when an imbalance between oncogene function with tumor suppresor genes in the process of growth and blossoms a sel.Perubahan or gene mutations that cause hiperekspresi oncogenes and / or lack / loss of gene function causes cell tumor suppresor grow and develop unchecked. This change goes in phases, known as the Multistep carcinogenesis . Changes in the chromosomes, such as chromosome loss or LOH heterogeniti also suspected as a mechanism of cell growth abnormalities in cancer cells. From various studies have to be known a few oncogenes that play a role in the carcinogenesis of lung cancer, among other genes myc, k-ras gene whereas tumor suppresor gene clusters antaralain, the p53 gene, rb gene. While changes in the chromosomal location of 1p, 3p and 9p frequently found in lung cancer cells.

            Lung cancer is the growth of cancer cells that are not controlled in the lung tissue. The pathogenesis of lung cancer has not been completely understood. Looks like bronchial mucosal cells undergo metaplastic changes in response to chronic exposure to inhaled particles and injured lungs. In response to cellular injury, inflammatory reactions and processes will evolve. Basal cell proliferation and mucosal will have differentiated into mucus-secreting goblet cells. It seems that the activity is due to metaplastic columnar epithelium lining the turn of the squamous epithelium, which is accompanied by cellular atypia and increased mitotic activity which develops into mucosal dysplasia. Span of time this process has not been established, only estimated approximately between 10 to 20 years.

            The origins of the causes of lung cancer cells still can not be explained. During these two theories evolve, Theory pleuripotential cell by Auerbach, which explains the deviations that occur in the process of stem cell differentiation into cells by Yesner lain.Teori small cells, which explains the small cell neoplasms transformed and evolved into cell kanker.Namun known that genetic mutations occur in p73, p53 and PRB, in addition to the role of the oncogene c-MYB, c-MYCA, mycc c-, c-raf, L-myc, N-myc, K-flavor, c-Fura, N-ras , H-ra, c-erbB1, c-fms, c-fes, c-rlf, c-erbB1, c-ErbB2, c-sis, BCL1.

            According to WHO, lung cancer is the leading cause of death in the group of cancer in both men and women

Types of lung cancer:

1. Squamous cell carcinoma

2. Lung Adenocarcinoma

3. Adenocarcinoma bronkioalveolar

4. Carcinoma large cell

Classification of lung cancer defined by WHO standards,

I. Epithelial Tumors

A. Sarcoma    

            1. Papilloma               

            2. Adenomas               

B. Dysplasia

C. Carcinoma 

            1. Squamous cell a. spindle cell variant      

            2. Tiny cell        a. wheat cells

                                    b. intermediate cells

                                    c. combination of wheat cells

            3. Adeno          a. acinar          

                                    b. papillary     

                                    c. bronkioalveolar       

                                    d. Solid carcinoma with mucin formation      

            4. Larger cell        a. giant-cell

                                    b. clear-cell

            5. Adenoskuamus                    

            6. Carcinoid tumors

            7. Bronchial glands                 

            8. Others                 

II. Soft tissue tumors

III. Mesothelial tumors

            A. Sarcoma                            

            B. Carcinoma                         

IV. Other Tumors

            A. Sarcoma                            

            B.Karsinoma                          

V. secondary tumors

VI. Tumors that have not been classified

VII. Tumor-like lesions

            More than 90% of lung cancers originated from the bronchi, to bronchogenic cancer is called carcinoma, which consists of:

1.                   squamous cell carcinoma

2.                   carcinoma small cell

3.                   carcinoma large cell

4.                   Lung Adenocarcinoma

            Alveolar cell carcinoma originating from the alveoli in the lungs. This cancer can be a single growth, but often strike more than one area of ​​the lung.

Lung tumors are less common are:

1.                   adenomas (either malignant or benign)

2.                   Hamartoma kondromatous (benign)

3.                   sarcoma (malignant)

            Lymphoma is a cancer of the lymph system, which can be derived from the lung or is spread from other organs. Many cancers that originated elsewhere spread to the lungs. This cancer usually comes from the breast, colon, prostate, kidney, thyroid, stomach, cervix, rectum, testicles, bones and skin.

Squamous cell carcinoma

           

            Called squamous cell carcinoma, or SCC in English, this type of cancer is common in the main bronchial tubes. Generally there is a development of keratin and keratin pearls.

Lung Adenocarcinoma

           

            Lung adenocarcinoma were recorded around 30% - 45% and will likely continue to increase. Cases of lung adenocarcinoma usually occurs in the lungs and organs are more common in women than in men, with a tendency to early metastasis in the area around the lymph nodes and brain. Patients with lung adenocarcinoma typically have a chronic history of interstitial lung disease, such as scleroderma, rheumatoid disease, sarcoidosis, interstitial pneumonitis, tuberculosis, recurrent lung infections or lung disease accompanied by necrosis. This causes scar carcinoma is often called adenocarcinomas.

Adenocarcinoma bronkioalveolar

            A subtype of lung adenocarcinoma with an incidence rate of approximately 2% - 4% of the total incidence of lung cancer, often associated with several lung diseases that result in pulmonary fibrosis, such as pneumonia, idiopathic pulmonary fibrosis, granulomata, asbestosis, alveolitis with fibrosis, scleroderma, and disease Hodgkin. The place of this cancer is still being debated, but the possibility has been minimized between Clara cell population or type II pneumocytes along the alveolar septa propagating.

Large cell carcinoma

            This cancer has an incidence rate of approximately 9%. Tumor cells characterized by large cells with large nuclei. Have not found the glandular or squamous differentiation.

            There is a classification of lung cancer,'s seen from both dijaringan pulmonary diffusion rate itself and to other organs. But basically lung cancer is divided into two criteria based on the level of distribution:

1.                   primary lung cancer

            Has two main types, namely Small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). SCLC is the type that sell small (many) which has a very rapid growth to swell. Usually called "oat cell carcinomas" (wheat cell carcinoma). This type is closely associated with smokers, Handling respond well enough through the action of chemotherapy and radiation therapy.

            While the growth of NSCLC is a single sell, but often affects more than one area of ​​the lung. For example adenoma, Hamartoma kondromatous and Sarcoma.

2.                   secondary lung cancer

            Lung cancer is a disease that arises as a result of the spread of cancer from the other organs, most commonly breast cancer and colon cancer (stomach). Cancer spreads through the blood, lymphatic system or because of the proximity of the organ.

Epidemiology

            Lung cancer is responsible for most deaths due to cancer in men and women throughout the world. The American Cancer Society memperkirakna that 213.380 new cases of lung cancer will be diagnosed in the United States and 160.390 deaths due to lung cancer will occur in 2007. Lung cancer is largely a disease of the elderly; nearly 70% of people diagnosed with the condition are over 65 years old, which is less than 3% of cases occur in people under the age of 45 years.

            Lung cancer was not common prior to the 1930s but increased dramatically over the following decades when the smoke rising. In many countries that are developing, the incidence of lung cancer is beginning to decline following the public education about the dangers of smoking and smoking cessation programs are effective. Nevertheless, lung cancer remains among the types most common cancer in both men and women throughout the world.

            Lung cancer has also been passed in breast cancer resulted in the most deaths related to cancer in women in the United States.

CAUSE

Smoke

            Incidence of lung cancer is strongly associated with cigarette smoking, with about 90% of cancer-lung cancer arising as a result of tobacco use. The risk of lung cancer increases with the number of cigarettes smoked over time; doctors refer to this risk in terms of annual pack history of smoking (number of packs of cigarettes smoked per day multiplied by the number of years of exploitation). For example, a person who has smoked two packs of cigarettes per day for 10 years has a 20 pack year history. When the risk of lung cancer increases even with a 10 pack year smoking history, those with a history of 30 pack-year history or more considered to have the greatest risk of developing lung cancer. Among who smoke two or more packs of cigarettes per day, one in seven will die of lung cancer.

            Pipe and cigar smoking can also cause lung cancer, although the risk is not as high as with cigarette smoking. Where a person who smokes one pack of cigarettes per day has a risk of developing lung cancer is 25 times higher than the non-smokers, smokers of pipes and cigars have a risk of lung cancer is approximately 5 times than someone who does not smoke.

            Tobacco smoke contains over 4,000 chemical compounds, many of which have been shown to cause cancer, or carcinogenic. Two major in-carcinogenic carcinogenic tobacco smoke are chemicals known as nitrosamines and polycyclic aromatic hydrocarbons . The risk of developing lung cancer decreases each year due to smoking cessation as normal cells grow and replace damaged cells in the lung. In former smokers, the risk of developing lung cancer begins to approach that of a nonsmoker about 15 years after cessation of smoking.

Passive Smoking

            Asbestos fibers (asbestos fibers) are silicate fibers (silicate fibers) that can persist for a lifetime in lung tissue due to exposure to asbestos. The workplace is a common source of exposure to asbestos fibers is common, because asbestos is widely used in the past for both of them, namely as heat insulation materials and acoustic. Today, asbestos use is limited or banned in many countries, including the United States. Both lung cancer and mesothelioma (a type of cancer of the pleura or lining of the abdominal cavity called the peritoneum ) are associated with exposure to asbestos. Mehisap smoking dramatically increases the chances of developing a lung cancer associated with asbestos-exposed workers. Asbestos workers who do not smoke have a risk of developing lung cancer five times than non-smokers, and asbestos workers who smoke have a risk of 50 to 90 times greater than nonsmokers.

Radon Gas

            Radon gas is a noble gas and natural chemical which is a breakdown product of natural uranium. He broke / crushed form products that emit a type of ionizing radiation. Radon gas is a known cause of lung cancer, with an estimated 12% of lung cancer deaths attributable to radon gas, or 15,000 to 22,000 deaths associated with lung cancer each year in the U.S., making radon the second leading cause of cancer lung in America. As with exposure to asbestos, smoking is simultaneously a very large increase in lung cancer risk with exposure to radon. Radon gas can move through the soil and into the house through gaps between the foundations, pipes, ducts, or other open places. The U.S. Environmental Protection Agency estimates that one out of every 15 homes in America contain levels of radon gas are dangerous. Radon gas is invisible and odorless, but it can be detected with a checkered simple test.

Tendency Family

            While the majority of lung cancers are associated with tobacco smoke, the fact that not all smokers eventually develop lung cancer suggests that other factors, such as individual genetic sensitivity, may play a role in causing lung cancer. Many studies have shown that lung cancer is likely to occur in both brothers who smoke and non-smokers who have had lung cancer than the general population. Recent research has localized a region on the long arm of human chromosome number 6 that is likely to contain a gene that confers an increased sensitivity of developing lung cancer in smokers.

Lung Diseases

            The presence of certain lung diseases, especially chronic obstructive pulmonary disease (COPD), is associated with a slightly increased risk (four to six times the risk of a nonsmoker) for developing lung cancer even after the effects of cigarette smoking have been dispensed simultaneously.

Previous history of Lung Cancer

            The survivors of lung cancer have a greater risk than the general population of developing a second lung cancer. The survivors of non-small cell lung cancers (NSCLCs, see below) have an additional risk of 1% -2% per year developing a second lung cancer. In those survivors of small cell lung cancers (SCLCs), the risk of developing second cancers approaches 6% per year.

Air Pollution

            Air pollution from vehicles, industry, and places of power generation (electricity) can increase the likelihood of developing lung cancer in exposed individuals. Up to 1% of lung cancer deaths are caused by breathing polluted air, and experts believe that prolonged exposure (long) at a very high polluted air can carry a risk similar to that of passive smoking to develop lung cancer.

DIAGNOSIS

            The symptoms of lung cancer varies depending on where and how wide spread of the tumor. Warning signs of lung cancer are not always present or easy to identify. A person with lung cancer may have all kinds of the following symptoms:

·                      No symptoms : In up to 25% of people who get lung cancer, cancer is first discovered on a chest x-ray and CT scans on a regular basis as a small remote mass sometimes called a coin lesion (coin lesion ). These patients with single masses often report no small symptoms of lung cancer at the time it was found.

·                      What are the symptoms associated with cancer : cancer Pertumubuhan and assault (invasion) of lung tissues and the environment-the environment may interfere with breathing, leading to symptoms such as cough, shortness of breath, wheezing (wheezing), chest pain, and coughing up blood ( hemoptysis ). If the cancer has invaded nerves, for example, it may cause shoulder pain that moves down the outside of the arm (called Pancoast's syndrome ) or paralysis suaru bands leads to a hoarse voice (hoarse). Attack the esophagus may lead to difficulty swallowing ( dysphagia ). If a large airway is obstructed, mengempisnya portion of the lung may occur and cause infections (abscesses, pneumonia) in the obstructed area.

·                      Symptoms related to metastasis : Lung cancer that has spread to the bones may produce excruciating pain at the sites of bone involved. Cancer that has spread to the brain may cause a number of neurologic symptoms that may include blurred vision, headaches, attacks (seizures), or symptoms of stroke such as weakness or numbness in parts of the body.

·                      Paraneoplastic Symptoms : Lung cancers are often accompanied by so-called paraneoplastic syndromes that result from the production of the elements that resemble hormones by the tumor cells. Paraneoplastic syndromes occur most commonly with SCLC but may be seen with any tumor type. A common paraneoplastic syndrome associated with SCLC is the production of a hormone called adrenocorticotrophic hormone (ACTH) by the cancer cells, leading to excessive secretion of cortisol by the adrenal glands ( Cushing's syndrome ). Paraneoplastic syndromes (paraneoplastic syndrome) is most often seen with NSCLC is the production of a substance similar to parathyroid hormone, resulting in calcium levels are increased in the blood stream.

·                      Nonspecific Symptoms : nonspecific symptoms seen with many cancers, including lung cancer include weight loss, weakness, and fatigue. Psychological symptoms such as depression and mood changes are also common.

Diagnostic procedures

Clinical picture

A. History

            Lung cancer clinical picture is not much different from other lung diseases, comprising darikeluhan subjective and objective symptoms. Of history will be obtained and perjalananpenyakit main complaint, as well as other factors that are often very helpful establishment of the diagnosis. Utamadapat complaint form:

• Cough-cough with / without sputum (phlegm white, can also purulent)

• Coughing up blood

• Shortness of breath

• Hoarseness

• Chest Pain

• Difficulty / pain swallowing

• A lump in the base of the neck

• swollen face and neck, sometimes accompanied by swollen arm pain

terrific.

            Not infrequently the first visible symptoms or complaints are due to metastases outside the lung, such as disorder arising from intense compression in the brain, liver enlargement or broken tulangkaki.

Symptoms and complaints that are not typical such as:

• Weight loss is reduced

• Appetite lost

• intermittent fever

• paraneoplastic syndromes, such as "Hypertrophic pulmonary osteoartheopathy", venous thrombosis and peripheral neuropatia.

Chronology of Early Detection of Lung Cancer

Scheme

CXR

Sputum Cytology

B. Physical Examination

            Physical examination should be done thoroughly and carefully. The results sangatbergantung on abnormalities on examination done. Lung tumor size is small and can give you an idea diperifer normal on examination. Tumors with large size, especially when accompanied by atelectasis due to bronchial compression, pleural effusion or venakava emphasis will provide a more informative. This examination can also provide datauntuk determination of the stage of disease, such as lymphadenopathy or tumors outside the lung. Another keorgan metastases can also be detected by palpation of the liver, funduscopic examination to mendeteksipeninggian intracranial pressure and the occurrence of fractures due to bone metastases.

Radiological

            The results of the radiological examination is one that is absolutely necessary investigations untukmenentukan primary and metastatic tumor sites, as well as disease staging based sistemTNM. Pulmonary radiological examination ie CXR PA / lateral, if possible thoracic CT scan, bone scan, Bone survey, abdominal ultrasound and CT Brain-disorders are needed to determine the location, size tumordan metastasis.

a. Chest X-ray: In radiographic examinations PA / lateral will be seen when the tumor future denganukuran tumors more than 1 cm. Signs that support malignancy was irregular edges, disertaiidentasi pleura, tumor satellite tumors, etc.. In the photos can also be found to have tumor invasion dindingdada, pleural effusion, effusion and metastasis perikar intrapulmoner. While the involvement of the KGB untukmenentukan N rather difficult to determine the radiographic saja.Kewaspadaan physician to the possibility of lung cancer in a patient's disease parudengan picture is not typical for malignancy is important to be reminded. A yangtergolong patients in high risk groups (GRT) with a diagnosis of lung diseases, should be accompanied by careful difollowup. Giving OAT showed no improvement or even deteriorate after 1bulan should rule out the possibility of lung cancer, but another problem pneumoniayang treatment is not successful after the administration of antibiotics for 1 week should also cause pneumonia dugaankemungkinan behind the tumor. If the chest X-ray showed a broad overview of pleural effusion should be followed by emptying isipleura with repeated puncture or insertion of WSD and repeat chest X-ray that can be shown when no tumorprimer. Malignancy should be contemplated when the fluid is productive, and / or cairanserohemoragik.

b.CT thoracic scan: This imaging technique can determine abnormalities in the lung better daripadafoto thorax. CT-scans can detect tumors with sizes smaller than 1 cm are more appropriate. Likewise, signs of malignant process also reflected better, even if terdapatpenekanan the bronchi, intra-bronchial tumor, atelectasis, pleural effusion and telahterjadi not massive invasion into the mediastinum and chest wall even without symptoms. Furthermore the CT-scan, the KGB's involvement was instrumental to determine the stage is also better because pembesaranKGB (N1 s / d N3) can be detected. Similarly, accuracy is the possibility to detect metastasisintrapulmoner.

Other radiological c.Pemeriksaan: Lack of chest radiograph and thoracic CT-scan is not mampumendeteksi the occurrence of distant metastases. That requires other radiological examinations, such as Brain-CT for detecting bone metastases in head / brain tissue, bone scan and / ataubone surveys can detect bone metastases throughout the body's tissues. Abdominal ultrasound can view the presence or absence of metastases in the liver, adrenal glands and other organs in the abdominal cavity.

Special Examination

a. Bronchoscopy

Bronchoscopy is a diagnostic examination with the goal at once be counted on to dapatmengambil tissue or material in order to ensure the presence or absence of malignant cells. Intrabronkus adatidaknya examination period or changes in the airway mucosa, as shown abnormalities mukosatumor example, craggy, hyperemia, or infiltrative stinosis, bleed easily. Tampakan yangabnormal should be followed by tumor biopsy / bronchial wall, flushing, bronchial brushings ataukerokan.

b. Needle aspiration biopsy

If intrabronkial tumor biopsy can not be done, for example, because it is very easy to bleed, or if the slippery mucosal berbenjol, then needle aspiration biopsy should be performed, because danbiopsi bronchial washings alone often give negative results.

c. Transbronchial needle aspiration (TBNA)

TBNA in karina, or trachea 1/1 down (2 rings above the carina) at the 1 o'clock position when the tumor adadikanan, will provide dual information, which obtained the material for cytology and informasimetastasis subkarina or paratracheal nodes.

d.Transbronchial Lung Biopsy (TBLB)

If the lesion is small and somewhat in peripheral locations, and no means of fluoroscopic lung biopsy lewatbronkus (TBLB) should be performed.

e.Biopsi transthoracic (Transthoraxic Biopsy, TTB)

If the lesion is located in the peripheral and more than 2 cm in size, with the help of TTB flouroscopic angiography . however if lesions smaller than 2 cm and located in the central TTB can be performed with CT scan guidance.

f. Another biopsy

Fine-needle biopsy can be performed if there is a palpable lymphadenopathy or superficial dapatterlihat period. BECs biopsy should be done when palpable lymphadenopathy supraclavicular, axillary leheratau, especially when cytological diagnosis / histology of the primary tumor in the lung is unknown. BiopsiDaniels recommended when no obvious lymphadenopathy tidakmenghasilkan suparaklavikula and other means of information about this type of cancer cell. Puncture and pleural biopsy should be performed if adaefusi pleura.

g.Torakoskopi medical

With this action the tumor mass in this part of the peripheral lung, visceral pleura, parietal pleura can be seen and biopsied danmediastinum.

h. Sputum Cytology

Sputum cytology is a diagnostic measures are most easily and cheaply. Pemeriksaanini shortage occurs when there is a tumor in the peripheral, dry cough and collection techniques and pengambilansputum are not eligible. With the help of 3% saline inhalation for sputum merangsangpengeluaran can ditingkatkan.Semua material taken with the above checks should be sent to the Anatomic laboratoriumPatologi for cytology / histology. Materials should be sent segeratanpa fixation fluid, or smears made, and then fixed with absolute alcohol, or at least alkohol90%. All materials must be fixed networks dalamformalin 4%.

Other invasive testing

            In the case of complicated cases sometimes invasive measures such as Thoracoscopy and action bedahmediastinoskopi, thoracoscopic, exploratory thoracotomy and open lung biopsy is needed in order diagnosisdapat enforced. This action is the last resort when all manner of telahdilakukan examination, diagnosis histological / pathological diagnosis can not ditegakkan.Semua action for lung cancer is directed to be determined:

1. Histological type.

2. Degrees (staging).

3. Views (levels appear, "performance status").  

So that kind of treatment can be chosen according to the condition of the patient.

 International Penderajatan Based Lung Cancer TNM System

Stage                                                                            TNM

occult carcinoma:                                                       Tx N0 M0

0:                                                                                Tis N0 M0

IA:                                                                              T1 N0 M0

IB:                                                                              T2 N0 M0

IIA:                                                                            T1 N1 M0

IIB:                                                                            T2 N1 M0

IIIA:                                                                           T3 N0 M0

                                                                                    T3 N2 M0

IIIB:                                                               any T   N3 M0

                                                                        T4 any N M0

IV:                                                      sembarangT any arbitrary N T

Category TNM for Lung Cancer

T           : Primary Tumor

To         : No evidence of primary tumor.

            Difficult to assess the primary tumor, or primary tumor cells as evidenced by the discovery of a malignant tumor         in bronchopulmonary secretions but does not appear to be radilogis or bronchoscopic.

Tx         : primary tumor is difficult to assess, or primary tumor cells as evidenced by the discovery of a malignant tumor        in bronchopulmonary secretions but does not appear to be radilogis or bronchoscopic.

Tis        : Carcinoma in situ

T1         : The tumor with a diameter not exceeding 3 cm in the largest, surrounded by a network of lung or visceral pleura invasion and bronchoscopic no more proximal than     lobar bronchus (not yet up to the lobar bronchus (not yet up to the main bronchus).      Tumor any size with superficial invasive component limited to the walls of             the bronchi that extends into the proximal main bronchus

T2         : Each tumor the size or expansion as follows:

            - The diameter of more than 3 cm in greatest

            - Regarding the main bronchus as far as 2 cm or more distal to the carina of the pleura                       visceral

            - Associated with atelectasis or obstructive pneumonitis that extends to the area

                        hilum, but not the entire lung.

T3         : Tumor any size with direct extension to the chest wall (including             superior sulcus tumors), diaphragm, mediastinal pleura or bronchial tumor in            the main a distance of less than 2 cm distal to the carina, or tumor             associated with atelectasis or obstructive pneumonitis of the entire lung.

T4         : Tumor any size of the mediastinum or heart, great vessels,          trachea, esophagus, vertebral body, carina, tumors were accompanied by pleural effusion      malignant or ipsilateral satellite tumor nodules in the same lobe as the primary tumor.

N          : regional lymph nodes (KGB)

Nx        : Lymph nodes can not be assessed

No        : Not proven lymph node involvement

N1        : Metastasis in lymph nodes peribronkial and / or ipsilateral hilar,          including direct tumor extension

N2        : Metastasis in ipsilateral lymph nodes mediatinum and / or KGB          subkarina

N3        : Metastasis in contralateral mediastinal or hilar or KGB scalenus /             supraklavila ipsilateral / contralateral

M Metastasis (spread child) away.

MX        : Metastasis can not be assessed

Mo        : No distant metastasis was found

M1        : distant metastasis was found. "Metastastic tumor nodule" (s) outside the ipsilateral lobe of             the primary tumor is considered as M1

Another examination

a. Tumor markers

Tumor markers that have, such as CEA, Cyfra21-1, NSE and other unusable untukmendiagnosis but still used in the evaluation of treatment outcomes.

b. Examination of molecular biology

Examination of molecular biology has been growing, the simplest way to menilaiekspresi multiple genes or gene products associated with lung cancer, such as p53 protein, bcl2, and others. The main benefit of the examination is to determine the molecular biology prognosispenyakit.

Histologic Types

            To determine the histological type, in more detail according to the WHO histological classification used tahun1999 (Appendix 1), but for the clinical needs enough if only knowable:

1. Squamous carcinoma (epidermoid carcinoma)

2. Small cell carcinoma (small cell carcinoma)

3. Adenocarcinoma (adenocarcinoma)

4. Large cell carcinoma (large cell carcinoma)

            Various limitations often lead to specialist physicians experienced Anatomical Pathology kesulitanmenetapkan types of cytological / histological right. Therefore, for the sake of the choice of therapy, at least harusditetapkan, whether including small cell carcinoma lung cancer (small cell or lungcancer KPKSK, SCLC) lung cancer or non-small cell carcinoma (KPKBSK, nonsmall cell lung cancer, NSCLC).

TREATMENT

            Lung cancer treatment is combined modality therapy (multi-modaliti therapy). In fact on saatpemilihan therapy, often not only expected to histologic type, degree and display patient sajatetapi also non-state facilities for the dimilikirumah medisseperti pain sufferers and economic jugamerupakan the crucial factor.

Surgery

            Indications of surgery in lung cancer is to KPKBSK stage I and II. Surgery jugamerupakan part of "a combined modality therapy", such as neoadjuvant chemotherapy for stage IIIA. Another indication is when there is gravity that require surgical intervention, such as the vena cava syndrome kankerparu superiror berat.Prinsip surgically resected tumor was complete as much as possible following KGBintrapulmoner network, lobectomy or pneumonectomy with. Segmentektomi or wedge resection hanyadikerjakan if pulmonary function is not enough to lobectomy. Incision edges examined by frozen section toensure that limit tumor-free bronchial incision. Mediastinal nodes were taken with diseksisistematis, and examined other important pathologies important anatomis.Hal remembered before performing surgery is knowing the type of toleransipenderita surgery to be performed. Tolerance of the patient to be dibedahdapat measured by pulmonary function test values ​​and if not can be judged from the results allow the analysis of blood gases (ABG):

Terms for lung resection

. mild risk for pneumonectomy, the contralateral lung bilaKVP well, VEP1> 60%

. risk being pneumonectomy, the contralateral lung bilaKVP> 35%, VEP1> 60%

Radiotherapy

            Radiotherapy in lung cancer can be curative or palliative therapy. In curative therapy, neoadjuvant chemotherapy radioterapimenjadi part of stage IIIA to KPKBSK. In certain circumstances, radiotherapy alone is not infrequently an alternative curative therapy.

Radiation is often an emergency measure that must be done to relieve the patient complaints, such superiror vena cava syndrome, bone pain due to tumor invasion into the chest wall and metastasistumor in bone or brain.

Determination of radiation policy on several factors determined KPKBSK

1. Staging of disease

2. Status display

3. Pulmonary Function

When the radiation is done after surgery, it must be known:

- Type of surgery including node dissection is done

- Assessment by an incision limits Anatomical Pathology (PA)

The radiation dose given in general is 5000 - 6000 cGy, by way of 200 cGy / x, 5hari week.

Standard terms before the patient is irradiated is:

1. Hb> 10 g%

2. Platelets> 100.000/mm3

3. Leukocytes> 3000/dl

Palliative radiation given to unfavorable group, namely:

1. The PS <70.

2. Decline BB> 5% in 2 months.

3. Poor lung function.

Chemotherapy

            Chemotherapy may be given in all cases of lung cancer. The main requirement to be determined jenishistologis tumor and appearance (performance status) and must be 60 or 2menurut Karnosfky scale according to the WHO scale. Chemotherapy uses anticancer drugs dalamkombinasi some chemotherapy regimens. In certain circumstances, the use of one type of anti-cancer drugs dapatdilakukan.

EVALUATION (follow-up)

            Recurrence (relapse) of lung cancer is highest in 2 years First, the making of evaluation in patients who have been treated optimally performed every 3 months. Pemeriksaanklinis and radiological evaluation included chest radiograph is PA / lateral and Ct-scan of thorax, while the other tests performed on the indication.

Preventing Lung Cancer

            Smoking cessation is the steps / actions most important to prevent lung cancer. Many products, such as nicotine gum, nicotine sprays, nicotine inhalers or inhaler, may be beneficial for people who are trying to quit smoking. Shrink exposure to passive smoking is also an effective preventive measures. Using a home radon test box can identify and allow correction of radon levels in homes increase, which also can cause lung cancers. Methods for early detection methods that allow cancers, such as low-dose helical CT scans, may also be useful in identifying small cancers that can be cured by surgical resection and prevention of widespread cancer and incurable.

REFERENCES

1.        Samsuhidajat R, De Jong W. surgical textbooks Sciences Edition 2 . Jakarta: EGC.2004.

2.        Soelarto, Reksoprodjo. Set of Surgery Lecture, Jakarta: Binarupa Aksara.1995.

3.        Sabiston, David C. Textbook of Surgery Part 2 . Jakarta: EGC 1994.

4. http://www.totalkesehatananda.com/lungcancer.htm      

5. http://www.suaradokter.com/2009/06/kanker-paru      

6. http://www.infopenyakit.com/2008/06/penyakit-kanker-paru-paru.htm