CHAPTER I

1.1 Background
Cancer is a major problem in medicine and is one of the 10 leading causes of death in
the world and is a malignant disease that can cause death to the sufferer because cancer
cells damaging other cells. Cancer cells are normal cells that have mutations / genetic
change and grow without coordinated with other body cells. The process of formation of
cancer (carcinogenesis) is a somatic events and has long thought to be caused due to
accumulation of genetic and epigenetic changes that cause normal setting changes the
molecular control of cell proliferation. Genetic changes can be the activation of proto-
oncogenes or inactivation of tumor suppressor genes that can trigger tumorigenesis and
progression enlarge.

Lung cancer is one type of lung disease that requires treatment and rapid and
effective action. The diagnosis of this disease requires skills and facilities that are not
simple and requires a multidisciplinary approach to medicine. This disease requires close
cooperation between the lung specialist and integrated with expert diagnostic radiology,
anatomy pathologists, radiologists therapy and thoracic surgeons, medical rehabilitation
specialists and other experts.

According to the data type of cancer that causes most deaths is lung cancer, 1.3
million deaths per year. Followed by stomach cancer (reaching more than 1 million deaths
per year), liver cancer (approximately 662,000 deaths per year), kanke colon (655,000
deaths per year), and lastly, breast cancer (502,000 deaths per year).

In the United States deaths from lung cancer reaches 36% of all cancer deaths in
men, is a sequence of first cause of death in men (Mangunnegoro, 1990). Mayo Lung
getting lung cancer deaths to the number of lung cancer patients found 3.1 per 1000 people
per year.

Disease treatment or containment procedures is highly dependent on the dexterity

lung specialist to get a definite diagnosis. The discovery of lung cancer at an early stage
will greatly help patients, and the discovery of the diagnosis in a faster time allows people

1
 obtain a better quality of life in the course of the disease although it can not cure it. The
choice of therapy should be immediate, given the poor response to various types of lung
cancer treatment. Even in some cases of lung cancer patients in need of handlers as soon as
possible although a definitive diagnosis can not be enforced. Lung cancer in the broadest
sense is all malignancies in the lung, including lung malignancy derived from itself or from
extrapulmonary malignancy (tumor metastasis in the lungs). In this management guidelines
is a lung cancer is the primary lung cancer, the malignant tumor derived from epithelial
bronchi or bronchial carcinoma (bronchogenic carcinoma). According to the present
concept of cancer is a disease of genes. A normal cells can become cancer cells if by
various causes imbalance occurs between the oncogene function of genes in the process
suppresor tumor grows and blossoms a sel.Perubahan or gene mutations that cause
hiperekspresi oncogenes and / or lack / loss of gene function causing cell tumor suppresor
grow and develop uncontrollably. This change goes in phases, known as the multistep
process of carcinogenesis. Changes in chromosome, for example chromosome heterogeniti
loss or LOH is also suspected as the mechanism of cell growth abnormalities in cancer
cells. From various studies have be known for several oncogenes involved in lung cancer
carcinogenesis process, including the gene myc, k-ras gene while group
suppresorantaralain tumor gene, p53 gene, rb gene. While chromosomal changes in the
location of 1p, 3p and 9p often found in lung cancer cells.

1.2 The formulation of the problem:

1. What Complaints and Symptoms of Lung Cancer

2. What is Staging of Lung Cancer ?

3. What is Etiology of Lung Cancer ?

4. How Lung Cancer Prevention?

5. How Lung Cancer Treatment?

1.3 Objectives

1. To know the Complaints and Symptoms of Lung Cancer

2. To determine staging Lung Cancer

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3. To determine the etiology of Lung Cancer

4. To find out How Lung Cancer Prevention

5. For Lung Cancer Treatment Method

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 CHAPTER II

2.1 Complaints and Symptoms of Lung Cancer

Clinical picture of lung cancer did not differ much from other lung diseases, consisting of
subjective complaints and objective symptoms. The history will be obtained major
complaints and course of the disease, as well as other factors that are often very helpful
upholding diagnosis. The main complaint may include: cough with / without sputum
(phlegm white, can also be purulent), coughing up blood, shortness of breath, hoarseness,
chest pain, difficulty / pain in swallowing, a lump at the base of the neck, swollen face and
neck, some- sometimes accompanied by a swollen arm with great pain.

Not infrequently the first visible symptom or complaint is the result of metastases outside
the lung, such as abnormalities that arise because of severe compression of the brain, liver
enlargement or leg fractures lesions caused by metaplasia, hyperplasia and dysplasia
penetrate the pleural space, usually arises pleural effusion, and can be followed by direct
invasion of the ribs and the vertebral body. Lesions of the central location comes from one
of the largest branches of the bronchi. These lesions cause obstuksi and ulceration bronchus
followed by suppuration in the distal part. The symptoms that arise can include cough,
hemoptysis, dyspnoea, fever, and cold. Wheezing can unilateral terdengan on auscultation.
In advanced stages, weight loss usually indicate the presence of metastases, particularly in
the liver. Lung cancer may be metastasized to the structure - the closest structure such as the
lymph nodes, the esophageal wall, pericardium, brain, skeletal.

Symptoms and complaints that are not typical, such as: weight loss, loss of appetite,
intermittent fever, paraneoplastic syndromes, such as "hypertrophic pulmonary
osteoartheopathy", peripheral venous thrombosis and neuropatia.

2.1.1 Pathophysiology

Initially attack branching segments / sub bronchus cause cilia missing and
desquamation resulting in the deposition of carcinogens. With the deposition of
carcinogens that cause metaplasia, hyperplasia and dysplasia. When the peripheral lesions
caused by metaplasia, hyperplasia and dysplasia penetrate the pleural space, usually

4
 arises pleural effusion, and can be followed by direct invasion of the ribs and the
vertebral body. The central location of lesions derived from one of the largest branches of
the bronchi. These lesions cause obstuksi and ulceration bronchus followed by
suppuration in the distal portion. The symptoms that arise can include cough, hemoptysis,
dyspnoea, fever, and cold. Wheezing can unilateral terdengan on auscultation. In
advanced stages, weight loss usually indicate the presence of metastases, particularly in
the liver. Lung cancer can be metastatic to the structure of nearby structures such as the
lymph nodes, the esophageal wall, pericardium, brain, skeletal.
2.1.2 Type histological

To determine the histologic type, in more detail the histological classification used by
WHO in 1999, but for the clinical needs enough if only it can be seen:

1. Squamous carcinoma (epidermoid carcinoma)

2. Small cell carcinoma (small cell carcinoma)

3. Adenocarcinoma (adenocarcinoma)

4. Large cell carcinoma (large Cell carcinoma)

Broadly speaking, lung cancer is divided into two parts namely Small Cel Lung Cancer
(SCLC) and Non Small Lung Cancer Cel (NCLC).

a. Small Cell Lung Cancer (SCLC)

The incidence of lung cancer have SCLC type only about 20% of the total
incidence of lung cancer. However, this type is growing very fast and aggressive. If
not promptly treated then it can only last 2 to 4 months.

b. Non Small Cell Lung Cancer

80% of the total incidence of lung cancer is a type of NSCLC. Broadly divided
into three, namely:

1. adenocarsinoma, this type is the most common (40%).

2. Cell Carcinoma Sekuamosa, many cases of around 20-30%.

3. Large cell carcinoma, the number of cases of about 10-15%.

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 Most patients diagnosed with NSCLC (70-80%) is already in an advanced stage III -
IV.Various limitations often lead Pathology specialist doctors had trouble specifies the
type of cytological / histological right. Therefore, for the sake of the choice of therapy, at
a minimum should be set, including whether the lung cancer small cell carcinoma
(KPKSK or small cell lung cancer, SCLC) or lung cancer types carcinoma non-small cell
(KPKBSK, nonsmall cell lung cancer, NSCLC).

2.2 Staging of Lung Cancer

Staging for KPKBSK to be determine according to the international System for Lung
cancer 1997, Based on the TNM system. Understanding T is a tumor that is categorized on
Tx to T4, N for lymph node involvement are categorized on Nx, No to N3, While M is
showing the presence or absenceof distant metatases.

International Staging Lung Cancer Based System TNM

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: across T N3 M0
T4 across N M0
IV: acrossT acrossN acrossT

Information
T Primary tumor
To No evidence of primary tumor is difficult
to measure, is evident from the secretions
Placem bronkopulmo appear to be
bronchoscopic.

Tx Primary tumor difficult primer evident

from Placem on secretions bronkopul
appear in radilogis or bronchoscopic.

Tis Carcinoma in situ line of Middle World

walkin surrounded by j pleura visceral
and not more proximal than lobar

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 bronchus (bronkuslobus (not until k
tumors are superficial with any
component invasive limited on the wall
of bronchus to extends proksimal primary
bronchus.
T2 Each tumor de expansion as
 The midline more than 3 cm
 The main bronchus as far as 2 cm
or more,distal to carina of the
pleura.
Viceral
Associated with atelektasisor
pneumonitis obstruktif that extend to area
hilum, but the entire lung.
T3 tumor any direct extension to the din of
tumors sulcus superior), in the
mediastinum or tumor in the main
bronchus that distance distally karina a
touch with atelectasis obstructive entire
lung.
T4 tumor any size about mediastinum or
large, trachea, esofag karina, tumors are
malignant pleural or ipsilateral to the lob
primary tumor.
N Reginal lymph nodes
Nx Lymph nodes can not be measured
No Not proven involved lymph nodes
N1 Metastasis in to peribronkial and / at
including hilum ipsilateral, involved
direct tumor extension
N2 metastases to mediatinum ipsilateral/
subkarina
N3 Metastasis in hilus or mediastinum
contralateral or supraklavila ipsilateral
M Far Metatases
Mx Metastases can not be measured
Mo Can not be found metastases
M1 Found metastases” Metatases tumor
nodule” (s) ipsilateral in ex lobe tumor
prime, called M1

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2.2.1 Pemeriksaan penunjang Diagnostik

a. Physical examination

Physical examination must be done thoroughly and carefully. The result is highly
dependent on the abnormality during the inspection carried out. Lung tumors of small
size and is located in the periphery can give you normal on examination. Tumor size,
especially when accompanied by atelectasis due to bronchial compression, pleural
effusion or vena cava emphasis will provide a more informative. This examination can
also provide data for determining the stage of disease, such as enlargement of lymph
node or tumor outside the lung. Metastasis to other organs can also be detected by
palpation of the liver, funduskopi examination to detect the elevation of intracranial
pressure and the occurrence of fractures due to bone metastases.

b. Radiologically

Radiological examination is one investigation that is absolutely necessary to

determine the location of the primary tumor and metastasis, as well as disease staging
by the TNM system. Radiological examination type, namely :

1. Chest X-ray:

On examination of the chest X-ray PA / lateral will be seen when the time
tumors with tumor sizes of more than 1 cm. Signs that support malignancy is an
irregular edge, accompanied by pleural indentation, satellite tumor tumor, etc. In the
photo can also be found tumor has invaded the chest wall, pleural effusion, effusion
intrapulmonerperikar and metastasis. While the KGB involvement is rather difficult
to determine N is determined by chest X-ray alone. Vigilance against the possibility
of lung cancer in a patient with lung disease with a picture which is not typical for
malignancy is important to be reminded. A person belonging to the high risk group
(GRT) with a diagnosis of lung diseases, should be accompanied by careful
difollowup. Giving OAT showed no improvement or even deteriorate after 1 month
should rule out the possibility of lung cancer, but another problem is the treatment of
pneumonia that is not successful after administration of antibiotics for 1 week also

8
 should raise suspicion of the possibility of a tumor behind pneumonia that When the
chest X-ray shows a picture pleural effusion comprehensive to be followed by the
emptying of the pleura with repeated puncture or installation of WSD and repeat
chest radiograph that when the primary tumor is shown. Malignancy should be
contemplated when the liquid is productive, and / or liquid serohemoragik.

2. CT scan of the thorax:

This imaging technique can determine abnormalities in the lung is better than
chest X-ray. CT scans can detect tumors smaller than 1 cm more precisely. Similarly,
signs of malignant process also reflected better, even if there is an emphasis on the
bronchus, bronchial intra tumor, atelectasis, pleural effusion were not massive and
have the invasion into the mediastinum and chest wall even without symptoms.
Furthermore with the CT-scan, the KGB's involvement was instrumental to
determine the stage is also better because of lymphadenopathy (N1 s / d N3) can be
detected. Likewise ketelitiannyaintrapulmoner detect possible metastasis.

3. Other radiological examination:

Disadvantages of a chest X-ray and CT-scan of the thorax is unable to detect

the occurrence of distant metastases. That requires another radiological examination,
eg Brain-CT for detecting bone metastases in the head / brain tissue, bone scan and /
or survey can detect bone metastases bone tissue throughout the body. Abdominal
ultrasound can see whether there is metastasis in the liver, adrenal glands and other
organs in the abdominal cavity.

c. Special examination
1. Bronchoscopy

Bronchoscopy is the examination with diagnostic purposes as well be counted on

to be able to take a tissue or material in order to ensure the presence or absence of
malignant cells. Check that no future intrabronkus or airway mucosal changes, such
as mucosal abnormalities visible tumor, for example, craggy, hyperemia, or stinosis
infiltrative, bleed easily. Tampakan abnormal should be followed by measures of
tumor biopsy / bronchial wall, rinses, bronchial brushings or scrapings.

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2. 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, as only rinses and bronchial biopsies often give negative
results.

3. Transbronchial Needle Aspiration (TBNA)

TBNA in karina, or trachea below 1/1 (2 rings on top karina) at 1 o'clock

position when the tumor is no right hand, will give double the information, which is
obtained the material for cytology and information subkarina or paratracheal lymph
nodes metastasis.

4. Transbronchial Lung Biopsy (TBLB)

If the lesion is small and somewhat peripheral location and no means of

fluoroscopic the lungs through the bronchial biopsy (TBLB) should be performed.

5. Transthoracic biopsy (biopsy Transthoraxic, TTB)

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

6. Additional Biopsy

Fine-needle biopsy may be done when there is a palpable lymphadenopathy

or time to look superficial. KBG biopsy should be done if a palpable
supraclavicular lymphadenopathy, neck or axillary, especially when cytological
diagnosis / histology of the primary tumor in the lung is not known. Daniels biopsy
is recommended if it is not clearly visible lymphadenopathy suparaklavikula and
other means do not yield information on the types of cancer cells. Puncture and
pleural biopsy should be performed if there is pleural effusion.

7. Medicalthoracoscopic

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 By this act of mass tumor in this part of the peripheral lung, pleura visceral,
parietal pleura and mediastinum can be seen and biopsied.

8. Sputum cytology

Sputum cytology is a diagnostic measures most convenient and inexpensive.

This occurs when the inspection deficiencies exist in peripheral tumors, patients
with dry cough and sputum collection techniques and retrieval are not eligible.
With the help of 3% NaCl inhalation to induce sputum spending could be
improved. All materials are taken by examination of the above must be sent to the
Anatomic Pathology laboratory for cytology / histology. Ingredients in liquid form
should be sent immediately without fixation, or smear preparations are made and
then fixed with absolute alcohol or a minimum of 90% alcohol. All materials must
be fixed network dalamformalin 4%.

d. Another invasive testing

In the case of complex cases often invasive measures such as thoracoscopic

surgery and Mediastinoscopy, thoracoscopic, exploratory thoracotomy and open lung
biopsy is needed so that a diagnosis can be established. This action is a last resort when
all the way checks have been done, the diagnosis of histological / pathological can not
be enforced.

All actions directed diagnosis for lung cancer to be determined:

a. Histologic type.

b. Degree (staging).

c. Display (level perform, "performance status").

d. another inspection

1. Tumor Markers

Tumor markers that have, such as CEA, Cyfra21-1, NSE and others can not be
used to diagnose but is still used in the evaluation of treatment outcomes.

2. Examination of molecular biology

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 Examination of molecular biology has been growing, the simplest way can assess
the expression of several genes or gene products associated with lung cancer, such as
protein p53, Bcl-2, and others. The main benefit of molecular biology examination is
to determine the prognosis of the disease.

2.3 Etiology

2.3.1 Smoking

Smoking is estimated to cause 90% of lung cancer in men, and about 70% in
women. In industrialized countries, approximately 56% - 80% smoking causes chronic
respiratory disease and about 22% of cardiovascular disease. Indonesia was ranked the
fourth highest number of smokers in the world with approximately 141 million people. It
is estimated that cigarette consumption Indonesia each year to reach 199 billion
cigarettes. The result was the death of as many as 5 million people annually.

Either lung cancer cases in the United States or other industrialized countries
about 90% related to smoking. Jakarta Friendship Hospital data show that 24.5% of
women and 83.6% of men with lung cancer are smokers.

a. Cigarette smoke contains more than 4,000 chemicals, many of which have been
identified as a cause of cancer.
b. People who smoked more than one pack of cigarettes per day have a 20-25 times
greater risk of developing lung cancer than people who never smoked.
c. After a person stops smoking, their risk for lung cancer is reduced gradually.
About 15 years after quitting, the risk of lung cancer decreases with the level of
someone who never smoked.
d. Cigar and pipe smoking increases the risk of lung cancer, but not as much as
smoking. About 90% of lung cancer arising from the use of tobacco. The risk of
developing lung cancer is related to the following factors: The number of
cigarettes smoked, age at which a person starts smoking, how long a person
smoking (or never smoked before quitting).

Other causes for lung cancer include the following:

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 1) Passive smoking, or secondhand smoke, presents another risk for lung cancer. An
estimated 3,000 deaths lung cancer occur each year in the United States are
attributable to passive smoking.
2) Most of the carcinogens in tobacco smoke (cigarette) found in tar phase PAH and
phenol as aromatic Tar kind of thick liquid is dark brown or black is a
hydrocarbon substance which is sticky and attach to the lungs - lungs. The tar in
tobacco between 0.5-35 mg / trunk. Tar is a carcinogen that can cause cancer in
the airway and lungs.
2.3.2 Air pollution

Pollution from motor vehicles, factories, and other sources may increase the risk of
lung cancer. Gas is the most dangerous for the lungs is SO2 and NO2. If this element is
smoked, the various complaints in the lungs will be embossed with the name CNSRD (non
spesific chronic respiratory disease) such as asthma and bronchitis (Aditama, 1992). The
increase in the concentration of SO2 and NO2 gas is associated with lung function
impairment

a. Effect of pollution caused by sulfur oxide is increased morbidity, the incidence of

respiratory diseases, such as bronchitis, emphysema and decline in general health.
SO2 concentration of 0.04 ppm with the particulate 169 ug / m3 lead to a rapid
increase in deaths from bronchitis and lung cancer.
b. The impact on health is the disruption of the respiratory system and can be
emphysema, if the conditions can potentially become chronic bronchitis and NO2
accumulation will occur and can be a source of carcinogenic.
2.3.3 Occupational
a. Exposure to asbestos increases the risk of lung cancer nine times. The combination of
asbestos exposure and cigarette smoking increases the risk to 50 times. Other cancer
known as mesothelioma (a type of cancer of the lining of the chest cavity called the
pleura or lining of the abdominal cavity called the peritoneum) is also strongly
associated with exposure to asbestos.
b. Certain jobs where exposure to arsenic ,, chromium nickel, aromatic hydrocarbons and
ethers occur can increase the risk of lung cancer.

13
 c. Lung Disease Due to exposure Spray Paint Job. Spray paint to change the substance
into an aerosol, which is a collection of fine particles of liquid or solid form, so that
because of its small size will easily exploited, then a particular potential exposure to
lung health. Pigment in paint is useful for coloring paints and increases endurance.
Many types of the pigment is a hazardous material that is Chromium and Cadmium
Provide green, yellow, and orange can cause lung cancer and skin irritation, nose, and
upper respiratory tract.
2.3.4 Lung Disease

Lung diseases such as tuberculosis (TB) and chronic obstructive pulmonary

disease (COPD), also makes the risk for lung cancer. A person with COPD have a risk
four to six times greater risk of lung cancer even when the effects of smoking are
excluded.

2.3.5 Irradiation
1. Radon poses another risk exposure is a natural byproduct of radium, which is a
product of uranium.
2. Radon is present in indoor and outdoor air.
3. The risk of lung cancer increases with significant long-term exposure to radon,
although no one knows the exact risk. An estimated 12% of deaths from lung
cancer arising radon gas, or approximately 21,000 deaths associated lung cancer
each year in the US Radon gas is the second leading cause of lung cancer in the
United States after smoking. As with exposure to asbestos, smoking greatly
increases the risk of lung cancer by exposure to radon.

4. Someone who had been suffering from lung cancer is more likely to develop lung
cancer than the average second person is to develop lung cancer first.
2.3.6 Genetic.

There is a change / mutation of several genes that play a role in lung cancer, namely:

a. Proton oncogene
b. Tumor suppressor gene

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 c. Gene encoding enzyme.
2.3.7 Diet

Reported that the low consumption of beta-carotene, vitamin A seleniumdan lead to a

high risk of lung cancer.

2.4 How to Prevention

Principle preventive better effort than merely treatment. There are 4 Levels of prevention in
epideemiologi lung cancer, namely:

2.4.1 Prevention Primordial

It is an effort to provide the community conditions that allow the disease of lung
cancer can not thrive in the absence of opportunities and support of habits, lifestyle and
any other condition that is a risk factor for the emergence of lung cancer. For example:
create the preconditions that people feel that smoking is a habit that is not good statu and
communities to be positive not to smoke.

Research on smoking say that more than 63 kinds of materials contained in

cigarette smoke that are carcinogenesis. Were epidemiologically also seen a strong link
between smoking and lung cancer incidence, then no doubt to avoid cigarette smoke is
the key to the success of prevention that can be done. The linkage of cigarettes with lung
cancer cases confirmed by the data that a woman's risk of passive smoking lung cancer
would be higher than those not exposed to smoke. On the basis of the above finding is
reasonable that the primary prevention of lung cancer in the form of efforts to eradicate
the smoking habit. Stopping an active smoker is rescuing more than a passive smoker.

2.4.2 Prevention First Level

Prevention of the first level that can be done include:

a) Public Health Promotion

• public awareness campaigns
• Health promotion
• Community Health Education
b) Special Prevention:

15
 • Prevention of exposure
• Giving kemopreventif
2.4.3 Second Level Prevention
a) Early Diagnosis: Screening for example.
b) Treatment: for example with Chemotherapy or Surgery.
2.4.4 Third Level Prevention

The third level of prevention can be done by way of rehabilitation.

2.5 How To Treatment

Lung cancer treatment is combined modality therapy (multi-modaliti therapy). In fact at

the time of the selection of therapy, often not only expected on histologic type, degree and see
the patient but also the condition of non-medissepertidimilikirumah facilities for the sick and
the economic patient is also a factor that was crucial.

According to the Association of Surgeons Oncology Indonesia (2005), management /

treatment of cancer includes four main kinds of surgery, radiotherapy, chemotherapy and
hormoterapi. Pembedaha done to take 'a cancerous mass' and fix komplikas that may occur.
While the actions carried out by sina ionization radiotherapy to destroy cancer. Untu
Chemotherapy kills cancer cells with anti-cancer drugs (sitostatika). While hormonterapi done
to change the environment so that the growth of cancer cells are disrupted and eventually die
alone.

a. Surgery

Surgical indications in lung cancer is to KPKBSK stage I and II. Surgery is also
part of "a combined modality therapy", such as neoadjuvant chemotherapy for stage IIIA
KPBKSK. Another indication is if there is urgency requiring surgical intervention, such
as lung cancer with heavy superiror vena cava syndrome. The principle of surgery is
complete as far as possible following resected tumor tissue intrapulmoner KGB, with
lobectomy or pneumonectomy. Segmentektomi or wedge resection is only carried out if
lung function is not enough for lobectomy. The edge of the incision examined by frozen
section to ensure that the incision limits bronchial tumor free. Mediastinal lymph nodes
taken with systematic dissection and anatomical pathology examined.

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b. chemotherapy

Chemotherapy is the main option for lung cancer are small cell carcinoma
(KPKSK) and a few years earlier given as palliative therapy for lung cancer non-small
cell carcinoma (KPKBSK) stage further. The purpose of giving palliative chemotherapy
is to reduce or eliminate the symptoms caused by the cancer cell growth and expect to be
able to improve the quality of life of patients. But recently various studies have shown the
benefits of chemotherapy for KPKBSK an effort to improve prognosis, both 3 as a single
or shared modalitimodaliti others, namely radiotherapy and / or surgery. Indications of
chemotherapy in lung cancer are:

1. Lung cancer patients types of small cell carcinoma (KPKSK) without or with
symptoms.
2. Patients with lung cancer non-small cell carcinoma types (KPKBSK) inoperable
(stage IIIB and IV), if eligible can be combined with radiotherapy, concurrently,
sequentially or alternating chemoradiotherapy.
3. adjuvant chemotherapy is chemotherapy in lung cancer patients with non-small cell
carcinoma types (KPKBSK) with stage I, II and III that have been dissected.
4. neoadjuvant chemotherapy is chemotherapy in patients with stage IIIA and stage IIIB
some cases which will undergo surgery. In this case the chemotherapy is part
multimodaliti therapy.

Patients will receive chemotherapy first must undergo examination and assessment,
so that fulfilled the requirements as follows :

1. The histological diagnosis has been confirmed

Selection of drugs used depends on the histologic type. Therefore a histological

diagnosis should be upheld. For the sake of it is recommended using histological
classification according to the WHO in 1997. If the pathologist difficult to tell for sure,
it is for the benefit of chemotherapy should at least distinguish between:

a. The type of small cell carcinoma

b. The type of non-small cell carcinoma, the squamous cell carcinoma,
adenocarcinoma and large cell carcinoma

17
2. Display / Karnofsky performance status according to a scale of at least 60-70 or scale
WHO
3. Examination of peripheral blood for the administration of the first cycle:
a. leukocytes> 4,000 / mm3
b. platelets> 100,000 / mm3
c. Hemoglobin> 10 g%. If necessary, blood transfusions given before treatment.

As for the administration of the next cycle, if values above the lower then some kind
of drug can still be provided with dose adjustment.

4. Should liver function are within normal limits

5. Renal Physiology within normal limits, especially when used nephrotoxic drugs. For
chemotherapy containing cisplatin, creatinine clearance should be greater than 70 ml /
min. If this value is smaller, whereas normal creatinine and elderly patients should be
used carboplatin.

Research in Asia, MTTH patients with limited stage (LD-SCLC) receiving

chemoradiotherapy 14.2 months (95% CI, 10.96 to 17.44) and increased to 16.9 months
(95% CI, 11.83 to 21 , 97) on receiving additional PCI. Figures MTTH lower the 8.17
months (95% CI, 5.44 to 10.89) in patients with extensive disease (ED_SCLC) who
received chemoradiotherapy.

Research on the provision of a combination of chemotherapy and radiotherapy in

small cell carcinoma / limited stage get differences in results regarding the effect on
survival. But the incidence of tumor relapse is reduced. Friendship Hospital, Jakarta
chemotherapy in KPKSK made with a blend of drug cyclophosphamide + vincristine +
adriamycin recommended by the UICC or cisplatin + etoposide. Number of patients with
this type is not so much, after all, is capable of providing the drug is still very limited.
Therefore, the treatment still can not be assessed accurately. But looks 70% of patients
experienced subjective responses were quite real. See improved in 71.4% and 14.3%
experienced weight gain. Side effects are hemopoetik disorders and gastrointestinal
symptoms was seen in all cases, 57% did not experience hair loss and objective responses
seen in 70% (ED-SCLC). Twenty-five percent of people living sam

18
c. other treatments

Another treatment that can be done to patients with lung cancer is

immunotherapy, Hormonoterapi and Therapy Gen. But for the third treatment is still
being tested and not yet widely used in Indonesia.

1. Rehabilitation

Cancer patients who become disabled due to illness or complications due to

cancer treatment, should be rehabilitated to restore form and / or function of the
defective organ so that people can live in a decent and reasonable in the community.
There are various rehabilitation needs to be done such as mental rehabilitation,
vocational rehabilitation, social rehabilitation and others.

a. mental rehabilitation

Lung cancer patients who knew her cancer can be stressful and felt he was quickly
die in a sad state, she felt she no longer useful to live only for the burden of the
family.

Mental depression faced by cancer patients and their families are generally caused
by lack of understanding of the cancer or because of a perception of the lung
cancer. To overcome mental depression, the need of the patient and or kelurganya
by mental guidance and counseling about the cancer disease. If necessary with the
help of a psychologist, theologian, or public figure. Patients need to know that in
fact cancer can be cured if only it can be treated at an early stage. When a terminal
should also be told how she should live with cancer, and taught how to adapt
himself to the life of his cancer illness and the fact that it faces.

b. Social rehabilitation

Rehabilitation is important that the patient after discharge from the hospital
keembali can live normally in society, can live independently in the family and
society as reasonable. Communities also need to be prepared to receive patients.

c. rehabilitation Works

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 Once patients leave the hospital and be rid of his cancer illness, is expected to work
again in the community with the normal healthy state. If it is not possible to work
any longer as usual, patients are given guidance and vocational training (vocational
training), so that it can work with other jobs in accordance with the state of physical
and mental.

2. Prognosis

Poor disease prognosis is not just because of late diagnosis but also due to the low
response of cancer cells to various cytostatic drugs that have .. Score 1 year survival of
2347 patients with lung cancer were studied by the National Cancer Institute in the year
1983 to 1998, calculated by life table method only 41.8% and the 5 year survival figure
of 12.0%. Various data reveal that it is related to stage of disease when it is found.

Preventive efforts should be made because of the link between the material
contained carcinogens in cigarette smoke and air pollution has been scientifically proven
as part of the pathogenesis of lung cancer. But the primary preventive measures that
prevent people from smoking is very difficult to do, as well as disease discovery efforts at
an early stage is also not encouraging. As a result, very few patients are detected at an
early stage, this has resulted in therapies can no longer be given for curative purposes. On
the other hand it appears that the provision of multi-modality therapy in patients can give
better results than those who received only a single modaliti. However surgery is still the
treatment of lung cancer gives the best results, if done to a degree that operable, ie stage I
and II (intrapulmoner, intrathoracic) as well as on histological types suitable for such
action. But the conclusion of various data indicate that the age of 5 year survival of lung
cancer patients with TNM stage T1N0 and T2N0 and underwent complete resection
(complete resection) still range between 40-50% (Deslauriers, 2000). Overseas numbers
are quite high, while the data in Indonesia is only 10-25% patients undergoing surgery
(Busroh, 1988) with numbers survival of cancer patients who dissected 1 year 56.6%, 2-
year and 5-year 16.4% 2.4%.

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2.6 Management In Special Circumstances
2.6.1 Malignant Pleural effusion (EPG)

Pleural cavity in a healthy person contains about 20 ml of liquid. Pleural effusion

(pleural fluid) Normal is usually clean colorless, contains <1.5 g protein / 100 ml and
1,500 cells / microliter. Pleural effusion may occur in malignant intrathoracic disease,
organ or systemic malignancy ekstratoraks. As in other patients with pleural effusion,
EPG provides shortness of breath, shortness of breath, coughing, chest pain and chest felt
full contents. These symptoms are very dependent on the amount of fluid in the pleural
cavity. On physical examination found the movement of the diaphragm is reduced and
the deviation of the trachea and / or heart towards the contralateral, fremitus weakened,
percussion dim and weakened breath sounds on the side of thoracic pain. In lung cancer,
pleural infiltration by tumor cells can occur secondary to direct expansion (inviltrasi),
especially adenocarcinoma tumor that is located peripherally. Can also occur due to
metastasis to blood vessels and lymph. When efuasi pleura caused by metastasis, fluid
pleuranya contains many malignant tumor cells so that pleural fluid cytology can be
expected to give positive results.

Malignant pleural effusion has two important aspects in penatalaksaannyayaltu

local treatment and causal treatment. Causal treatment tailored to the stage and type of
tumor. Not infrequently the primary tumor is difficult diternukan, the aspect of local
treatment of choice in order to reduce shortness of breath is very annoying, especially
when the production of excess fluid and fast. Actions that can be done, among others,
punksi pleura, installation of WSD and pleurodesis to reduce the production of fluid.
Substances that can dipakal, among others talk, tetrasikiin, mitomycin-C, adriamycin and
bleomycin. When the primary tumors derived from lung and pleural fluid diternukan of
malignant cells, the EPG including T4, but when diternukan malignant cells in pleural
biopsy including stage IV. If after conducting various examinations of primary lung
tumors are not diternukan, and tumors outside the lung also can not be proven, then the
EPG ascribed to the lung. If the primary tumor diternukan outside the lungs, the EPG
includes the tumor sisternik symptoms and treatment tailored to management for primary
cancer treatment.

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2.6.2 Syndrome Superior Vena Kava (SVSC)

Superior vena cava syndrome are caused by an interruption flow by various

causes, including lung tumors and tumors of the mediastinum. These disorders in patients
with lung cancer appears due to compression or invasion of the masses into the superior
vena cava, causing symptoms SVKS. Complaints largely depends the severity of the
disorder, headache, shortness of breath, cough, syncope, pain swallowing, and coughing
up blood. In severe circumstances in addition to symptoms of shortness of breath Violent
visible swelling of the neck and right arm with the widening of subcutaneous veins of the
neck and chest. This situation sometimes requires emergency action to deal with
complaints.

Based PDPI (2003) the management of lung cancer in cases when a state umurn
SVSC is a good patient (PS> 50) then had to do a diagnostic procedure to get this type of
cancer cell. Narnun action cito radiation should immediately diberikanbila shortness of
breath after a very heavy and reduced symptoms, diagnostic procedures should be
performed. Radiotherapy further action depends on the following conditions:

a. If there is no examination results patotogi anatomy: 2-3 Gy radiation perfraksi, with

a clinical assessment every day. Surgical treatment should be considered if the
response is not mernuaskan.
b. When the results of anatomic pathology already there:
i. For emergency illumination can be given at a dose of 3 Gy / fraction.
ii. If there is an emergency, the radiation dose based on the staging of the disease.
iii. For stage IV, a dose of 3 Gy / fraction to 10 times or dosage of 4 Gy / fraction
up to 5 times.
2.6.3 Obstruction bronchus

Obstruction occurs because tumors intrabronkial clog directly or suppress tumor

outside bronchus bronchi, causing obstruction. Intrabronkial blockage can be partial or
total and it is sometimes necessary actions to improve the quality of life of patients.
Shortness of breath accompanied by wheezing sound can occur in a great obstruction.
The complaint will be increased if accompanied by "mucus plug". On physical
examination will be found weakened breath sounds on the side of the diseased lung, and

22
 can also been found pathological breath sounds, such as wheezing on expiration and
inspiration, expiratory sounds elongated or stidor when airway obstruction is.

Based PDPI, its management is to perform bronchial toilet if there is mucus plug.
Bronchoscopy lase followed by stenting can be performed when the blockage thick
intrabronkialnnasih knowable. It Inl necessary in order to complications did not occur
and the laser action is also needed to determine the required size of the stent. If the
blockage is caused by compression ekstrabronkial mass, or blockage intrabronkialcan not
be solved with laser bronchoscopy and stent then surgery should be considered. In certain
circumstances may be given endobronchial radiation (brachytherapy) at the limit of 3 cm
proximally and distally of the stricture, doses (5-8 Gy) 1 cm from the axis of radioactive
sources. If the endobronchial radiation can not be done, it can be given in the area of
external radiation bronchial narrowing and mucosal areas with a dose of 3-4 Gy / fraction
of the subject.

2.6.4 Cough Blood (Hemoptasis)

Hemoptysis in lung cancer also often need as soon as it can be life threatening.
Coughing up blood massive bronchoscopy action should be done immediately, but to
remove a blood clot (stool cell), this action also needs to determine the source of bleeding
helpful when needed surgery to resolve it. Radiation is one noninvasiv to cough
darah.Target volume and dose as in bronchial obstruction.

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 CHAPTER III
Closing

3.1 Conclusions
1) Cancer cells are normal cells that have mutations / genetic change and grow without
coordinated with other body cells.
2) Clinical picture of lung cancer did not differ much from other lung diseases, consisting of
subjective complaints and objective symptoms. The history will be obtained major
complaints and course of the disease, as well as other factors that are often very helpful
upholding diagnosis.
3.2 Recommendations
1. Need for Health Services for People with lung disease that is carrying out the Promotive,
Healthy Lifestyle, Preventive efforts, efforts Curative and Rehabilitative Efforts,
2. The need for alternative programs more attention to the psychological aspects of lung
disease patients by integrating with other government programs.
3. The need for socialization of all age groups of society, in order to better understand the
characteristics of patients with pulmonary disease and risk factors and disease
characteristics in the elderly.

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 Reference

1. www.emedicinehealth.com
2. Alsagaf, H. 1995. Kanker Paru dan Terapi Paliatif . Penerbit Airlangga, Surabaya:11-14
3. Arisandi, Defa. 2008. Asuhan Keperawatan Pada Klien Dengan Kanker Paru . Sekolah Tinggi Ilmu
Keperawatan Muhammadiyah. Pontianak
4. Aditama, T.Y. 1992. Polusi Udara Dan Kesehatan. ARCAN
5. Anwar J, Elisna S, Ahmad H.
6. Kemoterapi Kanker Paru .Departemen Pulmonologi dan Ilmu Kedokteran Respirasi. Fakultas
Kedokteran Universitas Indonesia-RS Persahabatan, Jakarta

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