MODUL I

(Tumor/Tumor like Lesion pada Saluran Napas)

Skenario 1: Penyesalan tak pernah datang di awal

Dokter Indri adalah seorang dokter jaga yang bertugas di IGD RSUD Banyumanik. Pada shift
jaga malam hari ini, seorang laki-laki bernama Paras berusia 40 tahun diantar keluarganya dengan
keluhan sesak napas hebat sejak 4 jam yang lalu. Tidak ada riwayat kelainan jantung atau paru
sebelumnya. Pada pemeriksaan fisik dr Indri menemukan tanda efusi pleura bilateral. Setelah
melakukan anamnesis lagi, akhirnya keluarga pasien mengatakan bahwa sebenarnya Paras sudah
didiagnosis dengan kanker paru sejak 4 bulan yang lalu tetapi menolak berbagai jenis pengobatan
yang disarankan dokter onkologinya. Bahkan Paras masih terus merokok 1 bungkus per hari yang
sudah dilakukannya sejak remaja. Saat ini bahkan Paras bersikeras minta diberikan oksigen saja dan
setelah berkurang, ingin rawat jalan saja. Dengan bujukan keluarga, akhirnya Paras mau dirawat inap
untuk mendapatkan pemeriksaan dan penatalaksanaan selanjutnya.
Pasien selanjutnya adalah seorang laki-laki 35 tahun bernama Olta dengan keluhan
mimisan sejak 1 jam yang lalu, yang tidak berkurang walau sudah berusaha menekan hidungnya.
Tidak ada riwayat trauma sebelumnya. Pada pemeriksaan fisik dr Indri menemukan massa di kavum
nasi sinistra yang mudah berdarah. Olta mengatakan bahwa dia memang punya riwayat alergi dan
menganggap massa di hidung tersebut akibat alerginya saja. Olta bahkan pernah berobat ke dokter
THT tapi menolak ketika disarankan untuk melakukan biopsi massa di rongga hidungnya itu.
Akhirnya Olta bersedia untuk rawat inap dan melakukan pemeriksaan lanjutan.
Bagaimana anda menjelaskan permasalahan pada kedua pasien diatas?
Step 1: Terminology
1. Pleural effusion : the accumulation of abnormal fluid trapped
in the body cavity namely the pleural cavity (parietal and
visceral and actually this fluid is useful for lubricating in the
movement of breath, due to excessive production.
2. Lung cancer : gene mutations in lung cells that cause massive
growth, the most important and dangerous killer cause
3. Kavum nasal : the nasal cavity divided by the septum into the
sinstra and dextra
4. Nosebleeds : can be released from the nose because it is
divided into 2 namely anterior and posterior based on the
discharge of blood
Step 2: Formulate the problem
1. What is the relationship between age and sex with complaints that occur in these patients ?
2. What are the possibilities that cause tightness complaints that occur at night ?
3. Why do you need to know a history of previous heart and lung abnormalities ?
4. How can doctors conclude from a physical examination of the presence of pleural effusion?
5. Why can pleural effusion occur and is it related to lung cancer?
6. How is the relationship between lung cancer and the absence of treatment with the appearance of
complaints and what types of treatment might be recommended by the doctor ?
7. How to make a diagnosis of lung cancer?
8. How does smoking relate to the occurrence of lung cancer?
9. How is the provision of oxygen able to reduce the symptoms of shortness of breath experienced by
paras ?
10. What is the possibility of further examination and management on the face ?
11. Why can nosebleeds occur on the body and how do they relate to gender and age and why does a
nosebleed occur ?
12. Why doesn't the nosebleed decrease even though it's been pressed ?
13. Why is it known that there is no trauma in the olta?
14. How is the physical examination interpreted by the olta ?
15. Why can allergies cause nosebleeds and how does the allergy history relate to the mass in the nose?
16. Why is it recommended to biopsy the mass of the patient's nose and how it affects the patient's
current condition or complaint ?
17. What is the prognosis of patients 1 and 2 ?
18. What is the follow-up examination and management for the olta?
Step 3: Brain Storming
1. Cancer in most men no. 1 age> 40 years with cigarettes and most women no. 2, because men tend
to smoke where they contain nicotine and tar which mutate cells. In addition there are industrial
chemicals such as asbestos, men tend to eat less vitamin A and less vegetables and fruits, and
mutations of oncogenes such as kiras. Disnees occur at age ≥ 40 years and increase 25-70% at the
age of 70 years, prevalence of increasing obesity and low economic group.

2. Acute events can be disorders of the lungs, heart, etc. There are mechanical disorders in
obstructive disorders and weakness of breath pumps, neuromuscular diseases, wasted ventilation,
pulmonary capillary damage, causes of psychology such as anxiety, stress and possibly heart disease
such as heart failure and CHD, 65% of which occur in lung cancer. Can because of asthma, allergies
or exposure to air, COPD occurs at the age of> 50 years with a history of smoking, pleural effusion,
there are 2 causes of pneumothorax, namely primary acquired such as TB or cancer and the
secondary because of tearing. 3. The cause of 2/3 shortness of breath is caused by cardiopulmonary
or because of hypotensive bleeding, therefore it is necessary to ask a history of heart disease and to
rule out a differential diagnosis for the patient and facilitate the diagnosis.

4. Physical examination shows signs of pleural effusion such as chest pain, cough and fever (rare),
shortness of breath and shortness of breath. Pleural effusion is divided into two, namely transudative,
namely an increase in TD and exudative, namely inflammation, lung injury and tumor. Risk factors
such as smoking and hypertension. Inspection shows that the chest wall is not symmetrical.
Percussion of the chest cavity squeaks because there is fluid. Auscultation is heard wheezing in
bronchial asthma. Palpate unbalanced removal of the chest cavity. Investigation / follow up is
ultrasound and CT scan.
5. Pleural effusion can be due to lung cancer (40%), kidney disease, heart
abnormalities, autoimmune diseases, infection, pulmonary embolism. Malignancy ->
Oxidative stress -> increased permeability -> increased fluid accumulation in lung injury
The pleural cavity is 2, namely filtration (0.1-0.2 cc / kgBB) and absorbs (0.2-0.1 cc /
kgBB), a small portion of protein to maintain autonomic pressure. Tumor inhibits ->
increased pressure -> interferes with lung development.

6. surgery such as reviewer wedge, toracoscopic (partial removal of the lung)

Chemotherapy Radiotherapy (destroying cancer cells) Immunotherapy (immune
imaging to destroy cancer cells) Target therapy (slowing the progression of cancer)
Cryosurgery (injecting cryopresipitate)

7. History: Determine class (high risk , active smokers depend on the duration and
number of cigarettes, passive smokers can also be lung cancer, marijuana cigarettes
equal to 1 ordinary tobacco cigarette packs) Cytology Thoracic X-ray (there is a
pulmonary mass) Anatomy pathology Pulmonary biopsy Mediastinum KGB Test

8. Relationship to smoking with lung cancer 80-90 % of smokers affected by lung

cancer Cigarettes contain> 60 types of carcinogens Nicotine reduces the immune
response to cancer so that the early stages of cancer are less responding Smoke
causes a gene mutation Air pollution can also cause lung cancer
Step 5 : Learning Objective
1. Tumors in the Upper Respiratory Tract
2. Tumors in the Lower Respiratory Tract
3. Tumors in the Pleura
4. Tumors on the Mediastinum
Paranasal sinus cancers
Epidemiology
• Incidence
• representing about 5%of all H&N cancer patients
• 1 case every 100,000, with an average age at comparison between 50 and 60
years
• Survival
• 76% at one year after diagnosis and 47% at 5 years for whom diagnosed
between 2000-2007
• 5-year survival was 51% in peoplewho were under 65 years old at the
moment of diagnosis and 42% in people aged +65 at diagnosis
Risk Factor
• strong evidence
• isopropyl alcohol production, leather dust, nickel compounds, radium, wood
dust
• Limited evidence
• carpentry and joinery, chromium(VI) compounds, formaldehyde, textile
manufacture
Pathogenesis
• Wood dust is a complex mixture of organic and inorganic
components, including genotoxic and carcinogenic factors, It has
capacity to induce DNA damage and induce generation of ROS in cells
• In a retrospective review of 125 cases of patients with
ethmoidadenocarcinoma, more than 90% had a history of wood- or
leather-dust exposure
Pathogenesis
• Biomolecular alterations
• EGFR and HER2 are over-expressed in about 30% of cases
• Role of HPV
• HPV has been detected in about 30% of sinonasal carcinomas
• possible relation-ship between HPV infections and a subtype of sinonasal
cancer : non-keratinizing carcinoma
Signs and symptoms
• Nasal obstruction, nasal discharge, epistaxis, otitis media and facial
pain
• Neurologic related symtomps, headache, anaesthesia and/or pain,
smell disturbances, exophthalmos, epiphora, diplopia, loss of vision,
dental pain or mobility of maxillary teeth symptoms.
• Regional and distant metastases are not frequent
Diagnosis
• CT or MRI to evaluate neoplasma and guide endoscopy
• Nasal endoscopy to visualize and differentiate polyp, benign and
malignant neoplasma
• irregular surface, necrotic areas, and contact bleeding is suggestive cancer
• Mandatory imaging whenever otitis media is reported
Diagnosis
• cervical lymph node stations palpation
• Clinical examination of cranial nerves (from I to VI)
• PET-CT and PET-MRI plays a role during follow up of advanced
tumors.
• endoscopic biopsy, incision biopsy of paranasal sinus cavity
• Fine needle aspiration to cervical lymph nodes
Staging
• Staging is challenging due to the complexity of the anatomical site
and theheterogeneity of the tumours
• The Union Internationale Contre le Cancer/American Joint Committee
on Cancer (UICC/AJCC) classification is the most commonly used
staging system
Prognosis
• The 5-year actuarial specific survival were 91%,64%, 72%, and 49% for
patients with T1, T2, T3, and T4 tumours,respectively
Treatment
No standard treatment is establised, treatment include surgery,
radiotherapy, and chemotherapy
• T1 tumour is treated with surgery alone, radiotherapy is indicated in
positive surgical margin
• Advance tumour is treated with surgery and postoperative
radiotherapy w/wo chemo
Treatment
• Unresectable tumour is treated with definitive radiotherapy
• Chemotherapy is applied as multimodal curative with other
treatment, or singel therapeutic modality in palliative setting in
patient with recurrent disease not amendable surgical salvage or
reirradiation
Nasopharynx Tumor
Definition

Nasopharyngeal carcinoma
Ca is a malignant tumor arising
Nasopharynx in the epithelial lining of the
room behind the nose
(nasopharynx)
EPIDEMIOLOGY

 Many in Asia, rarely in Europe and America.

 The highest incidence: Guang Dong province
(PRC)  40 - 50/100 thousand inhabitants / year.
 Indonesia  4.7 / 100 thousand inhabitants / year.
 Male: Female = 2-3: 1
ETIOLOGY
Epstein-
Barr virus
Social Geographical
economy location

Life habits Racial

Nasopharyngeal
carcinoma

Environment Gender

Work Genetics
Patofisiology
Epstein-Barr virus
Infected cells can
EBV goes into die or
The virus replicates
lymph DNA B transformation into
a malignant form

Being latent in B Binds to virus

lymphocytes receptors

Occurs in Kel saliva

EBV infects lymph B
and lymph B
 GENETICS

Nasopha
HLA P450 2E1
ryngeal
gene cytochrome
Ca
 • nitrosodimethyamine
(NDMA)
FOOD • N-nitrospurrolidene
(NPYR)
• nitrospiperidine (NPIP)

ENVIRONMENTAL • Active dan pasive

CIGARATE
FACTOR • Formaldehid

WOOD • reactivate infection of

DUST EBV
CLINICAL PRESENTATION
Nasopharynx • Epistaxis
• Nose obstructions
Symptoms

• Tinitus
Ear Symptoms • Hearing Diasease
• Discomfort in the ear to otalgia

• Diplopia
Neural and Visual • Trigeminal neuralgia
Symptoms • Jackson syndrome

Metastasis or
symptoms in the • Lump on the neck
neck
DIAGNOSIS

Physical Supporting
Anamnese
Examinations Examinations

 CT-Scan
Clinical Rinhoscopy Serology Test
Presentation posterior Biopsy
STAGING
(TNM SYSTEM BASED ON IUCC 2002)
• T = Primary Tumor
• To= Tumor doesn’t appear
• T1= Tumor is limited on nasopharynx
• T2= Tumor spreads to the limphatic mass
T2a : Spreading to the oropharyng or nasal cavity without metastasis
to the parafaring
T2b : With spreading to the parafaring
• T3= Tumor invade the bone and paranasal sinus
• T4= Tumor with spreading to the intracranial, infratemporal fossa,
hypopharyng, orbita or masticator cavity
• Note: The preading to the parapharyng shows the infiltration of tumor to the
posteri-lateral more than pharyngo-basilar facia.
N = Enlargement of regional lymph nodes.
Nx = Enlarged lymph nodes cannot be assessed.
No = No enlargement.
N1 = Unilateral lymph node metastases, with the largest size
less than or equal to 6 cm above the supraclavicular fossa.
N2 = Bilateral lymph node metastases, with the largest size
less than or equal to 6 cm above the supraclavicular fossa.
N3 = Larger size bilateral lymph node metastases
from 6 cm, or located inside the supraclavicular fossa.
N3a = size more than 6 cm.
N3b = inside the supraclavicular fossa.

M = distant metastasis
Mx = distant metastasis cannot be assessed
Mo = There are no distant metastases
M1 = There are distant metastases
STAGING
Stage 0 T1s N0 M0
Stage I T1 N0 M0
Stage IIA T2a N0 M0
Stage IIB T1 N1 M0
T2a N1 M0
T2b N0,N1 M0
Stage III T1 N2 M0
T2a,T2b N2 M0
T3 N2 M0
Stage IVa T4 N0,N1,N2 M0
Stage IVb All T N3 M0
Stage IVc All T All N M1
DIFFERENTIAL DIAGNOSIS
• Nasopharyngeal angiofibroma
• Nasopharyngeal hyperplastic abnormalities
• Neck lymph node TB
TREATMENT

1. Radiotherapy
2. Chemotherapy
3. Surgery
TREATMENT
• Stage I  Radiotherapy
• Stage II  Chemoradiation
• Stage IV N< 6 cm  Chemoradiation
• Stage IV N> 6 cm  Full-dose chemotherapy
continued with chemoradiation
Surgery
Neck Resecktion

Nasopharyngektomi
PROGNOSIS
• Very striking difference in prognosis (5-year survival rate) from the
initial stage with the advanced stage, namely 76.9% for stage I, 56.0%
for stage II, 38.4% for stage III, and only 16.4% for stadium IV.
The prognosis is exacerbated by several factors, such
as:
• Further stadium.
• Age more than 40 years
• Men than women
• Chinese race rather than white race
• The enlargement of the neck glands
• The presence of cerebral nerve palsy is damage to the
skull
• The presence of distant metastases
PREVENTIONS

1. Vaccination
2. Change wrong life habits
3. Perform mass serologic IgA anti
VCA and IgA tests in bulk
Malignancy on the larynx
Epidemiology
• Male (5): female (1)
• 56-69 years
• Increased due to smoking
Etiology
•?
Risk Factor
• Smoking
• Asbestos
• Polution
• Alcohol
Histopatology
• Squamosa (95%)
• Adenocarsioma (supraglotis,subglotis)
• Condrosarcoma (Cricoid cartilago, thyroid)
Sign and Symptomps
• Dyspneu
• Breath sounds
• Sore throat
• KGB enlargement
• Dysphagia
• Cough
Diagnosis
• Anamnesis
• Physical Examination
• Direct Laryngoscopy
• Radiology
• CERTAIN DIAGNOSIS : HISTOPATOLOGY
TREATMENT
• Surgery (laryngectomy)
• Radiotherapy
• Chemotherapy
• Vocal rehabilitation
Lung Tumor
Epidemiology
National population prevalence for all ages 1.4%
The third most cancer after breast and cervical cancer
Presentation of a new case:
Men 34.2% with a mortality rate of 30%
Female 13.6% with a mortality rate of 11.1%
Etiology
The exact etiology is unknown, but there are several factors responsible
for the increased incidence of lung cancer
1. Smoking (85%)
2. Industrial hazards (asbestos, uranium, chromate, arsenic, iron, iron
oxide)
3. Air pollution (radon, wood burning smoke)
Classifications
• Malignancy >90%
 Brochogenic Carcinoma 95 %
Small cell lung cancer
Non-small cell lung cancer
Squamosa Carcinoma / epidermoid (most common)
Adenocarcinoma
Big Cell Carcinoma
Mixture
 Broncus Adenoma
 Mesotelioma malignancy
 Sarcoma dan melanoa malignancy
• Benigna
 Patogenesis dan Patofisiologi
Smoking and / or long- Common in the
term cigarette smoke Bronchial epithelial
exposure, exposure to
center and
metaplasia or Tumor
carcinogenic protruding into large
dysplasia
substances bronchi

Tends to spread to
Irritation and Dispneu Obstruction the chest wall and
ulceration mediastinum

Abscess infection
hemoptysis and formation
Clinical Presentation
• Anorexia, tired, bb down
• Cough, hemoptysis
• The volume of sputum increases
• Mild dyspnea
• SYMPTOMS OF SPREADING INTRATORS
• Recurrent laryngeal nerve : hoarse voice
• Esophagus : dysphagia
• N. Phrenic : diaphragm paralysis
• Superior Vena cava : vena cava syndrome
• Chest wall : chest pain
• Pericardium : cardiac tamponade
• Pleura : pericardial pain
Diagnosis
• History
• Physical examination
• Supporting investigation
• Radiology, bronchoscopy, sputum cytology, bronchial rinse, pleural
fluid examination
Staging
Treatment
SCLC  chemotherapy with or without radiation
NSCLC
stage I, II, and some cases of stage IIIa  Surgery
Stage I & II which have surgical contraindications, stage III which are
limited to hemithorax  radioterapy
Stage III and IV  combination chemotherapy
Mediastinal Tumor
Definition
• Mediastinal tumors are tumors located in the mediastinum, namely
the space from the thoracic inlet to the diaphragm and the space
between the right and left lung
• a. The superior mediastinum, from the upper door of the chest cavity to
the 5th thoracic vertebra and the lower part of the sternum. Contains the
thymus, upper trachea, esophagus and aortic arch and branches.
• b. The anterior mediastinum, from the superior mediastinal line to the
diaphragm in front of the heart. Contains inferior aspects of the thymus
and adipose, lymphatic and areola tissues.
• c. Posterior mediastinum, from the superior mediastinal line to the
diaphragm behind the heart. Contains the esophagus, vagus nerve,
sympathetic nerve chain, thoracic duct, descending aorta, azygotic and
hemiazygos systems, paravertebral lymph nodes and arteola tissue. d.
Medial mediastinum (middle), from the superior mediastinal line to the
diaphragm between the anterior and posterior mediastinum
• c. Posterior mediastinum, from the superior mediastinal line
to the diaphragm behind the heart. Contains the esophagus,
vagus nerve, sympathetic nerve chain, thoracic duct,
descending aorta, azygotic and hemiazygos systems,
paravertebral lymph nodes and arteola tissue.
• d. Medial mediastinum (middle), from the superior
mediastinal line to the diaphragm between the anterior and
posterior mediastinum
Mediastinal tumors that are often encountered
• Superior mediastinum: goitre, parathyroid adenoma and lymphoma.
• Anterior mediastinum: goitre, thymoma, teratoma, parathyroid
adenoma, lymphoma, fibroma, limfagioma hemangioma, and
morgagni hernia.
• Mediastinum medius: bronchogenic cysts, lymphomas, pericardial
cysts, aneurysms, and hernias.
• Posterior mediastinum: neurogenic tumor, fibrosarcoma, lymphoma,
aneurysm, condroma, bochdalek hernia.
Etiology
• Chemical  carbon
• Genetic  mutase
• Physical  trauma / blows, repeated irradiation
• Nutrition  alfatoxin in nuts
• Anterior mediastinum
a. Germ cells (germ cell): the majority of neoplasmic germ cells (60-70%) are
benign tumors and can be found in men and women.
b. Lymphoma: malignant tumors including Hodgkin's disease and non-
Hodgkin's lymphoma
c. Thymoma and thymus cyst: the most common cause of cyst mass. The
majority of thymomas are benign tumors contained in fibrous capsules. But
30% of thymomas can become more aggressive and become invasive
through fibrous capsules
d. Mediastinum thyroid mass: usually grows benign, like goiter, sometimes it
can become cancerous
Middle maediastinum

a. Bronchogenic cysts: benign tumor growth originating from

respirators
b. Mediastinal lymphadenopathy: enlargement of the lymph gland
c. Pericardial cysts: benign tumor growth resulting from "out-
pouching" of the pericardium.
d. Mediastinum thyroid mass: usually grows benign, like goiter,
sometimes it can become cancerous.
e. Tracheal tumors: including tracheal neoplasms and non-
euplastic masses such as tracheobronchopathia
osteochondroplastica (benign tumors).
f. Vascular abnormalities: including aortic aneurysms and
dissection
• Posterior mediastinum
a. Extramedullary haematopoiesis: a rare cause of mass
formed from spinal cord expansion and associated with severe
anemia.
b. Mediastinal lymphadenopathy
c. Neuroenteric mediastinal cyst: a rare growth involving the
nerves and gastrointestinal elements
d. Neurogenic mediastinal neoplasms: the most common
causes of posterior mediastinal tumors, classified as nerve
cavity neoplasms, ganglion cell neoplasms and paraganglionic
cell neoplasms. About 70% of neurogenic neoplasms are
benign. Esophageal abnormalities include esophageal
achalasia, esophageal neoplasms and hiatus hernias
Clinical Presentation
1 Cough, tightness or stridor
2. Dysphagia
3. Superior vena cava syndrome
4. Hoarseness and dry cough
5. Arise
6. Chest wall pain
Diagnostic Examination
• 1) X-rays: can indicate location, contour, density, presence or absence
of calcification or ossification, etc., so that it can determine the type
of tumor early. Examination of drinking barium can determine
whether the esophagus or the surrounding organ is tight.
• 2) Bronchoscopy or fiber esophagoscopy: helps show the condition
and degree of pressure on the bronchi or esophagus, to assess the
possibility of surgery.
• 3) Mediastinoscopy: showing the presence or absence of enlarged
lymphatic paratracheal glands, subcarcinia, can also do a biopsy for
eitological diagnosis.
• 4) CT scan: against anterior mediastinal tumors, lymphadenopathy,
mediastinal fatty tissue lesions (eg, lipomas) more reliable than X-
rays. CT-scan accuracy in tumor diagnosis and mediastinal
lymphadenopathy can reach 90% more.
• 5) Biopsy of the cervical lymph gland: lymph node tuberculosis and
bronchial lymphoma often affect the lymph nodes of the neck, lymph
node biopsy can help the diagnosis.
Laboratory Examination
• 1) Regular checks often do not provide information relating to the
tumor. LEDs sometimes increase in mediastinal lymphoma and TB.
• 2) The tuberculin test is needed if there is suspicion of TB
lymphadenitis.
• 3) Examination of T3 and T4 levels is needed for thyroid tumors.
• 4) Examination of a-fetoprotein and b-HCG is performed for
mediastinal tumors which belong to the group of germinal cell
tumors, ie if there is doubt between seminoma or nonseminoma.