Week Objectives

1. List the major air pollutants and the factors which influences depositions of
pollutants within the respiratory system (particles, ozone, oxides of Nitrogen,
sulfur oxides, environmental tobacco smoke, radon, organic dusts, metal fumes)
2. List the sources of exposure to pollutants in the workplace.
3. Describe the macroscopic and microscopic pathology of the major types of lung
and pleural cancers - squamous, adenocarcinoma, large cell, small cell
carcinoma and pleural mesothelioma.
4. Recognize the clinical and therapeutic implications of SCC and NSCC.
5. Describe the clinical procedures to get cells and tissues for the diagnosis of lung
cancer.
6. List some of Pneumoconiosis which will develop into lung cancer.
7. Distinguish lung tumor and mediastinal tumor.
8. Describe the principle of chest radiography, CT-scan, MRI and PET-scan.
9. Describe how important cigarette smoke in causing lung cancer.
10. Describe the indication of O2 Therapy.

Case Objectives
1. Explain the signs and symptoms of lung cancer.
2. Identify the risk factors of lung cancer pathogenesis (esp. smoking).
3. Mention classification of lung cancer based on pathology.
4. Describe lung cancer staging and diagnosis.
5. Explain lung cancer treatment guidelines.
6. Mention prognosis of lung cancer.
7. Describe ways to prevent lung cancer (Preventions and Screenings).
 Week Objectives
​ articles, ozone, oxides of Nitrogen, sulfur oxides,
1. Major air pollutants includes p
environmental tobacco smoke, radon, organic dusts, a
Pollutants Sources
Ozone Ozone is a gas compound
composed of three atoms of
oxygen (O​3​). There are ​Good
​ and B​ ad ozone. Bad ozone
are the one found at ground
level. This type is not emitted
directly into the air but is
produced when pollutants
emitted by cars, power
plants, etc. react under
sunlight.
Radon Radon is a colorless
chemically-unreactive inert
gas. It is a naturally occurring
radioactive gas and comes
from the natural breakdown
of Uranium. It is usually
found in igneous rocks and
soil.
Nitrogen Oxides (NOx) NOx is produced from the
reaction of nitrogen and
oxygen gases in the air
during combustion, especially
at high temperatures. This
substance usually produced
by the combustion inside car
engines and can also be
naturally produced during
​ nd​ metal fumes.
Effects
Breathing ozone can trigger a
variety of health problems
including chest pain,
coughing, throat irritation,
and airway inflammation. It
also can reduce lung function
and harm lung tissue. Ozone
can worsen bronchitis,
emphysema, and asthma,
leading to increased medical
care. This is because ozone
causes the muscles in the
airways to constrict, thus
trapping air in the alveoli.
It has been the subject of
various studies about the
correlation of Radon gas
exposure to lung cancer and
it has been established that
Radon exposure it one of the
leading causes of lung
cancer. Because Radon gas
is usually found in igneous
rocks, people who works in
confined space, particularly
those who works
underground (miners) are at
an increased risk.
NOx mainly impacts on
respiratory conditions
causing inflammation of the
airways at high levels. Long
term exposure can decrease
lung function, increase the
risk of respiratory conditions
and increases the response
to allergens​.
 lightning strike.

Sulphur Oxides (SOx)
Electric power companies
that burn coal are a major
source of sulfur oxides.
At lower levels, chest pains,
breathing problems, eye
irritation and a lowered
resistance to heart and lung
diseases can be
experienced. It has also
known to increase asthma
attacks.

Organic Dusts Organic dusts includes flour, Inhalation of organic dusts

wood, cotton, tea dusts and
pollen.
can induce allergic reaction
(e.g Hay fever) and also
cause irritation and
inflammation of the airway. It
can also induce asthma and
rhinitis.

Tobacco Smoke Cigarette Irritate airway epithelial cells

and cillia. Causes
hypertrophy and hyperplasia
of the mucus-producing cells
karena harus lebih aktif
ngeluarin mukus untuk buang
particles asap rokok yang
masuk. Perokok berat dan
lama bisa lebih gampang
develop lung cancer and
COPD later in life.

2. Many substances found in the workplace can cause breathing problems or lung damage.
Some of them include the following:
○ Dust​ from such things as wood, coal, asbestos, silica and talc. Dust from cereal
grains, coffee, pesticides, drugs or enzyme powders, metals and fiberglass can
also do damage to the lungs.
○ Fumes​ from metal that are heated and cooled quickly. This process results in
fine, solid particles to be released into the air. Example of jobs that expose
workers to these type of fumes includes, welding (pengelasan),
smelting(peleburan), furnace work, pottery making, plastic manufacture and
rubber operations.
○ Smoke​ from burning organic materials. Smoke contains a variety of particles,
gases and vapors depending on what substance is being burned. These
 particles, gases and vapors if inhaled, can damage the lungs. Firefighters are at
an increased risk.
○ Gases​ such as ​Formaldehyde, Ammonia, Chlorine, Sulfur dioxide, Ozone and
Nitrogen oxides. These gases are associated with jobs involving chemical
reactions and jobs that require high heat (e.g welding, smelting, oven drying and
furnace work).
○ Vapors ​are gas forms of liquids that can revert back to liquid forms with particular
temperature or pressure. Vapors given off by solvents usually irritate the nose
and throat first before affecting the lungs.
○ Mists​ or sprays from paints, lacquers (e.g varnish), hair spray, pesticides,
cleaning products, acids, oils and solvents (e.g turpentine)

3. Major types of lung and pleural cancers :

Squamous Cell Carcinoma ​= only about 20% of all bronchogenic carcinomas.

Malignancies originate within the epithelial layer of the bronchial wall, abnormalities
result from chronic or repetitive cigarette smoke-induced injury.

Metaplasia of normal bronchial columnar epithelial cells → replaced by squamous

epithelial cells

More atypical appearance → development of well localized carcinoma → carcinoma

exteds beyond the bronchial mucosa and become invasive → tumors become eventual
clinical attention : symptoms/radiographic changes.

Diagnosis : sputum obtained for cytologic examination / biopsy of abnormal appearing

bronchial mucosa during bronchoscopic.

Tumors are characterized by the visible presence of keratine , “squamous pearls” and
intracellular desmosomes / bridges .

Feature of squamous cell carcinomas

○ Generally arises in proximal ariways (most commonly : subsegmental,segmental,

or lobar level
 ○ May cause airway obstruction, leading to atelectasis or pneumonia because
growth of tumor into the bronchial lumen
○ May cavitate
○ Intrathoracic spread rather than distant metastasis

Spread of squamous cell carcinomas :

○ Direct extension to the pulmonary parenchyma / other neighboring structures

○ Invasion of lymphatic vessels, with spread to local lymph nodes in hilum /
mediastinum

Tumors have tendency to remain within the thorax and cause problems by intrathoracic
complications. Prognosis is better → 5 year survival

Small Cell Carcinoma

Feature of small cell carcinoma :

○ Generally arise in proximal airways

○ Commonly produce polypeptide hormones
○ Hilar and mediastinal node involvement
○ Early, distant metastatic disease

Appears small, darky stained cells with sparse cytoplasm

Local growth tumor follows submucosal pattern → tumor quickly invades lymphatic and
submucosal blood vessels

Metastatic spread : brain, liver, bone, bone marrow, and adrenal glands . early
metastatic involvement → worst / poor prognosis.

Adenocarcinoma ​(sering di type II alveolus)

Most frequent, occur in the lung periphery, much harder to relate their origin to the
bronchial wall. Tumors are arised at level of bronchioles/ alveolar walls
Sometimes appear at the site of parenchymal scarring → localized or part of a diffuse
fibrotic process

Characteristic appearance → tendency to form glands in many cases produce mucus

Malignant cells → grow and spread along the pre-existing alveolar walls →
bronchioalveolar carcinomas

Feature of adenocarcinoma :

○ Often manifest as a solitary preipheral pulmonary nodule

○ May arrise in an old parenchymal scar
○ Generally localized when manifest as a peripheral lung nodule → more likely to
be localized than small cell carcinoma
○ Spread to hilar and mediastinal nodes and to distant sites (it can spread to liver,
bone,CNS, adrenal glands)

Large Cell Carcinoma ​(kalo ga punya feature dari yang lain → large cell carcinoma)

Difficult to describe microscopically : collections of large polygonal cells → prominent

nucleoli and moderate amount of cytoplasm

Appear in the periphery of the lung as mass lessions, larger than adenocarcinoma

Similar to adenocarcinoma in terms both propensity for spread and overall prognosis

Malignant Mesothelioma

Arise from and primarily involves the plura rather than ariways/pulmonary parenchyma

Mesothelioma develops even in spouses of asbestos workers → inhalation of asbestos

dust while exposed to their partner clothes
 Main symptoms : chest pain, dyspnea, possibly cough, paraneoplastic syndrome.

Diagnosis : biopsy of the pleura and the hisotologic demonstration of malignancy

Presence of pleural fluid and often irregular / lobulated thickening of the pleura

Tumor originates in the plura and doesnt directly communicate with airways, malignant
cells are not shed into the tracheobronchial tree and cannot be found on the cytologic
examination of sputum/bronchoscopy specimens

4. Clinical Manifestations

Non Small Cell Carcinomas :​

○ Coughing (worsen)
○ Voice Changes
○ Decreased Weight, Loss Apetite
○ SOB
○ Batuk darah / dahak
○ Wheezing
○ Chest Pain

Ketika sudah metastasis ​:

○ Bone Pain
○ Headache
○ Dizziness
○ Numbness / Weakness di arm atau leg
○ Mata merah / kuning

Small Cell Carcinomas ​:

○ Coughing
○ Hemoptisis
 ○ SOB
○ Chest pain ( worsen when deep breathing )

Ketika sudah spreading :​

○ Voice Change ( nerve yang supply vocal cord tersupresi )
○ SOB ( karena nerve yang supply diafragma terkompresi, paru - paru terisi
fluid
○ Sulit Menelan ( compression of esophagus )
○ Swelling (face & hands) karen compression superior vena cava
○ Kalo menyebar ke organ spesifik
■ Brain : headache, blurring of vision, nausea, vomitting, seizures
■ Vertebral Column : back pain
■ Spinal Cord : Paralisis

Therapeutic

Small Cell Carcinomas ​(dibagi menjadi 2)

○ Extensive (ED)
■ ED - Stage bisa menyebar luas dari tempat ini. Malignant plural
effusion or disease extending to the contralateral supraclavicular
or hilar lymph node is generally considered to be ED\
■ Treated with the same platinum based Chemotherapy
○ Limited (LD)
■ LD - Stage disease terbatas pada satu hemithorax, mediastinum
dan kelenjar getah bening supraclavicular ipsilateral
supraclavicular or hilar lymph node
■ Chemotherapy or Thoracic Radiotherapy
 Pada kasus yang jarang, SCC ada peripheral nodule, the treatment of choice is surgical
resection diikuti dengan adjuvant chemotherapy and possibly sequential thoracic radiotherapy.

Kalo pasiennya relapse setelah initial therapy, kelangsungan hidupnya rata - rata 3
sampai 4 bulan. NO OBAT 2ND LINE.

Yang NSCC, ada di foto. Tabel nya panjang WKWK

5. A biopsy is a procedure performed to remove tissue or cells from the body for
examination under a microscope. A lung biopsy is a procedure in which samples of lung
tissue are removed (with a special biopsy needle or during surgery) to determine if lung
disease or cancer is present.

A lung biopsy may be performed using either a closed or an open method. Closed
methods are performed through the skin or through the trachea (windpipe). An open
biopsy is performed in the operating room under general anesthesia. Various biopsy
procedures include:

● Needle Biopsy​ → A needle is guided through the chest wall using the CT-scan
or fluoroscopy after local anesthesia is given. This type of biopsy is also know as,
Closed, Transthoracic, or ​Percutaneous biopsy.
● Transbronchial biopsy​ → This type of biopsy is performed during bronchoscopy
through a fibreoptic bronchoscope (long thin tube with close-focus telescope at
the end of it for viewing purpose).
● ​ After general anesthesia is given, an endoscope is
Thoracoscopic biopsy →
inserted through the chest wall into the chest cavity. Various biopsy tools then
can be inserted through the endoscope to obtain the lung tissue. This type of
biopsy can also be referred as video-assisted thoracic surgery (VATS).
● Open biopsy​ → General anesthesia is first given to the patient. Then the doctor
makes an incision in the skin on the chest and surgically remove the piece of the
lung tissue. This type of biopsy usually done if other method of biopsies have not
been successful or larger piece of lung tissue is needed for diagnosis.
● Pemeriksaan khusus versi PDPI:
○ Bronkoskopi
 ○ Biopsi aspirasi jarum
○ Transbronchial Needle Aspiration
○ Transbronchial Lung Biopsy
○ Transthoracic Needle Aspiration
○ Transthoracic Biopsy
○ Fine Needle Aspiration
○ Core Biopsy
○ Closed Pleural Biopsy
○ Pleuroscopy
○ VATS
6. Pneumoconiosis → lung diseases caused by inhalation of dust)

Depending upon the type of dust, the disease is given different names :
○ Asbestosis → asbes yang masuk ke paru dan tertimbun
■ Ada di home insulation, fireproof mineral, tiles for floor and ceiling
→ miners, construction, shipbuilder, Home yang atasnya asbes
○ Silicosis → silica yang bikin paru - paru fibrosis sehingga decreased lung
function
■ Ada di sand, sandstone, clays → yang kerja di sandblister, miners,
Tunnel Builder
○ Coalworker’s Pneumoconiosis → inhaling carbon particle from coal,
graphite, bikin paru - paru jadi fibrosis
○ Tale Pneumoconiosis → lead to lung fibrosis
■ Exposure to tale dust when tale mining
○ Kaolin → Manufacture ceramic, paper medicine, cosmetic, toothpaste
○ Siderosis (Welders Lung or Silver Polisher Lung) → caused of inhaling
iron particle
○ Byssinosis → cotton
○ Berylliosis → Beryllium
○ Bauxite Fibrosis → Bauxite
7. Mediastinum Tumor
 Causes : In Children biasa ada di posterior, mediastinum, tumor biasanya mulai dari
saraf dan non cancerous (jinak)

Kalo In Adults, biasanya di anterior, mediastinum, biasanya malignant lymphomas, germ

cell tumors or thymomas → commong in age 30 - 50

Symptoms ​:
○ Chest pain
○ Chills
○ Cough
○ Hemophysis
○ Fever
○ Night Sweats
○ SOB
○ Wheezing
○ Stridor
○ Swollen di Lymph Nodes
○ Weight Loss

Ada tabel pembeda antara mediastinum, anterior, sama posterior nanti dibawa pas
review hari selasa.

8. X-ray and CT-scan uses external source of ionising radiation beam which is shot through
the target. The beam which passes through the target’s tissues and then strikes the
radiographic film behind the target, leading to image production on the film. MRI on the
other hand, uses magnetic fields and radio frequency to produce anatomical images.
○ X-Ray
An X-ray is a noninvasive medical diagnostic tool that helps physicians to
diagnose a disease and also help treat medical conditions. It is the oldest and
most frequently used form of imaging. Doing X-rays involves exposing a part of
the patient’s body to a small dose ionizing radiation beam to produce images of
the inside of the body.
 Chest X-ray is the most commonly performed x-ray. In chest X-rays, we can see
the image of the heart, lungs, airways, blood vessels and also the bones of the
spine and chest.
○ CT-Scan
Computed tomography (CT scan or CAT scan) is a noninvasive diagnostic
imaging procedure that uses a combination of X ​ -rays a
​ nd computer technology to
produce horizontal, or axial, images (often called slices) of the body. A CT scan
shows detailed images of any part of the body, including the bones, muscles, fat,
and organs. CT scans are more detailed than standard X-rays.
In computed tomography, the X-ray beam moves in a circle around the body.
This allows many different views of the same organ or structure. The X-ray
information is sent to a computer that interprets the X-ray data and displays it in a
two-dimensional (2D) form on a monitor.
○ MRI
Magnetic resonance imaging, or MRI, is a noninvasive medical imaging test that
produces detailed images of almost every internal structure in the human body,
including the organs, bones, muscles and blood vessels. MRI scanners create
images of the body using a large magnet and radio waves. There is no radiation
produced during an MRI exam, unlike X-rays. Because ionizing radiation is not
used, there is no risk of exposure to radiation during an MRI procedure.These
images give your physician important information in diagnosing your medical
condition and planning a course of treatment

The strong magnetic field created by the MRI scanner causes the atoms in your
body to align in the same direction. Radio waves are then sent from the MRI
machine and move these atoms out of the original position. As the radio waves
are turned off, the atoms move back to their original position and send back radio
signals. These signals are received by a computer and converted into an image
of the part of the body being examined. This image appears on a viewing
monitor.

MRI may be used instead of C ​ T​ in situations where organs or soft tissue are
being studied. MRI is better at telling the difference between types of soft tissues
and between normal and abnormal soft tissues.​.

○ PET-Scan

PET (Positron Emission Tomography) is a type of n ​ uclear medicine​ procedure.

This means that a small amount of a radioactive substance, called a radionuclide
(radiopharmaceutical or radiotracer), is used to perform the procedure.
Specifically, PET studies evaluate the metabolism of a particular organ or tissue,
 so that information about the physiology (functionality) and anatomy (structure) of
the organ or tissue is evaluated, as well as its biochemical properties. Thus, PET
may detect biochemical changes in an organ or tissue that can identify the onset
of a disease process before anatomical changes related to the disease can be
seen with other imaging processes, such as c​ omputed tomography (CT scan)​ or
magnetic resonance imaging (MRI)​.

PET is most often used by oncologists (doctors specializing in cancer treatment),

neurologists and neurosurgeons (doctors specializing in treatment and surgery of
the brain and nervous system), and cardiologists (doctors specializing in the
treatment of the heart). However, as advances in PET technologies continue, this
procedure is beginning to be used more widely in other areas

9. Cigarette smoking remains as the leading causes of lung cancer, accounting for about
85% of lung cancers. The risk of developing lung cancer in cigarette smokers increased
​ uration​, ​amount​, and ​depth​ of
up to 20-folds. The risk of lung cancers increase by the d
inhalation.

Cigarettes contain multiples carcinogens (more than 60) that have been proven to be
able to induce cancers in laboratory settings. Some of which:
● Polycyclic Aromatic Hydrocarbon​ such as benzo[α]pyrene produce mutation in
the ​p53 gene. G to T transversion within the gene is a molecular signature of lung
tumors caused by tobacco mutagens.
● Nitrosamine ​which can be found in cigarettes are carcinogens.
Nicotine​ is one of the ingredients within cigarette notorious for its disadvantages, such
as:
● Sympathetic/parasympathetic activation: Nicotine binds to and activates nicotinic
cholinergic receptors, which are located both on sympathetic and
parasympathetic postganglionic neurons. The endogenous ligand of this receptor
is the hormone ACH. As Nicotine is not naturally found in the human bodies, the
entry of nicotine through smoking can activate both the sympathetic and
parasympathetic systems, releasing a whole range of hormones and
neurotransmitters into the circulation.
● Addiction: Nicotine causes dopamine release, mediating reward and addiction.
● Carcinogen: Nicotine is not directly carcinogenic, but it has been shown to inhibit
apoptosis, induce cell proliferation and cause angiogenesis in lung tumors.

10. Indications of O2 Therapy includes:

 ○ Any individual with one or more of the following:
■ Peri and Post cardiac or respiratory arrest
■ Hypoxia (O2 sats < 92%)
■ Acute and chronic Hypoxemia (PaO2< 65mmHg, SaO2 <92%)
■ Signs and symptoms of shock
■ Low CO and Metabolic acidosis (HCO3 <18 mmol/l)
■ Hypoxia and Hypercapnia
○ Also given in the following conditions:
■ Dyspnea without Hypoxemia
■ Post-operation
■ Pneumothorax treatment.

Case Objectives
1. Sign and Symptoms of lung cancer mirip sama penyakit-penyakit paru lainnya. Most
common symptoms includes:
● Persistent or progressive chronic cough
● Hemoptysis
● Chest pain that worsen with deep breathing, coughing or laughing
● Hoarseness
● Feeling tired/weak (malaise)
● Shortness of breath
● Weight loss and loss of appetite.
Kalau sudah ada metastasis tumor ke bagian tubuh yang lain, tanda dan gejala
tambahan bisa muncul, seperti:
● Bone Pain
● Nervous system changes (headaches, weakness/numbness of limb, balance
problems, seizures)
● Jaundice
● Lumps near the surface of the body (karena cancernya spread ke lymph nodes)
Some lung cancers can also cause syndromes tergantung tumornya ada dimana dan
juga tumornya ide bikin-bikin hormone-like substances.
● Horner Syndrome
Syndrome ini disebabkan oleh P​ ancoast tumors​ (Tumor yang letaknya di apex
paru). Karena lokasinya di apex deket brachial plexus dan saraf-saraf penting di
bagian leher-wajah, kalau tumornya big enough, bisa menekan saraf-saraf ini
dan cause a series of symptoms, such as:
★ Drooping of one eyelid (Ipsilateral ptosis)
★ Pupil contraction
★ Ipsilateral anhydrosis (gak ada keringet)
 ★ Gangguan extremitas

● Superior Vena Cava Syndrome

Superior Vena Cava, biar sampai ke jantung harus melewati bagian atas paru
kanan dan lymph nodes di dalam rongga dada. Kalau ada tumor, di
bagian-bagian sekitar SVC, bisa neken SVC dan menyebabkan reduced venous
return. This leads to:
★ Swelling in the face, neck, arms and upper chest.
★ Caput medusa (karena vena-venanya dilatasi, jadi keliatan deh)
★ Headaches, dizziness and changes in consciousness kalo sampe affect
brain.

● Paraneoplastic Syndrome
Some lung cancerscan make homone-like substances and release it into the
bloodstream, causing problems in other distant organs. Bikin susah diagnosis
karena, pas symptoms muncul dikiranya yang sakit emang organnya, padahal
karena ada lung cancer. Some common paraneoplastic syndromes associated
with CA Paru contohnya:
★ SIADH Syndrome → Cancer cells produces the hormone ADH, causing
kidney to retain water and thus lowers salt levels in the blood
(hyponatremia). Symptoms includes fatigue, loss of appetite, muscle
weakness or cramps, nausea and vomiting, restlessness and confusion.
★ Cushing Syndrome → Cancer cells makes the hormone ACTH, causing
the adrenal glands to produce cortisol. This leads to weight gain, easy
bruising, drowsiness, striae, moon-faced and osteoporosis sekunder.
★ Nervous system problems → Lung cancer kadang bisa menyebabkan
immune cell kita untuk menyerang nervous system. Pertama-tama yang
muncul adalah muscle disorder diaman kayak berdiri dari duduk sama
muscles jadi lemah. Pada rare cases, loss of balance, trouble speaking
and swallowing juga bisa muncul.
★ Hypercalcemia

2. Risk Factor exp. Smoking

Smoking :
Duration of smoking, history, number of cigarettes smoked each day, depth of inhalation,
and amount of cigarette smoked → Index Brinkman
 Cigarette smoke consist of gaseous phase and particulate phase → potential
carcinogens
Filters → appear to decrease but do not eliminate potential carcinogenic effects
Cigar and pipe smoking → lower risk, because not inhaled deeply to the lungs
Marijuana & Cocaine smoking → associated with pre cancerous histologic changes
Histologic abnormalities :
● Loss of bronchial cillia
● Hyperplasia of bronchial epithelial cells
● Nuclear abnormalities
If a person stop smoking → many of these precancerous changes appear to be
reversible
Initial cellular changes kalo malignant transformation

3. “Sama kayak WO no. 3” HAAHAHAHAHAH

4. Staging and determining the stages of a patient’s lung cancer can be determined by the
TNM staging as follows:
● T (Primary tumor)
○ Tx​→ Primary tumor cannot be assessed or can be proven via presence of
malignant cell in sputum but negative via radiology & bronchoscopy.
○ T​0​→ No evidence of primary tumor.
○ T​is​ →​ Carcinoma in situ
○ T​1​→ Tumor ≤ 3cm in greatest dimension
■ T​1a​ → Tumor ≤ 2cm
■ T​1b ​ →
​ Tumor 2cm < x ≤ 3cm
○ T​2 →​ Tumor 3cm < x ≤ 7cm or if there are involvements of main bronchi & invades
visceral pleural
■ T​2a​→ Tumor 3cm < x ≤ 5cm
■ T​2b​→ Tumor 5cm < x ≤ 7cm
○ T​3​→ Tumor > 7cm or if it has directly invaded one of the following Chest wall,
diaphargm, phrenic nerve, mediastinal pleura, parietal pericardium, tumor in main
bronchus, suspected atelectasis, obstructive pneumonitis.
○ T​4​→ Tumor of any size that has invaded any of the following: Mediastinum, heart,
great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebrae, carina.
● N (Regional Lymph Nodes)
○ N​x​→ Cannot be assessed
○ N​0​→ No metastasis
○ N​1​→ Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph node and
intrapulmonary nodes.
 ○ N​2​→ Metastasis in ipsilateral mediastinal and/or subcarinal lymph node.
○ N​3​→ Metastasis in contralateral mediastinal, hilar and supraclavicular nodes.
● M (Distant metastasis)
○ M​x​→ Cannot be assessed
○ M​0​→ No distant metastasis
○ M​1​→ Distant metastasis
■ M​1a​→ Separate tumor nodule in contralateral lobe
■ M​1b​→ Distant metastasis

Based on the TNM staging above, lung cancer stages then can be assessed as follows:
● Stage 0 → T​is​,N​0​,M​0
● Stage IA → T​1​,N​0​,M​0
● Stage IB → T​2​,N​0​,M​0
● Stage IIA → T​1​,N​1​,M​0
● Stage IIB → T​2​,N​1​,M​0
T​3​,N​0​,M​0
● Stage IIIA → T​1​,N​2​,M​0
T​2​,N​2,​M​0
T​3​,N​1​,M​0
T​3​,N​2​,M​0
● Stage IIIB → Any T,N​3​,M​0

​ T​4​, Any N,M​0

● Stage IV → Any T, Any N, M​1

5. Ada tabelnya nanti di tunjukin pas review hari selasa, HEHEHE

6. Lung cancer Prognosis (SCLC and NSCLC)
7. Prevention
● Avoid tobacco smoke, buat yang gapernah merokok
● Stop smoke, buat yang ngerokok (YA IYALAH YA ?) ← LAWAK
● Prevent using vitamin
○ Beta carotene, obat yang mengandung vit A untuk mencegah lung
cancer, but Beta Carotene ga guna kalo orangnya masih merokok, malah
beta carotene meningkatkan resiko lung cancer jadinya
Screening
● Target buat
○ Laki - laki >40 tahun, perokok
○ Paparan Industri tertentu
○ Disertai dengan 1 atau lebih gejala : batuk darah, batuk kronik, sesak
napas, nyeri dada
○ Perempuan sbg perokok pasif dengan gejala salah satu diatas
Selain pemeriksaan klinis : Peremiksaan radiologi toraks, sitologi sputum, dan
bronkoskopi autofluoresen
Bronkoskopi autofluoseren → mendeteksi lesi karsinoma insitu yang mungkin keliatan
normal pake bronkoskopi biasa.
Endoskopi autofluoseren→ mendeteksi lesi prakanker maupun lesi kanker yang
berlokasi sentral.