Bronchus obstruction

Obstruction due to tumors or tumor intrabronkial clog directly outside the bronchial pressure bronchus causing obstruction. Blockages can intrabronkial partial or total and sometimes necessary actions to improve patient quality of life.

Clinical features

Complaints of shortness of  breath accompanied by breath sounds can occur in severe obstruction. Complaints will increased when accompanied by "mucus plug". On physical examination will be found decreased breath sounds on the pulmonary side of the sick, and can also be found pathological breath sounds, such as wheezing on expiration and inspiration, expiratory sounds stidor elongated or when airway obstruction is great.

Perform bronchial toilet when there is a mucus plug. Lase bronchoscopy followed by stenting can done when a thick obstruction intrabronkial still known. It is necessary to complications this laser action does not occur and also needed to determine the required size of the stent. When blockages caused by suppression ekstrabronkial mass, or obstruction can not intrabronkial treated with laser bronchoscopy and stent then surgery should be considered. On certain circumstances can be given endobronchial radiation (brachytherapy) on the boundary of the proximal and distal 3 cm from the constriction, the dose (5-8 Gy) 1 cm from the axis of the radio source is active. If endobronchial radiation can not be done, it can be given external radiation in the area of ​​bronchial narrowing and mucosal area with a dose of 3-4 Gy / fraction subject.

Thoracic Wall Invasion

Not infrequently the tumor located in peripheral lung showed that the invasion of the thoracic wall cause severe pain complaints, for example in Pancoast tumors. Complaints can also occur due process of bone metastasis to different dads hit the cavity radiation action immediately to reduce the volume of complaints can be given .Target is the location that give rise to complaints heard adjacent mediastinum. Radiation dose: 3-4 Gy /fraksi.

Coughing blood (haemoptysis)

Hemoptysis in lung cancer as well as it can sometimes require immediate life-threatening. In massive blood coughing action bronchoscopy should be performed immediately, in addition to remove the clot blood (stool cell), this action is also necessary to know the source of bleeding is beneficial when required surgery to resolve it. Radiation is one of noninvasiv to blood cough. 

EPG diagnosis

Pleural cavity in healthy individuals contains about 20 ml of fluid. Pleural effusion (pleural fluid) is normal net usually colorless, containing <1.5 g protein / 100 ml and 1,500 cells / microliter. This fluid is composed of mesothelial cells, monocytes, lymphocytes and granulocytes. Pleural effusion can be detected on chest X-ray if> 50 ml. Pleural effusion can occur in intrathoracic malignant tumor disease, organ ekstratoraks or systemic malignancy. Malignant pleural effusion often cause problems in the field of diagnostics and treatment. Problems that need to be tackled is to find and treat the primary tumor, as well as cope with respiratory distress due to pleural fluid accumulation, which may threaten survival. 

Clinical symptoms 

As in other patients with pleural effusion, EPG gives symptoms of shortness of breath, shortness of breath, coughing, chest pain and chest full of content. This phenomenon is highly dependent on the amount of fluid in the cavity pleura. On physical examination found the movement of the diaphragm is reduced and the deviation of the trachea and / or heart towards the contralateral, fremitus weakening, faint percussion and decreased breath sounds on the side thoracic pain. In lung cancer, pleural infiltration by tumor cells may occur secondary to direct extension (inviltration), especially tumors located peripheral type adenocarcinoma. May also occur due to metastasis to lymph nodes and blood vessels. When efuasition pleural metastasis occurs as a result, fluid pleura many malignant tumors contain cells that cytologic examination of pleural fluid can expected to give positive results.

Malignant Pleural effusions (EPG) and Clinical symptoms

Pleural cavity in healthy individuals contains about 20 ml of fluid. Pleural effusion (pleural fluid) is normal net usually colorless, containing <1.5 g protein / 100 ml and 1,500 cells / microliter. This fluid is composed of mesothelial cells, monocytes, lymphocytes and granulocytes. Pleural effusion can be detected on chest X-ray if> 50 ml. Pleural effusion can occur in intrathoracic malignant tumor disease, organ ekstratoraks or systemic malignancy. Malignant pleural effusion often cause problems in the field of diagnostics and treatment. Problems that need to be tackled is to find and treat the primary tumor, as well as cope with respiratory distress due to pleural fluid accumulation, which may threaten survival. 

Clinical symptoms 

As in other patients with pleural effusion, EPG gives symptoms of shortness of breath, shortness of breath, coughing, chest pain and chest full of content. This phenomenon is highly dependent on the amount of fluid in the cavity pleura. On physical examination found the movement of the diaphragm is reduced and the deviation of the trachea and / or heart towards the contralateral, fremitus weakening, faint percussion and decreased breath sounds on the side thoracic pain. In lung cancer, pleural infiltration by tumor cells may occur secondary to direct extension (inviltration), especially tumors located peripheral type adenocarcinoma. May also occur due to metastasis to lymph nodes and blood vessels. When efuasition pleural metastasis occurs as a result, fluid pleura many malignant tumors contain cells that cytologic examination of pleural fluid can expected to give positive results.

Palliative Medicine and Rehabilitation OF Lung Cancer

Things that need to be emphasized in palliative therapy is the goal to improve patient quality of life as possible. Symptoms and signs bronkogenik carcinoma can be grouped on bronchopulmonary symptoms, extrapulmonary intratorasik, extratoraksik extratorasik non-metastatic and metastatic. While the complaints are often met by coughing, coughing up blood, shortness of breath and chest pain. Palliative treatment for lung cancer include radiotherapy, chemotherapy, medical, physiotherapy, and psychosocial. In some circumstances surgical intervention, stent implantation and cryotherapy can be performed.  

Medical Rehabilitation. In patients with lung cancer can occur musculoskeletal disorders mainly due to bone metastases. Manifestations may include inviltration to vetebra or got nerve. Symptoms that emerge in the form of tingling, numbness, pain and even paralysis can occur to muscle paresis, with the final result of interference with mobilization / ambulation.  

Medical rehabilitation efforts depends on the case, whether or not operable :

• When operable medical rehabilitation measures are preventive and restorative.

• When non-operable medical rehabilitation measures are supportive and palliative.  

For lung cancer patients before surgery is necessary to pre-surgical and medical rehabilitation after surgery, which aims to help obtain optimal surgical results, especially to prevent post-operative complications (eg, sputum retention, lungs do not expand) and speed up the mobilization. The goal of medical rehabilitation program for cases of non operabel is to improve and maintain functional abilities of patients assessed by Karnofsky scale. These efforts also include the handling of patients with lung cancer and palliative hospice care (In Hospital or at home ).  

Recurrence rates (relapse) the highest lung cancer occurs in the first 2 years, so the evaluation in patients who have been treated optimally performed every 3 months. Evaluation included clinical and radiological examination of chest X-ray PA / lateral and thoracic CT-scan, while the other checks done on indication.

Evaluation of treatment outcomes in lung cancer

Generally, chemotherapy is given up to 6 cycles / sequences, if the patient demonstrated an adequate response. Therapy response evaluation done by looking at changes in tumor size on chest X-ray PA after administration (cycles) chemotherapy to-2 and if possible use a CT scan of the thorax after 4 feedings.  

An evaluation of the : 

• Subjective response, namely a decrease initial complaint.

• Semi-subjective response is improved appearance, weight gain.

• Response objective.

•  Drug side effect.

Objective response was divided into four groups with the provisions : 

• Complete response (complete response, CR): tumor disappeared when the evaluation of 100% and this objec settled more than 4 weeks.

• Partial response (partial response, PR): if the reduction in tumor size> 50% but <100%. 

• Settled {stable disease, SD): if dont change or shrink tumor size> 25% but <50%. 

• Tumor progressive (progressive disease, PD): in case of adding tumor size> 25% tumor or pops new lesions in the lung or elsewhere. Another thing to consider in the administration of chemotherapy is the emergence of side effects or Toxicit.

CANCER TREATMENT IN THE LUNGS ( Surgery on Lung Cancer, Radiotherapy, Chemotherapy, Gene Therapy )

Lung cancer treatment is combined modality therapy (multi-modaliti therapy). In fact at the time of selection of treatment, often not only expected to histologic type, degree and appearance of the patient but also the condition of non-medisseperti owned facilities for hospital patients and the economy is also a factor that was crucial.  

Surgery on lung cancer

Indications of surgery in lung cancer is to KPKBSK stage I and II. Surgery is also part of the "combine modality therapy", for example neoadjuvan chemotherapy for stage IIIA KPBKSK. Another indication is if there is distress that requires surgical intervention, such as lung cancer with vena cava syndrome superiror weight. The principle of surgery is to resect the tumor as much as possible complete the following intrapulmoner KGB network, with lobectomy or pneumonectomy. Segmentektomi or wedge resection of lung physiology is only done if it is not enough for lobectomy. Edge of the incision checked with frozen cut incision to ensure that the boundary-free bronchial tumor. Mediastinal lymph nodes retrieved by a systematic dissection, and examined in anatomical pathology.  

Another important thing that is important to remember before doing surgery is knowing the patient tolerance to this type of surgery to be performed. Tolerance of patients before surgery can be measured by the value of pulmonary physiology testing and if it is not allowed can be judged from the results of blood gas analysis (AGD).

Terms for lung resection

• Mild risk for pneumonectomy, when KVP good contralateral lung, VEP1> 60% .

• Pneumonectomy moderate risk, when KVP contralateral lung> 35%, VEP1> 60%  

Radiotherapy  

Radiotherapy in lung cancer can be curative or palliative therapy. In curative therapy, radiotherapy became part of KPKBSK chemotherapy for stage IIIA neoadjuvan. In certain circumstances, radiotherapy alone is rarely a viable alternative curative therapy. Radiation is often an emergency action that should be done to alleviate complaints of the patient, such as vena cava syndrome superiror, bone pain due to chest wall tumor invasion and metastasis of tumors in bone or brain.  

Determination of radiation on KPKBSK policy determined several factors: 

1.  Staging the disease.
2. Status display.
3. lung function  

If radiation is done after surgery, then it must be known: 

• The type of surgery including lymph node dissection is done

• Assessment of the incision limits by experts Pathology (PA) Given radiation dose is generally 5000 - 6000 cGy, by providing 200 cGy / x, 5 days a week. 

Standard terms before patients are irradiated:

• Hb> 10 g% 

• Platelets> 100.000/mm3 

•  Leukocytes> 3000/dl 

Palliative radiation given to the unfavourable group, namely : 

• PS <70. 

•  Weight loss> 5% in 2 months. 

•  Poor lung function.  

Chemotherapy  

Chemotherapy can be given in all cases of lung cancer. The main requirement to be determined histologic type of tumor and appearance (performance status) should be more and 60 according to the scale Karnosfky or 2 according to the WHO scale. Chemotherapy is done by using multiple anticancer drugs in combination chemotherapy regimens. In certain circumstances, the use of an anti-cancer drugs do.  

The principle of selection and providing a type of anticancer chemotherapy regimens are:

• Platinum-based therapy (cisplatin or karboplatin) 

• Objective response of the anticancer drug's 15% 

• Toxicity of drugs does not exceed grade 3 WHO scale 

• Should be discontinued or replaced if, after giving two cycles occurred in the assessment of progressive tumor.  

Regimens to KPKBSK are: 

• Platinum-based therapy (cisplatin or karboplatin) 

• PE (cisplatin or etoposide + karboplatin) 

• Paklitaksel + cisplatin or karboplatin 

• Gemsitabin + cisplatin or karboplatin 

• Dosetaksel + cisplatin or karboplatin  

Standard terms that must be met before chemotherapy :

•  Display> 70-80, in patients with PS <70 or elderly, can be given the anticancer drug with specific regimens and / or specific schedule. 

• Hb> 10 g%, mild anemia in patients without acute bleeding, although Hb <10 g% do not need a blood transfusion immediately, simply given the treatment in accordance with the cause of anemia. 
• Granulocytes> 1500/mm3 

• Platelets> 100.000/mm3 5. Good liver function 6. Good renal function (creatinine clearance over 70 ml / min)  

Gene Therapy

Techniques and benefits of this treatment is still under investigation