KLASIFIKASI NEOPLASMADr.Adam Suyadi, SpB, MMBag Bedah FK UIIYogyakarta

Berdasar Asal SelTumor diklasifikasiSELJINAKGANASEpitelPapilomaCarcinomaKelenjarAdenomaAdeno CaMelanositNevusMelanomaFibrosaFibromaFibrosarcomaLemakLipomaLiposarcomaCartilagoChondromaChondrosarcomaTulang OsteomaOsteosarcoma

Berdasar Asal SelTumor diklasifikasiSELJINAKGANASVasculairHemangiomaHemangiosarcmOtot PolosLeiomiomaLeioimyosarcomOtot LurikRhabdomyomaRhabdomyosarcGlia-GliomaGanglion Saraf-NeuroblastomaMyelinNeurolinomaN SarcomaRetina-Retinoblastoma

Berdasar Asal SelTumor diklasifikasiSELJINAKGANAS

Nodul LymphLimphomaLimphosarcomaSumsum Tlg-LeukemiaPlasma Sel-Multipl myelomaHepar-HepatomaColon-Adeno Ca

COLORECTAL CARCINOMAAge: - 6 th decade of life - trend for younger age

Sex: colon carcinoma : female more than male rectal carcinoma : male more than female

Macroscopic Features ulcerativeprotuberantannuler stenosing polypoidalMicroscopic features : more than 90% is adenocarcinoma

Adeno Ca Colon

Small Intestine Tumour

Differentiation : - well differentiated- moderatelly differentiated- undifferentiated- signet ring cell carcinoma- mucoid carcinomaDistribution :- rectum: 50%- sigmoid colon: 20 %- cecum & ascending colon: 18%- transverse colon: 8%- descending colon: 6%- synchronous carcinoma: 5%- metachronous carcinoma: 3%

Presdisposing factor : - low fibers diet - adenomatous lesions - familial adenoma polyposis - ulcerative colitis - granulomatous colitis

SpreadingColon carcinoma1. Direct : circular, longitudinal, and penetrating the well2. Lymphatic : epicolic, paracolic, intermediate, and paraaortic nodes.3. Blood spread : portal, lumber, and vertebral vein.4. Transperitoneal / gravitational spread5. Intra luminar spread6. Along nerve fibers

Rectal carcinoma :

1. Direct : longitudinal, penetrating the wall2. Lympatic : haemorrhoidal nodeshypogastric nodesinguinal nodes3. Blood spread : portal vein, hypogastric vein4. Along nerve fibers

Complications

- obstruction- perforation :- the malignancy it self- infiltrating to the serosa- the cecum due to large bowel obstruction - fistula formation :- external- internal- haemorrhage

StagingDukesA : mucosal and submucosal layer B : infiltrating to the serosa C : involve regional lymph nodes D : distance metastasis

Dukes Classification

Symptom1. Carcinoma of the right colon :- abdominal pain or discomfort- weight loss and anaemia- bowel obstruction- mass in the right iliac fossa2. Carcinoma of the left colon :- alterations of bowel habit- large bowel obstruction (colicky pain of lower abdominal)3. Carcinoma of the rectum :- anal bleeding- alteration of bowel habit- tenesmus- feeling of incomplete defecation

Signs1. Right colon carcinoma- tenderness in the right iliac fossa- palpable mass in the right iliac fossa- occult blood in the faces2. Left colon carcinoma- palpable tumor in the left iliac fossa is unusual- abdominal distention3. Rectal carcinoma- about 75% rectal carcinoma palpable on rectal- digital examination

Laboratory test- full blood examination- CEA (carcinoma embryonic antigen)X-ray examination- plain x ray of the abdomen- thorax foto- barium enema & contrast double- IVP

Endoscopic examination- anoscopy, rectoscopy, sygmoidoscopy and colonoscopy - cystoscopyOthersUSG, CT scan, MRI (to search distance metastasis)

TreatmentThree modality of treatment :1. Surgical treatment ( cutting )2. Radiation treatment ( burning )3. Chemotherapy ( poisoning )

1. Surgical treatmentA. resectable- right hemicolectomy- extended right hemicolectomy- transverse colon resection- left hemicolectomy- sigmoid colon resection- for rectal carcinoma :- anterior resection- low anterior resection- abdomino perineal resection (Milles op)B. non resectable- ileotransversostomy- transversocolostomy- sigmoidostomy

2. Irradiation treatment :- pre operative irradiation- post operative irradiation- sandwich irradiation

3. Chemotherapy :- 5 fluoro uracil- 5 fu + levamizol - 5 fu + leucoforine

PrognosisDepend on :- site- extent- grade of malignancy

5 years survival rate :Dukes A : 80% B : 60% C : 30% D : -

EPIDEMIOLOGI DAN GAMBARAN KLINIS KANKER KULIT

Kanker kulit terbagi atas :Melanoma malignaNon Melanoma Maligna:Kanker sel basalKanker sel skuamosaKanker kulit lain

Diantara kanker kulit : Melanoma Maligna :Meningkat cepat terutama di BaratAngka kematian tinggi diantara kanker kulit lainInsiden 1 dari 2000 kulit putih pada tahun 2000Insiden tertinggi di Australia :Queensland : 53.5 / 100.000 penduduk Victoria : 30.3 / 100.000 penduduk (92 - 96)Laki - laki : 1:25Wanita :1:34

USA :1 diantara 74 beresiko MM th 20001:1500 th 1930Th 2000:47.700 kasus invasif MM baru20.000 - 40.000 kasus MM in situ baruKematian akibat MM th 2000: 7700Mortality rate MM : meningkat 2 % pertahun sejak 1960

Kanker sel Basal :Jenis terbanyak dari kanker kulitEtiologi terpenting : paparan sinar matahariInsidens rate meningkat sesuai dengan :Keadaan geografiPaparan sinar matahariPigmentasiKebiasaan setempatAustralia: insiden KSB meningkat 20-80 % (penelitian 1985 - 1995)saham terbesar : umur-umur tua, umur muda : menurun1995: Pengobatan KSB : 190.000 orang

USA : 1997 :Kanker kulit: 99.554 kasusKSB: 8730 kasus

Angka kematian KSB :Sangat rendahPada usia tua (>75th)

Metastase KSB0.03 %Umumnya pada lesi besar

Keganasan kulit primer seluruh sentra Indonesia :Urutan 3 pada pria dan wanitaUrutan 2 pada priaUrutan 4 pada wanita

Urutan kanker kulit di Indonesia :

KSB 65.5 %KSS 23 %MM 8,5 %Lain-lain 3 %

Kanker Sel BasalNodular: plak seperti mutiara, berbatas translusen, teleangiektasis, berkrusta bagian tengah

Superficial KSBPapul / plak eritematosa, umum pada batang tubuh / anggota gerak

Mikronodular KSB: = nodularlebih kecilPlak dengan indurasi dan batas tidak jelas

Morpheoform (Sclerosing)5% dari seluruh KSB, lebih agresif, invasif dalam ke otot & lemak

Infiltratif: secara histologis berada diantara noduler & morpheaform, kuning keputihan, batas tidak jelas, sering sulit dibedakan dengan warna jaringan sekitarnya

Pigmented: sering pada ras kulit berwarna gelap

MetatypicalMetatypical with adnexal diffMemiliki karakteristik klinis dan histologis KSB dan KSSNodul berulserasi

Fibroepithelium of PinkusVarian tidak umum, sering pada daerah lumbosacral

Kanker Sel SkuamosaPUVA: Psoralen & UV ASering pada penderita psoriasis dengan pengobatan lama

Actinic KeratosisFase peralihan insitu ke invasif

Keratoachantoma:Berbentuk seperti jamur

Bowens Disease(SCC insitu) berkembang lambat progresif menjadi kanker sel skuamosa invasif

Erythroplasia of QuayratKSS yang terletak di penis

Verrucous carcinoma(epitelioma cuniculatum) tumor eksofitik dengan ulserasi

Melanoma Maligna:ABCD dari melanoma malignaA. AssymmetryB. BorderC. ColorD. Diameter

Superficial Spreading Melanoma Maligna:Tipe terbanyak, sering muncul dari nevus prekursor dan displasia nevus

Nodular MelanomaMelanoticMelanoticBerupa papul atau nodul yang meninggi

Acral Lentiginous MelanomaBentuk makula, membesar dengan batas tidak jelas dan asimetris

Subungual MelanomaPada jari I tangan atau kaki, kecil, sering menyerupai nevus

Lentigo Melanoma MalignaLesi lambat membesar, coklat muda dan coklat tua, asimetris