Case Report

LEFT PLEURAL EFUSSION E.C. LUNG

ADENOKARCINOMA STADIUM IV

By:
Atsilah Ulfah
Lintang Brilianingtyas

Preceptor:

dr. Dedy Zairus , Sp.P

KEPANITERAAN KLINIK
BAGIAN ILMU PENYAKIT PARU
FAKULTAS KEDOKTERAN UNIVERSITAS LAMPUNG
RUMAH SAKIT UMUM DAERAH ABDUL MOELOEK
2014

CHAPTER I
PATIENT STATUS
Patient Identity
Name

: Mrs, S

Age

: 60 yo

Addres

: Wates

Job

: Housewife

Status

: Married

Entry Date

: 8 of March 2014

Examine Date : 25 of March 2014

Anamnesis

: autoanamnesis

Chief Complain

: Dyspneu

Secondary problem : Chest Pain, cough

History of present illness :
Since about a month before hospitalization patient felt shortness in breathing
(dyspneu), this feeling are getting heavier day by day, when doing some heavy
efforts, patient breathing more heavily. Patient felt more asphyxiated when sleep
in supine position, and get better in half sitting position. This feeling was not
influenced by weather change, and not induced by food or any other allergic
factors.
Along with the dyspneu, patient also felt pain in chest. This chest pain come and
go with no exact pattern of time and spread from the bottom left of chest to the
back. The pain feels sharp and did not get better if patient take rest. Patient has no
history of chest trauma beforehand. Patient also sustained cough with no produce
of sputum or blood. Patient did not experience fever, nor headache, bladder and
defecation function normal. In period of two months patient sustain a great
wightloss for about 10 kgs.

Sustaining progressive breathing heaviness and chestpain, patient seek for medical
care nearby and finaly referenced to Abdoel Moeloek Hospital in 8 of march 2014
after got thorax x-ray examination before hand.At the time of examination patient
feels less of the complain of dyspneu and chestpain along with the WSD
instalation in left hemithorax.
Past medical history :
no history of TB
Family history :
History of malignancy in the family denied.
Habits and socio-economic history :
Patients have the habit of cooking with firewood since adolescence .
Patients do not have the habit of smoking
The patient worked as housewives .
General Examination
General condition

: moderately ill

Awareness

: kompos mentis

Blood pressure

: 140/90 mmHg

Pulse

: 80 beats per minute

Respiratory rate

: 24 breaths per minute

Temperature

: 37,2 C

Physical Examination (26 of march 2014)

Head and neck
- Hair : black, normal
- Anemic conjunctiva : ( - / - )
- Sclera ikteric : ( - / - )
- Enlargement of the KGB : ( - )
- Increased JVP : ( - )

- Light Reflex + / +
- Pupils round , isokhor
Thorax
Inspection :
- asymmetrical in static and dinamic state . left hemithorax left as expiration
-WSD instaled at linea axilaris anterior ICS 6
Palpation : vocal fremitus weaker right than on the left. Chest expansion normal
Percussion : resonant to the righ lung field , dim in the left lung field from ICS III
below.
Auscultation : vesicular breathing voice sounded weaker on the left than on the
right lung , there is no crackles and wheezing .
Thorax ( Heart )
Inspection : ICTUS cordis is not visible .
Palpation : ICTUS Palpable cordis in ICS V midclavicularis the left .
Percussion : cardiac boundary in the normal range .
Auscultation : sounds S1 , S2 within normal limits , gallops ( - ) , murmur ( - )
Abdomen
Inspection : distention ( - ) ,
Auscultation : bowel ( + ) .
Percussion : timpani , shifting dullness ( - )
Palpation : outgoing, splenomegaly ( - ) , hepatomegaly ( - ) , tenderness ( - ) .
Extremity
- CRT < 2 seconds
- Akral warm , reddish color
- Edema ( - )
Supporting examination

Laboratory examine
Routine Blood 14 of March 2014
3

WBC 9.300/ul
HGB 13,5 g/dl
PLT 216.000/ul
HCT 38%

Blood Chemical
- GDS 179 mg / dl
- SGOT 154 u/L
- SGPT 121 u/L
Routine blood 15 of March 2014
- WBC 13.000/ul
- RBC 4.540.000/ul
- HGB 14,5 g/dl
- HCT 39,1 %
- MCV 86,1 FL
- MCH 31,9 Pg
- PLT 332.000/ul
- LYM 9,9%
- MXD 8,6%
- NEUT 81,5%
- LYM# 1.300/ul
- MXD# 1.100/ul
- NEUT# 10.600/ul
- RDW 46,1 Fl
- PDW 13,0 Fl
- MPV 10,2 Fl
- P-LCR 26,8%
Routine Blood 14 Maret 2014
- HGB 14,5 g/dl
- WBC 13.000/ul
- LED 23 mm/hour
- Basophil 0%
- Eosinophil 0%
- Batang 0%
- Segmen 82%
- LYM 10%
- Monosit 8%
- PLT 332.000/ul

Rontgen Toraks
29-8-2013

Expertise : Solid flect spreaded in left lungs, susp. TB infiltrat, the mass
is not clear, minimum pleural effusion, cor normal

Patologi anatomi
Sample is gotten from pleural fluid (19-3-2014)
Conclussion: c/w Metastase Adenocarcinoma

Resume
Female, 60 years came to the hospital in refference from nearby
healthcare with chief complaint of shortness heavier day by day.
Complaint become worse when pattient do some heavy efforts
and supine position. And decreased in half sitting position. The
patient also complained of sharp Chestpain in bottom left region
of chest diverted to the back. The Complaint is not getting better
at rest. No chest traumatic before. Patient also sustain a great
weightlost in period of 2 months. On physical examination found
weakened vocal fremitus on the left, percussion dims at the left
lung and the left lung vesicular weakened. On radiographic
examination found Solid flect spreaded in left lungs, susp. TB
infiltrat, the mass is not clear, minimum pleural effusion, cor
normal. In pleural fluid citological examination conclude the
metastase of Adenocarcinoma
Working Diagnostic : Left pleural effusion e.c. adenocarcinoma pulmo ST IV
Problem
1. Dyspneu
2. Cough
3. Chest Pain
Examination plan
CT-Scan, Biopsy, BTA
Therapy

Infus RL 20 gtt/m
WSD instalation wth fluid control
Ceftriaxon inj. 2 x 1
Ranitidin inj 2 x1
B complex tab 3x1

Salbutamol 0,5 mg/GG tab 1/ Metil Prednisolon 1 mg 3x 1 pc

Regiment Chemoterapy
Not yet decided
Follow up

CHAPTER II
DISCUSSION
A female patient , aged 60, a housewife with a history of cooking using
firewood . In terms of epidemiology of lung cancer by sex in general reported
similar results , ie more males than females with a ratio of 5:1 case . In addition it
was reported that approximately 90 % of cases found in patients aged over 40
years . The relationship between malignant lung tumors with the habit of cooking
with firewood it can not be proven more clearly. Because main factors are
smoking, statistically that the frequency of occurrence of lung carcinoma is more
common in smokers . Patients at high risk are women and men who smoked 1
pack per day for 20 years and aged over 50 years. The materials contained in
cigarette smoke include polonium 210 and 3.4 benzypyrene are substances that
are carcinogenic . If a smoker block the smoking habit , the risk reduction in new
look after three years of termination and will show the same risk to nonsmokers
after 10-13 years . The risk of developing lung carcinoma in addition to smoking
may also be caused by a variety of other ingredients that are carcinogens such as
asbestos , uranium , nickel and etc.
History of patients hospitalized complaint is a cough that does not go away ,
it can be the beginning of the diagnosis of abnormalities in the chest cavity , then
the presence of shortness of breath , chest pain that does not spread and are not
obtained a history and signs of heart disease found in directing pulmonary
pathology or lung and airway . Additional complaint history is obtained from an
easy body is weak , then most of the nonspecific clinical picture of pulmonary
malignancy ( paraneoplastic syndrome ) obtained in patients , although some
diseases such as pulmonary tuberculosis and respiratory diseases such as COPD
have the some clinical similarities . Complaints of cough present in 70-90 % of
cases . Besides coughing , another complaint is chest pain that is often unilateral
blunt and clear boundary . On the pathogenesis of chest pain is not known with

certainty and this type present in 42-67 % of cases . Shortness of breath was found
in 58 % of cases , may be caused by the tumor itself , or by obstruction caused or
atelaktasis.
On physical examination found weakened vocal fremitus on the left, percussion
dims at the left lung and the left lung vesicular weakened. And a great wightlost in
2 months. On radiographic examination found Solid flect spreaded in left lungs,
susp. TB infiltrat, the mass is not clear, minimum pleural effusion, cor normal. In
pleural fluid citological examination conclude the metastase of Adenocarcinoma.

CHAPTER II
LITERATURE REVIEW
1.

Definition
Lung cancer in the broadest sense are all malignant disease in the lung ,

including lung malignancy derived from its own ( primary ) and metastatic tumors
in the lung . Metastatic tumor in the lung is a tumor that grows as a result of the
spread ( metastasis ) of the primary tumors of other organs . Specific definition for
primary lung cancer which is a malignant tumor derived from bronchial
epithelium . Malignant lung tumors or lung cancer is often referred to generally
derived from the respiratory epithelium ( bronchial , and alveolar brongkhiolus ) ,
like carcinoma , alveolar cell carcinoma and other on.3 , 4
2.
Epidemiology
The prevalence of lung cancer in developed countries is very high , in the
USA in 2002 there were 169 400 new cases were reported with 154,900 deaths .
UK 40,000 cases were reported per year , Indonesia was ranked 4th in terbanyak.4
cancer Lung cancer causes about 28 % of all cancer deaths , 32 % in men and 25
% in women.1
3.
Risk factor and etiology
Like most other cancers definite cause of lung cancer is not known , but
prolonged exposure or inhalation of a substance that is carcinogenic is a major
causative factor in addition to other factors such as the immune , genetic , and
other - others.5
Risk factors for lung cancer include: 1,3,4
1 . Man
2 . Age over 40 years
3 . Smoking ( active , passive )
4 . Live / work in environments that contain carcinogens ( asbestos , radon ,
arsenic , chromium , nickel , polycyclic hydrocarbons , vinyl chloride ) or air
pollution .
5 . Exposure to industrial / workplace specific ( ionizing radiation on uranium

miners )
6 . History never gets cancer of other organs or close family members who
suffer from lung cancer ( still under investigation ) .
7 . Pulmonary tuberculosis ( scar cancer)
People belonging to or exposed to the risk factors above and have signs and
symptoms of respiratory cough , shortness of breath , chest pain called high- risk
groups ( GRT ) . The exact cause is unknown , but prolonged exposure or
inhalation of a substance that is carcinogenic is a major factor in addition to other
factors . Some kepustakan reported that the etiology of lung cancer is strongly
associated with smoking . The more cigarettes smoked , the greater the risk for
lung cancer . 1.5
The study also showed that even passive smokers at risk of lung cancer .
Children who are exposed to cigarette smoke smoked for 25 years , at age adults
are at risk of lung cancer 2-fold compared to non- exposed . Women who live with
smokers are also exposed to husbands lung cancer risk of 2-3 times lipat.1 , 4
Another etiology of lung cancer that have been reported are related to
exposure to carcinogens , such as asbestos , ionizing radiation on uranium miners ,
radon , arsenic , chromium , nickel , polycyclic hydrocarbons , vinyl chloride , and
so forth . Air pollution and genetics also play a role in cancer paru.4
4.
Classification
Based on practical interest for purposes of treatment , lung carcinoma divided4 :
a. Non Small Cell Lung Cancer ( NSCLC ) ( 85 % )
- Adenocarcinoma
- Squamous cell carcinoma
- Large cell carcinoma
b . Small Cell Lung Cancer ( 15 % ) ( SCLC
Staging Lung Cancer
Staging make by The International System for Staging Lung Cancer and
accepted The American Joint Committee on Cancer (AJCC) and The Union
International Contrele Cancer (UICC).1,2
STAGE

TNM

10

0
I
II
III A

Tis Carcinoma in situ

T1 N0M0
T2N0M0
T1N1M0

III B

T2N1M0
T1-3 N2 M0
T3N1M0
T4 Any N M0

IV
information

Any T N3M0
Any T Any N M1

Tx proven malignant tumors derived from bronchopulmonary secret , but not

visible in bronchoscopy and radiological or tumor can not be assessed on the
staging retreament
Tis Carcinoma in situ
T1 diameter < 3 cm
T2 diameter > 3 cm distal atelectasis or there hillus
T3 Tumor of any size extends to the pleura , chest wall , diaphragm ,
pericardium , < 2 cm from carina there is a total atelectasis
T4 tumor invasion into the mediastinum apaun size / contained malignant
pleural effusion
No N0 lymph kelenjer ( KGB ) involved
N1

Metastasis

KGB

ipsilateral

bronchopulmonary

or

hilar

Metastasis N2 mediastinal nodes above sub carina

N3 Metastasis contra lateral mediastinal nodes or hilar or supraclavicular nodes
or skaleneus
M0 No metastases
M1 metastases in organs ( brain , liver , etc. ) .
5.

Clinical Manifestasion
In the early phase of lung cancer generally show no clinical symptoms .

When it appears the symptoms of most patients already in an advanced stage .

Symptoms can be local , invasion , metastasis , paraneoplastic , and asimtomtik
with abnormalities radiologist.4,6

11

- Local : cough , hemoptysis , wheezing , shortness of breath , sometimes there is

a cavity such as lung abscess and atelectasis
- Local Invasion : Chest pain , Dispnue as pleural effusion , temponade or
arrhythmia , superior vena cava syndrome , Horner's syndrome , hoarseness ,
painful / difficult swallowing .
- Symptoms of metastatic disease : bone pain , headache , jaundice , neurological
changes , difficulty swallowing , shortness of breath , lymphadenopathy .
- Paraneoplastic syndrome : weight loss , anorexia , fever , leokositosis , anemia ,
hypercoagulable , dementia , ataxia , tremor , peripheral neuropathy ,
hypercalcemia , erythema multiform , hyperkeratosis and clubbing .
- Asymptomatic with radiologic abnormalities : Often found in COPD ,
abnormalities such as solitary nodules .
6.

Diagnosis
A complete anamnesa and thorough physical examination is the key to

proper diagnosis . This needs to be confirmed by radiological examination ,

cytology , and histopathology . Lung tumors of small size and located in the
peripheral can provide a picture of normal on examination . Tumors with large
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
lymphadenopathy or tumors outside the lung . Metastasis to other organs can also
be detected by palpation of the liver , funduscopic examination to detect the
elevation of intracranial pressure and the occurrence of fractures as a result of
metastasis to bones.1 , 2
Investigations can be carried out for the detection of lung cancer is 1 ,
2,7,8 :
- CXR
On chest X-ray PA / lateral will be seen when the period of the tumor with tumor
size of more than 1 cm . Signs that support malignancy was irregular edges , with

12

pleural indentation , satellite tumors tumors , etc. . In the photos can also be found
to have tumor invasion into the chest wall , pleural effusion , effusion and
metastasis perikar intrapulmoner .
- CT - scan of thorax
CT - scans can detect tumors with sizes smaller than 1 cm are more appropriate .
Likewise, signs of malignant process also reflected better , even if there is an
emphasis on the Bronchial , intra- bronchial tumor , atelectasis , pleural effusion ,
and there has been no massive invasion into the mediastinum and chest wall even
without symptoms . Furthermore the CT - scan , the KGB 's involvement was
instrumental to determine the stage is also better because lymphadenopathy ( N1 s
/ d N3 ) can be detected .
- Bronchoscopy
Check that period intrabronkus or airway mucosal changes , such as visible
mucosal abnormalities eg tumors , craggy , hyperemia , or infiltrative stinosis ,
bleed easily . Abnormal Tampakan should be followed by tumor biopsy /
bronchial wall , rinses , bronchial brushings or scrapings .
- Biopsy needle aspiration
If intrabronkial tumor biopsy can not be done , then you should do a needle
aspiration biopsy , because bronchial washings and biopsy alone often give
negative results
- Transbronchial needle aspiration ( TBNA )
TBNA in karina , or trachea 1/1 down ( 2 rings above the carina ) at the 1 o'clock
position when there is a tumor on the right , will give double the information ,
which is obtained for cytology material and information subkarina or paratracheal
nodes metastasis .
- Transbronchial lung biopsy ( TBLB )
If the lesion is small and somewhat in peripheral locations , and no means of
fluoroscopic through bronchial lung biopsy ( TBLB ) should be performed .
- Transthoracic biopsy ( Biopsy Transthoraxic , TTB )
If the lesion is located in the peripheral and more than 2 cm in size , with the help
of flouroscopic TTB angiography . However, if lesions smaller than 2 cm and

13

located in the central TTB can be performed with CT scan guidance .

- Thoracoscopy medical
With this action the tumor mass in this part of the peripheral lung , visceral
pleura , parietal pleura and mediastinum can be seen and biopsied .
- Sputum Cytology
This examination shortage occurs when there is a tumor in the peripheral , dry
cough and sputum collection techniques and retrieval are not eligible .
- Tumor Marker
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 .
- Examination of molecular biology
Examination of molecular biology has been growing, the simplest way to assess
the expression of multiple genes or gene products associated with lung cancer ,
such as p53 protein , bcl2 , and others . The main benefit of the examination of
molecular biology is to determine the prognosis of the disease .
7.

Management
Managenent lung cancer conducted by histological type of cancer , stage of

disease , and general appearance (performance status ) .1

Performance Status Based WHO Scale and Karnofsky Scale1
Skala

Skala

Performance Status

Karnofsky
90-100
70-80

WHO
0
1

Normal Activity
Can work normally but there complaints related to

50-60
30-40
10-20
In general,

2
3
4
treatment

pain
Requires people for doing specific activities
Highly dependent on others for routine activity
Can not get out of bed
options for NSCLC is combined modality therapy

( multi - modality therapy) , such as surgery , radiotherapy and chemotherapy and

other therapies . 1,2,4
Surgery is the primary choice in stage I or II in patients with residual lung

14

parenchyma adequate reserves . Done for the palliative treatment of lifethreatening conditions , for example : massive blood cough , respiratory distress
due to superior vena cava syndrome , severe pain in the Pancoast tumor , severe
pain in brachial plexus syndrome . If the current surgical lymphadenopathy
obtained then all should be removed and the postoperative cases with metastatic
mediastinal nodes ( N2 ) considered the provision of radiotherapy and /
kemoterapi.1 , 2.4
Radiotherapy or radiation given in the case of stage III and IV NSCLC , can be
given to solve the problem in a single lung ( local therapy ) or combined with
chemotherapy . Radiotherapy may be given if either yaitu2 homeostatic system , 4
:
- HB > 10 mg %
- Leokosit > 4000/dl
- Platelets > 100.000/dl
Chemotherapy may be given in all histological types of lung cancer . Although
chemotherapy can be given at all stages but on stage I and II postoperative
chemotherapy should be determined based on the postoperative stage .
Chemotherapy is used as a standard therapy for patients ranging from stage IIIA
and for palliative treatment . Adjuvant chemotherapy was administered starting
from stage II to target the tumor can be resected lokoregional complete , route of
administration given after definitive local therapy with surgery , radiotherapy or
both . Neo- adjuvant chemotherapy given from stage II to target the tumor can be
resected lokoregional lengkap2 , 6,7,9
SCLC is divided into two 1 , 4 :
- Limited stage disease treated with curative intent , the combination of
chemotherapy and radiation therapy and the success rate by 20 %
- Extensive stage disease treated with chemotherapy and initial treatment
response rates of 60-70 % and a complete response rate of 20-30 % therapy . 1,2,4

15

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1.

Minna JD. Neoplasms of the lung in : Harrisons principles of internal

2.

medicine 16th edition. USA : McGraw Hill. 2005.

PDPI. Kanker Paru: Pedoman Diagnosis dan Penatalaksanaan di Indonesia.

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2003. http://klikpdpi.com. [diakses 28 November 2013].

PB PAPDI. Panduan pelayanan medik-PAPDI. Jakarta : PB PAPDI.2008.
Amin Z. Kanker Paru dalam : Buku Ajar Ilmu Penyakit Dalam Edisi IV Jilid
II. Jakarta : Pusat Penerbit Departemen Ilmu Penyakit Dalam FKUI.2006.

5.
6.
7.

1015-1010.
Price SA, Wilson LM. Patofisiologi. Volume 2. Jakarta: EGC; 2005: 843-51.
Djojodibroto RD. Respirologi : Respiratory medicine. Jakarta : EGC. 2009.
Imaging in small cell lung cancer [Homepage on the internet]. USA:
WebMD; c1994-2013 [updated 2013 Oct 22; cited 2013 Nov 28]. Available

8.

from http://www.emedicine.medscape.com
Lung metastasesi imaging [Homepage on the internet]. USA: WebMD;
c1994-2013 [updated 2013 Oct 11; cited 2013 Nov 28]. Available from

9.

http://www.emedicine.medscape.com
Carcinoid lung tumors [Homepage on the internet]. USA: WebMD; c19942013 [updated 2013 March 19; cited 2013 Nov 28]. Available from

http://www.emedicine.medscape.com
10. Superior vena cava syndrome in Emergency Medical Clinical Presentation
[Homepage on internet]. WebMD; c1994-2013 [updated 2012 Nov 12; cited
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