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LIMFOMA MALIGNUMLIMFOMA MALIGNUM
DANDAN
KEMOTERAPIKEMOTERAPI
( KULIAH 4 )( KULIAH 4 )
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LIMFOMA MALIGNUM NON HODGKINLIMFOMA MALIGNUM NON HODGKIN
DEFINISIDEFINISI
Sekelompok keganaan p!"me!Sekelompok keganaan p!"me!l"m#o"$l"m#o"$ %ang &apa$ 'e!aal &a!"%ang &apa$ 'e!aal &a!"
l"m#o"$ l"m#o"$ Tl"m#o"$ l"m#o"$ T &an ka&ang&an ka&ang( ama$ *a!ang ) 'e!aal &a!"( ama$ *a!ang ) 'e!aal &a!" elel
NKNK ( natural killer( natural killer )) %ang 'e!a&a%ang 'e!a&a
&alam "$"m l"m#e&alam "$"m l"m#e anga$anga$+e$e!ogen+e$e!ogen 'a"k $"pe +"$olog"'a"k $"pe +"$olog"ge*ala pe!*alanan kl"n" !eponge*ala pe!*alanan kl"n" !epon$e!ap" ma,p,n p!ogno"$e!ap" ma,p,n p!ogno"
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ETIOLOGI DAN FAKTOR RISIKO
E$"olog" pa$" $"&ak &"ke$a+," 'e'e!apa#ak$o! !""ko -
Imm,n&e."en"
Agen "n#ek", epe!$" E/ HI/
Papa!an l"ngk,ngan &an peke!*aan epe!$"pe$e!nak peke!*a +,$an 0 pe!$an"an %ang&"e'a'kan papa!an +e!'""&a &an pela!,$o!gan"1 e!$a papa!an ,l$!a2"ole$
D"e$ $"ngg" lemak +e3an" &an me!okok
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A an1e! 5 l"n 67889:8-686;6
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Fo!me! F"!$ La&%
5a1>,el"ne Kenne&% Ona"
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K"ng H,e"n o#5o!&an
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Tele2""on $a! T+e A;Team=S%l2e$e! S$allone? a&2e!a!% "n @Ro1k% III=
BM!= T(La3!en1e T,!ea,&)
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KLASIFIKASIPenggolongan +"$olog" LNHme!,pakan maala+ %ang !,m"$&an ,ka!=
Pe!kem'angan $e!ak+"! kla".ka"%ang 'an%ak &"paka" a&ala+#o!m,la" p!ak$" ( working
formulation = WF8C6) &an
Re2"e& E,!ope Ame!"1anla".1a$"on o# L%mp+o"&Neoplam 0 o!l& Heal$+
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L%mp+oma la".1a$"onL%mp+oma la".1a$"on ( HO( HO6778 )6778 )
;1ell neoplam;1ell neoplam PrecursorPrecursorB-cell neoplass !" #$pes%B-cell neoplass !" #$pes%
Ma#ureMa#ureB-cell neoplass !&'%B-cell neoplass !&'% D()use lar*e B cellD()use lar*e B celll$p+oal$p+oa
B-cell prol(,era#(ons o, uncer#a(n al(*nan# po#en#(al !"%B-cell prol(,era#(ons o, uncer#a(n al(*nan# po#en#(al !"%
T;1ell NK;1ell neoplamT;1ell NK;1ell neoplam PrecursorPrecursorT-cell neoplass !%T-cell neoplass !%
Ma#ureMa#ureT-cell an. NK-cell neoplass !&/%T-cell an. NK-cell neoplass !&/%
T-cell prol(,era#(on o, uncer#a(n al(*nan# po#en#(al !&%T-cell prol(,era#(on o, uncer#a(n al(*nan# po#en#(al !&%
Ho&gk"n l%mp+omaHo&gk"n l%mp+oma la"1al Ho&gk"n l%mp+oma (4)la"1al Ho&gk"n l%mp+oma (4)
No&,la! l%mp+o1%$e p!e&om"nan$ Ho&gk"n l%mp+oma (8)No&,la! l%mp+o1%$e p!e&om"nan$ Ho&gk"n l%mp+oma (8)
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L$p+oa 0lass(1ca#(on ( HO "22& %
A. B-Cell Neoplasms
I. Precursor B-cell neoplasm : Precursor B- acute lymphoblastic
leukemia / lymphoblastic lymphoma (B-ALL, LBL)II. Mature (peripheral) B-neoplasms
a. B-cell chronic lymphocytic leukemia / small lymphocytic lymphoma
b. B-cell prolymphocytic leukemia
c. Lymphoplasmacytic lymphoma
. Mantle cell lymphomae. !olliculer lymphoma
". #plenic mar$inal %one B-cell lymphoma (& 'illous
lymphocytes)
$. airy cell leukemia
h. Plasma cell myeloma/plasmacytoma
i. *tranoal mar$inal %one B-cell lymphoma o" MAL+ type
oal mar$inal %one B-cell lymphoma (& monocytoi B cells)
k. i""use lar$e B-cell lymphoma
l. Burkitts lymphoma/Burkitt cell leukemia
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NNon;Ho&gk"nJon;Ho&gk"nJ LL%mp+oma%mp+oma
DL
L
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Klas(13as( 4F ! &'5" %Klas(13as( 4F ! &'5" %
Lo6 *ra.e al(*nanc$Lo6 *ra.e al(*nanc$Small l%mp+o1%$"1 0 plama1%$o"&Small l%mp+o1%$"1 0 plama1%$o"&
Foll"1,la! p!e&om"nan$l% mall 1lea2e& 1ellFoll"1,la! p!e&om"nan$l% mall 1lea2e& 1ell
Foll"1,la! m"e& mall 1lea2e& an& la!ge 1ellFoll"1,la! m"e& mall 1lea2e& an& la!ge 1ell
In#ere.(e#e *ra.e al(*nanc$In#ere.(e#e *ra.e al(*nanc$Foll"1,la! p!e&om"nan$l% la!ge 1ellFoll"1,la! p!e&om"nan$l% la!ge 1ell
D"#,e mall 1lea2e& 1ellD"#,e mall 1lea2e& 1ell
D",e m"e& mall an& la!ge 1ellD",e m"e& mall an& la!ge 1ell
H(*+ *ra.e al(*nanc$H(*+ *ra.e al(*nanc$
La!ge 1ell "mm,no'la$"1 La!ge 1ell "mm,no'la$"1
L%mp+o'la$"1 L%mp+o'la$"1
Small non 1lea2e& 1ellSmall non 1lea2e& 1ell
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LMPHOMA GRADATION ( NN 6787 )In&olen$ (lo3 g!o3"ng) ;1ell l%mp+omaFoll"1,la! l%mp+oma
+!on"1 l%mp+o1%$"1 le,kem"a 0 malll%mp+o1%$"1 l%mp+omaMALTSplen"1 ma!g"nal one l%mp+omaNo&al ma!g"nal oneAgg!e"2e (#a$ g!o3"ng) ;1ell l%mp+omaD",e la!ge ;1ell l%mp+oma
Man$le 1ell l%mp+omaH"g+l% agg!e"2e ;1ell l%mp+oma,!k"$$ l%mp+omaL%mp+o'la$"1 l%mp+oma
AIDS;!ela$e& ;1ell
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PENDEKATAN DIAGNOSTIKPENDEKATAN DIAGNOSTIK
&7 Ananes(s&7 Ananes(s
UuUuPem'ea!an KG a$a, o!ganPem'ea!an KG a$a, o!gan
men,!,n Q 87 &alam 3ak$, < ',lan men,!,n Q 87 &alam 3ak$, < ',lan
Demam $"ngg" Q
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La8ora#or(uLa8ora#or(u
R,$"n R,$"n
Da!a+ pe!"#e! lengkap ( DPL )Da!a+ pe!"#e! lengkap ( DPL )Gam'a!an &a!a+ $ep" ( GDT )Gam'a!an &a!a+ $ep" ( GDT )
U!"ne lengkapU!"ne lengkap
K"m"a Kl"n"k K"m"a Kl"n"k
Im,nop+eno$%p"ng Im,nop+eno$%p"ng pa!a.n panelpa!a.n panel D 67D 67D
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M"n"mal "mm,no+"$o1+em"$!% D67 "man&a$o!%
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PENATALAKSANAANPENATALAKSANAAN8= Ra&"o$e!ap"8= Ra&"o$e!ap"
6= Ra&"o$e!ap" Kemo$e!ap"6= Ra&"o$e!ap" Kemo$e!ap"
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LIMFOMA MALIGNUM HODGKINLIMFOMA MALIGNUM HODGKIN
K+a el Ree& S$e"n'e!gK+a el Ree& S$e"n'e!g
Klas(13as(Klas(13as(8= T"pe l%mp+o1%$e p!e&om"nan$8= T"pe l%mp+o1%$e p!e&om"nan$ p!ogno" 'a"kp!ogno" 'a"k
6= T"pe m"e& 1ell,la!"$%6= T"pe m"e& 1ell,la!"$%
p!ogno" le'"+ ',!,kp!ogno" le'"+ ',!,k
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PENATALAKSANAAN
8= Ra&"o$e!ap"
6= Ra&"o$e!ap" Kemo$e!ap"
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KEMOTERAPIKEMOTERAPI
KANKERKANKER FASE PERTUMBUHAN SELFASE PERTUMBUHAN SEL
MM
G"G"
G&G& G2G2
SS
Sesu.a+ (#os(s !M%:Sesu.a+ (#os(s !M%: G& !al#(, e8en#u3G& !al#(, e8en#u3
RNA: pro#e(n%RNA: pro#e(n% S ! s(n#es(s DNA%S ! s(n#es(s DNA% G" !a3#(, la*(G" !a3#(, la*(
e8en#u3 RNA: pro#e(n%e8en#u3 RNA: pro#e(n%
Sel a3#(, 8erprol(,eras(Sel a3#(, 8erprol(,eras( G& pen.e3G& pen.e3
Sel la8a# prol(,eras(Sel la8a# prol(,eras( G& pan;an*G& pan;an*
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KLASIFIKASI KEMOTERAPIKLASIFIKASI KEMOTERAPI
&7&7 NONSPESIFIK TERHADAP FASE SELNONSPESIFIK TERHADAP FASE SEL
A7A7 SPESIFIK SIKLUS: NONSPESIFIK FASESPESIFIK SIKLUS: NONSPESIFIK FASE
ALKILATING: DEKARBASINALKILATING: DEKARBASIN
B7 NON SPESIFIK SIKLUSB7 NON SPESIFIK SIKLUS
STEROID: ANTIBIOTIK KE0UALI BLEOMISINSTEROID: ANTIBIOTIK KE0UALI BLEOMISIN
SPESIFIK TERHADAP FASE SELSPESIFIK TERHADAP FASE SEL
A7 FASE G 2A7 FASE G 2 SEMUA KEMOTH< AKANSEMUA KEMOTH< AKAN
REFRAKTERREFRAKTER
B7 FASE G &B7 FASE G & L- ASPARAGINASEL- ASPARAGINASE07 FASE S07 FASE S ANTIMETABOLIT: HIDROKSIUREA:ANTIMETABOLIT: HIDROKSIUREA:
PROKARBA=INPROKARBA=IN
D7 FASE G "D7 FASE G "
BLEOMISIN: ALKALOID TANAMANBLEOMISIN: ALKALOID TANAMAN
E7 FASE ME7 FASE M ALKALOID TANAMANALKALOID TANAMAN
GOLONGANGOLONGAN SUBSUB O B A TO B A T
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GOLONGANGOLONGAN SUBSUBGOLONGANGOLONGAN
O B A TO B A T
ALKILATORALKILATOR MUSTAR NITROGENMUSTAR NITROGEN
DERI/AT ETILENAMINDERI/AT ETILENAMIN
ALKIL SULFONATALKIL SULFONAT
NITROSURIANITROSURIA
SIKLOFOSPAMID MELFALAN KLORAMUSILSIKLOFOSPAMID MELFALAN KLORAMUSIL
TIOTEPATIOTEPA
USULFANUSULFAN
KARMUSTIN LOMUSTIN SAMUSTINKARMUSTIN LOMUSTIN SAMUSTIN
ANTIANTIMETAOLITMETAOLIT
ANALOG PIRIMIDINANALOG PIRIMIDIN
ANALOG PURINANALOG PURIN
ANTAGONIS FOLATANTAGONIS FOLAT
;FU SITARAIN : AAURIDIN FLOKSURIDIN;FU SITARAIN : AAURIDIN FLOKSURIDIN
:;MERKAPTOPURUN :;TIOGUANID:;MERKAPTOPURUN :;TIOGUANID
METOTREKSATMETOTREKSAT
PRODUKPRODUK
ALAMIAHALAMIAH
ALKALOID /INKAALKALOID /INKA
ANTIIOTIKANTIIOTIK
ENIMENIM
/INLASTIN /INKRISTIN/INLASTIN /INKRISTIN
DAKTINOMISIN MITOMISINDAKTINOMISIN MITOMISIN
ANTRASIKLIN -ANTRASIKLIN - DAUNORUISIN DOORUISINDAUNORUISIN DOORUISIN
L;ASPARAGINASEL;ASPARAGINASE
HORMONHORMON ADRENOKORTIKOIDADRENOKORTIKOID
PROGESTINPROGESTINESTROGENESTROGEN
ANDROGENANDROGEN
PREDNISONPREDNISON
HIDROKSIPROGESTERON MEGESTROLHIDROKSIPROGESTERON MEGESTROLDIETILSTILESTEROL ETINILESTRADIOLDIETILSTILESTEROL ETINILESTRADIOL
TESTOTERON FLUOKSIMESTERONTESTOTERON FLUOKSIMESTERON
ISOTOPISOTOPRADIOAKTIFRADIOAKTIF
FOSFORFOSFOR
ODIUMODIUM
NATRIUM FOSFATNATRIUM FOSFAT
NATRIUM ODIDANATRIUM ODIDA
LAIN;LAINLAIN;LAIN SUSTITUSI UREASUSTITUSI UREADERI/AT METIHIDRAINDERI/AT METIHIDRAIN
HIDROKSIUREAHIDROKSIUREAPROKARAINPROKARAIN
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P E R H A T I A NP E R H A T I A N
TOKSISITAS OBATTOKSISITAS OBAT
SST SALURAN ERNA SEL FOLIKEL RAMUTSST SALURAN ERNA SEL FOLIKEL RAMUT KONTRA INDIKASIKONTRA INDIKASI
KU URUK KU URUK SKALA KARNOFSK KURANG EFEK IRITASI KULITEFEK IRITASI KULIT
EFEK KARSINOGENIK EFEK KARSINOGENIK
EFEK MUTAGENIK EFEK MUTAGENIK
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KARNOFSK SALEKARNOFSK SALE877 877 - AKTIFITAS NORMAL KELUHAN (;) GE5ALA PENAKIT (;)- AKTIFITAS NORMAL KELUHAN (;) GE5ALA PENAKIT (;)
C7 C7 - AKTIFITAS NORMAL KELUHAN () GE5ALA PENAKIT ()- AKTIFITAS NORMAL KELUHAN () GE5ALA PENAKIT ()
7 7 - AKTIFITAS NORMAL DENGAN USAHA EERAPA GE5ALA- AKTIFITAS NORMAL DENGAN USAHA EERAPA GE5ALA7 7 -- AKTIFITAS NORMAL (;) DAPAT MENGURUS DIRI SENDIRIAKTIFITAS NORMAL (;) DAPAT MENGURUS DIRI SENDIRI
:7 :7 -- AKTIFITAS NORMAL (;) KADANG PERLU ANTUANAKTIFITAS NORMAL (;) KADANG PERLU ANTUAN
7 7 - ANAK PERLU NATUAN- ANAK PERLU NATUAN
47 47 - PERLU PERAATAN DAN ANTUAN KHUSUS- PERLU PERAATAN DAN ANTUAN KHUSUS
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PERSIAPAN KEMOTERAPIPERSIAPAN KEMOTERAPI
8=8= INFORM ONSENTINFORM ONSENT
6=6= INFORMASI MANFAAT DAN EFEK SAMPINGINFORMASI MANFAAT DAN EFEK SAMPING