Tumor Stroma Gastrointestinal ( GIST ) Nisa Lystia Novianti, Bambang Am Am Setya Divisi Bedah Digestif, Departemen Ilmu Bedah Fakultas Kedokteran Universitas Padjadjaran / Rumah Sakit Dr. Hasan Sadikin Bandung
Abstract
Pendahuluan
Gastrointestinal stromal tumors (GISTs) are rare neoplasms of the gastrointestinal tract associated with high rates of malignant transformation. Most GIST present asymptomatically. Gastrointestinal stromal tumors (GIST) are the most common primary mesenchymal tumors of the gastrointestinal tract (80%), representing 5% of all sarcomas, with estimated incidence 14.5 per million.
Tumor stroma gastrointestinal (GIST) adalah neoplasma langka pada saluran cerna terkait dengan tingginya tingkat transformasi keganasan. Kebanyakan GIST muncul tanpa gejala.
Epidemiology of GIST is incompletely known. The median age at diagnosis of Gastrointestinal stromal tumors (GISTs) is 66–69 years in population with an equal gender distribution. Symptomatic patients may present nausea, vomiting, nonspecific abdominal distension, early satiety, abdominal pain, and rarely as a palpable abdominal mass
Tumor stroma gastrointestinal (GIST) adalah tumor mesenkim primer yang paling umum di saluran gastrointestinal (80%), mewakili 5% dari semua sarcoma dengan angka kejadian 5% dari seluruh sarkoma dengan perkiraan insidensi 14.5 per juta dan prevalensi 129 per juta, dan 5000 hingga 6000 kasus baru per tahun di Amerika Serikat. Usia rata-rata diagnosis adalah 60 tahun tanpa dominasi jenis kelamin.
Data was taken from medical record in August 3rd, 2020 at Dr. Hasan Sadikin Hospital, Bandung A female patient 35 years old came to Emergency Department of Dr. Hasan Sadikin Hospital Bandung with hematemesis since 1 day. Abdominal CT showed Inhomogenous isodense lesion, defined, regular margins, intralumen of the stomach attached to the inferior wall of the stomach. Confirmation of malignant tumour intralumen in stomach were established. An antrectomy (Billroth 1) was performed to remove the tumour. GIST diagnose was established from Hystopathology and IHC examination.
Sekitar 80% GIST memiliki mutasi KIT dan PDGFRA bermutasi 5%. Kebanyakan mutase KIT terjadi pada GIST yang tidak diobati di juxtamembrane ekson 11 dan hanya dalam domain kinase, sedangkan pada pasien diobati dengan imatinib terjadi mutasi sekunder sering dalam ekson yang mengkodekan ATP/ imitanib binding atau loop aktivasi kinase.
GIST can originate anywhere in the GI tract. The stomach (40–60%) and small intestine (30–40%) are the most common locations. GISTs present asymptomatically in 18% of cases, especially in cases of smaller tumours of the intestinal tract. Surgical resection with adjuvant imatinib 400 mg daily is the gold standard for the treatment of GIST
Tindakan pembedahan adalah standar pengobatan untuk GIST lokal. Tumor beresiko tinggi harus dipantau kekambuhan dengan CT scan abdomen serial.
Keywords: GIST, antrectomy
Pembahasan
Laporan Kasus
Tumor stroma gastrointestinal (GIST) neoplasma langka pada saluran cerna tinggi tingkat transformasi keganasan. Nama Umur Pekerjaan
: Ny. O : 35 Tahun : Swasta
Kebanyakan GIST muncul tanpa gejala khususnya pada kasus-kasus tumor yang lebih kecil pada traktus intestinal. Tumor-tumor ini biasanya ditemukan secara tidak sengaja pada CT Scan Abdomen, endoskopi, atau saat prosedur pembedahan pada penyakit lainnya.
Keluhan utama : Muntah darah dan muntah setelah makan Anamnesa Khusus : Sejak 1 hari yang lalu pasien mengeluhkan muntah darah, muntah 1 kali berisikan gumpalan darah sebanyak 1 gelas belimbing. Keluhan disertai lemah badan yang dirasa sejak 3 hari yang lalu. Pasien juga mengatakan terdapat keluhan sering muntah apabila pasien telah selesai makan sejak 10 bulan yang lalu. Pasien mengeluhkan perut yang dirasakan kembung yang dirasakan semakin lama semakin memberat sejak 10 bulan yang lalu bersamaan dengan keluhan muntah setiap setelah makan.. Keluhan BAB hitam, cair, sebanyak 2 kali, demam (-), riwayat keluhan sulit menelan (-), keluhan penurunan BB (-). Riwayat mengonsumsi "neuralgin" sejak 5 tahun terakhir untuk keluhan sakit kepala atau sakit badan yg dirasakan pasien. Keluhan serupa dirasakan pasien pada Juli 2020 dan di transfusi 3 labu PRC di RSUD Al Ihsan.
Gejala yang muncul dapat berupa gejala-gejala yang tidak khas seperti mual, muntah, rasa kenyang yang dini, nyeri perut dan jarang ditemukan massa perut yang teraba. Tumor-tumor yang lebih besar dapat menyebabkan obstruksi. Perforasi neoplasma gastrointestinal.
dapat muncul dengan tanda-tanda peritonitis atau perdarahan
Reseksi bedah secara laparaskopi dari GIST dengan adjuvant imatinib 400 mg sehari adalah standard emas untuk tatalaksana GIST. Pada kasus ini dilakukan reseksi gaster pada bagian antrum dikarenakan ukuran massa yang lebih dari 5cm, dimana tidak dapat dilakukan secara perlaparoskopi, dan dilakukan anastomosis gastro duodenostomy, serta biopsy KGB pada zona 6 dan zona 7.
Kesimpulan
Gambar 1. Foto Klinis
Gambar 4. penemuan intra operatif
Hasil Status generalis : dalam batas normal Status lokalis : At regio abdomen : Datar, lembut, bising usus (+), nyeri tekan (+) didaerah epigastrik, nyeri lepas (-), defans muskular (-), murphy sign (-), courvousier sign (-), hepar dan lien tidak membesar Gambar 2. CT Scan Abdomen
Kesimpulan: Suspek gastro intestinal stromal tumor
Dilakukan pemeriksaan penunjang berupa pemeriksaan CT scan abdomen, Gastroskopi dan pemeriksaan Patologi Anatomi dengan hasil yang mengarah pada diagnosis Diagnosis PSMBA ec tumor pada antrum e.c GIST Rencana tindakan : antrektomi (Billroth 1)
Gambar 3. Penunjang Gastroskopi
Temuan Intraoperatif • Ditemukan tumor ganas letak antrum intralumen, mobile, keras batas tegas, ukuran 10 x 6 x 5 cm, mukosa licin • Ditemukan KGB multiple pada zona 6 dan zona 7 • Hepar dalam batas normal, permukaan licin, tepi tajam, nodul (-) Dari temuan intraoperasi tersebut maka diputuskan untuk dilakukan anterektomi + Bilroth 1 + biopsi KGB
1. Etiologi GIST didapati pada usia dengan median 60-69 tahun. 2. GIST dapat berasal dari mana saja di saluran cerna. Lambung (40–60%) dan usus halus (30-40%) adalah lokasi yang paling umum. 3. Pasien dapat datang dengan gejala-gejala seperti mual, muntah, rasa kenyang yang dini, nyeri perut, ditemukan massa perut yang teraba, obstruksi dari lumen gastrointestinal, disfagia, ikterus obstruktif, konstipasi, peritonitis atau perdarahan gastrointestinal. 4. GIST bisa diidentifikasi dengan USG Abdomen, CT scan, MRI (magnetic resonance imaging), dan PET (Positron emission transverse tomography). 5. Reseksi bedah anterektomi + bilroth 1 + biopsi KGB merupakan Tindakan bedah yang dapat dilakukan sebagai terapeutik dan diagnostik. 6. Hasil histopatologi didapati GIST pada daerah gaster, dan KGB yang dilakukan biopsi bukan merupakan metastasis keganasan.
Daftar Pustaka 1. Parab, M. Trisha, et. all. 2018. Gastrointestinal stromal tumors: a comprehensive review. Departemen of Pathology, New York. 2. H. Joensuu. 2006. Gastrointestinal stromal tumor (GIST). Annal of Oncology 3. GASTROINTESTINAL STROMAL TUMOR Union for International Cancer Control. 2014. Review of Cancer Medicines on the WHO List of Essential Medicines 4. Nilsson BP, Bumming P, Meis-Kindblom JM et al. Gastrointestinal stromal tumors: The incidence, prevalence, clinical course, and prognostication in the preimatinib mesylate era. Cancer 2005; 103: 821–829. 5. Tryggvason G, Gislason HG, Magnusson MK et al. Gastrointestinal stromal tumors in Iceland, 1990–2003: The Icelandic GIST study, a populationbased incidence and pathologic risk stratification study. Int J Cancer 2005; 117: 289–293
THE APPLICATION OF EVIDENCE BASED NURSING PRACTICE: THE EFFECTIVENESS OF HONEY ON RADIATION-INDUCED ORAL MUCOSITIS AND CHEMOTHERAPY-INDUCED ORAL MUCOSITIS IN RSUPN DR CIPTO MANGUNKUSUMO
Author: 1 2 2 31 Yenny Tandi , Waluyo A , Yona S Gultom Y 2
RSUD Tarakan, Tarakan, Kalimantan Utara, Indonesia Fakultas Ilmu Keperawatan, Universitas Indonesia, 3 Depok, Jawa Barat, Indonesia RSUPN Dr Cipto Mangunkusumo
Background Ÿ Oral mucositis (OM)
is one of the common complication
Characteris cs of Par cipants
1
of cancer treatment Ÿ Incident OM in radiotherapy and chemoradiation reached 2 80-100% and chemotherapy 40% Ÿ Honey has many properties such as anti-microbial, anti-inflamation, antioxidant, anti-mutagenic and anti-tumor3
Treatment 10 % 30 %
60 %
Site of Tumor 10 %
Radiotherapy
Nasopharynx
Chemoradia on
oral cavity 30 %
Chemotherapy
60 %
Neck
Aim of Study To assess and evaluate the effectiveness of honey in reducing oral mucositis in patien cancer undergoing treatment
Age
Gender
10 %
20 %
20 %
17-25 36-45
Male 30 %
Methode
80 %
Female
Ÿ The intervention was based on two primary journal which was
the search result from databases. Ÿ Seven patients had radiation and chemoradiation and three patients with chemotherapy. Ÿ Patien had chemoradiation and radiotherapy were advised to dilute 10 ml of honey in 50 ml of purified water making gargles in the oral cavity (15 min befor dan after the radiotherapy session adn 6 h later), three times a day for four weeks. Ÿ Patient with chemotherapy sip 10 ml of honey and then swallowo, and reapeat every three hours for one week. Ÿ Measurements were performed using Oral Assessment Guide (OAG
46-55 40 %
56-65
Level of Schooling 10 %
90 %
Primary
Higher educa on
Conclusion Evidenced-based practice supported the effectiveness honey intervention in reducing oral mucositis among cancer patients undergoing treatments
Result The results of the study showed before and after application of honey show marked reduction in oral mucositis across patients
Means Mucosi s score 20
Discussion • The results of this EBNP were similar to the previous study by Charalambous et all, (2018) and Raeessi et al, (2014). The comparison between before and after application of honey show marked reduction in oral mucositis. • Honey is one of the natural ingredients commonly used of traditional medicine in Indonesian society. Honey is safe to use, easily available and can be an option in reducing the degree of oral mucositis
15 10
Reference
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II
III
IV
1. Raeessi, M. A., Raeessi, N., Panahi, Y., Gharaie, H., Davoudi, S. M., Saadat, A., … Jalalian, H. (2014). “ Coffee plus Honey ” versus “ topical steroid ” in the treatment of Chemotherapy-induced Oral Mucositis : a randomised controlled trial, 1–7. 2. Shankar, A., Roy, S., Bhandari, M., Rath, G. K., Biswas, S., Kanodia, R., … Sachan, R. (2019). Current Trends in Management of Oral Mucositis in Cancer Treatment, 18, 2019–2026. https://doi.org/10.22034/APJCP.2017.18.8.2019 3. Khanjani, A., Rahmani, A., & Ghahramanian, A. (2018). The effect of an oral care protocol and honey mouthwash on mucositis in acute myeloid leukemia patients undergoing chemotherapy: a single-blind clinical trial. 4. Charalambous, M., Raftopoulos, V., Paikousis, L., Katodritis, N., Lambrinou, E., Vomvas, D., … Charalambous, A. (2018). European Journal of Oncology Nursing The e ff ect of the use of thyme honey in minimizing radiation - induced oral mucositis in head and neck cancer patients : A randomized controlled trial. European Journal of Oncology Nursing, 34(August 2017), 89–97. https://doi.org/10.1016/j.ejon.2018.04.003
THEOUTCOME OF CHILDREN WITH ACUTE LYMPHOBLASTIC LEUKEMIA AT PROF.DR.R.D. KANDOU MANADO HOSPITAL Emanuela Tarang, Stefanus Gunawan, Max F.J. Mantik Departement of Child Health, Faculty of Medicine, Sam Ratulangi University Prof.Dr.R.D Kandou Hospital Manado BACKGROUND. In recent years the prognosis for childhood leukemia has increased, especially for acute lymphoblastic leukemia (ALL). The purpose of ths study s to evaluate the survival rate of ALL patients in Manado. METHODS All patients with acute lymphoblastic leukemia age 0-18 years from January 2012 to December 2016 were included in the study. Patients were treated with a protocol in department of pediatric Prof. Dr. R.D. Kandou Manado. Data were collected retrospectively from pediatric patient of RSUP Prof. Dr. R.D. Kandou including sex, age, category of acute lymphoblastic leukemia, treatment, and treatment outcome. Survival rate was Kaplan Meier method. Statistical differences were determined using a log-rank test. RESULT Category Of ALL
Sex
Frequency Percent
Frequency
Percent
L
36
54.5
HR
28
42.4
P
30
45.5
SR
38
57.6
Total
66
100.0
Total
66
100.0
Outcome
Death
On treatment Survivor
Relaps
DO
Total
HR
50%
10.76%
32.1%
7.1
7.14%
100%
SR
15.7%
31.5%
39.4%
7. 8%
13.14%
100%
CONCLUSION The overall survival rate of pediatric ALL in Manado is improved.
Impact of Epilepsy on Children’s Academic Grade at Prof.Dr.R.D. Kandou Manado Hospital Ledy N Tandiawan, Nurhayati Masloman Departement of Child Health, Faculty of Medicine, Sam Ratulangi University Prof.Dr.R.D Kandou Hospital Manado
Abstract Backgroud and objective: Most children living with epilepsy are typical learners who would, normal conditions, perform well academically. This is not always the case with children exhibiting complex and more severe forms of epilepsy in which the epilepsy is associated with known or suspected brain abnormalities. For some children, frequent seizures and medical investigations may result in several days of missed school, consequently compromising learning. The study aimed to examine the relationship between epilepsy and school academic grade.
Method Children with diagnose epilepsy attending at pediatric neurology clinic of Prof.Dr.R.D. Kandou Manado hospital during january 2018- april 2018, aged 7-14 year who attended elementary and junior high school. The parameters are duration of treatment (<12month, 12-24month, 24month), and the academic grade (with good,average,minus).
Result Table Duration of treatment * Academic grade Crosstabulation Academic grade good Duration of treatment
< 12 bln
Count % within Nilai Rapor
12 - 24 bln
Count % within Nilai Rapor
> 24 bln
Count % within Nilai Rapor
Total
Count % within Nilai Rapor
average
minus
Total
9
2
2
13
90.0%
9.5%
7.1%
22.0%
1
18
2
21
10.0%
85.7%
7.1%
35.6%
0
1
24
25
0.0%
4.8%
85.7%
42.4%
10
21
28
59
100.0%
100.0%
100.0%
100.0%
rG= 0,908 with P= < 0,0001.
100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%
good
average minus
Conclusion The relation between duration of epilepsy treatment and academic grade was tested with Gamma correlation analysis obtained rG = 0.908 with p <0.0001. There was a significant and strong relationship between the duration of epilepsy treatment and the academic grade