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Kanker Payudara
Dr Emir T Pasaribu SpB(K)Onk
Dr. Suyatno SpB(K)Onk
Bagian Ilmu Bedah FK USU/
RS H Adam Malik Medan
Kelenjar Getah Bening, tempat metastasis regional
BREAST CANCER Anatomical site
RIGHT
Upper inner Nipple Central portion Lower inner
Upper outer Axillary tail Lower outer
KPD: karsinoma berasal dari epitel duktus atau
lobulus
Keganasan paling sering di negara maju
Pria : wanita = 1 : 100
Insiden meningkat dengan pertambahan
usia,(setelah dekade ke 4)
Penyebab kematian no.2 setelah ca.paru
Di Indonesia
– No. 2 setelah Ca servik
– Kebanyakan datang std III & IV (M. Ramli, 43,9%)
Epidemiologi
BREAST CANCER Worldwide incidence in females*
*Incidence per 100,000 population.
Parkin DM, et al. CA Cancer J Clin. 1999;49:33-64.
67.4
36.0
28.6
71.7
21.2
25.0
31.5
25.5
86.3
Eastern Europe
Japan
Australia/ New Zealand
South Central Asia
Northern Africa
Southern Africa
Central America
Western Europe
North America
BREAST CANCER Age-specific incidence (per 100,000)
Adapted from New Horizons in Cancer Management, SRI International, 1990.
Inc
ide
nc
e R
ate
s
20 25 30 35 40 45 50 55 60 65 70 75 80 85+
24 29 34 39 44 49 54 59 64 69 74 79 84
420 400
300
200
100
0
Age
United
States
England
and Wales
Italy
France
Japan
BREAST CANCER Spread to lymph nodes
Supraclavicular
Subclavicular
Distal (upper)
axillary
Central (middle)
axillary
Proximal (lower)
axillary
Mediastinal
Internal mammary
Interpectoral
(Rotter’s)
BREAST CANCER Risk factors
Age: setelah dekade 4
Family history: mother, sister, dougther
Prior personal history of breast cancer
Increased estrogen exposure
– Early menarche (<12 years)
– Late menopause (> 55 years)
– HRT ( > 5years)
– Oral contraceptives (> 8 years)
Risk factors
Nulliparity
1st pregnancy after age 30
Diet and lifestyle (obesity, excessive alcohol consumption)
Radiation exposure before age 30
Mutation : BRCA1 and or BRCA 2
Prior benign or premalignant breast changes
– In situ cancer
– Atypical hyperplasia
Diagnostik Klinis
– Anamnesis
• Keluhan utama
• Keluhan tambahan
• RPO & RPT
– Pemeriksaan fisik
• Inspeksi
• Palpasi
Pememriksaan penunjang
– USG mammae
– Mamografi
– USG abdomen, F. Thorak, bone
scann
Biopsi
Tanda dan gejala :
Benjolan yang keras dengan atau tanpa rasa sakit
Bentuk puting berubah
– retraksi nipple
– putting mengeluarkan cairan /darah (nipple discharge)
Perubahan pada kulit
– berkerut seperti kulit jeruk (peau d’orange)
– melekuk ke dalam (dimpling)
– borok (ulcus)
– eritema, edema
benjolan kecil di kulit payudara (nodul satelit)
luka puting dipayudara yang sulit sembuh/
eczema (paget disease)
payudara terasa panas, memerah dan
bengkak
benjolan awalnya biasanya hanya pada 1
payudara
ada benjolan di aksila dengan atau tanpa
masa di payudara
Benjolan payudara kanan
Peau d’orange Pembesaran kgb aksila
Retraksi Nipple (Puting)
Masa menonjol dengan eritema dan retraksi
nipple
Masa keras, terfiksir dgn eritema dan retraksi nipple
Nipple discharge/ Keluar cairan puting
SKIN DIMPLING
Paget’s Disease
No
du
le
Sa
te
lit
Ulkus dengan retraksi nipple
Ulkus yang meluas mengenai kedua
payudara
BREAST CANCER Sites of distant metastases
Skin
Liver
Bone
Pleura
Lung
Lymph nodes
Brain
Gejala Klinis Metastasis Jauh
Paru/ pleura: batuk, sesak nafas , efusi pleura
Tulang: sakit pada tulang dan patah tulang
Otak: nyeri kepala hebat, muntah proyektil,
kesadarn menurun
Liver: hepatomegali, ikterus, sakit perut,
perut gembung, mual
BREAST CANCER Screening
Breast self-examination Examination Mammography—the
by physician only modality shown
to decrease mortality
SADARI (SBE)
Posisi berdiri
Posisi berbaring
Posisi berbaring dengan bantal diletakan di punggung
BREAST CANCER Examination by physician
Breast inspection
Skin dimpling
BREAST CANCER Breast palpation
BREAST CANCER Regional node assessment
BREAST CANCER Screening mammography
Reduces mortality by 26% in women
aged 50-74
ACS recommends
– 1st screening mammography by
age 40
– Mammography every 1 to 2 years
between the ages of 40 and 49
– Mammography annually thereafter
Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.
Fink DJ, Mettlin CJ. American Cancer Society Textbook of Clinical Oncology. 2nd ed. 1995;128-193.
BREAST CANCER Screening (high-risk)
Annual mammogram, beginning 5 yrs
before age of youngest affected
relative at time of diagnosis
– High familial risk
– BRCA 1/2-positive
Tripathy D, Henderson IC. Current Cancer Therapeutics. 3rd ed. 1999;123-129.
BREAST CANCER Horizontal mammography
BREAST CANCER Vertical mammography
BREAST CANCER Mammography
B I R A D S
Kategori
BIRADS Deskripsi
Resiko
Malignansi
Perencanaan
Tindakan
1 Negative 5 in 10,000 Continue annual
mammograpy
2 Benign finding,
noncancerous
5 in 10,000 Continue annual
mammograpy
3 Probably benign
finding
<2% Usually, 6-
month follow-up
mammography is
performed.
4 Suspicious
abnormality
25-50% Biopsy
5 Highly
suggestive of
malignancy
75-99%, Biopsy
USG Payudara
USG merupakan metode terpilih –untuk membedakan kistik dengan solid –sebagai guide untuk biopsi
Gambaran maligna: lesi hipoechoic dgn margin irregular
BREAST CANCER Biopsy
Excisional biopsy
Size < 3 cm
Incisional biopsy
– Size > 3 cm & operable
– inoperable
Core needle biopsy
– Histologic diagnosis
Fine-needle aspiration
– Cytologic diagnosis
Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.
FNAB CORE BIOPSY
BREAST CANCER Pathology
Non-invasive carcinoma in situ
– Ductal carcinoma in situ (DCIS)
– Lobular carcinoma in situ (LCIS)
Invasive carcinoma
– Infiltrating ductal or lobular carcinoma
– Medullary, mucinous, and tubular carcinomas
Uncommon tumors
– Inflammatory carcinoma
– Paget’s disease
Dollinger M, et al. Everyone’s Guide to Cancer Therapy. 1997;356-384.
BREAST CANCER Tumor definitions
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ: Intraductal carcinoma, lobular carcinoma in situ,
or Paget’s disease of the nipple with no tumor
T1 Tumor 2 cm or less in greatest dimension
T1mic Microinvasion more than 0.1 cm or less in greatest dimension
T1a Tumor more than 0.1 cm but not more than 0.5 cm in greatest dimension
T1b Tumor more than 0.5 cm but not more than 1 cm in greatest dimension
T1c Tumor more than 1 cm but not more than 2 cm in greatest dimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest dimension
T3 Tumor more than 5 cm in greatest dimension
T4 Tumor of any size with direct extension to (a) chest wall or (b) skin, only as described below
T4a Extension to chest wall
T4b Edema (including peau d’orange) or ulceration of the skin of the breast
or satellite skin nodules confined to the same breast
T4c Both (T4a and T4b)
T4d Inflammatory carcinoma
Used with the permission of the American Joint Committee on Cancer (AJCC®), Chicago, Illinois.
The original source for this material is the AJCC® Cancer Staging Manual, 5th edition (1997)
published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.
BREAST CANCER TNM stage grouping
Stage 0 Tis N0 M0
Stage I T1* N0 M0
Stage IIA T0 N1 M0
T1* N1** M0
T2 N0 M0
Stage IIB T2 N1 M0
T3 N0 M0
Stage IIIA T0, T1,* T2 N2 M0
T3 N1, N2 M0
Stage IIIB T4 Any N M0
Any T N3 M0
Stage IV Any T Any N M1
* Note: T1 includes T1 mic.
** Note: The prognosis of patients with N1a is similar to that of patients with pN0.
Used with the permission of the American Joint Committee on Cancer (AJCC®), Chicago, Illinois.
The original source for this material is the AJCC® Cancer Staging Manual, 5th edition (1997)
published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.
BREAST CANCER Stage 0: DCIS & LCIS
DCIS LCIS
Abnormal mammogram Microscopic characterization
on biopsy
Clustered microcalcifications Solid proliferation of small
or non-palpable masses cells with uniform round to
oval nuclei
30% risk of invasive cancer 37% chance of subsequent
at 10 years at or near invasive cancer
original biopsy site
DCIS – ductal carcinoma in situ.
LCIS – lobular carcinoma in situ.
Harris J, et al. Cancer: Principles & Practice of Chemotherapy. 5th ed. 1997;1557-1616.
Love S, Barsky SH. Cancer Treatment. 4th ed. 1995;337-340.
BREAST CANCER Stage I
T1a: T 0.5 cm T1b: 0.5 cm < T 1 cm T1c: 1 cm < T 2 cm
T1 N0 M0
T 2 cm
T1
N0 = no regional lymph node metastasis
M0 = no distant metastasis
BREAST CANCER Stage IIA
T2 N0 M0
N1 = metastasis to movable ipsilateral axillary lymph node(s)
M0 = no distant metastasis
2 cm < T < 5 cm
No evidence of tumor
T0
T0
T1 N1 M0 }
T2
BREAST CANCER Stage IIB
T3 N0 M0
N1 = metastasis to movable ipsilateral axillary lymph node(s) (p) N1a, N1b
M0 = no distant metastasis
T > 5 cm
T2 N1 M0
T3
BREAST CANCER Stage IIIA
T0
T1
T2
T3
Metastasis to ipsilateral axillary lymph node(s)
N1 = movable
N2 = fixed to one another or to other structures
M0 = no distant metastasis
T3 N1 M0 N2 M0
BREAST CANCER Stage IIIB
Any T N3 M0
N3 = metastasis to ipsilateral internal mammary lymph node(s)
M0 = no distant metastasis
Tumor of any size with direct extension to chest wall or skin T4d = inflammatory carcinoma
T4 any N M0
T4
BREAST CANCER Stage IV
M1 = distant metastasis (including metastases to ipsilateral supraclavicular,
cervical, or contralateral internal mammary lymph nodes)
Any T any N M1
Penatalaksanaan
1. PEMBEDAHAN
2. KEMOTERAPI
3. RADIOTERAPI
4. HORMONAL
5. TARGETING THERAPY
Pmbedahan
Radikal mastektomi
Modified radikal mastektomi
- Patey
- Madden
Breast conserving surgery (BCS)
– lumpectomi +
– diseksi aksila +
– radioterapi
Skin/Nipple sparing mastectomy
Disain operasi MRM (mastectomy
radical modification)
Pasca Operasi MRM
Operasi BCS
•Kosmetik
dapat diterima
•Survival sama
dengan MRM
•Kemungkinan
kambuh lebih
tinggi
SSM + TRAM FLAP
Kutis , sukutis dan lemak di bagian bawah
perut dipindahkan untuk mengisi rongga
bekas jaringan payudara
Tampilan 1 bulan pasca operasi
Kemoterapi
Bersifat lokal, regional dan sistemik
Berperan sebagai terapi utama (primer) atau
tambahan (adjuvan)
Bekerja dengan menghambat atau
mengganggu sintesa DNA dalam siklus sel
Dapat diberi tunggal atau kombinasi
Respon dinilai setelah 3 siklus
Indikasi adjuvan kemoterapi:
ukuran tumor lebih dari 2 cm
kgb aksila positif metastasis 1 atau lebih
kgb aksila negatif tapi penderita berusia
kurang dari 35 tahun atau grading tumor 2-3
atau terdapat invasi vaskular atau
overekspresi HER2 atau ER/PR negatif
(intermediate dan high risk kategori St. Gallen
2005).
Radioterapi
Bersifat: lokal dan regional
Peran: utama, tambahan atau kombinasi
Prinsip: kerusakan DNA dengan
gangguan proses replikasi
Tujuan menurunkan resiko rekurensi lokal/
regional dan berpotensi untuk menurunkan
mortalitas jangka panjang
Indikasi Radioterapi Adjuvan
Setelah operasi BCS
Ukuran tumor > 5 cm
Tepi sayatan dekat / tidak bebas tumor
Tumor letak sentral / medial
KGB (+) dgn ekstensi ekstra kapsular
KGB (+) 4 atau lebih
RADIOTERAPI
Hormonal
Bersifat sitemik, Peran: utama atau tambahan
Tujuan untuk menghilangkan atau mengurangi estrogen yang masuk ke sel tumor
Indikasi: ER atau PR positif
Anti hormon:
– SERM : tamoxifen
– aromatase inhibitor (AI): anastrozole,letrozole
Tamoxifen paling banyak digunakan dan merupakan terapi standar untuk wanita premenopause
TABLET HORMONAL
KANKER PAYUDARA METASTASE
JAUH (stage IV)
Sifat terapi paliatif
Terapi sistemik merupakan terapi primer
Terapi loko regional (radiasi dan bedah ) bila
diperlukan untuk paliatif
Tujuan terapi: meningkatkan kualitas hidup dan
survival
Metastasis ke paru atau tulang: mastectomy
meningkatkan survival
BREAST CANCER Commonly assessed prognostic factors
Slamon DJ. Chemotherapy Foundation. 1999;46.
Harris J, et al. Cancer: Principles & Practice of Oncology. 1997;1557-1616.
Nuclear grade
Estrogen/progesterone
receptors
HER2/neu overexpression
Number of positive axillary nodes
Tumor size
Lymphatic and vascular invasion
Histologic tumor type
Histologic grade
Faktor prognosis pada kanker payudara
Faktor prognosis Prognosis baik
Ukuran Kecil
Perabaan KGB tidak teraba
KGB secara PA Negatif
Derajat diferensiasi Baik
Infasi limpatik Negatif
ER / PR Tinggi
S- phase Rendah
HER- 2/neu Negatif
MDR Negatif
Angiogenesis Negatif
DNA ploidy Tinggi
Obesitas Negatif
Follow up
Setiap 4 bulan untuk 1-2 tahun pertama
Setiap 6 bulan untuk tahun ke 3-5
Setiap 12 bulan setelahnya
Setiap bulan direkomendasikan untuk SADARI
Mamografi dilakukan 6 bulan setelah BCT selesai,
kemudian setiap tahun
Untuk pasien yang dilakukan mastektomi mamografi
kontralateral dilakukan setiap tahun.
Routine bone scan, skeletal survey, CT abdomen
dan otak pada pasien asimptomatik, stadium dini
adalah tidak cost-effective, oleh karena occult
metastase sangat jarang.
Edukasi
KPD dapat disembuhkan asal diberikan
terapi tepat pada stadium dini
Deteksi dini dapat dilakukan dengan
SADAR, SARANIS dan Mamografi
Sebagian besar (80%) KPD merupakan
penyakit yang dapat dicegah
Strategi Pencegahan melibatkan
individu dan Instansi Pemerintah.
Kepustakaan
1. Devita VT, Hellman S, Rosenberg SA. Penyunting.
Cancer Principlels & practice of Oncology. Edisi ke-8.
Philadelphia. Lippincott William & Wilkins. 2008.
2. Feight BW, Berger DH, Fuhrman GM, penyunting.
The M.D Anderson surgical oncology handbook.
Edisi ke-4. Philadelphia. Lippincott William & Wilkins.
2006.
3. Suyatno, Emir T Pasaribu, Bedah Onkologi
Diagnostik dan Terapeutik, Jakarta, Sagung Seto,
2010
4. Foto: dokumentasi pribadi dan unduhan
Terima kasih