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KankerKanker payudarapayudaraKankerKanker payudarapayudara
Dr Emir T Pasaribu Sp B OnkDr Emir T Pasaribu Sp B Onk
Bagian bedah FK USU/
RS H Adam Malik MedanRS H Adam Malik Medan
PendahuluanPendahuluan
Sering didapat pada wanitaSering didapat pada wanita
penyakit yang sulit diprediksi
Di I d i N 2 t l h C ikDi Indonesia Nomer 2 setelah Ca servik
Pria : wanita = 1 : 100
Insiden meningkat dengan pertambahan usia
Kebanyakan datang dalam setadium lanjut
BREAST CANCERBREAST CANCERA t i l itA t i l itAnatomical siteAnatomical site
Upper innerpp
Nipple
Central portion
Upper outer
Axillary tailCentral portion
Lower innerLower outer
RIGHT
BREAST CANCERBREAST CANCERS d t l h dS d t l h dSpread to lymph nodesSpread to lymph nodes
Supraclavicular
SubclavicularSubclavicular
Distal (upper)axillary
Mediastinal
Internal mammaryaxillary
Central (middle)
Internal mammary
axillary
P i l (l )
Interpectoral(Rotter’s)
Proximal (lower)axillary
BREAST CANCERBREAST CANCERW ld id i id i f l *W ld id i id i f l *Worldwide incidence in females*Worldwide incidence in females*
67.4WesternWesternEurope Europe
36.0
28.6
Eastern Eastern EuropeEurope
JapanJapan
71.7
21.2
Australia/Australia/New ZealandNew Zealand
South CentralSouth CentralAsiaAsia
25.0
31 5
Northern Northern AfricaAfrica
Southern Southern 31.5
25.5
AfricaAfrica
Central Central AmericaAmerica
NorthNorth
*Incidence per 100,000 population.
Parkin DM, et al. CA Cancer J Clin. 1999;49:33-64.
86.3NorthNorthAmericaAmerica
BREAST CANCERBREAST CANCERAA ifi i id ( 100 000)ifi i id ( 100 000)AgeAge--specific incidence (per 100,000)specific incidence (per 100,000)
420
ss
400
300
denc
e R
ates
denc
e R
ates 300
200
UnitedStates
Englandand Wales
Inci
dIn
cid
100
Italy
France
Japan
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
0
Adapted from New Horizons in Cancer Management, SRI International, 1990.
AgeAge
BREAST CANCERBREAST CANCERSt t di i bSt t di i bStage at diagnosis by raceStage at diagnosis by race
WhitWhit62
29WhiteWhite 296
50AfricanAfrican
AmericanAmericanLocalizedRegionalDistant
5035
9
0 10 20 30 40 50 60 70
% of Cases% of Cases
Landis SH, et al. CA Cancer J Clin. 1999;49:8-31.
Categories do not total 100% because staging information is not available for all cases.
BREAST CANCERBREAST CANCER55 l ti i l t bl ti i l t b55--year relative survival rates by raceyear relative survival rates by race
WhiteWhite
8798
WhiteWhite
All Stages
Localized
Regional
78
71
23
AfricanAfricanAmericanAmerican
Regional
Distant
7189
6214
0 20 40 60 80 100 120
% Surviving 5 Years% Surviving 5 Years
Landis SH, et al. CA Cancer J Clin. 1999;49:8-31.
BREAST CANCERBREAST CANCERN t l hi tN t l hi tNatural historyNatural history
Highly variable in different patients
Relatively slow growth rate
Median survival without treatment: 2.8 yrs
Generally present several years by time ofGenerally present several years by time of diagnosis
Long preclinical period enables earlyLong preclinical period enables early detection
Henderson IC. American Cancer Society Textbook of Clinical Oncology. 1995;198-219.
BREAST CANCERBREAST CANCERRi k f tRi k f tRisk factorsRisk factors
AgeFamily history of breast cancerPrior personal history of breast cancerIncreased estrogen exposure
Early menarche– Early menarche– Late menopause– Hormone replacement therapy/oral contraceptives
Nulliparity1st pregnancy after age 30Diet and lifestyle (obesity, excessive alcohol consumption)Radiation exposure before age 40Prior benign or premalignant breast changes
– In situ cancer– Atypical hyperplasia– Radial scar
Henderson IC. American Cancer Society Textbook of Clinical Oncology. 2nd ed. 1995;198-219.Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.
Trichopoulos D, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;231-257.
BREAST CANCERBREAST CANCERSi d t t t tiSi d t t t tiSigns and symptoms at presentationSigns and symptoms at presentation
Mass or painMass or painin the axillain the axilla
Palpable massPalpable massThickeningThickeningPainPain
Nipple dischargeNipple dischargeNipple retractionNipple retraction
Edema or erythemaEdema or erythemaEdema or erythemaEdema or erythemaof the skinof the skin
BREAST CANCERBREAST CANCER
Gejala klinisGejala klinis
LOKALLOKAL
- benjolan 36%
b j l d kit 33%- benjolan dengan sakit 33%
- sakit 17,5 %
- sekret putting 5%
- tarikan putting 3%
Gejala klinisGejala klinis
LOKALLOKAL
- riwayat keluarga 3%
k l i b t k d 1%- kelainan bentuk payudara 1%
- bengkak / radang 1%
- eczema 0,5%
Gejala klinisGejala klinis
SISTEMIKSISTEMIK
- batuk, sesak nafas , efusi pleura
kit d t l d t h t l- sakit pada tulang dan patah tulang
- ganguan neurologi
- hepatomegali, ikterus, sakit perut
BREAST CANCERBREAST CANCERSit f di t tSit f di t tSites of distant Sites of distant metastasesmetastases
PleuraPleuraLymph nodesLymph nodes
BrainBrain
SkinSkin
PleuraPleura
LungLung
LiverLiver
BoneBone
BREAST CANCERBREAST CANCERS iS iScreeningScreening
Breast self-examination Examination Mammography—theby physician only modality shown
to decrease mortalityto decrease mortality
Breast self examination (BSE)Breast self examination (BSE)
Look for changes in front of a mirrorLook for changes in front of a mirror- first with arm at your sides- next with arm rised above your head
fi ll ith h d d fi l hi & h t l- finally with hands pressed firmly on hips & chest muscles contracted
- In each potition, turn slowly from side to side and look for :h i i h- change in size or shape
- dimpling on the skin- change in the nipple
Breast self examination (BSE)Breast self examination (BSE)
Feel for changes lying downFeel for changes lying down.
- put a small pillow under your shoulder
l h d d h d- place your hand under your head
- use your hand to examine
- make sure you do not miss any area
Breast self examination (BSE)Breast self examination (BSE)
Look for bleeding or change from the nippleLook for bleeding or change from the nipple.
Squeeze the nipple gently to see if there is bleeding or any dischargeor any discharge
BREAST CANCERBREAST CANCERB t i tiB t i tiBreast inspectionBreast inspection
Skin dimpling
BREAST CANCERBREAST CANCERB t l tiB t l tiBreast palpationBreast palpation
BREAST CANCERBREAST CANCERR i l d tR i l d tRegional node assessmentRegional node assessment
BREAST CANCERBREAST CANCERS i hS i hScreening mammographyScreening mammography
Reduces mortality by 26% in women aged 50-74Supports view that early diagnosis andSupports view that early diagnosis and treatment can prevent metastasisACS recommends– 1st screening mammography by age 40– Mammography every 1 to 2 years between
the ages of 40 and 49the 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 CANCERBREAST CANCERS i (hi hS i (hi h i k)i k)Screening (highScreening (high--risk)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 CANCERBREAST CANCERG l f h iG l f h iGoals of mammography screening Goals of mammography screening
Earlier diagnosis in asymptomatic individualsEarlier diagnosis in asymptomatic individuals
Reduction of mortality due to detection at earlier stage
AgeAge Mortality Reduction (%)Mortality Reduction (%)
40-49 17% 15 years post-screening
50-69 25%-30% 10-12 years post-screening
70+ Insufficient data
PDQ: Screening for breast cancer for health professionals: http://Cancernetnci.nih.gov/. Accessed November 28, 1999.
BREAST CANCERBREAST CANCERH i t l hH i t l hHorizontal mammographyHorizontal mammography
BREAST CANCERBREAST CANCERV ti l hV ti l hVertical mammographyVertical mammography
BREAST CANCERBREAST CANCERM hM hMammographyMammography
BREAST CANCERBREAST CANCERBi t h i f l bl dBi t h i f l bl dBiopsy techniques for palpable and Biopsy techniques for palpable and mammographically detected massesmammographically detected masses
Excisional biopsy (usually outpatient)Tumor size and histologic diagnosis– Tumor size and histologic diagnosis
Core-cutting needle biopsy (in-office)– Histologic diagnosis
Fine-needle aspiration (in-office)Fine needle aspiration (in office)– Cytologic diagnosis
Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.
BREAST CANCERBREAST CANCERP th lP th lPathologyPathology
Non invasive carcinoma in situNon-invasive carcinoma in situ– Ductal carcinoma in situ (DCIS)– Lobular carcinoma in situ (LCIS)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 CANCERBREAST CANCERP th l NP th l N i i DCIS & LCISi i DCIS & LCISPathology: NonPathology: Non--invasive DCIS & LCISinvasive DCIS & LCIS
DCISDCIS LCISLCIS
• Abnormal mammogram • Microscopic characterization on biopsy
• Clustered microcalcifications • Solid proliferation of smallor non-palpable masses cells with uniform round toor non palpable masses cells with uniform round to
oval nuclei
• 30% risk of invasive cancer • 37% chance of subsequentat 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 CANCERBREAST CANCERTNM t iTNM t iTNM stage groupingTNM stage grouping
Stage 0Stage 0 Tis N0 M0gg
Stage IStage I T1* N0 M0
Stage IIAStage IIA T0 N1 M0T1* N1** M0T2 N0 M0
Stage IIBStage IIB T2 N1 M0T3 N0 M0
St IIIASt IIIA T0 T1 * T2 N2 M0Stage IIIAStage IIIA T0, T1,* T2 N2 M0T3 N1, N2 M0
Stage IIIBStage IIIB T4 Any N M0Any T N3 M0
Stage IVStage 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 CANCERBREAST CANCERT d fi itiT d fi itiTumor definitionsTumor definitions
TX Primary tumor cannot be assessed
T0 N id f i tT0 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 dimensionT1mic Microinvasion more than 0.1 cm or less in greatest dimensionT1a Tumor more than 0.1 cm but not more than 0.5 cm in greatest dimensionT1b Tumor more than 0.5 cm but not more than 1 cm in greatest dimensionT1c 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 belowT4a Extension to chest wallT4a Extension to chest wallT4b Edema (including peau d’orange) or ulceration of the skin of the breast
or satellite skin nodules confined to the same breastT4c Both (T4a and T4b)T4d Inflammatory carcinomaT4d 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 CANCERBREAST CANCERSt ISt IStage IStage I
T1a: T T1a: T ≤≤ 0.5 cm0.5 cmT1 N0 M0T1 N0 M0T1b: 0.5 cm < T T1b: 0.5 cm < T ≤≤ 1 cm1 cm
T1c: 1 cm < T T1c: 1 cm < T ≤≤ 2 cm2 cm
TT ≤≤ 2 cm2 cm
T1T1
T T ≤≤ 2 cm2 cm
N0 = no regional lymph node metastasisM0 = no distant metastasis
BREAST CANCERBREAST CANCERSt IIASt IIAStage IIAStage IIA
T2 N0 M0T2 N0 M0T0 T0 T1T1 N1 M0N1 M0}T1T1 N1 M0N1 M0}
No evidenceNo evidenceof tumorof tumor
T0T0 T2T2
2 cm < T 2 cm < T << 5 cm5 cm
N1 = metastasis to movable ipsilateral axillary lymph node(s)M0 = no distant metastasis
BREAST CANCERBREAST CANCERSt IIBSt IIBStage IIBStage IIB
T3 N0 M0T3 N0 M0T2 N1 M0T2 N1 M0
T3T3
T > 5 cmT > 5 cm
N1 = metastasis to movable ipsilateral axillary lymph node(s) (p) N1a, N1bM0 = no distant metastasis
BREAST CANCERBREAST CANCERSt IIIASt IIIAStage IIIAStage IIIA
T0T0T1T1T2T2T3 N1 M0T3 N1 M0 N2 M0N2 M0T2T2T3T3
Metastasis to ipsilateral axillary lymph node(s) N1 = movableN2 = fixed to one another or to other structuresM0 = no distant metastasis
BREAST CANCERBREAST CANCERSt IIIBSt IIIBStage IIIBStage IIIB
Any T N3 M0Any T N3 M0T4 any N M0T4 any N M0
T f i
T4T4
Tumor of any sizewith direct extensionto chest wall or skin
T4d = inflammatorycarcinoma
N3 = metastasis to ipsilateral internal mammary lymph node(s)M0 = no distant metastasis
BREAST CANCERBREAST CANCERSt IVSt IVStage IVStage IV
Any T any N M1Any T any N M1
M1 = distant metastasis (including metastases to ipsilateral supraclavicular, cervical, or contralateral internal mammary lymph nodes)
PengobatanPengobatan
BEDAH
RADIASI
HORMONAL
SITOSTATIKA
BIOLOGI / MOLECULAR TARGETING THERAPYBIOLOGI / MOLECULAR TARGETING THERAPY
BedahBedah
Radikal mastektomiModified radikal mastektomi
- Patey- Madden
Breast conserving surgeryBreast conserving surgery- lumpectomi
segmentectomi- segmentectomi- quadrantectomi
KANKER PAYUDARA METASTASE JAUHKANKER PAYUDARA METASTASE JAUHKANKER PAYUDARA METASTASE JAUHKANKER PAYUDARA METASTASE JAUH
Sifat terapi paliatif
Terapi sistemik merupakan terapi primerp p p p
Terapi loko regional (radiasi dan bedah ) bila diperlukandiperlukan
RadiasiRadiasi
lokal dan regional- lokal dan regional
- utama, tambahan atau kombinasi
t d d t t- tumor, node dan metastase
- eksternal dan internal
RADIASI SEBAGAI ADJUVANRADIASI SEBAGAI ADJUVANSetelah tindakan operasi terbatas (BCT)
Tepi sayatan tidak bebas tumorTepi sayatan tidak bebas tumor
Tumor disentral / medial
KGB (+) dengan ekstensi ekstra kapsularp
HormonalHormonal- bersifat sitemik, utama atau tambahan- George Beatson 1896- De Courmelles, radiasi ovarium- Dresser 1936, ovarium dan metatulang- pemberian: ablasi,additive anti hormonpemberian: ablasi,additive anti hormon- anti hormon: - tamoxifen
- aminogluthemidin- Gn Rh
SitostatikaSitostatika
bersifat sistemik utama atau tambahan- bersifat sistemik, utama atau tambahan,
dan terapi kombinasi
- dapat diberi tunggal atau kombinasi
- kombinasi, CAF, CMF, CAVkombinasi, CAF, CMF, CAV
- performance status scales diperhatikan
il i di ti- penilaian respons diamati
BREAST CANCERBREAST CANCERC l d ti f tC l d ti f tCommonly assessed prognostic factorsCommonly assessed prognostic factors
Nuclear grade
Estrogen/progesterone
Number of positive axillary nodes
Tumor size Estrogen/progesteronereceptors
HER2/neu overexpression
Tumor size
Lymphatic and vascular invasionHER2/neu overexpression
Histologic tumor type
Histologic grade
Slamon DJ. Chemotherapy Foundation. 1999;46.Harris J, et al. Cancer: Principles & Practice of Oncology. 1997;1557-1616.
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