DEFENISIJINAKTUMORGANAS/KANKERTUMBUH DI SELURUH TUBUH

Leher rahim (Serviks)PayudaraIndung telur (Ovarium)

KELAINAN BAWAANTUMORDISPLASIAKELEBIHAN PAYUDARAKELEBIHAN PUTING SUSU

KISTAFIBROKISTIKFIBROADENOSISJINAKGANAS

INFEKSIAKUTSUBAKUTKRONISHIPERTROFINEONATUSWANITA DEWASAPRIA DEWASAKELAINAN YANG BERKAITAN DENGAN MELAHIRKAN DAN MENYUSUI GALAKTOKELINFEKSIGALAKTORHEA

Insidens :Urutan I di Eropa Barat & AS (32%)Urutan II di Indonesia (12.6%)

Stadium PenangananStadium Dini > 75% di AS & JepangStadium Lanjut > 60% di Indonesia

Terbanyak pada wanita Peringkat ke 2 setelah kanker rahim 126 orang/100.000 penduduk Di US 59.000 kasus baru / tahun Di Indonesia 177.000 kasus baru / tahun 80 % stadium lanjut (III & IV)

MULTIFAKTOR :Genetik :KeturunanJenis kelamin LingkunganLife style (Gaya hidup)HormonRadiasi

aGEFamily history of breast cancerPrior personal history of breast cancerIncreased estrogen exposureEarly menarcheLate menopauseHormone replacement therapy/oral contraceptivesNulliparity1st pregnancy after age 30Diet and lifestyle (obesity, excessive alcohol consumption)Radiation exposure before age 40Prior benign or premalignant breast changesIn situ cancerAtypical hyperplasiaRadial scarHenderson 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.

Mass or pain in the axilla

Palpable massThickeningPain

Nipple dischargeNipple retraction

Edema or erythema of the skin

LOKAL - benjolan 36% - benjolan dengan sakit 33% - sakit 17,5 % - sekret putting 5% - tarikan putting 3%

LOKAL - riwayat keluarga 3% - kelainan bentuk payudara 1% - bengkak / radang 1% - eczema 0,5%

SISTEMIK - batuk, sesak nafas , efusi pleura - sakit pada tulang dan patah tulang - ganguan neurologi - hepatomegali, ikterus, sakit perut

IPTEKDOKDeteksi DiniDiagnostikTerapeutikPencegahan

Kosmetik & EstetikStadium Dini : Less Radical (BCT/BCS,SLNB)

BiayaStadium Lanjut >> (Multimodalitas)

Pencegahan / Pencegahan Primer

Pencegahan Sekunder / Deteksi Dini (Skrining)

Diagnosis

Terapi

Rehabilitasi

Stage 0TisN0M0Stage IT1N0M0Stage IIA T0N1M0T1N1M0T2N0M0Stage IIB T2N1M0T3 N0M0Stage IIIAT0N2M0T1N2M0T2N2M0T3N1M0T3N2M0Stage IIIBT4N0M0T4N1M0T4N2M0Stage IIICAny TN3M0Stage IVAny TAny N M1

TXPrimary tumor cannot be assessedT0No evidence of primary tumorTisCarcinoma in situ: Intraductal carcinoma, lobular carcinoma in situ, or Pagets disease of the nipple with no tumorT1Tumor 2 cm or less in greatest dimension T1mic Microinvasion more than 0.1 cm or less in greatest dimensionT1aTumor more than 0.1 cm but not more than 0.5 cm in greatest dimensionT1bTumor more than 0.5 cm but not more than 1 cm in greatest dimensionT1cTumor more than 1 cm but not more than 2 cm in greatest dimensionT2Tumor more than 2 cm but not more than 5 cm in greatest dimensionT3Tumor more than 5 cm in greatest dimensionT4Tumor of any size with direct extension to (a) chest wall or (b) skin, only as described belowT4aExtension to chest wallT4bEdema (including peau dorange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breastT4cBoth (T4a and T4b)T4dInflammatory carcinomaUsed 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.

1. STADIUM DINI (I dan II) Keluhan sedikit/ tidak ada Tidak teraba/ada tumor kecil terbatas pada payudara Kelenjar limfe regional tidak membesarTidak ada penyebaran organ jauh

Keluhan: - benjolan payudara lebih besar, - ulkus - peau d orange dsb

Tumor pada payudara umumnya - tidak nyeri - melekat pada kulit - ulkus, berbau - Kanker telah menyebar ke kelenjar limfe regional di ketiak 2. STADIUM LANJUT LOKAL (III)

Keluhan stadium lanjut :- batuk-batuk - nyeri tulang - lemas - nafsu makan kurang, dsb.Penyebaran ke kelenjar limfe regionalPenyebaran ke organ jauh, misalnya di tulang, paru, hati, dan otak.

3. STADIUM SANGAT LANJUT (IV)

Kanker mamma

Invasi pembuluh darah

pembuluh limfe

Metastase kelenjar limfe

Transportasi

Sirkulasi

Implementasi

Ekstravasasi

Metastase dari metastase

Metastase paru

Metastase otak

Metastase tulang

Proliferasi

Invasi

Angiogenesis

PERJALANAN ALAMIAH KANKER PAYUDARA

RIGHTUpper inner

Nipple

Central portion

Lower innerUpper outer

Axillary tail

Lower outer

Supraclavicular

Subclavicular

Distal (upper)axillary

Central (middle)axillary

Proximal (lower)axillaryMediastinal

Internal mammary

Interpectoral(Rotters)

Skin

Liver

Bone

PleuraLungLymph nodesBrain

TAHUN SEJAK TIMBULNYA GEJALA

Tahanhidup median2,7 th.

Grafik tahan hidup penderita kanker mamma dihitung mulai timbulnya gejala dibandingkan dengan populasi normal ( Bloom et al. BMJ 2: 213-221, 1962 ).

Ketahanan hidup populasi normal

Ketahanan hidup penderita kanker mamma

% TAHAN HIDUP

*

Karsinoma leher rahimPap-tes2.Kolposkopi3.Jodium test

Kanker payudara1. klinis2. Mammografi/USG3. Histopatologi

SKRINING KANKER

Tumor borok

Uterus

Tuba

Tuba

Cerviks

Ovarium

Vagina

Vulva

*

Menentukan tanda dini KPD Diagnostik Didapat KPD Stadium Dini Mortalitas & MorbiditasHarapan hidup KPD

Stadium5 years (%)10 years (%)I9080II7050III2011,2IV00

1.Sangat sulit2. Kebiasaan hidup sehat3. Mencegah bahan-bahan karsinogenik4. Menggunakan obat-obatanPRIMER

METODE SKRININGPemeriksaan klinis : SADARIDokter/Petugas Medis.Pemeriksaan imaging : MamografiSetiap tahun : wanita > 50 tahunPemeriksaan dasar : 35- 40 tahunWanita dengan riwayat keluarga Pada usia 40-50 tahun antara : 1- 3tahun Ultrasonografi : pada usia muda. e. Pemeriksaan petanda tumor dari serum

Breast self-examinationExaminationMammographythe by physicianonly modality shown to decrease mortality

SaDaRi (Breast Self Examination)Disampaikan Dimengerti Dilakukan secara reguler (Brosur)

SARANIS (Cinical Breast Examination) Kemampuan Klinisi dalam menemukan tanda dini dan upaya diagnostik cepat dan tepat.Tumor / Skin / Nipple Areola Complex / L. Node / Distant Meta

*

PEMERIKSAAN PAYUDARA SENDIRI

1. Lengan menggantung disisi tubuh

1. Inspeksi payudara dengan berdiri dimuka kaca

2. Lengan diangkat disamping kepala

2. Palpasi payudara dengan tiduran dan punggung diganjal bantal

3. Palpasi payudara kiri dengan tangan kanan, dilihat dari kanan

4. Palpasi payudara kiri dengan tangan kanan, dilihat dari kiri

*Pemeriksaan payudara sendiriCara sirkulairCara radiair

PEMERIKSAAN PAYUDARA SENDIRI1.Dianjurkan pada setiap wanita dewasa dan tua secara teratur, sebulan sekali dalam waktu seminggu setelah selesai menstruasi 2. Pemeriksaan dikerjakan dengan: a). Inspeksi (melihat) payudara dimuka cermin b). Palpasi (meraba) payudara waktu berdiri dan berbaring c). Memijat puting susu dengan jari3. Pemeriksaan dikerjakan dengan menggunakan telapak ujung-ujung jari tangan ke-2 sampai 5. 4. Pemeriksaan dengan palpasi dikerjakan secara sirkulair atau radiair

Skin dimpling

Reduces mortality by 26% in women aged 50-74Supports view that early diagnosis and treatment can prevent metastasisACS recommends1st screening mammography by age 40Mammography every 1 to 2 years between the ages of 40 and 49Mammography annually thereafterHarris 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.

Earlier diagnosis in asymptomatic individualsReduction of mortality due to detection at earlier stagePDQ: Screening for breast cancer for health professionals: http://Cancernetnci.nih.gov/. Accessed November 28, 1999.

Annual mammogram, beginning 5 yrs before age of youngest affected relative at time of diagnosisHigh familial riskBRCA 1/2-positiveTripathy D, Henderson IC. Current Cancer Therapeutics. 3rd ed. 1999;123-129.

Mammografi & Ultrasonografi

*Pemeriksaan Mammografi & UsG

Excisional biopsy (usually outpatient)Tumor size and histologic diagnosisCore-cutting needle biopsy (in-office)Histologic diagnosisFine-needle aspiration (in-office)Cytologic diagnosisHarris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.

(Fine Needle Aspiration Biopsy) Kemampuan dokter umum / spesialis terkait, melakukan pengambilan spesimen biosi

Kemampuan patolog dalam menilai sitopatologi (kasus >>)

BAJAH(Biopsi Aspirasi jarum Halus

TINDAKAN POLIKLINIK LOKAL ANASTHESI / TANPA JAHITANHASIL HISTOPATOLOGI (DEFINITIF)

1.TUJUAN PENGOBATAN 1). Kuratif: untuk menyembuhkan 2). Paliatif : untuk memperbaiki kualitas hidup dan mengurangi keluhan 2. CARA PENGOBATAN 1). Operasi 2). Kemoterapi 3). Radioterapi 4). Hormonal terapi 5). Targeting terapi 6). KombinasiPENGOBATAN KANKER PAYUDARA

*

*

*

*7. Breast Cancer: Risk FactorsIn addition to female gender, several risk factors for developing breast cancer have been identified in epidemiologic studies. However, approximately half of all cases of breast cancer occur in women with no identifiable risk factors beyond being female and aging. *17. Breast Cancer: Signs and Symptoms at PresentationAlthough the use of mammography is increasing, more than 80% of all breast cancers are still diagnosed as a result of symptoms, most often a painless mass. However, as many as 10% of patients present with breast pain and no mass. Less common symptoms include nipple discharge, nipple erosion or ulceration, diffuse erythema of the breast, axillary adenopathy, and symptoms associated with distant metastases. ****34. Tumor definitionsThis slide further delineates the breakdown in staging of the primary tumor. *30. Breast Cancer: Anatomical SiteThe pathologic status of axillary nodes has more impact on relapse and ultimate survival than location of the primary tumor.

*31. Breast Cancer: Spread to Lymph NodesAxillary lymph nodes are most commonly involved in breast cancer. Internal mammary nodes can be involved if the tumor affects the internal part of the breast. Supraclavicular metastasis is rare unless axillary or internal mammary metastases are present.*32. Breast Cancer: Sites of Distant MetastasesThe most common initial sites of metastases are the skin and soft tissues of the chest wall and axilla or supraclavicular area (local-regional recurrence) and bone. The next most common sites of the first metastatic presentation are lung and liver; the central nervous system is an uncommon site of first metastasis. *8. Breast Cancer: ScreeningACS recommendations for screening and early detection of breast cancer for asymptomatic women with average risk include breast self-examination monthly for all women beginning at age 20; clinical breast exam every 3 years for women age 20 to 39 and yearly thereafter; and a mammography every 1 to 2 years between the ages of 40 and 49 and yearly thereafter. *11. Breast Cancer: Breast InspectionPositions in which the breasts should be inspected are illustrated here. Skin dimpling, nipple inversion, or architectural distortion can signify a cancer deeper within the breast and may be evident if the patient contracts the pectoralis muscles while pressing the palms together above her head. The breast should be gently palpated while the patient is sitting. *12. Breast Cancer: Breast PalpationBreast tissue should be examined with the hand held flat while the patient is lying flat with arms above her head. The breast should be systematically evaluated using the palmar surfaces of the second, third, and fourth fingers, rather than the fingertips. Evaluation of the tail of the breast, which extends high in the axilla, is especially important. *13. Breast Cancer: Regional Node AssessmentClinical assessment of axillary nodes is often inaccurate. Palpable nodes can be identified in up to 30% of patients with no clinically significant breast or other disease, while up to 40% of patients with breast cancer who have clinically normal axillary nodes actually have axillary nodal metastases. *14. Breast Cancer: Screening MammographyScreening mammography has been shown to reduce breast cancer mortality among women aged 50 to 74 by approximately 26%. The slide shows the American Cancer Society guidelines for screening mammography. *9. Breast Cancer: Goals of Mammography ScreeningThe use of systematic screening procedures is an important strategy to improve outcomes in breast cancer. Earlier detection, particularly when disease is detected before it is metastatic, can allow more effective treatment to be administered. Randomized trials indicate a reduction in mortality of about 17% for women 40 to 49 years of age occurring 15 years after the start of screening and a 25% to 30% reduction in women 50 to 69 years of age 10 to 12 years after screening. *10. Breast Cancer: Screening (High-Risk)Women with high familial risk for developing breast cancer or BRCA 1/2-positive patients should have an annual mammogram starting 5 years before the age when the youngest relative with breast cancer was diagnosed. *24. Breast Cancer: Biopsy Techniques for Palpable and Mammographically Detected MassesSuspicious palpable and mammographically detected breast lesions are diagnosed by excisional biopsy, core-cutting needle biopsy, and fine-needle aspiration (FNA). The last two techniques are in-office procedures, while excisional biopsy is usually an outpatient procedure performed with local anesthesia. The biopsy technique depends on the size and characteristics of the mass.