Dr Adam Management Neoplasma

8/10/2019 Dr Adam Management Neoplasma

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MANAGEMENTUMUM

NEOPLASMADr.GAPONG SUKOWIRATMOSPB.FINACS

FAK.KEDOKTERAN UKDW YOGYA


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:: ONKOLOGI UMUM

Tumor adalah pertumbuhan jaringanyang mengalami disregulasi tumbuhtidak terbatas, tidak terkoordinasi

dengan jaringan sekitarnya dan tidakberfungsi fisiologis.


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Dibedakan tumor jinak dan tumor ganas

Tumor jinak: tumbuh lebih lambat,ekspansif/mendesak jaringan sekitarnya, dan

bersimpai/berkapsul. Tumor ganas: tumbuh infiltratif jaringan sekitarnya,

tidak berkapsul dan mampu mengadakanmetastasie/penyebaran.

Selain ciri-ciri klinis diperhatikan juga keadaansitologik, histologik dan immuno histokimia.


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Metastase dapat menyebar melalui :infiltrasi, lymphogen, hematogen,saluran yang sudah ada, mis, ureter,bronkhus, perkontinuatum,menempel langsung, inoklulasi,iatrogen/tindakan manipulasi.


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Faktor-faktor yang dapatmempengaruhi pertumbuhan kanker :

1.intrinsik hormon, mis pada prostat,payudara, endometrium (uterus)

2.immunologik ada 2, humoral dan seluler

3.extrinsik mis. Kimia (zat kimia pewarna,asap rokok), sinar radioaktif, sinar gamma,sinar X, virus (virus onlologik) misal :Herpes simpleks, Hepatitis B, Epstein Bar.Faktor yang dapat menyebabkan terjadinyakanker : -karsinogen, tuan rumah(genotype), lingkungan


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Tingkat-tingkat pertumbuhan: prekarsinoma, karsinoma

in situ (stadium dini)Pengobatan kanker :

pembedahan, radiotherapi,

khemotherapi, hormontherapi Immunotherapi.


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:: TUMOR PAYUDARA

Tumor ganas pada payudara amatmenakutkan dan dapat merenggutnyawa wanita bila penanganannyaterlambat.

Kanker payudara paling banyakdikwadran lateral atas, areolar, dan

medial atas. Payudara sebelah kirilebih sering terkena dibanding yangkanan. Usia paling banyak antara 40-

49 (dekade V).


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Etiology

1. Genetika, belum jelas benar tetapiada bukti apabila salah seoranganggota keluarga terkena, anggotayang lain kemungkinan terkena pula.

2. Hormon, pada wanita lebih sering,pada pria rendah (gynekomasti).

3. Makanan, terutama yang berlemak.

4. Radiasi daerah dada.


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Prosedur penegakan diagnose : anamnese,terutama keluhan, perjalanan penyakit,keluhan tambahan, faktor resiko tinggi,

tanda-tanda umum keganasan. Pemeriksaan fisik, adanya benjolan, sakit

kalau dipegang, keras atau lunak, batastegas dengan daerah sekitar atau tidak,perubahan wama pada kulit, ada ulcerasi

dsb.


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Ukuran tumor, mobilitas tumor terhadapkulit, retraksi papila, kedalaman, kulitpayudara mengkerut seperti jeruk (Peau de

Orange) Pemeriksaan aksila, untuk mengetahui

adanya metastase, supraklavikula,pemeriksaan organ lain seperti hepar,

paru-paru Iien, tulang-tulang utama (bonescanning). Pemeriksaan penunjang(mammografi), pemeriksaan histopatologik.


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Faktor resiko tinggi

umur > 30 tahun anak pertama lahir waktu usia ibu >

35 tahun -tidak kawin

menarche < 12 tahun menopause terlambat > 55 tahun


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TUMOR PAYUDARA YANGINOPERABLE

terdapat edema kulit yangmeluas pada payudara

tumor payudara jenismastitis karsinomatosadengan metastase jauhedema lengan

aksila sudah ada benjolanbesar yang terfixir.


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Diagnose banding tumor ganaspayudara :

1.Fibroadenoma mamma (FAM)

2.Mammaria displasia

3.Sistosarcoma filoides

4.Galactocele

5.Mastitis


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Gambaran klinis yangmencurigakan keganasan

1.Paget's disease, ulcerasi di areola mama,tidak sembuh-sembuh dengan antibiotikperlu dicurigai keganasan dan perlu

diangkat dan di diperiksa PA nya.2.Nipple dischage : berwarna kemerahan

seperti darah disertai perabaan sepertitumor.

80 % intraductal papiloma,

20 % intraductal karsinoma.


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Stadium : dengan sistem TNM : Tbesarnya tumor, N adanya nodulelymphatic

M adanya metastase, baik ke hepar,paru atau tulang. Stadium untuk menentukan

therapynya.

Stadium I To No Mo Stadium II T 1No Mo Stadium III T 2 Ni Mo Stadium IV T 3 N 2 M 1


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KANKER PAYUDARA

Faktor resiko Umur Riwayat keluarga

Peningkatan paparan estrogen

Menstruasi awal

Menopause lambat

Hormone replacement therapy

Tidak mempunyai anak

Kehamilan pertama > 30

Diet and lifestyle (obesitas, Konsumsi alkohol

yang berlebihan) Paparan radiasi sebelum usia 40

Tumor jinak dengan hiperplasia atipik

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.


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BREAST CANCERBreast inspection

Skin dimpling


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BREAST CANCERBreast palpation


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BREAST CANCERRegional node assessment


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Signs and symptoms atpresentation

Mass or pain

in the axilla

Palpable mass

Thickening

Pain

Nipple discharge

Nipple retraction

Edema or erythema

of the skin


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FNAB

In

Back and

Forth

EndSuction

Suction

Out


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BREAST CANCERLiver metastasis


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Keluhan bahwa diperlukan pemeriksaanuntuk metastasis jauh:

Sakit skeletal

Keluhan saluran pernafasan

Sakit kepala

Keluhan tidak enak pada abdomen bagian atas

Malaise umum

Hilang apetite, merasa sakit-sakitan, nausea, vomitus

TNM stage grouping


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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 M0T3 N1, N2 M0

Stage IIIB T4 N0,1,2 M0

Stage IIIC 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 theAJCCCancer Staging Manual, 5th edition (1997)

published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.


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BREAST CANCERStage IV

M1 = distant metastasis (including metastases to ipsilateral supraclavicular,

cervical, or contralateral internal mammary lymph nodes)

Any T any N M1

M1

Advanced

In-operable


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BREAST CANCERStage IIIC

Any T N3 M0

N3 = metastasis to ipsilateral internal mammary lymph node(s)M0 = no distant metastasis

Tumor of any size

with direct extensionto chest wall or skin

T4d = inflammatorycarcinoma

T4

N3

Local Advanced

In-operable


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BREAST CANCERStage IIIB

N3 = metastasis to ipsilateral internal mammary lymph node(s)M0 = no distant metastasis

Tumor of any size

with direct extensionto chest wall or skin

T4d = inflammatorycarcinoma

T4 N0,1,2 M0

T4

Local Advanced

In-operable


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BREAST CANCERStage IIIA T0

T1T2

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 M0N2 M0

OPERABLE


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BREAST CANCERStage IIB

T3 N0 M0

N1 = metastasis to movable ipsilateral axillary lymph node(s) (p) N1a, N1b


T > 5 cm

T2 N1 M0

T3

OPERABLE


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BREAST CANCERStage IIA

T2 N0 M0

N1 = metastasis to movable ipsilateral axillary lymph node(s)


2 cm < T < 5 cm

No evidenceof tumor

T0

T0

T1N1 M0}

T2

OPERABLE


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BREAST CANCERStage 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


OPERABLE


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Operabilitas Ca Mammae

Stage 0 Tis N0 M0 Stage I T1* N0 M0 Stage IIA T0 N1 M0

T1* N1** M0T2 N0 M0

Stage IIB T2 N1 M0T3 N0 M0

Stage IIIA T0, T1,* T2 N2 M0T3 N1, N2 M0

Stage IIIB T4 N0,1,2 M0Stage IIIC Any T N3 M0 Stage IV Any T Any N M1


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Tindakan

Bila staging sudah dikerjakan, tindakan

direncanakan didasarkan atas :

Stadium TNM

Umur pasien

Status menopauseKeadaan umum pasien


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STADIUM LANJUTIn-operable

Ada 2: rekurensi loko-regionalre-eksisi(bila technically operable) dilanjutkanradiasi dan khemo adjuvan; metastasejauhterapi hormonal bila ER-PR (+)

Terapi mempertahankan kulaitas hidupnyaman, tak mengharapkan kuratif lagi

Khemo adjuvan tak berrespon bisa gantisecond/third line regimenhigh dose, bila

masih gagalstadium terminal.


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STADIUM LANJUT LOKALIn-operable

Terapi Neo-adjuvan khemobila

stadium membaik dapat diusulkanoperasi mastektomi.

Pascaoperasiradiasi dan

khemoterapi


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JENIS OPERASI

Simple / Total mastectomy :

Seluruh kel. Payudara .

Batas : cranial : subclavicula ; caudal : arcuscostae.

Medial : tepi sternum ; lateral : m. latissimus dorsi.

Radical Mastectomy :

Total mastectomy + diseksi aksilla Level I-II-III

Modified Radical Mastectomy.

Patey

Auchincloss

Madden


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INDIKASI OPERASI MRM

Kanker Payudara Operabel :

T0,TIS,T1,T2,T3 N0 , N1 M0.

PAGET

S DISEASE OF THE NIPPLE.


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Treatment

Pada stadium I dan II dapatdilakukan terapi kuratif

Untuk stadium II dan IV dilakukanterapi paliatif diikuti khemoterapi danhormon terapi


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Therapy Ektirpasi sampai daerah sekitarbebas tumor.Untuk menjaga agar tidak relapsdilakukan radiasi dan khemotherapi.

Sedang dikembangkan hormon therapyHormon terapy terutama berupaestrogen dan progesteron.Khemoterapy : berupa CMF :Cyclofosfamid Methotrexate Fluouracil


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Pencegahan : SADARIpemeriksaan dirisendiri.

Untuk mendapatkangejala sedini meungkin.


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Prognosis:Std I harapan usia ant. 5 -10 thn 80-90%

II 50-70%

III 11-20 %IV 0%

Hormonal therapy merupakan terapi utama padastadium IV disamping khemoterapi. Dibedakan tigagolongan penderita menurut status menstruasi,yaitu premenopause, 1-5 tahun menopause, post

menopause.


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Mammograf i


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Mammografi


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Mammografi


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Mammografi


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Mammografi


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Breast Self Exam inat ion

( BSE )


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Anatomi :

B S lf E i i (BSE)


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Breast Self Examination (BSE)

Step 1

B t S lf E i t i (BSE)


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Step 2



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Step 3

Breast Self Exam ination (BSE)



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Step 4




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Step 5

Breast Self Exam ination (BSE)

B t S lf E i ti (BSE)


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Use the pads of your fingers.

Feel your breast in

overlapping areas

Feel the tissue by pressing

your fingers in small,

overlapping areas aboutthe size of a dime.

To make sure that

you cover your entire breast,

take your time and follow

a definite pattern:

circles, lines, or wedges.

Start with your left breast,

then repeat the exam

on your right breast




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Circles




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Lines




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Wedges




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Step 6




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Step 8



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Clinical B reas t Exam inat ion

( CBE )


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Clinical B reast Exam ination ( CBE )

Clinical Breast Exam ination ( CBE )


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Cli i l B t E i t i ( CBE )


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Clinical Br east Exam ination ( CBE )


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Clinical Br east Exam ination ( CBE )


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Mastektom i Prof i laksi

Mastektomi Profilaksi


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JENIS INSISI :

1. Halsted


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JENIS INSISI :

2. Stewart

JENIS INSISI


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JENIS INSISI :

3. Orr

JENIS INSISI :


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JENIS INSISI :

4. Lazy S

COLORECTAL CARCINOMA


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COLORECTAL CARCINOMA

Age : - 6 th decade of life

- trend for younger age

Sex :

-colon carcinoma :

female more than male

- rectal carcinoma :

male more than female


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Macroscopic features

: - ulcerative

- protuberant

- annuler stenosing

- polypoidal Microscopic features :

more than 90% is

adenocarcinoma


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Adeno Ca Colon


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SmallIntestine

Tumour

Differentiation : - well differentiated


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- moderatelly differentiated

- undifferentiated

- signet ring cell carcinoma

- mucoid carcinoma

Distribution : - rectum : 50%

- sigmoid colon : 20 %- cecum & ascending colon : 18%

- transverse colon : 8%

- descending colon : 6%

- synchronous carcinoma : 5%

- metachronous carcinoma : 3%


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Presdisposing factor :

- low fibers diet

- adenomatous lesions

- familial adenoma polyposis- ulcerative colitis

- granulomatous colitis

S di


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Spreading

Colon carcinoma1. Direct : circular, longitudinal, and penetrating

the well

2. Lymphatic : epicolic, paracolic, intermediate,and paraaortic nodes.

3. Blood spread : portal, lumber, and vertebralvein.

4. Transperitoneal / gravitational spread

5. Intra luminar spread

6. Along nerve fibers


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Rectal carcinoma :

1. Direct : longitudinal, penetrating the wall

2. Lympatic : haemorrhoidal nodes

hypogastric nodesinguinal nodes

3. Blood spread : portal vein, hypogastric vein

4. Along nerve fibers


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Complications

- obstruction- perforation : - the malignancy it self

- infiltrating to the serosa

- the cecum due to large bowel obstruction

- fistula formation : - external- internal

- haemorrhage

St i


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Staging

Dukes A : mucosal and submucosal layer

B : infiltrating to the serosaC : involve regional lymph nodes

D : distance metastasis

Dukes Classification


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Symptom


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y p1. Carcinoma of the right colon :

- abdominal pain or discomfort

- weight loss and anaemia

- bowel obstruction

- mass in the right iliac fossa

2. Carcinoma of the left colon :

- alterations of bowel habit- large bowel obstruction (colicky pain of lower abdominal)

3. Carcinoma of the rectum :

- anal bleeding

- alteration of bowel habit

- tenesmus- feeling of incomplete defecation

Signs


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Signs1. Right colon carcinoma

- tenderness in the right iliac fossa- palpable mass in the right iliac fossa

- occult blood in the faces

2. Left colon carcinoma

- palpable tumor in the left iliac fossa is unusual

- abdominal distention

3. Rectal carcinoma

- about 75% rectal carcinoma palpable on rectal- digital examination


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Endoscopic examination- anoscopy, rectoscopy, sygmoidoscopi

and colonoscopy

- cystoscopyOthers

- USG, CT scan, MRI (to search distance metastasis)


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Treatment

Three modality of treatment :

1. Surgical treatment ( cutting )

2. Radiation treatment ( burning )

3. Chemotherapy ( poisoning )

1. Surgical treatment

A. resectable


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- right hemicolectomy

- extended right hemicolectomy

- transverse colon resection

- left hemicolectomy

- sigmoid colon resection

- for rectal carcinoma :

- anterior resection

- low anterior resection

- abdomino perineal resection (miles op)

B. non resectable

- ileotransversostomy- transversocolostomy

- sigmoidostomy


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2. Irradiation treatment :

- pre operative irradiation- post operative irradiation

- sandwich iradiation

3. Chemotherapy :

- 5 fluoro uracil

- 5 fu + levamizol- 5 fu + leucoforine

Prognosis


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Depend on :

- site

- extent

- grade of malignancy

5 years survival rate : Dukes A : 80%

B : 60%C : 30%

D : -

Ilustrasi Kasus Tumor


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PemeriksaanLimfonodi


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PemeriksaanLimfonodi


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Carsinoma

Lidah


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Tumor Kulit


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Dr Adam Management Neoplasma

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