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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