Download - 169658027 on k 17 Breast Cancer Blok Onk

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)


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


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


T3 N1 M0 N2 M0

BREAST CANCER Stage IIIB

Any T N3 M0

N3 = metastasis to ipsilateral internal mammary lymph node(s)


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