Download 2.3.5.4 tumor jinak dan ganas payudara

Breast Disease
DR. Dr. Wirsma Arif Harahap SpB(K)Onk
Konsultan Bedah Onkologi
Breast Disease
• Congenital
• Inflamation
• Metabolic / Hormonal
• Neoplasm
• Trauma
Breast Disease
• Congenital
• Inflamation
• Metabolic / Hormonal
• Neoplasm
• Trauma
The Bad News
• 1 diantara 8 wanita yang mencapai usia
85 tahun akan menderita KPD.
• Setiap 3 menit seorang wanita di
diagnosa menderita KPD.
• Setiap 13 menit 1 orang wanita meninggal
akibat KPD.
• Penyebab kematian pertama akibat
kanker pada wanita.
• Penyebab kematian utama wanita pada
usia 40 – 55 tahun
The Good News
• 80% benjolan pd payudara  jinak..
• 90% KPD stadium dini dapat sembuh.
• < 5% KPD terjadi pada usia <35 tahun.
• Lebih dari 2 juta pasien lolos dari KPD.
Breast Complaints
• Pain
• Mass
• Skin or Nipple
Changes
• Nipple Discharge
Diagnosis and Treatment of Breast
Complaints
• Most important is to rule out
malignancy
• Significance of a finding is greatest in
a high-risk patient
• Balance between reassurance and
exhausting all diagnostic options
• Treatment should not be worse than
the disease
Breast Complaints
• Pain
• Mass
• Skin or Nipple
Changes
• Nipple Discharge
Breast Neoplasm
1. Benign
1. Epitelial
2. Mesenchimal
3. Combine
2. Malignant
1. Primary
1. Epithelial
2. Mesenchimal
3. Combine
4. Others
2. Metastatic
1. Oposite breast
2. Other site
Breast Disease
 Benign
 Nonproliferative




Fibrocystic changes
Simple cysts
Lactational adenoma
Fibroadenoma
 Hyperplasia without
atypia
 Epithelial hyperplasia
 Sclerosing adenosis
 Intraductal papillomas
 Hyperplasia with atypia
 LCIS
 DCIS
 Malignant







Ductal carcinoma
Lobular carcinoma
Tubular carcinoma
Mucinous carcinoma
Micropapillary carcinoma
Metaplastic carcinoma
Inflammatory carcinoma
Benign Breast Tumor
•
•
•
•
Young age >>
Slow growing
Mass > pain
Part of ANDI (abberation normal
development and involution)
• Fibroadenoma >>
• Therapy :
– Wait and see
– Excision
Phylodes Tumor
•
•
•
•
•
Usually big tumor
Venaectasi
Wrong term : Cystosarcoma
Mesenchymal origin
Benign >> Malignant
– Benign : Phyllodes Tumor
– Malignant : Malignant Phyllodes Tumor
• High reccurence
• Treatment : wide excision to
mastectomy
BREAST CANCER IN THE WORLD
 1.15 million new cases
 Incidence increasing in most
countries
 470 000 deaths
 Half of the global burden in low- and
medium-resourced countries
Trends since 1950
in age-standardized
death rates
comparing breast
and selected other
types of cancer,
among women in
the USA
EBCTCG, Lancet, 2010
Penyebab KPD
• Mutasi gen..... ?
• Faktor risiko  mutasi gen 
pertumbuhan jaringan yang tidak
terkontrol  kanker
Periode laten, bisa lebih dari 20 th
Unspecialized
Cell
Initiated
Cell
Initiation
•Mutation
•Cancer Gene
Pre
kanker
Promotion
•Proliferation
•Independence
Kanker
Progression
•Mutation
•Invade & Spread
Stadium Terjadinya Kanker
Factors determining risk of
developing Breast Cancer
20
Breast Cancer Risk Factors
unalterable factors
Age
Family/Personal
History
GENDER - All
women are
at risk
Race
Treatment with
DES
Radiation
Reproductive
History
Menstrual
History
Genetic
Factors
Breast Cancer Risk Factors
that can be controlled
Obesity
All
women are
at risk
Exercise
Breastfeeding
Alcohol
Not having
children
Birth Control
Pills
Hormone
Replacement
Therapy
Family history as a risk factor-
Hereditary Breast and Ovarian
Cancer
15%-20%
5%–10%
Breast Cancer
5%–10%
Ovarian Cancer
Sporadic
Family clusters
Hereditary
Causes of Hereditary
Susceptibility to Breast Cancer
5 to 10% of breast cancers can be attributed to inherited factors
Gene
Contribution to
Hereditary Breast
Cancer
BRCA1
20%–40%
BRCA2
10%–30%
TP53
<1%
PTEN
<1%
Undiscovered genes
30%–70%
* Li-Fraumeni Syndrome, abnormal TP53 gene on
chromosome 17p, associated with premenopausal
breast cancer, childhood sarcomas, brain tumors,
leukemia, and adrenocortical adenomas
*Cowden’s Syndrome, abnormal PTEN tumor
suppressor gene on chromosome 10 associated
with premenopausal breast cancers,
gastrointestinal malignancies, and benign and
malignant
Features That Indicate Increased
Likelihood of Having BRCA Mutations
• Multiple cases of early onset breast
cancer
• Ovarian cancer (with family history
of breast or ovarian cancer)
• Breast and ovarian cancer in the
same woman
• Bilateral breast cancer
• Ashkenazi Jewish heritage
• Male breast cancer
BRCA1-Associated Cancers:
Lifetime Risk
Breast cancer 50%-85%
(often early age at onset, less than 40
years)
Second primary breast cancer 40%-60%
Ovarian cancer 15%-45%
Possible increased risk of other
cancers (e.g. prostate, colon)
BRCA2-Associated Cancers:
Lifetime Risk
breast cancer
(50%-85%)
male breast cancer
(6%)
ovarian cancer
(10%-20%)
Increased risk of prostate, laryngeal, and
pancreatic cancers (magnitude unknown)
Signs and Symptoms
Most common:
lump or
thickening in
breast. Often
painless
Discharge
or
bleeding
Change in size
or contours of
breast
Redness or pitting
of skin over the
breast, like the
skin of an orange
Change in color
or appearance
of areola
29
Gejala KPD Dini
Dini :
• Benjolan di payudara
• Teraba Keras
• Tidak terasa nyeri
Gejala KPD Stadium Lanjut
• Benjolan yang besar
• Tukak
• Benjolan di ketiak
• Gejala penyebaran
Diagnosis KPD
• Anamnesis
• Pemeriksaan Fisik
• Pemeriksaan Tambahan
– Pencitraan
• USG mamae
• Mamografi
– Patologi
• Sitologi / FNAB
• Histopatologi
• Imunohistokimia
Anamnesis
• Lokal
– Benjolan : kapan ? cepat ? nyeri ?
– Puting : discharge ? (darah, serous dst)
tertarik, berubah posisi
– Kulit : kulit jeruk, berubah warna,
tarikan, tukak
• Regional : apakah ada benjolan ?
– Payudara kontra lateral
– Aksila
– Supraclavikula
• Sistemik
– Metastase hati : dispepsia  ikterik
– Metastase tulang : nyeri tulang terutama
pada malam hari
– Metastase paru :
• Batuk batuk kering tidak sembuh > 3 minggu
• Sesak nafas : lanjut
• Faktor Risiko
Evaluation: Physical Exam
 Clinical Breast Exam:
 Inspect (relaxed, arms raised, hands on hips)
 Breast symmetry
 Skin changes (dimpling, retraction, edema,
ulceration)
 Nipples (symmetry, inversion/retraction, discharge)
 Palapation (breasts, axillae, entire chest wall)
 Pain
 Masses
 Regional lymph nodes (Axillary and Supraclavicular)
 Documentation
 “Clock” system
 Location of concern and abnormality
 Distance from areola
 Size of mass
Physical
 Evaluation:
Clinical Breast Exam:
Position the patient in the
direction of palpation for the
CBE.
Exam
Use pads of the index,
third, and fourth fingers
(inset) make small circular
motions
Make three circles with the finger
pads, increasing the level of
pressure (subcutaneous, midlevel, and down to the chest wall)
with each circle
Benign vs. Malignant
Chief Complaint
Breast mass
Nipple discharge
Benign Characteristics
Malignant Characteristics
Multiple lesions
Single lesion
“Rubbery”
Hard
Mobile
Immovable
Well circumscribed border
Irregular borders
Bilateral
Unilateral
Multiductal
Uniductal
Milky
Bloody, Clear, or Colored
Spontaneous
Persistent
Skin changes
Retraction
Dimpling
Thickening
Staging : TNM = AJCC 2012
KPD Dini : Stage 1 dan 2
KPD Lanjut :
- Lokal : Stage 3A dan 3B
- Jauh : Stage 4
Deteksi dini merupakan
proteksi terbaik
terhadap KPD
Deteksi Dini
1. Pemeriksaan Klinis Payudara
2. Mammogram
3. Sadari tiap bulan
Deteksi Dini
1. Pemeriksaan Klinis Payudara
2. Mammogram
3. Sadari tiap bulan
Pemeriksaan Klinis Payudara
1. Perawat terlatih
2. Dokter Umum
3. Dokter Bedah
4. Dokter Bedah Tumor
Pemeriksaan Klinis Payudara
Usia ... thn
Frekuensi
20 – 39
Setiap 3 tahun
40
Setiap 1 tahun
Deteksi Dini
1. Pemeriksaan Klinis Payudara
2. Mammogram
3. Sadari tiap bulan
Deteksi Dini
1. Pemeriksaan Klinis Payudara
2. Mammogram
3. Sadari tiap bulan
MAMMOGRAHY RESULTS
Mammography Equipment
50
SCREENING MAMMOGRAM
Tanda Ganas Pada Mamogram
Primer :
1.Densitas tinggi pada tumor
2.Batas tidak teratur
3.Translusen disekitar tumor
4.Stelata
5.Mikrokalsifikasi
6.Ukuran klinis lebih besar dari radiologis
Tanda Ganas Pada Mamogram
Sekunder :
1. Retraksi kulit
2. Vaskularisasi bertambah
3. Perubahan posisi putting
4. KGB aksila +
5. Arsitektur payudara berubah
Calcification
• Macrocalcifications
– Large white dots
– Almost always noncancerous and
require no further follow-up.
• Microcalcifications
– Very fine white specks
– Usually noncancerous but can
sometimes be a sign of cancer.
– Size, shape and pattern
Breast Imaging Reporting and Data
System (BI-RADS)
Category Definition
0
1
2
3
4
5
Action
Incomplete, possible Additional
finding
imaging
Negative
Routine
screening
Benign findings
Routine
screening
Probably benign
6 mo follow-up
findings
Suspicious
Biopsy
abnormality
Highly suggestive of Biopsy, action
malignancy
as indicated
PPVmalignancy
15%
<1%
<1%
2%
30-45%
93%
Deteksi Dini
1. Pemeriksaan Klinis Payudara
2. Mammogram
3. Sadari tiap bulan
Deteksi Dini
1. Pemeriksaan Klinis Payudara
2. Mammogram
3. Sadari tiap bulan
SELF BREAST EXAMINATION
=
SADARI
K
A
P
A
N
?
• Sekali sebulan dimulai pada usia
20 tahun.
• Pada hari ke 10-15 dari hari
pertama haid terakhir.
SADARI
2 Bagian SADARI :
–Looking
–Feeling
LOOKING
Benjolan
• Benjolan atau
penebalan kulit di
payudara atau di ketiak.
• Benjolan baru harus
diperiksa ulang pada
periode berikutnya.
Perubahan Warna Kulit, Ukuran dan
Tekstur
• Setiap perubahan
ukuran, bentuk
atau simetri
• Setiap penebalan /
pembengkakan
pada payudara.
Skin Dimpling
• Lesung ataupun
tarikan ke dalam
dari kulit atau
puting.
Perubahan Pada Puting
• Puting bewarna
merah atau bersisik.
• Nyeri pada puting.
• Puting dengan
retraksi, melipat
kedalam, perbahan
bentuk dan arah.
Nipple Discharge
• Discharge yang
berdarah, jernih
dan melengket,
ataupun gelap.
Feeling
• Periksa tiap payudara secara terpisah.
• Gunakan telapak tangan bukan ujung jari
• Pemeriksaan dengan perabaan bukan
dengan dijepit
• Periksa Aksila /Ketiak
FEELING
Patterns
Pengobatan
Tergantung pada :
– Ukuran tumor
– Jenis kanker
– Status kelenjar getah bening
– Penjalaran jauh ke organ lain spt :
hati, paru, tulang, otak dsb
TREATMENT
• Surgery
• Radiation Therapy
• Terapi sistemik :
– Chemotherapy
– Hormonal Therapy
– Targeted Therapy
SURGERY
RADIATION THERAPY
PROGNOSIS
• KPD dini ( Stage 1)
• 10 tahun survival - lebih 90%
• KPD lanjut ( Stage IV)
• 10 tahun survival – kurang dari 10%
DISINFORMASI MASYARAKAT
•
•
•
•
•
Takut ke dokter
Efek samping
Obat herbal
Bisnis
Tidak mengikuti prosedur riset
Apakah Obat Kanker Modern
Ada Yang Berasal Dari Alam ?
Taxus brevifolia
Paclitaxel
Docetaxel
Taxus brevifolia
Bagaimana Cara Menemukan
Obat Kanker Baru ?
Pencegahan
• Diet
• Olah Raga
• Gaya Hidup
• Hindari Faktor Risiko
EAT HEALTHY
EXERCISE
Things to Remember
• Kanker bukan merupakan hukuman mati
• 80% benjoan di payudara ternyata bukan
kanker.
• 90% KPD stadium awal dapat
disembuhkan.
• Deteksi dini merupakan cara yang paling
ampuh.
Things to Remember
• Deteksi dini merupakan proteksi
terbaik KPD.
• 3 cara untuk deteksi dini
– Mammogram regular
– Pemeriksaan klinis payudara
regular
– SADARI
Thank You