Kanker payudara

Dr Emir T Pasaribu Sp B Onk Bagian bedah FK USU/ RS H Adam Malik Medan


Sering didapat pada wanita penyakit yang sulit diprediksi Di I Indonesia d i N Nomer 2 setelah t l h C Ca servik ik Pria : wanita = 1 : 100 Insiden meningkat dengan pertambahan usia Kebanyakan datang dalam setadium lanjut


BREAST CANCER A t Anatomical i l site it Upper pp inner Upper outer Axillary tail Lower outer Nipple Central portion Lower inner RIGHT .

BREAST CANCER S Spread d to t lymph l h nodes d Supraclavicular Subclavicular Mediastinal Distal (upper) axillary Internal mammary Central (middle) axillary Interpectoral (Rotter’s) P i l (l Proximal (lower) ) axillary .

BREAST CANCER Worldwide W ld id incidence i id in i females* f l * Western Europe Eastern Europe Japan Australia/ New Zealand South Central Asia Northern Africa Southern Africa Central America North America *Incidence per 100. Parkin DM.5 25.3 .4 36. CA Cancer J Clin. 1999.0 31 5 31.6 71.0 28.2 25.7 21.49:33-64.000 population. 67.5 86. et al.

BREAST CANCER A -specific AgeAge ifi incidence i id (per ( 100. . 1990.000) 100 000) 420 400 Incid dence Rates s 300 United States 200 England and Wales Italy France 100 Japan 0 20 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 69 70 74 75 79 80 84 85+ Age Adapted from New Horizons in Cancer Management. SRI International.

CA Cancer J Clin. 1999.BREAST CANCER St Stage at t di diagnosis i by b race 62 Whit White 6 29 African American 9 0 10 20 30 50 35 Localized Regional Distant 40 50 60 70 % of Cases Categories do not total 100% because staging information is not available for all cases.49:8-31. et al. Landis SH. .

49:8-31. CA Cancer J Clin.BREAST CANCER 5-year relative l ti survival i l rates t by b race 87 White 23 98 78 All Stages Localized 71 Regional African American 14 0 20 40 60 89 62 Distant 80 100 120 % Surviving 5 Years Landis SH. 1999. et al. .

BREAST CANCER N t Natural l hi history t Highly variable in different patients Relatively slow growth rate Median survival without treatment: 2. 1995.198-219. .8 yrs Generally present several years by time of diagnosis Long preclinical period enables early detection Henderson IC. American Cancer Society Textbook of Clinical Oncology.

5th ed. American Cancer Society Textbook of Clinical Oncology. 1997. 2nd ed. Trichopoulos D. Cancer: Principles & Practice of Oncology. Harris J. . et al. 1997. Cancer: Principles & Practice of Oncology. et al. 5th ed.BREAST CANCER Ri k f Risk factors t Age Family history of breast cancer Prior personal history of breast cancer Increased estrogen exposure – Early menarche – Late menopause – Hormone replacement therapy/oral contraceptives Nulliparity 1st pregnancy after age 30 Diet and lifestyle (obesity.1557-1616.231-257. excessive alcohol consumption) Radiation exposure before age 40 Prior benign or premalignant breast changes – In situ cancer – Atypical hyperplasia – Radial scar Henderson IC. 1995.198-219.

BREAST CANCER Si Signs and d symptoms t at t presentation t ti Mass or pain in the axilla Palpable mass Thickening Pain Nipple discharge Nipple retraction Edema or erythema of the skin .




sekret putting .Gejala klinis LOKAL .tarikan putting 36% 33% 17.benjolan b j l d dengan sakit kit .sakit .benjolan .5 % 5% 3% .

kelainan k l i b bentuk t k payudara d .riwayat keluarga .5% .Gejala klinis LOKAL .bengkak / radang .eczema 3% 1% 1% 0.

efusi pleura . sakit perut .Gejala klinis SISTEMIK . sesak nafas .hepatomegali. ikterus.sakit kit pada d t tulang l d dan patah t ht tulang l .batuk.ganguan neurologi .

BREAST CANCER Sit of Sites f di distant t t metastases Brain Lymph nodes Skin Pleura Lung Liver Bone .

BREAST CANCER Screening S i Breast self-examination Examination by physician Mammography—the only modality shown to decrease mortality .

Breast self examination (BSE) - Look for changes in front of a mirror first with arm at your sides next with arm rised above your head fi ll with finally ith hands h d pressed d fi firmly l on hi hips & chest h t muscles l contracted In each potition. turn slowly from side to side and look for : .change in the nipple .change h i in size i or shape h .dimpling on the skin .

make sure you do not miss any area . .use your hand to examine .place l your h hand d under d your h head d .put a small pillow under your shoulder .Breast self examination (BSE) Feel for changes lying down down.

Squeeze the nipple gently to see if there is bleeding or any discharge .Breast self examination (BSE) Look for bleeding or change from the nipple nipple.

BREAST CANCER B Breast ti inspection ti Skin dimpling .


BREAST CANCER B Breast t palpation l ti .

BREAST CANCER Regional R i l node d assessment t .

128-193. Mettlin CJ. . et al. 2nd ed.1557-1616. 1997. Fink DJ. Cancer: Principles & Practice of Oncology. American Cancer Society Textbook of Clinical Oncology.BREAST CANCER S Screening i mammography h Reduces mortality by 26% in women aged 50-74 Supports view that early diagnosis and treatment can prevent metastasis 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. 1995. 5th ed.

3rd ed. 1999.123-129.BREAST CANCER Screening S i (high(high (hi h-risk) i k) Annual mammogram. Current Cancer Therapeutics. Henderson IC. beginning 5 yrs before age of youngest affected relative at time of diagnosis – High familial risk – BRCA 1/2-positive Tripathy D. .

gov/.nih. .BREAST CANCER G l of Goals f mammography h screening i Earlier diagnosis in asymptomatic individuals Reduction of mortality due to detection at earlier stage Age 40-49 50-69 70+ Mortality Reduction (%) 17% 15 years post-screening 25%-30% 10-12 years post-screening Insufficient data PDQ: Screening for breast cancer for health professionals: http://Cancernetnci. 1999. Accessed November 28.

BREAST CANCER H i Horizontal t l mammography h .

BREAST CANCER V ti l mammography Vertical h .

BREAST CANCER Mammography M h .

. 1997. et al. 5th ed.BREAST CANCER Bi Biopsy t techniques h i for f palpable l bl and d mammographically detected masses Excisional biopsy (usually outpatient) – Tumor size and histologic diagnosis Core-cutting needle biopsy (in-office) – Histologic diagnosis Fine-needle Fine needle aspiration (in-office) (in office) – Cytologic diagnosis Harris J. Cancer: Principles & Practice of Oncology.1557-1616.

1997. and tubular carcinomas Uncommon tumors – Inflammatory carcinoma – Paget’s disease Dollinger M. .BREAST CANCER Pathology P th l Non invasive carcinoma in situ Non-invasive – Ductal carcinoma in situ (DCIS) – Lobular carcinoma in situ (LCIS) Invasive carcinoma – Infiltrating ductal or lobular carcinoma – Medullary. mucinous. et al. Everyone’s Guide to Cancer Therapy.356-384.

5th ed. 4th ed.1557-1616. 1997. LCIS – lobular carcinoma in situ. Love S. LCIS • Microscopic characterization on biopsy • Solid proliferation of small cells with uniform round to oval nuclei • 37% chance of subsequent invasive cancer Harris J.BREAST CANCER P th l Pathology: Non NonN -invasive i i DCIS & LCIS DCIS • Abnormal mammogram • Clustered microcalcifications or non-palpable non palpable masses • 30% risk of invasive cancer at 10 years at or near original biopsy site DCIS – ductal carcinoma in situ. Cancer Treatment. . Barsky SH. Cancer: Principles & Practice of Chemotherapy.337-340. 1995. et al.

Pennsylvania. Used with the permission of the American Joint Committee on Cancer (AJCC®). Philadelphia.BREAST CANCER TNM stage t grouping i Stage g 0 Stage I Stage IIA Tis T1* T0 T1* T2 T2 T3 T0 T1. ** Note: The prognosis of patients with N1a is similar to that of patients with pN0.* T0. T1 * T2 T3 T4 Any T Any T N0 N0 N1 N1** N0 N1 N0 N2 N1. . Chicago. The original source for this material is the AJCC® Cancer Staging Manual. 5th edition (1997) published by Lippincott-Raven Publishers. N2 Any N N3 Any N M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1 Stage IIB St Stage IIIA Stage IIIB Stage IV * Note: T1 includes T1 mic. Illinois.

1 cm or less in greatest dimension T1a Tumor more than 0. 5th edition (1997) published by Lippincott-Raven Publishers.1 cm but not more than 0.5 cm in greatest dimension T1b Tumor more than 0. or Paget’s disease of the nipple with no tumor T1 Tumor 2 cm or less in greatest dimension T1mic Microinvasion more than 0. 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®). The original source for this material is the AJCC® Cancer Staging Manual. Pennsylvania. Philadelphia.BREAST CANCER T Tumor definitions d fi iti TX Primary tumor cannot be assessed T0 No N evidence id of f primary i t tumor Tis Carcinoma in situ: Intraductal carcinoma. Chicago. Illinois.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. . lobular carcinoma in situ.

5 cm T1b: 0.BREAST CANCER St Stage I T1 N0 M0 T1a: T ≤ 0.5 cm < T ≤ 1 cm T1c: 1 cm < T ≤ 2 cm T1 T ≤ 2 cm N0 = no regional lymph node metastasis M0 = no distant metastasis .

BREAST CANCER St Stage IIA T0 T1 } N1 M0 T2 N0 M0 T0 No evidence of tumor T2 2 cm < T < 5 cm N1 = metastasis to movable ipsilateral axillary lymph node(s) M0 = no distant metastasis .

N1b M0 = no distant metastasis .BREAST CANCER St Stage IIB T2 N1 M0 T3 N0 M0 T3 T > 5 cm N1 = metastasis to movable ipsilateral axillary lymph node(s) (p) N1a.

BREAST CANCER St Stage IIIA T3 N1 M0 T0 T1 T2 T3 N2 M0 Metastasis to ipsilateral axillary lymph node(s) N1 = movable N2 = fixed to one another or to other structures M0 = no distant metastasis .

BREAST CANCER St Stage IIIB T4 any N M0 Any T N3 M0 T4 Tumor of T f any size i with direct extension to chest wall or skin T4d = inflammatory carcinoma N3 = metastasis to ipsilateral internal mammary lymph node(s) M0 = no distant metastasis .

cervical.BREAST CANCER St Stage IV Any T any N M1 M1 = distant metastasis (including metastases to ipsilateral supraclavicular. or contralateral internal mammary lymph nodes) .


Madden Breast conserving surgery .quadrantectomi .segmentectomi .Bedah Radikal mastektomi Modified radikal mastektomi .Patey .lumpectomi .

KANKER PAYUDARA METASTASE JAUH Sifat terapi paliatif Terapi p sistemik merupakan p terapi p p primer Terapi loko regional (radiasi dan bedah ) bila diperlukan .








lokal dan regional . tambahan atau kombinasi .Radiasi . t node d d dan metastase t t .tumor.utama.eksternal dan internal .

RADIASI SEBAGAI ADJUVAN Setelah tindakan operasi terbatas (BCT) Tepi sayatan tidak bebas tumor Tumor disentral / medial KGB (+) dengan ekstensi ekstra p kapsular .


George Beatson 1896 .Dresser 1936.pemberian: ablasi.additive anti hormon .aminogluthemidin .Hormonal . utama atau tambahan .De Courmelles.tamoxifen .bersifat sitemik. radiasi ovarium .anti hormon: . ovarium dan metatulang .Gn Rh .



kombinasi. CAV . CMF.Sitostatika .penilaian il i respons di diamati ti .dapat diberi tunggal atau kombinasi .bersifat sistemik sistemik. CAF. dan terapi kombinasi . utama atau tambahan tambahan.performance status scales diperhatikan .


. Chemotherapy Foundation. Harris J.BREAST CANCER C Commonly l assessed d prognostic ti factors f t Number of positive axillary nodes Tumor size Lymphatic and vascular invasion Nuclear grade Estrogen/progesterone receptors HER2/neu overexpression Histologic tumor type Histologic grade Slamon DJ. et al. 1999.1557-1616. Cancer: Principles & Practice of Oncology. 1997.46.

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