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- 1. Kanker Kanker payudara payudara Kanker Kanker payudara payudara Dr Emir T Pasaribu Sp B Onk Dr Emir T Pasaribu Sp B Onk Bagian bedah FK USU/ RS H Adam Malik Medan RS H Adam Malik Medan
- 2. Pendahuluan Pendahuluan z Sering didapat pada wanita z Sering didapat pada wanita z penyakit yang sulit diprediksi Di I d i N 2 t l h C ik z Di Indonesia Nomer 2 setelah Ca servik z Pria : wanita = 1 : 100 z Insiden meningkat dengan pertambahan usia z Kebanyakan datang dalam setadium lanjut
- 5. BREAST CANCER BREAST CANCER A t i l it A t i l it Anatomical site Anatomical site Upper inner pp Nipple Central portion Upper outer Axillary tail Central portion Lower inner Lower outer RIGHT
- 6. BREAST CANCER BREAST CANCER S d t l h d S d t l h d Spread to lymph nodes Spread to lymph nodes Supraclavicular Subclavicular Subclavicular Distal (upper) axillary Mediastinal Internal mammary axillary Central (middle) Internal mammary axillary P i l (l ) Interpectoral (Rotter’s) Proximal (lower) axillary
- 7. BREAST CANCER BREAST CANCER W ld id i id i f l * W ld id i id i f l * Worldwide incidence in females* Worldwide incidence in females* 67.4 Western Western Europe Europe 36.0 28.6 Eastern Eastern Europe Europe Japan Japan 71.7 21.2 Australia/ Australia/ New Zealand New Zealand South Central South Central Asia Asia 25.0 31 5 Northern Northern Africa Africa Southern Southern 31.5 25.5 Africa Africa Central Central America America North North *Incidence per 100,000 population. Parkin DM, et al. CA Cancer J Clin. 1999;49:33-64. 86.3 North North America America
- 8. BREAST CANCER BREAST CANCER A A ifi i id ( 100 000) ifi i id ( 100 000) Age Age- -specific incidence (per 100,000) specific incidence (per 100,000) 420 s s 400 300 dence Rates dence Rates 300 200 United States England and Wales Incid Incid 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. Age Age
- 9. BREAST CANCER BREAST CANCER St t di i b St t di i b Stage at diagnosis by race Stage at diagnosis by race Whit Whit 62 29 White White 29 6 50 African African American American Localized Regional Distant 50 35 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.
- 10. BREAST CANCER BREAST CANCER 5 5 l ti i l t b l ti i l t b 5 5- -year relative survival rates by race year relative survival rates by race White White 87 98 White White All Stages Localized Regional 78 71 23 African African American American Regional Distant 71 89 62 14 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.
- 11. BREAST CANCER BREAST CANCER N t l hi t N t l hi t Natural history Natural history z Highly variable in different patients z Relatively slow growth rate z Median survival without treatment: 2.8 yrs z Generally present several years by time of z Generally present several years by time of diagnosis z Long preclinical period enables early z Long preclinical period enables early detection Henderson IC. American Cancer Society Textbook of Clinical Oncology. 1995;198-219.
- 12. BREAST CANCER BREAST CANCER Ri k f t Ri k f t Risk factors Risk factors z Age z Family history of breast cancer z Prior personal history of breast cancer z Increased estrogen exposure Early menarche – Early menarche – Late menopause – Hormone replacement therapy/oral contraceptives z Nulliparity z 1st pregnancy after age 30 z Diet and lifestyle (obesity, excessive alcohol consumption) z Radiation exposure before age 40 z Prior 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.
- 13. BREAST CANCER BREAST CANCER Si d t t t ti Si d t t t ti Signs and symptoms at presentation Signs and symptoms at presentation z z Mass or pain Mass or pain in the axilla in the axilla z z Palpable mass Palpable mass z z Thickening Thickening z z Pain Pain z z Nipple discharge Nipple discharge z z Nipple retraction Nipple retraction z z Edema or erythema Edema or erythema z z Edema or erythema Edema or erythema of the skin of the skin
- 17. Gejala klinis Gejala klinis LOKAL LOKAL - benjolan 36% b j l d kit 33% - benjolan dengan sakit 33% - sakit 17,5 % - sekret putting 5% - tarikan putting 3%
- 18. Gejala klinis Gejala klinis LOKAL LOKAL - riwayat keluarga 3% k l i b t k d 1% - kelainan bentuk payudara 1% - bengkak / radang 1% - eczema 0,5%
- 19. Gejala klinis Gejala klinis SISTEMIK SISTEMIK - 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
- 20. BREAST CANCER BREAST CANCER Sit f di t t Sit f di t t Sites of distant Sites of distant metastases metastases Pleura Pleura Lymph nodes Lymph nodes Brain Brain Skin Skin Pleura Pleura Lung Lung Liver Liver Bone Bone
- 21. BREAST CANCER BREAST CANCER S i S i Screening Screening Breast self-examination Examination Mammography—the by physician only modality shown to decrease mortality to decrease mortality
- 22. Breast self examination (BSE) Breast self examination (BSE) z Look for changes in front of a mirror z Look 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
- 23. Breast self examination (BSE) Breast self examination (BSE) z Feel for changes lying down z Feel 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
- 24. Breast self examination (BSE) Breast self examination (BSE) z Look for bleeding or change from the nipple z Look for bleeding or change from the nipple. Squeeze the nipple gently to see if there is bleeding or any discharge or any discharge
- 25. BREAST CANCER BREAST CANCER B t i ti B t i ti Breast inspection Breast inspection Skin dimpling
- 27. BREAST CANCER BREAST CANCER B t l ti B t l ti Breast palpation Breast palpation
- 28. BREAST CANCER BREAST CANCER R i l d t R i l d t Regional node assessment Regional node assessment
- 29. BREAST CANCER BREAST CANCER S i h S i h Screening mammography Screening mammography z Reduces mortality by 26% in women aged 50-74 z Supports view that early diagnosis and z Supports view that early diagnosis and treatment can prevent metastasis z ACS recommends – 1st screening mammography by age 40 – Mammography every 1 to 2 years between the ages of 40 and 49 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.
- 30. BREAST CANCER BREAST CANCER S i (hi h S i (hi h i k) i k) Screening (high Screening (high- -risk) risk) z 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.
- 31. BREAST CANCER BREAST CANCER G l f h i G l f h i Goals of mammography screening Goals of mammography screening z Earlier diagnosis in asymptomatic individuals z Earlier diagnosis in asymptomatic individuals z Reduction of mortality due to detection at earlier stage Age Age 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.
- 32. BREAST CANCER BREAST CANCER H i t l h H i t l h Horizontal mammography Horizontal mammography
- 33. BREAST CANCER BREAST CANCER V ti l h V ti l h Vertical mammography Vertical mammography
- 34. BREAST CANCER BREAST CANCER M h M h Mammography Mammography
- 35. BREAST CANCER BREAST CANCER Bi t h i f l bl d Bi t h i f l bl d Biopsy techniques for palpable and Biopsy techniques for palpable and mammographically detected masses mammographically detected masses z Excisional biopsy (usually outpatient) Tumor size and histologic diagnosis – Tumor size and histologic diagnosis z Core-cutting needle biopsy (in-office) – Histologic diagnosis z Fine-needle aspiration (in-office) z Fine needle aspiration (in office) – Cytologic diagnosis Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.
- 36. BREAST CANCER BREAST CANCER P th l P th l Pathology Pathology z Non invasive carcinoma in situ z Non-invasive carcinoma in situ – Ductal carcinoma in situ (DCIS) – Lobular carcinoma in situ (LCIS) Lobular carcinoma in situ (LCIS) z Invasive carcinoma – Infiltrating ductal or lobular carcinoma – Medullary, mucinous, and tubular carcinomas z Uncommon tumors – Inflammatory carcinoma – Paget’s disease Dollinger M, et al. Everyone’s Guide to Cancer Therapy. 1997;356-384.
- 37. BREAST CANCER BREAST CANCER P th l N P th l N i i DCIS & LCIS i i DCIS & LCIS Pathology: Non Pathology: Non- -invasive DCIS & LCIS invasive DCIS & LCIS DCIS DCIS LCIS LCIS • Abnormal mammogram • Microscopic characterization on biopsy • Clustered microcalcifications • Solid proliferation of small or non-palpable masses cells with uniform round to 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.
- 38. BREAST CANCER BREAST CANCER TNM t i TNM t i TNM stage grouping TNM stage grouping Stage 0 Stage 0 Tis N0 M0 g g Stage I Stage I T1* N0 M0 Stage IIA Stage IIA T0 N1 M0 T1* N1** M0 T2 N0 M0 Stage IIB Stage IIB T2 N1 M0 T3 N0 M0 St IIIA St IIIA T0 T1 * T2 N2 M0 Stage IIIA Stage IIIA T0, T1,* T2 N2 M0 T3 N1, N2 M0 Stage IIIB Stage IIIB T4 Any N M0 Any T N3 M0 Stage IV 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.
- 39. BREAST CANCER BREAST CANCER T d fi iti T d fi iti Tumor definitions Tumor definitions z TX Primary tumor cannot be assessed T0 N id f i t z T0 No evidence of primary tumor z Tis Carcinoma in situ: Intraductal carcinoma, lobular carcinoma in situ, or Paget’s disease of the nipple with no tumor z 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 z T2 Tumor more than 2 cm but not more than 5 cm in greatest dimension z T3 Tumor more than 5 cm in greatest dimension z T4 Tumor of any size with direct extension to (a) chest wall or (b) skin, only as described below T4a Extension to chest wall 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 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.
- 40. BREAST CANCER BREAST CANCER St I St I Stage I Stage I T1a: T T1a: T ≤ ≤ 0.5 cm 0.5 cm T1 N0 M0 T1 N0 M0 T1b: 0.5 cm < T T1b: 0.5 cm < T ≤ ≤ 1 cm 1 cm T1c: 1 cm < T T1c: 1 cm < T ≤ ≤ 2 cm 2 cm T T ≤ ≤ 2 cm 2 cm T1 T1 T T ≤ ≤ 2 cm 2 cm N0 = no regional lymph node metastasis M0 = no distant metastasis
- 41. BREAST CANCER BREAST CANCER St IIA St IIA Stage IIA Stage IIA T2 N0 M0 T2 N0 M0 T0 T0 T1 T1 N1 M0 N1 M0 } T1 T1 N1 M0 N1 M0 } No evidence No evidence of tumor of tumor T0 T0 T2 T2 2 cm < T 2 cm < T < < 5 cm 5 cm N1 = metastasis to movable ipsilateral axillary lymph node(s) M0 = no distant metastasis
- 42. BREAST CANCER BREAST CANCER St IIB St IIB Stage IIB Stage IIB T3 N0 M0 T3 N0 M0 T2 N1 M0 T2 N1 M0 T3 T3 T > 5 cm T > 5 cm N1 = metastasis to movable ipsilateral axillary lymph node(s) (p) N1a, N1b M0 = no distant metastasis
- 43. BREAST CANCER BREAST CANCER St IIIA St IIIA Stage IIIA Stage IIIA T0 T0 T1 T1 T2 T2 T3 N1 M0 T3 N1 M0 N2 M0 N2 M0 T2 T2 T3 T3 Metastasis to ipsilateral axillary lymph node(s) N1 = movable N2 = fixed to one another or to other structures M0 = no distant metastasis
- 44. BREAST CANCER BREAST CANCER St IIIB St IIIB Stage IIIB Stage IIIB Any T N3 M0 Any T N3 M0 T4 any N M0 T4 any N M0 T f i T4 T4 Tumor of any size with direct extension to chest wall or skin T4d = inflammatory carcinoma N3 = metastasis to ipsilateral internal mammary lymph node(s) M0 = no distant metastasis
- 45. BREAST CANCER BREAST CANCER St IV St IV Stage IV Stage IV Any T any N M1 Any T any N M1 M1 = distant metastasis (including metastases to ipsilateral supraclavicular, cervical, or contralateral internal mammary lymph nodes)
- 46. Pengobatan Pengobatan BEDAH RADIASI HORMONAL SITOSTATIKA BIOLOGI / MOLECULAR TARGETING THERAPY BIOLOGI / MOLECULAR TARGETING THERAPY
- 47. Bedah Bedah Radikal mastektomi Modified radikal mastektomi - Patey - Madden Breast conserving surgery Breast conserving surgery - lumpectomi segmentectomi - segmentectomi - quadrantectomi
- 48. KANKER PAYUDARA METASTASE JAUH KANKER PAYUDARA METASTASE JAUH KANKER PAYUDARA METASTASE JAUH KANKER PAYUDARA METASTASE JAUH z Sifat terapi paliatif z Terapi sistemik merupakan terapi primer p p p p z Terapi loko regional (radiasi dan bedah ) bila diperlukan diperlukan
- 59. Radiasi Radiasi lokal dan regional - lokal dan regional - utama, tambahan atau kombinasi t d d t t - tumor, node dan metastase - eksternal dan internal
- 60. RADIASI SEBAGAI ADJUVAN RADIASI SEBAGAI ADJUVAN z Setelah tindakan operasi terbatas (BCT) z Tepi sayatan tidak bebas tumor z Tepi sayatan tidak bebas tumor z Tumor disentral / medial z KGB (+) dengan ekstensi ekstra kapsular p
- 62. Hormonal Hormonal - bersifat sitemik, utama atau tambahan - George Beatson 1896 - De Courmelles, radiasi ovarium - Dresser 1936, ovarium dan metatulang - pemberian: ablasi,additive anti hormon pemberian: ablasi,additive anti hormon - anti hormon: - tamoxifen - aminogluthemidin - Gn Rh
- 65. Sitostatika Sitostatika bersifat sistemik utama atau tambahan - bersifat sistemik, utama atau tambahan, dan terapi kombinasi - dapat diberi tunggal atau kombinasi - kombinasi, CAF, CMF, CAV kombinasi, CAF, CMF, CAV - performance status scales diperhatikan il i di ti - penilaian respons diamati
- 67. BREAST CANCER BREAST CANCER C l d ti f t C l d ti f t Commonly assessed prognostic factors Commonly assessed prognostic factors z Nuclear grade z Estrogen/progesterone z Number of positive axillary nodes z Tumor size z Estrogen/progesterone receptors z HER2/neu overexpression z Tumor size z Lymphatic and vascular invasion z HER2/neu overexpression z Histologic tumor type z Histologic grade Slamon DJ. Chemotherapy Foundation. 1999;46. Harris J, et al. Cancer: Principles & Practice of Oncology. 1997;1557-1616.