The document discusses a case of a 20-year-old female patient presenting with a lump in her right breast that has been enlarging over the past year. Her medical history includes a previous tumor in her right breast that was treated with lumpectomy. On examination, a solitary mass was palpated in her right breast and enlarged lymph nodes were found, suggesting possible recurrence of breast cancer.

1. Breast cancer
By :
Saruveswaran R Rasasingam
Preceptopr :
dr. Adrioki Risa, Sp.B

2. Chapter 1:
Introduction

3. Introduction
Breast cancer
• Uncontrolled
growth of breast
tissue cells that can
invade and spread
to other parts of
the body
Breast cancer is the
most common cancer
in
developed/developin
g countries
• Fifth most
common cause of
death from cancer
The incidence rate in
developing countries
is 40/100,000
population
• Indonesia urutan
ke-8 di Asia
tenggara dan no-
23 di Asia

4. Introduction
 Research conducted at RSUP Dr. M. Jamil Padang on risk factors that can cause
breast cancer are non pregnant, very short duration of breastfeeding, menopause,
obesity, high fat intake, living in urban areas, family history of breast cancer and a
history of blunt breast trauma.
 For the prevention and control of cancer in Indonesia, the government has made
various efforts, including early detection of breast cancer in women aged 30-50
years using the Clinical Breast Examination (SADANIS) method.
Sindrome koroner Akut. Perki. 2018

5. Chapter 2:
Literature review

6. Anatomy of
breast
 Boundaries
 Superior : II-III ribs
 Inferior : VI-VII ribs
 Medial : linea
parasternalis
 Lateral : line anterior
axillae/ linea
mid axillae

7. Anatomy of
breast
 Each breast consists of 12-20
glandular lobules, each of which has
a duct called the lactiferous duct,
which opens into the mammary
papillae.
 Between the mammary glands and
the pectoral fascia, as well as
between the skin and the glands, is
adipose tissue.
 Between the lobules, there are
connective tissue called Cooper's
ligaments which form the framework
of the breast

8. Anatomy of breast
 Breast bleeding is mainly derived from branches of the anterior
perforating artery from the internal mammary artery, the lateral
thoracic artery which branches from the axillary artery, and several
intercostal arteries.
 About 75% of the lymphatic drainage of the breast drains into the
axillary lymphatic group
 Level I
 Located laterally / below the lower limit m. pectoralis minor
 Level II
 Located inside (deep) or behind m. pectoralis minor i.e. the
central group
 Level III
 Located medial to or above the upper limit of m. pectoralis
minor is the subclavicular group

9. Breast Cancer
• Breast cancer : a group of malignant tumors in breast tissue which can originate
from lactiferous duct epithelium (70%) or lobular epithelium (10%)
Definition
• Most common cancer in women
• The main cause of death from cancer
• The highest incidence is in developed countries, and there is an increase in
developing countries due to lifestyle changes
• Based on Riskesdas data, the prevalence of tumors/cancer in Indonesia shows an
increase from 1.4 per 1000 population in 2013 to 1.79 per 1000 population in
2018
Epidemiology

10. Etiology
 Gene mutation
1. BRCA-1 (locus 17q21)
2. Gen p53 (locus 17p13)
3. BRCA-2 at chromosome 13
 Mutasi tersebut diduga akibat paparan mutagen
 mutagen endogen : radikal bebas seperti lipid peroksidase
 mutagen eksogen : radiasi
 Virus (belum ada bukti pada manusia)

11. Risk factor
 Age
 It is rare under the age of 30 years, but the incidence
increases sharply until around the age of 50 years and
then it continues to increase but slowly --> ovarian
haemorrhagic effects
 Reproduction and hormones
 Age of menarche, age of menopause, 35th first birth,
hormonal contraception, postmenopausal hormone
replacement therapy
 Genetics and familial
 Approximately 5-10% of breast cancer occurs due to a
genetic predisposition. And the risk increases 2x if one of
the nuclear family members suffers from breast cancer
 Lifestyle
 Obesity, physical activity, smoking and alcohol
 Exogenous exposure
 Radiation, chemicals

12. Pathogenesis
• unevenly
distributed
proliferation of
polyclonal
epithelial cells with
overlapping nuclei
and disorganized
ductal lumens
Ductal hyperplasia
• the cytoplasm of the
cells becomes more
pronounced and
does not overlap the
regular duct lumen
hyperplasia
atypical
• cell proliferation
with cytological
features consistent
with malignancy.
Proliferation has not
invaded the stroma
or penetrated the
basement
membrane
Carcinoma in-situ
• Tumor cells have
penetrated the
basement
membrane and
invaded the stroma -
-> metastasized
Invasive
carcinoma

13. Clinical manifestation
Tumor Mass
• Most manifest as
a breast mass
that is not
painful. Most
common
location is the
upper lateral
quadrant
Mammary papilla
changes
• Retraction,
distortion of the
mammary
papillae,
papillary
discharge,
eczematoid
changes
Skin changes
• Dimple marks,
peau d'orange,
satellite nodules,
ulcerations,
inflammatory
changes
Regional lymph
node enlargement
• Pembesaran
kelenjar limfe
aksilar ipsilateral
dapat soliter
atau multiple.
kelenjar limfe
supraklavikular
juga dapat
membesar

14. Diagnosis
 Physical examination
 Inspection: size, symmetry of the two
mammary glands, pay attention to
whether there are tumor lumps or
pathological changes in the skin,
whether the two mammary papillae
are symmetrical, are there retraction,
distortion, erosion and other
abnormalities
 Anamnesis
 Patient identity, risk factors, course of
disease, signs and symptoms of
breast cancer, history of treatment
and history of disease ever suffered.

15. Palpation
 Breast
 Lymp nodes

16. Supporting investigation
 Mammography
 Breast ultrasound
 MRIs
 Immunohistochemistry
 FNAB
 Core biopsy
 Open biopsy
 Sentinel node biopsy
 Bone Scan, Chest Photo and Ultrasound Abdomen
 Laboratory Examination: tumor markers such as CA-15-3 and CEA

17. TNM Classification

18. TNM Classification

19. Classification
Non invasive carcinoma
• Ductal carcinoma in situ (DCIS)
• Lobular carcinoma in situ (LCIS)
Invasive carcinoma
• Invasive ductal carcinoma
• Adenocarcinoma with productive fibrosis (scirrhous, simplex, NST)
• Medullary carcinoma (4%)
• Mucinous (colloid) carcinoma (2%)
• Papillary carcinoma (2%)
• Tubular carcinoma (2%)
• Invasive lobular carcinoma (10%)
Paget’s disease

20. Procedures
• Classic Radical Mastectomy
• Modified Radical Mastectomy
• Simple Mastectomy
• BCS (Breast Conserving Surgery)
Operation
• adjuvant therapy
• Neoadjuvant therapy
• Primary therapy
Chemotherapy(systemic)
• DNA damage by interrupting the replication process and reducing the risk of local recurrence
Radiotherapy
• in the breast that shows positive expression of estrogen receptor (ER) or progesterone receptor (PR)
Hormanal therapy
• menghambat proses yang berperan dalam pertumbuhan sel-sel kanker
Target therapy

21. Prognosis
 The prognosis of breast cancer
is indicated by the life
expectancy or disease-free
interval

22. Chapter 3: Case
illustration

23. Patient identity
 Name : Miss Feb.Oz
 Gender : Female
 Age : 20 years old
 Address : Ombilin
 Occupation : Student
 Marital status : Single

24. Anamnesis
 A 20-year-old female patient came to the Policlinic of General Hospital
(RSU) Prof. Dr. M Ali Hanafiah with:
Chief Complaint
 Pain and Lump on the superior lateral of the right breast

25. History of Present Disease
- The lump in the right breast was initially felt since 1 years ago, the lump was felt as large as a marble and was
not painful. Then the lump felt increasingly enlarged to the size of a ping pong ball and with increasing pain
since 1 month . The patient did not complain of pus-like discharge and blood from the nipple, the nipple
wasn’t pulled inward and the skin around the breast had no changes in the breast skin resembling orange peel.
- Patient complaints that the pain gets worse while she’s resting.,
- Slight fever 2 days prior to getting admitted.
- There is no bony pain.
- There is no headache.
- Shortness of breath not present
- Decrease in appetite not present.
- No history of serious weight loss in this 1 year.
- Nausea and vomiting are absent.
- There is no complaint about bowel movements.
 There is no complaint about urination

26. Past medical history
- History of tumor on right breast inferior subareolar region.
- History of lumpectomy in the year 2019
- Diabetes Mellitus (-)
- Hypertension (-)
- Heart Disease (-)
- Kidney Disease (-)
- History of asthma (-)
- History of drug, food, and other substance allergies (-)

27. Family history of disease
 Patient’s aunty (mom’s sister) had similar issues before marriage and has gone through
lumpectomy thrice throughout till today

28. Social history, psychology, habits
- The patient is now a student.
- The patient had her menarche at the age of 15.
- Menstrual cycle 28-30 days, regular, 2-5 days in length, 3 sanitary pads usually used,
no serious pain.
- The patient has no children.
- No history of hormonal contraception
- There is no history of radiation to the chest wall.

29. Physical examination
 General condition: Appears moderately ill
Consciousness: Composmentis cooperative
 Vital Sign :
 -Blood Pressure: 110/70 mmHg
 -Pulse : 82 beats/minute
 -Breathing : 20 beats/minute
 -Temperature : 36,5°C

30. General Status
 -Head : normocephalic, no abnormalities
 -Eyes : non anemic conjunctiva, non-icteric sclera
 -Skin : good skin turgor
 -Nose : no abnormalities
 -Ears : no abnormalities
 -Mouth : no abnormalities
 -Neck : no abnormalities
 -KGB : no abnormalities

31. Cont.
Lungs
• Inspection:
normochest,
symmetrical chest
wall movement
• Palpation: left
fremitus equal to
right
• Percussion: sonor
• Auscultation:
vesicular breath
sounds, rhonki -/-,
wheezing -/-
Heart
• Inspection: ictus
cordis not visible
• Palpation: palpable
ictus cordis 1 finger
medial LMCS RIC V
• Percussion: heart
limits within normal
limits
• Auscultation:
regular heart sound,
normal S1 S2,
murmur (-), gallop
(-)
Abdomen
• Inspection:
distention (-)
• Auscultation: bowel
sounds (+) normal
• Palpation: sociable,
NT (-), NL (-), liver
and spleen not
palpable
• Percussion: timpani
Ekstremitas
• Udem -/-
• Warm acral
• CRT < 2 seconds

32. Local status
 Right mammary region
 Inspection: A mass in the upper outer quadrant, the mammary gland the size of a
chicken egg, peau d'orange (-), satellite nodules (-), nipple retraction (-), nipple
discharge (-), abscess (-), blood (-),
 Palpation: palpable solitary mass with a size of 4 x 4 cm in the region of upper outer
quadrant of the right breast, hard consistency, flat surface, firm boundaries, free to
move, and sensitive to touch
 Left Mammary Region
 Inspection: No visible lump
 Palpation: 1 corn seed sized palpable mass on the inferior subareolar region. Size of 0.5
x 0.5cm, hardconsistency, smooth surface, firm borders, free to move and sensitive to
touch

33. Cont.
 Right Axillary Region
 Inspection: no visible mass
 Palpation: palpable mass with a size of 1 x 1 cm, hard consistency, smooth surface, firm boundaries, fixed, and no pain.
 Left Axillary Region
 Inspection: no visible mass
 Palpation: no palpable mass
 Dextra supraclavicular region
 Inspection: no visible mass
 Palpation: 1 corn seed sized palpable mass on the inferior subareolar region. Size of 0.5 x 0.5cm, hard consistency,
smooth surface, firm borders, free to move and sensitive to touch.
 Left supraclavicular region
 Inspection: no visible mass
 Palpation: no palpable mass

34. Cont.
 Left Infraclavicular Region
 Inspection: no visible mass
 Palpation: no palpable mass
 Dextra infraclavicular region
 Inspection: no visible mass
 Palpation: no palpable mass

35. Diagnosis
 Right Mammary tumor Susp mammary fibroadenoma.

36. Supporting examination
 Laboratory examination
 Chest x-ray
 Anatomical pathology
 Abdominal ultrasound
 Immunohistochemistry

37. Procedures
 Lumpectomy
 Post lumpectomy lab test

38. Prognosis
 Quo ad vitam : Dubia ad malam
 Quo ad functionam : Dubia ad malam
 Quo ad sanationam : Dubia ad malam

39. Discussion

40. Discussion
 A patient Miss Feboz, a 20-year-old woman came to the Outpatient of General Hospital Prof.
Dr.M Ali Hanafiah with complaints of a lump the size of a table tenis ball in the right breast.
The patient felt a lump in the right breast initially felt in the last 1 year, the lump was felt as big
as a pea and painless. Then thelump is got bigger and denser in the past month. The patient does
not have previous breast discharge such as pus or blood from the nipple, and the the nipple
wasn’t pulled inward. If there was a retraction of the breast,it indicates tumor invasion into the
subpapillary tissue. There is no change in the breast skin that resembles orange peel. This is
because the tumor in this patient did not cause any drainage obstruction to the subcuticular
lymphatic vasa, causing this to occur.10

41. Discussion
 The patient has not complained of symptoms such as decreased appetite and drastic weight loss,
in this past year. The patient is 20 years old, where the age factor plays an important role in
causing breast cancer. With increasing age, the incidence of breast cancer will increase. After the
age of 50 years, the frequency continues to increase but slowly. This malignancy is very rare in
women under the age of 20. A patient's risk factors for mammary malignancy are sought by
asking about age at menarche, menstrual history, pregnancy, breastfeeding, hormonal
contraceptive use, and radiation exposure. Among these risk factors, the patient had never been
pregnant (reproductive) and never breastfed. According to research, breastfeeding reduces the
risk of developing breast cancer especially if the breastfeeding period is carried out for 27-52
weeks. This reduction in risk is thoughtto be because breastfeeding reduces a person's
menstrual period.3

42. Discussion
 On physical examination, a solitary mass with a size of 4 cm x 4 cm in the upper outer
quadrant, region of the mammary gland was palpated, hard consistency, flat surface,
well-defined, freely moving , painless, nipple discharge (-) peau consistency, flat surface,
well-defined, fixed, painless, nipple discharge (-) peau d'orange (-), nipple retraction (-).
 The presence of a mass with a hard consistency, fixed and painless is a description of a
malignancy. The presence of a mass with the diameter of 4cm x 4cm is classified to be
T2. There was no regional metastasis on the particular lump and it was mobile so it was
classified to be N0. There was no metastases to distant organs (M0). Therefore the lump
on the right breast of this patient was classified to be Stage 2A.

43. Discussion
 On examination of the left breast, a mass with a size of 0.5 x 0.5 cm, hard consistency,
smooth surface, firm boundaries, non-fixed and painless was palpated. This is the basis
for upholding the N0 classification in the diagnosis. The patient did not have any signs
of distant metastases, so M0 was established.
 Based on history, physical examination and support, this patient was diagnosed with
mammary tumor right suspected mammary fibroadenoma. In this patient, the
lumpectomy was performed and the lump the was removed was sent for lab
examinations to identify the type of tissues involved.

44. Discussion
 If the patient was histopathologically proven as mammary carcinoma, the therapy plan
will be neoadjuvant chemotherapy and MRM because the above 3 has to be
accompanied with tumor stage chemotherapy treatment. Chemotherapy is systemic,
serves to destroy cancer cells, works by inhibiting or disrupting DNA synthesis in the
cell cycle.3 However on this particular patient the lump wasn’t easily bleeding, was
freely moving and not fixated to any tissues. Therefore, its suspected to be a
Fibroadenoma and being removed early prevent complivations and preserves life
quality.

45. Discussion
 The prognosis of this patient's 5-year survival rate is high (Stage 2A, 92%). Education
that can be given to the family is education about the patient's disease and
management aimed at improving quality of life, and education to family members
about risk factors for breast cancer and breast cancer screening in family members at
risk. 3

46. Thank you