Kanker payudara
Dr Emir T Pasaribu Sp B Onk Bagian bedah FK USU/ RS H Adam Malik Medan
Pendahuluan z
Sering didapat pada wanita
z
penyakit yang sulit diprediksi
z
Di IIndonesia d i N Nomer 2 setelah t l h C Ca servik ik
z
Pria : wanita = 1 : 100
z
Insiden meningkat dengan pertambahan usia
z
Kebanyakan datang dalam setadium lanjut
BREAST CANCER A t Anatomical i l site it
Upper pp inner Upper outer
Nipple
Axillary tail
Central portion Lower inner
Lower outer
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
67.4
Eastern Europe
36.0
Japan
28.6
Australia/ New Zealand
71.7
South Central Asia
21.2
Northern Africa
25.0
Southern Africa
31 5 31.5
Central America
25.5
North America
86.3
*Incidence per 100,000 population. Parkin DM, et al. CA Cancer J Clin. 1999;49:33-64.
BREAST CANCER A -specific AgeAge ifi incidence i id (per ( 100,000) 100 000)
Incid dence Rates s
420 400
300
United States England and Wales
200
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, 1990.
BREAST CANCER St Stage att di diagnosis i by b race
62
Whit White
29 6
50
African American
Localized
35
Regional
9 0
10
Distant 20
30
40
50
60
70
% of Cases
Categories do not total 100% because staging information is not available for all cases. Landis SH, et al. CA Cancer J Clin. 1999;49:8-31.
BREAST CANCER 5-year relative l ti survival i l rates t by b race
87 98
White
78 23
All Stages Localized
71
African American
Regional
89
Distant
62 14 0
20
40
60
80
100
120
% Surviving 5 Years
Landis SH, et al. CA Cancer J Clin. 1999;49:8-31.
BREAST CANCER N t Natural l hi history t 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 diagnosis
z
Long preclinical period enables early detection
Henderson IC. American Cancer Society Textbook of Clinical Oncology. 1995;198-219.
BREAST CANCER Ri k ffactors Risk t z z z z
z z z z z
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, excessive alcohol consumption) Radiation exposure before age 40 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.
BREAST CANCER Si Signs and d symptoms t att presentation t ti z
Mass or pain in the axilla
z
Palpable mass Thickening Pain
z z
z z
z
Nipple discharge Nipple retraction
Edema or erythema of the skin
BREAST CANCER
Gejala klinis LOKAL - benjolan
36%
- benjolan b j l d dengan sakit kit
33%
- sakit
17,5 %
- sekret putting
5%
- tarikan putting
3%
Gejala klinis LOKAL - riwayat keluarga
3%
- kelainan k l i b bentuk t k payudara d
1%
- bengkak / radang
1%
- eczema
0,5%
Gejala klinis SISTEMIK - batuk, sesak nafas , efusi pleura - sakit kit pada d ttulang l d dan patah t h ttulang l - ganguan neurologi - hepatomegali, ikterus, sakit perut
BREAST CANCER Sit off di Sites distant t t metastases Brain Lymph nodes Skin
Liver
Bone
Pleura Lung
BREAST CANCER Screening S i
Breast self-examination
Examination by physician
Mammography—the only modality shown to decrease mortality
Breast self examination (BSE)
z
-
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 h iin size i or shape h - dimpling on the skin - change in the nipple
Breast self examination (BSE)
z
Feel for changes lying down down.
- put a small pillow under your shoulder - place l your h hand d under d your h head d - use your hand to examine - make sure you do not miss any area
Breast self examination (BSE)
z
Look for bleeding or change from the nipple nipple. Squeeze the nipple gently to see if there is bleeding or any discharge
BREAST CANCER B Breast t iinspection ti
Skin dimpling
BREAST CANCER B Breast t palpation l ti
BREAST CANCER Regional R i l node d assessmentt
BREAST CANCER S Screening i mammography h z
Reduces mortality by 26% in women aged 50-74
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 – 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 S i (high(high (hi h-risk) i k)
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.
BREAST CANCER G l off mammography Goals h screening i z
Earlier diagnosis in asymptomatic individuals
z
Reduction of mortality due to detection at earlier stage
Age
Mortality Reduction (%)
40-49
17%
50-69
25%-30% 10-12 years post-screening
70+
Insufficient data
15 years post-screening
PDQ: Screening for breast cancer for health professionals: http://Cancernetnci.nih.gov/. Accessed November 28, 1999.
BREAST CANCER H i Horizontal t l mammography h
BREAST CANCER V ti l mammography Vertical h
BREAST CANCER Mammography M h
BREAST CANCER Bi Biopsy ttechniques h i for f palpable l bl and d mammographically detected masses z
Excisional biopsy (usually outpatient) – Tumor size and histologic diagnosis
z
Core-cutting needle biopsy (in-office) – Histologic diagnosis
z
Fine-needle Fine needle aspiration (in-office) (in office) – Cytologic diagnosis
Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.
BREAST CANCER Pathology P th l z
Non invasive carcinoma in situ Non-invasive – Ductal carcinoma in situ (DCIS) – 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.
BREAST CANCER P th l Pathology: Non NonN -invasive i i DCIS & LCIS DCIS
LCIS
• Abnormal mammogram
• Microscopic characterization on biopsy
• Clustered microcalcifications or non-palpable non palpable masses
• Solid proliferation of small cells with uniform round to oval nuclei
• 30% risk of invasive cancer at 10 years at or near original biopsy site
• 37% chance of subsequent invasive cancer
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 TNM stage t grouping i Stage g 0
Tis
N0
M0
Stage I
T1*
N0
M0
Stage IIA
T0 T1* T2
N1 N1** N0
M0 M0 M0
Stage IIB
T2 T3
N1 N0
M0 M0
St Stage IIIA
T0 T1,* T0, T1 * T2 T3
N2 N1, N2
M0 M0
Stage IIIB
T4 Any T
Any N N3
M0 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 T Tumor definitions d fi iti z
TX Primary tumor cannot be assessed
z
T0 No N evidence id off primary i ttumor
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 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 St Stage I T1 N0 M0
T1a: T ≤ 0.5 cm T1b: 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
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, N1b M0 = no distant metastasis
BREAST CANCER St Stage IIIA
T0 T1 T2 T3
T3 N1 M0
Metastasis to ipsilateral axillary lymph node(s) N1 = movable N2 = fixed to one another or to other structures M0 = no distant metastasis
N2 M0
BREAST CANCER St Stage IIIB T4 any N M0
Any T N3 M0
T4 Tumor off any size T 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
BREAST CANCER St Stage IV Any T any N M1
M1 = distant metastasis (including metastases to ipsilateral supraclavicular, cervical, or contralateral internal mammary lymph nodes)
Pengobatan BEDAH RADIASI HORMONAL SITOSTATIKA BIOLOGI / MOLECULAR TARGETING THERAPY
Bedah Radikal mastektomi Modified radikal mastektomi - Patey - Madden Breast conserving surgery - lumpectomi - segmentectomi - quadrantectomi
KANKER PAYUDARA METASTASE JAUH z
Sifat terapi paliatif
z
Terapi p sistemik merupakan p terapi p p primer
z
Terapi loko regional (radiasi dan bedah ) bila diperlukan
Radiasi - lokal dan regional - utama, tambahan atau kombinasi - tumor, t node d d dan metastase t t - eksternal dan internal
RADIASI SEBAGAI ADJUVAN z
Setelah tindakan operasi terbatas (BCT)
z
Tepi sayatan tidak bebas tumor
z
Tumor disentral / medial
z
KGB (+) dengan ekstensi ekstra p kapsular
Hormonal - bersifat sitemik, utama atau tambahan - George Beatson 1896 - De Courmelles, radiasi ovarium - Dresser 1936, ovarium dan metatulang - pemberian: ablasi,additive anti hormon - anti hormon: - tamoxifen - aminogluthemidin - Gn Rh
Sitostatika - bersifat
sistemik sistemik, utama atau tambahan tambahan,
dan terapi kombinasi - dapat diberi tunggal atau kombinasi - kombinasi, CAF, CMF, CAV - performance status scales diperhatikan - penilaian il i respons di diamati ti
BREAST CANCER C Commonly l assessed d prognostic ti factors f t z
Number of positive axillary nodes
z
Nuclear grade
z
Tumor size
z
Estrogen/progesterone receptors
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.
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