Kanker payudara

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

Pendahuluan

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

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A t Anatomical i l site it

Upper pp inner Upper outer Axillary tail Lower outer Nipple Central portion Lower inner

RIGHT

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S Spread d to t lymph l h nodes d
Supraclavicular Subclavicular Mediastinal Distal (upper) axillary Internal mammary

Central (middle) axillary Interpectoral (Rotters) P i l (l Proximal (lower) ) axillary

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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 100,000 population. Parkin DM, et al. CA Cancer J Clin. 1999;49:33-64.

67.4 36.0 28.6 71.7 21.2 25.0 31 5 31.5 25.5 86.3

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A -specific AgeAge ifi incidence i id (per ( 100,000) 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, 1990.

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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. Landis SH, et al. CA Cancer J Clin. 1999;49:8-31.

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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, et al. CA Cancer J Clin. 1999;49:8-31.

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N t Natural l hi history t

Highly variable in different patients Relatively slow growth rate Median survival without treatment: 2.8 yrs Generally present several years by time of diagnosis Long preclinical period enables early detection

Henderson IC. American Cancer Society Textbook of Clinical Oncology. 1995;198-219.

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, 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.

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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

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

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

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

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Sit of Sites f di distant t t metastases
Brain Lymph nodes Skin Pleura Lung

Liver

Bone

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Screening S i

Breast self-examination

Examination by physician

Mammographythe 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 h i in size i or shape h - dimpling on the skin - change in the nipple

Breast self examination (BSE)

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)

Look for bleeding or change from the nipple nipple. Squeeze the nipple gently to see if there is bleeding or any discharge

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B Breast ti inspection ti

Skin dimpling

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B Breast t palpation l ti

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Regional R i l node d assessment t

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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, 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.

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Screening S i (high(high (hi h-risk) i k)

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.

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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.nih.gov/. Accessed November 28, 1999.

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H i Horizontal t l mammography h

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V ti l mammography Vertical h

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Mammography M h

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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, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.

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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, and tubular carcinomas

Uncommon tumors Inflammatory carcinoma Pagets disease

Dollinger M, et al. Everyones Guide to Cancer Therapy. 1997;356-384.

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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. LCIS lobular carcinoma in situ.

LCIS Microscopic characterization on biopsy Solid proliferation of small cells with uniform round to oval nuclei 37% chance of subsequent invasive cancer

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.

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TNM stage t grouping i
Stage g 0 Stage I Stage IIA Tis T1* T0 T1* T2 T2 T3 T0 T1,* T0, T1 * T2 T3 T4 Any T Any T N0 N0 N1 N1** N0 N1 N0 N2 N1, 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. ** 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.

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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, lobular carcinoma in situ, or Pagets disease of the nipple with no tumor 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 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, only as described below T4a Extension to chest wall T4b Edema (including peau dorange) 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.

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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

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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
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

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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

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

Sifat terapi paliatif Terapi p sistemik merupakan p terapi p p primer 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

Setelah tindakan operasi terbatas (BCT) Tepi sayatan tidak bebas tumor Tumor disentral / medial 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

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. Chemotherapy Foundation. 1999;46. Harris J, et al. Cancer: Principles & Practice of Oncology. 1997;1557-1616.

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