Kanker Payudara

Dr. Suyatno SpB(K)Onk

Divisi Bedah Onkologi
Bagian Bedah FK USU/RS HAM
Medan
BREAST CANCER
Anatomical site

Upper inner
Upper outer
Nipple
Axillary tail
Central portion

Lower inner
Lower outer

RIGHT
 Kelenjar Getah Bening,
tempat metastasis regional
Epidemiologi
 KPD: karsinoma berasal dari epitel duktus atau lobulus
 Keganasan paling sering di negara maju
 Pria : wanita = 1 : 100
 Insiden meningkat dgn pertambahan usia, (> dekade IV)
 Penyebab kematian no.2 setelah ca.paru
 Di Indonesia
 Insidens no.1 pada wanita
 Insidens no.1 secara keseluruhan
 Kebanyakan datang std III & IV (M. Ramli, 43,9%)
BREAST CANCER
Worldwide incidence in females*
Western
Europe 67.4

Eastern
Europe
36.0

Japan 28.6

Australia/ 71.7
New Zealand

South Central 21.2

Asia

Northern 25.0
Africa

Southern 31.5
Africa

Central 25.5
America
86.3
North
America
*Incidence per 100,000 population.

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

BREAST CANCER
Age-specific incidence (per 100,000)
420
400

300
Incidence Rates

United
States
England
and Wales
200
Italy
France
Japan

100

0
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

Age

Adapted from New Horizons in Cancer Management, SRI International, 1990.

BREAST CANCER
Spread to lymph nodes

Supraclavicular

Subclavicular

Mediastinal
Distal (upper)
axillary
Internal mammary

Central (middle)
axillary

Interpectoral
Proximal (lower) (Rotter’s)
axillary
BREAST CANCER
Risk factors
 Age: setelah dekade 4
 Family history: mother, sister, dougther
 Prior personal history of breast cancer
 Increased estrogen exposure
 Early menarche (<12 years)
 Late menopause (> 55 years)
 HRT ( > 5years)
 Oral contraceptives (> 8 years)
Risk factors
 Nulliparity
 1stpregnancy after age 30
 Diet and lifestyle (obesity, excessive alcohol
consumption)
 Radiation exposure before age 30
 Mutation : BRCA1 and or BRCA 2
 Prior benign or premalignant breast changes
 In situ cancer
 Atypical hyperplasia
Diagnostik
 Klinis
 Anamnesis
 Keluhan utama
 Keluhan tambahan
 Faktor risiko
 RPO & RPT
 Pemeriksaan fisik
 Inspeksi
 Palpasi
 Pemeriksaan penunjang
 USG mammae
 Mamografi
 USG abdomen, F. Thorak, bone scan, CT Scann
 Biopsi
Tanda dan gejala :
 Benjolan yang keras dengan atau tanpa rasa sakit
 Nipple areola berubah
 retraksi nipple
 putting mengeluarkan cairan /darah (nipple
discharge)
 Eczema (paget disease)
 Perubahan pada kulit
 berkerut seperti kulit jeruk (peau d’orange)
 melekuk ke dalam (dimpling)
 borok (ulcus)
 eritema, edema
 Benjolan kecil di kulit payudara (nodul
satelit)
 Payudara terasa panas, memerah dan
bengkak
 Benjolan awalnya biasanya hanya pada 1
payudara
 Ada
benjolan di aksila dengan atau tanpa
masa di payudara
Benjolan payudara kanan
Peau d’orange Pembesaran kgb aksila
Retraksi Nipple (Puting)
Masa menonjol dengan eritema dan retraksi
nipple
Masa keras, terfiksir dgn
eritema dan retraksi nipple
Nipple discharge/ Keluar cairan puting
SKIN DIMPLING

Paget’s Disease
 No
du
le

Sa
te
lit

Ulkus dengan retraksi nipple

Ulkus yang meluas mengenai kedua
payudara
BREAST CANCER
Sites of distant
metastases

Brain
Lymph nodes
Pleura
Skin
Lung

Liver

Bone
Gejala Klinis Metastasis Jauh
 Paru/ pleura:
 batuk, sesak nafas, efusi pleura
 Tulang:
 sakit pada tulang yg hebat, patah tulang
 Otak:
 nyeri kepala hebat, muntah proyektil, kesadaran
menurun
 Liver:
 hepatomegali, ikterus, sakit perut, perut gembung,
mual
BREAST CANCER
Screening

Breast self-examination Examination Mammography—the

by physician only modality shown
to decrease mortality
SADARI (SBE)

Posisi berdiri
Posisi berbaring
Posisi berbaring dengan bantal diletakan di punggung
BREAST CANCER Examination by
physician
Breast inspection

Skin dimpling
BREAST CANCER
Breast palpation
BREAST CANCER
Regional node assessment
BREAST CANCER
Screening mammography
 Reduces mortality by 26% in women
aged 50-74
 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 (high-risk)

 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
Horizontal mammography
BREAST CANCER
Vertical mammography
BREAST CANCER
Mammography
Kategori Resiko Perencanaan
Deskripsi
BIRADS Malignansi Tindakan
1 Negative 5 in 10,000 Continue annual
mammograpy
2 Benign finding, 5 in 10,000 Continue annual B
I
noncancerous mammograpy

3 Probably benign <2% Usually, 6- R

finding month follow-up
mammography is
A
performed. D
4 Suspicious
abnormality
25-50% Biopsy
S
5 Highly 75-99%, Biopsy
suggestive of
malignancy
USG Payudara
 USG merupakan metode terpilih
untuk membedakan kistik dengan solid
sebagai guide untuk biopsi
Gambaran maligna: lesi hipoechoic

dgn margin irregular

BREAST CANCER
Biopsy
 Excisional biopsy
 Size < 3 cm
 Incisional biopsy
 Size > 3 cm & operable
 inoperable
 Core needle biopsy
 Histologic diagnosis
 Fine-needle aspiration
 Cytologic diagnosis

Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.
FNAB CORE BIOPSY
BREAST CANCER
Pathology
 Non-invasive carcinoma in situ
 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
 Paget’s disease

Dollinger M, et al. Everyone’s Guide to Cancer Therapy. 1997;356-384.

BREAST CANCER
Tumor definitions
 TX Primary tumor cannot be assessed
 T0 No evidence of primary tumor
 Tis Carcinoma in situ: Intraductal carcinoma, lobular carcinoma in situ,
or Paget’s 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 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, 7th edition (2010)
published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.
BREAST CANCER
TNM stage grouping
Stage 0 Tis N0 M0
Stage I T1* N0 M0
Stage IIA T0 N1 M0
T1* N1** M0
T2 N0 M0
Stage IIB T2 N1 M0
T3 N0 M0
Stage IIIA T0, T1,* T2 N2 M0
T3 N1, N2 M0
Stage IIIB T4 Any N M0
Any T N3 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, 7th edition (2010)
published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.
BREAST CANCER
Stage 0: DCIS & LCIS

DCIS LCIS

 Abnormal mammogram  Microscopic characterization

on biopsy

 Clustered microcalcifications  Solid proliferation of small

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.
BREAST CANCER
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
Stage IIA
T0
T1 } N1 M0 T2 N0 M0

No evidence
T0 of tumor
T2

2 cm < T < 5 cm

N1 = metastasis to movable ipsilateral axillary lymph node(s)

M0 = no distant metastasis
BREAST CANCER
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
Stage IIIA T0
T1
N2 M0
T3 N1 M0 T2
T3

Metastasis to ipsilateral axillary lymph node(s)

N1 = movable
N2 = fixed to one another or to other structures
M0 = no distant metastasis
 BREAST CANCER
Stage IIIB
T4 any N M0 Any T N3 M0

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
BREAST CANCER
Stage IV
Any T any N M1

M1 = distant metastasis (including metastases to ipsilateral supraclavicular, cervical, or contralateral internal mammary lymph nodes)
Penatalaksanaan
1. PEMBEDAHAN
2. KEMOTERAPI
3. RADIOTERAPI
4. HORMONAL
5. TARGETING THERAPY
Pembedahan
 Radikal mastektomi
 Modified radikal mastektomi

- Patey
- Madden
 Breast conserving surgery (BCS)
 lumpectomi +
 diseksi aksila +
 radioterapi
 Skin/Nipple sparing mastectomy
Disain operasi MRM (mastectomy
radical modification)
Pasca Operasi MRM
Operasi BCS

•Kosmetik
dapat diterima

•Survival sama
dengan MRM

•Kemungkinan
kambuh lebih
tinggi
SSM + TRAM FLAP
Kutis , sukutis dan lemak di bagian bawah
perut dipindahkan untuk mengisi rongga
bekas jaringan payudara
Tampilan 1 bulan pasca operasi
Kemoterapi
 Bersifat lokal, regional dan sistemik
 Berperansebagai terapi utama (primer) atau
tambahan (adjuvan)
 Bekerjadengan menghambat atau
mengganggu sintesa DNA dalam siklus sel
 Dapat diberi tunggal atau kombinasi
 Respon dinilai setelah 3 siklus
Indikasi adjuvan kemoterapi:
 ukuran tumor lebih dari 2 cm
 kgb aksila positif metastasis 1 atau
lebih
 kgb aksila negatif tapi penderita berusia
kurang dari 35 tahun atau grading tumor 2-3
atau terdapat invasi vaskular atau
overekspresi HER2 atau ER/PR negatif
(intermediate dan high risk kategori St. Gallen
2005).
 Radioterapi

Bersifat: lokal dan regional
 Peran: utama, tambahan atau kombinasi
 Prinsip: kerusakan DNA dengan gangguan
proses replikasi
 Tujuan menurunkan resiko rekurensi
lokal/ regional dan berpotensi untuk
menurunkan mortalitas jangka panjang
Indikasi Radioterapi Adjuvan
 Setelah operasi BCS
 Ukuran tumor > 5 cm
 Tepi sayatan dekat / tidak bebas tumor
 Tumor letak sentral / medial
 KGB (+) dgn ekstensi ekstra kapsular
 KGB (+) 4 atau lebih
 Hormonal
 Bersifat sitemik
 Peran: utama atau tambahan
 Tujuan untuk menghilangkan atau mengurangi
estrogen yang masuk ke sel tumor
 Indikasi: ER atau PR positif
 Anti hormon:
 SERM : tamoxifen
 aromatase inhibitor (AI):
anastrozole,letrozole
 Tamoxifen paling banyak digunakan dan
merupakan terapi standar untuk wanita
premenopause
TABLET HORMONAL
KANKER PAYUDARA METASTASE JAUH
(stage IV)
 Sifat terapi paliatif
 Terapi sistemik merupakan terapi primer
 Terapi loko regional (radiasi dan bedah ) bila
diperlukan untuk paliatif
 Tujuan terapi: meningkatkan kualitas hidup dan
survival
 Metastasis
ke paru atau tulang: mastectomy
meningkatkan survival
BREAST CANCER
Commonly assessed prognostic
factors
Number of positive axillary nodes

 Nuclear grade
 Tumor size
 Estrogen/progesterone
 Lymphatic and vascular invasion
receptors
 Histologic tumor type

 Histologic grade
 HER2/neu overexpression

Slamon DJ. Chemotherapy Foundation. 1999;46.

Harris J, et al. Cancer: Principles & Practice of Oncology. 1997;1557-1616.
Faktor prognosis pada kanker payudara
Faktor prognosis Prognosis baik

Ukuran Kecil

Perabaan KGB tidak teraba

KGB secara PA Negatif

Derajat diferensiasi Baik

Infasi limpatik Negatif

ER / PR Tinggi

S- phase Rendah

HER- 2/neu Negatif

MDR Negatif

Angiogenesis Negatif

DNA ploidy Tinggi

Obesitas Negatif
 Follow up
 Setiap 4 bulan untuk 1-2 tahun pertama
 Setiap 6 bulan untuk tahun ke 3-5
 Setiap 12 bulan setelahnya
 Setiap bulan direkomendasikan untuk SADARI
 Mamografi dilakukan 6 bulan setelah BCT selesai,
kemudian setiap tahun
 Untuk pasien yang dilakukan mastektomi mamografi
kontralateral dilakukan setiap tahun.
 Routine bone scan, skeletal survey, CT abdomen
dan otak pada pasien asimptomatik, stadium dini
adalah tidak cost-effective, oleh karena occult
metastase sangat jarang.
Edukasi
 KPD dapat disembuhkan asal
diberikan terapi tepat pada stadium
dini
 Deteksi dini dapat dilakukan dengan
SADAR, SARANIS dan Mamografi
 Sebagian besar (80%) KPD merupakan
penyakit yang dapat dicegah
 Strategi Pencegahan melibatkan
individu dan Instansi Pemerintah.
Kepustakaan
1. Devita VT, Hellman S, Rosenberg SA. Penyunting. Cancer Principlels &
practice of Oncology. Edisi ke-8. Philadelphia. Lippincott William &
Wilkins. 2008.
2. Feight BW, Berger DH, Fuhrman GM, penyunting. The M.D Anderson
surgical oncology handbook. Edisi ke-4. Philadelphia. Lippincott
William & Wilkins. 2006.
3. Suyatno, Emir T Pasaribu, Bedah Onkologi Diagnostik dan Terapeutik,
Jakarta, Sagung Seto, 2010
4. Foto: dokumentasi pribadi dan unduhan
Terima kasih