kanker payudara sugiri
TRANSCRIPT
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KANKER PAYUDARA
Dr. Agung Budi Lemuel, SpB
Lamongan, 6 April 2013
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Tanda atau gejala yang mendorong
penderita ke dokter
1. Nyeri pada payudara2. Tumor atau massa pada payudara
3. Perubahan kulit pada payudara
4. Kelainan pada puting susu
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Prevalensi dari gejala / tanda
penderita datang ke klinik :
1. Benjolan/tumor pada payudara 36%
2. Benjolan yang nyeri/tidak nyeri 33%
3. Hanya nyeri pada payudara 17,5%
4. Nipple discharge 5%
5. Nipple retraction 3%
6. Riwayat keluarga dengan kanker payudara 3%
7. Bengkak/inflamasi 1%
8. Eksema 0,5%
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Apakah itu suatu “KANKER ” ??? :
1. Tumor yang timbul setelah umur 35 tahun, walaupun klinis kelihatannya jinak
2. Tumor yang tidak jelas suatu tumor mamma
3. Kiste yang berisi cairan berdarah
4. Erosi atau exzema puting susu yang tidak menyembuh dalam waktu 1 bulan
5. Nyeri pada mamma yang tidak ada kaitannya dengan siklus menstruasi
6. Pada mammografi terdapat :
a. Perubahan densitas yang dapat berbentuk : tumor (speculated, stellate),
perubahan arsitektur mamma dan asimetri
b. Mikrokalsifikasi : Bergerombol (clustered) atau tersebar (scattered)
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Manifestasi klinik kanker payudara
dapat berupa :1. Tumor mamma.
ini yang paling banyak. Dapat pula tidak teraba adanya tumor
dan tumor diketahui pada pemeriksaan mammografi
2. Ulkus pada mamma
3. Keluar cairan abnormal dari puting susu
4. Erosi atau exzema puting susu
5. Metastase ke organ lain.Dalam hal ini pada mamma mungkin terdapat lesi dan mungkin
pula kelihatan normal
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Kanker payudara merupakan solid
tumor
• Terapi utama adalah pembedahan
• Pengobatan penyerta: iradiasi, kemoterapi dan
terapi hormonal, terapi biologis atau
menargetkan terapi, imunoterapi
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Etiologi• Tidak diketahui
•Faktor risiko: umur, jenis kelamin, status
hormonal, faktor keluarga, paparan karsinogen
tertentu
• Pre malignant lesion ( proliferative breast
disease)
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Diagnosis
Uji triplet, kombinasi:
• Penilaian klinis
• Pencitraan (mamografi dan USG, magnetic
resonance mammografi)
• Temuan mikroskopis (FNA, Core-biopsi, biopsi
insisional)
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Clinical findings• Firm, rubber to hard inconsistency
• Irregular margin, or ill define
• Not smooth on surface tumor
•Partial or totally immobile, or fixed to surroundtissue.
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Breast imaging
• Mammography (age dependent, stromal density,
sensitivity 95 %)• Ultra sound (very effective, safe and convenient)
• Magnetic resonance mammography (most
sensitive 100 %, inconvenient)
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Breast biopsy
• FNA for cytology
• Needle core biopsy
• Incision or excision biopsy
• Wire-guided excision
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Tumor size
• Smaller tumor have a better long-term survival than
larger tumors. (Minimal invasive carcinoma have
15-20 % lymph node metastases, and tumor 1,5 cm
have 40 %)
• Pathologic tumor size is a valuable prognostic factor
• Small impalpable invasive carcinoma tumor can
detected by mammography,or MRI.
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Prognostic factors and Over survival
Differentiation of malignancy :
• Type of Invasive carcinoma (tubular, mucinous, medullary,
tubulo-lobuler have favourable prognosis)
• Grade of malignancy (Nottingham index, grade I have an 85
% surviving after 10 years diagnosis, grade 3 have 45 % )
• Lymphovascular invasion correlation to local and regional
involvement• Tumor necrosis is a worse prognosis
• Stromal fibrosis is a favourable prognosis.
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Estrogen receptor/progesterone receptor
• ER/PR are steroid receptor located in the cell
nucleus
• ER/PR status has a clearly defined role as a
predictive factor for the response of systemic
endocrine therapy.
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Surgical treatment of breast cancer
• Lumpectomy +/- Axillary lymph node dissection (ALND)
• Breast conserving therapy (BCT):
- Partial mastectomy (segmental mastectomy,quadrantectomy) +/-
ALND
- Lumpectomy + ALND.
• Total mastectomy (simple mastectomy)
• Radical mastectomy
• Modified Radical mastectomy
• Skin sparing mastectomy
• Breast reconstruction
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Local recurrence on Partial breast
reconstruction
Depend on :• Positive margin, tumor grade, extensive in situ
component, lymphovascular invasion and age
• Margin 2-4 cm : 2-7 %
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The axilla : current management including
sentinel node• The effication of axillary clearance are information for staging dan
prognosis that affect survival
• ALND and less invasive SNB
• Traditional ALND : ( NSABP-4),10 year: 1% (node neg), 3 % (node
pos)
• Risk and complications: seroma, wound infection, reduced shoulder
mobility and stiffness, damage to motor nerve (media pectoral
nerve, long thoracic nerve, thoraco dorsal nerve
• Numbness and parasthesia: damage to intercostobrachial nerve
• Lymph edema :10-25 %, intervention radiation40 %
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Breast reconstruction after mastectomy
• Breast reconstruction could be performed with
aotulogous graft or allograft
• Aotologous graft : Latissimus dorsi flap,
trasversus abdominis flap, gluteus free flap.
• Allograft : performed with silicon
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Breast conserving surgeryIndication :
• T1,T2 (<4cm), No,N1,Mo
• T2 >4cm for large breast
Absolute Contra indication: “
• T4, N2 or M1
• Patient who prefer mastectomy
• Clinically evident multi focal or multi centric disease
Relative contra indication :
•Collagen vascular disease
• Large or central tumor in small breast
• Strong family breast cancer
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Local recurrence of BCT
Depend on :
• Tumor size ( 4-20 %)
• Tumor grade ( grade 1 and grade 2-3 is 1,5)
• Histological type ( lobular carcinoma more multi
focal recurrence)
• Extensive in situ component increased local
recurrence
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1. Tumor payudara 30-35 th
USG
Kistik Solid
Cytologi FNA
Tidak adasel ganas
•Curiga/jelas•Massa residu
• Aspirasi hemoragic
konservatif mammografi
Tidak adasel ganas
•Jelas ganas• Ada sel atipiadan hiperplasia
konservatif mammografi
Tidak ada tandatanda ganas
Curiga/jelas tanda-tanda ganas
mammografitiap 6 bulan
MRS
VC
d h
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2. Tumor payudara < 30 th
A.Klinis jinak
• padat, kenyal• mobile• permukaan licin• batas tegas• risk factor
Operasi GA poliklinik• Tumor simple multi
/bilateral dengan O < 3 cm
• Pemeriksaan labDL/FH/LFT/RFT
• Foto thorax• Evaluasi/pre operatif di
poli anestesi
mammografi bisa konfirmasi USG
B. Klinis ganas
FNA
MRS• Tumor multiple
unilateral/bilateral• Pemeriksaan lab
• Pemeriksaan foto thorax• Tumor O > 3 cm
uni/bilateral
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3. Tumor payudara > 35 th
mammografi
Klinis jinak/ganas
FNA
MRS
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Teknik Operasi
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Teknik Insisi
Insisi modifikasi Orr Insisi modifikasi Stewart
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Cara membuat insisi “S” menurutProf DR Dr.IDG Sukardja
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Membuat Flap
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Diseksi Dan Pembebasan Payudara
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Diseksi aksilla
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Diseksi Aksilla Dan Preservasi Nervus
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Pengangkatan Payudara
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Pemasangan Drain
Dan Penutupan Luka Operasi
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Perawatan Paska Bedah
• Jahitan pada kulit diangkat pada hari ke 5-7.
• Drain diangkat kira-kira pada hari ke 5 bila
produksi masing-masing drain kurang dari 30ccperhari
• Mobilisasi lengan sedini mungkin
• Khemoterapi dapat dimulai 2 minggu paska operasi.
• Pemeriksaan patologi harus disertakan
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Komplikasi Operasi
Komplikasi akut :
• Cidera pada n.interkostobrakialis
• Cidera pada n.thorakalis longus
• Cidera pada n.thorakodorsalis
• Infeksi.
• Perdarahan dan hematoma
• Nekrosis flap.
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Komplikasi Operasi
Komplikasi kronis:
•Limfedema
• Seroma
• Kelebihan lemak dan kulit pada aksilla yang
menimbulkan rasa mengganjal.
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Terima Kasih