CA Mammae Akn
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REFERATCA MAMMAE
Pembimbing :
Dr. dr. Koernia Swa Oetomo, Sp.B.FINACS. FICS(K) TRAUMA.
Disusun Oleh :
Andre Kurniawan Nur Huda (AKN)
SMF ILMU BEDAHRSU HAJI SURABAYA
2015 1
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Pendahuluan
• Ca mammae menyumbang 26% dari semua kanker yang baru didiagnosis pada wanita. (Brunicardi, 2010)
• Pd tahun 2015 diperkirakan lebih dari 810.179 kasus baru yg akan terdiagnosis pada wanita di th 2015. (American Cancer Society, 2015)
• Kematian krn kanker payudara di Indonesia mencapai 20.052 (1,41%), tingkat kejadian 20,25 per 100.000 penduduk Indonesia. (Indonesia Health Profile, 2011)
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Pendahuluan
Brunicardi, 2010 3
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Embriologi
Brunicardi, 20104
• Berasal dari epidermis.• Putting susu merupakan
suatu proliferasi lokal dari stratum spinosum epidermis
• Pada bulan kedua kehamilan terbentuk milk line.
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Anatomi Mammae
5Brunicardi, 2010
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Anatomi (2) Vaskularisasi
6Brunicardi, 2010
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Anatomi (3) Aliran Limfatik
• Menurut Haagensen :1. External mammary
nodes2. Scapular nodes3. Central nodes4. Interpectoral nodes5. Axillary vein nodes6. Subclavicular nodes
• Menurut Rotter’s :– Level I, II, III
7Brunicardi, 2010
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Anatomi (4) Persyarafan
8Brunicardi, 2010
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Faktor ResikoRisk Factors
Advanced age Family history
• Family history of ovarian cancer in women < 50y
One first-degree relative Two or more relatives (mother, sister)
Personal history Personal history• Positive BRCA1/BRCA2 mutation Breast biopsy with atypical hyperplasia
Breast biopsy with LCIS or DCIS Reproductive history
Early age at menarche (< 12 y) Late age of menopause Late age of first term pregnancy (>30 y)
/nulliparity Use of combined estrogen/progesterone HRT
Current or recent use of oral contraceptives
Lifestyle factors Adult weight gain Sedentary lifestyle• Alcohol consumption 9Brunicardi, 2010
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Klasifikasi kanker payudara
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Staging Ca mamae (TNM)Tumor Primer (T)
TX Tumor primer tidak dapat dinilai
T0 Tidak ada bukti terdapat tumor primer
Tis Carcinoma in situ
Tis(DCIS) Ductal carcinoma in situ
Tis(LCIS) Lobular carcinoma in situ
Tis(Paget’s) Paget’s disease dari papilla mammae tanpa tumor (Catatan : Paget’s disease yang berhubungan dengan tumor diklasifikasikan menurut ukuran tumor)
T1 Tumor ≤ 2 cm
T1mic Microinvasion ≤ 0.1
T1a Tumor > 0.1 cm tetapi tidak lebih dari 0.5 cm
T1b Tumor > 0.5 cm tetapi tidak lebih dari 1 cm
T1c Tumor > 1 tetapi tidak lebih dari 2 cm
T2 Tumor > 2 cm tetapi tidak lebih dari 5 cm
T3 Tumor > 5 cm
T4 Tumor ukuran berapapun dengan perluasan langsung ke dinding dada atau kulit, seperti yang diuraikan dibawah ini :
T4a Perluasan ke dinding dada, tidak melibatkan otot pectoralis
T4b Edema (termasuk peau d’orange), atau ulserasi kulit [ayudara, atau ada nodul satelit terbatas di kulit payudara yang sama
T4c Kriteria T4a dan T4b
T4d Inflammatory carcinoma
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Staging Ca mamae (TNM)Kelenjar Getah Bening—Klinis (N)
NX KGB regional tidak dapat dinilai (misalnya sebelumnya telah diangkat)
N0 Tidak ada metastasis ke KGB regional
N1 Metastasis ke KGB aksilla ipsilateral tetapi dapat digerakkan
N2 Metastasis KGB aksilla ipsilateral tetapi tidak dapat digerakkan atau terfiksasi, atau tampak secara klinis ke KGB internal mammary ipsilateral tetapi secara klinis tidak terbukti terdapat metastasis ke KGB aksilla ipsilateral
N2a Metastasis ke KGB aksilla ipsilateral dengan KGB saling melekat atau melekat ke struktur lain sekitarnya.
N2b Metastasis hanya tampak secara klinis ke KGB internal mammary ipsilateral dan tidak terbukti secara klinis terdapat metastasis ke KGB aksilla ipsilateral
N3 Metastasis ke KGB infraklavikula ipsilateral dengan atau tanpa keterlibatan KGB aksilla, atau secara klinis ke KGB internal mammary ipsilateral tetapi secara klinis terbukti terdapat metastasis ke KGB aksilla ipsilateral; atau metastasis ke KGB supraklavikula ipsilateral dengan atau tanpa keterlibatan KGB infraklavikula atau aksilla ipsilateral
N3a Metastasis ke KGB infraklavikula ipsilateral
N3b Metastasis ke KGB internal mammary dan aksilla
N3c Metastasis ke KGB supraklavikula ipsilateral
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Staging Ca mamae (TNM)
Metastasis Jauh (M)
Metastasis jauh tidak dapat dinilai
Tidak terdapat metastasis jauh
Terdapat metastasis jauh
American Joint Committee on Cancer, 200213
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TNM Staging GroupTabel 1.4. TNM Stage Groupings
Stage 0 Tis N0 M0
Stage I T1a N0 M0
Stage IIA T0 N1 M0
T1a N1 M0
T2 N0 M0
Stage IIB T2 N1 M0
T3 N0 M0
Stage IIIA T0 N2 M0
T1a N2 M0
T2 N2 M0
T3 N1 M0
T3 N2 M0
Stage IIIB T4 N0 M0
T4 N1 M0
T4 N2 M0
Stage IIIC Any T N3 M0
Stage IV Any T Any N M1
American Joint Committee on Cancer, 2002
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Diagnosis
• Triple diagnosis : clinical, imaging, patological• Gejala :
– Merasakan perubahan pd payudara• Benjolan atau penebalan• Putting susu terasa mengeras
– Melihat perubahan pada payudara• Perubahan ukuran maupun bentuk, puting susu tertarik,
kulit bersisik, berkerut, merah atau bengkak– Keluarnya sekret atau cairan dari puting susu– Keluhan di tempat lain berhubungan dengan
metastasis
15Manuaba, 2010
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Pemeriksaan Fisik
• Inspeksi, palpasi
Brunicardi, 2010 16
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Diagnosis
• Pemeriksaan fisik :• Inspeksi
– Bentuk, ukuran, simetris, retraksi kulit atau puting
• Palpasi– Massa di mamae, aksila, supraclavicula,
parasternal– Ukuran massa, konsistensi, bentuk, mobilitas
Manuaba, 2010
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Pemeriksaan penunjang
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Pemeriksaan penunjang
• Mammografi– Memiliki 2 jenis gambaran : kraniokaudal (CC),
oblik mediolateral (MLO)– Mendeteksi karsinoma payudara dengan false
positive sebesar 10% dan false negative 7%– Dapat mengganmbarkan massa, stellate,
penebalan yg asimetris, mikrokalsifikasi– Dapat dilakukan utk screening– Dilakukan pd wanita usia >35 th.
Brunicardi, 2010
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Diagnosis
• Ultrasonografi– Praktis– Dapat digunakan sbg
guiding pd FNAB– Tidak dapat mendeteksi
lesi < 1 cm– Dilakukan pd wanita di
bawah 35 th.
Brunicardi, 2010
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Diagnosis
• MRI (Magnetic Resonance Imaging)– Sangat sensitif tetapi tdk spesifik– Dpt membedakan karsinoma yg rekuren atau
jaringan parut
Brunicardi, 2010
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Biopsi
• FNAB– Lebih murah– Less infasive– False positif 1-2%, false negatif 10%
• Core-needle biopsy– Cost efective, lebih infasive– Dapat dilakukan dgn lokal anaestesi
• Open biopsy– Dapat berupa incisional atau eksisional– Dilakukan bila FNAB/core biopsy hasilnya (-)
22Brunicardi, 2010 George, 2007
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Biomarker
• Biomarker mewakili gangguan biologik pada jaringan yang terjadi antara inisiasi dan perkembangan karsinoma.
• Biomarker antara lain :– Penanda proliferasi (PNCA, BrUdr dan Ki-67)– Penanda apoptosis (bcl-2)– Penanda angiogenesis (VEGF)
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Ki - 67
• Disarankan sbg biomarker kanker payudara yang menjanjikan
• Digunakan sbg penentu prognosis dan penanda prediktif.
• Penilaian prognosis pd ca mamae bila <10% (baik), 10 – 20% (perbatasan), >20% (jelek).
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(Esposito, 2015)
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Penatalaksanaan
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Modified Radical Mastectomy dengan Skin Flap
26Brunicardi, 2010
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Modified Radical Mastectomy dengan Skin Flap
27Brunicardi, 2010
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Modified Radical Mastectomy dan diseksi kelenjar getah bening axilla.
Brunicardi, 2010
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Terapi non pembedahan
• Radioterapi• Kemoterapi
– Adjuvant terapi– Neoadjuvant terapi
• Hormonal terapi– Terapi anti esterogen
• Terapi anti HER-2
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Radioterapi
• Dapat digunakan pd smua stadium ca mamae.• Bertujuan mengurangi resiko rekurensi.• Dianjurkan pada ca mamae stadium IIIa atau
Iib yg telah menjalani terapi pembedahan.
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Kemoterapi adjuvant
• Merupakan terapi tambahan setalh pembedahan.
• Berfungsi menurunkan angka rekurensi, terutama pada stadium dgn tingkat rekurensi tinggi.
• Contoh regimen : siklofosfamid, doxorubisin, 5-fluorourasil dan methotrexate.
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Neoadjuvant chemotherapy
• Kemoterapi inisial yg diberikan sebelum dilakukan pembedahan.
• Dengan tujuan utk down grading atau down staging.
• Regimen yg di rekomendasikan : Doxorubicin atau kandungan taxane diikuti mastectomy dan diseksi axillla.
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Ringkasan terapi
• Stadium I, II : MRM (Patey, Unchinloss)• Stadium IIIa : RM + kemo adjuvant +
radioterapi.• Stadium IIIb, IIIc : kemoterapi, jika tumor
mengecil dilakukan MRM/RM + adjuvant kemoterapi.
• Stadium IV : Kemoterapi dan radioterapi.
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Manuaba, 2010
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Terapi anti esterogen
• Diberikan kpd pasien dengan ER (+).• Obat yg di rekomendasikan : Tamoxifen, aromatase
inhibitor.• Diberikan selama 5 tahun.• Penelitian SOFT & TEXT menyatakan pemberian
tamoxifen + obat OFS atau exemestane + OFS meningkatkan disease free survival.
• Obat OFS : leuprolide (Lupron) / goserelin (Zoladex)
34(Brunicardi, 2010) (Esposito,2015).
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Terapi anti HER2/neu
• Merupakan protein yg menunjang pertumbuhan kanker yg terdapat pd permukaan sel kanker.
• Regimen utk pasien HER2/neu (+) : trastuzumab
• Penelitian terbaru memberian anti HER2.neu ganda dpt meningkatkan respon kemo sbnyak 70%
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36(Brunicardi, 2010)
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Prognosis
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Daftar Pustaka• Brunicardi FC, Anderson Dana K, Biliar Timothy R, Dunn David L,
Hunter John G, Matthews Jeffrey B, Pollock Raphael E. 2010. Schwartz’s Principles of Surgery Ninth edition. Page 797 – 915.
• Bailey, Loves, Williams NS, Bulstrode CJK, Ronan O’Connell P. 2008. Bailey & Loves Short Practice of Surgery 25th edition. Page 827 – 848.
• Townsend, Beauchamp, Evers, Mattox. 2012. Sabiston Textbook of Surgery The Biological Basis of Modern Surgical Practice. 19th edition. Elsevier Saunders. Page 824 – 884.
• De Jong W, Sjamsuhidajat R. 2010. Buku Ajar Ilmu Bedah Edisi Ketiga. Bab 27 Payudara. Halaman 471 – 497.
• Manuaba Tjakra W et al. 2010. Panduan Penatalaksanaan Kanker Solid PERABOI 2010. Bab II Kanker payudara. Halaman 17 – 50.
• Model. 2015.
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Daftar Pustaka (2)• George Burkitt H, Quick Clive RG, Reed Joanna B. 2007. Essential Surgery
Problems, Diagnosis & Management Fourth edition. Page 635 – 661.• Doherty Gerard M, Thompson NW et al. 2010. A Lange medical book
Current Diagnosis & Treatment Surgery 13th Edition. Page 279 – 304.• Stopeck Alison T, Thompson Patricia A, Chalasani P, Harris Jules E, Downey
Leona, Harvey Harold, Kaur Kanchan et al. Breast Cancer. 2015. http://emedicine.medscape.com/article/1947145-overview
• Nirmala Bhoo-Pathy, Peeters Petra HM, Ulterwaal Cuno SPM, Bueno-de-Mesquita H, Bulgiba Awang M, Bodil Hammer Bech et al. 2015. Coffe and tea consumption and risk of pre- and postmenopausal breast cancer in the European prospective Investigation into Cancer and Nutrition (EPIC) cohort study. Breast Cancer Research.
• Lelievre, shophie A. Weaver, Connie M. Global Nutrition and Breast Cancer Prevention as a
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TERIMA KASIH
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