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Bagian dari sistim reproduksi
Respon terhadap rangsangan seksual
Persusuan anak ASI Eksklusif ASI sempurna 2 tahun
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Nipple Areola Montgomery’s tubercles
Alveolus Milk duct Lactiferous duct Lactiferous sinus
A.
ANAMNESIS Keluhan Sejak kapan Riwayat terapi Riwayat menstruasi Riwayat persalinan/persusuan Riwayat keluarga dll
B.
PEMERIKSAAN FISIK: Inspeksi Palpasi Tumor primer Limfonodi regional Metastasis
C. PEMERIKSAAN PENUNJANG 1.
Mammografi (Screening):
Dosis rendah radiasi (0.1 rad) Tidak bisa menggantikan peran biopsi Mikrokalsifikasi,distorsi arsitektur, dilatasi duktus, densitas fibronodular-diduga Ca mamma Deteksi dini dari occult CA pada tumor berdiameter < 5 mm. Recommended Program of Using Mammography: 1. Age 35-40 yr baseline mammography 2. Age >40 yr annual mammography 3. Age>50 yr mammography q 1-2 yrs depend on doctor
malignant microcalcification
architectural distortion
6 Kategori BIRADS (Breast Imaging Recording And Data System)
Category 0 . Belum dilakukan, perlu dilakukan Category 1 . Normal : dianjurkan screening rutin Category 2 . Jinak, dianjurkan screening tiap tahun Category 3 . Kemungkinan jinak, dianjurkan mammografi diagnostik tiap 6 – 12 bulan Category 4 . Kemungkinan kecil jinak,dianjurkan diagnosis histopatologis/biopsi Category 5 . Kemungkinan keganasan, dianjurkan diagnosis histopatologis/biopsi
C.
PEMERIKSAAN PENUNJANG: Computed Tomography or Magnetic Resonant Imaging:
2.
Ultrasonography
3.
4.
Mahal Untuk deteksi metastasis vertebral Tanpa radiasi Bisa membedakan lesi kistik dan massa padat Tidak dapat mendeteksi tumor < 5 mm.
Interventional Technique: Ductography:
D.
Injeksi kontras radiopak ke duktus mammarius
Biopsi: Diagnosis pasti Excision biopsy Incision biopsy Core needle biopsy Fine needle biopsy
1.Fibroadenoma:
Lesi berbatas tegas, mobil, kenyal, lobulated, berkapsul, tidak sakit, tidak disertai nipple discharge Ukuran tidak mengecil sesudah menstruasi Etiology (?), mungkin bisa juga disebabkan hormonal imbalance Treatment: Biopsi eksisi (rule out malignancy)
2. Intra-ductal Papilloma:
Proliferasi dari epithelium duktus mammarius Paling sering menyebabkan Bloody Nipple Discharge Palpable mass – 95% is intra-ductal papilloma
Treatment: Biopsi eksisi
Do not touch
3. Phyllodes Tumor
Massa yang besar terdiri dari connective tissue, dengan area gelatinous, oedematous, dan area kistik yang disebabkan nekrosis dan degenerasi infark 80% jinak, ukurannya bisa sangat besar Treatment:
Biopsi eksisi: Benign – tidak perlu terapi lain, observasi Malignant – total mastectomy / MRM
4. Mammary Duct Ectasia (Plasma cell mastitis, Comedomasttitis & Chronic mastitis)
Inflamasi sub akut sistim duktus mammarius, biasanya mulai dari sub areolar, dengan obstruksi duktus Biasanya berupa massa keras di sekitar areola dengan retraksi kulit atau papilla karena fibrosis Timbul pada masa menopause Treatment: Biopsi eksisi
5. Gynecomastia:
Pertumbuhan payudara seperti wanita pada pria Unilateral atau bilateral Kausa : a. Cirrhosis hepatis (pada penderita alkoholik tua) b. Terapi oestrogen pada Ca prostat c. Tumor yang memproduksi estrogen/progesterone
Treatment:
Terapi kausatif Subcutaneous mastectomy
Etiology: - multifactorial 1. Usia 2. Usia menarche dan menopause 3. Usia pada saat kehamilan pertama 4. HRT (Hormone replacement therapy) 5. Radiasi 6. Diet 7. Faktor genetik 8. Riwayat neoplasma sebelumnya
Primary Tumor (T) TX – Primary tumor cannot be assessed T0 – No evidence of primary tumor Tis – CA in situ (LCIS / DCIS), Paget’s dse of the nipple w/o tumor T1 – 2 cm or less T1a – 0.5 cm. or less T1b - > 0.5 cm. to 1 cm. T1c - > 1cm. to 2 cm. T2 – 2 to 5 cm. T3 - > 5 cm. T4 – any size w/ direct extension to chest wall or skin T4a – extension to chest wall T4b – edema / ulceration of the skin / satelite nodule T4c – both T4a and T4b T4d – Inflammatory carcinoma
Regional Lymph Nodes (N) NX – Not assessed (previously removed) N0 – No regional LN metastasis N1 – (+) movable ipsilateral axillary LN N2 – (+) LN fixed to one another N3 – (+) Ipsilateral INTERNAL MAMMARY LN
Distant Metastasis (M):
MX – not assessed M0 – (-) M1 –(+) including metastasis to ipsilateral supraclavicular LN
Bone (49-60%) Lung (15-20%) Pleura (10-15%) Soft tissue (7-15%) Liver(5-10%)
Stage Grouping:
5-year survival rate
Stage 0 Stage I
Tis T1
N0 N0
M0 M0
Stage IIA
T0 T1 T2
N1 N1a N0
M0 M0 M0
Stage IIB
T2 T3
N1 N0
M0 M0
81
Stage IIIA
T0 – T2 T3
N2 N1-2
M0 M0
67
Stage IIIB
T4 Any T Any T
Any N N3 Any N
M0 M0 M1
54
Stage IV
100 100
92
20
1. 2.
3. 4.
Radical Mastectomy (Willi Meyer, Halsted) Extended Radical Mastectomy Modified Radical Mastectomy: Total mastectomy w/ or w/o radiation:
Surgical Management: 5. 6. 7.
Subcutaneous Mastectomy: Quandrantectomy, axillary, radiotherapy (QUART) Partial Mastectomy and Radiation:
Indications for Conservative Surgery: 1. 2. 3. 4.
Small breast CA < 4cm Clinically (-) axillary LN Breast volume adequate size to allow uniform dosage of irradiation Radiation therapist experience to avoid damage of retained breast
Chemotherapy: Adjuvant chemotherapy Neoadjuvant chemotherapy (Primary chemotherapy)
Radiation
conserving breast surgery post MRM 2-3 wks of post operative or after finished Chemotherapy
Hormonal therapy
hormonal dependent tumor estrogen growth stimulating factor epidermal growth factor
growth inhibitory factor
estrogen receptor progesterone receptor
1. Ablation: Oophorectomy,
adrenalectomy, hypophysectomy
2. Anti-estrogen: Tamoxifen a non-steroidal antiestrogenic.
Aromasin Aminogluthethimide
Stage 0 Non-infiltrating (In-situ) Carcinoma of duct and lobules: Increase diagnosis due to mammography 1.
LOBULAR CARCINOMA in SITU: duct lobular apparatus Tx: 1. Closed observation 2. Hormonal treatment (Tamoxifen/aromatase inhibitor) for 5 years 3. Surgery (bilateral mastectomy) w/ immediate reconstruction
2.
Ductal Carcinoma In Situ: Absence of invasion of surrounding stroma hence confined w/in the basement membrane
Treatment: Total mastectomy Wide local excision + Radiotherapy Wide local excision alone
Paget’s Disease of the nipple
≈0.7-4% Chronic eczematoid lesion of the nipple Tenderness, itching, burning and intermittent bleeding Tx: Mammogram, Paget ‘ s disease wide excision, Simple mastectomy, axillary dissection
Breast Cancer in Men:
Factors: a. b. c. d.
Klinefelter syndrome Estrogen therapy Irradiation Trauma
Age: 60-70y/o s/sx: breast mass, nipple retraction and/or discharge, ulceration and pain. Commonly ER positive and well differentiated Prognosis is similar w/ female Treatment:
MRM + radiation if with ulceration and high grade Orchiectomy / chemotherapy
Modified radical mastectomy (+) LN
(-) LN Low risk
(-) LN High risk
Hormonal / chemotherapy
observe
chemotherapy
High Risk Patients A.
B. C. D.
Histologic criteria: Rapid growth rate Youth of the patient Estrogen receptor negative
Advance Breast Cancer (III / IV): Palliative Mastectomy (+) Estrogen
(-) Estrogen
Chemotherapy/Hormonal/Radiotherapy
Chemotherapy/Radiotherapy
رب العلمني امحلد هلل ّ
