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DR. Dr. Wirsma Arif Harahap SpB(K)Onk Konsultan Bedah Onkologi Breast Disease.

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Presentasi berjudul: "DR. Dr. Wirsma Arif Harahap SpB(K)Onk Konsultan Bedah Onkologi Breast Disease."— Transcript presentasi:

1 DR. Dr. Wirsma Arif Harahap SpB(K)Onk Konsultan Bedah Onkologi Breast Disease

2 Congenital Inflamation Metabolic / Hormonal Neoplasm Trauma

3 Breast Disease Congenital Inflamation Metabolic / Hormonal Neoplasm Trauma

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7 The Bad News 1 diantara 8 wanita yang mencapai usia 85 tahun akan menderita KPD. Setiap 3 menit seorang wanita di diagnosa menderita KPD. Setiap 13 menit 1 orang wanita meninggal akibat KPD. Penyebab kematian pertama akibat kanker pada wanita. Penyebab kematian utama wanita pada usia 40 – 55 tahun

8 The Good News 80% benjolan pd payudara  jinak.. 90% KPD stadium dini dapat sembuh. < 5% KPD terjadi pada usia <35 tahun. Lebih dari 2 juta pasien lolos dari KPD.

9 Breast Complaints Pain Mass Skin or Nipple Changes Nipple Discharge

10 Diagnosis and Treatment of Breast Complaints Most important is to rule out malignancy Significance of a finding is greatest in a high-risk patient Balance between reassurance and exhausting all diagnostic options Treatment should not be worse than the disease

11 Breast Complaints Pain Mass Skin or Nipple Changes Nipple Discharge

12 Breast Neoplasm 1.Benign 1.Epitelial 2.Mesenchimal 3.Combine 2.Malignant 1.Primary 1.Epithelial 2.Mesenchimal 3.Combine 4.Others 2.Metastatic 1.Oposite breast 2.Other site

13  Benign  Nonproliferative  Fibrocystic changes  Simple cysts  Lactational adenoma  Fibroadenoma  Hyperplasia without atypia  Epithelial hyperplasia  Sclerosing adenosis  Intraductal papillomas  Hyperplasia with atypia  LCIS  DCIS Breast Disease  Malignant  Ductal carcinoma  Lobular carcinoma  Tubular carcinoma  Mucinous carcinoma  Micropapillary carcinoma  Metaplastic carcinoma  Inflammatory carcinoma

14 Benign Breast Tumor Young age >> Slow growing Mass > pain Part of ANDI (abberation normal development and involution) Fibroadenoma >> Therapy : –Wait and see –Excision

15 Phylodes Tumor Usually big tumor Venaectasi Wrong term : Cystosarcoma Mesenchymal origin Benign >> Malignant –Benign : Phyllodes Tumor –Malignant : Malignant Phyllodes Tumor High reccurence Treatment : wide excision to mastectomy

16 BREAST CANCER IN THE WORLD  1.15 million new cases  Incidence increasing in most countries  deaths  Half of the global burden in low- and medium-resourced countries

17 Trends since 1950 in age-standardized death rates comparing breast and selected other types of cancer, among women in the USA EBCTCG, Lancet, 2010

18 Penyebab KPD Mutasi gen..... ? Faktor risiko  mutasi gen  pertumbuhan jaringan yang tidak terkontrol  kanker

19 Initiation PromotionProgression Mutation Cancer Gene Proliferation Independence Mutation Invade & Spread Stadium Terjadinya Kanker Unspecialized Cell Initiated Cell Pre kanker Kanker Periode laten, bisa lebih dari 20 th

20 Factors determining risk of developing Breast Cancer 20

21 GENDER - All women are at risk Age Family/Personal History Reproductive History Menstrual History Race Genetic Factors Breast Cancer Risk Factors unalterable factors Radiation Treatment with DES

22 All women are at risk Obesity Breastfeeding Not having children Birth Control Pills Alcohol Hormone Replacement Therapy Exercise All women are at risk Obesity Breastfeeding Not having children Birth Control Pills Alcohol Hormone Replacement Therapy Breast Cancer Risk Factors that can be controlled Exercise

23 Family history as a risk factor - Hereditary Breast and Ovarian Cancer Sporadic Family clusters Hereditary Ovarian Cancer Breast Cancer 5%–10%5%–10% 15%-20%

24 Causes of Hereditary Susceptibility to Breast Cancer GeneBRCA1BRCA2TP53PTEN Undiscovered genes Contribution to Hereditary Breast Cancer 20%–40% 10%–30% <1% 30%–70% 5 to 10% of breast cancers can be attributed to inherited factors

25 * Li-Fraumeni Syndrome, abnormal TP53 gene on chromosome 17p, associated with premenopausal breast cancer, childhood sarcomas, brain tumors, leukemia, and adrenocortical adenomas *Cowden’s Syndrome, abnormal PTEN tumor suppressor gene on chromosome 10 associated with premenopausal breast cancers, gastrointestinal malignancies, and benign and malignant

26 Features That Indicate Increased Likelihood of Having BRCA Mutations Multiple cases of early onset breast cancer Ovarian cancer (with family history of breast or ovarian cancer) Breast and ovarian cancer in the same woman Bilateral breast cancer Ashkenazi Jewish heritage Male breast cancer

27 BRCA1-Associated Cancers: Lifetime Risk Possible increased risk of other cancers (e.g. prostate, colon) Breast cancer 50%-85% (often early age at onset, less than 40 years) Second primary breast cancer 40%-60% Ovarian cancer 15%-45%

28 BRCA2-Associated Cancers: Lifetime Risk breast cancer (50%-85%) ovarian cancer (10%-20%) male breast cancer (6%) Increased risk of prostate, laryngeal, and pancreatic cancers (magnitude unknown)

29 Signs and Symptoms 29 Most common: lump or thickening in breast. Often painless Change in color or appearance of areola Redness or pitting of skin over the breast, like the skin of an orange Discharge or bleeding Change in size or contours of breast

30 Gejala KPD Dini Dini : Benjolan di payudara Teraba Keras Tidak terasa nyeri

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32 Gejala KPD Stadium Lanjut Benjolan yang besar Tukak Benjolan di ketiak Gejala penyebaran

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34 Diagnosis KPD Anamnesis Pemeriksaan Fisik Pemeriksaan Tambahan –Pencitraan USG mamae Mamografi –Patologi Sitologi / FNAB Histopatologi Imunohistokimia

35 Anamnesis Lokal –Benjolan : kapan ? cepat ? nyeri ? –Puting : discharge ? (darah, serous dst) tertarik, berubah posisi –Kulit : kulit jeruk, berubah warna, tarikan, tukak Regional : apakah ada benjolan ? –Payudara kontra lateral –Aksila –Supraclavikula

36 Sistemik –Metastase hati : dispepsia  ikterik –Metastase tulang : nyeri tulang terutama pada malam hari –Metastase paru : Batuk batuk kering tidak sembuh > 3 minggu Sesak nafas : lanjut Faktor Risiko

37  Clinical Breast Exam:  Inspect (relaxed, arms raised, hands on hips)  Breast symmetry  Skin changes (dimpling, retraction, edema, ulceration)  Nipples (symmetry, inversion/retraction, discharge)  Palapation (breasts, axillae, entire chest wall)  Pain  Masses  Regional lymph nodes (Axillary and Supraclavicular)  Documentation  “Clock” system  Location of concern and abnormality  Distance from areola  Size of mass Evaluation: Physical Exam

38  Clinical Breast Exam: Evaluation: Physical Exam Use pads of the index, third, and fourth fingers (inset) make small circular motions Make three circles with the finger pads, increasing the level of pressure (subcutaneous, mid- level, and down to the chest wall) with each circle Position the patient in the direction of palpation for the CBE.

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40 Benign vs. Malignant Chief ComplaintBenign CharacteristicsMalignant Characteristics Breast massMultiple lesionsSingle lesion “Rubbery”Hard MobileImmovable Well circumscribed borderIrregular borders Nipple dischargeBilateralUnilateral MultiductalUniductal MilkyBloody, Clear, or Colored Spontaneous Persistent Skin changesRetraction Dimpling Thickening

41 Staging : TNM = AJCC 2012 KPD Dini : Stage 1 dan 2 KPD Lanjut : - Lokal : Stage 3A dan 3B - Jauh : Stage 4

42 Deteksi dini merupakan proteksi terbaik terhadap KPD

43 Deteksi Dini 1.Pemeriksaan Klinis Payudara 2.Mammogram 3.Sadari tiap bulan

44 Deteksi Dini 1.Pemeriksaan Klinis Payudara 2.Mammogram 3.Sadari tiap bulan

45 Pemeriksaan Klinis Payudara 1.Perawat terlatih 2.Dokter Umum 3.Dokter Bedah 4.Dokter Bedah Tumor

46 Pemeriksaan Klinis Payudara Usia... thnFrekuensi 20 – 39Setiap 3 tahun 40Setiap 1 tahun

47 Deteksi Dini 1.Pemeriksaan Klinis Payudara 2.Mammogram 3.Sadari tiap bulan

48 Deteksi Dini 1.Pemeriksaan Klinis Payudara 2.Mammogram 3.Sadari tiap bulan

49 MAMMOGRAHY RESULTS

50 Mammography Equipment 50

51 SCREENING MAMMOGRAM

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53 Tanda Ganas Pada Mamogram Primer : 1.Densitas tinggi pada tumor 2.Batas tidak teratur 3.Translusen disekitar tumor 4.Stelata 5.Mikrokalsifikasi 6.Ukuran klinis lebih besar dari radiologis

54 Tanda Ganas Pada Mamogram Sekunder : 1.Retraksi kulit 2.Vaskularisasi bertambah 3.Perubahan posisi putting 4.KGB aksila + 5.Arsitektur payudara berubah

55 Calcification Macrocalcifications –Large white dots – Almost always noncancerous and require no further follow-up. Microcalcifications –Very fine white specks –Usually noncancerous but can sometimes be a sign of cancer. –Size, shape and pattern

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58 Breast Imaging Reporting and Data System (BI-RADS) CategoryDefinitionActionPPVmalignancy 0Incomplete, possible finding Additional imaging 15% 1NegativeRoutine screening <1% 2Benign findingsRoutine screening <1% 3Probably benign findings 6 mo follow-up2% 4Suspicious abnormality Biopsy30-45% 5Highly suggestive of malignancy Biopsy, action as indicated 93%

59 Deteksi Dini 1.Pemeriksaan Klinis Payudara 2.Mammogram 3.Sadari tiap bulan

60 Deteksi Dini 1.Pemeriksaan Klinis Payudara 2.Mammogram 3.Sadari tiap bulan

61 SELF BREAST EXAMINATION = SADARI Sekali sebulan dimulai pada usia 20 tahun. Pada hari ke dari hari pertama haid terakhir. KAPAN?KAPAN?

62 SADARI 2 Bagian SADARI : –Looking –Feeling

63 LOOKING

64 Benjolan Benjolan atau penebalan kulit di payudara atau di ketiak. Benjolan baru harus diperiksa ulang pada periode berikutnya.

65 Perubahan Warna Kulit, Ukuran dan Tekstur Setiap perubahan ukuran, bentuk atau simetri Setiap penebalan / pembengkakan pada payudara.

66 Skin Dimpling Lesung ataupun tarikan ke dalam dari kulit atau puting.

67 Perubahan Pada Puting Puting bewarna merah atau bersisik. Nyeri pada puting. Puting dengan retraksi, melipat kedalam, perbahan bentuk dan arah.

68 Nipple Discharge Discharge yang berdarah, jernih dan melengket, ataupun gelap.

69 Feeling Periksa tiap payudara secara terpisah. Gunakan telapak tangan bukan ujung jari Pemeriksaan dengan perabaan bukan dengan dijepit Periksa Aksila /Ketiak

70 FEELING

71 Patterns

72 Pengobatan Tergantung pada : –Ukuran tumor –Jenis kanker –Status kelenjar getah bening –Penjalaran jauh ke organ lain spt : hati, paru, tulang, otak dsb

73 TREATMENT Surgery Radiation Therapy Terapi sistemik : –Chemotherapy –Hormonal Therapy –Targeted Therapy

74 SURGERY

75 RADIATION THERAPY

76 PROGNOSIS KPD dini ( Stage 1) 10 tahun survival - lebih 90% KPD lanjut ( Stage IV) 10 tahun survival – kurang dari 10%

77 DISINFORMASI MASYARAKAT Takut ke dokter Efek samping Obat herbal Bisnis Tidak mengikuti prosedur riset

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83 Apakah Obat Kanker Modern Ada Yang Berasal Dari Alam ?

84 Taxus brevifolia Docetaxel Paclitaxel Taxus brevifolia

85 Bagaimana Cara Menemukan Obat Kanker Baru ?

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88 Pencegahan Diet Olah Raga Gaya Hidup Hindari Faktor Risiko

89 EAT HEALTHY

90 EXERCISE

91 Things to Remember Kanker bukan merupakan hukuman mati 80% benjoan di payudara ternyata bukan kanker. 90% KPD stadium awal dapat disembuhkan. Deteksi dini merupakan cara yang paling ampuh.

92 Things to Remember Deteksi dini merupakan proteksi terbaik KPD. 3 cara untuk deteksi dini –Mammogram regular –Pemeriksaan klinis payudara regular –SADARI

93 Thank You


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