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

Breast Disease Congenital Inflamation Metabolic / Hormonal Neoplasm Trauma

Breast Disease Congenital Inflamation Metabolic / Hormonal Neoplasm Trauma

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

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.

Breast Complaints Pain Mass Skin or Nipple Changes Nipple Discharge

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

Breast Complaints Pain Mass Skin or Nipple Changes Nipple Discharge

Breast Neoplasm Benign Epitelial Mesenchimal Combine Malignant Primary Epithelial Others Metastatic Oposite breast Other site

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

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

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

BREAST CANCER IN THE WORLD 1.15 million new cases Incidence increasing in most countries 470 000 deaths Half of the global burden in low- and medium-resourced countries

Trends since 1950 in age-standardized death rates comparing breast and selected other types of cancer, among women in the USA EBCTCG, Lancet, 2010 Decreasing cancer mortality is due to Screening and early detection Effective local therapy Active systemic therapy

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

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

Factors determining risk of developing Breast Cancer

Breast Cancer Risk Factors unalterable factors Age GENDER - All women are at risk Reproductive History Family/Personal History Menstrual History Race Atypical ductal or lobular hyperplasia Lobular carcinoma in situ Gender Male:female –1:100 Age 1 in 50 by age 50 1 in 8 over life time Let’s talk about the most common risk factors that cannot be changed. Besides being a woman, you are at risk As you get older If you or close blood relatives have had or have this disease. A woman with breast cancer has 3 to 4 times a greater chance of developing a new cancer. Depending on your race: we talked before that white women are more frequently diagnosed with breast cancer than black women. But black women die more of this disease. Asian, Hispanic, and American Indian women are at lower risk. Treatment w/ DES (Diethylstilbestrol)- Between 1940 and 1960, some pregnant women were given DES to lower their chances of miscarriage. Recent studies show that these women have a 35% increased risk of getting breast cancer. Radiation: women who have had chest radiation treatment have a greater risk of breast cancer. Genetic factors: about 1 case of breast cancer in 10 is linked to changes/mutations in certain genes. Menstrual history: women having her menstrual periods before 12 years of age or who went through menopause after age 50 have a slightly higher risk. Reproductive history: women that have no children or who have their first child after 30 have a 40% higher risk. Radiation Treatment with DES Genetic Factors

Breast Cancer Risk Factors that can be controlled Obesity Obesity All women are at risk All women are at risk Not having children Not having children Exercise Exercise Hormone replacement therapy – yes Estrogen replacement therapy – no? Oral contraceptives – minimal ? High hormone levels Post menopausal obesity Increased bone density Now let’s take a look at the risk factors that can be controlled: Obesity: Being overweight increases the risk, especially after reaching menopause if that weight gain took place during adulthood. Exercise: Exercise can lower breast cancer risk by about 60% in adults. More research is being done to confirm these findings. Breastfeeding: Studies have shown that breastfeeding lowers breast cancer risk, especially is breastfeeding lasts 1½ to 2 years. One study found that having several children and breastfeeding could reduce the risk of breast cancer by half. This may be because breastfeeding lowers a woman’s total number of menstrual periods. Alcohol: Alcohol is clearly linked with an increased risk of breast cancer. Those who have 2 to 5 drinks daily have about 1½ times the risk of women who drink no alcohol. HRT: It has become clear that long term use (several years) of combined HRT (estrogens together with progesterone) for the relief of menopause symptoms may slightly increase the risk of breast cancer as well as the risk of heart disease, blood clots, and strokes. The breast cancers are also found at a more advanced stage. As well, HRT seems to reduce the effectiveness of mammograms. Birth control pills: studies have found that women now using birth control pills have a slightly increases risk of getting breast cancer. Not having children before the age of 30 increases a woman’s risk by 40%. Breastfeeding Breastfeeding Birth Control Pills Birth Control Pills Hormone Replacement Therapy Hormone Replacement Therapy Alcohol Alcohol

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

Causes of Hereditary Susceptibility to Breast Cancer 5 to 10% of breast cancers can be attributed to inherited factors Contribution to Hereditary Breast Cancer 20%–40% 10%–30% <1% 30%–70% Gene BRCA1 BRCA2 TP53 PTEN Undiscovered genes

* 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

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

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

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

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

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

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

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

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

Sistemik Faktor Risiko 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

Evaluation: Physical Exam 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 Clinical Breast Exam: Position the patient in the direction of palpation for the CBE. 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

Benign Characteristics Malignant Characteristics Benign vs. Malignant Chief Complaint Benign Characteristics Malignant Characteristics Breast mass Multiple lesions Single lesion “Rubbery” Hard Mobile Immovable Well circumscribed border Irregular borders Nipple discharge Bilateral Unilateral Multiductal Uniductal Milky Bloody, Clear, or Colored Spontaneous Persistent Skin changes Retraction Dimpling Thickening

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

Deteksi dini merupakan proteksi terbaik terhadap KPD

Deteksi Dini Pemeriksaan Klinis Payudara Mammogram Sadari tiap bulan

Deteksi Dini Pemeriksaan Klinis Payudara Mammogram Sadari tiap bulan

Pemeriksaan Klinis Payudara Perawat terlatih Dokter Umum Dokter Bedah Dokter Bedah Tumor

Pemeriksaan Klinis Payudara Usia ... thn Frekuensi 20 – 39 Setiap 3 tahun 40 Setiap 1 tahun

Deteksi Dini Pemeriksaan Klinis Payudara Mammogram Sadari tiap bulan

Deteksi Dini Pemeriksaan Klinis Payudara Mammogram Sadari tiap bulan

MAMMOGRAHY RESULTS

Mammography Equipment

SCREENING MAMMOGRAM

Tanda Ganas Pada Mamogram Primer : Densitas tinggi pada tumor Batas tidak teratur Translusen disekitar tumor Stelata Mikrokalsifikasi Ukuran klinis lebih besar dari radiologis

Tanda Ganas Pada Mamogram Sekunder : Retraksi kulit Vaskularisasi bertambah Perubahan posisi putting KGB aksila + Arsitektur payudara berubah

Calcification Macrocalcifications Microcalcifications 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

Breast Imaging Reporting and Data System (BI-RADS) Category Definition Action PPVmalignancy Incomplete, possible finding Additional imaging 15% 1 Negative Routine screening <1% 2 Benign findings 3 Probably benign findings 6 mo follow-up 2% 4 Suspicious abnormality Biopsy 30-45% 5 Highly suggestive of malignancy Biopsy, action as indicated 93%

Deteksi Dini Pemeriksaan Klinis Payudara Mammogram Sadari tiap bulan

Deteksi Dini Pemeriksaan Klinis Payudara Mammogram Sadari tiap bulan

SELF BREAST EXAMINATION = SADARI Sekali sebulan dimulai pada usia 20 tahun. Pada hari ke 10-15 dari hari pertama haid terakhir. K A P N ?

SADARI 2 Bagian SADARI : Looking Feeling

LOOKING

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

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

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

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

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

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

FEELING

Patterns

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

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

SURGERY

RADIATION THERAPY

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

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

Apakah Obat Kanker Modern Ada Yang Berasal Dari Alam ?

Taxus brevifolia Paclitaxel Docetaxel Taxus brevifolia

Bagaimana Cara Menemukan Obat Kanker Baru ?

Pencegahan Diet Olah Raga Gaya Hidup Hindari Faktor Risiko

EAT HEALTHY

EXERCISE

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.

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

Thank You