Presentasi Kasus

Identitas Pasien

• Nama: Ny. S• Umur: 35 th• Pekerjaan: Ibu rumah tangga• Suku: Sunda• Tanggal Kunjungan:8/5/2011

• Keluhan Utama: Benjolan di payudara sebelah kiri sejak 1 bulan SMRS

Riwayat Penyakit Sekarang

• Sejak 1 bulan SMRS pasien mengeluh ada benjolan di payudara sebesar biji salak (± 2cm)

• Benjolan keras, mudah digerakan, tidak terasa sakit, tidak bertambah besar

• Tidak ditemukan benjolan di tempat lain• Tidak keluar cairan dari putting• Tidak ada luka di payudara• Tidak ada penurunan berat badan, demam (-),

lemas (-)

Riwayat Penyakit Dahulu

• Hipertensi (-)• DM (-)• Asma (-)• Alergi (-)

Riwayat Penyakit Keluarga• Hipertensi (-)• DM (-)• Asma (-)• Alergi (-)• Riwayat penyakit serupa (-)• Riwayat keganasan (-)

Riwayat Social

• Pasien menikah usia 13 tahun• Memiliki 3 orang anak, dengan jarak masing-

masing 5 tahun• Tiap anak ASI eksklusif selama 2 tahun

• Menarche: usia 14 tahun, siklus normal 1x tiap bulan selama 7 hari

• KB: suntik 3 bulan baru mulai 9 bulan terakhir.

Pemeriksaan Fisik

• Keadaan Umum: CM, TSR• Tanda-tanda vital– TD: 140/90 mmHg– Nadi: 100– RR: 22– Suhu: afeb

Status Generalis

Status Lokalis

• Benjolan pada payudara kiri di sebelah lateral, • Warna ~ kulit sekitar, suhu ~ sekitar• Benjolan ukuran 2cm x 2cm x 2cm, permukaan

rata, padat, mobile, nyeri (-)

Working diagnosis

• Tumor mamae suspek FAM

Rencana diagnosis

• USG• Pro eksisi biopsi

LITERATURE REVIEW

Epidemiology

• 22% cases of primary cancer• In Indonesia, Breast cancer is the second

largest cancer after cervical cancer• More than 70% cases found in advance stage

Anatomy

Risk factor Major factors• Gender• Age• Previous breast cancer• Family history and genetic

predisposition (BRCA 1 or 2 mutations)

Intermediate factors• Alcohol and diet• Endocrine factors:• Early menarche• Late menopause• Oral contraceptive and hormone

replacement therapy

• Nulliparity• Irradiation• Benign proliferative breast disease

(e.g. multiple papillomatosis)• Benign breast disease (e.g.

hyperplasia with moderate or severe atypia)

Minor or controversial factors• Body size• Stress• Benign breast disease (e.g.

hyperplasia with moderate or mild atypia)

Pathogenesis

• Modification of DNA of breast epithelial caused by gene alteration & enviromental agents

• Growth factor increase the rate of premalignant to malignant cells

• Specific oncogenes are modified• Transition of carcinoma in situ into invasive

carcinoma

Clinical manifestation• A new lump ,a painless, hard

mass that has irregular edges • Swelling of all or part of a breast • Skin irritation or dimpling• Breast or nipple pain• Nipple retraction (turning

inward) • Redness, scaliness, or thickening

of the nipple or breast skin• Nipple discharge • The skin may have ridges or

pitting so that it looks like the skin of an orange.

Physical examination

• Both breast should be examined

• The tumor mass- Location- Size- Consistency- Surface- Form & tumor edge- Number of tumor- Fixated / not to surrounding

area

• Skin changes- redness, dimpling,

edema, satellite nodule- Peau d’orange, ulcer• Nipple - Retraction- Erosion- Crustae- Discharge

Physical examination

• Lymph node - axilla: number of

involved lymph node, size, consistency, fixation

- Infraclavicula- Supraclavicula

• Site of metastasis- Lung- Bone- Liver- Brain

Diagnosis

• Mammogram - It detects lump that cannot be felt in palpation• USG- Target a specific area of concern found on the

mammogram. Ultrasound helps distinguish between cysts & solid tumor

• Biopsy- Fine needle aspiration- Core biopsy- Open biopsy

Classification

Noninvasive Epithelial Cancers

• Lobular carcinoma in situ (LCIS) • Ductal carcinoma in situ (DCIS) or

intraductal carcinoma • Papillary, cribriform, solid, and comedo

types Invasive Epithelial Cancers (Percentage of

Total) • Invasive lobular carcinoma (10%-15%) • Invasive ductal carcinoma • Invasive ductal carcinoma, NOS (50%-

70%) • Tubular carcinoma (2%-3%) • Mucinous or colloid carcinoma (2%-3%)

• Medullary carcinoma (5%) • Invasive cribriform carcinoma (1%-3%) • Invasive papillary carcinoma (1%-2%)• Adenoid cystic carcinoma (1%) • Metaplastic carcinoma (1%)

Mixed Connective and Epithelial Tumors • Phyllodes tumors, benign and

malignant • Carcinosarcoma • Angiosarcoma • NOS (which is an abbreviation for not

otherwise specified).

STAGE

0 Tis N0 M0

I T1* N0 M0

IIA T0

T1*

T2

N1

N1

N0

M0

M0

M0

IIB T2

T3

N1

N0

M0

M0

IIIA T0

T1

T2

T3

T3

N2

N2

N2

N1

N2

M0

M0

M0

M0

M0

IIIB T4

T4

T4

N0

N1

N2

M0

M0

M0

IIIC Any T N3 M0

IV Any T Any N M1

Management Treatment of stage I, stage II, stage IIIA and operable stage IIIC breast cancer may include the following:

• Breast-conserving surgery to remove only the cancer and some surrounding breast tissue, followed by lymph node dissection and radiation therapy.

• Modified radical mastectomy with or without breast reconstruction surgery.

• Sentinel lymph node biopsy followed by surgery.

Adjuvant therapy (treatment given after surgery to increase the chances of a cure) may include the following:

• Radiation therapy to the lymph nodes near the breast and to the chest wall after a modified radical mastectomy.

• Systemic chemotherapy with or without hormone therapy.

• Hormone therapy

Management Treatment of stage IIIB and inoperable stage IIIC breast cancer may include the following:

• Systemic chemotherapy• Systemic chemotherapy

followed by surgery (breast-conserving surgery or total mastectomy), with lymph node dissection followed by radiation therapy. Additional systemic therapy (chemotherapy, hormone therapy, or both) may be given.

Stage IV and metastatic breast cancer

• Treatment of stage IV or metastatic breast cancer may include the following:

• Hormone therapy and/or systemic chemotherapy with or without trastuzumab (Herceptin).

• Radiation therapy and/or surgery for relief of pain and other symptoms.

• Bisphosphonate drugs to reduce bone disease and pain when cancer has spread to the bone.

Screening

• Self breast exams - Started since fertile: next week after first day of

menstruation• Physical examination by doctor• Mammogram- Women 35-50 years old every two years- Women 50 years old every year