deteksi dini kpd
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KPDTRANSCRIPT
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Masalah Kanker Masalah Kanker Payudara dan Deteksi Payudara dan Deteksi
DiniDiniAgus SutarmanAgus Sutarman
Departemen Bedah RSPAD Gatot SoebrotoDepartemen Bedah RSPAD Gatot Soebroto
Sub SMF Bedah Tumor / HNBSSTSub SMF Bedah Tumor / HNBSST
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PendahuluanPendahuluan
• Kanker adalah petumbuhan sel yang abnormal tak terkendali dan terus menerus serta dapat merusak jaringan setempat serta dapat menjalar ke tempat yang jauh dari asalnya
• Dapat tumbuh/berasal dari setiap jenis sel di tubuh manusia
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Loss of contact inhibitionIncrease in growth factor secretionIncrease in oncogene expressionLoss of tumor suppressor genesNeovascularization
Oncogene expression is rare
Intermittent or coordinatedgrowth factor secretion
Presence of tumor suppressor genes
Banyak mitosis
Nukleus
Blood vessel
Abnormalheterogeneous cells
selnormal
sedikitmitosis
Perbedaan sel kanker dan normal
Sel Kanker Sel normalSel Kanker Sel normal
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TumorigenesisTumorigenesis
Kastan MB. Cancer: Principles & Practice of Oncology. 5th ed. 1997;121-134.
Initialgenetic change
(eg, loss of function of pRb or overexpression of c-myc)
Decreasein apoptosic
cell death
Subsequentgenetic change
Normalcell
Increase incell proliferationand apoptosic
cell death
Secondarygenetic change
(eg, dysfunction of p53or overexpression of bcl-2)
Further alterationsin phenotype(eg, invasivenessand metastasis)
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KANKER TERBANYAK DI KANKER TERBANYAK DI DUNIADUNIA
KANKER TERBANYAK DI KANKER TERBANYAK DI DUNIADUNIA
Lung Breast Stomach 669,000Stomach Cervix Lung 661,000Colon/rectum Colon/rectum Breast 572,000Mouth/pharynx Stomach Colon/rectum 572,000Prostate Corpus uteri Cervix 466,000Esophagus Lung Mouth/pharynx
379,000Liver Ovary Esophagus 310,000Bladder Mouth/pharynx Liver 251,000Lymphoma Esophagus Lymphoma 238,000Leukemia Lymphoma Prostate 236,000
- - Bladder 219,000- - Leukemia 188,000- - Uterus 150,000- - Ovary 140,000- - Pancreas 140,000
Rank
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Both SexesTogether
Number of New Cases Per Annum (WHO Estimates)
FemalesMalesNumber of
Cases
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KEMATIAN AKIBAT KANKERKEMATIAN AKIBAT KANKERKEMATIAN AKIBAT KANKERKEMATIAN AKIBAT KANKER
1930 1940 1950 1960 1970 1980 1990
US data/Adapted from Cancer Journal for Clinicians, 1994.
MalesMales80
70
60
50
40
30
20
10
0
Year
ProstateProstateColon and rectumColon and rectum
PancreasPancreasStomachStomachEsophagusEsophagusBladderBladder
LungLung
Rat
e p
er 1
00,0
00 M
ale
Pop
ula
tion
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KEMATIAN AKIBAT KANKERKEMATIAN AKIBAT KANKERKEMATIAN AKIBAT KANKERKEMATIAN AKIBAT KANKER
19301930 19401940 19501950 19601960 19701970 1980198019901990
US data/Adapted from Cancer Journal for Clinicians, 1994.
FemalesFemales8080
7070
6060
5050
4040
3030
2020
1010
00
YearYear
LungLungBreastBreast
Colon and rectumColon and rectum
OvaryOvaryPancreasPancreasUterusUterusStomachStomach
Rat
e p
er 1
00,0
00 F
em
ale
Pop
ulat
ion
Rat
e p
er 1
00,0
00 F
em
ale
Pop
ulat
ion
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STADIUM KANKER STADIUM KANKER PAYUDARAPAYUDARA
STADIUM KANKER STADIUM KANKER PAYUDARAPAYUDARA
Stage 0Stage 0 Tis.Tis. N0N0 M0M0
Stage IStage I T1T1 N0N0 M0M0
Stage IIAStage IIA T0, T1T0, T1 N1N1 M0M0
T2T2 N0N0 M0M0
Stage IIBStage IIB T2T2 N1N1 M0M0
T3T3 N0N0 M0M0
Stage IIIAStage IIIA T0, T1, T2T0, T1, T2 N2N2 M0M0
T3T3 N1, N2N1, N2 M0M0
Stage IIIBStage IIIB Any TAny T N3N3 M0M0
T4T4 Any NAny N M0M0
Stage IVStage IV Any TAny T Any NAny N M1M1
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Difinisi tumor primer Tx1º tumor tidak dapat dinilaiT0No tidak diketahui massa tumornyaTis Carcinoma in situT1 diameternya 2 cm T1a diameter 0.5 cm T1b diameter 0.5 - 1 cm T1c diameter > 1 cm but 2 cm nT2 diameter > 2 cm tetapi 5 cm T3 diameter 5 cmT4 berapapun ukuran, dengan perlekatan pada dd thorax atau kulit T4a melekat pada dd thoraxl T4b Oedema, ulceration atau satellite nodules pd kulit, pada sisi payudara yg sama T4c terdapat spt T4a & T4b T4d Inflammatory carcinoma
Difinisi tumor primer Tx1º tumor tidak dapat dinilaiT0No tidak diketahui massa tumornyaTis Carcinoma in situT1 diameternya 2 cm T1a diameter 0.5 cm T1b diameter 0.5 - 1 cm T1c diameter > 1 cm but 2 cm nT2 diameter > 2 cm tetapi 5 cm T3 diameter 5 cmT4 berapapun ukuran, dengan perlekatan pada dd thorax atau kulit T4a melekat pada dd thoraxl T4b Oedema, ulceration atau satellite nodules pd kulit, pada sisi payudara yg sama T4c terdapat spt T4a & T4b T4d Inflammatory carcinoma
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STADIUM IIASTADIUM IIASTADIUM IIASTADIUM IIAT2 N0 M0T2 N0 M0
T T << 2 cm 2 cmT1T1
N1 = metastasis to movable ipsilateral axillary lymph node(s)N1 = metastasis to movable ipsilateral axillary lymph node(s)
2 cm < T 2 cm < T << 5 cm 5 cm
No evidenceNo evidenceof tumorof tumor
T0T0
T0 T0 T1T1
N1 M0N1 M0}
T2T2
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STADIUM IVSTADIUM IVSTADIUM IVSTADIUM IV
M1 = Distant metastasis (including metastases to ipsilateralM1 = Distant metastasis (including metastases to ipsilateralsupraclavicular, cervical, or contralateral internal mammary lymph nodes)supraclavicular, cervical, or contralateral internal mammary lymph nodes)
Any T any N M1Any T any N M1
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10 KANKER TERBANYAK DI 10 KANKER TERBANYAK DI INDONESIAINDONESIA
Number ICD Location Relative Frequency
1.2.3.4.5.6.7.8.9.
10.
180174173147
183196154171193
Cervix
Women's breastSkin
NasopharynxUnknownOvaries
Lymphoid nodesRectum
Soft tissueThyroid
18,41 % 11,57 % 8,24 % 6,15 % 5,16 % 4,94 % 4,91 % 4,42 % 3,50 % 3,38 %
Source: Bulletin of Pathology Based Cancer Registry, BRK-IAP, No. 4, 1989.
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PERBANDINGAN INSIDENS PERBANDINGAN INSIDENS KANKER DI INDONESIA KANKER DI INDONESIA
Padang Palembang Bandung Semarang Surabaya U. Pandang
1. Breast2. Soft tissue3. Unknown4. Rectum5. Ovary6. Cervix7. Nasopharynx8. Lymph nodes9. Soft tissue10.Prostate
CervixSkinBreastUnknownNasopharynxPlacentaRectumOropharynxColonLymph nodes
CervixBreastSkinNasopharynxLymph nodesUnknownRectumOvarySoft tissueThyroid
CervixBreastSkinUnknownOvaryNasopharynxLymph nodesRectumThyroidSoft tissue
CervixBreastLymph nodesSkinNasopharynxOvarySoft tissueThyroidRectumColon
BreastSkinCervixUnknownOvaryLymph nodesThyroidNasopharynxSoft tissueRectum
Ramli, JICC 1995
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Sebagian besar kanker payudara di Indonesia masih dalam stadium lanjut (>50%)
• 1968 - Sjamsuhidayat, Djamaluddin 22% stadium operable ; 78% stadium inoperable
• 1984 - Tjindarbumi 30-35% stadium operable ; 67-70% stadium
inoperable
• 1991 – Ramli42% stadium operable ; 58% stadium inoperable
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Kesintasan 5 tahun Kanker payudaraKesintasan 5 tahun Kanker payudara
0
20
40
60
80
100
120
1 2 3 4 5
untreatedtreatednatural
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BREAST CANCERBREAST CANCERSurvival by stageSurvival by stage
BREAST CANCERBREAST CANCERSurvival by stageSurvival by stage
Stage 0
Stage I
Stage IIA
Stage IIB
Stage IIIA
Stage IIIB
Stage IV
Percent surviving
100
80
60
40
20
01 2 3 4 5 6
Years after diagnosis
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Program Deteksi Dini dan Program Deteksi Dini dan SasarannyaSasarannya
Program deteksi dini sangat penting, berupa :1. Penyuluhan kepada masyarakat tentang
permasalahan kanker :a) Kanker payudara yang tergolong kepada
kanker yang dapat ditemui pada stadium dinib) Kanker payudara bukanlah penyakit yang tidak
dapat disembuhkan asal berobat dalam stadium dini
c) Memperkenalkan “faktor risiko”d) Tidak semua kelainan payudara adalah kanker
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Faktor RisikoFaktor Risiko
• Umur > 30 thUmur > 30 th• Anak pertama lahir setelah usia 35 thAnak pertama lahir setelah usia 35 th• Tidak kawinTidak kawin• Menarche < 12 thMenarche < 12 th• Menopause datang terlambat (>55 th)Menopause datang terlambat (>55 th)• Pernah operasi tumor jinak payudaraPernah operasi tumor jinak payudara• Adanya kanker pada payudara kontralateralAdanya kanker pada payudara kontralateral• Mendapat terapi hormonal yang lama (oral Mendapat terapi hormonal yang lama (oral
kontrasepsi)kontrasepsi)• Operasi ginekologiOperasi ginekologi• Radiasi dinding dada, 2-3 kali lebih tinggiRadiasi dinding dada, 2-3 kali lebih tinggi• Riwayat keluarga, 2-3 kali lebih tinggiRiwayat keluarga, 2-3 kali lebih tinggi
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Kelainan-kelainan yang sering dijumpai dalam klinik, seperti :
• Fibroadenoma• Mammary dysplasia (fibrocystic disease of the breast)• Galactocele• Tumor Phyllodes• Kanker payudara
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2. Memasyarakatkan program SADARI bagi wanita mulai usia subur. 85% kelainan di payudara justru pertama kali dikenali oleh penderita. Setiap selesai menstruasi pada setiap bulan
3. Pemeriksaan screening mammografiPenelitian di :Neijmegen : Wanita (35-65th)mortalitas 50%Utrectht : Wanita (50-65th)mortalitas 70%
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Sadari…… jangan TerlambatSadari…… jangan Terlambat
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Pemeriksaan PayudaraPemeriksaan Payudara
Sadari Pemeriksaan dokter Mamografi
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Waktu mamografiWaktu mamografi
Sebaiknya dikerjakan pada :• Wanita usia diatas 40 tahun
sebagai baseline• Wanita dengan faktor risiko tinggi• 7-10 hari setelah masa haid• Diulang 2-3 tahun,setelah 50
tahun tiap tahun
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MamografiMamografi
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American Cancer Society dalam proyek Breast American Cancer Society dalam proyek Breast Cancer Screening menganjurkan untuk Cancer Screening menganjurkan untuk
mendapatkan kasus-kasus dini pada wanita mendapatkan kasus-kasus dini pada wanita tanpa keluhan melakukan upaya :tanpa keluhan melakukan upaya :
• Wanita > 20 tahun melakukan SADARI tiap bulan• Wanita 20-40 tahun; tiap 3 tahun memeriksakan diri ke
dokter• Wanita > 40 tahun; tiap tahun memeriksakan diri ke dokter• Wanita 35-40 tahun; melaksanakan baseline mammografi• Wanita < 50 tahun; konsultasi ke dokter untuk kepentingan
mammografi• Wanita > 50 tahun; kalau bisa tiap tahun mammografi• Wanita dengan riwayat keluarga (+); memerlukan
pemeriksaan fisik oleh dokter lebih sering dan pemeriksaan mammografi secara periodik sebelum 50 tahun
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Kecurigaan keganasan pada tumor Kecurigaan keganasan pada tumor payudara secara klinis :payudara secara klinis :
• Tumor payudara secara klinis tidak jelas suatu Tumor payudara secara klinis tidak jelas suatu tumor jinaktumor jinak
• Tumor payudara terdapat pada golongan “risiko Tumor payudara terdapat pada golongan “risiko tinggi”tinggi”
• Kista payudara yang cairannya berdarahKista payudara yang cairannya berdarah• Keluar darah atau cairan serous dari puting susu Keluar darah atau cairan serous dari puting susu
atau puting susu, areola terdapat koreng dan atau puting susu, areola terdapat koreng dan gambaran seperti eksimgambaran seperti eksim
• Pada mamogram terdapat tanda-tanda Pada mamogram terdapat tanda-tanda keganasan: mikrokalsifikasi, gambaran bintang, keganasan: mikrokalsifikasi, gambaran bintang, dsb.dsb.
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Gejala & Tanda Gejala & Tanda Kanker PayudaraKanker Payudara
Adanya benjolan di ketiakAdanya benjolan di ketiak
Benjolan di payudaraBenjolan di payudara PenebalanPenebalan NyeriNyeri
Cairan putting susuCairan putting susu Retraksi putting/kulitRetraksi putting/kulit
Oedema kulitOedema kulit
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Kanker PayudaraKanker Payudara
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Skin dimplingSkin dimpling
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Benjolan payudaraBenjolan payudara
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Nipple dischargeNipple discharge
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Kelainan kongenital
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Paget`s disesase
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Pemeriksaan penunjangPemeriksaan penunjang
• Pemeriksaan fisik sangat penting• Mammografi 80%• Ultrasonografi(USG)• Sitologi (FNAB) > 90%
standar blok parafin PA
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Mamografi Kanker PayudaraMamografi Kanker Payudara
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Ultrasonografi(USG)Ultrasonografi(USG) Kanker Payudara Kanker Payudara
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• 21–23 gauge needle
• Sensitivity: 68–100%
• Specificity: 82–100%
• Guidance
– Free hand
– Stereotactic
– UltrasoundBio
psy
Opt
ions
Bio
psy
Opt
ions
Jackson VP, Bassett, LW
Stereotactic fine-needle aspiration biopsy for nonpalpable breast lesions.
AJR AM J Roentgenol 1990; 154:1196-97
FNAFNA
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Bio
psy
Opt
ions
Bio
psy
Opt
ions
Core Needle BiopsyCore Needle Biopsy Can be performed in an
outpatient setting or doctor’s office
Local anesthesia
No sutures
4 – 6 needle insertions to collect a sufficient amount of breast tissue for an accurate diagnosis
Unable to mark biopsy site
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MammotomeMammotome® ®
Breast Biopsy SystemBreast Biopsy System BenefitsBenefits
Single insertion, local anesthesia
Large contiguous tissue samples
Vacuum-assisted enables aspiration of fluids
Device may / may not be “fired”
Sutureless - 2-5 mm skin incision dependant upon the size of the probe
Ability to mark biopsy site with MicroMark ™ II Tissue Marker for mammographic follow-up
Bio
psy
Opt
ions
Bio
psy
Opt
ions
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Open biopsyOpen biopsy
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Triple DiagnosticTriple Diagnostic
• Klinis Karsinoma• Mammografi Karsinoma• FNAB Karsinoma
boleh dilakukan tindakan definitif
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PengobatanPengobatan
• Bedah
• Radiasi
• Kemoterapi
• Hormonal
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Breast conserving treatment(BCT)Breast conserving treatment(BCT)
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Sentinel Lymph node dissectionSentinel Lymph node dissection
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Mastektomi Radikal ModifikasiMastektomi Radikal Modifikasi
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Rekonstruksi pasca mastektomiRekonstruksi pasca mastektomi
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Terima kasihTerima kasih