BREAST CANCER AT AGLANCE

INTRODUCTION
1.1. Background
Breast cancer is a malignant tumor derived from cells located in the breast. -Lobular breast consists of lobules, ducts, fatty and connective tissue, blood and lymph vessels. In general, cancer originating from the cells contained in the ducts, some of which came from the lobular and other tissues.
Breast cancer is a malignancy that affects nearly one-third of all malignancy found in women. Breast cancer is also the second leading cause of death after cervical cancer in women as well as occupying the highest incidence of all malignancies. Each year, more than one million new cases of breast cancer are diagnosed worldwide, and nearly 400,000 people will die from the disease. By 2003, breast cancer is the cancer with the highest incidence of 2 in Indonesia and there is a trend from year to year, the incidence is increasing, and as well as in western countries. The incidence of breast cancer in the United States 92/100.000 women per year with a high mortality 27/100.000 or 18% of the deaths were found in women. In Indonesia by "Pathological Based Registration" relative incidence of breast cancer has 11.5%. Indonesia has the incidence is estimated at a minimum of 20,000 new cases per year; with the fact that over 50% of cases are still in the advanced stages.
There are so many risk factors that can lead to the development of breast cancer. Statistically the risk of breast cancer in women increased in nullipara, early menarche, late menopause and in women who are pregnant her first child at the age of 30 years. A total of less than 1% of breast cancers occur in less than 25 years of age, after the age of 39 years the incidence increased rapidly. The highest incidence is found in the age of 45-50 years. While breast cancer in men in the epidemiology of less than 1% of all breast cancers.




LITERATURE REVIEW
II.1 BREAST
II.1.1 Embryology BREAST
In the human embryo, the first breast is known as the "milk steak" that grew around the sixth week of fetal development. An area of ​​thickening ektodermis are known as milk shoots, develops in the embryo body parts pectoralis. Elevation is strictly linear stretches of bilateral axillary to the vulva and is known as the milk line or "mammary ridge". After reaching the ninth week in the womb, milk line to atrophy, except in the pectoral region and the introduction of the first primodrium breast buds nipple. After reaching the twelfth week, the nipple buds invaded by squamous epithelium ektodermis. In the fifth, mesenchymal connective tissue infiltrating breast primordium and berdifrensiasi into dense filaments 15 to 20, which is distributed under the skin shoots symmetrical nipple.
Duktulus mammary develop as growth in the ventral from the rest of embryology, which is divided into the primary milk ducts and lobules end in shoots. Then the buds begin to proliferate into acini after stimulation of ovarian estrogen. During the growth of the uterus, the primary milk duct branching and splitting wide. By reaching the seventh to the eighth month in the womb, duct lumen berkanulasi form associated with immature lactiferous ducts. At birth, the nipple buds have a central cavity corresponding to the area penetrated by the lumen duktulus primary milk. Soon after birth, the nipples shoots full penetration, he bereversi and more basaloid cells invaded by the dark dipigmentasi to form the areola.


II.1.2 ANATOMY OF BREAST
Mammary gland is located at pectoris fascia covering the anterior chest wall. In children and men rudimentary mammary glands. In women after puberty enlarged mammary glands and are considered spherical. In women young adult mammary gland is located in the costa II to VI and prone costanya and extending from the lateral edge of the sternum to the axillary line media. Upper lateral edge extends around the major m.pectoralis and into the axilla. At the top of the exit lateral to the axillary form protrusions called tail protrusion Spencer or breasts.
Each breast consists of 12 to 20 lobules, each of which has a channel to the mammary papilla, called lactiferous ducts. In between there are lobules of connective tissue called Cooper ligament that gives order to the breast. Lobule is a unit of mammary secretions. Each lobule consists of a number of acini, or glands that are in the loose connective tissue and is associated with duct intralobularis. Each acini are composed of two types of cells, namely epithelial and mioepitel. Epithelial cells are secretory cells. Although the synthesis of breast milk only lasts for the duration of pregnancy and post-partum, these cells continuously secrete different types of glycogen proteins inserted into the lumen of the gland. Epithelial cells surrounded by cells containing contractile proteins mioepitel having mechanical functions.
Intralobularis duct associated with duct ekstralobularis. Ekstralobularis duct in the same area interconnected forming subsegmental ducts, which are interconnected to form segmental duct. This will lead to the lactiferous ducts and lactiferous sinus associated with mammary papilla surface through a separate orifice. There are 15-20 lactiferous ducts, each draining a breast segment. The ducts are lined by epithelial cells surrounded by cells mioepitel. Stromal tissue binding denser than lobulusnya and ducts surrounded by elastic tissue Formatting duct drainage function.

Blood supply to the breast is mainly derived from a.perforantes anterior branch of the internal a.mamaria, a.torakalis lateral branching from a.aksilaris, and some a.interkostalis. Innervation is segmental and breast skin from T2 to T6 dermatome segments. Segments can be didenervasi dermatome area totally or partially after the elevation of the skin flap for radical mastectomy or modified. By cutting the skin flap in the axilla, then a main branch can be identified and sacrificed. The nerves of the breast skin taken care of by the cervical plexus branches and n.interkostalis. Breast gland tissue itself maintained by the sympathetic nerves. There were a few nerves more thing to remember with respect to complications of paralysis and numbness after surgery, namely n.interkostobrakialis and n.kutaneus brakius medius taking care sensibility axillary region and the medial part of the upper arm. In the axillary nerve dissection is often difficult to be removed so that numbness in the area.
The flow of lymph from the breast approximately 75% to the axilla, partly to parasternal lymph, mainly from the central and medial and some flow into the gland interpektoralis. In the axilla there were an average of 50 (range 10-90) fruit lymph nodes that lie along the brachial artery and vein. Lymph channels from the breast flow to the anterior axillary, axillary central group, part of the axillary nodes, passing along v.aksilaris and continued directly into the cervical glands in the caudal part in supraklavikuler. Other lymph pathways from areas other than the central and medial vessel leading to the glands along the internal mamaria, also leading to the contralateral axilla, to m.rektus abdominis via falciparum hepatic ligament to the liver, to the pleura, and the contralateral breast.

II.1.3 PHYSIOLOGY BREAST
Throughout his life, the woman's breast and physiological changes patalogis varied. It is mainly associated with variations in hormone levels that occur before, during and after reproduction. Hormones that affect breast development is estrogen, progesterone, LH, FSH (Follicle Stimulating Hormone) and Prolactin. Estrogen and progesterone produced by the ovaries, LH and FSH secreted by basophils cells located in the anterior hypophysis gland whereas prolactin secreted by cells asidofil hypophysis. A few days after birth most babies, both men and women showed slight enlargement of the mammary gland and begin to secrete a little colostrum and disappeared after about a week later. Then again Infantile mammary gland, not active.
With the onset of puberty between 10-15 years, areola enlarges and contains more pigment. Breasts like a "disc". Gland growth will continue until the age of adulthood to spherical. This happened under the influence of estrogen levels are elevated. Especially the growing tissue is fat and connective tissue in the breast between 15-20 lobes. Usually breast shape is perfect after menstruation begins. In the phase of menstruation, breast is very sensitive to changes in estrogen and progesterone. Stromal edema lobularis be very long due to the mitotic phase of the secretion of estrogen and progesterone, making it about the 8th day menstrual phase breasts become larger. On day 22 to day 24 of the menstrual cycle, levels of estrogen and progesterone which reached its peak, there was a maximum breast enlargement. During pregnancy, a proliferation and enlargement of the lobules in preparation for the synthesis and secretion activity to lactation. In the third trimester the number of acini per lobule and lobule size and  differentiate be greatly improved. -Lactalbumin epithelial cells synthesize and secrete milk (casein, and fat globule membrane of milk which is a derivative of mammary luminal surface of the cell) is a useful marker for determining the status of mammary cell differentiation. Estrogen, progesterone, and prolactin together with other hormones is very important in mammary development during pregnancy though so after delivery of estrogen and progesterone levels will decrease and prolactin increases to trigger lactation. If breast milk is stopped, it will happen quickly lobularis structure involution, and mammary structures back to pre-pregnancy structure. During menopause, the effects of estrogen and progestrogen ovarian function stops and starts progressive involution. Regression to the epithelium atrophy or hypoplastic evident in the ducts and lobules and the stroma is replaced by dense fibrous tissue periduktus. Lactiferous duct dilatation braid arise in the lobules isolated. Toraksnya epithelial acini and lobules run may enlarge and form makrokista. On examination, senile or postmenopausal breast asymmetry often with lobular component irregularities and formation of cysts varied in size. Because of the fat content and fibrostoma periduktus advocates depressed, the elderly breast into a structure pendulosa, homogeneous with losing shape and configuration.








II.2 BREAST CARCINOMA
II.2.1 DEFINITION
Breast carcinoma (breast cancer) is a malignancy derived from the parenchyma, stroma, mammary areola and papilla.
Breast cancer is a malignancy that starts from cells in the breast subsequently grow in the breast tissue. Cancer can begin to grow in the milk glands, milk ducts, fatty tissue and connective tissue padapayudara .. It is particularly common in women, but not menutupkemungkinan occurs also in men.

II.2.2 EPIDEMIOLOGY
Breast cancer is the most common cancer in women in Western countries, which is about 32% of all malignancies in women, is the number two cause of death in women. In Indonesia, breast cancer is the biggest cancer in women after cervical cancer. The incidence of approximately 18 per 100,000 women, and mostly found already in an advanced stage. Breast cancer that has predisposisiketurunan is usually suffered by patients with younger age, payudarabilateral cancer patients, patients with a family history positive tumors.
Breast carcinoma rarely before the age of 25 years and is unusual before age 30tahun, but the incidence increases rapidly after the age of 30 years with a mean rat-medium age of 60 years. This disease primarily affects women, breast cancer in priahanya about 1% of cancers North mammae.Eropa, North America is a high incidence area, Southern Europe, an area the incident was AmerikaSelatan, Asia, Africa was a low incidence area. Studiepidemiologi showed geographical differences incidence of breast carcinoma is not entirely related to genetic susceptibility, but also influenced by environmental factors, especially environmental or life style today.




II.2.3 Etiology
The cause is unknown, but there are some risk factors that cause a woman to be more likely to suffer from breast cancer. Some risk factors are:
1. Age
As in many types of cancer, incidence by age rise with age.
2. Family
From epidemiological seem that likely to suffer from breast cancer two to three times greater in women whose mother or sibling with breast cancer. This possibility is greater when the mother or siblings have cancer or premenopausal bilateral. Women who have dealt with breast carcinoma, it has got a high risk of carcinoma in the other breast.
3. Hormonal
Breast cancer growth is often affected by changes in hormone balance. High levels of hormones during the reproductive female, especially if not interrupted by the hormonal changes of pregnancy, appears to increase the chances of growth of cells that have undergone genetic damage and cause cancer.
4. Menarche (first menstruation)
Before the age of 11, menopause after age 55 years, first pregnancy after age 30 years or had never been pregnant. The earlier the menarche, the greater the risk of breast cancer. Similarly, the first pregnancy or menopause. The slower the menopause and first pregnancy, the greater the risk of breast cancer.
5. Use of birth control pills or estrogen replacement therapy
Birth control pills may slightly increase the risk of breast cancer, depending on age, duration of usage and other factors. Not yet known how long the effects of the pill will still be there after pill use is stopped.
Estrogen replacement therapy who lived for more than 5 years seems also slightly increase the risk of breast cancer and the risk increases if longer use.

6. Obesity after menopause
Several studies suggest obesity as a risk factor for breast cancer, possibly because of high levels of estrogen in obese women
7. Use of alcohol
Use of alcohol more than 1-2 cups / day can increase the risk of breast cancer.
8. Chemicals
Several studies have cited exposure to chemicals that mimic estrogen (found in pesticides and other industrial products) may increase the risk of breast cancer.
9. Irradiation
Exposure to radiation (especially radiation to the chest), in childhood can increase the risk of breast cancer.
10. Other risk factors
Several studies have shown that cervical cancer, ovarian cancer and colon cancer and the presence of a family history of cancer can increase the risk of breast cancer.

Ii.2.4 Pathophysiology
Associated with the incidence of breast carcinoma cell hyperplasia denganperkembangan atypical cells, then there intraepithelial carcinoma (carcinoma in situ), after the carcinoma in situ will be multiplication of cells with cepat.Selanjutnya these cells will invade the surrounding connective tissue stroma padapayudara.Membutuhkan time is approximately 7 years to grow carcinoma darisebuah single cell to a mass large enough to be felt (about 1 cm diameter). In size it was about one-quarter of cases are accompanied by event location metastasis.Untuk breast cancer, left breast more often daripadapayudara right, with a ratio of 60:40. With the presentation of the left lateral quadrant dankanan 45:63%, quadrants on the left and right medial 15:14%, lower left quadrant lateral dankanan 25:17%, 15:6% lower medial quadrant.

II.2.5 Clinical manifestations
Early symptoms include a lump that is usually perceived differently than the surrounding breast tissue, painless and usually memilikipinggiran irregular. In the early stages, when driven by a finger, a lump can be moved easily under the skin. In later stages, the lump is usually attached to the chest wall or surrounding skin. Padakanker advanced stage, could form a swollen lump or breast skin ulcers. Sometimes the skin over the lump shrank and looked like an orange peel.
Other symptoms that may be found in a lump or mass diketiak, changes in the size or shape of the breast, nipple discharge abnormaldari milk (usually bloody or yellow to green, may also be pus), changes in the color or texture of the skin on the breast or areola putingsusu ( dark brown colored area around the nipple), breast looks red, the skin around the nipple scaly, nipples susutertarik in or feel itching, breast tenderness or swelling of one breast.
Patients usually present with a lump or mass in the breast, pain, discharge from the nipple, skin abnormalities (dimpling, redness, ulceration, peaude "orange), enlarged lymph nodes, or distant metastases mark. Each kelainanpada breast should be considered malignant until proven not. Changes in the skin that occur are:
1. Signs dimples.
When the mammary gland tumors of the ligaments, the ligaments tersebutakan shortened to local skin becomes concave, called "dimple sign".


2. Changes in orange peel (peau de 'orange).
When vasa subcutaneous lymphatic congestion selkanker, lymph drainage barrier causing edema of skin, hair follicles appear to be sinking down "sign orange peel"

3. Satellite skin nodules.
When cancer cells in the lymphatic vasa masingmembentuk subcutaneous metastatic nodules each, around the primary lesion may appear many scattered nodules, clinically referred to as "satellite signal"

4. Invasion, ulceration of the skin.
When a tumor invades the skin, it appears dark red merahatau berwrna changes. When the tumor grew, the site may become ischemic, ulserasimembentuk flower upside down, it's called "mark cauliflower"

5. Inflammatory changes.
Clinically called "inflammatory breast carcinoma", appear as whole breast is red swollen skin, like inflammation, dapatdisebut "inflammatory markers". This type is often found in breast cancer during pregnancy or lactation.
Changes in mammary papilla mammary carcinoma are:
A. Retraction, distortion mammary papilla. Generally, due to the tumor invading jaringansubpapilar.
B. Secretions papillary (generally sanguineus). Often due to papillary carcinoma or tumor in the duct duktusbesar great.
C. Eksematoid changes. Is a specific manifestation of cancer eksematoid (Paget's disease). Clinically visible areola, mammary papilla eroded, berkrusta, secretions, desquamation, much like eczema.




Enlargement of regional lymph nodes. Enlarged lymph nodes ipsilateral aksilar dapatsoliter or multiple, initially mobile, then are able to berkoalesensi ataua dhesi with surrounding tissue. With the progression of the disease, supraclavicular lymph nodes can also follow enlarged. Noteworthy is that there is a very small fraction of breast cancer patients with lymphadenopathy only appear aksilar but no palpable breast mass, is referred to as a hidden type of mammary carcinoma.
The symptoms of distant metastasis:
1. Brain: headache, nausea, vomiting, epilepsy, ataxia, paresis, paralysis.
2. Lung: effusion, shortness of breath
3. Heart: sometimes no symptoms, mass, obstructive jaundice.
4. Bones: pain, broken bones.

Table 1. Symptoms and signs of breast disease
Signs or symptoms of Interpretation
a. Painful
- Changed the menstrual cycle as the physiological causes of premenstrual tension or fibrocystic disease
Menstrual cycle-dependent tumors are benign, malignant tumor or infection.
b. Lump in the breast
- Hard surface slippery and fibroudenoma or cysts
Hard surface, or attached berbenjol cancer or non-infective inflammatory
- Chewy abnormalities fibrocystic
- Soft Lipoma
c. Skin changes
- Bercawak Very suspicious carcinoma
- Lump visible cysts, carcinoma, large fibroadenoma
- Peel Above lump: cancer (a typical sign)
- Redness infection if the heat
- Ulcers Cancer while (especially in the elderly)
d. Abnormalities of the nipple or areola
- Fibrosis retraction of cancer
- New infections of new retraction from cancer (ductal dilation)
- Eksoma Unilateral: Paget's disease (a typical sign of cancer)
e. Liquid state
- As pregnancy or lactation milk
- Cleanest Normal
- Green Perimenopause
Duct dilation
Abnormalities fibrolitik
f. Hemorrhagic Carcinoma
Papilloma Intraduktus
II.2.6 CLASSIFICATION AND STADIUM

Classification Stadium
TNM Classification System American Joint Committee on Cancer (AJCC) 2010, Issue 7, for Breast Cancer

Primary Tumor (T)

Restriction
Tx Primary tumor can not be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
Tis (DCIS) Ductal Carcinoma in situ
Tis (LCIS) Lobular Carcinoma in situ
Tis
(Paget's) Paget's disease of the nipple with no tumor breast
Note: Paget's disease associated with a tumor is classified based on the size of the tumor
T1 Tumor ≤ 20 mm in greatest dimension
T1 Tumor mi ≤ 1 mm in greatest dimension
T1a Tumor> 1 mm but ≤ 5 mm in greatest dimension
T1b Tumor> 5 mm but ≤ 10 mm in greatest dimension
T1c Tumor> 10 mm but ≤ 20 mm in greatest dimension
T2 Tumor> 20 mm but ≤ 50 mm in greatest dimension
T3 tumors measuring> 50 mm in greatest dimension
T4 Tumor of any size with direct extension to the chest wall and / or skin (ulceration or skin nodules). Note: the invasion of the dermis alone does not include T4
T4a Extension to chest wall, not including pectoralis muscle
T4B Ulceration and / or ipsilateral satellite skin nodules and / or edema (including peau d'orange) of the skin, which does not include criteria for inflammatory carcinoma.
Combined T4a and T4B T4C
Inflammatory carcinoma T4d











Regional Lymph Nodes (N)
Restriction
Nx Regional nodes can not be assessed (eg, already appointed)
N0 No regional metastatic nodes
N1 Metastasis in ipsilateral axillary nodes were still level 1-2 can be driven
N2 Metastasis in ipsilateral axillary nodes fixed to the 1-2 level or Matted, or KGB internal mamaria clinically detected * if there is metastatic axillary nodes clinically
N2A Metastasis in ipsilateral axillary nodes fixed to the 1-2 level with each other (Matted) or fixed to other structures.
Metastasis N2B only on internal mamaria KGB clinically detected * and if there are no clinically metastatic axillary nodes.
N3 Metastasis in ipsilateral infraclavicular nodes level 3 with or without involvement of axillary nodes level 1-2, or the ipsilateral internal mamaria KGB clinically detected * and if there is a level 1-2 axillary nodes metastasis clinically, or metastasis in ipsilateral supraclavicular nodes with or without involvement of axillary nodes or internal mamaria.
N3a Metastasis in ipsilateral infraclavicular KGB
N3b Metastasis in ipsilateral internal mamaria KGB and KGB axilla.
N3C Metastasis in ipsilateral supraclavicular nodes
* Detected clinically meaning detected in the imaging examination (excluding lymphoscintigraphy) or on physical examination and have suspicious characteristics of a malignancy or suspected pathological makrometastasis by FNAB cytology.

Far metastasis (M)
Restriction
Mx Distant metastases can not be assessed
There are no distant metastases M0
M1 Distant metastases

Grouping Stage (Stage Grouping) AJCC 2010
Tis N0 M0
Stage 0
Stage IA T1 N0 M0 *
Stage IB Mi T0 N1, M0
T1 * N1 M1, M0
Stage IIA T0 N1 M0 **
* T1 N1 M0 **
T2 N0 M0
Stage IIB T2 N1 M0
T3 N0 M0
T0 N2 M0
T1 * N2 M0
T2 N2 M0
T3 N1 M0
T3 N2 M0
T4 N0 M0 Stage IIIB
T4 N1 M0
T4 N2 M0
Stage IIIC Any T N3 M0
Stage IV Any T Any N M1

















* Includes T1mic ** T0 and T1 are the only nodules micrometastases not included in stage IIA and stage IB put

Classification of Breast Cancer Staging
Clinical staging


Histopathological classification (WHO)

Carcinoma In Situ
Can not be determined
Intraductal


Paget's disease and intraductal

















Invasive Carcinoma
Can not be determined Lobular
Paget Disease and duct inflammatory infiltrates
Medullary undifferentiated
Madullary with lymphoid stroma cell carcinoma
Mucinous cyst adenoid
Papillary (predominantly micropapillary pattern) Cribriform




II.2.7 DIAGNOSIS DIAGNOSIS AND APPEALS
1. Diagnosis
Diagnosis based on history, physical examination, and investigation.
A. Anamnesis
Main complaint
- Lump in the breast
- Speed ​​grown with / without pain
- Nipple discharge, retracted nipple, and crusting
- Abnormalities of the skin, dimpling, peau d'orange, ulceration, venektasi
- Lump armpit and arm edema
Additional complaints
- Painful bone (vertebra, femur)
- Shortness etc.

B. Physical examination
- Generalist status (Karnofsky score or ECOG / WHO)
- Status localist:
Right or left breast or bilateral
The mass of tumors:
Location
Size
Consistency
Shape and limit tumor
Fixed or not to skin or chest wall M.pectoral

Skin changes
Redness, dimpling, edema / satellite nodules, Peau d'orange, ulceration
Redness
 

Dimpling



Edema


Peau d'orange


Changes in the nipple / nipple
Interested, erosion, crusting, Discharge

Interested


Discharge

Lymph node status
Enlarged axillary nodes, infraklafikula, and / or supraclavicular (number, size, fixed to the neighbors or the surrounding tissue)
            Examination of regional metastasis
Location
Form
Complaint

C. Examination Support

Laboratory
1. Recommended
- Routine blood examination and blood chemistry examination in accordance with the estimated metastasis
- Estrogen receptor (ER), progesterone receptor (PR), and HER-2
2. The indication
- Tumor markers CEA and CA 15-3

Examination radiology / imaging
1. Examination shall be recommended
- Ultrasonography (USG) of the breast and mammography
- CXR
- USG Abdomen
2. Top Indication
- Bone scanning or / and bone survey (if cytology and clinical or highly suspected malignant lesions> 5 cm)
- Computed Tommography (CT) scan
a. CT thorax if there is suspicion of tumor infiltration into the chest wall or lung metastases
b. CT abdomen if there is clinical suspicion of tumor infiltration into the intra-abdominal organs but not visible on ultrasound Abdomen
- Scintimammography if there is suspicion or residue residif
- Examination of MRI for cases with suspicion of intraductal breast carcinoma

Fine Needle Aspiration Biopsy Examination / Fine Needle Aspiration Biopsy (FNAB)
Cytologic examination performed on lesions that are clinically and radiologic suspicion of malignancy.






Histopathology examination (Golden Standard Diagnostic)
Histopathological examination of material taken through:
- Biopsy eksisional and pieces of frozen tumor <T2 (<5cm)
- Incisional biopsy and frozen cut to tumor
a. Operabel> T2 before definitive surgery
b. Inoperable
- Paraffin coupe

Mammography
Mammography is one of the chosen to detect karsinomamammae, both in patients with a clinical suspicion of carcinoma of the breast or small tumors pasiendengan
Non-palpable (Occult lession).
Indications mammography are:
1. Clinical suspicion of breast cancer and carcinoma mammaekontralateral aside.
2. Follow up post mastectomy detection of second primary in the other breast
3. Post breast conserving measures the detection of a recurrence / second primary
Screening mammography is an X-ray of the breast of a woman who was not adakeluhan / symptoms of breast cancer, targeted screening is to detect breast cancer in which the mass is still small to be touched by the patient themselves or olehklinisi. Several studies have shown that early detection of breast cancer that masihdalam early stage, eg in ductal carcinoma in situ the therapeutic efficacy mencapai100%.
The National Cancer Institute recommends that women receive screening mammography-wanitamulai age 40 every 1-2 years and age> 50tahun once a year. Recommended mammography screening in women <40 years of high-risk groups (positive family history or gene mutations are BRCApositif). Implemented using two x-ray projections for each breast, namely:
Ultrasound examination can only distinguish lesion / solid or cystic tumor, but dapatmengetahui kandisi blood supply as well as the surrounding tissue. In mammography, keganasandapat gives signs of primary and secondary. Signs primary form of reactive fibrosis, comet sign (Stellata), the existence of significant differences between the clinical and radiological measures, the mikrokalsifikasi, the spikulae, and distortions in the secondary payudara.Tanda architectural structures such as retraction, skin thickening, increased vascularity, perubahanposisi papilla and areola , the bridge of the tumor, and the tumor area state jaringanfibroglandular irregular infiltration of the soft tissues at the back of the breast, and adanyametastasis the gland (the picture is not typical).
Combined ultrasound examination danmammografi provide a higher diagnostic accuracy. Due mammary tumors containing microvascular density (MVD = microvascular density) abnormal, breast MRI with contrast sensitivity and high specificity dalamdiagnosis early stage breast carcinoma. But this test is quite expensive, sulitdigunakan extends only be an option in the differential diagnosis terhadapmikrotumor.
Today there are no specific tumor marker for breast cancer. CEA has nilaipositif varies from 20 to 70%, CA 15-3 monoclonal antibody positive rate around 33-60%, are all references to the clinical diagnosis and follow-up. Cytologic examination of fine-needle aspiration method it is simple, safe, danakurasinya reached more than of 90%. The data suggest a fine needle aspiration puncture did not affect the outcome of therapy.
Histological examination of the puncture needle Mandrin memilikicara a simple and secure as well as fine-needle aspiration cytology diagnosis, histological diagnosis jugaketepatan excisional biopsy, and can be made suitable imunohistologik examination. This examination is widely used in clinical trials, particularly suitable for patients who diberikemoterapi adjuvant.

Definitive diagnosis is only confirmed by histopathologic examination were performed by:

1. Excisional biopsy, by lifting the entire tumor tissue with little jaringansehat around, done when the size or tumor diameter <2 cm
2. Incisional biopsy, to remove part of tumor tissue and a little healthy tissue, performed for tumors that are inoperable or greater than 2 cm (Anonymous, 2009).

2.DIAGNOSA BANDING

Diagnosis bandingnya terdiri dari :

1.      Fibroadenoma mammae (FAM), merupakan tumor jinak payudara yang biasa terdapatpada usia muda (15-30 tahun), dengan konsistensi padat kenyal, batas tegas, tidak nyeri danmobile.

2.      Kelainan fibrokistik, merupakan tumor yang tidak berbatas tegas, konsistensi padatkenyal atau kistik, terdapat nyeri terutama menjelang haid, ukuran membesar, biasanyabilateral/multipel.

3.      Kistosarkoma filoides menyerupai FAM yang besar, berbentuk bulat lonjong, berbatastegas, mobile, dengan ukuran dapat mencapai 20-30 cm.

4.      Galaktokel, merupakan massa tumor kistik yang timbul akibat tersumbatnyasaluran/duktus laktiferus, terdapat pada ibu yang baru/sedang menyusui.

5.      Mastitis, yaitu infeksi pada payudara dengan tanda radang lengkap, bahkan dapatberkembang menjadi abses, biasanya terdapat pada ibu yang menyusui.

6.      Lipoma, merupakan tumor pada jaringan lemak dengan batas tegas, lunak, tidak nyeritekan, dan dapat digerakkan.

7.      Nekrosis lemak, berbatas tegas, keras, kadang disertai dengan penarikan kulit. 

II.2.8 PENATALAKSANAAN

Bila staging sudah dikerjakan, rencana tindakan didasarkan atas :

Ø  Stadium TNM

Ø  Umur pasien

Ø  Status menopause

Ø  Keadaan umum pasien

Tujuan terapi adalah :

Ø  Kratif menyembuhkan penderita

Ø  Paliatif meringankan penderitaan penderita dan perbaiki kualitas hidup

Ø  Terminal supaya penderita meninggal dengan tenang dan damai

Terapi

Dibedakan menurut:

1.      Kanker payudara stadium 0 (TIS/T0, N0M0)

Terapi definite pada T0 bergantung pada pemeriksaan blok paraffin.

Lokasi didasarkan pada hasil pemeriksaan radiologik.

2.      Kanker payudara stadium dini/operabel (stadium I dan II, tumor ≤ 3 cm)

Dilakukan tindakan operasi:

-          Mastektomi

-          Breast Conserving Therapy (BCT) (harus memenuhi persyaratan tertentu)

Terapi adjuvant operasi:

-          Kemoterapi bila KGB aksila (+) > 3 buah

-          Radiasi bila :

Setelah tindakan operasi terbatas

Tepi sayatan dekat/tidak bebas tumor

Tumor sentral/medial

KGB (+) > 3 buah atau dengan ekstensi ektrakapsular

Radiasi eksterna diberikan dengan dosis 50 Gy, pada kasus BCT dilanjutkan dengan diberikan booster pada tumor bed 10-20 Gy.

-          Indikasi BCT :

Tumor tidak lebih dari 3 cm

Atas permintaan pasien

Tidak multiple dan/atau mikrokalsifikasi luas

Ukuran tumor dan payudara seimbang untuk tindakann kosmetik

Bukan ductal carcinoma in situ (DCIS) atau lobular carcinoma in situ (LCIS)

Belum pernah diradiasi di bagian dada

Tidak ada Systemic Lupus Erythematosus (SLE) atau scleroderma

Memiliki alat radiasi yang adekuat

3.      Kanker Payudara locally advanced

a.       Operabel (IIIA)

-          Mastektomi + radiasi dengan/tanpa kemoterapi, adjuvant dengan/ tanpa hormonal

-          Mastektomi radikal modifikasi + radiasi dengan/tanpa kemoterapi

-          Kemoradiasi preoperasi dilanjutkan dengan atau tanpa BCT atau mastektomi simple

b.      Inoperabel (IIIB)

-          Radiasi kuratif +kemoterapi + hormonal terapi

-          Radiasi preoperasi dengan/tanpa operasi + kemoterapi + hormonal terapi

-          Kemoterapi preoperasi dengan/tanpa operasi + kemoterapi + radiasi + terapi hormonal

-          Kemoradiasi preoperasi dengan/tanpa operasi, dengan/tanpa radiasi atau kemoterapi

4.      Kanker Payudara Stadium Lanjut

Prinsip :

-          Sifat terapi paliatif

-          Terapi sistemik merupakan terapi primer (kemoterapi dan terapi hormonal)

-          Terapi lokoregional (radiasi dan bedah) apabila diperlukan

Pola operasi yang sering dipakai adalah :

1.      Mastektomi radikal, lingkup reseksinya mencakup kulit berjarak minimal 3 cm daritumor, seluruh kelenjar mammae, m.pektoralis mayor, m.pektoralis minor, jaringan limfatik dan lemak subskapular, aksilar secara kontinyu enblok direseksi.

2.      Mastektomi radikal modifikasi, lingkup reseksinya sama dengan teknik radikal, tapimempertahankan m.pektoralis mayor dan minor (model Auchincloss) atau mempertahankanm.pektoralis mayor, mereseksi m.pektoralis minor (model Patey). Pola operasi ini memilikikelebihan antara lain memacu pemulihan fungsi pasca operasi, tapi sulit membersihkankelenjar limfe aksilar superior.

3.      Mastektomi total, hanya membuang seluruh kelenjar mammae tanpa membersihkankelenjar limfe. Model operasi ini terutama untuk karsinoma in situ atau pasien lanjut usia.

4.      Mastektomi segmental plus diseksi kelenjar limfe aksilar, secara umum disebut denganoperasi konservasi mammae (BCT). Biasanya dibuat dua insisi terpisah di mammae dan aksila.

5.      Mastektomi segmental bertujuan mereseksi sebagian jaringan kelenjar mammaenormal di tepi tumor, di bawah mikroskop tak ada invasi tumor di tempat irisan. Lingkupdiseksi kelenjar limfe aksilar biasanya juga mencakup jaringan aksila dan kelenjar limfeaksilar kelompok tengah.

6.      Mastektomi segmental plus biopsi kelenjar limfe sentinel, metodenya sama dengan diatas. Kelenjar limfe sentinel adalah terminal pertama metastasis limfogen dari karsinoma mammae, saat operasi dilakukan insisi kecil di aksila dan secara tepat mengangkat kelenjar limfe sentinel, dibiopsi, bila patologik negatif maka operasi dihentikan, bila positif maka dilakukan diseksi kelenjar limfe aksilar.

Mastektomi radikal, mastektomi madifikasi, dan mastektomi total dilakukan untuk terapi,sedangkan mastektomi segmental plus diseksi kelenjar limfe alsila maupun plus biopsikelenjar limfe sentinel termasuk operasi biopsi (Desen, 2008).Radioterapi terutama mempunyai 3 tujuan, yaitu radioterapi murni kuratif, radioterapiadjuvan, dan radioterapi paliatif. Radioterapi murni kuratif terhadap kanker payudara hasilnya kurang ideal, survival 5 tahun 10-37 %. Terutama digunakan untuk pasien dengan kontraindikasi atau menolak operasi. Radioterapi adjuvan menjadi bagian integral pentingdari terapi kombinasi. Menurut pengaturan waktu radioterapi pra operasi dan pasca operasi.

Radioterapi pra-operasi terutama untuk pasien stadium lanjut lokalisasi, dapat membuatsebagian kanker mammae nonoperabel menjadi yang operabel. Radioterapi pasca operasiadalah radioterapi seluruh mammae (bila perlu ditambah radioterapi kelenjar limfe regional)pasca operasi konservasi mammae dan radioterapi adjuvan pasca mastektomi (Desen, 2008).Dewasa ini indikasi radioterapi pasca mastektomi adalah : diameter tumor primer • 5 cm,fasia pektoral terinvasi, jumlah kelenjar limfe aksilar metastatik lebih dari 4 buah dan tepiirisan positif .Radioterapi paliatif terutama untuk terapi paliatif kasus stadium lanjut dengan rekurensi,metastasis. Dalam hal meredakan nyeri efeknya sangat baik. Selain itu kadang kaladigunakan radiasi terhadap ovarium bilateral untuk menghambat fungsi ovarium (Desen,2008).Kemoterapi dibagi menjadi kemoterapi pra-operasi, kemoterapi adjuvan pasca operasi,kemoterapi terhadap kanker payudara stadium lanjut atau rekuran dan metastatik. Kemoterapipra-operasi, terutama kemoterapi sistemik, bila perlu dapat dilakukan kemoterapiintraarterial, mungkin dapat membuat sebagian kanker mammae lanjut lokal nonoperabelmenjadi operabel. Kemoterapi adjuvan pasca operasi, diindikasikan untuk operasi yang relatif luas, terhadap semua pasien karsinoma invasif dengan diameter terbesar tumor  1 cm.Hanya terhadap pasien lanjut usia dengan ER, PR positif dapat dipertimbangkan hanyadiberikan terapi hormonal. Kemoterapi terhadap kanker payudara stadium lanjut atau rekurendan metastatik sebagian kecil masih memakai regimen CMF, semakin banyak yang memakaikemoterapi kombinasi berbasis golongan antrasiklin .Dewasa ini dilakukan pemeriksaan reseptor estrogen (ER) dan progesteron (PR) dari tumor untuk menentukan efek terapi hormonal. Pasien dengan hasil pemeriksaan positif tergolongkanker mamae tipe bergantung hormon, hasil terapi hormonal baik, pasien dengan hasil tesnegatif tergolong kanker mamae tipe tak bergantung hormon, efek terapi hormonal agak kurang. Terapi hormonal terutama mencakup bedah dan hormon.

Terapi Hormonal / Kemoterapi

-       Terapi Hormonal paliatif dapat diberikan sebelum kemoterapi, karena efek terapinya lebih lama dan efek sampingnya kurang, tetapi tidak semua karsinoma mamae peka terhadap hormonal.

     Terapi hormonal paliatif dapat dilakukan pada penderita yang pra menopause dengan cara ovarektomi bilateral atau dengan aminoglutetimid.

-       Terapi hormon diberikan sebagai ajuvan kepada pasien pascamenopause yang uji reseptor estrogennya positif dan pada pemeriksaan histopatologik ditemukan kelenjar axilla yang berisi metastasis.

-       Terapi radiasi : lokoregional atau untuk mengendalikan metastase jauh (seperti metastase tulang yang nyeri).

Radioterapi paliatif dapat dilakukan dengan hasil baik untuk waktu terbatas bila tumor sudah tak mampu-angkat. Tumor disebut tak mampu angkat bila mencapai tingkat T4 misalnya ada perlengketan pada dinding thoraks dan kulit.

Biasanya seluruh payudara dan kelenjar aksila dan supra klavikula diradiasi. Tetapi penyulitnya adalah pembengkakan lengan karena limfodem akibat rusaknya kelenjar ketiak supra klavikula.

Terapi hormonal bedah terutama adalah ooforektomi (disebut juga kastrasi) terhadap wanita pramenopause,sedangkan adrenalektomi dan hipofisektomi sudah ditinggalkan. Yang sekarang digunakan adalah :

1.      Obat antiestrogen, seperti tamoksifen

2.      Inhibitor aromatase, sepertiaminoglutetimid tetapi saat ini obat ini sudah tidak dipakai karena efek sampingnya yangberbahaya, yang sekarang digunakan adalah golongan steroid anastrozol, letrozol, dangolongan steroid eksemestan

3.      Obat sejenis LH-RH (luteining hormon-realising hormon),seperti goserelin

4.      Obat sejenis profesteron, seperti medroksiprogesteron asetat (MPA) danmegesterol asetat (MA).Yang terbaru adalah terapi biologis, menggunakan herseptin dengan overekspresi terhadapgen cerbB-2 (HER-2). Herseptin adalah antibodi monoklonal hasil teknologi transgenik yangberefek antiprotein HER-2 secara langsung dan menghasilkan efek sitotoksik yang dimediasisel dan bergantung antibodi, sehingga berefek antitumor .

II.2.9 PERAWATAN

Disesuaikan dengan indikasi dan kondisi. Pemulihan tergantung beberapa faktor antara lain faktor umum pasien, faktor pilihan pengobatan, faktor stadium penyakit, faktor adanya penyulit infeksi, faktor penyembuhan luka.

II.2.10 PENYULIT

Akibat penyakit atau penatalaksanaan.

Informed Consent

Penjelasan tentang stadium penyakit, rencana terapi, hasil pengobatan dan kemungkinan komplikasi pengobatan.

Follow-up/Pengamatan lanjut

-          Pemeriksaan sendiri oleh pasien setiap bulan

-          Pemeriksaan klinis oleh dokter setiap 3 bulan selama 1-2 tahun pertama, dilanjutkan setiap 6 bulan hingga 5 tahun, kemudian setiap tahun sekali

-          Mammografi payudara bilateral setiap tahun. Beberapa menganjurkan dapat dilakukan mammografi ipsilateral setiap 6 bulan selama 5 tahun pertama.

-          Waktu median terjadinya rekurensi adalah 5-7 tahun pada wanita yang telah mendapatkan terapi hormonal dan/atau kemoterapi. Waktu median tersebut lebih singkat pada pasien dengan triple negative (< 3 tahun)

II.2.11 PENCEGAHAN

Banyak faktor resiko yang tidak dapat dikendalikan. Beberapa ahli diet dan ahli kanker percaya bahwa diet dan gaya hidup secara umum bisa mengurangi angka kejadian kanker.

Diusahakan untuk melakukan diagnosis dini kanker payudara lebih mudah diobati dan masih bisa disembuhkan jika masih pada stadium dini. SADARI, pemeriksaan payudara secara klinis dan mammografi sebagai prosedur penyaringan merupakan 3 alat untuk mendeteksi kanker secara dini.

Penelitian terakhir telah menyebutkan 2 macam obat yang terbukti bisa mengurangi resiko kanker payudara, yaitu tamoksifen dan raloksifen. Keduanya adalah anti estrogen di dalam jaringan payudara.Tamoksifen telah banyak digunakan untuk mencegah kekambuhan pada penderita yang telah menjalani pengobatan untuk kanker payudara. Obat ini bisa digunakan pada wanita yang memiliki resiko sangat tinggi.

Mastektomi pencegahan adalah pembedahan untuk mengangkat salah satu atau kedua payudara dan merupakan pilihan untuk mencegah kanker payudara pada wanita yang memiliki resiko sangat tinggi (misalnya wanita yang salah satu payudaranya telah diangkat karena kanker).

II.2.12 PROGNOSIS

Banyak faktor yang mempengaruhi prognosis. Tapi yang paling jelas dan berpengaruhterbesar atas prognosis adalah kondisi kelenjar limfe dan stadium. Dari hasil analisis atas data6263 kasus karsinoma mammae yang operabel di RS Kanker Universitas Zhongshan, survival5 tahun pasca operasi pada kasus kelenjar limfe negatif dan positif adalah masing-masing 80% dan 59 %, survival 5 tahun untuk stadium ) I, II dan III adalah masing-masing 92 %, 73 %,dan 47 %. Sedangkan pada yang inoperabel, survival 5 tahun kebanyakan dilaporkan dalambatas 20 %.

Oleh karena itu dalam kondisi dewasa ini, untuk meningkatkan angka kesembuhan kanker payudara kuncinya adalah penemuan dini, diaognosis dini, terapi dinidan tepat .

REFERENCE

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4.      Standar Pelayanan Medis, RSU Dr Sarjito,penerbit Medika FKU UGM,Jogjakarta

5.      Sjamsuhidayat, R, Wim de Jong, Buku Ajar Ilmu Bedah Edisi 2, EGC, Jakarta, 2005

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