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  1. 1. Breast cancer By : Saruveswaran R Rasasingam Preceptopr : dr. Adrioki Risa, Sp.B
  2. 2. Chapter 1: Introduction
  3. 3. Introduction Breast cancer • Uncontrolled growth of breast tissue cells that can invade and spread to other parts of the body Breast cancer is the most common cancer in developed/developin g countries • Fifth most common cause of death from cancer The incidence rate in developing countries is 40/100,000 population • Indonesia urutan ke-8 di Asia tenggara dan no- 23 di Asia
  4. 4. Introduction  Research conducted at RSUP Dr. M. Jamil Padang on risk factors that can cause breast cancer are non pregnant, very short duration of breastfeeding, menopause, obesity, high fat intake, living in urban areas, family history of breast cancer and a history of blunt breast trauma.  For the prevention and control of cancer in Indonesia, the government has made various efforts, including early detection of breast cancer in women aged 30-50 years using the Clinical Breast Examination (SADANIS) method. Sindrome koroner Akut. Perki. 2018
  5. 5. Chapter 2: Literature review
  6. 6. Anatomy of breast  Boundaries  Superior : II-III ribs  Inferior : VI-VII ribs  Medial : linea parasternalis  Lateral : line anterior axillae/ linea mid axillae
  7. 7. Anatomy of breast  Each breast consists of 12-20 glandular lobules, each of which has a duct called the lactiferous duct, which opens into the mammary papillae.  Between the mammary glands and the pectoral fascia, as well as between the skin and the glands, is adipose tissue.  Between the lobules, there are connective tissue called Cooper's ligaments which form the framework of the breast
  8. 8. Anatomy of breast  Breast bleeding is mainly derived from branches of the anterior perforating artery from the internal mammary artery, the lateral thoracic artery which branches from the axillary artery, and several intercostal arteries.  About 75% of the lymphatic drainage of the breast drains into the axillary lymphatic group  Level I  Located laterally / below the lower limit m. pectoralis minor  Level II  Located inside (deep) or behind m. pectoralis minor i.e. the central group  Level III  Located medial to or above the upper limit of m. pectoralis minor is the subclavicular group
  9. 9. Breast Cancer • Breast cancer : a group of malignant tumors in breast tissue which can originate from lactiferous duct epithelium (70%) or lobular epithelium (10%) Definition • Most common cancer in women • The main cause of death from cancer • The highest incidence is in developed countries, and there is an increase in developing countries due to lifestyle changes • Based on Riskesdas data, the prevalence of tumors/cancer in Indonesia shows an increase from 1.4 per 1000 population in 2013 to 1.79 per 1000 population in 2018 Epidemiology
  10. 10. Etiology  Gene mutation 1. BRCA-1 (locus 17q21) 2. Gen p53 (locus 17p13) 3. BRCA-2 at chromosome 13  Mutasi tersebut diduga akibat paparan mutagen  mutagen endogen : radikal bebas seperti lipid peroksidase  mutagen eksogen : radiasi  Virus (belum ada bukti pada manusia)
  11. 11. Risk factor  Age  It is rare under the age of 30 years, but the incidence increases sharply until around the age of 50 years and then it continues to increase but slowly --> ovarian haemorrhagic effects  Reproduction and hormones  Age of menarche, age of menopause, 35th first birth, hormonal contraception, postmenopausal hormone replacement therapy  Genetics and familial  Approximately 5-10% of breast cancer occurs due to a genetic predisposition. And the risk increases 2x if one of the nuclear family members suffers from breast cancer  Lifestyle  Obesity, physical activity, smoking and alcohol  Exogenous exposure  Radiation, chemicals
  12. 12. Pathogenesis • unevenly distributed proliferation of polyclonal epithelial cells with overlapping nuclei and disorganized ductal lumens Ductal hyperplasia • the cytoplasm of the cells becomes more pronounced and does not overlap the regular duct lumen hyperplasia atypical • cell proliferation with cytological features consistent with malignancy. Proliferation has not invaded the stroma or penetrated the basement membrane Carcinoma in-situ • Tumor cells have penetrated the basement membrane and invaded the stroma - -> metastasized Invasive carcinoma
  13. 13. Clinical manifestation Tumor Mass • Most manifest as a breast mass that is not painful. Most common location is the upper lateral quadrant Mammary papilla changes • Retraction, distortion of the mammary papillae, papillary discharge, eczematoid changes Skin changes • Dimple marks, peau d'orange, satellite nodules, ulcerations, inflammatory changes Regional lymph node enlargement • Pembesaran kelenjar limfe aksilar ipsilateral dapat soliter atau multiple. kelenjar limfe supraklavikular juga dapat membesar
  14. 14. Diagnosis  Physical examination  Inspection: size, symmetry of the two mammary glands, pay attention to whether there are tumor lumps or pathological changes in the skin, whether the two mammary papillae are symmetrical, are there retraction, distortion, erosion and other abnormalities  Anamnesis  Patient identity, risk factors, course of disease, signs and symptoms of breast cancer, history of treatment and history of disease ever suffered.
  15. 15. Palpation  Breast  Lymp nodes
  16. 16. Supporting investigation  Mammography  Breast ultrasound  MRIs  Immunohistochemistry  FNAB  Core biopsy  Open biopsy  Sentinel node biopsy  Bone Scan, Chest Photo and Ultrasound Abdomen  Laboratory Examination: tumor markers such as CA-15-3 and CEA
  17. 17. TNM Classification
  18. 18. TNM Classification
  19. 19. Classification Non invasive carcinoma • Ductal carcinoma in situ (DCIS) • Lobular carcinoma in situ (LCIS) Invasive carcinoma • Invasive ductal carcinoma • Adenocarcinoma with productive fibrosis (scirrhous, simplex, NST) • Medullary carcinoma (4%) • Mucinous (colloid) carcinoma (2%) • Papillary carcinoma (2%) • Tubular carcinoma (2%) • Invasive lobular carcinoma (10%) Paget’s disease
  20. 20. Procedures • Classic Radical Mastectomy • Modified Radical Mastectomy • Simple Mastectomy • BCS (Breast Conserving Surgery) Operation • adjuvant therapy • Neoadjuvant therapy • Primary therapy Chemotherapy(systemic) • DNA damage by interrupting the replication process and reducing the risk of local recurrence Radiotherapy • in the breast that shows positive expression of estrogen receptor (ER) or progesterone receptor (PR) Hormanal therapy • menghambat proses yang berperan dalam pertumbuhan sel-sel kanker Target therapy
  21. 21. Prognosis  The prognosis of breast cancer is indicated by the life expectancy or disease-free interval
  22. 22. Chapter 3: Case illustration
  23. 23. Patient identity  Name : Miss Feb.Oz  Gender : Female  Age : 20 years old  Address : Ombilin  Occupation : Student  Marital status : Single
  24. 24. Anamnesis  A 20-year-old female patient came to the Policlinic of General Hospital (RSU) Prof. Dr. M Ali Hanafiah with: Chief Complaint  Pain and Lump on the superior lateral of the right breast
  25. 25. History of Present Disease - The lump in the right breast was initially felt since 1 years ago, the lump was felt as large as a marble and was not painful. Then the lump felt increasingly enlarged to the size of a ping pong ball and with increasing pain since 1 month . The patient did not complain of pus-like discharge and blood from the nipple, the nipple wasn’t pulled inward and the skin around the breast had no changes in the breast skin resembling orange peel. - Patient complaints that the pain gets worse while she’s resting., - Slight fever 2 days prior to getting admitted. - There is no bony pain. - There is no headache. - Shortness of breath not present - Decrease in appetite not present. - No history of serious weight loss in this 1 year. - Nausea and vomiting are absent. - There is no complaint about bowel movements.  There is no complaint about urination
  26. 26. Past medical history - History of tumor on right breast inferior subareolar region. - History of lumpectomy in the year 2019 - Diabetes Mellitus (-) - Hypertension (-) - Heart Disease (-) - Kidney Disease (-) - History of asthma (-) - History of drug, food, and other substance allergies (-)
  27. 27. Family history of disease  Patient’s aunty (mom’s sister) had similar issues before marriage and has gone through lumpectomy thrice throughout till today
  28. 28. Social history, psychology, habits - The patient is now a student. - The patient had her menarche at the age of 15. - Menstrual cycle 28-30 days, regular, 2-5 days in length, 3 sanitary pads usually used, no serious pain. - The patient has no children. - No history of hormonal contraception - There is no history of radiation to the chest wall.
  29. 29. Physical examination  General condition: Appears moderately ill Consciousness: Composmentis cooperative  Vital Sign :  -Blood Pressure: 110/70 mmHg  -Pulse : 82 beats/minute  -Breathing : 20 beats/minute  -Temperature : 36,5°C
  30. 30. General Status  -Head : normocephalic, no abnormalities  -Eyes : non anemic conjunctiva, non-icteric sclera  -Skin : good skin turgor  -Nose : no abnormalities  -Ears : no abnormalities  -Mouth : no abnormalities  -Neck : no abnormalities  -KGB : no abnormalities
  31. 31. Cont. Lungs • Inspection: normochest, symmetrical chest wall movement • Palpation: left fremitus equal to right • Percussion: sonor • Auscultation: vesicular breath sounds, rhonki -/-, wheezing -/- Heart • Inspection: ictus cordis not visible • Palpation: palpable ictus cordis 1 finger medial LMCS RIC V • Percussion: heart limits within normal limits • Auscultation: regular heart sound, normal S1 S2, murmur (-), gallop (-) Abdomen • Inspection: distention (-) • Auscultation: bowel sounds (+) normal • Palpation: sociable, NT (-), NL (-), liver and spleen not palpable • Percussion: timpani Ekstremitas • Udem -/- • Warm acral • CRT < 2 seconds
  32. 32. Local status  Right mammary region  Inspection: A mass in the upper outer quadrant, the mammary gland the size of a chicken egg, peau d'orange (-), satellite nodules (-), nipple retraction (-), nipple discharge (-), abscess (-), blood (-),  Palpation: palpable solitary mass with a size of 4 x 4 cm in the region of upper outer quadrant of the right breast, hard consistency, flat surface, firm boundaries, free to move, and sensitive to touch  Left Mammary Region  Inspection: No visible lump  Palpation: 1 corn seed sized palpable mass on the inferior subareolar region. Size of 0.5 x 0.5cm, hardconsistency, smooth surface, firm borders, free to move and sensitive to touch
  33. 33. Cont.  Right Axillary Region  Inspection: no visible mass  Palpation: palpable mass with a size of 1 x 1 cm, hard consistency, smooth surface, firm boundaries, fixed, and no pain.  Left Axillary Region  Inspection: no visible mass  Palpation: no palpable mass  Dextra supraclavicular region  Inspection: no visible mass  Palpation: 1 corn seed sized palpable mass on the inferior subareolar region. Size of 0.5 x 0.5cm, hard consistency, smooth surface, firm borders, free to move and sensitive to touch.  Left supraclavicular region  Inspection: no visible mass  Palpation: no palpable mass
  34. 34. Cont.  Left Infraclavicular Region  Inspection: no visible mass  Palpation: no palpable mass  Dextra infraclavicular region  Inspection: no visible mass  Palpation: no palpable mass
  35. 35. Diagnosis  Right Mammary tumor Susp mammary fibroadenoma.
  36. 36. Supporting examination  Laboratory examination  Chest x-ray  Anatomical pathology  Abdominal ultrasound  Immunohistochemistry
  37. 37. Procedures  Lumpectomy  Post lumpectomy lab test
  38. 38. Prognosis  Quo ad vitam : Dubia ad malam  Quo ad functionam : Dubia ad malam  Quo ad sanationam : Dubia ad malam
  39. 39. Discussion
  40. 40. Discussion  A patient Miss Feboz, a 20-year-old woman came to the Outpatient of General Hospital Prof. Dr.M Ali Hanafiah with complaints of a lump the size of a table tenis ball in the right breast. The patient felt a lump in the right breast initially felt in the last 1 year, the lump was felt as big as a pea and painless. Then thelump is got bigger and denser in the past month. The patient does not have previous breast discharge such as pus or blood from the nipple, and the the nipple wasn’t pulled inward. If there was a retraction of the breast,it indicates tumor invasion into the subpapillary tissue. There is no change in the breast skin that resembles orange peel. This is because the tumor in this patient did not cause any drainage obstruction to the subcuticular lymphatic vasa, causing this to occur.10
  41. 41. Discussion  The patient has not complained of symptoms such as decreased appetite and drastic weight loss, in this past year. The patient is 20 years old, where the age factor plays an important role in causing breast cancer. With increasing age, the incidence of breast cancer will increase. After the age of 50 years, the frequency continues to increase but slowly. This malignancy is very rare in women under the age of 20. A patient's risk factors for mammary malignancy are sought by asking about age at menarche, menstrual history, pregnancy, breastfeeding, hormonal contraceptive use, and radiation exposure. Among these risk factors, the patient had never been pregnant (reproductive) and never breastfed. According to research, breastfeeding reduces the risk of developing breast cancer especially if the breastfeeding period is carried out for 27-52 weeks. This reduction in risk is thoughtto be because breastfeeding reduces a person's menstrual period.3
  42. 42. Discussion  On physical examination, a solitary mass with a size of 4 cm x 4 cm in the upper outer quadrant, region of the mammary gland was palpated, hard consistency, flat surface, well-defined, freely moving , painless, nipple discharge (-) peau consistency, flat surface, well-defined, fixed, painless, nipple discharge (-) peau d'orange (-), nipple retraction (-).  The presence of a mass with a hard consistency, fixed and painless is a description of a malignancy. The presence of a mass with the diameter of 4cm x 4cm is classified to be T2. There was no regional metastasis on the particular lump and it was mobile so it was classified to be N0. There was no metastases to distant organs (M0). Therefore the lump on the right breast of this patient was classified to be Stage 2A.
  43. 43. Discussion  On examination of the left breast, a mass with a size of 0.5 x 0.5 cm, hard consistency, smooth surface, firm boundaries, non-fixed and painless was palpated. This is the basis for upholding the N0 classification in the diagnosis. The patient did not have any signs of distant metastases, so M0 was established.  Based on history, physical examination and support, this patient was diagnosed with mammary tumor right suspected mammary fibroadenoma. In this patient, the lumpectomy was performed and the lump the was removed was sent for lab examinations to identify the type of tissues involved.
  44. 44. Discussion  If the patient was histopathologically proven as mammary carcinoma, the therapy plan will be neoadjuvant chemotherapy and MRM because the above 3 has to be accompanied with tumor stage chemotherapy treatment. Chemotherapy is systemic, serves to destroy cancer cells, works by inhibiting or disrupting DNA synthesis in the cell cycle.3 However on this particular patient the lump wasn’t easily bleeding, was freely moving and not fixated to any tissues. Therefore, its suspected to be a Fibroadenoma and being removed early prevent complivations and preserves life quality.
  45. 45. Discussion  The prognosis of this patient's 5-year survival rate is high (Stage 2A, 92%). Education that can be given to the family is education about the patient's disease and management aimed at improving quality of life, and education to family members about risk factors for breast cancer and breast cancer screening in family members at risk. 3
  46. 46. Thank you