NEOPLASM

of The BREAST

Dr.dr. Daan Khambri Sp.B(K)Onk, M.Kes, FINACS

Surgical Oncology Division
Faculty of Medicine Andalas University/
Dr.M.Djamil Hospital
 Dr.dr. Daan Khambri, SpB(K)Onk, M.Kes, FINACS
Dokter Spesialis Bedah
Konsultan Bedah Onkologi / HNB
Lahir di DUMAI, tanggal 6 Mei 1967
Pendidikan : SD, SMP, SMA di DUMAI s/d Th 1985.
S1 – Dokter Umum (FK-UNAND Padang, 1991).
Sp1 – Spesialis Bedah (FK-UNAND Padang, 2003).
S2 – Magister Kesehatan (FK-UNPAD Bandung, 2007).
Sp2 – Konsultan Bedah Onkologi (FK-UNPAD Bandung, 2007).
S3 – Ilmu BioMedik (FK-UNAND Padang, 2015).
Pekerjaan :- Kepala Bagian Perencanaan RSUP Dr.M.Djamil.
- Sekretaris Bagian Bedah FK-UNAND.
Pembicara Seminar dalam negeri buat kalangan ilmiah intelektual dan awam.
Seminar/Workshop : St.Gallen Breast Cancer, Switzerland 2007, 2009, 2013. Vienna 2015, 2017
ABC (Advanced Breast Cancer) Lisbon, Portugal 2011, 2017
SABC (San Antonio Breast Cancer Conference), Texas, USA 2012, 2014.
ASCO (American Society of Clinical Oncology) meeting, Chicago, USA 2013
ESSO Congress, Budapest Hungary 2004, Liverpool UK 2014
Oncoplastic Masterclass, Paris Breast Center 2014
Masterclass in Molecular Oncology, Prague, Czech Republic 2015
IMPAKT Breast Cancer Conference, Brussels, Belgium 2015, 2017
ESMO Amsterdam 2013, Madrid 2014, Vienna 2015, Copenhagen 2016, Madrid 2017
EBCC (European Breast Cancer Conference) Glasgow Scotland 2014, Amsterdam 2016,
Barcelona 2018
Organisasi Profesi : * Dalam Negeri : IDI, IKABI, PABI, PERABOI, POI
* Luar Negeri : ESSO (European Society of Surgical Oncology)
ESMO (European Society for Medical Oncology)
Padang, 2018
 BREAST
Schwartz's Principles of
Surgery, 10th Edition

Referensi / Kepustakaan
 EMBRIOLOGI
• Embryology
•  5th or 6th minggu perkembangan janin
Pada embrio muda, 5-6 mgg Tersisa
timbul garis penebalan ektoderm milk line di
yang disebut dengan “MILK LINE” regio
terbentang dari regio axilla pectoralis
sampai ke regio inguinal
 Milk Line
Pada usia janin 5
bulan, dapat
ditemukan areola
pada kulit sebagai
area sirkular
yang berpigmen di
sekitar bakal
papilla mammaria
Perbedaan fase payudara secara
histologi

A. Remaja.

B. Kehamilan.

C. Menyusui.

D. Menopause.
 Involution
Breast
Development Reproductive
Breast Breast
ANATOMI PAYUDARA
 Suplai perdarahan
Blood Supply arteri

1.cabang dari arteri

aksilaris, termasuk
cabang a torakalis, a
lateral toraks, dan dari
arteri torakoacromial.

2.cabang a.perforantes
arteri mamaria interna

3.cabang lateral arteri

interkostal posterior
 Kelenjar Limfe
- Kelenjar getah bening aksila biasanya
menerima > 75% drainase getah bening
dari payudara

- Sisanya mengalir melalui pembuluh

getah bening yang menyertai cabang
perforasi arteri mamaria interna dan
memasuki kelompok nodus limfa (internal
mammae)
Axillary lymph node group
Level I :
lymph nodes located lateral
to the pectoralis minor muscle;
level II :
lymph nodes located deep to the
pectoralis minor
level III
lymph nodes located medial to the
pectoralis minor.
The axillary vein with its major tributaries
and the supraclavicular lymph node group
are also illustrated.
 FISIOLOGI PAYUDARA
Perkembangan dan Fungsi
• Pertumbuhan dan perkembangan payudara di
pengaruhi oleh stimulus hormon
• Estrogen, progesteron, dan prolaktin adalah hormon
penting untuk pertumbuhan dan perkembangan
payudara
• Estrogen mempengaruhi perkembangan ductus
lactiferous
• Prolactin adalah hormon utama yang menginisiasi
terjadinya pembentukan ASI atau laktogenesis.
 FISIOLOGI PAYUDARA
cont...
• Payudara tidak berkembang pada perempuan
sampai mengalami fase pubertas
• Payudara mulai membesar karena respon dari
hormon estrogen dan progesteron dari
ovarium, yang berfungsi memulai proliferasi
jaringan epitel dan jaringan ikat.
• Payudara tidak berkembang dan berfungsi
sempurna sampai fase kehamilan
 FISIOLOGI PAYUDARA
• The gonadotropins luteinizing
hormone (LH) dan follicle-
stimulating hormone (FSH)
mengatur keluarnya hormon
estrogen dan progesterone
dari ovarium
DISEASE OF THE BREAST
Source: Breast Disease, Marcia Corner, Peggy Mancuso, CNM Program Editior.
16
 Gynecomastia
• Gynecomastia adalah suatu pembesaran payudara
yang terjadi pada pria.
• Grade 1  Pembesaran payudara ringan tanpa
redundansi kulit
• Grade IIa  Pembesaran payudara sedang tanpa
redundansi kulit
• Grade IIb  Pembesaran payudara sedang dengan
redundansi kulit
• Grade 3  Pembesaran payudara yang jelas dengan
redundansi kulit dan penonjolan
 Gynecomastia
• Ginekomastia fisiologis biasanya terjadi
selama tiga fase kehidupan:
• - Periode neonatal
• - Masa remaja
• - Penuaan

• Yang umum untuk masing-masing fase ini

adalah kelebihan estrogen yang beredar
sehubungan dengan sirkulasi testosteron
Gynecomastia
 PENYAKIT INFEKSI DAN
INFLAMASI PAYUDARA
• Infeksi bakteri
• S. aureus and Streptococcus species  paling sering
menginfeksi payudara.
• Mycotic Infection
• Blastomycosis
• Sporotrichosis
• Hidradenitis Supuratif
• Mondor’s desease
• Salah satu varian dari penyakit trombophlebitis
TUMOR JINAK PAYUDARA
Prinsip dasar yang mendasari klasifikasi
Aberrations of Normal Development and
Involution (ANDI) dari kondisi payudara jinak
adalah :
• Gangguan dan penyakit payudara jinak terkait
dengan proses normal reproduksi dan involusi
• Spektrum kondisi payudara yang berkisar dari
normal sampai gangguan penyakit
• Klasifikasi ANDI mencakup semua aspek
kondisi payudara, termasuk patogenesis dan
tingkat kelainan
KLASIFIKASI TUMOR
JINAK PAYUDARA
 KLASIFIKASI PAGE

Sistem klasifikasi yang dibuat oleh Page

memisahkan berbagai jenis kelainan payudara
dan penyakit jinak menjadi tiga kelompok yang
secara klinis relevan :
• - Kelainan nonproliferatif payudara
• - Kelainan proliferatif tipikal
• - Kelainan proliferatif atipikal
 Penyakit Payudara
Nonproliferatif
Kelainan nonproliferatif pada payudara paling sering,
70% kejadian tumor jinak payudara adalah
nonproliferatif dan tidak membawa peningkatan risiko
berkembang menjadi kanker payudara.
Kategori ini meliputi :
• - kista
• - ektasia ductus
• - mastitis periductal
• - kalsifikasi
• - fibroadenoma
 Penyakit Proliferatif
tipikal payudara

• Penyakit proliferatif tipikal terdiri dari:

• Sclerosing adenosis
• Radial scars
• Complex sclerosing lesions
• Ductal epithelial hyperplasia
• Intraductal papillomas
 Penyakit Proliferatif Atipikal

• Penyakit proliferatif atipikal memiliki beberapa

ciri karsinoma in situ namun tidak memiliki ciri
utama karsinoma in situ.
• Hiperplasia duktal atipikal (ADH) tampak
serupa dengan karsinoma ductus in situ (DCIS)
secara histologis dan terdiri dari sel monoton,
bulat, atau poligonal yang tertutup oleh
membran basal dengan mitosis jarang.
Terapi dan penanganan pada
Penyakit Payudara tertentu
• Kista
• Fibroadenomas
• Sclerosing disorders
• Periductal mastitis
• Nipple inversion
 Cause Lump of the Breast

Source:Benign Disorders and Diseases of the Breast; Hughes, Mansel, Webster, 3rd ed, 2010.
30
Another Disease

Amastia
congenital
absence one
Or both
breasts

31
Symastia :
medial
confluence
of the breast
Hypoplasia
of the left
breast
+
Hypertrophy
and ptosis of
the right
breast
 Tubular and
hypoplasia in
both breast

34
Breast Hypertrophy Bilateral =
Macromastia = Gigantomastia
 Mammary
Abberan =
Polimastia =
Supernumary
breast =
Ectopic breast
 Diagnosis

Clinical examination
Imaging
USG: < 40 yo (USA & Europe < 35)
Mammography : > 40 yo (USA & Europe > 35)
MRI
Ductography
Biopsi: FNAB, Core Biopsy, mammotome
Incisional/excional biopsy
37
 Ultrasound Guided Procedure

USG guide biopsy USG appearance that show needle

in the lesion

38
 Fibroadenoma (FAM)

Formed: fibrous stroma &

proliferation of epithelial
lobules
As the result of increased
sensitivity to estrogen
Proportion: India & Africa >
Chinese & Western
Highest insidence 21-25 yo
Increase of size during
pregnant
 Behaviour of Fibroadenoma

Most FAM do not progressive growth

Growth phase, followed static phase: 80%
Regression: 15% case
Progression only 5-10% case
Risk to became malignt: small

40
 Variants/Type of FAM

Hamartoma
Tubular adenoma
Lactating adenoma
Juvenile fibroadenoma
Giant fibroadenoma
Complex FAM
Sumber: Benign Disorder and Disease
of the Breast; Hughes, Mansel, Webster,
3rd edition, 2010.
Woman, 19 yo, Giant FAM
 Phyllodes Tumor
Initially, cystosarcoma phyllodes by Johann
Muller, 1838
Phyllodes tumor for benign
Phyllodes sarcoma for malignant
Incidence: 0,3-1% ♀ breast tumor
Age : 10-90 yo
The most: age 35- 55 yo (Haagensen’s
series)
Majority are benign
 Phyllodes….

Clinically
Quick growth
Usually large size while consulting
Mobile, clear margin
Firm and cystic, surface not smooth
No pain, some time formed ulcer
USG or mammogram
Indistinguishable from FAM.
43
 Treatment
The main principle: local excision with free margin (1 or 2
cm)
Margin 2-3cm in practice difficult to achieve with good
cosmesis. Except if the breast is quite large and the tumor
favorably located
Recommendation:
Age < 20 yo → excision with margin 1 cm
Age ≥ 20 yo → wide excision with margin 2 cm
Large or recurrence → simple mastectomy
Incision : full thickness
Phyllodes……
Indication for radiotherapy adjuvant:
Recurrence phyllodes post mastectomy
Post operation with closed or unclear margin
Dosage 50-50.4 gray, Booster: 10-20 gray
Fibrocystic Changes (FCC)

Synonim: Fibrocystic disease, cystic

mastopathy, fibrosclerosis of breast, chronic
cystic mastitis, fibrocystic mastopathy and
mammary dysplasia
Triple conditions: pain, cyst and lump
Pathogenesis: Excessive response from
alteration level of estrogen dan progesterone
hormone each mount.
FCC……

Incidence
Estimate: 30-60% women
Majority (minimal 50%)at birth
age: 20-40 yo
Risk Factors for FCC
Factors possibly related to
Fibrocystic Breast Changes
1 Age
2 Hormones
3 Premenstrual syndrome
4 Duct ectasia
5 Stress
6 Smoking
7 Caffeine
FCC…..
Clinical :
Lump or cyst with tenderness
tend to fluctuate with the menstrual cycle
Diagnostic:
Clinical+Usg/mammography ± MRI± biopsy
Biopsy : FNA or Surgical
 Surgical Biopsy:
bloody cyst
recurrence after aspiration
cyst which recur in short time
Not associated with an
increased risk for breast
cancer
unless biopsy reveals lobular or
ductal hyperplasia with atypia
difficult to cancer detection

50
 Treatment

Reassurance
Mostly, no need treatment
Elimination: caffe, cocholate, decrease lipid
consumption
Vit. E and oral contrasepsi can decrease
symptom
If present classical symptom or there is no
persistent mass → EPO, danazol, tamoxifen,
NSAID.
Single dominant cyst → aspirate fluid
 Intraductal Papilloma

A benign local proliferation of ductal epithelial cells

Type:
Papilloma soliter (central)
Multipel (peripheral).
Juvenile papilomatosis
Soliter :
age 30-50 yo
diameter of lesion usually 3-4mm,
nipple discharge unilateral, serosanguineous or bloody
 Clinical appearance

Subareolar mass and or spontaneous nipple discharge

Evaluation:
radially compress of the breast to determine which
lactiferous duct expresses fluid
Proponent:
USG, mammography, MRI, ductulography, ductoscopy,
cytology nipple discharge
 Intraductal Papilomatosis

Tabar L, Dean P. Teaching atlas of mammography. 2nd ed. New York, New York:
Thieme Inc. 1985:192
 Ductulography
Safe and easy to visualize condition in duct
Papilloma intraductal → filling defect in duct
Papilloma soliter → in collecting duct
Papilloma multiple often in branch of duct
This Procedure, pain full and has limitation in detection
multiple lesion in one duct or if there is total obstruction
Procedure is no longer widely practised
 Mammary Ductoscopy (MD).
Mini-endoscope with 0.55 mm diameter. Inserted
to ductal opening on the nipple surface, they
allow direct visualization of the mammary ductal
These scopes also provide: insufflation, irrigation,
ductal lavage, and possible therapeutic
intervention
Breast ductoscopy can be performed under local
anaesthesia with minimal discomfort and no
reported complications
Still not widely used in clinical practice due to the
high cost and limited expertise
Intraductal Papilloma at Mammary
Ductoscopy
 Diagnosis :
Pathologic evaluation of resected specimen
Treatment :
Excise affected duct
(Microdochectomy)
Indication:
Papilloma with serosanguinous or bloody
nipple discharge
Microdocechtomy
 Galactocele
Cyst filled with milky material as result from
obstruction of the duct
Develops during or after peiode of lactation
Fitzwilliams, 1845
Pathegenesis, 3 factors in galactocele
development :
Secretion of ductal epithelial
Prolactin stimulus
Ductal obstruction

60
 Galactocele
Often concomitant with duct ectasia and recurrent sub
areola abses
Clinically:
painless mass during or after lactation
the most location: sub areolar.
smooth, mobile, firm, clear margin

Often suspected as tumor solid

Will resolve by it self or after aspiration
USG of the breast and FNA are needed
Clinical and usg appearances
of Galactocele
62
 Treatment
Asymptomatic and small → observation
Symtomatic → massage + pumping
Aspiration for diagnostic and therapy
Concomitant with infection: aspiration or
and drainage
Excision, if has been encapsulated
 Kanker
• Sel tumor adalah sel yang tetap melakukan
pembelahan meskipun tidak dibutuhkan,
berupa
• Tumor jinak  dapat dibuang, biasanya tidak
kambuh dan tidak mengancam jiwa
• Tumor ganas (kanker)  membelah tidak
terkontrol, dapat memasuki serta merusak jaringan
sekitarya, dan menyebar ke tempat lain melalui
peredaran darah atau limfe (getah bening).
Penyebaran ini disebut metastasis.
 Gejala dan Tanda Kanker Payudara
• Benjolan atau penebalan pada atau dekat
payudara atau di ketiak
• Perubahan ukuran dan bentuk payudara
• Putting tertarik ke dalam, nyeri, mengeluarkan
darah atau cairan
• Kulit payudara berkerut atau tampak seperti kulit
jeruk
• Perubahan kulit, areola, atau putting payudara
yang tidak biasa (bengkak, panas, kemerahan,
bersisik)
 BREAST CANCER
Stage I
T1 N0 M0 T1a: T  0.5 cm
T1b: 0.5 cm < T 
1 cm
T1c: 1 cm < T  2
T1 cm
T  2 cm

N0 = no regional lymph node metastasis

M0 = no distant metastasis
 BREAST CANCER
Stage IIA
T0
T1
} N1 M0 T2 N0 M0

T0 No evidence
T2
of tumor

2 cm < T < 5 cm

N1 = metastasis to movable ipsilateral axillary lymph node(s)

M0 = no distant metastasis
 BREAST CANCER
Stage IIB
T2 N1 M0 T3 N0
M0

T3

T > 5 cm

N1 = metastasis to movable ipsilateral axillary lymph node(s) (p) N1a, N1b

M0 = no distant metastasis
 BREAST CANCER
Stage IIIA T0
T3 N1 M0 T1 N2
T2 M0
T3

Metastasis to ipsilateral axillary lymph node(s)

N1 = movable
N2 = fixed to one another or to other structures
M0 = no distant metastasis
 BREAST CANCER
Stage IIIB
T4 any N M0 Any T N3
M0
T4
Tumor of any size
with direct extension
to chest wall or skin

T4d = inflammatory
carcinoma

N3 = metastasis to ipsilateral internal mammary lymph node(s)

M0 = no distant metastasis
 BREAST CANCER
Stage IV
Any T any N
M1

M1 = distant metastasis (including metastases to ipsilateral supraclavicular,

cervical, or contralateral internal mammary lymph nodes)
 KANKER PAYUDARA

People Living With Cancer. 2006. ASCO Slide Deck Series:

Understanding Breast Cancer.
 Kanker Payudara
Stadium Awal (Std I atau II)
 Kanker Payudara
Lanjut Lokal (Std III)
 Kanker Payudara
Stadium Lanjut (Std IV)
 Pemeriksaan Dokter

• Pemeriksaan klinis
USG & MAMOGRAFI
 BAJAH / FNAB
• Biopsi jarum • pengambilan contoh jaringan
untuk benjolan untuk diperiksa
secara mikroskopis
• cepat, prosedur rawat jalan,
dilakukan dg anastesi lokal
• 5 % pasien yang menjalani
mamografi akan dilakukan biopsi
 Modalitas Terapi
• Terapi Lokal
• Pembedahan
• Mastektomi (seluruh payudara)
• Breast Conserving Surgery (BCT)  hanya
tumornya saja
• Radioterapi
• Terapi Sistemik
• Kemoterapi
• Terapi Hormonal
• Targetted therapy
 Radioterapi
Radioterapi merupakan suatu bentuk pengobatan
lokal pada kanker dan beberapa penyakit bukan
kanker yang menggunakan sinar pengion.
Bertujuan membunuh sel kanker sebanyak-
banyaknya.
 Kemoterapi
• Kemoterapi adalah penggunaan obat-
obatan untuk membunuh sel kanker.
• Digunakan secara kombinasi
(beberapa obat-obatan), baik injeksi
maupun dimakan.
• Pengobatan diberikan dalam
beberapa kali/siklus  biasanya
diberikan 4-6 siklus selama 3-6 bulan
• Jenis obat kemoterapi :
• 5 Fluorouracil (5FU)
• Cyclophosphamide
• Metothrexate
• Anthracycline
• Taxanes
 Terapi Hormonal
Bagaimana ??
Examination
Ductogram
USG
MRI
• Breast Biopsy
• Nonpalpable Lesions
• Palpable Lesions
BREAST CANCER STAGING
AND BIOMARKERS
• Breast Cancer Staging  TNM Staging
• Biomarkers
• Steroid Hormone Receptor Pathway
• Growth Factor Receptors and Growth Factors
• Indices of Proliferation
• Indices of Angiogenesis
• Indices of Apoptosis
• Coexpression of Biomarkers
STAGING
SURGICAL TECHNIQUES IN
BREAST CANCER THERAPY
• Eksisi biopsi dengan Needle
• Diseksi Nodus Lymfe Sentinel
• Breast Conservation
• Mastectomy and Axillary Diseksi
• Modified Radical Mastectomy
• Reconstruction of the Breast and Chest Wall
 NONSURGICAL BREAST
CANCER THERAPIES

• Radiation Therapy
• Chemotherapy
• Hormonal therapy
• Targetted therapy