Tumor

Payudara
Fanny Indarto, dr., Sp.B
Ruang Lingkup
 Fibroadenoma mammae
 Fibrokistik
 Ca mammae
 Phyllodes
 Paget’s disease
Aberrations of normal
development and involution
(ANDI)
 Classification of benign breast conditions are
the following:
(a) benign breast disorders and diseases are
related to the normal processes of reproductive
life and to involution
(b) there is a spectrum of breast conditions that
ranges from normal to disorder to disease
(c) the ANDI classification encompasses all
aspects of the breast condition, including
pathogenesis and the degree of abnormality
Fibroadenoma mammae
 Fibroadenomas are seen and present
symptomatically predominantly in
younger women aged 15 to 25 years.
 Fibroadenomas usually grow to 1 or 2 cm
in diameter and then are stable but may
grow to a larger size.
 Small fibroadenomas (≤1 cm in size) are
considered normal, whereas larger
fibroadenomas (≤3 cm) are disorders and
giant fibroadenomas (>3 cm) are disease.
 Similarly,
multiple fibroadenomas (more
than five lesions in one breast) are very
uncommon and are considered disease.
 Mostfibroadenomas are self-limiting and
many go undiagnosed, so a more
conservative approach is reasonable.
 Careful ultrasound examination with core-
needle biopsy will provide for an
accurate diagnosis.
 Options for treatment include surgical
removal, cryoablation, vacuum assisted
biopsy, or observation.
Fibrokistik
 Theterm fibrocystic disease is nonspecific.
Too frequently, it is used as a diagnostic
term to describe symptoms, to rationalize
the need for breast biopsy, and to explain
biopsy results.
 Synonyms include fibrocystic changes,
cystic mastopathy, chronic cystic disease,
chronic cystic mastitis, Schimmelbusch’s
disease, mazoplasia, Cooper’s disease,
Reclus’ disease, and fibroadenomatosis.
Fibrocystic disease refers to a spectrum of
histopathologic changes that are best
diagnosed and treated specifically.
Treatment
 In practice, the first investigation of
palpable breast masses may be a needle
biopsy.
 In most cases however imaging has been
performed prior to a needle being
introduced into the breast and indeed
the majority of cysts are now aspirated
under ultrasound guidance.
 If the fluid that is aspirated is not
bloodstained, then the cyst is aspirated to
dryness, the needle is removed, and the
fluid is discarded, because cytologic
examination of such fluid is not cost
effective.
 After aspiration, the breast is carefully
palpated to exclude a residual mass.
 Ifa mass was noted on initial ultrasound or
there is a residual mass post-aspiration
then a tissue specimen is obtained usually
by core biopsy.
 When cystic fluid is bloodstained, fluid can
be sent for cytologic examination.
 A simple cyst is rarely of concern, but a
complex cyst may be the result of an
underlying malignancy.
Breast cancer
 Breastcancer is the most common site-
specific cancer in women and is the
leading cause of death from cancer for
women aged 20 to 59 years.
 Increasing Risk Protective
 Increase the number  Moderate levels of
of menstrual cycles : exercise and a
early menarche, longer lactation
nulliparity, and late period
menopause  The terminal
differentiation of
 older age at first live breast epithelium
birth associated with a
 obesity full-term pregnancy
Diagnostic
 Calcifications
that are associated with
cancer include microcalcifications, which
vary in shape and density and are <0.5
mm in size, and fine, linear calcifications,
which may show branching.
Mammography
 Specific mammographic features that
suggest a diagnosis of breast cancer
include a solid mass with or without
stellate features, asymmetric thickening of
breast tissues, and clustered
microcalcifications.
CA 15-3
 CA 15-3 levels are most useful in following the
course of treatment in women diagnosed
with advanced breast cancer.
 CA 15-3 levels are infrequently elevated in
early-stage breast cancer.
 CA 15-3 levels can be increased in benign
conditions such as chronic hepatitis,
tuberculosis, sarcoidosis, pelvic inflammatory
disease, endometriosis, systemic lupus
erythematosus, pregnancy, and lactation,
and in other types of cancer such as lung,
ovarian, endometrial, and GI cancers
USG
 ultrasonography is an important method
of resolving equivocal mammographic
findings, defining cystic masses, and
demonstrating the echogenic qualities of
specific solid abnormalities.
 Ultrasonography is used to guide fine-
needle aspiration biopsy, core-needle
biopsy, and needle localization of breast
lesions.
Magnetic Resonance Imaging
 Inthe process of evaluating magnetic
resonance imaging (MRI) as a means of
characterizing mammographic
abnormalities, additional breast lesions
have been detected.
BSE : Brest Self Examination, CBE : Clinical
Breast Examination
Screening
 Routineuse of screening mammography
in women ≥50 years of age has been
reported to reduce mortality from breast
cancer by 25%.
MRI for breast cancer
screening
 a 20% to 25% or greater lifetime risk using risk
assessment tools based mainly on family history
 BRCA mutation carriers, those individuals who
have a family member with a BRCA mutation who
have not been tested themselves
 individuals who received radiation to the chest
between the ages of 10 to 30 years
 and those individuals with a history of Li-Fraumeni
syndrome, Cowden syndrome, or Bannayan-Riley-
Ruvalcaba syndrome or those who have a first-
degree relative with one of these syndromes.
Biopsy
 Nonpalpable mass : Ultrasound localization
techniques are used when a mass is present,
whereas stereotactic techniques are used when
no mass is present (microcalcifications or
architectural distortion only). The combination of
diagnostic mammography, ultrasound or
stereotactic localization, and fine-needle
aspiration (FNA) biopsy achieves almost 100%
accuracy in the preoperative diagnosis of breast
cancer.
 Palpable mass :FNA or core biopsy of a palpable
breast mass can usually be performed in an
outpatient setting
Natural history
 Desmoplastic response entraps and shortens
Cooper’s suspensory ligaments to produce a
characteristic skin retraction.
 peaud’orange develops when drainage of
lymph fluid from the skin is disrupted.
 Cancer cells invade the skin, and eventually
ulceration occurs.
 As new areas of skin are invaded, small
satellite nodules appear near the primary
ulceration.
 As the size increases, cancer cells are shed
into cellular spaces and transported via the
lymphatic network especially the axillary
lymph nodes.
 at first lymph nodes ill-defined and soft,
become firm or hard with continued growth
become a conglomerate mass.
 Cancer cells may grow through the lymph
node capsule and fix to contiguous structures
in the axilla, including the chest wall
 Atapproximately the twentieth cell
doubling, breast cancers acquire their
own blood supply (neovascularization).
 Cancer cells may be shed directly into
the systemic venous blood to seed the
pulmonary circulation via the axillary and
intercostal veins or the vertebral column
via Batson’s plexus of veins.
Staging
 Theclinical stage of breast cancer is
determined primarily through physical
examination of the skin, breast tissue, and
regional lymph nodes (axillary,
supraclavicular, and internal mammary).
Stage 0
 Both LCIS and DCIS may be difficult to
distinguish from atypical hyperplasia or from
cancers with early invasion
 There is no benefit to excising LCIS, because
the disease diffusely involves both breasts in
many cases and the risk of developing
invasive cancer is equal for both breasts. The
use of tamoxifen as a risk reduction strategy
should be considered in women with a
diagnosis of LCIS.
 Women with DCIS and evidence of
extensive disease (>4 cm of disease or
disease in more than one quadrant)
usually require mastectomy
 For women with limited disease,
lumpectomy and radiation therapy are
generally recommended.
Early Invasive Breast Cancer
(Stage I, IIA, or IIB)
 Mastectomy with axillary node dissection,
Breast Conserving Therapy
 Adjuvant chemotherapy for
1. patients with node-positive cancers
2. patients with cancers that are >1 cm
3. patients with node-negative cancers of
>0.5 cm with adverse prognostic feature.
Advanced Local-Regional
Breast Cancer
(Stage IIIA or IIIB)
 surgery is integrated with radiation therapy
and chemotherapy
 Preoperative chemotherapy (neoadjuvant) ,
especially those with estrogen receptor
negative tumors.
 Chemotherapy is used to maximize distant
disease-free survival
 radiation therapy is used to maximize local-
regional control and disease-free survival.
Distant Metastases (Stage IV)
 not curative but may prolong survival and
enhance a woman’s quality of life
 Endocrine therapies that are associated with
minimal toxicity are preferred to cytotoxic
chemotherapy in estrogen receptor positive
disease.
 Appropriate candidates for initial endocrine
therapy include women with hormone receptor-
positive cancers who do not have immediately life
threatening disease (or ‘visceral crisis’). This
includes not only women with bone or soft tissue
metastases but also women with limited visceral
metastases.
Prognostic
 Approximately 95% of the women who
die of breast cancer have distant
metastases, and traditionally the most
important prognostic correlate of disease-
free and overall survival was axillary lymph
node status
Prognostic
 Women with node-negative disease had
less than a 30% risk of recurrence,
compared with as much as a 75% risk for
women with node-positive disease.
 The size of the primary breast cancer
correlates with disease-free and overall
survival, but there is a close association
between cancer size and axillary lymph
node involvement
Phyllodes
 These tumors are classified as benign,
borderline, or malignant. Borderline
tumors have a greater potential for local
recurrence.
 it is difficult to differentiate benign
phyllodes tumors from the malignant
variant and from fibroadenomas.
 Connective tissue composes the bulk of
these tumors, which have mixed
gelatinous, solid, and cystic areas.
Treatment
 Small phyllodes tumors are excised with a
margin of normal-appearing breast tissue.
 When the diagnosis of a phyllodes tumor with
suspicious malignant elements is made,
reexcision of the biopsy specimen site to
ensure complete excision of the tumor with a
1-cm margin of normal-appearing breast
tissue is indicated.
 Large phyllodes tumors may require
mastectomy. Axillary dissection is not
recommended because axillary lymph node
metastases rarely occur.
Paget’s disease
of the breast
History
 Paget disease of the breast is named
after the 19th century British doctor Sir
James Paget, who, in 1874, noted a
relationship between changes in the
nipple and breast cancer.
A rare type of cancer involving the skin of
the nipple and the areola.
 Most people with Paget disease of the
breast also have one or more tumors
inside the same breast.
 Often mistaken for benign skin conditions,
such as dermatitis or eczema
 Itching, tingling, or redness in the nipple
and/or areola
 Flaking, crusty, or thickened skin on or
around the nipple
 A flattened nipple
 Discharge from the nipple that may be
yellowish or bloody
Diagnostic
 Surface biopsy: A glass slide or other tool is
used to gently scrape cells from the surface of
the skin.
 Shave biopsy: A razor-like tool is used to
remove the top layer of skin.
 Punch biopsy: A circular cutting tool, called a
punch, is used to remove a disk-shaped piece
of tissue.
 Wedge biopsy: A scalpel is used to remove a
small wedge of tissue.
 Palpable breast mass (50%) cases
 No palpable breast mass with
mammography abnormality (20%) cases
 DCIS (25%) cases
 Not associated with mass,
mammographic abnormality or
parenchimal breast cancer (12-15%)
Treatment
 Mastectomy
 BCT
Sumber
 Schwartz’s Principles of Surgery, Tenth
edition, 2015