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BREAST CANCERBREAST CANCERBYBY

DR.T.FARIZAL FADIL Sp.BDR.T.FARIZAL FADIL Sp.B

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Breast cancer is an uncontrolled Breast cancer is an uncontrolled growth of breast cells or breast growth of breast cells or breast tissue, which can occur in both tissue, which can occur in both women and men. Worldwide, women and men. Worldwide, breast cancerbreast cancer is the fifth most is the fifth most common cause of cancer death (after common cause of cancer death (after lung cancer, stomach cancer, liver lung cancer, stomach cancer, liver cancer, and colon cancer) cancer, and colon cancer)

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Breast CancerBreast Cancer

Breast cancer is an uncontrolled growth of breast cells or breast Breast cancer is an uncontrolled growth of breast cells or breast tissue, which can occur in both women and men. Worldwide, tissue, which can occur in both women and men. Worldwide, breast cancerbreast cancer is the fifth most common cause of cancer death (after is the fifth most common cause of cancer death (after lung cancer, stomach cancer, liver cancer, and colon cancer).lung cancer, stomach cancer, liver cancer, and colon cancer).

No one knows why some women get breast cancer, but Breast No one knows why some women get breast cancer, but Breast cancer the most common cause by :cancer the most common cause by :

Age, the chance of Age, the chance of getting breast cancergetting breast cancer rises as a woman gets older rises as a woman gets older

Genes, there are two genes, BRCA1 and BRCA2, that greatly increase Genes, there are two genes, BRCA1 and BRCA2, that greatly increase the risk. Having one close relative (mother or sister) with breast the risk. Having one close relative (mother or sister) with breast cancer doubles your risk of getting breast cancercancer doubles your risk of getting breast cancer

Certain Medications, Taking hormone replacement therapy (HRT) Certain Medications, Taking hormone replacement therapy (HRT) drugs after menopause may increase your chance of getting breast drugs after menopause may increase your chance of getting breast cancer.cancer.

Personal factors, beginning periods before age 12 or going through Personal factors, beginning periods before age 12 or going through menopause after age menopause after age

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Symptoms & DiagnosisSymptoms & Diagnosis : :If you discover a persistent lump in your If you discover a persistent lump in your breast or any changes in breast tissue, it is breast or any changes in breast tissue, it is very important that you see a physician very important that you see a physician immediately. Other thing that you should immediately. Other thing that you should See your health professional if :See your health professional if :- A new lump in the breast- A new lump in the breast- A lump that has changed- A lump that has changed- change in the size or shape of the breast- change in the size or shape of the breast- Pain in the breast or nipple that does not - Pain in the breast or nipple that does not go awaygo away- Skin anywhere on the breast that is flaky, - Skin anywhere on the breast that is flaky, red, or swollenred, or swollen- A nipple that is very tender or that - A nipple that is very tender or that suddenly turns inwardsuddenly turns inward- Fluid coming from the nipple when not - Fluid coming from the nipple when not nursing a baby nursing a baby

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The most important method used to The most important method used to diagnose breast cancer is by taking a diagnose breast cancer is by taking a biopsy (a biopsy (a tissue sampletissue sample), The shape ), The shape and appearance of the cells in the and appearance of the cells in the tissue sample reveals whether the tissue sample reveals whether the lump is benign, which is true of the lump is benign, which is true of the vast majority, or if it is cancerous.vast majority, or if it is cancerous.

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Type of Breast Cancer :Type of Breast Cancer :

Ductal carcinoma in situ, is an early breast cancer Ductal carcinoma in situ, is an early breast cancer in the milk ducts. It can be detected by in the milk ducts. It can be detected by mammograms and is normally easy to cure.mammograms and is normally easy to cure.

Lobular carcinoma in situ, this is not considered Lobular carcinoma in situ, this is not considered to be breast cancer but a pre-cancerous to be breast cancer but a pre-cancerous condition. They just have an increased condition. They just have an increased risk of breast cancerrisk of breast cancer, so they are given frequent , so they are given frequent checkups.checkups.

Invasive lobular carcinoma, is a breast cancer Invasive lobular carcinoma, is a breast cancer that starts in the lobules and has spread. It's may that starts in the lobules and has spread. It's may difficult to diagnose because they do not always difficult to diagnose because they do not always form a lump or show up on mammograms. form a lump or show up on mammograms.

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Types of Breast CancerTypes of Breast Cancer Ductal carcinomaDuctal carcinoma is the most common form of breast is the most common form of breast

cancer. Tumors form in the cells of the milk ducts, which cancer. Tumors form in the cells of the milk ducts, which convey milk to the nipples. Ductal carcinoma can either be convey milk to the nipples. Ductal carcinoma can either be invasive, with the potential to spread, or non-invasive.invasive, with the potential to spread, or non-invasive.

Lobular carcinomaLobular carcinoma occurs in the lobules, which are the occurs in the lobules, which are the milk-producing glands. Lobular carcinoma can be invasive, milk-producing glands. Lobular carcinoma can be invasive, with a tendency to spread, or non-invasive.with a tendency to spread, or non-invasive.

Inflammatory breast cancer (IBC)Inflammatory breast cancer (IBC) is a rare, aggressive is a rare, aggressive form of breast cancer that affects the dermal lymphatic form of breast cancer that affects the dermal lymphatic system. Rather than forming a lump, IBC tumors grow in flat system. Rather than forming a lump, IBC tumors grow in flat sheets that cannot be felt in a breast exam. sheets that cannot be felt in a breast exam. Read more about IBCRead more about IBC

Recurrent breast cancerRecurrent breast cancer means that the cancer has means that the cancer has returned after being undetected for a time. Recurrent returned after being undetected for a time. Recurrent cancer can occur in the remaining breast tissue, and also at cancer can occur in the remaining breast tissue, and also at other sites such as the lungs, liver, bones or brain. Even other sites such as the lungs, liver, bones or brain. Even though these tumors are in a new location, they are still though these tumors are in a new location, they are still called breast cancer.called breast cancer.

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Symptoms include:Symptoms include: Lump or mass in your breastLump or mass in your breast Enlarged lymph nodes in the armpitEnlarged lymph nodes in the armpit Changes in breast size, shape, skin texture or Changes in breast size, shape, skin texture or

colorcolor Skin rednessSkin redness Dimpling or puckeringDimpling or puckering Nipple changes or dischargeNipple changes or discharge ScalinessScaliness Nipple pulling to one side or a change in directionNipple pulling to one side or a change in direction Many breast changes – including lumps – are not Many breast changes – including lumps – are not

cancer, but if you notice one or more of these cancer, but if you notice one or more of these symptoms for more than two weeks, see your symptoms for more than two weeks, see your doctor.doctor.

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Symptoms includeSymptoms include • • lump or mass in your breastlump or mass in your breast • • enlarged lymph nodes in the armpitenlarged lymph nodes in the armpit • • changes in breast size, shape, skin changes in breast size, shape, skin

texture or colortexture or color • • skin rednessskin redness • • dimpling or puckeringdimpling or puckering • • nipple changes or dischargenipple changes or discharge • • scalinessscaliness • • nipple pulling to one side or a nipple pulling to one side or a

change in directionchange in direction

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• age Most cases occur in women 50 or older; it is less• common in women 35 or younger. Age is the most• influential risk factor.• • family history Your risk is higher with a family history• (especially mother, sister, daughter) of breast and/or• ovarian cancer.• • hormones / childbirth Your risk is higher if you had• your first period before age 12, began menopause after• age 55, never had children or had your first child after• age 30. Postmenopausal use of hormonal therapy• increases your risk of developing breast cancer.• • previous biopsy If you’ve had abnormal breast biopsy• results or benign breast diseases requiring biopsies, you• may be at increased risk. Other breast diseases such as• atypical hyperplasia, lobular or ductal carcinoma in situ• are risk factors, too.• • education / socioeconomic status Women with a• higher socioeconomic status and/or education tend to• have fewer children and start childbearing after age 30 –• both of which put them at higher risk.• • weight Obesity or weight gain after menopause are risk• factors.• • genetic alterations Inherited alterations in the genes,• called BRCA1 and BRCA2, account for about five to 10• percent of all breast cancer cases.• Other risk factors include:• • oral contraceptive use• • a diet high in saturated fats• • physical inactivity• • alcohol (more than one alcoholic drink a day)

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ScreeningScreening Cancer screening exams are medical tests that are Cancer screening exams are medical tests that are

performed when a person has no symptoms.performed when a person has no symptoms. All women should be familiar with their breasts so that they All women should be familiar with their breasts so that they

will notice any changes and reportwill notice any changes and report them to their doctor without delay. M. D. Anderson also them to their doctor without delay. M. D. Anderson also

recommends the following:recommends the following: • • Clinical breast exams every one to three years beginning Clinical breast exams every one to three years beginning

at age 20.at age 20. • • Yearly mammograms and clinical breast exams beginning Yearly mammograms and clinical breast exams beginning

at age 40 and continuing forat age 40 and continuing for as long as a woman is in good health.as long as a woman is in good health. M. D. Anderson breast cancer experts recommend that all M. D. Anderson breast cancer experts recommend that all

women practice “breast selfawareness”women practice “breast selfawareness” (BSA) as part of the triad of breast cancer screening (BSA) as part of the triad of breast cancer screening

guidelines, which includesguidelines, which includes breast exams by physicians (clinical breast exams) and breast exams by physicians (clinical breast exams) and

mammograms.mammograms. TipsTips ••

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TipsTips • • Schedule a clinical breast exam at the time of or just Schedule a clinical breast exam at the time of or just

before your regularly scheduledbefore your regularly scheduled mammogram.mammogram. • • If you are age 35 or older, ask your doctor to calculate If you are age 35 or older, ask your doctor to calculate

your breast cancer risk.your breast cancer risk. • • Consider additional screening if you are at risk.Women at Consider additional screening if you are at risk.Women at

increased risk of breastincreased risk of breast cancer (e.g., family history, genetic predisposition, past cancer (e.g., family history, genetic predisposition, past

breast cancer) should talk to theirbreast cancer) should talk to their doctor about the benefits and limitations of starting doctor about the benefits and limitations of starting

mammograms earlier, having additionalmammograms earlier, having additional test (e.g., breast ultrasound or MRI) or having more test (e.g., breast ultrasound or MRI) or having more

frequent exams.frequent exams. These recommendations are provided as a guide. If exam These recommendations are provided as a guide. If exam

results suggest cancer, more extensiveresults suggest cancer, more extensive diagnostic tests, such as an ultrasound or biopsy of the diagnostic tests, such as an ultrasound or biopsy of the

breast tissue, should be conductedbreast tissue, should be conducted

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Reducing Your RiskReducing Your Risk You can take action to reduce your risk of developing breastYou can take action to reduce your risk of developing breast cancer. M. D. Anderson suggests:cancer. M. D. Anderson suggests: • • talking to your doctor about your use of oraltalking to your doctor about your use of oral contraceptives and hormonal therapycontraceptives and hormonal therapy • • maintaining your ideal weightmaintaining your ideal weight • • eating at least five servings of fruits and vegetableseating at least five servings of fruits and vegetables per dayper day • • following recommended screening guidelinesfollowing recommended screening guidelines • • exercising regularlyexercising regularly • • eliminating tobacco use and using alcohol in moderationeliminating tobacco use and using alcohol in moderation • • getting your breast cancer risk assessedgetting your breast cancer risk assessed • • if you’re at increased risk, talk to your doctor aboutif you’re at increased risk, talk to your doctor about medications that can reduce your risk of developingmedications that can reduce your risk of developing breast cancer.breast cancer. Take time to discuss your own risks with your health careTake time to discuss your own risks with your health care

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Biopsy:Biopsy: a small sample of the suspicious area of a small sample of the suspicious area of the breast is removed for examination under a the breast is removed for examination under a microscope. Biopsies can be done in the following microscope. Biopsies can be done in the following ways:ways:

Surgical biopsy:Surgical biopsy: an incision is made in the an incision is made in the breast. Surgeons locate the tumor by palpation or breast. Surgeons locate the tumor by palpation or with the aid of images from a CT scan, ultrasound with the aid of images from a CT scan, ultrasound or mammogram. In an or mammogram. In an excisional biopsyexcisional biopsy, the , the entire mass is removed. In an entire mass is removed. In an incisional biopsyincisional biopsy, , only a portion of the tumor is removed.only a portion of the tumor is removed.

Fine Needle Aspiration (FNA):Fine Needle Aspiration (FNA): a thin, hollow a thin, hollow needle is inserted into the breast to the tumor, and needle is inserted into the breast to the tumor, and fluid and cells are removed from the tumor. While fluid and cells are removed from the tumor. While this test can help to determine if there is cancer this test can help to determine if there is cancer present, it cannot determine if the cancer is present, it cannot determine if the cancer is invasive and additional biopsies may be needed if invasive and additional biopsies may be needed if cancer is actually present.cancer is actually present.

Core biopsy:Core biopsy: a thicker needle is used to remove a thicker needle is used to remove one or more small cylinder-shaped tissue samples one or more small cylinder-shaped tissue samples from the tumor.from the tumor.

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shaped tissue samples from the tumor.shaped tissue samples from the tumor. Diagnostic mammogram:Diagnostic mammogram: this procedure is similar this procedure is similar

to the mammogram used for screening, but to the mammogram used for screening, but provides more detailed images of the breast tissue.  provides more detailed images of the breast tissue.  

Magnetic Resonance Imaging (MRI):Magnetic Resonance Imaging (MRI): images of images of the breast are created with powerful magnets that the breast are created with powerful magnets that interact with a computer.interact with a computer.

Ultrasound:Ultrasound: a special wand placed against the skin a special wand placed against the skin transmits sound waves, which bounce off breast transmits sound waves, which bounce off breast tissue and are used create an image on a monitor. tissue and are used create an image on a monitor. 

Sentinel lymph node biopsy:Sentinel lymph node biopsy: lymph nodes are lymph nodes are olive-sized glands which are part of a system that olive-sized glands which are part of a system that circulates lymph fluid throughout the body. The circulates lymph fluid throughout the body. The lymphatic system can also carry cancer cells from lymphatic system can also carry cancer cells from the tumor site to other areas of the body. In breast the tumor site to other areas of the body. In breast cancer patients, the first nodes to be affected are cancer patients, the first nodes to be affected are under the armunder the arm

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Staging TNM SYSTEM• Primary tumor (T)• Tx: Primary tumor cannot be assessed• T0:  No evidence of primary tumor• Tis: (DCIS) Carcinoma in situ• Tis: (LCIS) Carcinoma in situ• Tis: Paget disease of the nipple with no tumor (Paget disease

associated with a tumor is classified according to the size of the tumor.)

• T1:  Tumor 2 cm or smaller in greatest diameter– T1mic: Microinvasion 0.1 cm or less in greatest dimension– T1a: Tumor >0.1 but not >0.5 cm in greatest diameter– T1b: Tumor >0.5 but not >1 cm in greatest diameter– T1c: Tumor >1 cm but not >2 cm in greatest diameter

• T2:  Tumor >2 cm but not >5 cm in greatest diameter• T3: Tumor >5 cm in greatest diameter• T4:  Tumor of any size, with direct extension to (a) the chest wall or (b)

skin only, as described below– T4a: Extension to the chest wall, not including the pectoralis muscle– T4b: Edema (including peau d’orange) or ulceration of the skin of the breast

or satellite skin nodules confined to the same breast– T4c: Both T4a and T4b– T4d: Inflammatory disease

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• Regional lymph nodes (N)• Nx: Regional lymph nodes cannot be assessed (eg, previously

removed)• N0: No regional lymph node metastasis• N1: Metastasis in movable ipsilateral axillary lymph node(s)• N2: Metastasis in ipsilateral axillary lymph node(s) fixed or matted,

or in clinically apparent ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastasis– N2a: Metastasis in ipsilateral axillary lymph nodes fixed to one another

or to other structures– N2b: Metastasis only in clinically apparent ipsilateral internal mammary

nodes and in the absence of clinically evident axillary lymph nodes• N3: Metastasis in ipsilateral infraclavicular or supraclavicular lymph

node(s) with or without axillary lymph node involvement, or clinically apparent ipsilateral internal mammary lymph node(s) and in the presence of axillary lymph node– N3a: Metastasis in ipsilateral infraclavicular lymph node(s)– N3b: Metastasis in ipsilateral internal mammary lymph node(s) and

axillary lymph node(s)– N3c: Metastasis in ipsilateral supraclavicular lymph node(s)

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• Distant metastasis

• Mx: Distant metastasis cannot be assessed

• M0:  No distant metastasis

• M1: Distant metastasis

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Table 2. TNM Staging System for Breast CancerTable 2. TNM Staging System for Breast Cancer

Open table in new windowOpen table in new window [ CLOSE WINDOW ][ CLOSE WINDOW ] Table Table StageTumorNodeMetastasesStageTumorNodeMetastasesStage 0TisN0M0Stage IT1N0M0Stage IIAT0Stage 0TisN0M0Stage IT1N0M0Stage IIAT0

T1T1T2N1T2N1N1N1N0M0N0M0M0M0M0Stage IIBT2M0Stage IIBT2T3N1T3N1N0M0N0M0M0Stage IIIAT0M0Stage IIIAT0T1T1T2T2T3N2T3N2N2N2N2N2N1-2M0N1-2M0M0M0M0M0M0Stage IIIBT4M0Stage IIIBT4T4T4T4N0T4N0N1N1N2M0N2M0M0M0M0Stage IIICAny TN3M0Stage IVAny TAny NM1M0Stage IIICAny TN3M0Stage IVAny TAny NM1StageTumorNodeMetastasesStageTumorNodeMetastasesStage 0TisN0M0Stage IT1N0M0Stage IIAT0Stage 0TisN0M0Stage IT1N0M0Stage IIAT0T1T1T2N1T2N1N1N1N0M0N0M0M0M0M0Stage IIBT2M0Stage IIBT2T3N1T3N1N0M0N0M0M0Stage IIIAT0M0Stage IIIAT0T1T1T2T2T3N2T3N2N2N2N2N2N1-2M0N1-2M0M0M0M0M0M0Stage IIIBT4M0Stage IIIBT4T4T4T4N0T4N0N1N1N2M0N2M0M0M0M0Stage IIICAny TN3M0Stage IVAny TAny NM1M0Stage IIICAny TN3M0Stage IVAny TAny NM1

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THERAPIE :THERAPIE :

1.OPERASI.1.OPERASI.

2.CHEMOTHERAPIE.2.CHEMOTHERAPIE.

3.RADIASI.3.RADIASI.

4.HORMONAL.4.HORMONAL.

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PROGNOSA :PROGNOSA :

TERGANTUNG STADIUM.TERGANTUNG STADIUM.

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Facing a mirrorFacing a mirror Stand before a mirror and compare both breasts for Stand before a mirror and compare both breasts for

differences in size, nipple inversion (turning in), bulging, or differences in size, nipple inversion (turning in), bulging, or dimpling. Note any skin or nipple changes, such as a hard dimpling. Note any skin or nipple changes, such as a hard knot or knot or nipple dischargenipple discharge..

Inspect your breasts in the following 4 steps: Inspect your breasts in the following 4 steps:

– With your With your armsarms at your sides at your sides

– With your arms overhead With your arms overhead

– With your hands on hips - Press firmly to flex your With your hands on hips - Press firmly to flex your chestchest muscles. muscles.

– Bent forward - Inspect your breasts. Bent forward - Inspect your breasts.

In these positions, your pectoral muscles are contracted, In these positions, your pectoral muscles are contracted, and a subtle dimpling of the skin may appear if a growing and a subtle dimpling of the skin may appear if a growing tumor has affected a ligamenttumor has affected a ligament

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Lying downLying down Right breast Right breast

and Left breastand Left breast

– Place a pillow under your right shoulder. Place a pillow under your right shoulder.

– Put your right hand under your head. Put your right hand under your head.

– Check the entire breast area with the finger pads of your left hand. Check the entire breast area with the finger pads of your left hand.

– Use small circles and follow an up-and-down pattern. Use small circles and follow an up-and-down pattern.

– Use light, medium, and firm pressure over each area of the breast. Use light, medium, and firm pressure over each area of the breast.

– Feel the breast with the surfaces of the second, third, and fourth Feel the breast with the surfaces of the second, third, and fourth fingers, moving systematically and using small, circular motions from fingers, moving systematically and using small, circular motions from the nipple to the outer margins. the nipple to the outer margins.

– Gently squeeze the nipple for any discharge.Gently squeeze the nipple for any discharge.

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In the showerIn the shower

A BSE can easily be performed while you're in the A BSE can easily be performed while you're in the bath or shower. Some women discover breast bath or shower. Some women discover breast masses when their skin is moist. masses when their skin is moist.

– Raise your right arm. Raise your right arm.

– With soapy hands and fingers flat, check your right With soapy hands and fingers flat, check your right breast. breast.

– Use the same small circles and up-and-down pattern Use the same small circles and up-and-down pattern described earlier. described earlier.

– Repeat on the left breast.Repeat on the left breast.

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