Post on 01-Sep-2014
transcript
Compiled by :
Aria Adhitya S 1102003035
Mentor:
Dr. H. Herry Setya Yudha Utama, Sp.B, MHKes, FInaCs
SURGERY DEPARTMENTRSUD ARJAWINANGUN
PERIOD 30 January – 7 April 2012
PERSONAL CASE CARCINOMA MAMMAE
BAB ICa Mamae case
STATUS OF PATIENTS :
A. PATIENT IDENTITY
Name : Mrs. S L
Age : 42 years
Sex : Female
Job : Housewife
Religion : Moslem
Address : Arjawinangun
B. ANAMNESA
Main complaint :
Lump in left breast
Additional complaints : -
History of present illness :
Mrs N, 42 years old, comes to Arjawinangun Hospital complains there’s a lamp in
left breast that she had since 4 years ago. At first, it is a mobile sized, but in several mounth
it becomes bigger than before. On palpable, it feels pain. There’s no discharge comes from
nipple, It is immobile / fixed, There is no lumps on the right breast. Mrs S L said that this
lump doesn’t affect patient’s breath. Patient said that her mother had the same illness.
Past medical history :
There’s no same medical history in the past
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Family history of disease:
Her mother had the same illness.
C. PHYSICAL EXAMINATION
Status Present
General condition : Moderate ill appearance
Consciousness : compost mentis
vital sign :
Blood pressure : 120/80 mmHg
Pulse : 80x/mnt
respiratory rate : 24x/mnt
temperature : 36.6 °C
Generalis Status
Skin : Skin color is black, no jaundice, enough turgor
Head : Symmetrical, normochepal, equitable distribution of hair
Eyes : conjunctiva anemis (- / -), sclera jaundice (- / -), light reflex (+ / +) normal
Nose : Deviation of the septum (-), discharge (-)
Ears : symmetrical, cerumen right-left (+)
Mouth and throat :
Lips : not dry, and no cyanosis
Tonsils : T1/T1
Pharing : not hiperemis
Neck : Not deviasi, No enlargement of lymph glands
Thoracic :
Inspection : hemithorak symmetrical right and left in a state of static and dynamic
Palpation : tactile fremitus symmetrical right and left
Percussion : sonor to the hemithorax
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Auscultation:
Pulmo : vesicular breath sound, Ronchi - / -, wheezing - / -
Cor : heart sound I / II regular, Murmur (-), Gallop (-)
Abdomen
Inspection : symmetrical, flat abdomen, does not look any mass
Palpation : palpable weakness, no muscular defense, tenderness (-), liver and
spleen
not palpable
Percussion : timpani in the entire quadrant of the abdomen.
Auscultation : bowel sounds (+)
Extremity:
Warm acral, cyanosis - / -, edema - / -
Localist Status
Regio mammary sinistra
Inspection: visible lump in left breast, the skin does not look redness, does not look fluid out
of the nipple, peau d'orange (-)
Palpation: palpable mass in the right lateral region of the irregular-shaped, solitary,
measuring 7cm x 7cm x 3 cm, hard consistency, well defined, the surface does not lump,
Immobile movement, tenderness (+), the temperature is warmer than surrounding, nipple
discharge (-).
D. WORKUP
Complete Blood :
- Hemoglobin :11,6 g/dl
- Hematocrit :36,5 %
- Leukosites :8500 sel/cmm
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- Platelet :256.000 sel/cmm
Blood glucose level :
96 mg/dl
Rontgen :
Results : No vesible heart enlargement
No vesible metastasis intra pulmonal
E. WORKING DIAGNOSIS
Carcinoma mammae sinistra
F. MANAGEMENT
- IVFD NaCl 20 drops/minutes
- Cefotaxim 2x 1amp
- Tramadol 2x1 amp
- Ranitidin 2x1 amp
- Modified Radical Mastectomy by lifting the breast tissue around the sinistra
G. PROGNOSIS
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad bonam
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CARCINOMA MAMMAE
A. DefinisiBreast cancer is cancer that originates from the breast tissue. It can affect women of all ages
but most commonly affects those above 40. It is potentially fatal but achieving a complete
cure is also possible. There are 5 stages of breast cancer (stage 0, 1, 2, 3 and 4). Treatment
at stage 0 & 1 can result in cure rates of above 90%.
Fig 1. Most breast cancers begin in the cells that line the ducts (ductal cancers). Some begin in the cells that line the lobules (lobular cancers), while a small number start in other tissues.
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B. Pathophysioilogy
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C. Stages of Breast Cancer
S t a g e s o f B r e a s t C a n c e r
Stage DefinitionStage 0
Cancer cells remain inside the breast duct, without invasion into normal adjacent breast tissue.
Stage I
Cancer is 2 centimeters or less and is confined to the breast (lymph nodes are clear).
Stage IIA
No tumor can be found in the breast, but cancer cells are found in the axillary lymph nodes (the lymph nodes under the arm) OR the tumor measures 2 centimeters or smaller and has spread to the axillary lymph nodes OR the tumor is larger than 2 but no larger than 5 centimeters and has not spread to the axillary lymph nodes.
Stage IIB
The tumor is larger than 2 but no larger than 5 centimeters and has spread to the axillary lymph nodes
OR the tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes.
Stage IIIA
No tumor is found in the breast. Cancer is found in axillary lymph nodes that are sticking together or to other structures, or cancer may be found in lymph nodes near the breastbone OR the tumor is any size. Cancer has spread to the axillary lymph nodes, which are sticking together or to other structures, or cancer may be found in lymph nodes near the breastbone.
Stage IIIB
The tumor may be any size and has spread to the chest wall and/or skin of the breast AND may have spread to axillary lymph nodes that are clumped together or sticking to other structures, or cancer may have spread to lymph nodes near the breastbone.
Inflammatory breast cancer is considered at least stage IIIB.
Stage IIIC
There may either be no sign of cancer in the breast or a tumor may be any size and may have spread to the chest wall and/or the skin of the breast AND
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the cancer has spread to lymph nodes either above or below the collarbone AND the cancer may have spread to axillary lymph nodes or to lymph nodes near the breastbone.
Stage IV
The cancer has spread — or metastasized — to other parts of the body.
D. Risk Factors- Risk factors you cannot change
1. Gender
Simply being a woman is the main risk factor for developing breast cancer.
Although women have many more breast cells than men, the main reason they
develop more breast cancer is because their breast cells are constantly exposed to
the growth-promoting effects of the female hormones estrogen and progesterone
2. Aging
Your risk of developing breast cancer increases as you get older.
3. Genetic risk factors
About 5% to 10% of breast cancer cases are thought to be hereditary,
4. Family history of breast cancer
Breast cancer risk is higher among women whose close blood relatives have this
disease
5. Personal history of breast cancer
A woman with cancer in one breast has a 3- to 4-fold increased risk of developing a
new cancer in the other breast or in another part of the same breast
- Risk factors you can control
1. Weight
Being overweight is associated with increased risk of breast cancer, especially for
women after menopause
2. Diet
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Diet is a suspected risk factor for many types of cancer, including breast cancer, but
studies have yet to show for sure which types of foods increase risk
3. Exercise
Evidence is growing that exercise can reduce breast cancer risk
4. Alcohol consumption
Studies have shown that breast cancer risk increases with the amount of alcohol a
woman drinks
5. Smoking
Smoking is associated with a small increase in breast cancer risk
6. Exposure to estrogen
Because the female hormone estrogen stimulates breast cell growth, exposure to
estrogen over long periods of time, without any breaks, can increase the risk of
breast cancer
7. Stress and anxiety
There is no clear proof that stress and anxiety can increase breast cancer risk. However,
anything you can do to reduce your stress and to enhance your comfort, joy, and satisfaction
can have a major effect on your quality of life.
E. Signs and symptoms
Although widespread use of screening mammograms has increased the number of breast
cancers found before they cause any symptoms, some breast cancers are not found by
mammogram, either because the test was not done or because, even under ideal conditions,
mammograms do not find every breast cancer.
The most common sign of breast cancer is a new lump or mass. A painless, hard mass that
has irregular edges is more likely to be cancerous, but breast cancers can be tender, soft, or
rounded. For this reason, it is important that any new breast mass or lump be checked by a
health care professional experienced in diagnosing breast diseases
Other possible signs of breast cancer include:
swelling of all or part of a breast (even if no distinct lump is felt)
skin irritation or dimpling
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breast or nipple pain
nipple retraction (turning inward)
redness, scaliness, or thickening of the nipple or breast skin
a discharge other than breast milk
Sometimes a breast cancer can spread to underarm lymph nodes and cause a lump or
swelling there, even before the original tumor in the breast tissue is large enough to be felt
F. Workup
Breast self-exam should be part of your monthly health care routine, and you should visit
your doctor if you experience breast changes.
Use the finger pads of the 3 middle fingers on your left hand to feel for lumps in the
right breast. Use overlapping dime-sized circular motions of the finger pads to feelthe
breast tissue
Fig 2. Breast Self Examination
Use 3 different levels of pressure to feel all the breast tissue. Light pressure is needed
to feel the tissue closest to the skin; medium pressure to feel a little deeper; and firm
pressure to feel the tissue closest to the chest and ribs. A firm ridge in the lower curve
of each breast is normal. If you're not sure how hard to press, talk with your doctor or
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nurse. Use each pressure level to feel the breast tissue before moving on to the next
spot
Move around the breast in an up and down pattern starting at an imaginary line drawn
straight down your side from the underarm and moving across the breast to the
middle of the chest bone (sternum or breastbone). Be sure to check the entire breast
area going down until you feel only ribs and up to the neck or collar bone (clavicle).
Mammogram . If you're over 40 or at a high risk for the disease, you should also have an
annual mammogram.
Magnetic resonance imaging (MRI)
For certain women at high risk for breast cancer, screening MRI is recommended along
with a yearly mammogram. It is not generally recommended as a screening tool by itself,
because although it is a sensitive test, it may still miss some cancers that mammograms
would detect.
Physical Exam by a doctor. The earlier breast cancer is found and diagnosed, the better
your chances of beating it.
The actual process of diagnosis can take weeks and involve many different kinds of tests.
Waiting for results can feel like a lifetime. The uncertainty stinks. But once you understand
your own unique “big picture,” you can make better decisions. You and your doctors can
formulate a treatment plan tailored just for you.
G. Treatment
General types of treatment
Local versus systemic therapy
Local therapy is intended to treat a tumor at the site without affecting the rest of the
body. Surgery and radiation therapy are examples of local therapies
Adjuvant and neoadjuvant therapy
Patients who have no detectable cancer after surgery are often given adjuvant
(additional) systemic therapy. Doctors believe that in some cases cancer cells may break
away from the primary breast tumor and begin to spread through the body by way of the
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bloodstream even in the early stages of the disease. These cells can't be felt on a
physical exam or seen on x- rays or other imaging tests, and they cause no symptoms.
But they can establish new tumors in other organs or in bones. The goal of adjuvant
therapy is to kill these hidden cells. Some patients are given systemic therapy, usually
chemotherapy, before surgery to shrink a tumor in the hope it will allow a less extensive
operation to be done. This is called neoadjuvant therapy.
Surgery for breast cancer
Breast conserving surgery
Lumpectomy removes only the breast lump and a surrounding margin of normal tissue.
Radiation therapy is usually given after a lumpectomy. If adjuvant chemotherapy is to
be given as well, the radiation is usually delayed until the chemotherapy is completed.
Partial (segmental) mastectomy or quadrantectomy removes more breast tissue than a
lumpectomy. For a quadrantectomy, one-quarter of the breast is removed. Radiation
therapy is usually given after surgery. Again, this may be delayed if chemotherapy is to
be given as well.
For most women with stage I or II breast cancer, breast conservation therapy
(lumpectomy/partial mastectomy plus radiation therapy) is as effective as mastectomy.
Survival rates of women treated with these 2 approaches are the same. However, breast
conservation therapy is not an option for all women with breast cancer (see "Choosing
between lumpectomy and mastectomy" below
Radiation therapy can sometimes be omitted as a part of breast-conserving therapy.
Women who may consider lumpectomy without radiation therapy typically have all of -
the following characteristics
- they are age 70 years or older
- they have a tumor 2 cm or less that has been completely removed
- the tumor is hormone receptor-positive, and the women is getting hormone
therapy (such as tamoxifen)
- they have no lymph node involvement
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Mastectomy
Mastectomy involves removing all of the breast tissue, sometimes along with other
nearby tissues.
In a simple or total mastectomy the surgeon removes the entire breast, including the
nipple, but does not remove underarm lymph nodes or muscle tissue from beneath the
breast. Sometimes this is done for both breasts (a double mastectomy), especially when
it is done as preventive surgery in women at very high risk for breast cancer. Most
women, if they are hospitalized, can go home the next day
A modified radical mastectomy involves removing the entire breast and some of the
axillary (underarm) lymph nodes. This is the most common surgery for women with
breast cancer who are having the whole breast removed.
For some women who have smaller tumors, one option may be a newer procedure
known as a skin-sparing mastectomy, where most of the skin over the breast (other than
the nipple and areola) is left intact. This procedure is described in more detail in
"What's new in breast cancer research and treatment?"
A radical mastectomy is an extensive operation where the surgeon removes the entire
breast, axillary lymph nodes, and the pectoral (chest wall) muscles under the breast.
This surgery was once very common. But because of the disfigurement and side effects
it causes, and because a modified radical mastectomy has been proven to be as effective
as a radical mastectomy, it is rarely done today
Lumpectomy
A lumpectomy is surgery to remove a small area of breast tissue that is cancerous.This
surgery is carried out only in early breast cancer, if the area of tissue to be removed is
relatively small. Women who choose a lumpectomy will require radiation therapy to
destroy any cancer cells that may remain in the area
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REFERENCES
1. Abeloff MD, Wolff AC, Wood WC, et al. Cancer of the Breast. In: Abeloff MD, Armitage
JO, Lichter AS, et al, eds. Clinical Oncology. 3rd Ed. Philadelphia, Pa: Elsevier; 2004: 2369-
2470.
2. American Cancer Society. Cancer Facts and Figures 2008. Atlanta, Ga: American Cancer
Society; 2008
3. American Joint Committee on Cancer. AJCC Cancer Staging Manual, 6th ed. New York:
Springer; 2002: 221-240.
4. Avis N, Crawford S, Manuel J, et al. Quality of life among younger women with breast
cancer. J Clin Oncol. 2005;23:3322-3330.
5. Darbre PD, Aljarrah A, Miller WR, et al. Concentrations of parabens in human breast
tumours. J Appl Toxicol. 2004;24:5-13.
6. National Cancer Institute. Surveillance Epidemiology and End Results (SEER) Cancer
Statistics Review, 1975-2005. 2008. Available at:
http://seer.cancer.gov/csr/1975_2005/sections.html. Accessed July 17, 2008.
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