PERSONAL CASE

CARCINOMA MAMMAE

Compiled by :
Aria Adhitya S 1102003035

Mentor: Dr. H. Herry Setya Yudha Utama, Sp.B, MHKes, FInaCs

SURGERY DEPARTMENT RSUD ARJAWINANGUN PERIOD 30 January 7 April 2012

BAB I Ca Mamae case

STATUS OF PATIENTS :

A.

PATIENT IDENTITY

Name Age Sex Job Religion Address

: Mrs. S L : 42 years : Female : Housewife : Moslem : 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 theres 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. Theres no discharge comes from nipple, It is immobile / fixed, There is no lumps on the right breast. Mrs S L said that this lump doesnt affect patients breath. Patient said that her mother had the same illness. Past medical history : Theres no same medical history in the past

 Family history of disease: Her mother had the same illness.

C. PHYSICAL EXAMINATION Status Present General condition : Moderate ill appearance Consciousness vital sign : compost mentis :

Blood pressure : 120/80 mmHg Pulse : 80x/mnt

respiratory rate : 24x/mnt temperature Generalis Status : 36.6 C

Skin Head Eyes Nose Ears

: Skin color is black, no jaundice, enough turgor : Symmetrical, normochepal, equitable distribution of hair : conjunctiva anemis (- / -), sclera jaundice (- / -), light reflex (+ / +) normal : Deviation of the septum (-), discharge (-) : 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

Auscultation: Pulmo : vesicular breath sound, Ronchi - / -, wheezing - / Cor : heart sound I / II regular, Murmur (-), Gallop (-)

Abdomen Inspection Palpation spleen not palpable Percussion : timpani in the entire quadrant of the abdomen. : symmetrical, flat abdomen, does not look any mass : palpable weakness, no muscular defense, tenderness (-), liver and

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 Hematocrit :11,6 g/dl :36,5 %

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Leukosites

:8500 sel/cmm

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 Quo ad functionam

: dubia ad bonam : dubia ad bonam

CARCINOMA MAMMAE

A. Definisi
Breast 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.

B. Pathophysioilogy

C. Stages of Breast Cancer S t a g e s

Stage Stage 0 Stage I

o f

B r e a s t

C a n c e r

Stage IIA

Stage IIB

Stage IIIA

Stage IIIB

Definition Cancer cells remain inside the breast duct, without invasion into normal adjacent breast tissue. Cancer is 2 centimeters or less and is confined to the breast (lymph nodes are clear). 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. 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. 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. 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.

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 Stage the cancer has spread to lymph nodes either above or IIIC below the collarbone AND the cancer may have spread to axillary lymph nodes or to lymph nodes near the breastbone. Stage The cancer has spread or metastasized to other IV 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 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)
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skin irritation or dimpling 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
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of each breast is normal. If you're not sure how hard to press, talk with your doctor or 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
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break away from the primary breast tumor and begin to spread through the body by way of the 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: 23692470. 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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