STUDI KASUS

TUMOR MAMMAE

 Ny. UH , Umur 49 Tahun

Keluhan :
Benjolan di Payudara sebelah kiri sejak September
2003, setelah September benjolan bertambah besar.
Hasil pemeriksaan fisik sebelumnya , besar benjolan
tetap keras , tidak nyeri , tidak gatal , tidak ada
hubungan dengan menstruasi .
Hasil Pemeriksaan Patologi Anatomi : memberikan
kesimpulan Suspect Tumor Ganas Mammae Sinistra
Fibro Cyste Mammae Dextra
Diagnosa :
Ca Mammae Sinistra Stadium II B ( T2N1M0 )

Hasil Pemeriksaan Laboratorium :

Hb
: 13,1 g/dl
LED
: 21 mm/1 jam
Leucocyt : 9000 /L
Trombocyt : 384 /L
Hematokrit : 39,9 %
PPT
: 10,6
APTT
: 37,0

n:12-16
n: 0-20
n: 4500-10000
n: 0,15-0,4X1012
n: 36-46%
n: 60-70 detik
n: 20-35 detik

Pertanyaan :
Bagaimana Tata-laksana terapi kasus
ini ?
Apa saja Efek Samping yang dapat
timbul pada penderita ?
Informasi apa yang perlu diberikan
mengenai penggunaan obatnya ?

Klasifikasi Tumor
dilakukan dengan sistem TNM dimana

T : Tumor
T1 - 3 menyatakan besarnya tumor
N : Nodul
N1- 3 luasnya kelenjar limfe yang
terlibat
M : Metastase
M0 - 1 ada atau tidak adanya
metastase

Interpretasi data Tumor

berdasarkan TNM Stage Grouping for Breast Cancer dr AJCC
th. 2002

Untuk Stadium II B ,
T2N1M0 yang artinya :
T2 : > 2 cm 5 cm
N1: Metastasis in movable ipsilateral
axillary lymph node(s)
( Kelenjar getah bening aksila ipsilateral dapat
digerakkan )
M0: No distant metastasis
( Belum ada metastasis jauh )

Tata laksana terapi berdasarkan

4T&1W
Semua Ca mammae yang baru
terdeteksi baik itu di stadium
manapun langkah awal adalah
Pembedahan, kemudian dilanjutkan
radioterapi dan kemoterapi.
(dipiro,2005)
Pembedahan bermacam macam,
pemilihan pembedahan dan
radioterapi adalah wewenang dokter.

Surgery

Surgery is the mainstay of therapy for breast cancer. The choice as to which type of surgery is
based on a number of factors, including the size and location of the tumor, the type of tumor, and
the person's overall health and personal wishes. Breast-sparing surgery is often possible.

Lumpectomy involves removal of the cancerous tissue and a surrounding area of normal tissue.
Generally the lymph nodes in the armpit are sampled at the same time. This is not considered
curative and should almost always be done in association with other therapy such as radiation
therapy with or without chemotherapy or hormonal therapy.

Simple mastectomy removes the entire breast but no other structures. If the cancer is invasive,
this surgery alone will not cure it. It is a common treatment for DCIS, a noninvasive type of
breast cancer.

Modified radical mastectomy removes the breast and the axillary (underarm) lymph nodes but
does not remove the underlying muscle of the chest wall. Although additional chemotherapy or
hormonal therapy is almost always offered, surgery alone is considered adequate to control the
disease if it has not metastasized.

Radical mastectomy involves removal of the breast and the underlying chest wall muscles, as
well as the underarm contents. This surgery is no longer done because current therapies are less
disfiguring and have fewer complications.

Radioterapy Treatment

In this disease, patient preference plays a major role in decisions regarding

treatment. Treatment depends on a large number of factors, including the type
of breast cancer, the hormone receptor status of the tumor, the stage of the
tumor, the size of the breast, and the person's general health, age, and
menstrual status (has or has not been through menopause).

Radiation therapy is used to kill tumor cells if there are any left after surgery.

Radiation is a local treatment and therefore works only on tumor cells that are
directly in its beam.

Radiation is used most often in people who have undergone conservative

surgery such as lumpectomy. Conservative surgery is designed to leave as
much of the breast tissue in place as possible.

Radiation therapy is usually given 5 days a week over 5-6 weeks. Each
treatment takes only a few minutes.

Radiation therapy is painless and has relatively few side effects. However, it can
irritate the skin or cause a burn similar to a bad sunburn in the area.

Chemotherapy

Chemotherapy consists of the administration of medications that kill cancer

cells or stop them from growing.
Most chemotherapy agents are given through an IV line, but some are given
as pills.

Chemotherapy is usually given in "cycles." Each cycle includes a period of

intensive treatment lasting a few days or weeks followed by a few weeks of
recovery. Most people with breast cancer receive at least 2, more often 4,
cycles of chemotherapy to begin with. Tests are then repeated to see what
effect the therapy has had on the cancer.

Chemotherapy differs from radiation in that it treats the entire body and
thus may find stray tumor cells that may have migrated from the breast
area.

The side effects of chemotherapy are well known. Side effects depend on
which drugs are used, but some that are common to many of these drugs
include loss of hair, nausea and vomiting, loss of appetite, fatigue, and low
blood cell counts, which may cause you to be more susceptible to infections,
to feel sick and tired, or to bleed more easily than usual.

Systemic Adjuvant Therapy

berdasarkan treatment guidelines for
invasive breast cancer dari NCCN 2004
maka systemic adjuvant treatment yang
digunakan adalah
adjuvant Chemotherapy AC ( Doxorubicin
+ Cyclophosphamide ) + adjuvant
Tamoxifen

Tepat penderita
Ny UH 49 th dengan ca mammae stadium
II T N M dengan pemberian Doxorubicin dan
2

cyclophaspamid (kemoterapi) adalah tepat

karena Doxorubicin dan cyclophaspamid
(kemoterapi) dengan tujuan pemberian adalah
CURE
tamoxifen diperuntukkan bagi penderita ca
mammae yang sudah/belum
metastase(jauh/dekat).
Dipiro,2005

Tepat obat
Doxorubicin dan cyclophosphamid
(kemoterapi)

Tamoxifen (hormonal terapi)

tepat diberikan pada pasien Ca
mammae st. II T2N1M0 setelah

melakukan surgery dan radioterapy,

dimana ca sudah/belum metastase.

Tepat indikasi
Doxorubicin (antibiotik berasal dr jenis
streptomyces)berkhasiat sitostasis
disamping kerja bakterinya, jg bersifat
imunosupresif.
Cyclophosphamid diindikasikan untuk terapi
kombinasi ca mamae ca ovarium,
berkhasiat jg sebagai imunosupresif.
Tamoxifen diindikasikan untuk ca mammae
yang peka untuk estrogen berdasarkan
blokade reseptor estrogen dalam tumor.

Tepat dosis
Doxorubicin 60mg/m iv hari pertama
Cycloposphamid 600 mg/m iv hari
pertama
diulang tiap 21 hari untuk 4 cycle
Tamoxifen 20mg single dose perhari
selama 5 th

Waspada ESO
Doxoribicin
depresi tulang yang berdurasi pendek dan bisa
disembuhkan, toxycitas jantung, mual, hematologi
( Myosuppression, leukopenia, trombocytopenia, anemia)
Cyclophosphamid
dermatologic (alopecia), endokrin dan metabolisme
(fertillity), GI (nusea vomiting), hematologi
(thrombocytopenia)
Tamoxifen
hot flashe, mual, mutah, ruam kulit, pendarahan vagina,
penurunan leukore, dapat menyebabkan nyeri hebat jika
tumor sudah metastase ke tulang dan berpotensi
menyebabkan ca endometriomin.

Info pada penderita

Untuk mencegah kekambuhan obat
harus diminum selama 5 th sesuai
aturan.
Tetap konsultasi perkembangan
terapi, maupun perjalanan penyakit.

selesai
MFK 2005

Efek samping kemoterapi.

Cepat (acut)
Segera (subacut)
Lambat (chronic)
Sangat Lambat(late effect)

Onset dari efek samping kemoterapi

bervariasi :

Immediate :
Efek samping yang terjadi dalam waktu beberapa jam sampai
beberapa hari setelah kemoterapi.
Contoh : Nausea/Vomiting, local tissue necrosis,
Phlebitis,
Hyperuricemia, Skin rash, anaphylaxis,
demam&menggigil (bleomycin), hypotension
(etoposide),
hypertension (Procarbazine).
Early :
Efek samping yang terjadi dalam waktu beberapa
hari
sampai beberapa minggu setelah kemoterapi.
Contoh : Leukopenia, Thrombocytopenia, Alopecia,
Stomatitis, Diarrhea, Hypercalcemia (esterogen),
Hypomagnesemia (cisplatin), DIC (asparaginase),
Hyperglycemia (corticosterid), ototoxicity (cisplatin),
Conjungtivitis (Methotrexate, Ara-C)

 Delayed :
Efek samping yang terjadi dalam waktu
beberapa
minggu sampai beberapa bulan setelah kemoterapi.
Contoh : Anemia, Aspermia, Hepatocellular damage,
Hyperpigmentation, pulmonary fibrosis.
Peripheral neuropathy (vincristine), Cardiac
necrosis
(cyclophosphamide),
Cholestatic jaundice (6-MP)
Late :
Efek samping yang terjadi dalam waktu beberapa bulan
sampai beberapa tahun setelah kemoterapi.
Contoh : Sterility, Premature menopause, Acute
eukemia, Lymphoma, solid tumor.Hepatic cirrhosis
(Mtx.), Osteoporosis (Corticosteroid),
Cataracts(busulfan)