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Daftar SKDI

Inflamasi, abses
Mastitis
Cracked nipple
Inverted nipple
Nipple discharge
Fibrocystic
FAM
Tumor filodes
Ca Mamae
Pagets disease

1. FIRBOCYSTIC
Sering pada usia 30-50
Jarang pada postmenopause yang tidak mendapat terapi hormonal
Estrogen diduga menjadi faktor penyebab
Resiko tinggi pada wanita peminum alkohol terutama usia 18-22
Mikroskopik : perubahan pada epitel payudara, ditemukan adanya kista, papillomatosis,
adenosis, fibrosis, ductal epithelial hyperplasia

Symptoms and Signs

Massa yang asimptomatik


Ditemukan secara insidensial
Ketidaknyamanan timbul atau memburuk pada pre-menstruasi, dimana kista menjadi lebih
besar
Ukuran massa yang berubah-ubah, kadang-kadang massa hilang-timbul
Benjolan yang hilang timbul atau nyeri yang hilang timbul
Multipel / bilatera disertai dengan serous nipple discharge

Diagnostic Test

USG / Mamografi
FNA (Fine-needle Aspiration)

Differential Diagnosis

Breast cancer : Pain, fluctuation in size and multiplicity of lesions


FAM : terutama yang mendapat terapi hormonal

Treatment

Aspirasi massa : untuk mengurangi nyeri


Jika tidak ada cairan pada aspirasi, jika isi aspirasi berisi darah, jika masih ada massa setelah
dilakukan aspirasi, atau jika setelah di follow-up beberapa waktu masih ada massa atau
masih terdapat massa yang rekuren = biopsi
Hindari trauma
Menggunakan good supportive braissere (bra yang nyaman) pada malam dan siang
Diet rendah lemak : dapat mengurangi nyeri
Lakukan sadari secara teratur setelah menstruasi

Prognosis

Eksaserbasi mungkin muncul hingga menopause

2. FIBROADENOMA
Benign neoplasm
Usia muda, usia 20-30 tahun
Hormonal (estrogen) diduga menjadi faktor pencetus
Fibroadenoma dapat membesar pada masa menstruasi, kehamilan, dan setelah menopause
bagi yang menerima terapi hormonal.
Setelah menopause dapat regresi dan mengalami kalsifikasi.

Symptoms and Signs

Massa bulat, tegas, discrete, tidak terfiksir, keras, diameter 1-5cm

Treatment

Bedah : eksisi

Differential Diagnosis

Fibrocystic
Phyllodes tumor

3. PHYLLODES TUMOR
Fibroadenoma-like tumor with cellular stroma that grows rapidly
Dapat jinak atau ganas
Tumornya bersifat lokal
Dapat metastasis ke paru
Multipel / bilatera disertai dengan serous nipple discharge

Treatment

Bedah : eksisi

4. NIPPLE DISCHARGE

Intraductal Papilloma

Spontaneous, unilateral, serous / serosanguineous discharge from a single duct


Mass may not palpable
Bloddy Discharge

Suggestive cancer
Benign papilloma in the duct
Cytologic exam : identify malignat cells, negative findings dont rule out cancer. More likely
in women over 50 years old.
Ductogram : mamogram of a duct

Green of Brownish Discharge

Fibrocystic condition :
Young women
Before menstruation
Unilateral / bilateral

Hyperprolactinemia

Milky discharge from multiple ducts in non-lactating breast


Serum prolactin levels should be obtanied to search for a pituitary tumor
Numerous antipsychotic drugs and other drugs may also cause milky discharge

Oral Contraceptive or Estrogen Replacement

Clear, serous or milky discharge


In the pre-menopause women, the discharge is mor evident just before menstruation and
dissapears on stopping the medication

Subareolar Abscess

Purulent discharge
Removal of the abscess and the related lactiferous sinus

To eliminate the discharge, proximal duct excision can be performed both for treatment
and diagnosis.
5. MASTITIS AND BREAST ABSCESS
Lactating women
Risk factor : history of mastitis with a previous child, cracks and nipple sores, use of an
antifungal nipple cream in the same month, use of manual breast pump
Breast abscess also can occur in older women unrelated to pregnancy and breast-feeding
Staphylococcus aureus, Streptococcus sp, Escherichia coli
Reccurent mastitis can result from poor selection or incomplete of antibiotic therapy
Mastitis that repeatedly recurs in the same location, or doesnt respond to appropriate
therapy, may indicate the presence of breast cancer

Symptoms and Signs

Hard, tender, red, swollen, pain


Fever
Systemic complaints : myalgia, chills, malaise, flu-like symptoms
Breast abscess : fluctuant mass is palpable
Usually unilateral

Diagnosis

Midstream milk sample may be cultured

Differential Diagnosis

Plugged lacrimal ducts : hard, locally tender, red areas without associated regional pain or
fever
Tinea corporis : erythema and scaling on any part of the body including breast. It is often
annular and pruritic

Treatment

Acetaminophen / anti-inflamatory agent such as Ibuprofen : for pain control


Antibiotics
Dicloxaxillin or Cephalexine (500mg PO 4 times daily) for 10-14 days
Consider Clindamycin if the patient is allergic to penicillin and/ or cephalosporins. Also good
choice for MRSA.
Trimethoprim/Sulfamethoxazole is an alternative for MRSA, BUT SHOULD BE AVOIDED near
term pregnancy and in the first 2 months of breast-feeding = RISK TO THE BABY OF
KERNICTERUS
Breast abscess : incision and drainage

Education

Warm compresses before and after feedings = can relief some pain
Finish the antibiotic prescription
Continue feedings and use a breast pump to completely empty the breast if necessary
Educate the parents that mastitis or the antibiotics will not harm the baby
Drink plent of water and eat well-balances meals
6. BREAST CANCER
Locally Advanced Breast Cancer (LABC)
Inflammatory Breast Cancer (IBC)

Risk Factors

Positive family history of breast and/ or ovarian cancer (with BRCA mutations)
Personal history of breast cancer
Increasing age
Early menarche
Late menopause
Prolonged exposure to and higher concentrations of endogenous or exogenous estrogen
Exposure to ionizing radiation
Dense breast tissue and atypical hyperplasia
Women who have had no children or who had their first child after age 30 have a slightly
higher breast cancer risk
Low physical activity levels
High-fat diet
Alcohol intake

Symptoms and Signs

Lump (usually painless)


Solitary, discrete, non-tender, firm or hard mass with poorly delinated margins
Less frequent symptoms : breast pain, nipple discharge, erosion, retraction, enlargement,
itching of the nipple, redness, generalized hardness, shrinking of the breast
Axillary mass or swelling of the arm
Back or bone pain, jaundice, weight loss may be the result of the systemic metastases
Abnormal variations in breast size and contour
Minimal nipple retraction
Slight edema
Redness
Retraction or dimpling of the skin (peau de orange)

Diagnosis

USG / Mamography
Biopsi : FNA

Differential Diagnosis

Fibroadenoma : smooth, rounded, rubbery mass


Infectious mastitis and breast abscess : similiar to IBC

Treatment

Surgical
Hormone therapy
Chemotherapy
CONSULT

Education

Breast exam 1-2 weeks after the onset of menstruation


Mamography every 1 to 2 years for women ages 40 years and older
7. PAGETS DISEASE / MAMMARY PAGET DISEASE
Low-grade malignancy
Often associated with other malignancies
Peak incidence 50-60 years old

Symptoms and Signs

Dermatitis on the nipple : erythematous, eczematous, scaly, raw, vesicular or ulcerated


Pain, burning, pruritus of the nipple
Unilateral
Palpable breast mass in 50% cases
Nipple retraction (rare)
Often located more than 2cm from the nipple-areolar complex

Diagnosis

Mammography
Biopsy

Differential Diagnosis

Superficial spreading malignant melanoma


Seborrheic keratosis
Benign lichenoid keratosis

Treatment

Surgical

REFERENCES

1. Colour Atlas of Internal Medicine


2. Current Medical Diagnosis and Treatment 2016
3. Robbins Basic Pathology