Disusun oleh :
Inge A Syafrida (1102011126)
Dosen Pembimbing :
Dr. Zwasta P.M, MMED
Skenario
Seorang wanita berusia 58 tahun dating ke dokter dengan keluhan timbul benjolan di payudara kiri. Benjolan tersebut dirasakan
tidak sakit, namun bertumbuh besar dalam setahun terakhir. Hasil anamnesis menyatakan bahwa pasien punya riwayat pertama kali
haid saat kelas 4 SD, lebih awal daripada teman-teman sebayanya. Pasien juga melahirkan anak pertama pada usia 39 tahun dan
ibunda pasien meninggal karena keganasan pada payudara. Pada pemeriksaan fisik didapatkan massa dengan konsistensi keras
dengan ukuran 5x2x3cm di kuadran lateral atas, mobile. Pada payudara terdapat peau de orange, retraksi papilla mammae dan
keluar cairan dari putting. Terdapat pula pembesaran kelenjar getah bening pada aksila yang dapat digerakkan. Setelah dilakukan
rontgen dan biopsy, dokter mendiagnosis pasien terkena tumor ganas payudara dengan rincian T3N1MX. Dokter
mempertimbangkan untuk melakukan masektomi radikal modifikasi ditambah kemoterapi. Pasien menanyakan apakah kemoterapi
harus dilakukan karena pasien khawatir kemoterapi memberi dampak negative terhadap pasien.
Pertanyaan :
Apakah pasien dengan keganasan mammae yang melakukan radioterapi memberi hasil yang lebih baik daripada pasien yang tidak
melakukan radioterapi?
PICO
PETUNJUK SEKUNDER
a. Apakah pasien, klinisi dan staf peneliti dibutakan oleh terapi?
TIDAK
Penelitian ini membandingkan kelompok radioterapi (RT) dan non radioterapi (NRT) dimana baik pasien, klinisi dan
staf peneliti tahu ada/tidaknya perlakuan RT tersebut.
b. Apakah kedua kelompok sama pada awal penelitian?
TIDAK
Seluruh pasien (n=90) pada awal penelitian telah menjalani MRM. Namun beberapa karakterisitik pasien seperti status
menopause, staging, grade histologi jauh berbeda
2011, 6:28 Page 2 of 8
tent/6/1/28
c. Selain perlakuan eksperimen, apakah kedua kelompok pendapat perlakuan yang sama?
UNCLEAR
oco-regional RT or no-RT after nuclear grade, extracapsular extension, lymphatic, vascu-
Bersamaan
ever, this study was dengan
closedMRM,lar sebanyak 89 sampel
and perineural (99%)and
invasion, menerima
ratio ofkemoterapi adjuvan dan sebanyak 66 sampel (73%)
involved nodes/
crual. Another closed
menerima study
terapi dissected
endokrin adjuvan nodes),
selama 5and treatment-related
tahun. factors apakah
Namun tidak diberitahu (PMRT,pasien tersebut berasal dari sampel
nducted by the same group, chemotherapy and hormonal therapy) were analyzed
eksperimen atau sampel kontrol.
ad undergone breast-conserving (Table 1).
ode positive, and node negative,
to receive standard only breast Treatment
RT. Nevertheless, this study All patients underwent MRM. Median tumor size was 3
r to our question because the cm (range, 1-5). The median number of dissected lymph
ndergone breast conserving sur- nodes was 11 (range, 3-37). Following MRM, FAC
ected to receive planned breast (5-fluorouracil, adriamycin, cyclophosphamide) or CMF
stion, which requires a precise (cyclophosphamide, methotrexate, 5-fluorouracil) adju-
oncologists, is the rate of LRR vant chemotherapy were administered to 89 of patients
e positive patients who never (99%) and 66 patients (73%) received adjuvant endocrine
MRM. Additional two questions therapy for 5 years. One patient only received hormonal
ld disease free survival (DFS), therapy. Sixty-six patients (73%) received PMRT (RT
S) could be affected by PMRT. group) and 24 patients (27%) did not (no-RT group). All
wer will wait to be clarified by patients were simulated with conventional simulator.
ming years. Ongoing randomized The postmastectomy chest wall received a dose of
signed to evaluate the results of 50 Gy through two tangential fields with 6 MV foton.
n management of the patients The mid-axilla received a dose of 50 Gy through an
pT1N0M0 or pT2N0-1M0 dis- anterior supraclavicular and posterior axillary fields with
etter information the role of cobalt-60. Intended dose was given in 25 fractions in a
oup [6]. period of 5 week.
often confront patients with 1-3
llowing MRM in their routine Follow-up
Figure 3 Kaplan-Meier c
Figure 1 Kaplan-Meier curve of local failure-free probability (Five years OS in RT group
(Five year local-regional failure-free survival in RT group 0.087 (71.127-199.340 CI 9
92.6%, no-RT group 87.1%, p = 0.038, (78.152-220.361 CI
95%)).
Regarding the ratio of
for 1 patient and invasive Pagets disease for 1 patient. group (20%) had a ratio
Remarkably, 3 of the patients with LRR (50%) were est ratio 37%). Eleven of
event but 2 had recurren
%)
al Rate (%
SEMBUH* TIDAK SEMBUH TOTAL radiotherapy and no-rad
Group
Radiotherapy
Diisease-Freee Surviva
INTERVENSION 54 (A) 12 (B) 66
Local-regional recurrence
Chest wall alone
No Radiotherapy
Peripheral lymphatics alo
Total LRRa
CONTROL 13 (C) 11 (D) 24 Long rankk p value=0.034
L l 0 034
(42.842-132.158 CI 95%)
Distant metastasis
Total Events
Current Status
Death
TOTAL 67 23 90
b
Figure 2 Kaplan-Meier curve of disease-free probability. (Five DFS (5 yrs actuarial)
years DFS in RT group 82.4%, no-RT group 52.4%, p = 0.034 (42.842- OSc (5 yrs actuarial)
132.158 CI 95%)). a
Local-regional recurrence, bDise
* kriteria sembuh berdasarkan kurva Kaplan Meier atas DFS (Disease Free
Survival) dengan perhitungan setelah 5 tahun follow up.
EER (Experimental Event Rate) : B/total CER (Control Event Rate) : D/total
= 12/66 = 11/24
= 0.181x100% = 0.46x100%
= 18.1% = 46%
Kesimpulan : PMRT pada pasien breast cancer bisa menurunkan angka kegagalan sebesar 60.6% dibandingkan
eksperimen kontrol.
2.Bagaimana presisi estimasi efek terapi?
95%)).
but only 1 of 4 LRRs in no-RT group was T2 (4.5 cm). LRR, both dying subsequently after treatment.
There was distant metastatic event in 10 patients in
no-RT group (42%). Five of them developed bone
Disease-Free Survival metastasis first and liverLocal Failure-Free SurvivalSurvival
Local Failure-Free
metastasis subsequently. Two Overall Survival
Overall Survival
Radiotherapy
Diisease-Freee Survivaal Rate (%
(+) (-)
Sumber : http://www.royalmarsden.nhs.uk/cancer-information/treatment/pages/radiotherapy.aspx
ALHAMDULILLAH