WEEKLY CASE

BREAST CANCER
By.
Selestinus Lobeqmato
Indriani L. Purwanti

Mentor : dr. Alders K. Nitbani, Sp.B

Breast Cancer
 INTRODUCTION

• Breast cancer is the most common cancer and

also the leading cause of cancer mortality in
women worldwide
• Low and middle income countries face
resource and infrastructure constraints that
challenge the goal of improving breast cancer
outcomes by early detection, diagnosis and
treatment
ANATOMY
ANATOMY
ANATOMY
 DEFENITION

Breast cancer (KPD) is a malignancy in

breast tissue that can originate from the
ductal epithelium or lobulus

PANDUAN PENATALAKSANAAN KANKER PAYUDARA KEMENTERIAN KESEHATAN RI

http://kanker.kemkes.go.id/guidelines/PPKPayudara.pdf
 CAUSES OF BREAST CANCER

• We do not know the cause of most breast

cancers
• Most likely cause is related to changes in the
genetic material (DNA) in our cells
• DNA changes are often related to our lifestyle,
but some can be due to age and other factors.

Breast CancerAmerican Cancer Society Reviewed February 2017

https://www.cancer.org/content/dam/cancer-org/cancer-control/en/presentations/breast-cancer-presentation.pdf
 BREAST CANCER RISK FACTORS

• Gender : a woman is the main risk factor for developing

breast cancer
• Aging: Breast cancer risk increases as a woman gets older
• Genetic risk factors mutasi gen BRCA1, BRCA2, ATM /TP53
(p53)),
• Personal history of breast cancer
• Previous chest radiation
• Post-menopausal hormone therapy (PHT)

Breast CancerAmerican Cancer Society Reviewed February 2017

https://www.cancer.org/content/dam/cancer-org/cancer-control/en/presentations/breast-cancer-presentation.pdf
 BREAST CANCER RISK FACTORS

• Dense breast tissue

• Not having children or having them later in life (after age 30)
• More menstrual cycles
• Not breastfeeding
• Physical activity More active lowers risk
• Obesity
• Alcohol use

Breast CancerAmerican Cancer Society Reviewed February 2017

https://www.cancer.org/content/dam/cancer-org/cancer-control/en/presentations/breast-cancer-presentation.pdf
 DIAGNOSIS
Anamnesis
Main complaint
1. Lump in the breast
2. Speed grows with / without pain
3. Nipple discharge, nipple retraction, and crusting
4. Skin disorders, dimpling, peau d'orange, ulceration.
5. Underarm lump and arm edema

Additional Complaints
1. Bone pain (vertebrae, femur)
2. Shortness of breath and so forth
PHYSICAL EXAMINATION

Inspection
 PHYSICAL EXAMINATION
• Palpation
 LABORATORY

• Recommended:

– Routine blood examination and blood chemistry

examination in accordance with estimated metastasis
– Tumor marker: if the result is high, it needs to be
repeated for follow up
 RADIOLOGY
Mammography

Primary marks are:

1. Increased density of the tumor
2. Irregular tumor boundaries due to infiltration to surrounding tissue
or unclear boundary (comet sign).
3. Transparent image around the tumor
4. Stelata picture.
5. The existence of microcalsification according to Egan criterion
6. The clinical size of the tumor is greater than radiological.
Secondary mark:
1. Skin retraction or thickening of the porters
2. Increased vascularization
3. Change position of putting
4. Axillary lymph nodes (+)
5. The state of the tumor region and fibroglandular tissue is
irregular
6. Substantial sub-isolar tissue density.
• Breast Ultrasound
Use of ultrasound for additional mammography
increases its accuracy to 7.4%.
 ANATOMICAL PATHOLOGY EXAMINATION

• cytological examination
• Morphology (histopathology)
• Immunohistochemical examination
• In situ hybridization and gene arrays (only done in
research and special cases).
 IMMUNOHISTOCHEMICAL EXAMINATION

1. Hormonal receptors are estrogen receptor (ER)

and progesterone receptor (PR)
2. HER2
3. Ki-67
CASE
 IDENTITY

• Name : Ny. NF
• Age : 47 years
• Gender : female
• Religion : Catholic
• Address : Liliba
• Occupation : civil servant
 ANAMNESIS

• Chief complaint : weak

• current disease history :
Patients come with weakness complaints since 1
day before into the hospital. These complaints do
not diminish with rest, patients planned to do
chemotherapy today (27 July 2018) eat and drink
good, defecation and urination smoothly, no pain
in the breast
 ANAMNESIS

• past medical history :

Patients complain of a lump in the right breast since 2013. At first the lump in
the right breast is the size of the coin. Then by the patient is given herbal
medicine but the lump is getting bigger and painful until in 2014 the lump
widened and the skin of the breast turns blackish and hard, the patient
checks in RSUD surgery RSUD WZ Yohannes Kupang, doctors advise surgery
and chemotherapy so patients continue treatment to surabaya. In surabaya
patients do the examination and found that suffered from breast cancer, then
returned to Kupang for surgery and chemotherapy. In 2016 the patient's right
breast was removed and in December 2017 the patient felt a lump in the left
breast, when examined in Surabaya found that a lump in the left breast is also
a breast cancer so that in June 2018 performed surgical removal of the
patient's left breast.
• family history
Patient’s mother died due to liver cancer, patient’s
aunt suffering from breast cancer, patient’s nephew
also have breast tumors
• History exposed to radiation on the chest (-)
• A history of tumor surgery on the breast (+)
• Habitual history alcohol & smoking (-)
 ANAMNESIS

• Obstetric and Gynecological History

– Married at 31 years of age
– Have one child
– Childbirth at the age of 33 years
– Breastfeeding history (+) until the child is 5
months old
– Menarche: at the age of 15 years
– Menopause is 46 years old
– Use of injecting family planning of 3 months (2
injection)
 PHYSICAL EXAMINATION

• General Condition : moderate pain

• Awareness : E4 V5 M6
• Vital signs:
– blood pressure : 120/80 mmHg,
– Heart rate : 80x /minute
– Respiratory rate : 20x / minute
– temperature : 36.4 C
• Head: no hair
• Eyes: Conjunctival anemis (+ /+), anicteric sclera, isokor pupil
• Nose: within normal limits
• Ears: otorea (-), mastoid tenderness (-)
• Mouth: moist mucosa, pink color.
• Neck: enlarged lymph nodes (-), struma (-).
• Chest:
• Inspection: spontaneous breath,
symmetrical chest development, retraction
(-)
• Palpation: left vocal fremitus = right
• Percussion: sonor + / +
• Auscultation: vesicular breath sounds + /
+, rhonki - / -,
• wheezing - / -
• Breast Examination
• Inspection: looks post masectomy scar on
right breast and left breast, lump (-)
• Palpation: no mass and enlarged lymph
nodes are obtained
• Abdomen
– Inspection: flat, skar (-)
– Auscultation: Bowel sound (+) normal impression
– Palpation: tenderness (-), liver and lien are not
palpable
– Percussion: tympanic throughout the abdominal
field
• Extremities
– Akral warm
– Udema limbs (-)
 LOCALIST STATUS

• Inspection and palpation of both breasts

– Inspection: looks post masectomy scar on
right breast and left breast, lump (-)
– Palpation: no mass and enlarged lymph
nodes are obtained
• Skin changes in the left breast
– Redness (-), dimpling (-), edema (-), satellite
nodule (-)
– Peau d'orange (-), ulcer (-)
• Breast left breast
– Not interested, erosion (-), crust (-), discharge
(-)
 SUPPORTING INVESTIGATION
Hematologi Hasil
• Laboratory
Hemoglobin 9,8 g/dL (L)
Jumlah Eritrosit 3,94 x 106/uL (L)
Hematokrit 29,4% (L)
MCV 74,6 fL (L)
MCH 24,9 pg (L)
MCHC 33,3 g/L
Leukosit 8,13 x 103/uL
Trombosit 506 x 103/uL (H)
BUN 7,0 mg/dL
Kreatinin darah 0,57 mg/dL (L)
SGPT 9 U/L
SGOT 22 U/L
• Mammae ultrasound examination (9/12/2013)
Impression:
• solid mass with calcification (+) in quadrant lateral lower right
mammae
• Multiple bilateral mammary cysts
• Examination left right mammography position CC & MLO
(9/12/2013)
– Impression: Asymetric prominent density in the lower middle
quadrant of the right mamma, probably benign. BI-RADS
category 3
• Examination USG (13/09/2013)
USG mammae dextra
Conclusion : suspect ca mammae dd/ FAM
 The results of anatomical pathology
examination (06/08/2016)

Kesimpulan :
Invasive carcinoma of no special type
Grade histologik 3 (skor tubular 3, skor inti 2,
skor mitosis)
(NST)
No invasive lymphovascular invasion
• Examination of immunohistochemical results
(31/10/2016)
– Reseptor estrogen : positif pada 60% sel tumor, intensitas
kuat
– Reseptor progesteron : positif pada 60% sel tumor,
intensitas kuat
– C-erb-B2 : meragukan (setara 2+ skor herceptest)
– Xl-67 : Positif pada 50% sel tumor, intensitas kuat
– Topo Isomerase 2 Alfa : Negatif

Conclusion: The tumor is predicted respond to hormonal

manipulation
• Immunopathology check cish (31/10/2016)
Immunopathology check cish (31/10/2016)
Probe Result: ZytoDot 2C SPEC HER2 / Cen17 (CISH)
Calculations were performed on 20 tumor cell nuclei
with the following results:
Total score Her2: 181
Total score Cen17: 39

Conclusion:
HER2 Status: Positive / Amplification
• USG mammae left
examination (15/2/2018)
Impression :
- Single circumscribed solid
mass left mamma
- Multipel simple cysts left
mamma Non specific
lymphadenopathy axilla left
• Anatomical pathology examination
(5/3/2018)

Conclusion:
Upper lateral mammary nodules
FNAB: benign fat tissue
• Anatomical pathology examination
(27/03/2018)

• Conclusion:
• nodul mamma sinistra
• FNAB: ductal carcinoma
• Anatomical pathology examination (4/5/2018)

• Conclusion:
• Histologic according to description of invasive
carcinoma of no special type grade 2 (tubular
score: 3, pleomorphic core: 2, mitosis: 1) and
ductal carcinoma in situ (DCIS) ± 50%
comedo type, cribriform
• No invasive lymphovascular invasion
• Anatomical pathology examination
(9/6/2018)

• Conclusion:
• Found viable tumor cells support clinical
diagnoses, recurrent carcinoma mammae
• Examination of
plain thorax photo
(7/6/2018)
• Impression:
normal, no
abnormalities
 DIAGNOSA
 Carcinoma Mammae sinistra PTxN0M0
 PLANNING DIAGNOSA

Cek darah lengkap

 PLANNING THERAPY

Pro kemoterapi