Escolar Documentos
Profissional Documentos
Cultura Documentos
OF
BREAST CANCER
Muchlis Ramli,MD
Sub.Div.Surgical Oncology-Dept of Surgery
University of Indonesia,Jakarta
Incidence :
USA
: 80-100/100.000/year
Japan : 30-40/100.000/year
Korea : 20-25/100.000/year
World : 29,8/100.000/year
Indonesia
: second highest incidence by
PBR 11,57%.
Stage
Korea
%
Indonesia
%
6,2
25,3
II
52,8
16
IIIa
11.0
23
IIIb
2,5
40
IV
2.2
19
Treatment Decission:
Properly
Evaluate and assesment of prognostic factors priorly
decision making be taken.
Prognostic factors :
1. Tumor factor
- stage
- histology :type;subtype;grading
- hormonal dependency
2. Host factor
- age : pre/post menopause
- underlying disease
3. Treatment retalted factors
- Human resource (Doctors)
- Equipment
* the patient
* family
Modalities of treatment
Surgery
Radiation
Chemotherapy
Hormonal therapy
Imunotherapy
Combination
Razes
Renaissance
Modern period
- WS. Halsted (1852-1922)
- Willy Meyer (1854-1932)
Bernard Fisher ( 1970)
- Radical mastectomy
- Supraradical
- Modified radical
- Simple mastectomy
- BCT
Breast cancer is systemic disease
Systemic & local treatment are important.
Combine modality treatment :
- Adjuvant
- Neo Adjuvant
Type of surgery
Radical mastectomy
Entended (supra)radical mastectomy
Simple mastectomy + irradiation
Modified radical mastectomy
Breast concerving treatment
Sentinel node
15 year
Treatment
Overall
survival
Disease Free
RM
51%
49%
ERM
51%
47%
5 year survival
10 year survival
Clinical
Stage
SM & RT
ERM
SM & RT
ERM
70%
74%
50%
55%
II
50%
47%
32%
34%
5 years %
10 years %
No
Alive
NED
Alive
NED
Axilla
176
89
82
83
75
Axilla +
175
70
62
57
50
TOTAL
351
80
72
70
63
Axilla
64
82
75
73
66
Axilla +
41
78
61
59
49
TOTAL
105
80
69
67
60
RM
ERM
Clinical Stage
SM & RT
ERM
19%
20%
II
29%
32%
5 years
10 years
15 years
RM
69%
60%
51%
ERM
75%
60%
51%
Treatment
Overall
Disease Free
RM
70%
58%
MRM
70%
58%
Overall
Survival
Disease Free
Survival
RM Alone
58%
47%
4.4%
1.4%
SM & RT
59%
48%
1.1%
3.1%
SM Alone
54%
42%
7.7%
1.1%
Clinical Stage I
Axillary
Recurrence
o Lumpectomy/segmentegtomy/quadrantec
Survival Rates
Five years
Ten Years
Stage
Local Excision
+ RT
Radical
Mastectomy
+ RT
96%
81%
68%
69%
II
74%
70%
53%
59%
Local Excision
+ RT
Radical
Mastectomy
+ RT
Conservation
+ RT
Surgery
5 year
10 year
Radical or
Mastectomy
5 year
Modified Radical
Alone
10 year
Mininal Breast
Cancer
97%
92%
97%
95%
Stage I
T1 N0
85%
78%
88%
80%
Stage II
T1 N1
T2N0N1
78%
73%
77%
65%
disection
Short hospitalized
Prevent : - Limited arm mobility
- Lymph edema of the arm
T 1 - 2 N0 - 1
Surgery (with/without adjuvant)
*
*
*
*
*
Radikal mastectomy
Modified Radical Mastectomy
BCT
(Sentinel node biopsy)
Adjuvant therapy : d.o
- Node (+)/(-)
- Er/Pr
- Age
Menopausal status
Hormonal Receptor
High Risk
Premenopause
Er (+)/Pr (+)
Er (-) and Pr (-)
Chemo + Tam/Oov
Chemo
Post menopause
Er (+)/Pr (+)
Er (-) and Pr (-)
Tam + Chemo
Chemo
Old age
Er (+)/Pr (+)
Er (-) and Pr (-)
Tam + Chemo
Chemo
Menopausal status
Hormonal Receptor
High Risk
Premenopausal
Er (+)/Pr (+)
Er (-) and Pr (-)
Chemo + Tam/Oov
Chemo
Post menopausal
Er (+)/Pr (+)
Er (-) and Pr (-)
Chemo + Tam
Chemo
Old age
Er (+)/Pr (+)
Er (-) and Pr (-)
Tam + Chemo
Chemo
Adjuvant chemotherapy
Lymph node positive
Lymph node negative but,high risk factors
Operable
: T3 N0-1 M0
Inoperable
: T3b-4 N0-1 M0
T0-4 N2-3 M0
Distant metastase
Hartobagyi
: 63% 5 yrs SR
MD Anderson : 66% 5 yrs SR
Institutionally
: Not yet applied in Dr. Cipto Mangunkusumo
Hospital
Treatment
No. of patients
5 years S.R. (%)
LABC
S
2453
36
2386
29
S + R
4249
33
C + S + R
1923
63
398
334
S + R
142
C + S + R
708
47
Tjindarbumi, Tjahyadi, Ramli, et.al. Longitudinal Clinicopathological follow up of Breast Cancer Patient from 1988 to
1996 MJI vol.. 8 No.2 1999.
Stage
5-
10-
5-
Median
years
years
years
Disease-
Diseas
Disease
Free
e-Free
-Free
Survival
Surviv
Surviva
al
III A
NA
66%
47% 1
III B
30 months
32%
31%
1 Projected
survival
NA = Not available
Median
Overall
Survival
Overal
l
Surviv
al
NA
48
months
10years
Overall
Surviva
l
80%
64%
45%
28%
Call
Call
Project
Project
II
Surabaya
U.Pandang
(Reupassa
Ramli
(Sukarja)
1.3 %
2 %
1.3 %
2.5 %
4.1 %
7.1 %
II
16 %
11.9 %
12.3 %
17.6 %
27.7 %
IIIa
23 %
17.7 %
26.3 %
55.9 %
49.2 %
IIIb
40 %
56.2 %
43.4 %
IV
19 %
11.9 %
14.3 %
19.6 %
15.8 %
0.8 %
2.9 %
Tis
I
Unclassif
ied
IIIA
IIIB*
Total
T1a N0
Cases
M0
T2a N0
M0
T2b N0
M0
T2a N1a M0
12
T2b N1a M0
T2c N1b M0
T3a N0
33
T3a N1a M0
32
T3a N1b M0
T4a N0
M0
T4a N1b M0
T4a N2
M0
7.32
31
28.2
71
64.5
110
100.0
T1b N1a M0
M0
Total
110
Stage Tis
: SM
Stage I & II : RM or MRM adjuvant therapy
No Axillary lymph node consist tumor metastase, No Adj. Therapy
Axillary lymph node consist tumor metastase + Adj. Therapy
Ax. LN. 3 : Adj. Rad.
Ax. LN. 4 : Adj. Rad. + Ch.
Alternative :
SM + Rad. + Adj. Ch.
BCT
Stage IIIa
Stage IIIb
Stage IV
Type of surgery
Cases
Radical Mastectomy
23
21.0
13
11.8
Simple Mastectomy
72
65.4
1.8
110
100.0
(BCT)
Total
Alive
Recurrence
without
Deceased
Total
Recurrence
Clinical stage :
I
II
13
12
31
28
13
30
71
13
Radical mastectomy
12
23
Simple Mastectomy
19
23
30
72
Breast Conserving
III
Surgical procedure
:
Modified Radical
Mastectomy
Treatment
CONCLUSION :
1.
CONCLUSION :
2. Adjuvant chemotherapy will uncrease the survival rate
and increase disease free internal
3. Neoadjuvant chemotherapy will
- shrink the tumor burden so increase the resectability
- increase the survival rate and disease free interval
4. Application neoadjuvant chemotherapy for LABC in
Indonesia will increase the role of surgery in LABC
treatment.