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 n:12-16

LED : 21 mm/1 jam n: 0-20

Leucocyt : 9000 /L n: 4500-10000

Trombocyt : 384 /L n: 0,15-0,4X1012

Hematokrit : 39,9 % n: 36-46%

PPT : 10,6 n: 60-70 detik

APTT : 37,0 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 Tumordilakukan dengan sistem TNM dimana :T : Tumor T1 - 3 menyatakan besarnya tumorN : Nodul N1- 3 luasnya kelenjar limfe yang

terlibatM : 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 4 T & 1 W 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 T2N1M0 dengan pemberian Doxorubicin dan 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/m² iv hari pertama Cycloposphamid 600 mg/m² iv hari

pertamadiulang 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)

Cyclophosphamiddermatologic (alopecia), endokrin dan metabolisme (fertillity), GI (nusea vomiting), hematologi (thrombocytopenia)

Tamoxifenhot 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.

selesaiMFK 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)