Compiled by :

Aria Adhitya S 1102003035

Mentor:

Dr. H. Herry Setya Yudha Utama, Sp.B, MHKes, FInaCs

SURGERY DEPARTMENTRSUD ARJAWINANGUN

PERIOD 30 January – 7 April 2012

PERSONAL CASE CARCINOMA MAMMAE

BAB ICa Mamae case

STATUS OF PATIENTS : 

A.    PATIENT IDENTITY

Name                    : Mrs. S L

Age                     : 42 years

Sex           : Female

Job              : Housewife

Religion                : Moslem

Address                : Arjawinangun

B.     ANAMNESA

Main complaint :

Lump in left breast

Additional complaints : -

History of present illness :

Mrs N, 42 years old, comes to Arjawinangun Hospital complains there’s a lamp in

left breast that she had since 4 years ago. At first, it is a mobile sized, but in several mounth

it becomes bigger than before. On palpable, it feels pain. There’s no discharge comes from

nipple, It is immobile / fixed, There is no lumps on the right breast. Mrs S L said that this

lump doesn’t affect patient’s breath. Patient said that her mother had the same illness.

Past medical history :

There’s no same medical history in the past

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Family history of disease:

Her mother had the same illness.

C. PHYSICAL EXAMINATION

Status Present

General condition : Moderate ill appearance

Consciousness : compost mentis

vital sign :

Blood pressure : 120/80 mmHg

Pulse : 80x/mnt

respiratory rate : 24x/mnt

temperature : 36.6 °C

Generalis Status

Skin : Skin color is black, no jaundice, enough turgor

Head : Symmetrical, normochepal, equitable distribution of hair

Eyes : conjunctiva anemis (- / -), sclera jaundice (- / -), light reflex (+ / +) normal

Nose : Deviation of the septum (-), discharge (-)

Ears : symmetrical, cerumen right-left (+)

Mouth and throat :

Lips : not dry, and no cyanosis

Tonsils : T1/T1

Pharing : not hiperemis

Neck : Not deviasi, No enlargement of lymph glands

Thoracic :

Inspection : hemithorak symmetrical right and left in a state of static and dynamic

Palpation : tactile fremitus symmetrical right and left

Percussion : sonor to the hemithorax

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Auscultation:

Pulmo : vesicular breath sound, Ronchi - / -, wheezing - / -

Cor : heart sound I / II regular, Murmur (-), Gallop (-)

Abdomen

Inspection : symmetrical, flat abdomen, does not look any mass

Palpation : palpable weakness, no muscular defense, tenderness (-), liver and

spleen

not palpable

Percussion : timpani in the entire quadrant of the abdomen.

Auscultation : bowel sounds (+)

Extremity:

Warm acral, cyanosis - / -, edema - / -

Localist Status

Regio mammary sinistra

Inspection: visible lump in left breast, the skin does not look redness, does not look fluid out

of the nipple, peau d'orange (-)

Palpation: palpable mass in the right lateral region of the irregular-shaped, solitary,

measuring 7cm x 7cm x 3 cm, hard consistency, well defined, the surface does not lump,

Immobile movement, tenderness (+), the temperature is warmer than surrounding, nipple

discharge (-).

D. WORKUP

Complete Blood :

-        Hemoglobin :11,6 g/dl

-        Hematocrit :36,5 %

- Leukosites :8500 sel/cmm

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-        Platelet :256.000 sel/cmm     

Blood glucose level :

96 mg/dl

Rontgen :

Results : No vesible heart enlargement

No vesible metastasis intra pulmonal

E.     WORKING DIAGNOSIS

Carcinoma mammae sinistra

F. MANAGEMENT

- IVFD NaCl 20 drops/minutes

- Cefotaxim 2x 1amp

- Tramadol 2x1 amp

- Ranitidin 2x1 amp

- Modified Radical Mastectomy by lifting the breast tissue around the sinistra

G. PROGNOSIS

Quo ad vitam : dubia ad bonam

Quo ad functionam : dubia ad bonam 

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CARCINOMA MAMMAE

A. DefinisiBreast cancer is cancer that originates from the breast tissue. It can affect women of all ages

but most commonly affects those above 40. It is potentially fatal but achieving a complete

cure is also possible. There are 5 stages of breast cancer (stage 0, 1, 2, 3 and 4). Treatment

at stage 0 & 1 can result in cure rates of above 90%.

Fig 1. Most breast cancers begin in the cells that line the ducts (ductal cancers). Some begin in the cells that line the lobules (lobular cancers), while a small number start in other tissues.

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B. Pathophysioilogy

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C. Stages of Breast Cancer

S t a g e s o f B r e a s t C a n c e r

Stage DefinitionStage 0

Cancer cells remain inside the breast duct, without invasion into normal adjacent breast tissue.

Stage I

Cancer is 2 centimeters or less and is confined to the breast (lymph nodes are clear).

Stage IIA

No tumor can be found in the breast, but cancer cells are found in the axillary lymph nodes (the lymph nodes under the arm) OR the tumor measures 2 centimeters or smaller and has spread to the axillary lymph nodes OR the tumor is larger than 2 but no larger than 5 centimeters and has not spread to the axillary lymph nodes.

Stage IIB

The tumor is larger than 2 but no larger than 5 centimeters and has spread to the axillary lymph nodes

OR the tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes.

Stage IIIA

No tumor is found in the breast. Cancer is found in axillary lymph nodes that are sticking together or to other structures, or cancer may be found in lymph nodes near the breastbone OR the tumor is any size. Cancer has spread to the axillary lymph nodes, which are sticking together or to other structures, or cancer may be found in lymph nodes near the breastbone.

Stage IIIB

The tumor may be any size and has spread to the chest wall and/or skin of the breast AND may have spread to axillary lymph nodes that are clumped together or sticking to other structures, or cancer may have spread to lymph nodes near the breastbone.

Inflammatory breast cancer is considered at least stage IIIB.

Stage IIIC

There may either be no sign of cancer in the breast or a tumor may be any size and may have spread to the chest wall and/or the skin of the breast AND

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the cancer has spread to lymph nodes either above or below the collarbone AND the cancer may have spread to axillary lymph nodes or to lymph nodes near the breastbone.

Stage IV

The cancer has spread — or metastasized — to other parts of the body.

D. Risk Factors- Risk factors you cannot change

1. Gender

Simply being a woman is the main risk factor for developing breast cancer.

Although women have many more breast cells than men, the main reason they

develop more breast cancer is because their breast cells are constantly exposed to

the growth-promoting effects of the female hormones estrogen and progesterone

2. Aging

Your risk of developing breast cancer increases as you get older.

3. Genetic risk factors

About 5% to 10% of breast cancer cases are thought to be hereditary,

4. Family history of breast cancer

Breast cancer risk is higher among women whose close blood relatives have this

disease

5. Personal history of breast cancer

A woman with cancer in one breast has a 3- to 4-fold increased risk of developing a

new cancer in the other breast or in another part of the same breast

- Risk factors you can control

1. Weight

Being overweight is associated with increased risk of breast cancer, especially for

women after menopause

2. Diet

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Diet is a suspected risk factor for many types of cancer, including breast cancer, but

studies have yet to show for sure which types of foods increase risk

3. Exercise

Evidence is growing that exercise can reduce breast cancer risk

4. Alcohol consumption

Studies have shown that breast cancer risk increases with the amount of alcohol a

woman drinks

5. Smoking

Smoking is associated with a small increase in breast cancer risk

6. Exposure to estrogen

Because the female hormone estrogen stimulates breast cell growth, exposure to

estrogen over long periods of time, without any breaks, can increase the risk of

breast cancer

7. Stress and anxiety

There is no clear proof that stress and anxiety can increase breast cancer risk. However,

anything you can do to reduce your stress and to enhance your comfort, joy, and satisfaction

can have a major effect on your quality of life.

E. Signs and symptoms

Although widespread use of screening mammograms has increased the number of breast

cancers found before they cause any symptoms, some breast cancers are not found by

mammogram, either because the test was not done or because, even under ideal conditions,

mammograms do not find every breast cancer.

The most common sign of breast cancer is a new lump or mass. A painless, hard mass that

has irregular edges is more likely to be cancerous, but breast cancers can be tender, soft, or

rounded. For this reason, it is important that any new breast mass or lump be checked by a

health care professional experienced in diagnosing breast diseases

Other possible signs of breast cancer include:

swelling of all or part of a breast (even if no distinct lump is felt)

skin irritation or dimpling

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breast or nipple pain

nipple retraction (turning inward)

redness, scaliness, or thickening of the nipple or breast skin

a discharge other than breast milk

Sometimes a breast cancer can spread to underarm lymph nodes and cause a lump or

swelling there, even before the original tumor in the breast tissue is large enough to be felt

F. Workup

Breast self-exam should be part of your monthly health care routine, and you should visit

your doctor if you experience breast changes.

Use the finger pads of the 3 middle fingers on your left hand to feel for lumps in the

right breast. Use overlapping dime-sized circular motions of the finger pads to feelthe

breast tissue

Fig 2. Breast Self Examination

Use 3 different levels of pressure to feel all the breast tissue. Light pressure is needed

to feel the tissue closest to the skin; medium pressure to feel a little deeper; and firm

pressure to feel the tissue closest to the chest and ribs. A firm ridge in the lower curve

of each breast is normal. If you're not sure how hard to press, talk with your doctor or

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nurse. Use each pressure level to feel the breast tissue before moving on to the next

spot

Move around the breast in an up and down pattern starting at an imaginary line drawn

straight down your side from the underarm and moving across the breast to the

middle of the chest bone (sternum or breastbone). Be sure to check the entire breast

area going down until you feel only ribs and up to the neck or collar bone (clavicle).

Mammogram . If you're over 40 or at a high risk for the disease, you should also have an

annual mammogram.

Magnetic resonance imaging (MRI)

For certain women at high risk for breast cancer, screening MRI is recommended along

with a yearly mammogram. It is not generally recommended as a screening tool by itself,

because although it is a sensitive test, it may still miss some cancers that mammograms

would detect.

Physical Exam by a doctor. The earlier breast cancer is found and diagnosed, the better

your chances of beating it.

The actual process of diagnosis can take weeks and involve many different kinds of tests.

Waiting for results can feel like a lifetime. The uncertainty stinks. But once you understand

your own unique “big picture,” you can make better decisions. You and your doctors can

formulate a treatment plan tailored just for you.

G. Treatment

General types of treatment

Local versus systemic therapy

Local therapy is intended to treat a tumor at the site without affecting the rest of the

body. Surgery and radiation therapy are examples of local therapies

Adjuvant and neoadjuvant therapy

Patients who have no detectable cancer after surgery are often given adjuvant

(additional) systemic therapy. Doctors believe that in some cases cancer cells may break

away from the primary breast tumor and begin to spread through the body by way of the

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bloodstream even in the early stages of the disease. These cells can't be felt on a

physical exam or seen on x- rays or other imaging tests, and they cause no symptoms.

But they can establish new tumors in other organs or in bones. The goal of adjuvant

therapy is to kill these hidden cells. Some patients are given systemic therapy, usually

chemotherapy, before surgery to shrink a tumor in the hope it will allow a less extensive

operation to be done. This is called neoadjuvant therapy.

Surgery for breast cancer

Breast conserving surgery

Lumpectomy removes only the breast lump and a surrounding margin of normal tissue.

Radiation therapy is usually given after a lumpectomy. If adjuvant chemotherapy is to

be given as well, the radiation is usually delayed until the chemotherapy is completed.

Partial (segmental) mastectomy or quadrantectomy removes more breast tissue than a

lumpectomy. For a quadrantectomy, one-quarter of the breast is removed. Radiation

therapy is usually given after surgery. Again, this may be delayed if chemotherapy is to

be given as well.

For most women with stage I or II breast cancer, breast conservation therapy

(lumpectomy/partial mastectomy plus radiation therapy) is as effective as mastectomy.

Survival rates of women treated with these 2 approaches are the same. However, breast

conservation therapy is not an option for all women with breast cancer (see "Choosing

between lumpectomy and mastectomy" below

Radiation therapy can sometimes be omitted as a part of breast-conserving therapy.

Women who may consider lumpectomy without radiation therapy typically have all of -

the following characteristics

- they are age 70 years or older

- they have a tumor 2 cm or less that has been completely removed

- the tumor is hormone receptor-positive, and the women is getting hormone

therapy (such as tamoxifen)

- they have no lymph node involvement

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Mastectomy

Mastectomy involves removing all of the breast tissue, sometimes along with other

nearby tissues.

In a simple or total mastectomy the surgeon removes the entire breast, including the

nipple, but does not remove underarm lymph nodes or muscle tissue from beneath the

breast. Sometimes this is done for both breasts (a double mastectomy), especially when

it is done as preventive surgery in women at very high risk for breast cancer. Most

women, if they are hospitalized, can go home the next day

A modified radical mastectomy involves removing the entire breast and some of the

axillary (underarm) lymph nodes. This is the most common surgery for women with

breast cancer who are having the whole breast removed.

For some women who have smaller tumors, one option may be a newer procedure

known as a skin-sparing mastectomy, where most of the skin over the breast (other than

the nipple and areola) is left intact. This procedure is described in more detail in

"What's new in breast cancer research and treatment?"

A radical mastectomy is an extensive operation where the surgeon removes the entire

breast, axillary lymph nodes, and the pectoral (chest wall) muscles under the breast.

This surgery was once very common. But because of the disfigurement and side effects

it causes, and because a modified radical mastectomy has been proven to be as effective

as a radical mastectomy, it is rarely done today

Lumpectomy

A lumpectomy is surgery to remove a small area of breast tissue that is cancerous.This

surgery is carried out only in early breast cancer, if the area of tissue to be removed is

relatively small. Women who choose a lumpectomy will require radiation therapy to

destroy any cancer cells that may remain in the area

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REFERENCES

1. Abeloff MD, Wolff AC, Wood WC, et al. Cancer of the Breast. In: Abeloff MD, Armitage

JO, Lichter AS, et al, eds. Clinical Oncology. 3rd Ed. Philadelphia, Pa: Elsevier; 2004: 2369-

2470.

2. American Cancer Society. Cancer Facts and Figures 2008. Atlanta, Ga: American Cancer

Society; 2008

3. American Joint Committee on Cancer. AJCC Cancer Staging Manual, 6th ed. New York:

Springer; 2002: 221-240.

4. Avis N, Crawford S, Manuel J, et al. Quality of life among younger women with breast

cancer. J Clin Oncol. 2005;23:3322-3330.

5. Darbre PD, Aljarrah A, Miller WR, et al. Concentrations of parabens in human breast

tumours. J Appl Toxicol. 2004;24:5-13.

6. National Cancer Institute. Surveillance Epidemiology and End Results (SEER) Cancer

Statistics Review, 1975-2005. 2008. Available at:

http://seer.cancer.gov/csr/1975_2005/sections.html. Accessed July 17, 2008.

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