Modul

MASTEKTOMI RADIKAL

KOMANG AGUS SETIAWAN

 Breast cancer is the most common site-specific cancer in
women and is the leading cause of death from cancer for
women age 4044 years.

It accounts for 33 percent of all female cancers and is

responsible for 20 percent of the cancer-related deaths in
women.

It is predicted that approximately 211,240 invasive breast

cancers will be diagnosed in women in the United States in
2005 and 40,410 of those diagnosed will die from that cancer
Anatomy

The breast extends from approximately the second to the sixth ribs and
from the sternum medially to the midaxillary line.

Mammary gland tissue lies in the superficial fascia, is a modified sweat

gland, and is supported by strands of fibrous tissue called suspensory
ligaments (of Cooper).

The nipple usually lies at approximately the level of the fourth intercostal
space and is surrounded by the pigmented areola.

Gland lobules drain into lactiferous ducts that open on the nipple surface.
 Lymph drains from the glandular tissue to the subareolar lymphatic plexus
and then to axillary lymph nodes (approximately 75%) or to infraclavicular,
pectoral, or parasternal (internal thoracic) nodes (it may also drain to the
opposite breast).

Arteries supplying the breast include the

Anterior intercostal branches of internal thoracic (mammary) artery
Lateral thoracic artery (branch of axillary artery)
Thoracodorsal artery (branch of axillary artery)
Tripple diagnostic

- Pemeriksaan klinis
- Pencitraan
- FNAB/Histopatologi.
History

The examiner should determine the patients age and obtain a reproductive
history. The age of menarche, menstrual irregularities, and the age at menopause
should be sought.
In younger women, a recent history of pregnancy and lactation should be
recorded. A drug history should pay attention to hormone replacement therapy or
the use of hormones for contraception.
The family history should be directed to cancer of the breast and ovaries in
primary relatives (parents, siblings, and offspring).
In questioning the patient about the specific breast problem, it is worthwhile to
inquire about breast pain, nipple discharge, and new masses in the breast.
If a mass is present, it helps to know how it was found, how long it has been
present, what has happened since its discovery, and if it changes with the
menstrual cycle.
If cancer is likely, inquiry about constitutional symptoms, bone pain, weight loss,
respiratory changes, and similar clinical indications of metastatic disease may
occasionally reveal unsuspected distant spread
Physical Examination

Inspection
- The surgeon inspects the womans breast with her arms by her side, with
her arms straight up in the air, and with her hands on her hips (with and
without pectoral muscle contraction).

- Symmetry, size, and shape of the breast are recorded, and any evidence of
edema (peau dorange), nipple or skin retraction, and erythema.

- With the arms extended forward and in a sitting position, the women
leans forward to accentuate any skin retraction.
A, Pagets disease of the nipple. Malignant
ductal cells invade the epidermis, without
traversing the basement

B, Skin dimpling. Traction on Coopers

ligaments by a scirrhous tumor distorts the
surface of the breast, producing the
dimple best seen with angled indirect
lighting during abduction

C, Nipple discharge. Discharge from

multiple ducts or bilateral discharge is a
common finding in healthy breasts. In this
case, the discharge is from a single duct

D, Peau dorange (skin of the orange) or

edema of the
Palpated

- Examination of the patient in the supine position is best performed with a pillow
supporting the ipsilateral hemithorax.

- The surgeon gently palpates the breast from the ipsilateral side, making certain to
examine all quadrants of the breast from the sternum laterally to the latissimus
dorsi muscle, and from the clavicle inferiorly to the upper rectus sheath.

- Supporting the upper arm and elbow, the shoulder girdle is stabilized.

- Using gentle palpation, all three levels of possible axillary lymphadenopathy are
assessed.

- Careful palpation of supraclavicular and parasternal sites also is performed.

- A diagram of the chest and contiguous lymph node sites is useful for recording
location, size, consistency, shape, mobility, fixation, and other characteristics of
any palpable breast mass or lymphadenopathy.
BREAST IMAGING

Breast radiographic imaging is used to detect small, nonpalpable breast abnormalities, to

evaluate clinical findings, and to guide diagnostic procedures.

Mammography is the most sensitive and specific imaging test currently available, though
10% to 15% of clinically evident breast cancers have no mammographic correlate.

Ultrasonography is not used as a screening tool or in the evaluation of mammographic

microcalcifications, but in a directed fashion to evaluate a breast mass and characterize it as
cystic or solid.

Computed tomography appears to be the best way to image internal mammary nodes and to
evaluate the chest and axilla after mastectomy.

Magnetic resonance imaging (MRI) is the imaging method of choice to evaluate implant
rupture. It may be used in efforts to identify the primary site of cancer in the breast of a
woman who presents with malignant axillary adenopathy in the context of an unrevealing
breast physical examination and mammogram (occult breast cancer).
A, A stellate mass in the breast.

B, Clustered microcalcifications. Fine,

pleomorphic, and linear calcifications that
cluster together suggest the diagnosis of
ductal carcinoma in situ (DCIS).

C, An ultrasound image of breast cancer.

The mass is solid, containing internal
echoes, and displaying an irregular
border. Most malignant lesions are
taller than they are wide.

D, Ultrasound image of a simple cyst. By

ultrasound, the cyst is round with smooth
borders, there is a paucity of internal
sound echoes, and there is increased
through-transmission of sound with
enhanced posterior echoes.
Pemeriksaan Histopatologi
Stereotatic biopsy dengan bantuan USG atau mammogram pada
lesi nonpalpabel

Core Needle Biopsy

Vacuum assited biopsy

Biopsy insisional

Biopsy eksisional

Pemeriksaan Imunohistokimia (IHC)

 Problem pada Payudara
Kelainan Pertumbuhan dan Perkembangan
Ginekomastia
Anomali mamma
Infeksi
Mastitis puerperalis akut
Mastitis tuberkulosa
Fistel paraareola
Tumor Jinak
Kista
Fibroadenoma
Perubahan Fibrokistik
Tumor filoides
Galaktokel
Papiloma intraduktus
Duktus ektasia
dll
Tumor Ganas
MASTEKTOMI RADIKAL

Suatu tindakan pembedahan onkologis pada tumor ganas payudara

dengan mengangkat seluruh jaringan payudara yang terdiri dari seluruh
stroma dan parenkhim payudara, areola, puting susu dan kulit diatas
tumornya disertai diseksi kelenjar getah bening aksila ipsilateral serta otot
pektoralis mayor dan minor secara enbloc.
Indikasi operasi
Kanker payudara yang mengenai otot pektoralis mayor
Keganasan jaringan lunak pada payudara

Kontra indikasi operasi

Tumor melekat dinding dada
Edema lengan
Nodul satelit yang luas
Mastitis inflamatoar
Teknik operasi
Penderita dalam general anaesthesia, lengan ipsilateral dengan yang dioperasi
diposisikan abduksi 900, pundak ipsilateral dengan yang dioperasi diganjal bantal
tipis.

Desinfeksi lapangan operasi, bagian atas sampai dengan pertengahan leher, bagian
bawah sampai dengan umbilikus, bagian medial sampai pertengahan mammma
kontralateral, bagian lateral sampai dengan tepi lateral skapula. Lengan atas
didesinfeksi melingkar sampai dengan siku kemudian dibungkus dengan doek steril
dilanjutkan dengan mempersempit lapangan operasi dengan doek steril

Bila didapatkan ulkus pada tumor payudara, maka ulkus harus ditutup dengan kasa
steril tebal ( buick gaas) dan dijahit melingkar.

Dilakukan insisi (macam macam insisi adalah Stewart, Orr, Willy Meyer, Halsted,
insisi S) dimana garis insisi paling tidak berjarak 2 cm dari tepi tumor, kemudian
dibuat flap. Ketebalan flap 0.5 cm.

Flap atas sampai dibawah klavikula, flap medial sampai parasternal ipsilateral, flap
bawah sampai inframammary fold, flap lateral sampai tepi anterior m. Latissimus
dorsi dan mengidentifikasi vasa dan. N. Thoracalis dorsalis

Mastektomi disertai dengan memotong m.pektoralis dimulai dari bagian medial

menuju lateral sambil merawat perdarahan, terutama cabang pembuluh darah
interkostal di daerah parasternal selanjutnya muskulus pektoralis dipotong dekat
dengan origonya.
 Diseksi aksila dimulai dengan mencari adanya pembesaran KGB aksila Level I
(lateral m. pektoralis minor), Level II (di belakang m. Pektoralis minor) dan level III (
medial m. pektoralis minor). Diseksi jangan lebih tinggi pada daerah vasa aksilaris,
karena dapat mengakibatkan edema lengan. Vena-vena yang menuju ke jaringan
mamma diligasi. Selanjutnya mengidentifikasi vasa dan n. Thoracalis longus, dan
thoracalis dorsalis, interkostobrachialis. KGB internerural selanjutnya didiseksi dan
akhirnya jaringan mamma dan KGB aksila dan m.pektoralis terlepas sebagai satu
kesatuan (en bloc)

Lapangan operasi dicuci dengan larutan sublimat dan Nacl 0,9%.

Semua alat-alat yang dipakai saat operasi diganti dengan set baru, begitu juga
dengan handschoen operator, asisten dan instrumen serta doek sterilnya.

Evaluasi ulang sumber perdarahan

Dipasang 2 buah drain, drain yang besar ( redon no. 14) diletakkan dibawah vasa
aksilaris, sedang drain yang lebih kecil ( no.12) diarahkan ke medial.

Luka operasi ditutup lapis demi lapis

Komplikasi operasi

Dini : - pendarahan,
- lesi n. Thoracalis longus wing scapula
- Lesi n. Thoracalis dorsalis.

Lambat : - infeksi
- nekrosis flap
- seroma
- edema lengan
- kekakuan sendi bahu kontraktur
Perawatan pasca bedah

Pasca bedah penderita dirawat di ruangan observasi produksi drain,

Drain dilepas bila produksi masing-masing drain < 20 cc/24 jam.
Medial dilepas lebih awal, karena produksinya lebih sedikit. Bila luka operasi baik, umumnya
jahitan dilepas hari ke 12 s/d 14
Hb pasca bedah?
Rehabilitasi sesegera melatih pergerakan sendi bahu.

Follow up

Tahun 1 dan 2 kontrol tiap 2 bulan

Tahun 3 s/d 5 kontrol tiap 3 bulan
Setelah tahun 5 kontrol tiap 6 bulan

Pemeriksaan fisik : tiap kali kontrol

Thorax foto : tiap 6 bulan
Lab. Marker : tiap 2-3 bulan
Mammografi kontralateral : tiap tahun atau ada indikasi
USG abdomen : tiap 6 bulan atau ada indikasi
Bone scanning : tiap 2 tahun atau ada indikasi
TERIMA KASIH