Kelainan jinak payudara

Dr Emir T Pasaribu Sp B (K) Onk

Dr. Suyatno SpB(K) Onk
Bagian I Bedah FK USU /
RS. HAM Medan
ANATOMI
Pendahuluan

Merupakan kelainan terbanyak 90 %

Sir Astley Cooper (1829)
- fibrokistik, fibroadenosis, pain, FAM.
French surgeon Reclus (1893)
- aspek klinis dan patologis
Foot & Stewart (1945)
- chronic cystic mastitis --- lokal eksisi
Pendahuluan

Kelainan Jinak
Risiko
- lesi non proliferasi (70 %) 0,89
- lesi proliferasi tanpa atipik 1,5 2
- hyperplasia dengan atipik 35 - 5
Penyebab Benjolan di Payudara
Kelainan jinak lain
Breast hipertrophy
Amastia, symastia, hipoplasia
Tubular breast
Mammary aberrant (Ectopic axillary
breast tissue, supernumerary breast)
Supernumerary nipple
Amastia
(conenital
absence one
Or both
breasts)
Symastia :
medial
confluence
of the breast
HIPOPLASIA
payudara kiri
+
hipertrophy
dan ptosis
payudara
kanan
Tubular dan
hipoplasia
kedua
payudara
Breast
Hipertrophy
Bilateral =
Macromastia =
Gigantomastia
Mammary
Abberan =
Polimastia =
Supernemary
breast =
Ectopic breast
Diagnosis

Pemeriksaan klinis
- riwayat penyakit (Anamnesis)
- inspeksi
- palpasi
Pemeriksaan imaging
USG: < 40 thn,
Mamografi : > 40 thn
Pemeriksaan Patologi (Biopsi)
INFECTIOUS / INFLAMMATORY

Mastitis

Usual etiologic : Staphylococcus aureus

or Streptococcus spp. & Tbc(rare)
Most commonly occurs during early
weeks of breast-feeding
Tuberculosis of the breast is rare
disease. However, both clinical and
radiological features of tuberculous
mastitis, can be confused with either
breast cancer or pyogenic
MASTITIS AKUT
 Phusical exam :
Focal tenderness with erythema
warmth of overlying skin
fluctuant mass Occasionally
palpable.
Diagnosis : Ultrasound can be used
to localize an abscess
Treatment :

1. Continue breast feeding and

recommend use of breast pump
2. Contralateral breast: Safe
3. Cellulitis : Wound care and IV
antibiotics
4. Abscess : Incision and drainage
followed by IV antibiotics
Abses Payudara
INFECTIOUS / INFLAMMATORY

Fat Necrosis
Presentation :
Firm
irregular mass of varying tenderness
History of trauma; in 50% of patient
Predisposing factors : Chest wall or
breast trauma
There is no association with ca. or ca. risk
 Physical exam : Irregular mass without
discrete borders that may or may not be
tender ; later, collagenous scars
predominate
Often indistinguishable from
carcinoma by clinical exam or
mammography
Diagnosis and treatment : Excisional
biopsy with pathologic evaluation for
carcinoma
BENIGN DISEASE

Fibroadenoma (FAM)

Definition : Fibrous stroma surrounds

duct-like epithelium and forms a benign
tumor
Risk factors : More common in black
women than in white women.
Incidence : Typically occurs in late teens
to early 30s; estrogen-sensitive
(increased tendernessduring pregnancy).
Variant/ Tipe FAM

Hamartoma, (usia 2 dekade >>)

Tubular adenoma, (dominan elemen
tubula dengan sedikit stroma)
Lactating adenoma
Juvenile fibroadenoma
Giant fibroadenoma , (Size > 5 cm)
Complex FAM :(kista, sklerosing adenosis,
kalsifikasi epiteleal)
 Signs and symptoms :
Smooth, discrete, circular, mobile
Diagnosis : Clinical + USG + FNA
Treatment :
observe if age < 30 & size <3cm
excise mass: over 30 years
symptomatic
size > 3 cm
Fibroadenoma
19 tahun, giant FAM
BENIGN DISEASE

Mondors Disease

Definition : Superficial thrombophlebitis

of lateral thoracic or thoracoepigastric
vein.
Predisposing factors : Local trauma,
surgery,. Infection, repetitive
movements of upper extremity.
Presentation : Acute pain in axilla or
superior aspect of lateral breast.
Physical exam : Tender cord palpated.
Mondors Disease
 Diagnosis : Confirm with ultrasound.
Treatment :
Warm compresses, limit motion of
affected upper extremity. Usually
resolve within 2 to 6 weeks.
If persistens, surgery to divide the
vein above and below the site of
thrombosis or resectthe affected
segment.
Usg nondiagnostic or an associated
mass present : Excisional biopsy.
BENIGN DISEASE

Intraductal Papilloma
Definition : A benign local
proliferation of ductal epithelial cells.
Characteristics : Unilateral
serosanguineous or bloody nipple
discharge.
Presentation : Subareolar mass and /
or spontaneous nipple discharge.
 Evaluation : Radially compress breast
to determine which lactiferous duct
expresses fluid ;USG, mammography.
Diagnosis : Definitive diagnosis by
pathologic evaluation of resected
specimen
Treatment : Excise affected duct.
Microdoechtomy
 BENIGN DISEASE

Phyllodes Tumour

Majority are benign.

Malignant phyllodes sarcoma
Patients tend to present later than those
with fibroadenoma (>30 years).
Indistinguishable from FAM by usg or
mammogram.
phylloides tumors have more mitotic
activity
 Exam : Large, freely movable mass
with overlying skin changes.
Diagnosis : Definitive diagnosis
requires biopsy with pathologic
evaluation
Treatment :
Smaller tumors : Wide local excision
with at least a 1-cm margin
Larger tumors : Simple mastectomy
Phyllodes Tumour
BENIGN DISEASE

Mammary Duct Ectasia (Plasma Cell

Mastitis)

Definition : Inflammatory and dilation

of mammary ducts.
Most commonly occurs in the
perimenopausal years.
Presentation : Noncyclical breast pain
with lumps under nipple/areola with or
without a nipple discharge.
 Exam :
Palpable lumps under areola, possible
nipple discharge
Diagnosis :
Clinical exam
Duktulografi identi. affected duct
Excisional biopsy
Treatment :
Excision of affected ducts
BENIGN DISEASE

Fibrocystic Changes
Usuallydiagnosed in 20s to 40s.
Presentation : Breast swelling (often
bilateral), tenderness, and/or pain.
Physical exam : Discrete areas of
nodularity within fibrous breast tissue.
Evaluation : Fluctuating of the symtoms is
usually sufficient unless a persistent
discrete mass is identified
Definitive diagnostic: FNAB or biopsy with
pathologic evaluation.
 Fibrocystic Changes
Symtoms thought to be of hormonal
etiology and tend to fluctuate with the
menstrual cycle

Each of which has a variable relative

risk for the development of cancer

Not associated with an increased risk

for breast cancer unless biopsy reveals
lobular or ductal hyperplasia with atypia
Treatment :
Conservative management: classic
history or absence of a persistent
mass (NSAIDs, EPO,danazol, or
tamoxifen)
Single dominant cyst, aspirate
fluid ; send to cytology
Excise cyst if bloody.
Solid - Cyst
 Galaktokel
Fitzwilliams 1845
Kista berisi susu, sering pada masa laktasi
Bersamaan dengan duct ectasia dan
recurrent sub areola abses
Klinis timbul massa tanpa nyeri setelah
beberapa minggu/ bulan menyapih
Dapat hilang sendiri a setelah aspirasi
Lokasi tersering sub areola
Galaktokel gambaran
klinis dan USG
terimakasih
Sampai jumpa
lagi
BENIGN DISEASE

Gynecomastia
Definition : Development of female-like breast tissue
in males ( enlargement of ductal and stromal tissue)
Presentation: male with swelling of the breast, often
unilateral
May be physiologic (primary) or pathologic
(secondary).
Primary: infantile, adolescence, adult
Secondary: decreased androgen, increased
oestrogen , drug induced
Ditemukan pada 60 % remaja normal
Insiden tertinggi: 10-16 tahun
Risiko keganasan 1%
Grading menurut Simon:
G. I. Ukuran kecil tidak ada kelebihan kulit
G.II. Ukuran sedang tidak ada kelebihan kulit
G.III. Ukuran sedang dengan kelebihan kulit
G.IV. Ukuran besar seperti payudara wanita
Treatment :

Treat underlying cause if specific

cause identified
Indication of surgical excision are:
Reassurance is inadequate
Drug treatment inappropriate or
unstisfactory
Gynecomastia
Unilateral
(subkutan mastektomi
dengan insisi V)
 Tehnik operasi
terbaru untuk
Ginekomastia
(Subkutan mastektomi
dengan Periareolar
incision )
 MASTALGIA

Merupakan penyebab utama morbiditas pada

payudara
Secara umum, 50% dari pasien berobat
mengeluhkan mastalgia
Saat ini, 11% wanita menderita mastalgia
Menganggu: aktifitas seksual (48%), aktifitas
fisik (37%), sosial (12%), dan kerja (8%)
Klasifikasi : cyclical pronounced, non
cyclical, chest wall pain
Dasar penyebab cyclical mastalgia: endocrine
problems
Kanker, sclerosing adenosis, dan skar pasca
operasi jarang menyebabkan mastalgia
Reffered pain terkadang dikeluhkan sebagai
mastalgia
Penyebab:
Retensi air
Psikoneurosis
Abnormalitas endokrin
Kafein & metil xanthin,
Prostaglandin dan asam lemak esensial
Campuran.
 Abnormalitas endokrin
peningkatan sekresi estrogen
defisiensi produksi progesteron
hiperprolaktinemia
Kafein & metilxantin
Konsumsi kafein tinggi degradasi ATP oleh
metilxantin over stimulation of breast cells
Prostaglandin dan asam lemak esensial
Abnomalitas sistesis prostaglandin karena defisiensi
asam lemak esensial
 Cyclical Mastalgia

Nyeri berhubungan siklus menstruasi khusunya

terhadap ovulasi
Rerata usia 34 tahun
Sering bilateral dan fibroglandular yang kasar
(terutama kwadrant lateral atas)
Karakteristik:
o Heaviness and tenderness to touch
Nyeri terkadang menyebar ke aksila dan
lengan atas
Mamografi: unhelpful
Relief by menstruation and menopause
 Non Cyclical
Mastalgia

Dua group: 1. true Non Cyclical Mastalgia

2. musculoskeletal pain
1.True Non Cyclical Mastalgia
Dapat terjadi pre dan post menopaus
Rerata usia 34 tahun
Nyeri terlokalisisr terutama di subareola atau
lateral atas
 Jarang bilateral
Burning, drawing and abcess like
Remisi spontan setelah 27 minggu 50% kasus
Mamografi : kalsifikasi dan dilatasi duktal
(duct ectasia atau periductal mastitis)
 2. musculoskeletal/ chest wall pain
Selalu unilateral (92%)
Terdiri 2 kelompok: Tietzes syndrome dan
lateral chest wall pain
Respon yang baik terhadap injeksi steroid dan
anastesi lokal
Tietzes syndrome = painfull costochonral
junction
Penatalaksanaan Mastalgia
Surgical excision
Untuk semua tipe mastalgia dengan
simptom yang meluas mengenai hampir
seluruh jaringan payudara setelah gagal
dengan semua jenis terapi non bedah
Jenis operasi :
sub kutan mastektomi atau mastektomi
simpel
 Nipple Discharge

Dikeluhkan oleh 5% wanita yang berobat

95% nipple discharge penyebabnya
kelainan jinak
Discharge patologis:
Keluar spontan
Berasal dari satu duktus
Persisten atau menyusahkan
Mengandung darah
Karakteristik disharge :
Viskous ( seperti air) - Serous
Serosanguinous - Bloody
Milky - Clear
Green - Blue black
Penyebab Nipple Discharge

Fisiologis
Papiloma Intra Duktal
Papiloma Intra Duktal Multipel
Juvenila papillomatosis
Carcinoma
Bloody Discharge in Pregnancy
Galactorrhea
Fisiologis
Ditemukan pd 2/3 wanita saat di masase atau
di suction genlte
Sekresi fisiologis ini bervariasi dari putih,
kuning, hijau, coklat sampai hitam kebiruan
Umumnya berasal dari multipel duktus dan
discharge di setiap duktus warnanya bervariasi
Fisiologis
Discharge keluar sering ditemukan setelah
mandi air hangat atau manipulasi nipple
Umumnya tidak spontan dan tidak mengandung
darah
Tidak ada terapi terapi spesifik
Reassurance harus diberikan
Nipple discharge/ Keluar cairan
puting
Papiloma Intra Duktal
Papiloma di duktus mayor sub areola
merupakan penyebab tersering discharge
serous atau serosanguinous
Bloody discharge : 50% kasus
Masa dapat teraba pada 1/3 kasus
Terkadang papiloma dekat dengan nipple yang
dapat dilihat dari orifisium duktus
Terapi pilihan: microdochectomy
Juvenila papilomatosis
Usia antara 10 44 thn
Umumnya terdapat discrete mass
Terapi: eksisi
Papiloma Intra Duktal Multiple
Berkisar 10% dari intra papiloma adalah
multiple, umumnya 2-3 dalam 1 duktus
 Galactorrhea

Adalah milky discharge yg tidak berhubungan

dengan kehamilan atau laktasi
Penyebab: obat obat psikotropik pencetus
hiperprolaktinemia, adenoma
Terapi medikamen (bromocriptine) atau
surgical (eksisi adenoma)
Discharge in pregnancy
Bloody discharge sering saat kehamilan dan laktasi
20% berupa bloody discharge
Penyebab : hipervascularisasi jaringan mammae
Carcinoma
Invasif dan non invasif dapat menyebabkan
discharge
DCIS > 10% unilateral discharge
Discharge: merah kahitaman
Penyebab Nipple Discharge
Yang Lain
Periductal mastitis
Duktal ectasia
Nipple adenoma
Pagetdisease
Eczema
Ulcerating carcinoma
Nipple inversion with maceration
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