Simple Mastectomy (Total Mastektomy): pada prosedur operasi ini, keseluruhan jaringan payudara diangkat, tapi kelenjar getah

bening yang berada di bawah ketiak ( axillary lymph nodes) tidak diangkat. Kadang-kadang sentinel lymph node, yaitu kelenjar getah bening utama, yang lags berhubungan dengan payudara, diangkat juga. Untuk mengidentifikasi sentinel lymp node ahli bedah akan menyuntikkan suatu cairan dan / atau radioactive tracer kedalam area sekitar puting payudara. Cairan atau tracer tadi akan mengalir ketitik-titik kelenjar getah bening, yang pertama akan sampai ke sentinel lymp node. Ahli bedah akan menemukan titik-titik pada KGB (kelenjar Getah Bening) yang warnanya berbeda (apabila digunakan cairan) atau pancaran radiasi (bila menggunakan tracer). Cara ini biasanya mempunyai resiko rendah akan terjadinya lymphedema (pembengkakan pada lengan) daripada axillary lymp node dissection. Bila ternyata hasilnya sentinel node bebas dari penyebaran kanker, maka tidak ada operasi lanjutan untuk KGB. Apabila sebaliknya, maka dilanjutkan operasi pengangkatan KGB. Operasi ini kadang-kadang dilakukan pada kedua payudara pada penderita yang berharap menjalani mastektomi sebagai pertimbangan pencegahan kanker. Penderita yang menjalani simple mastectomy biasanya dapat meninggalkan rumah sakit setelah dirawat dengan singkat . Seringkali, saluran drainase dimasukkan selama operasi di dada penderita dan menggunakan alat penghisap (suction) kecil untuk memindahkan cairan subcutaneous (cairan di bawah kulit). Alat-alat ini biasanya dipindahkan beberapa hari setelah operasi apabila drainase telah berkurang dari 20-30 ml per hari.

Modified Radical Mastectomy: Keseluruhan jaringan payudara diangkat bersama dengan jaringan-jaringan yang ada di bawah ketiak (kelenjar getah bening dan jaringan lemak). Berkebalikan dengan simple mastectomy, m. pectoralis (otot pectoralis) ditinggalkan.

Radical Mastectomy atau Halsted Mastectomy : pertama kali ditunjukkan pada tahun 1882, prosedur operasi ini melibatkan pengangkatan keseluruhan jaringan payudara, kelenjar getah bening di bawah ketiak, dan m. pectoralis mayor dan minor (yang berada di bawah payudara). Prosedur ini lebih jelek dari pada modified radical mastectomy dan tidak memberikan keuntungan pada kebanyakan tumor untuk bertahan. Operasi ini, saat ini lebih digunakan bagi tumor-tumor yang melibatkan m. pectoralis mayor atau kanker payudara yang kambuh yang melibatkan dinding dada.

Skin-sparing Mastectomy: pada operasi ini, jaringan payudara diangkat dengan irisan konservatif (conservative incision) yang dibuat mengeliligi areola (area kehitaman di sekitar puting susu). Peningkatan jumlah area kulit yang tersis jika dibandingkan dengan mastectomy secara tradisional, dapat memfasilitasi prosedur dari breast reconstruction (operasi rekonstruksi payudara). Penderita dengan kanker yang juga melibatkan kulit pda payudaranya, tidak tepat untuk menggunakan prosedur operasi ini.

Subcutaneous Mastectomy: jaringan payudara diangkat, tapi area putting susu ( nippleareola complex) ditinggalkan. Prosedur ini dalam sejarah dikerjakan hanya sebagai profilaksis atau dengan mastektomi pada tumor jinak yang dikhawatirkan dapat berkembang menjadi kanker pada daerah sekitar putting susu.

KARNOFSKY PERFORMANCE STATUS SCALE DEFINITIONS RATING (%) CRITERIA

100 Able to carry on normal activity and to work; no special care needed. 90 80 70 Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed. 60 50 40 30 Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly. Normal no complaints; no evidence of disease. Able to carry on normal activity; minor signs or symptoms of disease. Normal activity with effort; some signs or symptoms of disease. Cares for self; unable to carry on normal activity or to do active work. Requires occasional assistance, but is able to care for most of his personal needs. Requires considerable assistance and frequent medical care. Disabled; requires special care and assistance. Severely disabled; hospital admission is indicated although death not imminent. Very sick; hospital admission necessary; active supportive treatment necessary. Moribund; fatal processes progressing rapidly. Dead

20 10 0

Karnofsky skoring The Karnofsky score runs from 100 to 0, where 100 is "perfect" health and 0 is death. Nilai Karnofsky berjalan 100-0, di mana 100 adalah "sempurna" kesehatan dan 0 adalah kematian. Although the score has been described with intervals of 10, a practitioner may choose decimals if he or she feels a patient's situation holds somewhere between two marks. Meskipun nilai tersebut telah dijelaskan dengan interval 10, seorang praktisi dapat memilih desimal jika dia merasa situasi pasien memegang suatu tempat antara dua tanda. It is named after Dr David A. Karnofsky, who described the scale with Dr Joseph H. Burchenal in 1949. Hal ini dinamai Dr David A. Karnofsky, yang menggambarkan skala dengan Dr Joseph H. Burchenal pada tahun 1949.

100% - normal, no complaints, no signs of disease 100% - normal, tidak ada keluhan, tidak ada tanda-tanda penyakit 90% - capable of normal activity, few symptoms or signs of disease 90% - mampu aktivitas normal, beberapa gejala atau tanda-tanda penyakit 80% - normal activity with some difficulty, some symptoms or signs 80% - aktivitas normal dengan susah payah, beberapa gejala atau tanda-tanda 70% - caring for self, not capable of normal activity or work 70% - merawat diri, tidak mampu kegiatan normal atau pekerjaan 60% - requiring some help, can take care of most personal requirements 60% - yang membutuhkan bantuan, bisa mengurus kebutuhan personal yang paling 50% - requires help often, requires frequent medical care 50% - membutuhkan bantuan seringkali, membutuhkan perawatan medis sering 40% - disabled, requires special care and help 40% - dinonaktifkan, membutuhkan perawatan khusus dan bantuan 30% - severely disabled, hospital admission indicated but no risk of death 30% - sangat cacat, masuk rumah sakit tetapi tidak menunjukkan risiko kematian 20% - very ill, urgently requiring admission, requires supportive measures or treatment 20% - sangat sakit, sangat membutuhkan pengakuan, memerlukan tindakan yang mendukung atau perawatan 10% - moribund, rapidly progressive fatal disease processes 10% - hampir mati, penyakit mematikan proses cepat progresif 0% - death. 0% - kematian.

ECOG/WHO/Zubrod score [ sunting ] ECOG / WHO / skor Zubrod The ECOG score (published by Oken et al. in 1982), also called the WHO or Zubrod score (after C. Gordon Zubrod ), runs from 0 to 5, with 0 denoting perfect health and 5 death: [ 2 ] The ECOG skor (diterbitkan oleh Oken et al). Pada tahun 1982, juga disebut WHO atau nilai Zubrod (setelah C. Gordon Zubrod ), berlangsung dari 0 hingga 5, dengan 0 yang menunjukkan kesehatan yang sempurna dan 5 kematian: [2]

0 - Asymptomatic (Fully active, able to carry on all predisease activities without restriction) 0 - Asimtomatik (Fully aktif, mampu melaksanakan semua kegiatan predisease tanpa batasan)

1 - Symptomatic but completely ambulatory (Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. For example, light housework, office work) 1 - simtomatik tetapi sepenuhnya rawat jalan (yang dibatasi penggunaannya dalam kegiatan fisik berat tapi rawat jalan dan mampu melaksanakan pekerjaan yang bersifat cahaya atau menetap. Sebagai contoh, pekerjaan rumah cahaya, pekerjaan kantor) 2 - Symptomatic, <50% in bed during the day (Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours) 2 - simtomatik, <50% di tempat tidur selama sehari (Rawat Jalan dan mampu semua perawatan diri tetapi tidak dapat melaksanakan kegiatan pekerjaan. Up dan sekitar lebih dari 50% dari bangun jam) 3 - Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair 50% or more of waking hours) 3 - simtomatik,> 50% di tempat tidur, tetapi tidak bedbound (Mampu hanya terbatas perawatan diri, terbatas pada tempat tidur atau kursi 50% atau lebih dari bangun jam) 4 - Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair) 4 - Bedbound (Lengkap dinonaktifkan tidak dapat melakukan apa pun perawatan diri.. Benar-benar terbatas pada tempat tidur atau kursi) 5 - Death 5 - Kematian

[ edit ] Lansky score [ sunting ] skor Lansky Children, who might have more trouble expressing their experienced quality of life, require a somewhat more observational scoring system suggested and validated by Lansky et al. in 1987: [ 3 ] Anak-anak, yang mungkin lebih sulit mengekspresikan mengalami kualitas hidup mereka, memerlukan pengamatan penilaian sistem yang lebih agak diusulkan dan disahkan oleh et al Lansky:. Pada tahun 1987 [3]

100 - fully active, normal 100 - sepenuhnya aktif, normal 90 - minor restrictions in strenuous physical activity 90 - pembatasan kecil dalam aktivitas fisik berat 80 - active, but tired more quickly 80 - aktif, tetapi lebih cepat lelah 70 - greater restriction of play and less time spent in play activity 70 - lebih besar pembatasan bermain dan sedikit waktu yang dihabiskan dalam kegiatan bermain 60 - up and around, but active play minimal; keeps busy by being involved in quieter activities 60 - dan sekitar, tapi bermain aktif minimal; terus sibuk dengan terlibat dalam kegiatan yang lebih tenang 50 - lying around much of the day, but gets dressed; no active playing participates in all quiet play and activities 50 - berbaring sekitar banyak hari, tapi berpakaian, tidak bermain aktif berpartisipasi dalam semua kegiatan bermain tenang dan 40 - mainly in bed; participates in quiet activities 40 - terutama di tempat tidur; berpartisipasi dalam kegiatan-kegiatan yang tenang 30 - bedbound; needing assistance even for quiet play 30 - bedbound; memerlukan bantuan bahkan untuk bermain tenang 20 - sleeping often; play entirely limited to very passive activities 20 - tidur sering; bermain seluruhnya terbatas pada kegiatan yang sangat pasif

10 - doesn't play; does not get out of bed 10 - tidak bermain; tidak bangun dari tempat tidur 0 - unresponsive 0 - responsif

[ edit ] Comparison [ sunting ] Perbandingan A comparison between the Zubrod and Karnofsky scales has been validated in a large sample of patients: [ 4 ] Perbandingan antara Zubrod dan skala Karnofsky telah divalidasi dalam sampel besar pasien: [4]

Zubrod 0 equals Karnofsky 100; 90-100 Zubrod 0 sama dengan Karnofsky 100; 90-100 Zubrod 1 equals Karnofsky 80-90; 70-80 Zubrod 1 sama dengan Karnofsky 80-90; 70-80 Zubrod 2 equals Karnofsky 60-70; 50-60 Zubrod 2 sama dengan Karnofsky 60-70; 50-60 Zubrod 3 equals Karnofsky 40-50; 30-40 Zubrod 3 sama dengan Karnofsky 40-50; 30-40 Zubrod 4 equals Karnofsky 20-30;10-20 Zubrod 4 sama dengan Karnofsky 20-30; 10-20

Lumpectomy is a type of surgery for breast cancer. It is considered "breast-conserving" surgery because only the malignant tumor and a surrounding margin of normal breast tissue are removed. Lymph nodes in the armpit (axilla) may also be removed. This procedure is also called lymph node dissection.

Purpose
Lumpectomy is a surgical treatment for newly diagnosed breast cancer. It is estimated that at least 50% of women with breast cancer are good candidates for this procedure. The location, size, and type of tumor are of primary importance when considering breast cancer surgery options. The size of the breast is another factor the surgeon considers when recommending surgery. The patient's psychological outlook, as well as her lifestyle and preferences, should also be taken into account when treatment decisions are being made. The extent and severity of a cancer is evaluated, or "staged," according to a fairly complex system. Staging considers the size of the tumor and whether the cancer has spread (metastasized) to adjacent tissues, such as the chest wall, the lymph nodes, and/or to distant parts of the body. Women with early stage breast cancers are usually better candidates for lumpectomy. In most cases, a course of radiation therapy after surgery is part of the treatment. Chemotherapy or hormone treatment may also be prescribed. In some instances, women with later stage breast cancer may be able to have lumpectomies. Chemotherapy may be administered before surgery to decrease tumor size and the chance of metastasis in selected cases.

Contraindications to lumpectomy
There are a number of factors that may prevent or prohibit a breast cancer patient from having a lumpectomy. The tumor itself may be too large or located in an area where it would be difficult to remove with good cosmetic results. Sometimes several areas of cancer are found in one breast, so the tumor cannot be removed as a single lump. A cancer that has already attached itself to nearby structures, such as the skin or the chest wall, needs more extensive surgery. Certain medical or physical circumstances may also eliminate lumpectomy as a treatment option. Sometimes lumpectomy may be attempted, but the surgeon is unable to remove the tumor with a sufficient amount of surrounding normal tissue. This may be termed "persistently positive margins," or "lack of clear margins." Lumpectomy is suitable for women who have had previous lumpectomies and have a recurrence of breast cancer. Because of the need for radiation therapy after lumpectomy, this surgery may be medically unacceptable. A breast cancer discovered during pregnancy is not amenable to lumpectomy because radiation therapy is part of the treatment. Radiation therapy cannot be administered to pregnant women because it may injure the fetus. If, however, delivery would be completed prior to the need for radiation, pregnant women may

During a lumpectomy, a small incision is made around the area of the lump (A). The skin is pulled back, and the tumor removed (B). The incision is closed (C). (

Illustration by GGS Inc. ) undergo lumpectomy. A woman who has already had therapeutic radiation to the chest area for other reasons cannot undergo additional exposure for breast cancer therapy. The need for radiation therapy may also be a barrier due to nonmedical concerns. Some women simply fear this type of treatment and choose more extensive surgery so that radiation will not be required. The commitment of time, usually five days a week for six weeks, may not be acceptable for others. This may be due to financial, personal, or job-related constraints. Finally, in geographically isolated areas, a course of radiation therapy may require lengthy travel and perhaps unacceptable amounts of time away from family and other responsibilities.

Demographics
The American Cancer Society estimated that in 2003, 211,300 new cases of breast cancer would be diagnosed in the United States and 39,800 women would die as a result of the disease. Approximately one in eight women will develop breast cancer at some point in her life. The risk of developing breast cancer increases with age: women aged 30 to 40 have a one in 252 chance of developing breast cancer; women aged 40 to 50 have a one in 68 chance; women aged 50 to 60 have a one in 35 chance; and women aged 60 to 70 have a one in 27 chanceand these statistics do not even account for genetic and environmental factors. In the 1990s, the incidence of breast cancer was higher among white women (113.1 cases per 100,000 women) than African-American women (100.3 per 100,000). The death rate associated with breast cancer, however, was higher among African American women (29.6 per 100,000) than white women (22.2 per 100,000). Rates were lower among Hispanic women (14.2 per 100,000), American Indian women (12.0), and Asian women (11.2 per 100,000).

Description
Any amount of tissue, from 150% of the breast, may be removed and called a lumpectomy. Breast conservation surgery is a frequently used synonym for lumpectomy. Partial mastectomy, quadrantectomy , segmental excision, wide excision, and tylectomy are other, less commonly used names for this procedure. The surgery is usually done while the patient is under general anesthetic. Local anesthetic with additional sedation may be used for some patients. The tumor and surrounding margin of tissue is removed and sent to a pathologist for examination. The surgical site is then closed. If axillary lymph nodes were not removed before, a second incision is made in the armpit. The fat pad that contains lymph nodes is removed from this area and is also sent to the pathologist for analysis. This portion of the procedure is called an axillary lymph node dissection; it is critical for determining the stage of the cancer. Typically, 10 to 15 nodes are removed, but the number

may vary. Surgical drains may be left in place in either location to prevent fluid accumulation. The surgery may last from one to three hours.

Diagnosis/Preparation
Routine preoperative preparations, such as having nothing to eat or drink the night before surgery, are typically ordered for a lumpectomy. Information about expected outcomes and potential complications is also part of preparation for lumpectomy, as it is for any surgical procedure. It is especially important that women know about sensations they might experience after the operation, so the they are not misinterpreted as signs of further cancer or poor healing. If the tumor is not able to be felt (not palpable), a pre-operative localization procedure is needed. A fine wire, or other device, is placed at the tumor site, using x ray or ultrasound for guidance. This is usually done in the radiology department of a hospital. The woman is most often sitting up and awake, although some sedation may be administered.

Aftercare
The patient may stay in the hospital one or two days, or return home the same day. This generally depends on the extent of the surgery, the medical condition of the patient, and physician and patient preferences. A woman usually goes home with a small bandage. The inner part of the surgical site usually has dissolvable stitches. The skin may be sutured or stitched; or the skin edges may be held together with steristrips, which are special thin, clear pieces of tape. After a lumpectomy, patients are usually cautioned against lifting anything which weighs over five pounds for several days. Other activities may be restricted (especially if the axillary lymph nodes were removed) according to individual needs. Pain is often enough to limit inappropriate motion. Women are often instructed to wear a well-fitting support bra both day and night for approximately one week after surgery. Pain is usually well controlled with prescribed medication. If it is not, the patient should contact the surgeon, as severe pain may be a sign of a complication, which needs medical attention. A return visit to the surgeon is normally scheduled approximately ten days to two weeks after the operation. Radiation therapy is usually started as soon as possible after lumpectomy. Other additional treatments, such as chemotherapy or hormone therapy, may also be prescribed. The timing of these is specific to each individual patient.

Risks
The risks are similar to those associated with any surgical procedure. Risks include bleeding, infection, breast asymmetry, anesthesia reaction, or unexpected scarring. A lumpectomy may also cause loss of sensation in the breast. The size and shape of the breast will be affected by the operation. Fluid can accumulate in the area where tissue was removed, requiring drainage. If lymph node dissection is performed, there are several potential complications. A woman may experience decreased feeling in the back of her armpit. She may also experience other sensations, including numbness, tingling, or increased skin sensitivity. An inflammation of the arm vein, called phlebitis, can occur. There may be injury to the nerves controlling arm motion. There is a risk of developing lymphedema (swelling of the arm) after axillary lymph node dissection. This swelling can range from mild to very severe. It can be treated with elastic bandages and specialized physical therapy, but it is a chronic condition, requiring continuing care. Lymphedema can arise at any time, even years after surgery.

Normal results
When lumpectomy is performed, it is anticipated that it will be the definitive surgical treatment for breast cancer. Other forms of therapy, especially radiation, are often prescribed as part of the total treatment plan. The expected outcome is no recurrence of the breast cancer.

Morbidity and mortality rates

Approximately 210% of patients develop lymphedema after axillary lymph node dissection. Five percent of women are unhappy with the cosmetic effects of the surgery. The rate of cancer recurrence after five years is about 510%, and 1015% after 10 years.

Alternatives
A procedure in which the entire affected breast is removed, called a mastectomy, has been shown to be equally effective in treating breast cancer as lumpectomy, in terms of rates of recurrence and survival. Some women may choose to have a mastectomy because they strongly fear a recurrence of breast cancer, and may consider a lumpectomy too risky. Others may feel uncomfortable with a breast that has had a cancer, and would experience more peace of mind with the entire breast removed. A new technique that may eliminate the need for removing many axillary lymph nodes is being tested. Sentinel lymph node mapping and biopsy is based on the idea that the condition of the

first lymph node in the network, which drains the affected area, can predict whether the cancer may have spread to the rest of the nodes. It is thought that if this first, or sentinel, node is cancerfree, then there is no need to look further. Many patients with early-stage breast cancers may be spared the risks and complications of axillary lymph node dissection as the use of this approach continues to increase.