Tumor kandungan

dr.Hariadi, SpOG-K.Onk
RSUD Ulin / FK Unlam Banjarmasin
 Tumor
Tumor = benjolan
jinak/ganas
Kanker = tumor ganas
– Jaringan abnormal
– tumbuh banyak
– tdk terkoordinasi
Kista Ovarium
Kista ovarium
Fibro lipoma vulva
Prolap uteri
Mioma uteri
Apakah ini tumor ???
 Leading causes of death
in 2001
Percentage of Total Deaths,
US
Heart Diseases 31.0
Cancer 23.2
Cerebrovascular Diseases 6.8
Chronic Obstructive Lung Diseases 4.8
Accidents 4.2
Pneumonia & Influenza 3.9
Diabetes Mellitus 2.8
Suicide 1.3
Nephritis 1.1
Cirrhosis of the Liver 1.1

Greenlee RT, et al. CA Cancer J Clin.

2001:51;15-36.
Estimated percentage of new cancer
cases for 10 leading sites
Estimated percentage of cancer deaths
for 10 leading sites
 Etiologi kanker

Faktor lingkungan
Exposure to carcinogens
Lifestyle factors
Biologic agents
Pharmacologic/Iatrogenic factors
Alkohol yang berhubungan
dengan kanker

Kanker esophagus

kanker Head and neck

Kanker Liver

kanker payudara
Virus berhungan kanker
Agents Site of Cancer
Hepatitis B Liver
Hepatitis C Liver
HIV-1 Kaposi’s sarcoma
HTLV-1 Adult T-cell lymphoma
HPV Uterine cervix
Epstein-Barr Burkitt’s lymphoma, nasopharynx,
Hodgkin lymphoma

Cole P, Rodu B. Cancer: Principles & Practice ofOncology. 6th ed. 2001;241-252.
Bacterial berhubungan kanker

Agents Site of Cancer

Helicobacter pylori Stomach, Pancreas
Schistosoma haematobium (?)
Opisthorchis viverrini Urinary bladder
Liver

Ullrich RL, et al. Cancer: Principles & Practice of Oncology. 6th ed. 2001;195-206.
 Penyebab Iatrogenic

Agents Site of Cancer

Ionizing radiation Breast cancer
Leukemia
Skin cancer
Thyroid cancer
Lung cancer

Cole P, Rodu B. Cancer: Principles & Practice of Oncology.

6th ed. 2001;241-252.
 Kanker berhubungan dengan pekerjaan

Industry Carcinogen Cancer

Shipbuilding,demolition Asbestos Lung, pleura, skin
Varnish, glue Benzene Leukemia

Pesticides, smelting Arsenic Lung, skin, liver

Mineral refining and manufacturing Nickel, chromium Lung, nasal

Furniture manufacturing Wood dusts Nasal passages

Petroleum products Polycyclic hydrocarbons Lung

Rubber manufacturing Aromatic amines Bladder
Vinyl chloride Vinyl chloride Liver
Radium Radium Lung, bone

Outdoor occupations Ultraviolet light Skin

Bale AE, Brown SJ. Cancer: Principles & Practice of Oncology. 6th ed. 2001;207-217.
 Kanker Hereditary/familial
5 dan 10% dari semua tumor, mempunyai karakter
yang herediter
Penting untuk diidentifikasi
 deteksi dini dan pencegahan tumor
Beberapa anggota sering mewarisi jenis kanker
yang sama, dari generasi ke generasi
Terjadi pada usia dini: 40 - 50 tahun
 Kanker Hereditary/familial
Konseling genetik:
1. Probabilitas untuk terjadinya kanker.
2. Probabilitas untuk mentransmisikan kepada
keturunannya.
3. Probabilitas bahwa pada gilirannya akan
mendapatkan suatu neoplasia.
4. Prognosis dan strategi untuk deteksi dini dan
pendekatan terapeutik
Esensial : dukungan psikologis
 Mechanisms of cancer

Germline TSG inactivation

Germline oncogene activation
DNA repair defects
Ecogenetic traits
Abnormal tissue architecture
Humoral tumor promoters and regressors
Organ reproduksi

Harapan kebahagiaan
Masalah duka
– Rentan terhadap kanker
Payudara, Leher rahim,
indung telur, badan rahim
Kanker pada Perempuan
Kenali masalah
ORGAN REPRODUKSI !!!!

Rentan terhadap kanker

•Payudara
•Serviks (Leher rahim) >>>>)
•Ovarium (Indung telur)
•Badan rahim (Endometrium)
Organ reproduksi
 Gejala perlu perhatian

Tanpa
Perdarahan, gejala
Keputihan, Benjolan, Nyeri

 Ggn kencing  Ggn mentruasi

 Ggn BAB  Tanda infeksi
 Bengkak  Sesak
 Rasa berat  Asites
 Syok
 Program skrining
Payudara (mammografi, thermografi)
KLR (PAP Smear)

Tiga kriteria manilai screening

– Validitas
– Reliabilitas
– Yield
 Epidemiologi klinik kanker
ginekologi
Di Indonesia kanker ginekologi, masih
urutan pertama (serviks)
Kanker ginekologi terbanyak
– Kanker serviks
– Kanker Ovarium
– Kanker endometrium
 Penyakit kanker di dunia
C.ute ri
Pancre as
Prostat
O vary
Bladde r
Le uke mia
Lymph
Colo-re ct
Live r
Lung
Bre ast
Esoph
Mth-phx
Stomach
Ce rvix 0 100000 200000 300000 400000
Kanker Leher Rahim
– >> 100 kasus/100.000 /thn (dep-kes)
– 70% ke RS stdm lanjut
– HPV >>
Ca Endometrium
– Wanita gemuk, postmenopause, paritas rendah,
walaupun ada pd wanita muda (1,2-8,4%)
– Meningkat scr gradual sesuai usia
Ovarium
– 90% timbul sporadik (kebetulan)
– 10% et.faktor genetik
– Tantangan awalnya tdk ada gejala
– 2/3 kasus stadium lanjut
 Ca serviks
Urutan 3 di dunia
100 kasus/100.000 /thn (dep-kes)
70% ke RS stdm lanjut
HPV >> diteliti scr molekular
>> wanita Amerika latin, Afrika, Asia
Di negara maju (KLR stlh ca.payudara,
kolorectal)
ASR di US meningkat scr gradual
Risk factor
 Ca.Endometrium
Sering di US
Wanita gemuk, postmenopause, paritas
rendah, walaupun ada pd wanita muda
(1,2-8,4%)
Meningkat scr gradual sesuai usia
Insiden rendah di jepang, india, kulit hitam
Tinggi negara barat
 Faktor risiko
Estrogen > progesteron (eliminasi , tumor
granulosa, obesitas: konversi, hipertensi,
DM
risiko : oophorectomy, kurus, olah raga,
merokok
 Penelitian epidemiologik
Ca.endometrium
Pemberian estrogen terus hiperplasi
>>estrogen dr tumor granulosa kanker
endometrium
Ggn hepar kanker endometrium
Gemuk konversi androstenodion
Premenopause (unovulasi)
ca.endometrium
 Ca.ovarium

90% timbul sporadik

10% et.faktor genetik
Kematian ginekologi utama di US
>> jenis epithelial, usia muda germinal
pd usia 45 th
Tantangan awalnya tdk ada gejala
2/3 kasus stadium lanjut
 Ca.vulva
4% dr kanker gin
Umumnya usia lanjut (postmenopause)
Risk fc: HPV, merokok, distropia kronik
(licher scrosus)
3x lebih sering dr Ca.vagina
 Ca.vagina
Primer (tdk meliputi serviks dan vulva)
Jarang : 0,23/100.000 wanita
Umumnya sel skuamosa
Usia > 60 thn
Risk fc: sosek , HPV, iritasi kronis, DES
pd wanita hamil (clear cell
adenocarcinoma
US: 2x lebih sering pd kulit hitam
Usia muda : sarcoma botyroides
Penyakit trophoblast gestasional
Termasuk kelainan Mola (1:100 kelahiran)
Perubahan ganas 20% mola
invasive, choriocarsinoma
PTG ditangani dini dpt sembuh
Ca cervix
 Ca cerviks
Penderita kanker  sang pencipta
Apa ya….(biasa)
kematia
Kanker rahim itu ???
Wanita mengetahui kanker
– Bersikap apa?
n
– Tdk mengerti skrining (masalah Informasi)

Peran
tenaga kesehatan
 Global Problem
466,000 new cases identified each year
80% of the new cases occur in
developing countries
At least 231,000 women die of cervical
cancer each year
Cervical cancer is the third most
common cancer worldwide

7/8/2019 46
 Indonesian Problems
1. Cervical Ca still a leading type of Ca among the
woman
2. Ca Cervix represent 11 % of total cancer in
woman and 66 % of gynecology Cancer
3. Overall survival rate cervical cancer in INA is low
4. Patients come to hosp. in the late stages
5. Death can prevent only by screening routinely
6. Adeno Ca of the cervix is increasing
7. Developing of the early detection and
the management of the cervical cancer is
important
7/8/2019 47
 Prognostic Factors
 Stage
 Histology
 Lymph node metastasis
 Angiogenesis
 Tumor size
 Extra cervical involvement
 Hemoglobin level before treatment
 Educational status
 Economic status

7/8/2019 48
Masalah kes reproduksi  luas
Kanker  menderita (tak tertahankan)
Ilmu  meninggal (tdk selayaknya)
– Ada keluhan  invasive- stadium lanjut

pengobatan lama/mahal
follow up/harapan hidup
khawatir kambuh
 Displasi
a

Noninvasiv
e Cancer

Invasive
Cancer
 NORMAL CELL PRE CANCER
LAYERS CELL LAYERS

Facing Superficial
outside Superficial
the cervix Intermediate Intermediate
Pra Basal Basal
Basal
LGSIL

Inside Upper layers

cervix
Columnar Lower layers
Reserve
HGSIL

Superficial Upper layers

Basal Lower layers

Cancer prone area HGSIL

where the two above
layers meet in the
cervix opening
Stadium lanjut (harapan hidup)

Stadium FIGO Cipto

I 80,0-95,1% 48 %

II 63,5—66,3%, 42%

III 33,3-38,7 % 19%

IV 9,4-17,1% 0%
 Masalah kanker leher rahim
di Indonesia

Peringkat pertama dari seluruh kanker di

Indonesia ~ (34.4% dari kanker
perempuan)

60 - 70%  sudah STADIUM LANJUT

tingkat kesembuhan rendah  kematian
tinggi
 Kasus KLR RSUD.Ulin (Bag.PA)

Ca. Cervix Th. 2005 s/d 2007

100
80
60
Ca. Cervix
40
20
0
2005 2006 2007
 Faktor risiko KLR
•Menikah usia muda (<18 hn)
•Berganti pasangan (suami atau istri
•Banyak melahirkan
•Sering infeksi daerah rahim
•Perokok pd wanita (2x lebih tinggi

Penyebab utama
Virus (HPV)
 Natural History of Cervical
Cancer
Normal Cervix

About 60%
regress within HPV Infection
2-3 yrs
HPV-related Changes

Low-Grade SIL (Atypia, CIN I)

Cofactors
High-Risk HPV Types
About 15% progress within 3-4 yrs
(16, 18, 33, etc.)

High-Grade SIL (CIN II, III/CIS)

30%-70% progress within 10 yrs

Source: Sherris 1998; Bishop et al 1995

Invasive Cancer
57
 The Natural History of HPV Infection
Inoculation

Sustained
Immune About clinical
First lesion response 9 mo remission

Active growth Host

(1-8 mo)
Incubation Containment Late
(1 – 8 mo) (3-6 mo) stage

Persistent
7/8/2019
or recurrent58
What is
HPV?
 HPV
DNA Tumor virus
Over 100 HPV types
– infect different areas
of skin
– 38 genital HPV types
– do not circulate in
blood
Not easy to grow
Test for HPV DNA in
patient samples
 1.4 million (1%)
Genital warts

5 million (4%)
Detected by colposcopy

14 million (10%)
HPV Pos but colposcopy Neg

81 million (60%)
Negative HPV test
Antibodies detect

34 million (25%)
Ever infected

From Koutsky LA

Estimated Prevalence of HPV

Epidemiology of Genital HPV
Estimated to be one of the most common
STDs; exact numbers are impossible since
HPV is not a reportable STD
>50% of all sexually active adults likely
infected with at least one HPV type
Vast majority of infections resolve
spontaneously
Minority of HPV infections will progress to
cancer
Potential Routes of
Transmission
oral sex - rare
perinatal - rare
digital - rare
“outercourse” – rare
anal intercourse - common
vaginal intercourse -
common
 HPV Types
High Risk types :
16, 18,
31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82
Probable high risk types :
26, 53, and 66
Low risk type :
6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81, and CP6108
(Munos et al, N Engl J Med 2003; 348:518-27)
- HPV 16 & 18 most prevalent
Ca.CX
- HPV 18 related to Adeno
type
- HPV DNA almost 100%
Ca.CX
- The presence of HPV DNA in
cytologycally normal Pap
smears is associated with
increased risk of future
cervical cancer.
- Positivity HPV DNA =
prognostic for progression
Ca.CX
kunci kesembuhan kanker serviks 
ketanggapan dan deteksi dini.
Masyarakat sering  stigma negatif.
kanker serviks (>> virus, mutasi gen)
– hubungan seksual
– tetapi lewat banyak medium perantara virus
 Perjalanan penyakit
KLR
Normal Lesi
Kanker
Prakanker

Vaksin
TANTANGAN
Deteksi dini
 Apa dan bagaimana perjalanan
KLR
SEHAT

LAMA …. !!
skrining
PROSES

KLR
 How can HPV
Be prevented ?
Prevention of Genital HPV
Abstinence and lifetime mutual monogamy
– risk avoidance Vs. risk reduction
Condoms offer little protection from
infection but may reduce the likelihood of
developing warts or cancer
Prophylactic vaccines offer strong promise
for prevention in the future
 KLR informasi yg penting
perkembangan penyakit KLR lambat
Skrining: stdm awal  terapi
Usia > 35 lebih berisiko terkena KLR
Usia 30 & 40an harus diskrining 1x
Prosedur skrining harus mudah, sederhana,
dan tidak lama
Pada sebagian kecil perlu tindak lanjut
yang relatif sederhana pada lesi prakanker
serviks.
 KLR Bukan penyakit mematikan
apalagi berstigma "penyakit kotor“

Pap Sederhana
Mendeteksi dini
Smear
IVA

Risiko cepat teratasi.

 Stadium
Sayangnya lanjut

Minimnya budaya PAP Smear sebagai

upaya pemeriksaan dini  ancaman
kematian tinggi.
 Apa Pap Smear
??????

Normal Ab
Normal

Pemeriksaan
lanjutan
 Skrining
Negara maju  test Pap
– insiden 90%
– Mortalitas 70-80%
Negara berkembang
– SDM terbatas (patolog)
– Biaya
MASALAH
 Masalah
Di Indonesia, hanya 14,1% pemeriksaan
(stadium dini) Selebihnya, sudah lanjut.
di negara-negara maju  80%.
"Di Indonesia memang agak repot”
– di YKI, PAP Smear biayanya ...........
– Gratis
– vaksinasi anti-HPV.
 Masalah
kesadaran dan pengetahuan
(pencegahan)
Indonesia keterbatasan tenaga medis.
– hanya punya 1.500 ginekolog
– < 3.000 treat screener.

Jumlah penduduk Indonesia (230 juta jiwa,

dan 50% perempuan).
 Masalah di Indonesia
MASALAH INDONESIA

• Faktor Geografik > 13.000 pulau

• Kurangnya fasilitas sitologi

• Kurangnya fasilitas terapi

• Kurangnya kepatuhan pasien

 Skrining

insidens bisa turun 70 — 90 %,

idealnya tes Pap 1x dalam 5 thn
– (di negara sedang berkembang hanya 5 %).
TENG KYU
Wassalam
Terima kasih
Arigato
Mercy Beaucoup
Vielen Dank
Thank You