LESI PRAKANKER HUT YALA SEPT 2016

1. KESEHATAN
REPRODUKSI
30/10/2016 KIA RSMC 1

2. 30/10/2016 KIA RSMC 2

3. 30/10/2016 KIA RSMC 3
• Nama : Arie Widiyasa
• Temp/tgl lahir : Makassar, 11 Februari 19. .
• Alamat : Jln Pulau Dewata 18
Kompleks TNI-AL Kodamar
Sunter Kelapa Gading, Jak Ut
• Jabatan : Staf SMF Obstetri Ginekologi
- RS Marinir Cilandak, JakSel
- RSAL dr Mintohardjo, JakPus
• Riwayat pendidikan:
– S1 : FK Unair, lulus 1992
– Spesialis ObsGyn : FK Unair, lulus 2005

4. 30/10/2016 KIA RSMC 4

5. 30 Oktober 2016 RSAL dr MINTOHARDJO 5
0 100000 200000 300000 400000
C.uteri
Pancreas
Prostat
O vary
Bladder
Leukemia
Lymph
Colo-rect
Liver
Lung
Breast
Esoph
Mth-phx
Stomach
Cervix
Insiden pertahun temuan kasus keganasan
baru pada negara berkembang (< TAHUN 2000)

6. 30 Oktober 2016 RSAL dr MINTOHARDJO 6
10 terbanyak kasus keganasan pada wanita
Indonesia (pathological based registry) 1991-1995
Lokasi Jumlah % ♀ %♀+
♂
Leher Rahim 19.952 27,95 18,14
Payudara 13.136 18,40 11,95
Indung telur 5.504 7,71 5,00
Kulit 4.215 5,90 3,83
Tiroid 3.370 4,72 3,06
Rektum 3.464 3,45 2,24
Kelenjar Limfe 2.344 3,28 2,13
Badan Rahim 2.268 3,17 2,06
Nasofaring 2.011 2,81 1,82
Jaringan lunak 1.750 2,45 1,59
♀ = 71.383, ♀ + ♂ = 109.962

7. 30 Oktober 2016 RSAL dr MINTOHARDJO 7
0
1000
2000
3000
4000
5000
6000
7000
<15 15-
24
25-
34
35-
44
45-
54
55-
54
55-
64
65-
74
>75
Cervix
0
10
20
30
40
50
60
70
80
<15 15-
24
25-
34
35-
44
45-
54
55-
54
55-
64
65-
74
>75
Kidney
0
500
1000
1500
<15 15-
24
25-
34
35-
44
45-
54
55-
54
55-
64
65-
74
>75
Ovary
0
20
40
60
80
100
120
140
<15 15-
24
25-
34
35-
44
45-
54
55-
54
55-
64
65-
74
>75
Bladder
Distribusi berdasarkan usia, kasus keganasan
Urogenital wanita Indonesia,1991-1995

8. 30 Oktober 2016 RSAL dr MINTOHARDJO 8
Stage Number %
Early
invasive: IA 2 0.4
IB 89 18.2 28.5%
IIA 48 9.8
Advanced :
IIB 112 22.9
IIIA 3 0.6
IIIB 195 39.9
IVA 27 5.5 71.6%
IVB 13 2.7
Total 489 100
DISTRIBUSI KASUS KEGANASAN LEHER
RAHIM BERDSRKAN DERAJAT (RSCM,1992)

9. RS DARMAIS 2007
30/10/2016 KIA RSMC 9

10. RSAL MTH
(2001-2010)
30 Oktober 2016 RSAL dr MINTOHARDJO 10

11. REKAPITULASI
HASIL PA
(2001-2010)

12. }
REKAPITULASI
HASIL PA
(2001-2010)

13. REKAPITULASI
TINDAKAN (2001-2010)
30 Oktober 2016 RSAL dr MINTOHARDJO 13

14. 5,65%4,92%
4,92%
53,55%
18,58%
12,38%
30 Oktober 2016 14RSAL dr MINTOHARDJO
(2001-2010)

15. Sebanyak 58 kasus baru kanker
serviks terjadi setiap harinya.1
26 wanita Indonesia meninggal
setiap hari karena kanker serviks1
17
Globocan data 20121
BEBAN KANKER SERVIKS DI INDONESIA 2012
Tingkat Kematian, Insidensi, Prevalensi 5
Tahun Tertinggi diantara Negara-negara di
Asia Tenggara1 !!!!!
WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human
Papillomavirus and Related Cancers in Indonesia. Summary Report 2014-08-22. Available at www.
Hpvcentre.net

16. KEJADIAN CACX DI INDONESIA (BERDASARKAN USIA)
Souce:INASGONATIONALCERVICALCANCERREGISTRY

17. 30/10/2016 KIA RSMC 19

18. Perkembangan
VAKSIN HPV
dimulai dengan
PENELITIAN
lebih dari 20 tahun
yang lalu
www.cegahkankerserviks.org

19. Perkembangan vaksin HPV dimulai
dengan penelitian lebih dari 20 tahun yang lalu
www.cegahkankerserviks.org

20. Vaccines

21. KEGANASAN
LEHER RAHIM
PAKES TNI AL
RS MARINIR CILANDAK

22. 30 Oktober 2016 RSAL dr MINTOHARDJO 24
ORGAN KANDUNGAN WANITA :
2. ALAT KELAMIN DALAM
(GENITALIA INTERNA)
1. ALAT KELAMIN LUAR
(GENITALIA EKSTERNA)

23. 30 Oktober 2016 RSAL dr MINTOHARDJO 25
2
3
1. VAGINA/LIANG SENGGAMA
2. RAHIM (UTERUS)
* BADAN RAHIM (CORPUS UTERI)
* ISTHMUS UTERI
* LEHER RAHIM (SERVIKS)
* MULUT RAHIM (PORTIO)
3. SALURAN TELUR (TUBA FALLOPII)
4. INDUNG TELUR (OVARIUM)
1
4
GENITALIA INTERNA

24. 30 Oktober 2016 RSAL dr MINTOHARDJO 26
GENITALIA EKSTERNA
1. BIBIR BESAR (LABIA MAYORA)
2. BIBIR KECIL (LABIA MINORA)
3. KLITORIS
4. INTROITUS VAGINA

25. 30 Oktober 2016 27RSAL dr MINTOHARDJO
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26. 30/10/2016 KIA RSMC 28
Sambungan Skuamo Kolumner
(SSK)
30 Oktober 2016 28RSAL dr MINTOHARDJO

27. 29
Peningkatan resiko infeksi HPV pada remaja wanita : Progresi dari
“Transformation Zone”
• Selama dan setelah masa pubertas,
“transformation zone” sangat
mudah terinfeksi dan terjadi
carcinogenesis.1,2
• Transformation zone, berada pada
exocervix, dan merupakan
daerah epitel columnar terluas
yang mudah ter-exposure
infeksi HPV .2
–~99% dari infeksi HPV yang
berhubungan dengan penyakit
genital banyak “menyerang”
daerah “transformation zone”
dari serviks.1
• Setelah menopause, Serviks shrinks.
Dimana “transformation zone”
bergerak masuk kedalam jalur
endocervical.
1. Castle PE. J Low Genit Tract Dis. 2004;8:224–230. 2. ACOG Committee on Adolescent Health Care. Obstet Gynecol.
2004;104:891–898. 8
SCJ = squamocolumnar junction

28. The Cervical Transformation Zone
Original SCJ
Functional SCJ
• Remaja punya resiko
tinggi alami invasi HPV
karena jaringan yg
imatur serta proses
fisiologis epitel skuamosa
yg alami metaplasia
• Most centers have found
an increase in abnormal
Pap smears in adolescents
and young women
Emans and Goldstein,1994

29. RESPON SERVIKS THD “TRAUMA”:
• Permukaan mukosa alami trauma oleh berbagai
macam faktor (mekanis, mikrobiologis, kimiawi
dan hormonal)
• Respon mukosa :
• Reaksi inflamasi akut hingga kronis
• Respon adaptasi seperti proses proliferasi :
Hyperplasia, Metaplasia & Dysplasia.
• Anaplasia – Tumor jinak atau ganas.
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30. NORMAL CERVIX
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36. PENYEBAB?
KANKER LEHER RAHIM DISEBABKAN OLEH HUMAN PAPILLOMAVIRUS
100 Macam HPV
Low risk (HPV type 6 & 11)
(non cancerous / nononcogenic)
Cause external anogenital warts
High risk (HPV type 16(43%)& 18(38%)
(cancerous / oncogenic)
Cause cervical cancer (31,33,45)
HPV sering tidak memberikan gejala/simptom
Most people DO NOT know if they acquire HPV
Most people can transmit HPV WITHOUT even knowing it
(Anogenital : genital area include
the skin of penis, vulva , anus)
30 Oktober 2016 38RSAL dr MINTOHARDJO
30/10/2016 KIA RSMC 38

37. HPV Life Cycle
The Journal of Clinical Investigation, Volume 116 Number 5 May 2006
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38. HPV:
A sophisticated immune evasion mechanism1-4
1.Stanley M. Vaccine 2006; 24: S106-13, 2.Tindle, Nat Rev Cancer 2002; 2, 59,
3.Stanley M. Vaccine 2006; 24: S16-22, 4. Stanley M. HPV Today 2007; 11:1-16
Infeksi lokal,1-4 HPV menginfeksi epitel melalui
perlukaan mikro1-4Tdk ada Viremia
Masuk ke sel basal epitel, integrasii DNA dengan sel Host1-4
Bereplikasi di sel dan tinggal di dalam epitel1-4Immunosuppresi Lokal1-4
Memanfaatkan siklus hidup sel normal tubuh utk memperbanyak dan
melepaskan virus1-4 Tidak menyebabkan kematian sel 1-4Tdk ada peradangan, sel-sel imun tidak terpanggil

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41. aEstimated gender ratio of genital warts: 54% males, 46% females.5
1. Forman D et al. Vaccine. 2012;30(Suppl 5):F12−23. 2. Executive summary: the state of world health, 1995. World Health Organization website.
http://www.who.int/whr/1995/media_centre/executive_summary1/en/index.html. Accessed March 12, 2013. 3. Greer CE et al. J Clin Microbiol.
1995;33:2058–2063. 4. Human papillomavirus and HPV vaccines: technical information for policy-makers and health professionals, 2007. World Health
Organization website. http://whqlibdoc.who.int/hq/2007/WHO _IVB_07.05_eng.pdf. Accessed March 12, 2013. 5. Health Protection Agency (HPA). Health
Protect Rep. 2012;6:9−15. http://www.hpa.org.uk/HPR/archives/2012/hpr2212.pdf. Accessed March 12, 2013.
GLOBAL BURDEN OF HPV
RELATED DISEASE
43
Male Female
Penile cancer1
11,000
21,000 Vulvar & vaginal cancer1
530,000 Cervical cancer1
14,700,000 Genital warts2–4,a
Genital warts2−4,a
Oropharyngeal cancer1 Oropharyngeal cancer14,40017,000
Anal cancer1 Anal cancer111,000 13,000
17,300,000
Harald zur Hausen
2008 Nobel Prize Winner:
HPV role in cervical cancer
Human Papilloma
Virus

43. Central/South
America
Northern Africa
North America/
Europe
South Asia
16
18
45
31
33
HPV Type
52
Others
*A pooled analysis and multicenter case control study (N = 3607)
1. Muñoz N, Bosch FX, Castellsagué X, et al. Int J Cancer. 2004;111:278–285.
Worldwide Prevalence of HPV Types in
Cervical Cancer1
58
57
12.6
69.7
14.6
67.6
17
52.5
25.7

44. Precancer cervical lesions
• Cervical intraepithelial
neoplasia (CIN)
• Erythroplakia with atypia
• Leukoplakia with atypia
• Adenomatosis

45. Layers of squamosus
epithelium of cervix

46. CIN Classification
• CIN I: Mild dysplasia;
abnormal cells can be
found in 1/3 of the lining of
the cervix
• CIN II: Moderate
dysplasia; abnormal cells
can be found in 2/3 of the
lining of the cervix
• CIN III: Severe dysplasia;
abnormal cells can be
found in more than 2/3 of
the lining of the cervix and
up to the full thickness of
the lining

47. 49
CIN (CERVICAL INTRAEPITHELIAL NEOPLASIA)
as Seen in Colposcopy
CIN 1 CIN 2 CIN 3
1. Wright TC Jr, Cox JT, Massad LS, et al, for the ASCCP-Sponsored Consensus Congress. JAMA. 2002;287:2120–2129. 2. Bonnez W. In: Richman DD,
Whitley RJ, Hayden FJ, eds. Washington, DC: American Society for Microbiology Press; 2002:557–596. 3. Canadian Cancer Society. Cervical Cancer: What
you need to know. Available at: http://www.cancer.ca/vgn/images/portal/cit_86751114/63/40/151140772cw_library_wyntk_cervical_en.pdf. Accessed March 13,
2006. 4. Reprinted with permission from Sellors JW, Sankaranarayanan R, eds. Colposcopy and Treatment of Cervical Intraepithelial Neoplasia. A Beginner’s
Manual. Lyon, France: International Agency for Research on Cancer; 2003.
Photo courtesy of Dr. J. Monsonego Photo courtesy of Dr. J. Monsonego From IARC, 2003.4
Colposcopy findings confirmed by histology1

48. DETEKSI
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• Pap smear
• Colposcopy
• HPV DNA
typing
• Punch biopsy
• Conization(LEEP)
• Endocervical
curettage

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55. PENATALAKSANAAN
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#Observation #Laser vaporization
#Local excision #Cold coagulation
#Electrocautery #Conization
#Cryosurgery #Hysterectomy
#LEEP(Loop Electrosurgical Excision procedure)

56. Natural History CIN
Natural history of cervical intraepithelial neoplasia: A critical review Int. J Gynecol. Pathol.
12:186-92, 1993. (Literature Review)
Regress Persist Progression to
CIN 3 Invasion
CIN 1 57% 32% 11% 1%
CIN 2 43% 35% 22% 5%
CIN 3 32% 56% >12%
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(CIN : CERVICAL INTRA EPITHELIAL LESION)

57. TREATMENT OPTIONS

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61. KANKER LEHER RAHIM
• The most female cancer in Indonesia
• > 60 – 70 % advanced stage
• No routine program for mass screening
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67. FAKTA ILMIAH
• EPIDEMIOLOGI : (SHT,KOGI 2009)
 2.329.080 WANITA YG BERESIKO
 493.243 KASUS BARU/THN
 55% KASUS KEMATIAN/THN
 80% WANITA SEKSUAL AKTIF TERINFEKSI HPV
 SATU-SATUNYA KANKER YG DPT DICEGAH !!
• PROGRAM KESEHATAN :
# NEGARA MAJU
 TX PADAT TEKHNOLOGI, BIAYA TINGGI
(ASURANSI)
# NEGARA BERKEMBANG (dana terbatas dan “tabu”)
 OPTIMALISASI UPAYA PREVENTIF
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30/10/2016 Arie Widiyasa 71

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73. 75ARIE WIDIYASA30-Oct-16

74. 76ARIE WIDIYASA30-Oct-16

75. 77ARIE WIDIYASA30-Oct-16

76. Faktor risiko
Kanker Leher
Rahim
PENURUNAN
KEKEBALAN
TUBUH
MEROKOK
PASANGAN > 1
SEKS PERTAMA < 18 TAHUN
RWYT CACX IBU &
SAUDARA WANITA
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Riwayat papsmear (+)
SEKS ABNORMAL
Penyakit STD

77. KONTAK KELAMIN
JALUR SEKSUAL JALUR NON SEKSUAL
www.cegahkankerserviks.org
CARA PENULARAN
HPV
● HUBUNGAN INTIM
● KELAMIN – KELAMIN
● TANGAN – KELAMIN
● MULUT - KELAMIN
● WC UMUM
● PAKAIAN DALAM
● ALAT-ALAT
KEDOKTERAN YANG
TIDAK STERIL
DILUAR KELAMIN PENULARAN LANGSUNG
IBU
BAYI
SAAT PERSALINAN
TIMBUL KUTIL PADA
SALURAN PERNAPASAN
BAYI
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78. ● Pendarahan yg tidak normal
- Pendarahan sesudah melakukan hubungan intim
- Pendarahan abnormal (diluar waktu haid)
- Pendarahan sesudah menopause
● Kelainan pada vagina
( keluarnya cairan kekuningan kadang bercampur darah,
berbau sangat busuk )
● Gejala lain
- Sakit / nyeri di sekitar pinggul
- Sakit / nyeri pada kaki
" Pada kebanyakan wanita tidak merasakan gejala "
KELUHAN
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79. TERAPI
• Stage 1:
– Kemo lanjut surgery
– Dpt disertai kombinasi
dengan kemo & radiasi
bila terdapat sisa tumor
• Stage 2:
– Surgery dan kombinasi
kemoradioterapi
• Stage 3:
– Kemoradiasi stage 3a dan
3b
• Stage 4:
– Surgery /kemo /
radioterapi / kombinasi

82. Who will be screened ?
• Setiap wanita yg pernah lakukan hub bdn :
– 3 thn setelah hubungan badan pertama kali
– Diatas usia 21 thn
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83. 1,2. Riskesdas 2010. Badan Penelitian dan Pengembangan Kesehatan, Kemenkes RI
Age at first marriage1
•Survei dilakukan pada 63.428 responden usia
10-24 tahun, 86.7% dari mereka belum menikah2
•Di antara mereka yang belum menikah, 3%
laki-laki dan 1.1% perempuan telah aktif secara
seksual.2
Pre-marital sex and aged of
sexual activity2
Percentage of women aged 10-59 years
based on age at first marriage1
Proporsi dari
responden usia
10-24 tahun yang
belum menikah
berdasarkan usia
pertama kali
melakukan
hub.seksual 2

85. VAKSINASI ?
30/10/2016 87KIA RSMC
GARDASIL

86. 30/10/2016 KIA RSMC 88
Vactination is effective, however…
• Kpn di vaksin?
• Pre-puberty?
• Cultural issues?
GARDASIL

87. 30/10/2016 KIA RSMC 89
Rekomendasi (ACOG)
• Utama diberikan usia muda (9-26 th)
• Skrining papsmear tetap harus rutin dilaksanakan
• T’ harus lakukan tes HPV sebelum vaksinasi
• Px dgn hasil papsmear CIN dpt diberikan, namun
manajemen terhadap CIN dan follow up tetap harus
dilakukan
• Bukan untuk pengobatan, px dgn genital warts atau
sitologi abnormal tetap harus dapat tx yang sesuai
• Pemberian vaksinasi pada usia >26 th dapat
diberikan.

88. KENDALA
• MALU
• GENGSI
• TAKUT
• MALAS
• TDK SEMPAT
• PILIH2
• MEREMEHKAN
• MENYANGKAL
• TAK PERDULI
• dll
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SINDO
MEI 2009

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JANUARI 2009

91. KOMPAS 27 MEI 2009
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ICENBERG
PHENOMENA

93. GEJALA YANG SERING
TAK DISADARI WOMEN’S HEALTH (2007)
• KELUARNYA
KOTORAN YANG
TAK BIASA.
• KUTIL.
• ADANYA NYERI
DAN ATAU
PERDARAHAN
PERVAGINAM.
• ANEMIA
• MASALAH
BERKEMIH
• NYERI TERUS
MENERUS PADA
KAKI, PINGGUL
DAN PINGGANG
• BERAT BADAN
YANG TURUN
DRASTIS
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94. 30/10/2016 KIA RSMC 96
AMERICAN CANCER SOCIETY
• HEALTHY STYLE (VEGETARIAN)
• MENGURANGI ASUPAN TINGGI LEMAK
JENUH (HEWANI) PERBANYAK MAKANAN
BERSUMBER DARI LAUT.
• RUTIN LAKUKAN GIAT FISIK (EXERCISE)
• HINDARI ALKOHOL, TEMBAKAU DAN
KARSINOGENIK

95. TERIMA KASIH

96. KASUS 1
www.cegahkankerserviks.org
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97. www.cegahkankerserviks.org
KASUS 1
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98. www.cegahkankerserviks.org
KASUS 1
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99. www.cegahkankerserviks.org
KASUS 1
30/10/2016 101KIA RSMC

100. Selama kehamilan sistem imunitas
tersupresi lebih suseptibel
Benjolan cepat membesar
Tumor, soliter, batas tegas, spt bunga kol,
sewarna kulit, 14 x 8 x 5 cm
• Courtesy of : dr. I Gusti Ayu Agung Elis Indira,
Sp.KK
RS Sanglah, Bali
KASUS 2

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KASUS 3

102. Papilloma
1. University of Maryland Medicine. Available at: http://www.marylandthoracic.com. Accessed March 29, 2006.
Reprinted with permission of the University of
Maryland Medical Center (www.umm.edu)1
Vocal
cords
Papillomas
Airway
Photos courtesy of Craig S. Derkay, MD
Eastern Virginia Medical School
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KASUS 4

103. KASUS 5
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ASCUS : Atypical Squamous Cell of
Undetermined Significance

104. 80+%
~40%
~100%
60-90%
~100%
Percentages represent cases attributable to HPV infection
1.Braaten KP et al. Rev Obstet Gynecol. 2008;1:2–10.
2.Hoots BE et al. Int J Cancer. 2009;124:2375–2383.
3.IARC. IARC monographs on the evaluation of carcinogenic risks to humans. Human papillomaviruses. Vol 90. Lyon, France: IARC, 2007.
Human Papilloma Virus Penyebab Berbagai Macam
Kanker
Kanker
Serviks1,3
Kanker
Vulva1
Kanker
Vagina1
Kanker
Anal1-3
Kutil
Kelamin1,3
12-70%
Kanker
Orofaring3
45%
Kanker
Penis3
Harald zur Hausen
2008 Nobel Prize Winner:
HPV role in cervical cancer
Tipe kanker High risk
group-6,18,31,33,45,52,58
Tipe non-kanker
grup low risk –
6,11.
40 tipe menyerang
Kelamin dan Anus

105. New Alternative Schedule : Two Dose of
HPV Quadrivalent Vaccine for 9-13 years old
girls
In individuals 9 through 13 years
of age, HPV Quadrivalent can be
administered according to a 2-
dose (0, 6 months) schedule.
Flexible Schedule : Within one
year period
The need for a booster dose has
not been established.
BPOM approved March 2015

106. HPV Quadrivalent is
indicated in boys and men
9 through 26 years of age
for the prevention of external
genital lesions including
genital warts (condyloma
acuminata), anal
intraepithelial neoplasia (AIN
1/2/3), and infection caused
by HPV types 6, 11, 16, and
18.
HPV Quadrivalent Vaccination for
Boys
BPOM Approved Nov 2013

107. ADA
PERTANYAAN ?
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108. TERIMA KASIH

109. TERIMA KASIH