PROMKES RSMC

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

2. 30/10/2016 KIA RSMC 2
• 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

3. PERDARAHAN
PERVAGINAM
30/10/2016 KIA RSMC 3

4. 30/10/2016 KIA RSMC 4
PERDARAHAN PERVAGINAM

5. 30/10/2016 KIA RSMC 5
PERDARAHAN PERVAGINAM

6. 30/10/2016 KIA RSMC 6

7. RS DARMAIS 2007
30/10/2016 KIA RSMC 7

8. RSAL MTH
(2001-2010)
30 Oktober 2016 RSAL dr MINTOHARDJO 8

9. REKAPITULASI
HASIL PA
(2001-2010)

10. }
REKAPITULASI
HASIL PA
(2001-2010)

11. 30 Oktober 2016 RSAL dr MINTOHARDJO 11
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)

12. 30/10/2016 KIA RSMC 12
BLOOD LOSS

13. 30/10/2016 KIA RSMC 13

14. 30/10/2016 KIA RSMC 14

15. Sebanyak 58 kasus baru kanker
serviks terjadi setiap harinya.1
26 wanita Indonesia meninggal
setiap hari karena kanker serviks1
15
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 17

19. NORMAL CERVIX
30/10/2016 19KIA RSMC

20. 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.
30/10/2016 20KIA RSMC

21. 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

22. 30/10/2016 KIA RSMC 22
Sambungan Skuamo Kolumner
(SSK)
30 Oktober 2016 22RSAL dr MINTOHARDJO

23. 23
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

24. 30/10/2016 24KIA RSMC

25. 30/10/2016 25KIA RSMC

28. 30/10/2016 28KIA RSMC

29. 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 29RSAL dr MINTOHARDJO
30/10/2016 KIA RSMC 29

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

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

32. HPV:
A sophisticated immune invasion 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

33. HPV Life Cycle
The Journal of Clinical Investigation, Volume 116 Number 5 May 2006
30/10/2016 33KIA RSMC

34. 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

35. 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
30/10/2016 35KIA RSMC

36. 30/10/2016 36KIA RSMC

37. 30/10/2016 37KIA RSMC

38. DETEKSI
30/10/2016 KIA RSMC 38
• Pap smear
• Colposcopy
• HPV DNA
typing
• Punch biopsy
• Conization(LEEP)
• Endocervical
curettage

39. 30/10/2016 KIA RSMC 39

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

48. 48
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

49. 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
49
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

50. PENATALAKSANAAN
30/10/2016 KIA RSMC 50
#Observation #Laser vaporization
#Local excision #Cold coagulation
#Electrocautery #Conization
#Cryosurgery #Hysterectomy
#LEEP(Loop Electrosurgical Excision procedure)

51. 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%
30/10/2016 51KIA RSMC
(CIN : CERVICAL INTRA EPITHELIAL LESION)

52. TREATMENT OPTIONS

55. Vaccines

56. 30/10/2016 KIA RSMC 56
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.

57. 30/10/2016 KIA RSMC 57

58. KANKER LEHER RAHIM
• The most female cancer in Indonesia
• > 60 – 70 % advanced stage
• No routine program for mass screening
30/10/2016 KIA RSMC 58

59. 30/10/2016 59KIA RSMC

60. 30/10/2016 60KIA RSMC

61. 30/10/2016 61KIA RSMC

63. Faktor risiko
Kanker Leher
Rahim
PENURUNAN
KEKEBALAN
TUBUH
MEROKOK
PASANGAN > 1
SEKS PERTAMA < 18 TAHUN
RWYT CACX IBU &
SAUDARA WANITA
30/10/2016 63KIA RSMC
Riwayat papsmear (+)
SEKS ABNORMAL
Penyakit STD

64. 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

66. 30/10/2016 66KIA RSMC
30/10/2016 Arie Widiyasa 66

68. 30/10/2016 68KIA RSMC

69. 69ARIE WIDIYASA30-Oct-16

70. 70ARIE WIDIYASA30-Oct-16

71. 71ARIE WIDIYASA30-Oct-16

72. 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

74. VAKSINASI ?
30/10/2016 74KIA RSMC
GARDASIL

75. KENDALA
• MALU
• GENGSI
• TAKUT
• MALAS
• TDK SEMPAT
• PILIH2
• MEREMEHKAN
• MENYANGKAL
• TAK PERDULI
• dll
30/10/2016 KIA RSMC 75

76. TAKE HOME MESSAGE

77. 30/10/2016 KIA RSMC 77
ICENBERG
PHENOMENA

78. 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
30/10/2016 KIA RSMC 78

79. TERIMA KASIH

80. ADA
PERTANYAAN ?
30/10/2016 KIA RSMC 80

81. KASUS 1
www.cegahkankerserviks.org
30/10/2016 81KIA RSMC

82. www.cegahkankerserviks.org
KASUS 1
30/10/2016 82KIA RSMC

83. www.cegahkankerserviks.org
KASUS 1
30/10/2016 83KIA RSMC

84. www.cegahkankerserviks.org
KASUS 1
30/10/2016 84KIA RSMC

85. 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

86. 30/10/2016 KIA RSMC 86
KASUS 3

87. 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
30/10/2016 87KIA RSMC
KASUS 4

88. KASUS 5
30/10/2016 KIA RSMC 88
ASCUS : Atypical Squamous Cell of
Undetermined Significance

89. 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.
HPV Pada 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

90. New Alternative Schedule
In individuals 9 - 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

91. HPV Quadrivalent is indicated in boys
and men 9 - 26 yo 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 Vaccination for Boys
BPOM Approved Nov 2013

92. TERIMA KASIH