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ABSTRAK
Latar Belakang: NAC neoadjuvant chemotherapy secara umum telah digunakan di LABC locally advanced breast cancer untuk mengurangi ukuran tumor dan membuat tumor tersebut bisa untuk dioperasi. Meskipun ukuran tumor telah berkurang, masih diperdebatkan batas pembedahan pasca NAC untuk LABC dengan karsinoma mastitis, ulkus payudara, dan fitur agresif lainnya bebas dari tumor karena kemoterapi tidak bisa membunuh 100 dari sel-sel tumor.Metode: Desain penelitian adalah studi potong lintang. Sampel diambil dari semua pasien dengan LABC yang datang ke klinik onkologi rawat jalan dari RS Cipto Mangunkusumo dan ditato untuk batas pembedahan berdasarkan ukuran tumor sebelum NAC. Penelitian ini dilakukan untuk menentukan batas pembedahan yang benar di LABC setelah NAC.Hasil: Dari total 85 pasien, 42 pasien termasuk dalam studi dan 30 pasien masih menjalani pemberian NAC. Umur pasien berkisar antara 27-70 tahun dengan frekuensi tertinggi adalah 40-50 tahun 47,6 . Frekuensi kasus tersering adalah pasien dengan stadium IIIB 92,9 , grade 2 66,7 , histopalogi karsinoma duktal invasif 92,8 hasil IHK imunohistokimia over-ekspresi HER2 42,8 , volume tumor sebelum NAC > 100cc 85,8 dan volume tumor setelah NAC 50-100cc 57,2 . Regimen kemoterapi yang banyak digunakan CAF 76,1 dengan respon parsial 95,2 .Kesimpulan: Batas sayatan kulit berdasarkan ukuran tumor pasca NAC dapat menjadi acuan untuk operasi, namun pada dasar sayatan operasi masih perlu dilakukan frozen section untuk memastikan bebas tumor atau tidak. Seorang ahli bedah juga harus lebih berhati-hati dalam menentukan batas sayatan operasi pada kasus mastitis karsinomatosis, ulkus payudara yang besar dan tumor yang terletak di medial payudara dimana pada kondisi ini batas sayatan operasi dapat beresiko tidak bebas tumor.

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ABSTRACT
Introduction There is limited evidence regarding the effectivness of neoadjuvant chemotherapy NAC to improve surgical margins for locally advanced breast cancer LABC patients. In this study, NAC was used to reduce tumor size to improve operability and reduce surgical margins, with confirmation of tumor free areas provided by post operative histopathology. The reduction of surgical margins has the potential to reduce the need for extensive surgery and the risk of complications in LABC patients.Method The study participants were patients diagnosed with LABC in Ciptomangunkusumo Hospital Jakarta and Awal Bros Bekasi Hospital Bekasi between 2014 and 2015. Patients underwent NAC, and those with partial or complete response were sent for surgery. Tumor excision was done according to the pre NAC surgical margin, which was marked by tattoo. Histopathology then checked for tumor cells in the surgical margins based on breast tumor size of pre and post NAC. Data was analyzed with SPSS version 20 with numerous statistical tests. Cross tabulation analyses were done to examine the characteristics of the study participants. McNemar test was used to determine and compare the pre and post NAC surgical margins.Results Out of 42 patients, 38 were observed to have tumor free surgical margins in both pre and post NAC. Of the remaining four patients, three patients had tumor cells in both surgical margins, and one patient had a tumor free pre NAC but positive tumor cells post NAC. McNemar analysis suggests no significant difference p 1,000 in the two surgical margins evaluated. Based on Wilson score analysis, agreement of negative result of surgical margin in pre NAC compare to post NAC is 97.3 CI 86,18 99.52 . Mean while, agreement of positive tumor cell in pre NAC to post NAC surgical margin is 100 CI 90.36 100 .Conclusion Surgical margins in the skin based on the post NAC tumor size can be used as a guide for surgery, but not in the tumor base. If the surgical margin of tumor base is ambiguos, frozen section can be performed to confirm tumor free in the tumor base. This will reduce the risk of residual tumor cells in surgical margins.

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RINGKASAN EKSEKUTIF
Ruang Lingkup dan Cara Penelitian: Pengobatan kanker payudara sudah banyak diupayakan, melalui tindakan bedah, radioterapi, kemoterapi dan terapi hormonal, namun hasilnya kurang memuaskan. Yang sangat didambakan dan ideal ialah cara pencegahan timbulnya kanker atau setidaknya upaya menekan perkembangan kanker. Beberapa jenis bahan makanan telah dilap orkan mempuny ai kh asiat mencegah timbulnya keganasan . Vitamin A alami maupun sintetik dilaporkan dapat mempengaruhi pertumbuhan sel, sehingga \litamin A dosis tinggi diperkirakan dapat mencegah atau menghambat pertumbunan tumor.

Dilakukan penelitian eksperimental untuk menilai daya hambat retinil asetat terhadap pertumbuhan tumor transplantabel kele njar susu mencit. Tiga kelompok mencit ja tan strain GR, umur ± 2 bulan dan berat badan 18 - 23 g, masing-masing 12 ekor, diinokulasi secara subkutan dengan 0,2 ml suspensi tumor kelenjar susu yang diperoleh dari mencit GR donor. Tiga jam kemudian kelompok perlakuan RA dicekok dengan sonde lambung 0,2 ml larutan retinil asetat 1500 IU, dan dila njutkan se tiap li ari selama 14 h a ri. Kelompok kontro l KP mempero leh 0,2 ml akuades sebagai ganti retinil asetat, sedangkan kelompok K tidak dibeliikan apa-apa. Daerah inokulasi diraba setiap hari untuk mengetahui pertumbuhan tumor. Volume tumor dan berat badan mencit diukur setiap 3 haui, dan pada hari ke-15 semua mencit dimatikan dengan cara dislokasi servikal. Tumor diangkat dan diukur volumenya, lalu dibuat sediaan mikroskopik dengan pewarnaan HE.

Hasil dan Kesimpulan: Volume tumor pada mencit kelomQok RA ternyata Jebih kecil daripada elompok KP dan K (p < 0,01). Tumor pada kedua kelompok kontrol maupun perlakuan RA menunjukkan gambaran adenokarsinoma, namun indeks mitosis pada kelompok RA lebih kecil daripada kedua kelompok kontrol. Dengan demikian dapat disimpulkan bahwa pemberian retinil asetat 1500 IU setiap hari selama 14 hari dengan dicekokkan dapat menghambat pertumbuhan tumor transplantabel kelenjar susu mencit GR.

Scope and Method of Study: Breast cancer has been treated by various means of surgery, radiotherapy, chemotherapy and hormonal therapy, however, the outcome are still unsatisfactory. The ideal approach should be through prevention, or at least the development and progress of cancer inhibited. Different kinds of foodstuffs have been reported to be useful in the protection against malignancy. Vitamin A, either natural or synthetic, has been reported to affect cell growth, and a high dose was considered to be protective and inhibit tumor growth.

An experiment was carried out on male GR mice, approximately 2 months old and weighing 18 - 23 g, to evaluate the inhibitory action of retinyl acetate on the growth of transplantable mammary tumor. Thirty six mice were divided into 3 groups of 12. They were all inoculated subcutaneously with a porridge of tumor cells (0.2 ml) prepared from a donor mouse. Three hours following inoculation, each of the treatment group (RA) was given through a gastric tube 1500 IU of retinyl acetate in 0.2 ml of distilled water, and the treatment continued daily for 14 days. The control group KP received daily 0.2 ml of distilled water, and group K was without any treatment. The mice were observed daily for tumor growth, and tumor volume and body weight were measured every three days starting from day 3. At the end of the experiment (day 15), the mice were sacrificed by cervical dislocation. The tumor was excised from each mouse and the volume measured, and further processed for microscopic examination by HE stain.

Findings and Conclusions: The volume of the tumor of the mice receiving retinyl acetate was significantly smaller than those of the control groups K and KP (p < 0.01). Tumors from the treatment group as well as both control groups showed the characteristics of adenocarcinoma, but the mitotic index was significantly smaller in the treatment group. It is concluded that treatment with retinyl acetate, 1500 IU daily for 14 days, could inhibit the growth of transplantable mammary tumor in GR mice.

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Beberapa bukti menunjukkan perubahan metabolik pada pasien kanker payudara dengan indeks massa tubuh (IMT) tinggi berhubungan resistensi insulin dan khususnya perubahan terkait produksi sitokin oleh jaringan adiposa yang merupakan kontributor utama terhadap sifat agresif dari kanker payudara yang berkembang melalui pengaruhnya terhadap angiogenesis dan stimulasi kemampuan invasif dari sel kanker. Studi kohort retrospektif yang dilakukan di Rumah Sakit Kanker Dharmais ini bertujuan untuk mengetahui pengaruh IMT terhadap disease-free survival (DFS) lima tahun pasien kanker payudara. Penelitian ini dilakukan dari bulan Agustus sampai November 2014. Sampel yang digunakan pada studi ini diambil secara konsekutif sebanyak 127 pasien. Dari studi ini, diketahui bahwa DFS lima tahun pasien kanker payudara adalah 70,0%. Berdasarkan kategori IMT, pasien kanker payudara dengan IMT tinggi (>22,9 kg/m2) memiliki DFS lima tahun yang paling besar, yaitu 75,5% , diikuti pasien dengan IMT rendah (<18,5 kg/m2) sebesar 68,6%, dan 60,4% untuk pasien dengan IMT normal (18,5?22,9 kg/m2). Hasil analisis multivariat menunjukkan bahwa IMT tidak memiliki asosiasi dengan kejadian kekambuhan atau metastase (HR=1,052, 95% CI 0,413-2,678) setelah dikontrol oleh variabel pendidikan, sosioekonomi, stadium, keterlibatan kelenjar getah bening, histopatologi, pekerjaan, dan subtipe biologis.

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ABSTRACT
There are some evidences that the metabolic changes in breast cancer patients with high body mass index (BMI) associated with insulin resistance and, in particular, the related alteration in cytokine production by adipose tissue which are major contributors to the aggressive behavior of breast cancer that develop through their effects in angiogenesis and stimulation of invasive capasity of cancer cells. Retrospective cohort study conducted at the Dharmais National Cancer Hospital aims to determine the effect of BMI on five-year disease-free survival (DFS) breast cancer patients. This study was conducted from August to November 2014. The samples in this study were collected consecutively as many as 127 patients. From this study, it is known that the five-year DFS of breast cancer patients was 70.0%. Based on the category of BMI, breast cancer patients with high BMI (>22.9 kg/m2) had the biggest DFS, followed by low BMI (<18,5 kg/m2) and normal BMI (18,5 ? 22,9 kg/m2) that the precentages successively were 75.5%, 68.6%, and 60.4%. Multivariate analysis showed that BMI was not associated with the events of recurrence or metastases (HR 1.055; 95% CI 0.413-2.678) after being controlled by other variables, such as education, sosioeconomic, staging, lymph node involvement, histopathology, occupation, and biological subtypes.;There are some evidences that the metabolic changes in breast cancer patients with high body mass index (BMI) associated with insulin resistance and, in particular, the related alteration in cytokine production by adipose tissue which are major contributors to the aggressive behavior of breast cancer that develop through their effects in angiogenesis and stimulation of invasive capasity of cancer cells. Retrospective cohort study conducted at the Dharmais National Cancer Hospital aims to determine the effect of BMI on five-year disease-free survival (DFS) breast cancer patients. This study was conducted from August to November 2014. The samples in this study were collected consecutively as many as 127 patients. From this study, it is known that the five-year DFS of breast cancer patients was 70.0%. Based on the category of BMI, breast cancer patients with high BMI (>22.9 kg/m2) had the biggest DFS, followed by low BMI (<18,5 kg/m2) and normal BMI (18,5 ? 22,9 kg/m2) that the precentages successively were 75.5%, 68.6%, and 60.4%. Multivariate analysis showed that BMI was not associated with the events of recurrence or metastases (HR 1.055; 95% CI 0.413-2.678) after being controlled by other variables, such as education, sosioeconomic, staging, lymph node involvement, histopathology, occupation, and biological subtypes., There are some evidences that the metabolic changes in breast cancer patients with high body mass index (BMI) associated with insulin resistance and, in particular, the related alteration in cytokine production by adipose tissue which are major contributors to the aggressive behavior of breast cancer that develop through their effects in angiogenesis and stimulation of invasive capasity of cancer cells. Retrospective cohort study conducted at the Dharmais National Cancer Hospital aims to determine the effect of BMI on five-year disease-free survival (DFS) breast cancer patients. This study was conducted from August to November 2014. The samples in this study were collected consecutively as many as 127 patients. From this study, it is known that the five-year DFS of breast cancer patients was 70.0%. Based on the category of BMI, breast cancer patients with high BMI (>22.9 kg/m2) had the biggest DFS, followed by low BMI (<18,5 kg/m2) and normal BMI (18,5 – 22,9 kg/m2) that the precentages successively were 75.5%, 68.6%, and 60.4%. Multivariate analysis showed that BMI was not associated with the events of recurrence or metastases (HR 1.055; 95% CI 0.413-2.678) after being controlled by other variables, such as education, sosioeconomic, staging, lymph node involvement, histopathology, occupation, and biological subtypes.]

Abstrak :
Latar belakang. Neutrophil-lymphocyte ratio (NLR) dan platelet-lymphocyte ratio (PLR) merupakan pemeriksaan indikator inflamasi yang sederhana, yaitu hanya membutuhkan pemeriksaan darah perifer lengkap dengan menghitung jenis leukosit absolut. Beberapa studi telah menunjukkan bahwa peningkatan NLR dan PLR berasosiasi dengan keluaran yang lebih buruk pada subjek dengan kanker payudara. Sampai saat ini, studi yang meneliti peran NLR dan PLR sebagai penanda biologis keganasan dan indikator penilaian risiko terhadap kanker payudara masih sangat sedikit, sehingga bukti ilmiah yang ada belum konklusif. Tujuan dari penelitian ini adalah untuk menganalisis hubungan antara NLR dan PLR terhadap risiko kanker payudara di Rumah Sakit dr. Cipto Mangunkusumo. Metode. Studi potong lintang dilakukan di RSCM dengan melibatkan perempuan dewasa dengan atau tanpa diagnosis kanker payudara yang belum pernah menerima kemoterapi, terapi radiasi, dan pembedahan. Usia, stadium kanker payudara, subtipe molekuler kanker payudara, indeks massa tubuh (IMT), komorbiditas, NLR, dan PLR merupakan variabel yang diteliti terhadap kejadian kanker payudara. Hasil. Pada penelitian ini, didapatkan sebanyak 65 subjek dengan kanker payudara dan 70 subjek tanpa kanker payudara. Hasil menunjukkan bahwa terdapat hubungan bermakna antara NLR tinggi dengan risiko kejadian kanker payudara dengan OR(IK95%) = 5,47 (2,39-12,52) dan p <0,001. Selain itu, didapatkan hubungan bermakna antara PLR tinggi dengan peningkatan risiko kejadian kanker payudara dengan OR(IK95%) = 4,67 (2,18-10) dan p <0,001. Dari uji multivariat didapatkan NLR dan PLR merupakan faktor-faktor yang berhubungan bermakna secara statistik (p = 0,001) dengan terjadinya kanker payudara dibandingkan dengan faktor-faktor lain. Kesimpulan. Terdapat asosiasi antara NLR dan PLR tinggi dengan peningkatan risiko kanker payudara. ......Background. The neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are simple inflammatory indicator tests, which only require a complete peripheral blood count by calculating the absolute leukocyte type. Several studies have shown that increased NLR and PLR are associated with poorer outcomes in subjects with breast cancer. To date, there have been very few studies examining the role of NLR and PLR as biological markers of malignancy and risk assessment indicators for breast cancer, so that the scientific evidence is not conclusive. The purpose of this study was to analyze the relationship between NLR and PLR on the risk of breast cancer at dr. Cipto Mangunkusumo. Methods. A cross-sectional study was conducted at RSCM involving adult women with or without a diagnosis of breast cancer who had never received any chemotherapy, radiation therapy, and surgery. Age, stage of breast cancer, molecular subtype of breast cancer, body mass index (BMI), comorbidities, NLR, and PLR are the variables studied on the incidence of breast cancer. Results. In this study, there were 65 subjects with breast cancer and 70 subjects without breast cancer. The results showed that there was a significant association between high NLR and the increased risk of breast cancer with OR(95% CI) = 5.47 (2.39-12.52) and p <0.001. In addition, a significant association was found between high PLR and an increased risk of breast cancer with OR (95% CI) = 4.67 (2.18-10) and p <0.001. From the multivariate test, it was found that only increased NLR and increased PLR were independent factors that were statistically significant (p = 0.001) related to the occurrence of breast cancer compared to other factors. Conclusion. High NLR and PLR are associated with an increased risk of breast cancer