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Breast Cancer in Pregnancy Steven Stanten MD Rupert Horoupian MD AltaBates Summit Medical Center Oakland, California.

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Presentation on theme: "Breast Cancer in Pregnancy Steven Stanten MD Rupert Horoupian MD AltaBates Summit Medical Center Oakland, California."— Presentation transcript:

1 Breast Cancer in Pregnancy Steven Stanten MD Rupert Horoupian MD AltaBates Summit Medical Center Oakland, California

2 Introduction One of the most commonly diagnosed cancers of pregnancy –More advanced stage –Poorer prognosis Pregnancy-associated –During pregnancy –During lactation –Up to 12 months post-partum

3 Epidemiology 12.67% within their lifetime Mean age % between 20 and 44 Of women with breast cancer before 40, 10% will be pregnant 1/3000 pregnancies

4 Pathology Invasive ductal predominates Larger in size at presentation Higher frequency of lymphovascular invasion Higher nuclear grade Higher hormonal independence Her-2/neu – no concensus

5 Diagnosis Clinical exam –Usually a mass –Broad differential diagnosis –Most are benign Medical Imaging –Mammography usually not helpful Safety and efficacy

6 Diagnosis (con’t) Medical Imaging –Screening - not when pregnant –UTZ –CXR –Other staging modalities

7 Diagnosis (con’t) Cytology and Histology Biopsy recommended if questions persist FNA, core needle biopsy, excisional biopsy -rare milk fistula and infection

8 Treatment Surgery Radiotherapy Chemotherapy Obstetric outcome Endocrine therapy Supporting agents

9 Treatment (con’t) No longer a role for termination of pregnancy Goals are to achieve control of disease and prevent distant metastasis Fetal protective modifications Multi-disciplinary team –Medical oncology, surgical oncology, high-risk obstetrics, genetic counseling, psychological support

10 Treatment (con’t) Surgery –Lumpectomy –Mastectomy –Axillary dissection –Sentinel node biopsy *Breast conservation is the standard of care when appropriate in a non-pregnant patient

11 Treatment (con’t) NSABP trials –B06 - established the safety of breast conserving surgery for early stage breast cancer and demonstrated the importance of adjuvant breast radiation to minimize risk of in-breast recurrence.

12 Treatment (con’t) Surgery –Lumpectomy Anesthesia Wire localization X-ray confirmation Wide margins

13 Treatment (con’t) Surgery –Try to wait until the 12 th week –Breast conservation - i.e.. Lumpectomy –Need to consider need for XRT Don’t give during pregnancy –Consider neo-adjuvant chemotherapy

14 Treatment (con’t) Axillary Surgery – – Veronessi demonstrated that sentinel lymph node biopsy was accurate and reliable. –B32 – sentinel lymph node biopsy is safe and relaible * ~8-10% false negative rate

15 Treatment (con’t) Axillary surgery –Blue dye –Radioisotope –Filtered vs. unfiltered –Injection site –Timing

16 Treatment Axillary Surgery –Increased incidence of nodal involvement –Consider neo-adjuvant treatment –UTZ and FNA –Sentinel node biopsy has problems Isosulfan blue Radiocolloid –Consider axillary dissection

17 Lymphoscintigraphy

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19 Sentinel Lymph Node

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23 Treatment (con’t) Radiation Treatment –Risks are highest during first trimester –Decrease gradually –Try to avoid during pregnancy –Risks may be overstated

24 Treatment (con’t) Chemotherapy –Important role –Advanced disease often –Teratogenic effects –Long term safety profile Preterm delivery Low birth weight Transient leukopenia IUGR

25 Treatment (con’t) Chemotherapy –MD Anderson study –Anthracyclines –methotrexate

26 Treatment (con’t) Endocrine therapy –Contraindicated during pregnancy

27 Treatment (con’t) Other agents –Trastuzumab – unknown –Taxanes - unknown

28 Prognosis Use TNM staging Most women have stage II or III disease Same prognosis stage for stage Delay in diagnosis has impact % - 5 year survival 31-52% - 10 year survival

29 Pregnancy after Treatment Conflicting data 2 years 5 years Ever?

30 Conclusion Due to lack of prospective randomized clinical studies, both ongoing studies and future evidence are expected to solve problems related to breast cancer management during pregnancy. Must balance aggressive maternal care with appropriate modifications that will ensure fetal protection.


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