Presentation on theme: "Breast cancer in pregnancy sadaf alipour assistant professor general surgeon tehran university of medical sciences."— Presentation transcript:
1breast cancer in pregnancy sadaf alipour assistant professor general surgeon tehran university of medical sciences
2INTRODUCTION Gestational or pregnancy-associated breast cancer is defined as breast cancer that is diagnosed during pregnancy, in the first postpartum year, or any time during lactation.
3a challenging clinical situation Welfare of both mother and fetus must be taken into account in any treatment planningProspective studies are very fewMuch of the clinical evidence is limited to retrospective case series and case reports.
4incidenceOne of the most common cancers in nonpregnant and pregnant womenUp to %20 of BCs under 30 are Py-associatedFewer than %5 of BCs diagnosed under 50 are detected during Py or in postpartum
5A relatively uncommon event. Incidence: 15-35 per 100,000 deliveries epidemiologyA relatively uncommon event.Incidence: per 100,000 deliveriesFewer cases during Py than in first postpartum yearIncidence appears to be increasing as more women delay childbearing
6PathologyMajority : infiltrating ductal carcinomas, as in nonpregnantsBut predominantly poorly differentiated and advanced stage, esp. those in lactationMay higher incidence of inflammatory breast cancer than nonpregnantsMost series report lower frequency of ER and PR compared to nonpregnants(% 25 versus %55- 60)
7presentationUsually present similarly to nonpregnantsMass or thickening in the breastRarely, a nursing infant has refused a breast that harbors an occult carcinoma, leading to an early diagnosis of breast cancer; this has been named the milk rejection sign
8Diagnosis (1)Physiologic changes in the breast in pregnancy (eg, engorgement and hypertrophy) make examination more challenging, interpretation of findings more difficult, and limit the utility of mammographyDiagnostic delays of 2m or longer commonSuch delays may adversely impact outcome, since even a one month delay in diagnosis can increase the risk of nodal involvement by 1 to 2 percentIndex of suspicion for cancer must be high in Py with a breast mass
9Diagnosis (2)Index of suspicion for cancer must be high in Py with a breast massA breast mass that persists for more than two weeks should be investigated, although the majority (80 percent) will be benign
10Differential diagnosis A breast mass in a pregnant or lactating woman can be:breast cancer,lactating adenoma,fibroadenoma,cystic disease,lobular hyperplasia,milk retention cyst (galactocele),abscess,lipoma,hamartoma, andrarely, leukemia, lymphoma, phyllodes tumors, sarcoma, neuroma, or tuberculosis
11Not contraindicated in pregnancy Mammography (1)Not contraindicated in pregnancyAverage dose to breasts for a two-view mammogram (200 to 400 millirad) provides a negligible radiation dose to the fetusAbdominal shielding is recommended.
12Sensitivity is altered by changes of pregnant or lactating breasts: Mammography (2)Sensitivity is altered by changes of pregnant or lactating breasts:increased water content,higher densityloss of contrasting fatNevertheless, data suggest that mammography is sufficiently sensitive to diagnose breast cancer during pregnancy and lactation
13ultrasonographyOften the first imaging test ordered to evaluate a breast mass in a pregnant womanDetermines simple or complex cysts or solid tumors without risk of fetal radiation exposureA focal solid mass is observed in majority of gestational BCs
14MRI (1) Not systematically studied for gestational breast masses No harmful effects from MRI during pregnancy have been reportedBut the National Radiological Protection Board avoids it in T1 if possible since limited experience during organogenesisHowever, MRI considered in T1 when benefits exceed risks
15Mri (2)Gadolinium-enhanced MRI more sensitive than mammography for detecting invasive breast cancer, esp. with dense breastsBut gadolinium avoided in pregnancy due to potentially long half-life in fetus and lack of safety information.Gadolinium-enhanced breast MRI may be considered in postpartum
16Biopsy A clinically suspicious breast mass requires biopsy for definitive diagnosis, regardless of whether or not a woman is pregnant, and despite negative mammographic or ultrasound findings.Core, incisional, or excisionalBx relatively safe during Py, preferably under LA
17Lymph nodesDebate over safety and efficacy of sentinel lymph node biopsy in Py-associated BCAreas at risk for and/or clinically suspicious for LAP should be further evaluated with US and FNA
18Systemic staging Tendency to Dx at advanced stage As in nonpregnants, locally advanced stage BC [stage III or IV ] and/or suspicious symptoms should prompt complete stagingIn contrast, if asymptomatic and clinically node-negative and early stage, no need for evaluation of lung, liver, bone, or brain metastases
19lung metastases For lung metastases: CXR with abdominal shielding Estimated dose to the fetus :0.06 millirad.Ability to evaluate lower lung parenchyma with CXR limited late in gestation when gravid uterus pressing against diaphragm.CTscan generally avoided in Py because of the large cumulative radiation dose with multiple slicesIf further evaluation of chest warranted:MRI preferred but gadolinium avoided
20 liver metastasesUS safe for evaluation in Py but significantly less sensitive than CT or MRICT of abdomen or pelvis not performed in PyMRI preferred if further visceral organ evaluation requiredNational Radiological Protection Board advises MRI be avoided in T1 if possible
21If suspected: MRI the safest and most sensitive way Brain metastasesIf suspected: MRI the safest and most sensitive wayInformation regarding safety and efficacy of PET in Py limited
22Bone evaluation: Radionuclide bone scan Safe in Py.A "low-dose" bone scan described that exposes fetus to 0.08 rad as compared to the standard 0.19 rad for a conventional bone scanFetal exposure may also result from proximity to radionuclides excreted in bladder:Maternal hydration and frequent voiding can reduce this exposure.Not recommended in absence of signs or symptoms of bone abnormality.
23Bone evaluation:skeletal MRI May be considered as alternative to bone scan, (without contrast until further safety data are available).Since breast metastases are deposited in red marrow, imaging of axial skeleton (spine, pelvis, ribs and sternum) include approximately %80 of all metastatic sitesAlternatively, screening MRI of thoracic and lumbar spine may be considered if no complaints of extraspinal bony metastasesThe safety of plain skeletal radiographs is unclear. Although these films result in less than 1 rad exposure to the fetus and have been obtained during pregnancy by obstetricians for pelvimetry measurements and to evaluate for renal stones, even low levels of ionizing radiation may increase the risk of childhood leukemia
24Bone evaluation: Alkaline phosphatase Increases markedly during Py due to placental productionCannot be used as indicator of bone metastasesEven bone specific ALP is not a reliable measure of bone disease.
25monitoring of pregnancy The pregnant woman with BC requires careful and continuous monitoring of her Py by her obstetricianConfirmation of gestational age and EDC importantAniocentesis may be required to determine pulmonary maturity if early delivery is being considered.
28note:Early termination of Py does not improve survival of gestational BC and some series suggest a decreased survival associated with early termination of PyIndications of local and systemic adjuvant therapy are similar to non- pregnantsHerceptin and endocrine therapy are not safe during any trimester of Py. When these therapies are administered post- partum, breast feeding should be avoided
29SUMMARY AND RECOMMENDATIONS Gestational or Py-associated BC is a BC diagnosed in Py, 1st postpartum year, or any time during lactationA relatively uncommon event although one of the most common cancers in PyIncidence increasing as more women delay PyPredominantly poorly differentiated and advancedIndex of suspicion for cancer must be high in Py with a breast massBreast US and mammo in any suspicious massClinical suspicion requires Bx for definitive Dx
30references 1- Schwartz Principles of Surgery (book) 2- Diseases of the Breast (book)3-UptoDate (online)