1. breast cancer in pregnancy sadaf alipour assistant professor general surgeon tehran university of medical sciences

2. INTRODUCTION
 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.

3. a challenging clinical situation
Welfare of both mother and fetus must be taken into account in any treatment planning
Prospective studies are very few
Much of the clinical evidence is limited to retrospective case series and case reports.

4. incidence
One of the most common cancers in nonpregnant and pregnant women
Up to %20 of BCs under 30 are Py-associated
Fewer than %5 of BCs diagnosed under 50 are detected during Py or in postpartum

5. A relatively uncommon event. Incidence: 15-35 per 100,000 deliveries
epidemiology
A relatively uncommon event.
Incidence: per 100,000 deliveries
Fewer cases during Py than in first postpartum year
Incidence appears to be increasing as more women delay childbearing

6. Pathology
Majority : infiltrating ductal carcinomas, as in nonpregnants
But predominantly poorly differentiated and advanced stage, esp. those in lactation
May higher incidence of inflammatory breast cancer than nonpregnants
Most series report lower frequency of ER and PR compared to nonpregnants(% 25 versus %55- 60)

7. presentation
Usually present similarly to nonpregnants
Mass or thickening in the breast
Rarely, 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

8. Diagnosis (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 mammography
Diagnostic delays of 2m or longer common
Such delays may adversely impact outcome, since even a one month delay in diagnosis can increase the risk of nodal involvement by 1 to 2 percent
Index of suspicion for cancer must be high in Py with a breast mass

9. Diagnosis (2)
Index of suspicion for cancer must be high in Py with a breast mass
A breast mass that persists for more than two weeks should be investigated, although the majority (80 percent) will be benign

10. Differential 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, and
rarely, leukemia, lymphoma, phyllodes tumors, sarcoma, neuroma, or tuberculosis

11. Not contraindicated in pregnancy
Mammography (1)
Not contraindicated in pregnancy
Average dose to breasts for a two-view mammogram (200 to 400 millirad) provides a negligible radiation dose to the fetus
Abdominal shielding is recommended.

12. Sensitivity 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 density
loss of contrasting fat
Nevertheless, data suggest that mammography is sufficiently sensitive to diagnose breast cancer during pregnancy and lactation

13. ultrasonography
Often the first imaging test ordered to evaluate a breast mass in a pregnant woman
Determines simple or complex cysts or solid tumors without risk of fetal radiation exposure
A focal solid mass is observed in majority of gestational BCs

14. MRI (1) Not systematically studied for gestational breast masses
No harmful effects from MRI during pregnancy have been reported
But the National Radiological Protection Board avoids it in T1 if possible since limited experience during organogenesis
However, MRI considered in T1 when benefits exceed risks

15. Mri (2)
Gadolinium-enhanced MRI more sensitive than mammography for detecting invasive breast cancer, esp. with dense breasts
But 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

16. Biopsy
 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

17. Lymph nodes
Debate over safety and efficacy of sentinel lymph node biopsy in Py-associated BC
Areas at risk for and/or clinically suspicious for LAP should be further evaluated with US and FNA

18. Systemic 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 staging
In contrast, if asymptomatic and clinically node-negative and early stage, no need for evaluation of lung, liver, bone, or brain metastases

19. lung 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 slices
If further evaluation of chest warranted:MRI preferred but gadolinium avoided

20.  liver metastases
US safe for evaluation in Py but significantly less sensitive than CT or MRI
CT of abdomen or pelvis not performed in Py
MRI preferred if further visceral organ evaluation required
National Radiological Protection Board advises MRI be avoided in T1 if possible

21. If suspected: MRI the safest and most sensitive way
Brain metastases
If suspected: MRI the safest and most sensitive way
Information regarding safety and efficacy of PET in Py limited

22. Bone 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 scan
Fetal 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.

23. Bone 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 sites
Alternatively, screening MRI of thoracic and lumbar spine may be considered if no complaints of extraspinal bony metastases
The 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

24. Bone evaluation: Alkaline phosphatase
Increases markedly during Py due to placental production
Cannot be used as indicator of bone metastases
Even bone specific ALP is not a reliable measure of bone disease.

25. monitoring of pregnancy
The pregnant woman with BC requires careful and continuous monitoring of her Py by her obstetrician
Confirmation of gestational age and EDC important
Aniocentesis may be required to determine pulmonary maturity if early delivery is being considered.

28. note:
Early termination of Py does not improve survival of gestational BC and some series suggest a decreased survival associated with early termination of Py
Indications of local and systemic adjuvant therapy are similar to non- pregnants
Herceptin and endocrine therapy are not safe during any trimester of Py. When these therapies are administered post- partum, breast feeding should be avoided

29. SUMMARY AND RECOMMENDATIONS
Gestational or Py-associated BC is a BC diagnosed in Py, 1st postpartum year, or any time during lactation
A relatively uncommon event although one of the most common cancers in Py
Incidence increasing as more women delay Py
Predominantly poorly differentiated and advanced
Index of suspicion for cancer must be high in Py with a breast mass
Breast US and mammo in any suspicious mass
Clinical suspicion requires Bx for definitive Dx

30. references 1- Schwartz Principles of Surgery (book)
2- Diseases of the Breast (book)
3-UptoDate (online)

31. Thank you