Gestational or pregnancy-associated breast cancer - PowerPoint Presentation

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Gestational or pregnancy-associated breast cancer

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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.

Up to 20 percent of breast cancers in women under age 30 are pregnancy associated

Slide3

The patient was a

32

year

old

female

past

medical history who presented to breast

clinic due to breast lump.

At time of presentation patient was in the 3rd trimester of her 4th pregnancy (G4P3). She first noticed the palpable mass 1 month prior.

Patient

had ultrasound evaluation of both breasts prior to clinic visit in

which

showed 2.8 x 1.8 x 2.7 cm irregular mass at the 8 o’ clock position 7 to 8 cm from the nipple of the right breast

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Exam was positive for a palpable mass in the right breast located in the lower outer quadrant measuring 2.5 cm.

The

mass was mobile and well circumscribed. No skin changes or nipple discharge were noted.

The

right

axilla

was without

lymphadenopathy

.

Exam was also positive for a gravid abdomen consistent with gestational age for her 3rd trimester

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Primary tumor

 The

physiologic changes in the breast

that accompany pregnancy (

eg

, engorgement and hypertrophy) make

physical examination

more challenging, interpretation of findings more difficult, and may limit the utility of mammography

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Mammography

 Mammography is

not contraindicated

in pregnancy as the average glandular dose to the breast for a two-view mammogram (200 to 400

millirad

) provides a negligible radiation dose to the fetus as long as abdominal

shielding

is used

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Ultrasonography

 Breast

ultrasonography

can determine whether a breast mass is a simple or complex

cyst or a solid

tumor without the risk of fetal radiation exposure and may be used to guide the diagnostic biopsy.

A

focal solid mass

is observed in the majority of cases of gestational breast cancer

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Breast MRI

Gadolinium-enhanced MRI

appears to be more

sensitive

than mammography for detecting invasive breast cancer, particularly in women with dense breast tissue.

Studies demonstrate potential fetal harm with gadolinium exposure in the first trimester

Gadolinium

should therefore be

avoided

during pregnancy if possible

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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

excisional

biopsies can be performed relatively safely during pregnancy, preferably under local anesthesia

Needle core biopsy

is the preferred method.

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No masses were seen in the left breast. She then underwent ultrasound guided core biopsy of the right breast.

Pathology

showed

invasive

ductal

carcinoma (Grade III, moderate to poorly differentiated) with a malignant

stromal

component consistent with

metaplastic

carcinoma

(

carcinosarcoma

).

Receptors

were ER, PR and Her2 negative.

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PATHOLOGIC FEATURES

The majority of breast cancers in pregnant women are

infiltrating

ductal

adenocarcinomas

as in

nonpregnant

women.

However, pregnancy-associated breast cancers are predominantly

poorly differentiated

and diagnosed at an

advanced stage

, particularly in those diagnosed while lactating

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Hormone receptor expression

 Most series report a

lower frequency of estrogen receptor and progesterone receptor

expression in pregnancy-associated breast cancer compared with breast cancer in

nonpregnant

patients (approximately 25 versus 55 to 60 percent)

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It was decided that the patient should undergo

neoadjuvant

chemotherapy

as soon as possible as she was in the 3rd trimester.

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Staging

Chest computed tomography

(CT) scans are generally avoided during pregnancy

If further evaluation of the chest is warranted, an MRI of the thorax is preferred.

 

Abdominal ultrasound

for the evaluation of liver metastases is a safe procedure in pregnant women but is significantly less sensitive than CT or MRI

MRI without contrast

is preferred if further visceral organ evaluation is required

Bone evaluation

 — Radionuclide bone scans are reported to be safe during pregnancy

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MONITORING OF THE PREGNANCY

The pregnant woman with breast cancer requires careful and continuous monitoring of her pregnancy by her obstetrician (often a specialist in maternal and fetal medicine) and her oncologist.

Confirmation of gestational age and expected date of delivery are important as both are significant factors in treatment planning.

Amniocentesis may be required to determine pulmonary maturity if early delivery is being considered

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Systemic therapy 

 The data suggest it is safe to administer many agents used in the treatment of breast cancer during pregnancy when initiated

after the first trimester

, and that the majority of pregnancies result in live births with low related morbidity in the newborns

The most data available are with

anthracycline

-based chemotherapy

, often on an every-three-week schedule.

Taxanes

appears feasible and safe during the second and third trimesters of pregnancy, with minimal maternal, fetal, or neonatal toxicity

 The use of

trastuzumab

during pregnancy is

contraindicated.

The use of selective estrogen receptor modulators (SERMs) such as

tamoxifen

during pregnancy is generally

avoided

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Timing of chemotherapy

 For pregnant breast cancer patients who need chemotherapy treatment, clinicians should

advise against a delay

in the initiation of systemic chemotherapy once the pregnancy has safely reached the

second or third trimester

Care needs to be taken to avoid exposing the fetus to chemotherapy during the first trimester, and to stop chemotherapy prior to delivery so that the mother and infant are not experiencing treatment-related toxicities in the delivery or postpartum stages

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She then received 4 cycles of

Adriamycin

and

Cytoxan

.

Roughly at the end of the

chemotherapy treatment the patient had a repeat breast ultrasound which showed the mass to be increased in size to 5.1 x 3.7 x 5.1 cm

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Locoregional treatment

 The same local treatment options that are available for

nonpregnant

patients should be considered in pregnant women, with the

exception of radiation therapy (RT)

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Mastectomy

  Mastectomy may be chosen when the patient opts to continue the pregnancy, even for women with clinical anatomic stage I and II disease

An advantage of mastectomy may be the

elimination of the need for breast RT

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Breast-conserving surgery

 The therapeutic equivalence of mastectomy and breast-conserving therapy (breast-conserving surgery [BCS] followed by RT) has been demonstrated in

nonpregnant

women; this is also true for the pregnant patient.

BCS can be used effectively as

RT

can be

delayed

after the administration of adjuvant or

neoadjuvant

chemotherapy.

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Radiation therapy

Radiation should be

delayed

whenever possible until

after delivery.

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Management of the axilla

The use of

sentinel lymph node biopsies

during pregnancy is controversial, with case series demonstrating increasing evidence of safety and efficacy in pregnant patients

Therefore,

axillary

lymph node dissection

should be considered as

standard

approach.

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she

was taken for a right skin sparing mastectomy with right

axillary

sentinel lymph node biopsy

and

placement of tissue expander.

Of

the 3 sentinel lymph nodes taken all were negative

.

Final pathology of the mass showed

metaplastic

carcinoma (

carcinosarcoma

).

The

epithelial component was invasive

ductal

carcinoma grade III/III (Mitotic rate 3, Nuclear

pleomorphism

3, Glandular/Tubular differentiation 2,

Histologic

grade 3) and the

mesenchymal

component was poorly differentiated sarcoma.

The

mass was 6.2 cm at the widest diameter with necrosis and areas of infarct present. Final tumor stage was pT3N0Mx, Stage IIB, ER (+) (<5%), PR (-), Her2 (-).

Patient

had genetic testing and was found to be BRCA (-).

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Timing of delivery

 Delivery should occur

following

the mother's white blood cell count and platelet count

nadir

to reduce the potential risk of infectious complications and bleeding from thrombocytopenia.

Chemotherapy should be

avoided for three to four weeks

before delivery to avoid transient neonatal

myelosuppression

and potential complications of sepsis and death whenever possible.

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Elective termination of pregnancy 

The decision to continue or terminate the pregnancy should be individualized and made by a fully informed woman in conjunction with her clinician.

Early termination of pregnancy does not improve the outcome of gestational breast cancer

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Maternal health

  Contemporary studies that specifically evaluated the outcomes of women diagnosed with breast cancer

during

pregnancy have consistently shown that there is

no negative impact

on survival

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PREGNANCY AFTER BREAST CANCER

Pregnancy in breast cancer survivors did not significantly impact survival and suggested that pregnancy after breast cancer may have a

protective effect

It is common for clinicians to advise women to wait for at least

two years

before contemplating pregnancy

The primary reason for this recommendation is that most

recurrences

of breast cancer occur within the

first two years

after initial diagnosis and treatment

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Thanks for your patient attention