Breast cancer in pregnancy

02/05/2023Okechukwu Ugwu 1

BREAST CANCER IN PREGNANCY

Dr. Okechukwu Ugwu

OUTLINE

Introduction Epidemiology Anatomy Risk factors Histopathology Clinical presentation Differential diagnosis Diagnosis Treatment Special considerations Prognosis Conclusion

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Introduction

Breast cancer is the second most common malignancy in pregnancy (after cervical cancer).

Diagnosis and treatment of breast cancer during pregnancy encompasses many diagnostic and therapeutic dilemmas

Overall survival of pregnant women generally worse than in nonpregnant women

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INTRODUCTION -2

Breast cancer in pregnancy is defined as breast cancer diagnosed during pregnancy, lactation or within twelve months postpartum.

EPIDEMIOLOGY The incidence of BC in pregnancy is estimated to be about 1 in 3000

pregnancies.

10% of BC are diagnosed before the age of 40years.

Average age at diagnosis is 32 to 38 years.

Median gestational age at diagnosis is 17–25 weeks.

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ANATOMY OF THE BREAST Modified sweat gland.

Greater part of gland lies in sup: fascia.

extends vertically from 2nd-6th ribs.

Horizontally from lat: border of sternum to mid axillary line. Overlies P. major, S.anterior and rectus sheath

Parenchyma of breast consist of 15 to 20 lobes Each lobe is made up of 20-40 lobules. 02/05/2023Okechukwu Ugwu 6

ANATOMY-2

A- Lactiferous Ducts B- Lobules C- Lactiferous sinus D-Lactiferous orifice in Nipple E- Fats F- Pectoralis major muscle G- Chest wall/Rib cage-

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ANATOMY -3

VASCULAR SUPPLY LYMPHATIC DRAINAGE

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BREAST CHANGES IN PREGNANCY Pregnancy induces both proliferation and

differentiation of the mammary epithelium. Both lobular and alveolar growth occur. Weight and blood supply Differentiation of the alveoli into mature milk-

producing cells requires the stimulus of cortisol, insulin, and prolactin

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RISK FACTORS Age Family history Proliferative breast disease Environmental factors Obesity/Physical inactivity Previous history of malignancy Smoking BRCA 1 and BRCA 2 mutations Dietary factors

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HISTOPATHOLOGY

Ductal carcinoma 79% Lobular carcinoma 10% Tubular/cribriform carcinoma 6% Mucinous carcinoma 2% Medullary carcinoma 2% Papillary carcinoma 1%

T = Primary TumorTis (T0) = carcinoma in situT1 = less than 2 cm in diameterT2 = between 2 and 5 cm in diameterT3 = more than 5 cm in diameterT4 = any size, but extends to the skin or chest wall

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TNM StagingNodal Involvement Nx - Regional lymph nodes cannot be assessed N0 - No regional lymph node metastasis

N1 - Metastasis to movable ipsilateral axillary lymph node(s)

N2 - N2a - Ipsilateral axillary lymph nodes fixed (matted) - N2b - Ipsilateral internal mammary nodes

N3 - N3a - Ipsilateral infraclavicular lymph node(s) - N3b - Ipsilateral internal mammary and axillary

lymph nodes - N3c - Ipsilateral supraclavicular lymph nodesOkechukwu Ugwu 1302/05/2023

CLINICAL PRESENTATION

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Most common: lump or thickening in breast. Often painless

Change in color or appearance of areola

Redness or pitting of skin over the breast, like the skin of an orange

Discharge or bleeding

Change in size or contours of breast

rg

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DIFFERENTIAL DIAGNOSIS OF A BREAST LUMP IN PREGNANCY

Carcinoma Galactocoele Breast abscess Lactating adenoma Fibroadenoma Fibrocystic disease Lobular hyperplasia

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DIAGNOSIS

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Diagnosis should be made by combination of1:clinical assessments2:radiological imaging3:cytological or thru histological analysis

DIAGNOSIS-2 ULTRASOUND For evaluation of palpable breast mass during pregnancy Distinguishes solid from cystic masses No radiation exposure to the fetus Also used in ultrasound guided biopsy

MAMMOGRAPHY With abdominal shield can be done in all trimesters Increase water content in the breast may decrease sensitivity- 70%

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DIAGNOSIS-3

Malignant masses have a more spiculated appearance

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malignant

benign

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DIAGNOSIS-4

BIOPSY Gold standard in diagnosis- sensitivity of about 90% Core needle vs FNAC.

OTHER INVESTIGATIONS

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TREATMENTDepends on:

Stage of the disease

Hormone receptor status

Her2 receptor status

Gestational Age

Patient preference

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TREATMENT-2 Surgical

Chemotherapy

Radiotherapy

Supportive therapy

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TREATMENT-3 Protocol of treatment should be as close as possible to non-pregnant

state. Multidisciplinary approach is essential First line of treatment is surgery- mastectomy/conservative surgery Selection criteria for breast conservative surgery Single lesion clinically and on mammography Tumour not larger than 3cm Tumours more than 2cm away from nipple/areola Lesion of lower histological grade No nodal involvement

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TREATMENT-4

CONSERVATIVE surgery include; wide local excision and Quadrantectomy.

MASTECTOMY can either be – MRM or TM

INDICATIONS FOR MASTECTOMY. Large tumor size. Central tumor beneath the areola or involving nipple. Multi focal disease. Local recurrence.

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TREATMENT-5

RADIOTHERAPY CI in pregnancy unless life saving or to prevent organ function. Used only in first or early second trimester Radiation dose used is usually less than 100mGy

Minimise radiation exposure by :

using precise radiation techniques,

appropriate shielding of the abdomen

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TREATMENT-6Effects of radiation Miscarriage

Teratogenicity

Microcephaly

Fetal growth restriction

Learning difficulties

Induction of childhood malignancies

Haematological disordersOkechukwu Ugwu 02/05/2023

TREATMENT-7CHEMOTHERAPY Classified as class D-drugs Can cross the placenta CI in first trimester Anthracycline based regimens are safer- FEC Other options for high risk or metastatic disease are the TAXANES Should not be given after 34-35weeks. Reduces the recurrence of breast cancer by 37% and deaths by 27% Treatment of first choice in stage IV breast cancer.

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TREATMENT-8

Adverse effects of chemotherapy

Intrauterine growth restriction

Preterm delivery

Low birthweight,

Transient tachypnoea of the newborn

Transient neonatal leucopenia

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TREATMENT-9

Supportive therapy Ondansetron

Granulocyte colony-stimulating factor

Methylprednisolone

Hydrocortisone

Psychological support

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TREATMENT-10

Foetal Surveillance USS for anatomic evaluation

Growth scan every 4 weeks and Doppler USS if concern for growth restriction

Antepartum foetal testing at 32 weeks or sooner if growth restriction noted

Delivery at close to term as possible

Not an indication for caesarean section

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SPECIAL CONSIDERATIONSTERMINATION OF PREGNANCY Advanced disease with poor prognosis Poor patient condition Fetal exposure to more than 100mGy of radiation in first trimester.BREASTFEEDING Breast conserving surgery may not limit lactation CI in women on chemotherapy Time interval of 14 days from the last dose CI if on Tamoxifen of Trastuzumab Radiation may cause fibrosis making lactation unlikely.

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SPECIAL CONSIDERATIONS-2SUBSEQUENT FERTILITY

Chemotherapy induced gonadotoxicity may cause Amenorrhoea, subfertility

And Premature ovarian failure

Advised to wait for 2 years after diagnosis before conception

No hormonal contraceptive method is recommended after diagnosis.

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PROGNOSIS

PABC has poor prognosis - delayed diagnosis, young age at presentation.

Pregnancy doesn’t appear to worsen prognosis when matched age for stage.

Commonly assessed prognostic factors Number of positive axillary nodes. Tumor size Lymphatic and vascular invasion Histologic tumor type and grade Estrogen/progesterone

receptors. HER2/neu overexpression

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CONCLUSION Breast cancer in pregnancy poses dilemmas for both women and their

carers.

Triple assessment with clinical examination, imaging and biopsy provides an accurate investigation of symptomatic breast cancer.

Awareness of the current literature on PABC, and the limitations in diagnosing and treating PABC, are imperative for all providers who care for women with this diagnosis.

There is an urgent need for further research in this field.

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References

1. Smith LH, Danielsen B,Allen ME,Cress R.Cancer associated with obstetric delivery:results of linkage with the California cancer registry.Am J Obstet Gynecol 2003;189:1128–35

2. AnderssonTM,Johansson AL, Hsieh CC,Cnattingius S, Lambe M.Increasing incidence of pregnancy-associated breast cancer in Sweden. Obstet Gynecol 2009; 114:568–72.

3. Early Breast CancerTrialists’Collaborative Group (EBCTCG). Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005;365:1687–717

4. Association of Breast Surgery at Baso 2009. Surgical guidelines for the management of breast cancer. Eur J Surg Oncol 2009;35 Suppl 1:s1.1–22.

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