Consideration in the local management of breast cancer

during pregnancy

Omar Zakaria Youssef M.DA.Professor of surgical oncology

NCI- Cairo University

Definition

• Pregnancy associated breast cancer (PABC)

Breast cancer is diagnosed during pregnancy or up to

1 year post partum (or at any time during lactation)

PABC

Subdivided into:

1.Breast cancer during pregnancy (BCDP)

2.Breast cancer during lactation

3.Fertility and pregnancy after breast cancer

treatment

Epidemiology

• Frequency ranges from 1 in 3000 to 1 in 10000

deliveries

• At least 10% of patients with breast cancer who are

younger than 40y will be pregnant at diagnosis

• It is expected to be increasingly common as women

delay childbearing until later in life.

Woo et al. Arch Surg. 2003;138:91-98

Breast

• Anatomy and development

Breast changes during pregnancy

• Pregnancy

Distal ducts grow and branch; breasts enlarge to twice their

normal weight; increase in mammary blood flow leads to

vascular engorgement and areolar pigmentation; sometimes

bloody nipple discharge occurs due to hypervascularity.

• Lactation

Acini are dilated and engorged with colostrum and then milk.

Clinical picture

Mean breast weight normally doubles in pregnancy from

200 g to 400 g, and the resulting breast firmness and

density make the clinical examination and mammogram

more difficult to interpret.

70 to 80% of breast lumps during pregnancy are benign

(Scott-Connor C, Schorr S. Am J Surg. 1995;170:401-405.)

Clinical picture

• Breast cancer appears as painless lump, firm

• Skin thickness, induration and edema

• Nipple discharge

• Nipple retraction

• Axillary mass

• Milk rejection sign

• A 1-month delay in primary tumor treatment

increases the risk of axillary metastases by 0.9%,

given a tumor-doubling time of 130 days. A 6-

month delay increases the risk by 5.1%.

(Nettleton J, Long J, Kuban D, et al. Obstet Gynecol. 1996; 87:414-418.)

differential diagnosis

• Lactating adenoma• Fibroadenoma• Breast Infarcts• Galactocele• Infection• Although 80% of breast masses are benign, any

mass persisting for 2 to 4 weeks deserves further workup

Radiological work-up

• 1st trimester: • Chest X-ray seems safe with appropriate

radioprotection (lead apron). • Pelvi-abdominal U/S• MRI if needed to search for metastasis,

should be done with no contrast

Diagnostic work-up

• ionizing radiation might cause pregnancy loss,

malformations, growth retardation, and

neurobehavioral defects.

• These anomalies appear at fetal doses in excess of

200 mGy, although avoidance of exposure to doses

higher than 100 mGy is advised

International Commission on Radiological Protection 2003; Kal and Struikmans 2005).

No single diagnostic procedure results in a radiation dose that

threatens the well being of the developing embryo and fetusAmerican college of radiology

Tissue diagnosis

• FNAC• Core needle biopsy• Vacuum assisted Breast biopsy• ?? Incisional/Excisional biopsy• F.S

Pathology

• Type : Carcinoma ( invasive/noninvasive) other

pathology ( e.g. Phyllodes T, others)

• grade

• hormonal status

Surgical Management

• The decision to proceed to mastectomy or breast

conservative surgery (BCS) should follow the

standard practice as in the non-pregnant setting.

• Both can be safely performed throughout the

course of gestation.

Surgical management

• 1st Trimester:Termination of pregnancy (non-therapeutic)Surgery: Mastectomy and axillary stagingNo role for BCS because RT will not be

delivered until end of pregnancy ( almost 6 months)

Surgical management

• 2nd trimester and early 3rd trimesterSurgery: Mastectomy vs BCS

Axillary stagingFollowed by adjuvant treatment

ORNeoadjuvant CT followed by surgery

Surgical management

• Late 3rd trimester:

Surgery: either mastectomy or BCS and axillary staging

Followed by adjuvant treatment postpartum

Surgical management of the Axilla

• Routine ALND• Role of SLNB:

• Only one clinical series involving 12 pregnant breast

cancer patients has been reported to date, No fetal

defects secondary to SLNB were observed and no

evidence of axillary relapse was encountered at a

median follow-up of 32 months.

Gentilini et al. Eur J Nucl Med Mol Imaging (2010) 37:78–83

ESMO recommendations

• It is clear that more data on SLNB are needed in the

pregnancy setting; however, we would not

discourage SLNB in pregnant breast cancer patients

in centers in which SLNB is routine practice in the

non-pregnant setting We discourage the use of vital

blue dye in pregnant patients, which is associated

with 2% risk of allergic reactions that could be life-

threatening

Conclusion

• Breast cancer in pregnancy will increase as more

women postpone childbearing until middle age.

• Breast examination at the first prenatal visit and

maintain a high index of suspicion for cancer.

• Although pregnancy-associated cancers tend to occur

at a later stage and are more often ER- negative, they

carry a similar prognosis to other breast cancers

when matched for stage and age.

Conclusion

• Mastectomy and axillary dissection is the traditional

treatment of choice.

• Therapeutic radiation during pregnancy cannot be

recommended because of the risk to the fetus.

• Surgical management should be tailored as for non-

pregnant breast cancer patients