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Breast cancer in pregnancy

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Breast cancer in pregnancy

  1. 1. BREAST CANCER IN PREGNANCY Dr. Okechukwu Ugwu Okechukwu Ugwu 131/05/2016
  2. 2. OUTLINE  Introduction  Epidemiology  Anatomy  Risk factors  Histopathology  Clinical presentation  Differential diagnosis  Diagnosis  Treatment  Special considerations  Prognosis  Conclusion 2Okechukwu Ugwu 31/05/2016
  3. 3. 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 3Okechukwu Ugwu 31/05/2016
  4. 4. INTRODUCTION -2  Breast cancer in pregnancy is defined as breast cancer diagnosed during pregnancy, lactation or within twelve months postpartum. 4
  5. 5. 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. 31/05/2016Okechukwu Ugwu 5
  6. 6. 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. 31/05/2016Okechukwu Ugwu 6
  7. 7. 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- 31/05/2016Okechukwu Ugwu 7
  8. 8. ANATOMY -3 VASCULAR SUPPLY LYMPHATIC DRAINAGE 31/05/2016Okechukwu Ugwu 8
  9. 9. 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 9Okechukwu Ugwu 31/05/2016
  10. 10. 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 31/05/2016Okechukwu Ugwu 10
  11. 11. HISTOPATHOLOGY Ductal carcinoma 79% Lobular carcinoma 10% Tubular/cribriform carcinoma 6% Mucinous carcinoma 2% Medullary carcinoma 2% Papillary carcinoma 1% 11
  12. 12. T = Primary Tumor Tis (T0) = carcinoma in situ T1 = less than 2 cm in diameter T2 = between 2 and 5 cm in diameter T3 = more than 5 cm in diameter T4 = any size, but extends to the skin or chest wall Okechukwu Ugwu 1231/05/2016
  13. 13. TNM Staging Nodal 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 nodes Okechukwu Ugwu 1331/05/2016
  14. 14. CLINICAL PRESENTATION 14 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 Okechukwu Ugwu 31/05/2016
  15. 15. DIFFERENTIAL DIAGNOSIS OF A BREAST LUMP IN PREGNANCY  Carcinoma  Galactocoele  Breast abscess  Lactating adenoma  Fibroadenoma  Fibrocystic disease  Lobular hyperplasia 15Okechukwu Ugwu 31/05/2016
  16. 16. DIAGNOSIS 31/05/2016Okechukwu Ugwu 16 Diagnosis should be made by combination of 1:clinical assessments 2:radiological imaging 3:cytological or thru histological analysis
  17. 17. 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% 31/05/2016Okechukwu Ugwu 17
  18. 18. DIAGNOSIS-3 Malignant masses have a more spiculated appearance 18 malignant benign Okechukwu Ugwu 31/05/2016
  19. 19. DIAGNOSIS-4  BIOPSY  Gold standard in diagnosis- sensitivity of about 90%  Core needle vs FNAC.  OTHER INVESTIGATIONS 31/05/2016Okechukwu Ugwu 19
  20. 20. TREATMENT Depends on: Stage of the disease Hormone receptor status Her2 receptor status Gestational Age Patient preference Okechukwu Ugwu 2031/05/2016
  21. 21. TREATMENT-2  Surgical  Chemotherapy  Radiotherapy  Supportive therapy 21Okechukwu Ugwu 31/05/2016
  22. 22. 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 31/05/2016Okechukwu Ugwu 22
  23. 23. 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. 31/05/2016Okechukwu Ugwu 23
  24. 24. 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 31/05/2016Okechukwu Ugwu 24
  25. 25. TREATMENT-6 Effects of radiation  Miscarriage  Teratogenicity  Microcephaly  Fetal growth restriction  Learning difficulties  Induction of childhood malignancies  Haematological disorders 25Okechukwu Ugwu 31/05/2016
  26. 26. TREATMENT-7 CHEMOTHERAPY  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. 31/05/2016Okechukwu Ugwu 26
  27. 27. TREATMENT-8 Adverse effects of chemotherapy  Intrauterine growth restriction  Preterm delivery  Low birthweight,  Transient tachypnoea of the newborn  Transient neonatal leucopenia 27Okechukwu Ugwu 31/05/2016
  28. 28. TREATMENT-9  Supportive therapy  Ondansetron  Granulocyte colony-stimulating factor  Methylprednisolone  Hydrocortisone  Psychological support 28Okechukwu Ugwu 31/05/2016
  29. 29. 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 29Okechukwu Ugwu 31/05/2016
  30. 30. SPECIAL CONSIDERATIONS TERMINATION 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. 31/05/2016Okechukwu Ugwu 30
  31. 31. SPECIAL CONSIDERATIONS-2 SUBSEQUENT 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. 31/05/2016Okechukwu Ugwu 31
  32. 32. 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 31/05/2016Okechukwu Ugwu 32
  33. 33. 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. 33Okechukwu Ugwu 31/05/2016
  34. 34. Okechukwu Ugwu 3431/05/2016
  35. 35. Okechukwu Ugwu 3531/05/2016
  36. 36. 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. 31/05/2016Okechukwu Ugwu 36

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