peer review presentation

1. BREAST CANCER IN PREGNANCY
Dr. Okechukwu Ugwu
Okechukwu Ugwu 131/05/2016

2. OUTLINE
 Introduction
 Epidemiology
 Anatomy
 Risk factors
 Histopathology
 Clinical presentation
 Differential diagnosis
 Diagnosis
 Treatment
 Special considerations
 Prognosis
 Conclusion
2Okechukwu Ugwu 31/05/2016

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. INTRODUCTION -2
 Breast cancer in pregnancy is defined as breast cancer
diagnosed during pregnancy, lactation or within twelve
months postpartum.
4

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. 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. 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. ANATOMY -3
VASCULAR SUPPLY LYMPHATIC DRAINAGE
31/05/2016Okechukwu Ugwu 8

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. 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. HISTOPATHOLOGY
Ductal carcinoma 79%
Lobular carcinoma 10%
Tubular/cribriform carcinoma 6%
Mucinous carcinoma 2%
Medullary carcinoma 2%
Papillary carcinoma 1%
11

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. 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. 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. 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. 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. 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. DIAGNOSIS-3
Malignant masses have a more spiculated appearance
18
malignant
benign
Okechukwu Ugwu 31/05/2016

19. DIAGNOSIS-4
 BIOPSY
 Gold standard in diagnosis- sensitivity of about 90%
 Core needle vs FNAC.
 OTHER INVESTIGATIONS
31/05/2016Okechukwu Ugwu 19

20. TREATMENT
Depends on:
Stage of the disease
Hormone receptor status
Her2 receptor status
Gestational Age
Patient preference
Okechukwu Ugwu 2031/05/2016

21. TREATMENT-2
 Surgical
 Chemotherapy
 Radiotherapy
 Supportive therapy
21Okechukwu Ugwu 31/05/2016

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. 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. 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. 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. 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. 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. TREATMENT-9
 Supportive therapy
 Ondansetron
 Granulocyte colony-stimulating factor
 Methylprednisolone
 Hydrocortisone
 Psychological support
28Okechukwu Ugwu 31/05/2016

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. 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. 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. 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. 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. Okechukwu Ugwu 3431/05/2016

35. Okechukwu Ugwu 3531/05/2016

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