Breast cancer is the second most common malignancy in pregnancy (after
Diagnosis and treatment of breast cancer during pregnancy encompasses
many diagnostic and therapeutic dilemmas
Overall survival of pregnant women generally worse than in nonpregnant
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Breast cancer in pregnancy is defined as breast cancer
diagnosed during pregnancy, lactation or within twelve
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. 31/05/2016Okechukwu Ugwu 6
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
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Proliferative breast disease
Previous history of malignancy
BRCA 1 and BRCA 2 mutations
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T = Primary Tumor
Tis (T0) = carcinoma in situ
T1 = less than 2 cm in diameter
T2 = between 2 and 5 cm in
T3 = more than 5 cm in diameter
T4 = any size, but extends to the
skin or chest wall
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Change in color
Redness or pitting
of skin over the
breast, like the
skin of an orange
Change in size
or contours of
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DIFFERENTIAL DIAGNOSIS OF A BREAST
LUMP IN PREGNANCY
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Diagnosis should be made by combination of
3:cytological or thru histological analysis
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
With abdominal shield can be done in all trimesters
Increase water content in the breast may decrease sensitivity- 70%
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Malignant masses have a more spiculated appearance
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Gold standard in diagnosis- sensitivity of about 90%
Core needle vs FNAC.
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Stage of the disease
Hormone receptor status
Her2 receptor status
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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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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.
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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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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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Adverse effects of chemotherapy
Intrauterine growth restriction
Transient tachypnoea of the newborn
Transient neonatal leucopenia
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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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TERMINATION OF PREGNANCY
Advanced disease with poor prognosis
Poor patient condition
Fetal exposure to more than 100mGy of radiation in first trimester.
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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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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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.
Lymphatic and vascular invasion
Histologic tumor type and grade
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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
There is an urgent need for further research in this field.
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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
2. AnderssonTM,Johansson AL, Hsieh CC,Cnattingius S, Lambe M.Increasing
incidence of pregnancy-associated breast cancer in Sweden. Obstet Gynecol
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
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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