Post on 15-Dec-2015
Breast Cancer in Pregnancy
Steven Stanten MDRupert Horoupian MD
AltaBates Summit Medical CenterOakland, California
Introduction
• One of the most commonly diagnosed cancers of pregnancy– More advanced stage– Poorer prognosis
• Pregnancy-associated– During pregnancy– During lactation– Up to 12 months post-partum
Epidemiology
• 12.67% within their lifetime
• Mean age 61
• 12.7% between 20 and 44
• Of women with breast cancer before 40, 10% will be pregnant
• 1/3000 pregnancies
Pathology
• Invasive ductal predominates
• Larger in size at presentation
• Higher frequency of lymphovascular invasion
• Higher nuclear grade
• Higher hormonal independence
• Her-2/neu – no concensus
Diagnosis
• Clinical exam– Usually a mass– Broad differential diagnosis– Most are benign
• Medical Imaging– Mammography usually not helpful
• Safety and efficacy
Diagnosis (con’t)
• Medical Imaging– Screening - not when pregnant– UTZ– CXR– Other staging modalities
Diagnosis (con’t)
• Cytology and Histology
Biopsy recommended if questions persist
FNA, core needle biopsy, excisional biopsy
-rare milk fistula and infection
Treatment
• Surgery
• Radiotherapy
• Chemotherapy
• Obstetric outcome
• Endocrine therapy
• Supporting agents
Treatment (con’t)
• No longer a role for termination of pregnancy
• Goals are to achieve control of disease and prevent distant metastasis
• Fetal protective modifications• Multi-disciplinary team
– Medical oncology, surgical oncology, high-risk obstetrics, genetic counseling, psychological support
Treatment (con’t)
• Surgery– Lumpectomy– Mastectomy– Axillary dissection– Sentinel node biopsy
*Breast conservation is the standard of care when appropriate in a non-pregnant patient
Treatment (con’t)
• NSABP trials
– B06 - established the safety of breast conserving surgery for early stage breast cancer and demonstrated the importance of adjuvant breast radiation to minimize risk of in-breast recurrence.
Treatment (con’t)
• Surgery– Lumpectomy
• Anesthesia• Wire localization• X-ray confirmation• Wide margins
Treatment (con’t)
• Surgery– Try to wait until the 12th week– Breast conservation - i.e.. Lumpectomy– Need to consider need for XRT
• Don’t give during pregnancy
– Consider neo-adjuvant chemotherapy
Treatment (con’t)
• Axillary Surgery –
– 2003 - Veronessi demonstrated that sentinel lymph node biopsy was accurate and reliable.
– B32 – sentinel lymph node biopsy is safe and relaible
* ~8-10% false negative rate
Treatment (con’t)
• Axillary surgery– Blue dye– Radioisotope– Filtered vs. unfiltered– Injection site– Timing
Treatment
• Axillary Surgery– Increased incidence of nodal involvement– Consider neo-adjuvant treatment– UTZ and FNA– Sentinel node biopsy has problems
• Isosulfan blue• Radiocolloid
– Consider axillary dissection
Lymphoscintigraphy
Sentinel Lymph Node
Sentinel Lymph Node
Treatment (con’t)
• Radiation Treatment– Risks are highest during first trimester– Decrease gradually– Try to avoid during pregnancy– Risks may be overstated
Treatment (con’t)
• Chemotherapy– Important role– Advanced disease often – Teratogenic effects– Long term safety profile
• Preterm delivery• Low birth weight• Transient leukopenia• IUGR
Treatment (con’t)
• Chemotherapy– MD Anderson study– Anthracyclines– methotrexate
Treatment (con’t)
• Endocrine therapy– Contraindicated during pregnancy
Treatment (con’t)
• Other agents– Trastuzumab – unknown– Taxanes - unknown
Prognosis
• Use TNM staging
• Most women have stage II or III disease
• Same prognosis stage for stage
• Delay in diagnosis has impact
• 60-100% - 5 year survival
• 31-52% - 10 year survival
Pregnancy after Treatment
• Conflicting data
• 2 years
• 5 years
• Ever?
Conclusion
• Due to lack of prospective randomized clinical studies, both ongoing studies and future evidence are expected to solve problems related to breast cancer management during pregnancy.
• Must balance aggressive maternal care with appropriate modifications that will ensure fetal protection.