Transcript Breast Cancer in Pregnancy

Breast Cancer in Pregnancy
Steven Stanten MD
Rupert Horoupian MD
AltaBates Summit Medical Center
Oakland, 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
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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
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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
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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
Lymphoscintigraphy
Sentinel Lymph Node
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
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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
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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
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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.