Case presentation: ( Breast Cancer in Pregnancy)

32 yrs female, FH negative, Pregnancy 11 weeks

CC: Rt Breast mass feeling

PE: Rt UIQ mass, size 4-5 cm,No palpable lymph node

US( 2.5 months ago):  Rt breast hypoechoic mass 21*15 mm , (B 3)

MG: Dense breast, No mass (B 0)

CNBx Pathology: IDC, G 2, LVI - , PNI - , ER + , PR - , HER2 - , Ki-67  80-85%

Question: Need to abortion? Plan of treatment?

Joint recommendation:

 -
No need to abortion

 -Surgery (Mastectomy or OBS) + Initiation of Chemotherapy after 12 w

 + Radiotherpy after delivery

Reference:                                                           

 

1-Jay R Harris,Monica Moro, et al .”Diseases of the breast”. 5th ed. ,2014:

 

Breast cancer and cervical cancer are the most commonly diagnosed malignancies during pregnancy. Due to the physiologic changes in the breast that occur during pregnancy and lactation, including increased size and density of the breast tissue, there may be a delay in diagnosis of breast cancer as these physiologic changes can obscure detection. Mammography should be ordered in pregnancy with abdominal shielding. With mammography the fetal radiation exposure is estimated to be 0.4 mrad. Data regarding the safety of gadolinium( in MRI ) during pregnancy are limited. Gadolinium has been shown to cross the placenta and be associated with fetal abnormalities in animal models.

Surgery and Anesthesia

Breast surgery can be safely performed in all trimesters of pregnancy; however, patients and surgeons may choose to wait until after the 12th week of gestation when the risk of spontaneous abortion may be lower. A recent review of surgery in the pregnant patient recommends that the preferred timing for surgical intervention is 16 to 20 weeks of gestation. Breast-conserving surgery is an option, especially in women in the third trimester of pregnancy who can receive radiation therapy after delivery. With the potential of preoperative chemotherapy during pregnancy, breast-conserving surgery can be done later in the pregnancy or after delivery.

SLNB

Estimated radiation exposure to the fetus is low and calculated to a maximum of 4.3 mGy. However, isosulfan blue dye mapping is not recommended due to concerns of unknown effects for the fetus as well as risk of anaphylaxis for the patient.

 Radiation Therapy

 If the patient meets criteria for postmastectomy radiation therapy or they have had breast-conserving surgery, radiation therapy should be administered and this is recommended only after delivery of the fetus. Radiation exposure during pregnancy may result in fetal death, malformations, growth and/or mental impairment, and induction of cancers or hereditary defects. A significant portion of fetal exposure can occur from internal radiation scatter from the mother, for which abdominal shielding may be ineffective.

 

 Chemotherapy

Although most chemotherapeutic agents are Category D, there are data demonstrating that systemic chemotherapy can be given safely during pregnancy during the second and third trimester. Clinical consideration for the use of systemic therapies should be similar in pregnant and nonpregnant patients. Published reports demonstrate that first trimester chemotherapy exposure is associated with a 14% to 19% risk of fetal  malformations while second and third trimester exposure is significantly safer with a fetal malformation risk of 1.3%. Methotrexate and methotrexate-containing regimens such as CMF generally are not given during pregnancy.

Biologic Agents

There have been multiple reports of trastuzumab administration during pregnancy. No fetal abnormalities have been reported; however, anhydramnios with its use has been described in 6 of the case reports and fetal death has been noted. There are  very limited data of biologic agent(Trastuzumab or TDM-1 ) use during pregnancy, it is recommended that they not be used as part of standard adjuvant treatment protocols.

 Endocrine Therapy

Endocrine therapy, if indicated, should be initiated after delivery and completion of chemotherapy. Although there are case reports of fetal exposure to tamoxifen without with fetal damage, there are others that have reported Goldenhar syndrome (microtia, preauricular skin tags, and hemifacial microsomia), ambiguous genitalia, and other birth defects as well as reports of vaginal bleeding and spontaneous abortion .

 Aromatase inhibitors are not indicated for use in premenopausal women.

 

2-NCCN Guidelines 2016 :

 





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