C ONSIDERATION IN THE LOCAL MANAGEMENT OF BREAST CANCER DURING PREGNANCY Omar Zakaria Youssef M.D A.Professor of surgical oncology NCI- Cairo University

Definition Pregnancy associated breast cancer (PABC) Breast cancer is diagnosed during pregnancy or up to 1 year post partum (or at any time during lactation)

PABC Subdivided into: 1.Breast cancer during pregnancy (BCDP) 2.Breast cancer during lactation 3.Fertility and pregnancy after breast cancer treatment

Epidemiology Frequency ranges from 1 in 3000 to 1 in deliveries At least 10% of patients with breast cancer who are younger than 40y will be pregnant at diagnosis It is expected to be increasingly common as women delay childbearing until later in life. Woo et al. Arch Surg. 2003;138:91-98

Breast Anatomy and development

Breast changes during pregnancy Pregnancy Distal ducts grow and branch; breasts enlarge to twice their normal weight; increase in mammary blood flow leads to vascular engorgement and areolar pigmentation; sometimes bloody nipple discharge occurs due to hypervascularity. Lactation Acini are dilated and engorged with colostrum and then milk.

Clinical picture Mean breast weight normally doubles in pregnancy from 200 g to 400 g, and the resulting breast firmness and density make the clinical examination and mammogram more difficult to interpret. 70 to 80% of breast lumps during pregnancy are benign (Scott-Connor C, Schorr S. Am J Surg. 1995;170: )

Clinical picture Breast cancer appears as painless lump, firm Skin thickness, induration and edema Nipple discharge Nipple retraction Axillary mass Milk rejection sign

A 1-month delay in primary tumor treatment increases the risk of axillary metastases by 0.9%, given a tumor-doubling time of 130 days. A 6- month delay increases the risk by 5.1%. (Nettleton J, Long J, Kuban D, et al. Obstet Gynecol. 1996; 87: )

differential diagnosis Lactating adenoma Fibroadenoma Breast Infarcts Galactocele Infection Although 80% of breast masses are benign, any mass persisting for 2 to 4 weeks deserves further workup

Radiological work-up 1 st trimester: Chest X-ray seems safe with appropriate radioprotection (lead apron). Pelvi-abdominal U/S MRI if needed to search for metastasis, should be done with no contrast

Diagnostic work-up ionizing radiation might cause pregnancy loss, malformations, growth retardation, and neurobehavioral defects. These anomalies appear at fetal doses in excess of 200 mGy, although avoidance of exposure to doses higher than 100 mGy is advised International Commission on Radiological Protection 2003; Kal and Struikmans 2005).

No single diagnostic procedure results in a radiation dose that threatens the well being of the developing embryo and fetus American college of radiology

Tissue diagnosis FNAC Core needle biopsy Vacuum assisted Breast biopsy ?? Incisional/Excisional biopsy F.S

Pathology Type : Carcinoma ( invasive/noninvasive) other pathology ( e.g. Phyllodes T, others) grade hormonal status

Surgical Management The decision to proceed to mastectomy or breast conservative surgery (BCS) should follow the standard practice as in the non-pregnant setting. Both can be safely performed throughout the course of gestation.

Surgical management 1 st Trimester: Termination of pregnancy (non-therapeutic) Surgery: Mastectomy and axillary staging No role for BCS because RT will not be delivered until end of pregnancy ( almost 6 months)

Surgical management 2 nd trimester and early 3 rd trimester Surgery: Mastectomy vs BCS Axillary staging Followed by adjuvant treatment OR Neoadjuvant CT followed by surgery

Surgical management Late 3 rd trimester: Surgery: either mastectomy or BCS and axillary staging Followed by adjuvant treatment postpartum

Surgical management of the Axilla Routine ALND Role of SLNB:

Only one clinical series involving 12 pregnant breast cancer patients has been reported to date, No fetal defects secondary to SLNB were observed and no evidence of axillary relapse was encountered at a median follow-up of 32 months. Gentilini et al. Eur J Nucl Med Mol Imaging (2010) 37:78–83

ESMO recommendations It is clear that more data on SLNB are needed in the pregnancy setting; however, we would not discourage SLNB in pregnant breast cancer patients in centers in which SLNB is routine practice in the non-pregnant setting We discourage the use of vital blue dye in pregnant patients, which is associated with 2% risk of allergic reactions that could be life- threatening

Conclusion Breast cancer in pregnancy will increase as more women postpone childbearing until middle age. Breast examination at the first prenatal visit and maintain a high index of suspicion for cancer. Although pregnancy-associated cancers tend to occur at a later stage and are more often ER- negative, they carry a similar prognosis to other breast cancers when matched for stage and age.

Conclusion Mastectomy and axillary dissection is the traditional treatment of choice. Therapeutic radiation during pregnancy cannot be recommended because of the risk to the fetus. Surgical management should be tailored as for non- pregnant breast cancer patients