Gynaecological Oncology Pregnancy and Breast Cancer Kristel Van Calsteren1 and Frédéric Amant2 1. Trainee, Obstetrics and Gynaecology; 2. Professor, and Head, Section of Gynaecological Oncology, Catholic University of Leuven


Abstract


Pregnancy-associated breast cancer is a rare and challenging problem that requires a multidisciplinary approach. A delay in diagnosis, probably related to gestational changes in breast constitution, leads to more advanced stages of the disease at presentation. Diagnostic and imaging examinations are possible during pregnancy and are required to determine the optimal treatment strategy. Treatment should adhere to standard treatment for non-pregnant breast cancer patients. Surgery, chemotherapy (not in the first trimester) and radiotherapy (not in the third trimester) can safely be applied in pregnancy. Hormonal therapy and trastuzumab should be deferred until the post-partum period. The prognosis of pregnancy-associated breast cancer is not different from that of stage-matched non-pregnancy-associated breast cancer.


Keywords Breast cancer, pregnancy, neonatal, chemotherapy, radiotherapy, surgery


Disclosure: Kristel Van Calsteren has no conflicts of interest to declare. Frédéric Amant is a senior clinical investigator for the Research Foundation – Flanders (FWO). Received: 12 June 2010 Accepted: 8 July 2010 Citation: European Obstetrics & Gynaecology, 2010;5:51–7 Correspondence: Frédéric Amant, UZ Gasthuisberg Leuven, Department of Gynaecological Oncology, Herestraat 49, 3000 Leuven, Belgium. E: frederic.amant@uz.kuleuven.ac.be


Cancer is the second leading cause of death in women during the reproductive years and complicates between one in 1,000 and one in 1,500 pregnancies.1


a clinically suspicious breast mass or a mass that persists for two to four weeks should be imaged and, if necessary, biopsied.


benign,4


In Europe, this number translates into 3,000–5,000 new patients diagnosed with cancer during pregnancy each year. As women in developed societies are increasingly deferring childbearing to the third or fourth decade of life, and the incidence of most malignancies rises with increasing age, the co-incidence of cancer and pregnancy is likely to become more common. Breast cancer is the most frequently diagnosed tumour during pregnancy. The reported incidence of pregnancy-associated breast cancer (PABC) varies between one in 3,000 and one in 10,000 pregnancies since different definitions are used, sometimes including breast cancer diagnosed within one year post-partum.1 breast cancer cases.2


PABC accounts for 0.8–3.8% of all The diagnosis and treatment of cancer in


pregnant women is a multidisciplinary clinical and ethical challenge for all medical care workers. The benefits and risks of the various diagnostic and therapeutic modalities should be carefully assessed for both the mother and the foetus. Optimal treatment of the mother must be combined with minimal risk of harm to the foetus.


Diagnosis of Breast Cancer During Pregnancy History and Physical Examination


The parameters that influence the risk of PABC are the same genetic and environmental factors that define the risk of cancer in the general population.3


Due to physiological changes in the breast


during pregnancy, including engorgement, hypertrophy and nipple discharge, the diagnosis of breast cancer is more challenging in pregnant and post-partum women. Delay in diagnosis is common, with consequently larger tumour sizes at diagnosis. Although the majority (80%) of breast biopsies performed in pregnant women are


© TOUCH BRIEFINGS 2010


Imaging of the Breast and Nodal Basins in Pregnant Women


Many clinicians are hesitant to prescribe or perform imaging studies in pregnant patients. However, a missed diagnosis or delayed treatment often poses a greater risk to the patient and her pregnancy than the hazard associated with ionising radiation. Therefore, if a radiographic scan is indicated for the benefit of the mother, it should be carried out as long as the safety limit of a maximum foetal radiation exposure of 100mSv (~100mGy) is respected.5


Table 1 shows the estimated foetal


doses from common radiological diagnostic procedures, which are all below the threshold dose of 100mSv.6,7


Nevertheless, it is generally


advised to replace X-ray examinations with ultrasonographic or nuclear magnetic resonance (NMR) examinations. When various examinations are indicated, an optimal staging strategy should be discussed in a multidisciplinary setting, including a radiologist, a nuclear medicine specialist and an oncologist, to reduce the foetal radiation exposure.


Also, mammography with abdominal shielding can be performed safely in pregnant women and is required to exclude bilateral and multicentric disease.7


Breast ultrasonography permits the differentiation of solid and cystic breast masses without the risk of foetal radiation exposure. An ultrasound of the breast, with draining nodal basins if clinically indicated, has a high sensitivity and specificity and is therefore the preferred examination for evaluation of palpable breast masses during pregnancy.8


However, breast imaging modalities are more difficult to interpret during pregnancy due to the 51


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