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Breast Conference 2/15/2012. RN. 39 Asian/Pacific Islander presenting with a right breast mass and swelling 1-2 month duration Pain in the area. RN. Menarche: 18y G1P1 (33y), breastfeeding: 6m OCP: none HRT: none Premenopausal (LMP 12/2011) Hx breast bx : none Hx breast Ca: none

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Presentation Transcript
slide2
RN
  • 39 Asian/Pacific Islander presenting with a right breast mass and swelling
    • 1-2 month duration
    • Pain in the area
slide3
RN

Menarche: 18y

G1P1 (33y), breastfeeding: 6m

OCP: none

HRT: none

Premenopausal (LMP 12/2011)

Hx breast bx: none

Hx breast Ca: none

Fhx: none

Shx: caffeine(+), soy(-), tobacco(-), ETOH(-)

Bra: 38C

slide4
RN

PMH: none

PSH: c/s

Meds: multivitamins

Allergies: Percocet

slide5
RN

PE:

Right breast:

Large, hard mass involving 4 quadrants, minimal nipple retraction. Thickening of the skin and peaud’orange

Left breast:

Within normal limits

Right axilla:

Enlarged lymph node, relatively immobile

No left axillary, supraclavicular or cervical adenopathy

slide6
RN
  • Pregnancy test – positive
  • OB-GYN:
    • Missed abortion?
slide7
RN

Radiology:

Diagnostic mammogram:

Right – 21 o’clock anterior depth density. Skin thickening and nipple retraction.

Right posterior superior breast – multiple enlarged nodes

US:

Right – 5.2*2.8*5.7cm irregular mass central to the nipple anterior depth, associated with skin thickening

Right axilla – multiple enlarged nodes with no fatty hilum

slide8
RN

Radiology:

MRI:

PET/CT:

slide9
RN

Pathology:

Right breast lesion:

Infiltrating ductal carcinoma with mucinous features

Grade 2

ER(98%) PR(61%), HER2(+2, FISH pending)

Right axillary lesion:

Mucinous carcinoma

No lymph tissue seen

slide10
RN
  • 39 F, right breast inflammatory carcinoma stage IIIB, cT4dN2Mx
    • FISH pending
slide12
RN
  • Surgery –
    • Mediport
  • Medical oncology –
    • Neoadjuvant chemotherapy
  • Radiation oncology –
  • Plastic surgery –
  • Genetics –
  • Psychosocial –
slide13
35 F, pregnancy 13w
  • inflammatory breast carcinoma, bulky axillaryadenopathy
  • Grade 3, ER/PR+, HER2-
  • Chest MRI, liver US – negative
  • Neoadjuvant chemotherapy – FAC (5FU, doxorubicin, cyclophosphamide)
  • Minimal response only, tx changed to Docetaxel (week 25)
  • Healthy newborn (week 39)
slide14
sf
  • Clinical exam, US, MRI – complete response
  • MRM – no residual breast tumor, 5/16 nodes
  • Goserelin and Tamoxifen
  • Radiation
slide15
Pregnancy related breast cancer:
    • Diagnosed during pregnancy or within a year after delivery
  • History and Physical examination
    • Genetic and environmental risk factors are similar to those for the age adjusted population
    • No increased risk for BRCA mutation carriers during pregnancy
    • Patients are young, refer to genetic counseling
    • Physiological breast changes can obscure masses, and the patients tend to be diagnosed at a later stage
    • 80% of breast lesions during pregnancy are benign
slide16
Diagnosis
    • Gestational changes might alter the tissue structure
    • US –
      • First tool for diagnosis
    • Mammogram –
      • To rule out bilateral and multicentric disease
    • MRI
      • Should only be used when would change treatment
      • No well designed studies of efficacy and safety of breast MRI in pregnancy
      • Gadolinium may pass through the placenta, potential toxic effects are unknown
      • Other approved contrast agents can be used
    • Core biopsy –
      • Safe
      • Sensitivity around 90%
      • Rare milk fistulas
      • FNA not recommended
      • Notify pathologist of pregnancy
slide28
More women are delaying childbirth
  • More diagnosis during pregnancy
  • More women choosing not to terminate the pregnancy
  • Incidence in California Obstetrics Registry: 13:100,000 live births
  • Swedish study: 37.4:100,00 (pregnancy associated breast cancer)
slide29
Diagnosis and staging:
    • Imaging:
      • Mammogram – with proper fetal shielding

lower sensitivity during pregnancy

      • US – high rates of mass identification in pregnancy
      • MRI – animal models showed Gadolinium to cross the placenta, and is

associated with fetal abnormalities

scant data on the use of Gadolinium for non breast MRI in

pregnancy

slide30
Diagnosis and staging:
    • Biopsy – case report of milk fistula with core needle biopsy

(other reports showed no complications)

mention to the pathologist that the patient is pregnant

    • Staging evaluations –
      • Echo – prior to anthracyclines
      • Stage ≥II:
        • Liver ultrasound
        • MRI without contrast of the spine
        • Chest x-ray with fetal shielding
      • CT, bone scans – not recommended routinely
      • Evaluation of the fetus before initiation of therapy
slide31
Surgery –
    • Similar risk of fetal abnormalities as pregnant patients without surgery
    • Both mastectomy and breast conservation surgery are feasible with minimal post-op complications
    • SLN biopsy:
      • Estimated radiation to fetus is low
      • Concern regarding the use of isosulfan blue dye – unknown fetal effect
      • More safety data needed
  • Radiation –
    • Should be delayed until after delivery
slide32
Chemotherapy –
    • Same indications as in a non-pregnant patients
    • Most are rated pregnancy category D
    • 14-19% fetal malformations when given in first trimester
    • 1.3% fetal malformations in second and third trimester
    • Anthracyclines –
      • Multiple case series, …
    • Taxanes –
      • Several studies, often delayed until after delivery
      • Concerns of effectiveness d/t up-regulation of P-450 during pregnancy
slide33
Biological agents
    • Trastuzumab – oligo and anhydramnios

should be delayed

    • Lapatinib – 1 case report (women conceived while on drug,

with a healthy newborn)

not recommended – lack of information

  • Endocrine therapy
    • Tamoxifen – associated with birth defects
slide34
Prognosis
    • Delays in diagnosis and treatment may influence outcomes
    • Recent studies did not show pregnancy associated breast cancer to be an adverse prognostic sign
slide35
Less recommendations for termination of pregnancy
  • Chemotherapy during pregnancy decreased milk production
  • Secreted in breast milk and contraindicated in lactating patients

Conclusion –

Treatment with multidisciplinary approach, communication with obstetrician

There should be minimal delay in therapy

No significant long term concerns identified in children exposed to chemotherapy in utero

slide36
LT
  • 58 AAF presenting with a palpable mass and an abnormal mammogram
slide37
LT

Menarche: 9y

G4P2 (20y), breastfeeding: none

OCP: 10y

HRT: none

Postmenopausal (41y)

Hx breast bx: none

Hx breast Ca: none

Fhx:

Breast cancer – maternal aunt (60y)

Colon cancer - maternal aunt (61y)

Unknown cancer – paternal uncle

Shx:

caffeine(3cups/d), soy(-), tobacco(recent smoker: 15 pack years), ETOH(occasionally)

Bra: 38D

slide38
LT

PMH: HLD, anemia, seizure (childhood)

PSH: cholecystectomy, c/s*2

Meds: Lisinopril, Vytorin, Chantix

Allergies: Ibuprofen, Penicillin

slide39
LT

PE:

Right breast:

1.5cm hard mass, 12 o’clock 10cm from nipple

Left breast:

Within normal limits

No axillary, supraclavicular or cervical adenopathy

slide40
LT

Radiology:

Diagnostic mammogram:

Right – lobulated mass 12 o’clock, far superior position

US:

Right – solid irregular mass, 1.4*1.5*1.7cm, 1 o’clock 10cm from nipple

Right axilla – no suspicious findings

slide41
LT

Pathology:

Right breast lesion:

Infiltrating ductal carcinoma

Grade 2

ER(100%) PR(100%), HER2(-)

slide42
LT
  • 58 F, IDC stage IA cT1cN0M0
slide44
LT
  • Surgery –
  • Medical oncology –
  • Radiation oncology –
  • Plastic surgery –
  • Genetics –
  • Psychosocial –