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Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
Breast Cancer during pregnancy
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Breast Cancer during pregnancy

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  1.  
  2.  
  3. <ul><li>Cancer complicate 1 / 1,000 pregnancies </li></ul><ul><li>1/3 maternal death during pregnancy </li></ul><ul><li>Commonly diagnosed cancer during pregnancy: </li></ul><ul><ul><ul><ul><li>Breast cancer </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cervical ca </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Melanoma </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thyroid ca </li></ul></ul></ul></ul>2/46
  4. <ul><li>Diagnostic delay is not rare </li></ul><ul><li>The management of pregnant mother is difficult </li></ul><ul><li>Concern : </li></ul><ul><ul><ul><ul><li>Save mother’s life </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Protect fetus </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Intact reproductive system </li></ul></ul></ul></ul>3/46
  5. 4/46
  6. <ul><li>Tumours diagnosed during pregnancy or within one year post partum </li></ul>5/46
  7. 6/46
  8. <ul><li>Diagnosed 1 / 3000 pregnancies </li></ul><ul><li>Incidence 0.76 – 3.8 % </li></ul><ul><li>Median age 33 ( 23 - 47 y) </li></ul>Saunders CM,Baum M Breast cancer and pregnancy review .J R Soc Med 1993;86:162-5 7/46
  9. 8/46
  10. <ul><li>Similar to non pregnant lady </li></ul>- Painless mass - Nipple discharge - Inflammatory breast 9/46
  11. 10/46
  12. Histopathology LN Status Receptor status 11/46
  13. Histopathology Invasive ductal ca Invasive lobular ca Inflammatory breast ca Middleton LP , et al. Breast carcinoma in pregnant women.Assissment of clinicopathologic & immunohistochemical features. Cancer 2003;98:1055-60 12/46
  14. <ul><li>Similar to non pregnant women in : </li></ul><ul><ul><ul><li>Histological frequencie </li></ul></ul></ul><ul><ul><ul><li>Grade </li></ul></ul></ul>Histopathology Middleton LP , et al. Cancer 2003;98:1055-60 13/46
  15. <ul><li>+ve ER , PR < 30 % </li></ul><ul><li>Her-2 / neu over expression 28-58% </li></ul><ul><li>p53 50 % </li></ul>Receptor status Elledge RM ,et al ER , PR and Her-2/neu protien in breast cancer from pregnant patients. Cancer 1993;71:2499-506 14/46
  16. <ul><li>Involved in 60 - 90 % </li></ul><ul><li>Similar to general population </li></ul>LN status Isaac J . Cancer of the breast in pregnancy. Surg clin North Am 1995;75:47-51 15/46
  17.  
  18. <ul><li>Diagnostic delay </li></ul><ul><li>Average delay 8.2 months ‘ 2-15 months ‘ </li></ul><ul><li>Advanced breast cancer ‘ 2.5 fold ‘ </li></ul>Moore HCF, Foster Jr Rs. Breast cancer and pregnancy Semin oncol.2000;27:646-53 17/46
  19. <ul><li>FNA </li></ul><ul><li>Core biopsy – Cost effective </li></ul><ul><li>Early stage breast ca accounts 60% </li></ul>Sorosky JI ,Scott-conner. Breast cancer complicating pregnancy.Obst Gynecol clin North Amer 1998;25(2):353-63 18/46
  20.  
  21. Radiation effect Dose dependant Gestational age 20/46
  22. < 0.1 Gy > 3 Gy Dose No effect Fetal malformation 21/46
  23. Teratogenic Gestational age 16 w 2 w Abortion 25 w Sterility malignancy Mole RH.childhood cancer after prenatal exposure to diagnostic x-ray examinations in Britain. Br J Cancer 1990;62:152-68 22/46
  24. <ul><li>Ultrasound sensitivity 93 % </li></ul><ul><li>Diagnostic Mammogram: </li></ul><ul><li>- 0.004 Gy </li></ul><ul><li>- sensitivity 70% </li></ul>Nicklas A, Baker M. Imaging strategies in pregnant caner patients. Semin oncol 2000;27:623-32 23/46
  25. <ul><li>Staging – CXR , Ultrasound </li></ul><ul><li>Avoid CT </li></ul><ul><li>Pvlidis NA. The oncologist 2002;7:279-87’ </li></ul><ul><li>MRI </li></ul><ul><li>- No proof of safety </li></ul><ul><ul><ul><li>Aloraini et al Ann.Saud.Med. July-Aug. 2006 </li></ul></ul></ul>24/46
  26.  
  27. Surgery Chemotherapy Radiotherapy 26/46
  28. <ul><li>Gold standard </li></ul><ul><li>BCS </li></ul><ul><li>2 nd - 3 rd trimester </li></ul><ul><li>Axillary LN dissection </li></ul><ul><li>SLNB not recommended </li></ul>Surgical Rx 27/46
  29. <ul><li>Chemotherapy </li></ul>Chemotherapy 28/46 teratogenic <ul><li>2 - 3 trimester </li></ul><ul><li>CAF , CMF </li></ul><ul><li>Giacalone PL.et al chmotherapy for breast carcinomaduring </li></ul><ul><li>pregnancy . Cancer 1999;86:2266-72 </li></ul>
  30. <ul><li>Epirubicin not recommended </li></ul><ul><li>Peccatori F. chemotherapy during pregnancy : what is really safe? </li></ul><ul><li>Lancet oncol 2004;5:398 </li></ul><ul><li>Taxol </li></ul><ul><li>Eur J Cancer care 2000;9:235-7 </li></ul>Chemotherapy 29/46
  31. <ul><li>Not offered during pregnancy </li></ul><ul><li>Threshold fetal dose for complication </li></ul><ul><ul><ul><ul><li>10-15 rad 20 wks gestation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>25-50 rad after </li></ul></ul></ul></ul>Radiotherapy Woo JC et al Breast cancer in pregnancy: a literature review. Arch Surg 2003;138:91-8 30/46
  32.  
  33. <ul><li>Inadequate information </li></ul><ul><li>Delivery 2-3 wk after Rx </li></ul><ul><li>Similar survival rate among pregnant & non pregnant lady </li></ul>Mother and fetal outcome Petrek JA et al. Prognosis of pregnancy associated breast cancer. Cancer 1991;67:869-72 32/46
  34. <ul><li>Rate of malformation 2-3% </li></ul><ul><li>Stillbirth 5-15% </li></ul><ul><li>Breast feeding – not recommended </li></ul><ul><li>Suppression of lactation does not improve prognosis </li></ul>Mother and fetal outcome 33/46
  35. <ul><li>G-CSF: </li></ul><ul><li>- Reduce duration of neutopenia </li></ul><ul><li>- Improve overall survival </li></ul><ul><li>- safe ? </li></ul>Supportive drug 34/46
  36. <ul><li>Erythropoietin </li></ul><ul><li>Scott LL et al.Erythropoietin use I pregnancy: two cases & review </li></ul><ul><li>Am JP parinatol 1995;12:22-4 </li></ul><ul><li>Ondansteron , metochlopramide </li></ul>Supportive drug 35/46
  37.  
  38. <ul><li>Recommended 1950-1960s </li></ul><ul><li>Abortion doesn’t prolong survival </li></ul><ul><li>Currently indicated in : </li></ul><ul><li>- Very aggressive tumor </li></ul><ul><li>- Advanced disease with dismal </li></ul><ul><li>prognosis </li></ul>Petrek JA et al. Prognosis of pregnancy associated breast cancer. Cancer 1991;67:869-72 37/46
  39. Petrek JA et al. Prognosis of pregnancy associated breast cancer. Cancer 1991;67:869-72
  40. <ul><li>Chemotherapy may cause premature ovarian failure </li></ul><ul><li>Depending upon the woman’s age & the Rx regimen Bonadonna and Valgussa ‘ </li></ul>39/46
  41. <ul><li>‘ </li></ul><ul><li>CMF </li></ul><ul><li>> 40 y 96% developed amenorrhoea </li></ul><ul><li>< 40 y 54% </li></ul><ul><li>Doxorubicin </li></ul><ul><li>< 35 y 9% permanent amenorrhea </li></ul><ul><li>Taxol ??? </li></ul>40/46
  42. <ul><li>Resumption of menstruation doesn’t confirm restoration of fertility </li></ul><ul><li>It seems that pregnancy after Rx for breast cancer has an increased chance of spontaneous pregnancy loss </li></ul>Bonadonna G, Valgussa P. Adjuvant systemic therapy for resectable breast cancer . J Clin Oncol 1985:3:259–75. 41/46
  43. <ul><li>Long-term survival after breast cancer not affected by pregnancy </li></ul><ul><li>five-year survival rate of 80% </li></ul><ul><li>The survival of women who were node-negative was 90% at ten years </li></ul>42/46
  44. <ul><li>No difference between those who had subsequent pregnancies & who did not </li></ul>43/46
  45. <ul><li>Delay pregnancy < 33 years </li></ul><ul><li>Decisions about future conception based on prognosis : </li></ul><ul><li>- Stage IV deferring pregnancy for 5 y </li></ul><ul><li>- Recurrent stage-I or -II should not </li></ul><ul><li>contemplate conception </li></ul>44/46
  46. <ul><li>It is recommended that pregnancy should be deferred for at least 2 years after treatment </li></ul>Berry et al . Management of breast cancer during pregnancy using a standardized protocol J Clin Oncol 1999 45/46
  47. <ul><li>Women planning a pregnancy after Rx for breast cancer should consult their obstetrician, breast surgeon and clinical oncologist </li></ul>46/46
  48.  

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