Breast Conference 2/15/2012

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• 39 Asian/Pacific Islander presenting with a right breast mass and swelling– 1-2 month duration– Pain in the area

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• 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

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• PMH: none• PSH: c/s• Meds: multivitamins• Allergies: Percocet

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• PE:– Right breast:

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

– Left breast: • Within normal limits

– Right axilla:• Enlarged lymph node, relatively immobile

– No left axillary, supraclavicular or cervical adenopathy

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• Pregnancy test – positive• OB-GYN:

– Missed abortion?

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• 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

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• Radiology:– MRI:

– PET/CT:

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• 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

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• 39 F, right breast inflammatory carcinoma stage IIIB, cT4dN2Mx– FISH pending

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• Surgery – – Mediport

• Medical oncology –– Neoadjuvant chemotherapy

• Radiation oncology – • Plastic surgery – • Genetics – • Psychosocial –

• 35 F, pregnancy 13w• inflammatory breast carcinoma, bulky axillary adenopathy• 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)

sf

• Clinical exam, US, MRI – complete response

• MRM – no residual breast tumor, 5/16 nodes • Goserelin and Tamoxifen• Radiation

• 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

• 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

• 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)

• 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

• 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

• 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

• 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

• 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

• Prognosis– Delays in diagnosis and treatment may influence outcomes– Recent studies did not show pregnancy associated breast

cancer to be an adverse prognostic sign

• 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

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

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• 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

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• PMH: HLD, anemia, seizure (childhood)• PSH: cholecystectomy, c/s*2• Meds: Lisinopril, Vytorin, Chantix• Allergies: Ibuprofen, Penicillin

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• PE:– Right breast:

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

– Left breast: • Within normal limits

– No axillary, supraclavicular or cervical adenopathy

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• 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

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• Pathology:– Right breast lesion:

• Infiltrating ductal carcinoma• Grade 2• ER(100%) PR(100%), HER2(-)

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• 58 F, IDC stage IA cT1cN0M0

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• Surgery – • Medical oncology – • Radiation oncology – • Plastic surgery – • Genetics – • Psychosocial –