Case presentation

Presented by Gehan Omran

Under supervision of professor Doctor
Mohamed Hesham
summary

• 34 years G2P1001,22 weeks with painless Rt breast lump

• No nipple discharge
• Family history is negative for breast cancer
• Examination:2cm mobile,firm, mass in right upper outer quadrant,no
nipple reaction or adenopathy
• US solid mass,
• core needle biopsy showing infiltrating intraductal carcinoma
Diagnosis
• G2p1 22 weeks with breast cancer in pregnancy
• Confirmed by biopsy and histopathology to be intraductal carcinoma
• Ask patient about medical and surgical history and family history of cancer
• Ask about early menarche
• Ask about previous radiotherapy
• Ask about mode of delivery
• asses BMI ,general examination for signs of meatastasisas cachexia,anemia,pallor
• Abdominal examination
• Chest examination
• Examin other breast
Investigations
• Us for fetal wellbeing
• Abdominal us for metasis
• Chest x-ray
• Tumour markers not reliable in pregnancy
• Cbc ,LFT,KFT
 Next step
• Investigations for metastasis including MRI ,chest xray ,CT scan with abdominal
shielding
• Sentinel lymphnode testing
• Mamography with shielding of contralateral breast
• Risk factors
• Caucasian
• Low parity
• Age (34 years)
• Examin BMI
• Genetic examination for BRACA 1 AND 2 to asses risk of ovarian and
endometrial cancer
• Ask about menstrual history
• Ask about intake radiotherapy
Best therapy
• Multidisciplinary team
• Modified radical mastectomy and axillary lymphadenectomy if
positive then chemotherapy as it has no adverse effect in second and
third trimester
• Breast reconstruction is delayed after puerperium to avoid prolonged
anasethia and allow breast symmetry
• Asses hormonal status ,grade of the tumour by histopathology
• Radiotherapy is contraindicated in pregnancy
• tamoxifen is contraindicated in pregnancy
Effect of chemotherapy
• Counsel patient about effect of chemotherapy on future fertility and gonadotoxicity
• If patient desires future fertility we can consider ovarian tissue cryopreservation at
time of delivery then consider delivery at 34 weeks then start chemotherapy
postpartum
• No adverse effect of chemotherapy in second and third trimester and no effect on
spontaneous preterm labour or SGA or anomalies
• Cyclophosphamide , anthracycline and 5 flurouracil can be used
• Anthracyclin may cause left ventricular dysfunction and so echo needed for follow
up
• Antimetabolites contraindicated in pregnancy
• Taxanes are used in lymphnode positive tumours.
Considerations
• MDT
• Consultant led antenatal follow up
• Reassurance
• Support groups to avoid depression and anxiety in pregnancy and
proper care of pregnancy and baby
• Counsel patient that pregnancy doesnot affect disease prognosis and
survival rate
• Reassure that if no metastasis the prognosis is good and high survival
• Symptomatic treatment for side effect of chemotherapy as
• pain :give paracetamol or opoids, vomiting :give antiemetic
 follo
• Serial growth scan in pregnancy
• we may induce delivery at 34 weeks to decrease exposure to chemotherapy and
complete treatment as radiotherapy or tamoxifen if estrogen receptor positive tumour
• Stop chemotherapy 3-4 weeks before delivery to allow recovery of bone marrow of
mother and fetus to avoid neutropenia and pan cytopenia and infection for mother
and fetus.
• Give antenatal steroids before delivery for lung maturity
• Mode of delivery according to obstetric indication.
• IF positive BRACA we may consider risk reducing surgery during cs by bilateral
salpingo oophorectomy after counselling the patient
• Guard against postpartum sepsis
• Breast feeding is contraindicated with chemotherapy as it is secreted in milk causing
neonatal neutropenia.
• Stop chemotherapy 2 weeks before breast feeding to allow clearance
• Avoid hormonal contraception
• Use non hormonal contraception .
• Pregnancy can be allowed again 2 years after treatment
• Pregnancy is contraindicated if metastatic disease or not cured
• Complications
• Metastasis
• Progression of disease
• Complications of prematurity
• Effect of chemotherapy
• Follow up with oncology unit for course of disease and response of tumour to
treatment
• And radiotherapy and tamoxifen can be given postpartum but not with breastfeeding.
•Thank you