BREAST CANCER IN PREGNANCY

M.I. Nor Azlin[a], *M. Rohaizak[b], M.R. Zainul Rashid^a, I. Fuad[c], F.A Meah^b

Having fear of breast cancer in a woman’s life time is natural, as breast cancer is the female’s main killer. Breast cancer in the child bearing age in the Malaysian population is no longer uncommon. The increasing awareness and health conscious among women nowadays has made early detection of breast cancer possible especially during pregnancy. Even so, the acceptance of the disease varies among them which somehow affects further management processes. In our report, three cases of breast cancer in pregnancy were managed differently. In the first case, breast cancer was diagnosed in the first trimester of the pregnancy in which termination was performed. The second case was diagnosed in the second trimester and ended up with a successful pregnancy. The final case, in which the breast lump was noted during pregnancy, however was only diagnosed as breast cancer in the post partum period. Each of these three cases had different management processes.

Breast cancer has been reported to be the major malignant disease killing the species of female human beings. It is therefore not an abnormal feeling for a woman to fear the disease in her life time. The incidence of breast cancer-related pregnancy is ranging from 0.7 to 3.9%¹. In the Malaysian population, breast cancer in the child bearing age is no longer uncommon although the true prevalence is unknown. Early detection is made possible due to the increasing awareness and health consciousness especially during pregnancy. Despite this, the management of breast cancer in pregnancy still remains difficult and tailored individually. This series showed three patients with different approach of management.

Madam NZAR, a 35 year old housewife G₄P₃ at 8 weeks period of amenorrhoea (POA) was referred for a left breast lump in pregnancy. She noticed the lump 3 months prior to conception. It was not painful and was progressively getting bigger. Her last child birth (LCB) was 10 months prior to this unplanned pregnancy. Examination revealed a 6 x 6 cm left breast lump. Fine-needle aspiration cytology (FNAC) was performed and the result showed infiltrating ductal carcinoma. The patient and her husband were counseled on the disease and her pregnancy. They decided to have termination of pregnancy (TOP) and agreed to further management of breast cancer. The mammogram shows cluster of micro calcification at the left upper outer quadrant with architecture distortion (Figure 1)

Left mastectomy and axillary clearance were performed on the same day with TOP. An intra uterine device (IUD) was inserted on day 3 post-operative as a method of contraception and the patient was discharged home well. The histo-pathological examination (HPE) result confirmed an infiltrating ductal carcinoma grade 2 with negative expression for estrogen (ER) and progesterone receptors (PR). Madam NZAR had completed 6 courses of chemotherapy which involved cyclophosphamide(C), doxorubicin(A) and 5-flurouracil (F) . She further had radiotherapy with minimal adverse side effects.

Madam NAK a 32 year old bank officer, G₃P₂ at 20 weeks POA was referred for further management of right breast cancer in pregnancy. She noticed a right breast lump which was associated with an inverted nipple since 16 weeks POA when she first presented to her private gynaecologist. The lump was 10 x 10 cm and FNAC revealed an infiltrating ductal carcinoma. A multidisciplinary team involving an obstetrician, a breast surgeon, an oncologist, and a neonatologist was managing her.

The couple was counseled on the disease process and the effect on the pregnancy as well as the fetus. They decided to continue with the pregnancy at the same time agreed to surgical intervention followed by adjuvant therapy. A right mastectomy and axillary clearance were performed at 21 weeks of POA. The patient had no complication and the pregnancy was progressing well. The HPE result showed a tumour size of 11 x 11 x 2.5 cm with final diagnosis of infiltrating ductal carcinoma Grade 2 with positive PR and negative ER. At 26 weeks, corticosteroid injections for fetal lung maturity were started. Elective delivery at 34 weeks POA ended with SVD of a normal baby boy weighing 2.2 Kg with good APGAR score. The delivery was uncomplicated and IUD was inserted at 6 weeks post-partum. However the baby developed hypoglycaemia and congenital pneumonia and was warded in the NICU for 2 weeks. Madam NAK had total of 4 cycles of AC two of them during pregnancy. Subsequently, she had radiotherapy after completing her chemotherapy.

Madam SH, 27 year old teacher in her first pregnancy presented with a right breast lump at 14 weeks POA. FNAC revealed fibroadenoma for which conservative management was decided. The pregnancy progressed well until she was diagnosed to have placenta praevia. The breast lump was increasing in size and an excision biopsy was performed at the same time of caeserian section. The HPE of the breast lump revealed an infiltrating ductal carcinoma with involved surgical margin. The patient initially refused further surgery but after subsequent consultation with the couple, they finally agreed to mastectomy with axillary clearance which was performed on day 23 post-partum.

The surgery was uncomplicated and the patient was discharged home well with subsequent adjuvant therapy. The final HPE showed a tumour of 2.5 x 2 x 3 cm with malignant cells in sheets intersected by dense fibrous tissue with moderate pleiomorphic vesicular nuclei and cytoplasm. The final diagnosis was infiltrating ductal carcinoma grade 2 with negative ER and PR.

Breast masses are frequently encountered during pregnancy, like those in non-pregnant women of child bearing age, are mostly are benign. Pregnant women with breast cancer tend to be younger and more likely to have unfavourable prognostic features. The earlier belief was that the aggressiveness of the cancer was due to continued stimulation by high levels of pregnancy hormones. But recent evidence has shown that the mortality of breast cancer during pregnancy is related to delay in presentation and if compared stage for stage to non-pregnant controls, the prognosis is similar².

Diagnosis of breast cancer during pregnancy by fine needle aspiration cytology is difficult as the physiological changes modify the breast architecture, as illustrated in our case 3. A mammogram is difficult to interpret due to increased breast density, vascularity, and water content during pregnancy. Max and Klamer showed that 6 of 8 pregnant patients with breast cancer had ‘normal’ mammograms³. Only one of our patients (case 1) had mammographic changes suggesting malignancy. Open biopsy may be needed if there is a high level of clinical suspicious as performed in the case 3. Careful serial examination is still the cornerstone of detection and even more important during pregnancy.

Surgical intervention should not be delayed and the pregnancy may confidently be continued. Awaiting fetal viability prior to surgery has not been proven to be beneficial to the mother or the fetus. Adjuvant chemotherapy is potentially teratogenic and carries a small incidence of malformation especially if given during the teratogenic period. Shapira and Chudley reported 12.7% fetal malformation when the chemotherapy was given in the first trimester⁴. The effect of chemotherapy is less if given during the second and third trimester. Berry et al. found in his series of 24 pregnant patients with breast cancer that there were no antenatal complications and also reported normal birth weight and neonatal health⁵. However, radiotherapy is best avoided during pregnancy due to potential teratogenicity. After proper counseling with the patients, partners and managing teams, all of our patients had mastectomy with axillary clearance with the adjuvant therapy given during and/or after either completion of pregnancy or termination of pregnancy.

A multidisciplinary approach involving obstetricians, surgeons, oncologists, and neonatologists is mandatory for the best treatment without jeopardising the fetus or compromising the health of the mother. Adequate counseling should be given prior to any decision-making and should be tailored according to each patient’s needs. Despite the above, at the end of the day, the decision on the management comes from the patient’s wishes as shown in these cases. The treatment should be what is the best for the patient and not what is the best for the doctor.

REFERENCES

[a] Department of Obstetric and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaakub Latiff, Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia. Telephone
603-91703043. Telefax 603-91738946. E-mail: norazlin366@hotmail.com

[b] Department of Surgery, Universiti Kebangsaan Malaysia, Jalan Yaakub Latiff, Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia

[c] Department of Oncology, Faculty of Medicine, , Universiti Kebangsaan Malaysia, Jalan Yaakub Latiff, Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia

BREAST CANCER IN PREGNANCY: THE CASE SERIES OF DIFFERENT MANAGEMENTS.

REFERENCES