Breast: Special Populations

Prognosis

• Worse Prognosis During Pregnancy
• Predominantly Poorly-Differentiated & Diagnosed at an Advanced Stage
• Lower Frequency of Hormone Receptor (ER/PR) Expression – About 25%
• Physical Exam More Difficult Due to Engorgement & Hypertrophy
• Mammography Less Sensitive Due to Edema, Increased Density & Loss of Fat

Diagnosis

• Diagnostic Work-Up Should Proceed as Normal
• Mammogram Not Contraindicated Due to Pregnancy
  • Use Abdominal Shield to Protect Fetus

Treatment

• Primary Lesion:
  • Early: Mastectomy
  • Late: Mastectomy vs. Breast-Conserving Therapy (BCT) with Delayed Radiation Therapy
• Lymph Node Management:
  • SLNB is Generally Preferred for Lymph Node-Negative Women (Debated)
  • Only Use Radioactive Colloid (Dye is Teratogenic)
  • ALND May Also Be Considered – Some Believe the Lymphatic Pathways May Be Altered Making Sentinel Node Identification More Difficult
• Radiation Therapy (RT):
  • Never Use in Pregnancy, Delay Until After Delivery
  • Risk for Pregnancy Loss, Malformation, Growth Disturbance or Mutation
• Medical Therapies:
  • Hormonal Therapy: Never Use in Pregnancy, Delay Until After Delivery
  • Immunotherapy (Trastuzumab): Never Use in Pregnancy, Delay Until After Delivery
  • Chemotherapy:
    • First Trimester: Never
      • Risk for Malformation During Organogenesis
    • Second-Third Trimesters: Use vs. Delay Until After Delivery
      • Risk for Intrauterine Growth Restriction, Prematurity & Low Birth Weight
      • Choice Made on an Individual Basis

Management by Trimester

• First Trimester: MRM
  • May Consider Mastectomy with SLNB (Debated)
• Second/Third Trimester:
  • Options:
    • MRM
    • Mastectomy with SLNB (Debated)
    • BCT with Delayed Radiation Therapy (If Later in Second-Third Trimester)
  • Selective Chemotherapy