Cancer in pregnancy Flashcards

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1
Q

Discuss breast cancer in pregnancy
-Incidence
-Most common type
-Investigations
-Staging investigations

A
  1. Incidence
    -1-4:1000 (most common cancer in pregnancy)
    -80% of breast lumps investigated in pregnancy are benign
  2. Most common type
    - ductal adenocarcinoma
    - More advanced stage
    - Lower oestrogen / progesterone receptor expression
  3. Investiagtions:
    -All women with a breast lump should be assessed by a breast specialist if present for >2weeks.
    -Ultrasound = first line 93% sensitivity
    -If ultrasound supicious then do mamography with fetal sheilding (68% sensitivity)
    -Ultrasound guided core biopsy for histology - grade, hormone receptor status
  4. Staging investigations
    -CXR and liver USS
    -Axillary USS and FNB for cytology
    -Targeted XR or MRI for metastases
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2
Q

Discuss treatment of breast cancer in pregnacy (4)

A
  1. Surgery
    -acceptable at any gestation
    -Delay breast reconstruction until after pregnancy
    -If axillary positive do full axillar clearence
    -If axillar neg do sentinal LN asessment
    -Surgery is non-breast sparing generally
  2. Chemotherapy
    -Contra-indicated in first trimester
    -OK in 2nd and 3rd trimesters
  3. Radiation
    -Contraindicated in pregnancy unless for life preserving measures
  4. Adjuvant therapy
    -Tamoxifen, trastuzumab are contra-indicated in pregnancy
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3
Q

What is the impact of:
-Pregnancy on breast cancer (1)
-Breast cancer on pregnancy, delivery and breast feeding (6)

A
  1. Impact of pregnancy on breast cancer
    -Doesn’t impact prognsis
  2. Impact of breast cancer on pregnancy
    -No known impact on adverse pregnancy out comes
    -If first trimester and treatment delayed duet o this can consider TOP
    -Most women can go to full term and aim NVD
    -Delivery should be 2-3 weeks post stopping chemo to avoid maternal neutropenia and fetal bone marrow supression
    -Can still breast feed from non surgically afected breast
    -Breast feeding contra-indicated if chemo ongoing, on tamoxifen or trastuzumab
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4
Q

Discuss contraception post breast cancer

A
  1. Avoid all hormonal contraception in curent or recent breast cancer
  2. OK to have hormonal contraception five yrs post breast cancer
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5
Q

Discuss previous breast cancer and fertility
-Who should be involved (1)
-Issues with timing of next pregnancy (3)
-Impact of treatment on fertility (6)
-Impact of pregnancy on breast cancer prognosis (1)

A
  1. Who should be involved?
    Women should consult their oncologist, breast surgeon and obsterician before embarking on pregnancy
  2. Timing of pregnancy
    -Delay pregnancy for 2 yrs after completion of treatment
    -Delay pregnancy for 5 yrs to allow for completion of tamoxifen in E receptor positive women.
    -Pregnancy should be delayed for 2-3 months post completion of tamoxifen
  3. Impact of treatment on fertility
    -Chemotherapy can be gonadotoxic
    -Infertility less likely with newer taxanes
    -Adjuvant therapy doesn’t impact fertility but can delay attempting pregnancy (Tamoxifen)
    -Women should be offered a discussion with fertility specialists to consider cryopreservation
    -Possible increased risk of miscarriage.
    -No impact to congenital malformations or still birth
  4. Impact on prognosis
    -Pregnancy is not thought to impact breast cancer prognosis
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6
Q

How should pregnancy be managed in a woman with previous breast cancer
-Preconception (1)
-Timing (2)
-Antenatal (3)
-Postnatal (2)

A
  1. Preconception
    -Make sure UTD with imaging
  2. Timing
    -2 yrs post treatment completion
    -2-3 months post completion of taxoxifen
  3. Antenatal
    -Have MDT input
    -If treated with doxirubicin/epirubicin consider echo as can rarely cause cardiomyopathy and LV dysfunction
    -Hormonal changes to breasts can cause asymmetry. May need temporary prostheses
  4. Postnatal
    -No evidence previous chemo affects breast feeding
    -Ideally don’t breast feed from an irradiated breast due to risk of mastitis
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7
Q

Discuss ovarian cancer and pregnancy
-Incidence of adnexal masses in pregnancy
-Incidence of malignant adnexal masses in pregnancy
-Types of adnexal masses in pregnancy
-Simple
-Complex
-Malignant

A
  1. Incidence of adnexal masses in pregnancy
    - 1-3% of pregnancies
  2. Incidence of malignant adnexal masses in pregnancy
    - of the adnexal masses in pregnancy 1-6% are malignant
  3. Types of adnexal masses
    Simple adnexal masses 1% = malignant
    -Most = functional cysts
    Complex adnexal masses 9% = malignant
    -Corpus luteum
    -Mature teratoma
    -Hydrosalpinx
    -Theca luteal cyst
    -Endometrioma
    -Cystadenoma
    Malignant adnexal masses
    -50% EOC of which 50% are boarderline
    -33% germ cell (75% dysgerminoma)
    -33% stroma/sarcoma/metastatic (50% of stroma are granulosa cells)
    -10% of adnexal masses that persist into second trimester are malignant
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8
Q

Discuss the diagnosis of adnexal masses in pregnancy
-Presentation
-Tumour markers
-Imaging

A
  1. Presentation
    -Usually incidental findings during USS or CS
    -Non specific abdo pain, back pain
    -Tortion - Occurs in 5% of pregnant women with an adexal mass
  2. Tumour markers
    -Pregnancy impacts levels of tumour markers and so should be interpreted with caution
    -Ca-125 raised in EOC. Can be raised in early gestation. Consider after 15 weeks
    -CEA - elevated in 3rd trimester but usually within normal range
    -CA19-9 - elevated in 3rd trimester but usually within normal range
    -AFP - normal rise in pregnancy. High in NTD. If >1000 then consider germ cell tumours
    -LDH - elevated in dysgerminoma. Reliable to use in pregnancy
    -Inhibin A. Not useful in pregnancy
    -HCG. Not useful in pregnancy
  3. Imaging
    -USS or MRI if USS unable to distinguish pedunculated fibroid from adnexal mass
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9
Q

Discuss the management of adnexal masses in pregnancy
-Characteristics which should prompt surgical resection
-Type of surgical resection
-Timing of resection
-Intra-operative considerations
-POst operative considerations

A
  1. Criteria for resection:
    Resect asymptomatic masses that are present after the first trimester if:
    - >10cm
    -Solid or cystic
    -Papillary areas or septae
    -Symptomatic
  2. Resection type
    -Cystectomy if looks like benign disease
    -USO if concern for malignancy
    -BSO if both ovaries look abnormal
  3. Timing of rescetion:
    Second trimester because:
    -Functional cysts have regressed
    -Organogenisis complete and so will avoid tetragenic impact
    -CL hormone function taken over by placenta
    -Spontaneous abortion rates reduced in second trimester
  4. Intraoperative considerations
    -Do frozen section
  5. Post operative ocnsiderations
    -If CL removed prior to 8/40 give progesterone
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