Cancer in pregnancy Flashcards
1
Q
Discuss breast cancer in pregnancy
-Incidence
-Most common type
-Investigations
-Staging investigations
A
- Incidence
-1-4:1000 (most common cancer in pregnancy)
-80% of breast lumps investigated in pregnancy are benign - Most common type
- ductal adenocarcinoma
- More advanced stage
- Lower oestrogen / progesterone receptor expression - 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 - Staging investigations
-CXR and liver USS
-Axillary USS and FNB for cytology
-Targeted XR or MRI for metastases
2
Q
Discuss treatment of breast cancer in pregnacy (4)
A
- 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 - Chemotherapy
-Contra-indicated in first trimester
-OK in 2nd and 3rd trimesters - Radiation
-Contraindicated in pregnancy unless for life preserving measures - Adjuvant therapy
-Tamoxifen, trastuzumab are contra-indicated in pregnancy
3
Q
What is the impact of:
-Pregnancy on breast cancer (1)
-Breast cancer on pregnancy, delivery and breast feeding (6)
A
- Impact of pregnancy on breast cancer
-Doesn’t impact prognsis - 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
4
Q
Discuss contraception post breast cancer
A
- Avoid all hormonal contraception in curent or recent breast cancer
- OK to have hormonal contraception five yrs post breast cancer
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
- Who should be involved?
Women should consult their oncologist, breast surgeon and obsterician before embarking on pregnancy - 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 - 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 - Impact on prognosis
-Pregnancy is not thought to impact breast cancer prognosis
6
Q
How should pregnancy be managed in a woman with previous breast cancer
-Preconception (1)
-Timing (2)
-Antenatal (3)
-Postnatal (2)
A
- Preconception
-Make sure UTD with imaging - Timing
-2 yrs post treatment completion
-2-3 months post completion of taxoxifen - 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 - Postnatal
-No evidence previous chemo affects breast feeding
-Ideally don’t breast feed from an irradiated breast due to risk of mastitis
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
- Incidence of adnexal masses in pregnancy
- 1-3% of pregnancies - Incidence of malignant adnexal masses in pregnancy
- of the adnexal masses in pregnancy 1-6% are malignant - 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
8
Q
Discuss the diagnosis of adnexal masses in pregnancy
-Presentation
-Tumour markers
-Imaging
A
- 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 - 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 - Imaging
-USS or MRI if USS unable to distinguish pedunculated fibroid from adnexal mass
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
- Criteria for resection:
Resect asymptomatic masses that are present after the first trimester if:
- >10cm
-Solid or cystic
-Papillary areas or septae
-Symptomatic - Resection type
-Cystectomy if looks like benign disease
-USO if concern for malignancy
-BSO if both ovaries look abnormal - 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 - Intraoperative considerations
-Do frozen section - Post operative ocnsiderations
-If CL removed prior to 8/40 give progesterone
