IMATY

Iglesias - Ligsay

41 year old, Female, nulligravid 10 weeks age of gestation

Chief complain: Bloody nipple discharge

HPI
3 weeks PTA- Bloody nipple discharge, Palpable mass on the right breast
No other associated symptoms.

Family history: No breast cancer

Obstetrical history: Menarche at 11 years old, regular menstrual periods
Personal/social history: Denies use of illicit drugs, non-smoker, non-alcoholic

Case
PG, 41 year old, nulligravid, at 10 weeks gestational age, presents with bloody
nipple discharge and a palpable mass on her right breast of three weeks duration.
There were no other associated symptoms.

She has no family history of breast cancer and denies any use of alcohol,
cigarettes, or intravenous drugs.

Menarche was at 11 years of age. She has regular menstrual periods and denies ever
using oral contraceptive pills.

OB history is unremarkable.
PE: Normal vital signs, BMI of 34.1. There was a firm, non-tender mass

SURGICAL ONCOLOGY
Lancero - Ledesma

GQ 1: What is the appropriate surgical plan for the case?

GQ #2: If you plan to do surgery, what type of surgical procedure is best for the
patient?

Treatment of breast cancer is by a multidisciplinary team that includes a

obstetrician, surgeon, and medical oncologist.
Treatment is similar to that of a nonpregnant patient, however chemotherapy is
delayed until the second and third trimesters as a neoadjuvant approach.
Radiation therapy is considered after the delivery of the fetus
Surgery is generally safe in pregnancy.
Chemotherapy administered during the first trimester carries a risk of spontaneous
abortion and a 12% risk of birth defects.
Radiation therapy has potential deleterious effects on the fetus, so radiation
cannot be considered until the fetus is delivered.

Modified Radical Mastectomy

Definitive procedure of choice in patients with stage I-III disease
Mastectomy and axillary lymph node dissection
Entire breast is removed, including the skin, areola, nipple, and most axillary
lymph nodes
Pectoralis major muscle is spared
Can be performed during the first and second trimesters of pregnancy, even though
there is an increased risk of spontaneous abortion after first-trimester
anesthesia.
Modified radical mastectomy is the single treatment modality that allows the
pregnancy to continue with minimal risk to both the mother and the fetus. A delay
in surgical intervention for breast cancer is as detrimental in a pregnant woman as
it is in a nonpregnant woman.

Because of the potential deleterious effects of radiation therapy on the fetus,

radiation cannot be considered until the fetus is delivered.

Modified Radical Mastectomy

Anatomic Boundaries
Lateral - anterior margin of the latissimus dorsi
Medial - midline of septum
Superior - subclavius muscle
Inferior - caudal extension of the breast 2 to 3 cm inferior to the inframammary
fold

Lumpectomy with Axillary Node Dissection

Not advisable
Can be considered in pregnant patients in the third trimester if adjuvant radiation
therapy is deferred until after delivery
Resection of the primary breast cancer
Breast conservative surgery
Sometimes called lumpectomy, quadrantectomy, partial mastectomy, or segmental
mastectomy. In this surgery, only the part of the breast containing the cancer is
removed.

Overall, breast-conserving surgery is not advisable in pregnant women. However,

breast-conserving surgery with axillary node dissection may be offered to women who
are diagnosed in the third trimester. In this situation, radiotherapy can be
delayed until after delivery of the baby. Women undergoing wide local excision
procedures should be warned that radiotherapy will be necessary to prevent local
recurrence and that further surgery may be required if surgical margins are not
disease-free. The maximum delay in initiating radiotherapy following breast
conserving surgery should be approximately 12 weeks, as delay in treatment
increases the likelihood of axillary metastasis by 0.028–0.057% per day.

Guide Question 3: When is the best time to do the surgery?

Important points:
Radiation therapy CANNOT be performed until the fetus is delivered
MRM - can be performed during 1st and 2nd trimesters
Increased risk of spontaneous abortion after 1st trimester anesthesia
Lumpectomy with LN dissection - during 3rd trimester, if adjuvant radiation therapy
is deferred until after delivery
Neoadjuvant chemotherapy - 2nd and 3rd trimesters (no evidence of teratogenicity)
Allows local therapy decisions to be made after delivery
12% risk of birth defects and spontaneous abortion if during 1st trimester
Schwartz’s Principles of Surgery, 10th ed.

GQ.4 How is breast cancer diagnosed in pregnancy, is it different from non-pregnant

patients?

Similar to non-pregnant women, the diagnosis of breast cancer in pregnancy is based

on clinical examination, histology, mammography and breast ultrasound with or
without magnetic resonance imaging (MRI).
Routine examination of the breast is not part of the general examinations for
pregnant women, in contrast to the Papanicolaou test (Pap smear) for early
detections of cervical cancer. Signs and symptoms should not be neglected and a
lump should be biopsied for histology if it does not disappear after 4 weeks, to
avoid unnecessary delays in the right diagnosis and treatment, even if 80% of
breast biopsies will prove to be benign.
Loibl, S., Han, S. N., & Amant, F. (2012). Being Pregnant and Diagnosed with Breast
Cancer. Breast Care,7(3), 204-209. doi:10.1159/000339674

Breast cancer in pregnancy: Recommendations of an international consensus meeting

Amant et.al - European Journal of Cancer 2010
This is due to the fact that Routine examination of the breast is not part of the
general examinations for pregnant women, in contrast to the Papanicolaou test (Pap
smear) for early detections of cervical cancer. There are no typical signs or
symptoms for BCP. BCP is not screen detected because general screening is not
indicated in this age group. Signs and symptoms should not be neglected and a lump
should be biopsied for histology if it does not disappear after 4 weeks, to avoid
unnecessary delays in the right diagnosis and treatment, even if 80% of breast
biopsies performed in pregnant women will prove to be benign (Etiologies include
lobular hyperplasia, fibroadenoma, cystic disease, galactocele, abscess, and
lipoma)

Pregnant woman may present with similar physical examination findings to

nonpregnant breast cancer patients such as a mass or palpable thickening of the
breast tissue
A delay in cancer diagnosis in pregnant breast cancer patients is secondary to
pregnancy and lactation, including increased size and density of the breast tissue
Pregnant breast cancer patients often present with an advanced disease stage and
with axillary lymph node involvement
Prognostic staging is the same as in a non-pregnant woman (Schwartz 10th ed.)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2753540/

Work Up for Breast Mass

Pregnancy-Associated Breast Cancer, Keyser et.al ,Rev Obstet Gynecol. 2012; 5(2):
94–99. PMCID: PMC3410508
MRI has not yet been prospectively studied for the diagnosis of breast masses in
pregnant or lactating women. The use of gadolinium during pregnancy is not widely
accepted. Gadolinium has been shown to cross the placenta and be associated with
fetal abnormalities in animal models

ULTRASOUND
routine imaging method during pregnancy
used to distinguish between cystic and solid breast masses and does not carry with
it any risk for fetal radiation exposure
It is usually used before mammography to evaluate a palpable lump

MAMMOGRAPHY
should be ordered in pregnancy with proper abdominal shielding. Radiation exposure
for the fetus is estimated at 0.4 cGy
According to the American Cancer Society, it's fairly safe to have a mammogram when
you're pregnant.

BIOPSY
Any clinically suspicious mass should be biopsied, even if the ultrasound and
mammogram are nondiagnostic. Fine needle aspirate (FNA) in the pregnant breast is a
well-established technique

BREAST MRI
According to the U.S. Food and Drug Administration, the safety of magnetic
resonance imaging (MRI) during pregnancy hasn't been established.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2753540/
MRI has not yet been prospectively studied for the diagnosis of breast masses in
pregnant or lactating women. The use of gadolinium during pregnancy is not widely
accepted. Gadolinium has been shown to cross the placenta and be associated with
fetal abnormalities in animal models

Liver metastases can be evaluated with ultrasound. Outside of pregnancy, evaluation

of bony metastasis is usually accomplished with a bone scan; however, in pregnancy
the radioactive technetium can be harmful to the rapidly developing fetal skeleton.
Therefore, evaluation for bony metastasis in pregnancy can be done with noncontrast
magnetic resonance imaging

Tissue diagnosis is with ultrasound-guided biopsy for histology rather than

cytology,as proliferative change during pregnancy renders cytology inconclusive in
many women.Histology is similar to that in age matched non-pregnant counterparts:
histological grade, receptor status and human epidermal growth factor receptor 2
(HER2) inform treatment planning
Bone scanning and pelvic X-ray computed tomography are not recommended because of
the possible effect of irradiation on the fetus.
Pregnancy and Breast Cancer , Green–top Guideline No. 12 March 2011 , Royal College
of Obstetricians and Gynaecologists
The pathologist should be informed that the specimen is from a pregnant patient
because pregnant breast tissue is rapidly dividing and can be confused with rapidly
dividing cancer cells

Bone scanning and pelvic X-ray computed tomography are not recommended because of
the possible effect of irradiation on the fetus.- In women who are not pregnant, X-
ray computed tomography (CT) and isotope bone scan are the preferred methods of
investigation to establish or exclude metastases.These methods are not appropriate
in women who are pregnant, in whom chest X-ray and liver ultrasound are preferred.
If there is concern about bone involvement, a plain film of the relevant area
and/or magnetic resonance imaging to minimise radiation exposure to the fetus is
suggested.

OBSTETRICS
Legaspi - Ligsay

What is the association of breast cancer and pregnancy?

BRCA1 and BRA2 mutation carriers
Lower hormone receptor expression
HER2 overexpression
Breast malignancies are the most frequent cancer found in pregnant women. And, as
more women choose to delay childbearing, the frequency of associated breast cancer
is certain to increase. (Amant, 2012)

Women with a genetic predisposition to breast cancer may be overrepresented among

pregnant women with cancer, although the available evidence is limited. In women
who inherit BRCA1 and BRCA2 mutations, the protective effect of multiparity on
breast cancer risk may be lost.

Most series report a lower frequency of estrogen receptor (ER) and progesterone
receptor (PR) expression in pregnancy-associated breast cancer compared to breast
cancer in nonpregnant patients (approximately 25 versus 55 to 60 percent). It is
thought that high levels of circulating steroid hormones during pregnancy may
interfere with ligand-binding assays or down regulate estrogen receptors found in
neoplastic cells and thus immunohistochemistry should be used for assessing tumour
receptor status.

Whether or not there is a higher incidence of human epidermal growth factor

receptor 2 (HER2) overexpression in pregnancy-associated breast cancer as compared
to nonpregnant controls is unclear
Prenatal Care in Medical and Surgical Management
Weigh benefits and risks of delaying treatment
Prenatal visits are normally done,
✦every 4 weeks until 28 weeks,
✦every 2 weeks until 32 weeks,
✦every week until delivery.

High Risk Pregnancy

Every 1-2 weeks

Ultrasound
Fetal heart rate, fetal growth, amniotic fluid volume and fetal activity
Maternal BP, weight, other vitals signs (HR, Temperature, RR)
Lab tests such as CBC, Urinalysis, FBS
Symptoms (Bleeding, headache, altered vision, abdominal pain, nausea and vomiting,
dyspnea)

Surgical Risk for Mother and Fetus

Well tolerated by both mother and fetus
Classically been deferred until 12 - 14th weeks AOG to minimize abortion risk
If maternal well being is imperiled it can be performed regardless of gestational
age
Risk for thromboembolism
Pneumatic compression
LMWH

Chemotherapeutic Risk for Mother and Fetus

Chemotherapy often improves long-term maternal outcomes however there are several
fetal concerns which we should consider. The considerations are:
Malformations
Growth restrictions
Mental Retardation
Risk of future malignancies

Chemotherapeutic Risk for Mother and Fetus

Risks are dependent primarily on fetal age at exposure and most agents are
potentially detrimental when given on the first trimester of pregnancy
Chemotherapy in the 1st trimester:
Antimetabolites (methotrexate) and alkylating agents (cyclophosphamide) associated
with miscarriage and malformations
When pregnant women with early breast cancer needs chemotherapy after surgery
(adjuvant), it’s usually delayed until at least the second trimester
Chemotherapy in 2nd and 3rd trimesters:
NO increase risk in risk of malformation
Anthracycline based treatments
Chemotherapy should not be given after 35 weeks of pregnancy or within 3 weeks it
can lower the mother’s blood count

Radiotherapeutic Risks for the Mother and Fetus

Therapeutic radiation often results in fetal exposure
Amount depends on tumor size, location, dose
Organogenesis (1st trimester) – most susceptible period; but no gestational age is
considered safe
Malformations, retardation, growth restriction
Risks dependent primarily on gestational age

Risk are dependent on AOG

Given on the second trimester
Do not give during first trimester (miscarriage and malformation may occur)
Stop at 35 weeks AOG or 2-4 weeks before ETD
Allow fetal excretion of drugs
Prevents neutropenic mother and child during delivery and post partum age
4. When will you recommend giving chemotherapy

MEDICAL ONCOLOGY
Kinoshita - Lacson, JM

Surgery vs Chemotherapy
Our patient is 41 years old, nulligravid, at 10 weeks age of gestation. According
to the NCCN Guideline of the breast cancer management in the pregnancy, patient who
is confirmed to have breast cancer diagnosis (in our case it is confirmed by core
needle biopsy as invasive ductal carcinoma) without distant metastasis (our patient
has mass at the right axilla, but it is considered as regional metastasis and other
imaging showed no masses), and at 1st trimester, termination of the pregnancy is
discussed. If the patient wishes to continue her pregnancy, then the primary
treatment is surgical resection by modified radical mastectomy. Axillary lymph node
dissection is recommended in all invasive ductal carcinoma where nodal involvement
is high. Breast surgery is is done safely in all trimesters with negligible risk to
fetus.

After the primary treatment by surgery, patient may begin the adjuvant treatment by
chemotherapy starting 2nd trimester and/or radiation therapy or endocrine therapy
postpartum.

Estrogen-receptor-positive (or ER+) if cancer has receptors for estrogen

Progesterone-receptor-positive (PR+) if it has progesterone receptors
This suggests that the cancer cells may receive signals from estrogen or
progesterone that could promote their growth
ER(+) and PR(+) cancers are likely to respond from hormonal therapy (Ie anti-
estrogen)
Her2/Neu- in 25% of breast cancers, HER2 gene doesn't work correctly and makes too
many copies of itself (Her2 amplification)
HER2-positive breast cancers tend to grow faster
more likely to spread
Importance of Hormonal Panel Result
BreastCancer.Org Pathology report guide (2017).
Why is knowing the hormone receptor status important?
Because it this will affect our medical management. Certain drugs are used to treat
breast cancers that have one or both of ER or PR receptors. Most types of hormone
therapy for breast cancer either lower estrogen levels or stop estrogen from acting
on breast cancer cells. This kind of treatment is helpful for hormone receptor-
positive breast cancers, but it doesn’t work on tumors that are hormone receptor-
negative (both ER- and PR-negative).##All invasive breast cancers should be tested
for both of these hormone receptors either on the biopsy sample or when the tumor
is removed with surgery. About 2 of 3 breast cancers have at least one of these
receptors. This percentage is higher in older women than in younger women. DCIS
should be checked for estrogen receptors, too.
Testing for hormone receptors is important because the results help you and your
doctor decide whether the cancer is likely to respond to hormonal therapy or other
treatments. Hormonal therapy includes medications that either (1) lower the amount
of estrogen in your body or (2) block estrogen from supporting the growth and
function of breast cells. If the breast cancer cells have hormone receptors, then
these medications could help to slow or even stop their growth. If the cancer is
hormone-receptor-negative (no receptors are present), then hormonal therapy is
unlikely to work. You and your doctor will then choose other kinds of treatment.

Treatments for HER2-positive breast cancer

There are some treatments available specifically for HER2-positive breast cancer.
Such as
Herceptin (chemical name: trastuzumab), which works against HER2-positive breast
cancers by blocking the ability of the cancer cells to receive chemical signals
that tell the cells to grow.
Kadcyla (chemical name: T-DM1 or ado-trastuzumab emtansine), a combination of
Herceptin and the chemotherapy medicine emtansine. Kadcyla was designed to deliver
emtansine to cancer cells in a targeted way by attaching emtansine to Herceptin.
Herceptin then carries emtansine to the HER2-positive cancer cells.
Perjeta (chemical name: pertuzumab); like Herceptin, Perjeta works against HER2-
positive breast cancers by blocking the cancer cells’ ability to receive growth
signals.
Tykerb (chemical name: lapatinib), which works against HER2-positive breast cancers
by blocking certain proteins that can cause uncontrolled cell growth.

According to NCCN guidelines, recommended single agent chemotherapeutic agents are

anthracycline-‐containing or taxane-‐containing or both

Anthracycline-‐containing (Doxorubicin)

Taxane-‐containing (Paclitaxel)

Chemotherapy

Chemotherapy
Chemotherapy often improves long-‐term maternal outcomes however there are several
fetal concerns which we should consider. The considerations are:

• Malformations
• Growth restrictions
• Mental retardation
• Risk of future malignancies

Chemotherapy often improves long-‐term maternal outcomes however there are several
fetal concerns which we should consider. The considerations are:
• Malformations
• Growth restrictions
• Mental retardation
• Risk of future malignancies

Chemotherapy
• Risks are dependent primarily on fetal age at exposure and most agents are
potentially detrimental when given on the first trimester of pregnancy
• When a pregnant woman with early breast cancer needs chemo after surgery
(adjuvant chemo), it’s usually delayed until at least the second trimester
• Chemotherapy should not be given after 35weeks of pregnancy or within 3 weeks of
delivery because it can lower the mother’s blood counts
Staging of Breast Cancer

Harrison’s Principles of Internal Medicine 19th edition p527

Harrison’s Principles of Internal Medicine 19th edition p527

Patient’s Stage: STAGE 1A

T: 2cm x 1.5cm (firm, non tender, right breast mass located upper outer quadrant)
N: (-) palpable axillary lymph nodes
M: no evidence of metastasis

PATHOLOGY
Iglesias - Javier

Breast Lesions
BENIGN
MALIGNANT
Smooth, rubbery
Often painful
Well-defined
Easily moves under skin
Skin dimpling unlikely
May have green/yellow coloured nipple discharge
No nipple retraction

Hard consistency
Painless (pain in 1/100)
Irregular edge
Fixation to skin or chest wall
Can cause dimpling of the skin
May have unilateral, bloody nipple discharge
Can have nipple retraction

“Differentiate benign from malignant breast lesions based on pathologic features”

Fibrocystic changes accounts for most of the signs observed in benign tumors.

A general lumpiness that can be described as “ropy” or “granular,” these lumps are
the most commonly seen benign breast condition, affecting at least half of all
women. Other symptoms include tenderness, fibrous, rubbery tissue; a thickening of
tissue; or a round, fluid-filled cyst. These changes, related to hormone
fluctuation, may increase as you approach middle age and then disappear with
menopause.

In contrast, the characteristics of a malignant tumor is usu accounted for the

presence of the growing mass itself which unlike benign tumors who stay in place,
these types of tumors invade other structures pulling on them causing the dimpling
and nipple retraction. This also accounts for the uneven shape, irregular edge or
appearance of most of these tumors. It is said that another factor which
contributes to this is the lack of a capsule which is observed in benign tumors but
not in malignant ones. Both types are initially moveable due to their small size
but malignant tumors become fixed almost eventually as they invade and hold on to
other structures.

Sometimes women experience nipple discharge with or without a breast lump. The
color of nipple discharge related to benign fibrocystic changes can vary from
yellow to green. A clear to milky discharge may mean a hormonal malfunction. Green-
black discharge could be related to duct ectasia, a narrowing or blockage of the
duct. It can even be bloody in appearance, which can, in fact, mean cancer. More
than likely though, a red discharge means injury, infection, or a benign tumor.

Amount of gland formation

Nuclear features
Mitotic activity

The final total score is used to determine the grade:

Grade 1 tumors have a score of 3-5
Grade 2 tumors have a score of 6-7
Grade 3 tumors have a score of 8-9
Grading of Breast Cancer
There are different coring system available for determining the grade of a breast
cancer. One of these systems is the Nottingham Histologic score system. There are 3
factors that the pathologist take into. consideration:
how well the tumor cells try to recreate normal glands)
(pleomorphism or how ugly the tumor cells look)
(how much the tumor cells are dividing)

Each of these are scored from 1-3 and then each score is added to give a final
total score ranging from 3-9.

Grading of Breast cancer

Glandular (Acinar)/ Tubular Differentiation

Score 1: >75% of tumor area forming glandular/ tubular structures

Score 2: 10%-75% of tumor area forming glandular/ tubular structures
Score 3: <10% of tumor area forming glandular/ tubular structures
http://www.breastpathology.com
http://pathology.jhu.edu/breast/grade.php

Nuclear Grading

Score 1
Nuclei small with little increase in size, regular outlines, uniform nuclear
chromatin, little variation in size

Score 2
Cells larger than normal with open vesicular nuclei, visible nucleoli, and moderate
variability in both size and shape

Score 3
Vesicular nuclei, often with prominent nucleoli, exhibiting marked variation in
size and shape, occasionally with very large and bizarre forms
Grading of Breast Cancer
http://pathology.jhu.edu/breast/grade.php
http://www.breastpathology.info/Grading.html
Nuclear Grading is the evaluation of the size and shape of the nucleus in the tumor
cells.

https://www.cancer.gov/about-cancer/diagnosis-staging/prognosis/tumor-grade-fact-
sheet
There are 3 scores

Score 1 is
Score 2 is
Score 3 is …..

Mitotic Grading

Score 1
less than or equal to 7 mitoses per 10 HPF
Score 2
8-14 mitoses per 10 HPF
Score 3
equal to or greater than 15 mitoses per 10 HPF
Grading of Breast Cancer
http://tvmouse.ucdavis.edu/bcancercd/311/images/MitoticCounts.html
http://pathology.jhu.edu/breast/grade.php
(deo)Mitotic grading is as follows:

Score 1: less than or equal to 7 mitoses per 10 high power fields

Score 2: 8-14 mitoses per 10 high power fields
Score 3: equal to or greater than 15 mitoses per 10 high power fields

RADIOLOGY
Jurilla - King, R

“Breast Imaging Reporting & Data System” developed by American College of Radiology
in 1993 - standardized classification for mammographic studies
Risk assessment and quality assurance tool to make the reporting of mammograms
comprehensible to the non-radiologist reading the report
BIRADS
Eberl, M. M., Fox, C. H., Edge, S. B., Carter, C. A., & Mahoney, M. C. (2006). BI-
RADS Classification for Management of Abnormal Mammograms. The Journal of the
American Board of Family Medicine,19(2), 161-164. doi:10.3122/jabfm.19.2.161
Table presents BI-RADS classifications and management recommendations as an
evidence table
Classifications are divided into assessments (categories 0, 1, 2, 3, 4, 5, 6)
Possible outcomes: (1) additional imaging studies, (2) routine interval
mammography, (3) short-term follow-up, and (4) biopsy
All categories reflect the radiologist’s level of suspicion for malignancy, and
these assessment categories have been shown to be correlated with the likelihood of
malignancy

Mammography
Normal
BI-RADS 4B
Burivong, W., Amornvithayacharn., O. 2011. Accuracy of subcategories A, B, C in BI-
RADS 4 lesions by combined mammography and breast ultrasound findings. Journal of
Medicine and Medical Sciences Vol. 2(3) pp. 728-733
LEFT: normal

RIGHT: BIRADS 4B: Mammogram of right breast shows a lobulated shape with indistinct
border lesion at lower inner quadrant. (The final pathology is mucinous carcinoma)

Mammography Findings typical of BIRADS 4

Asymmetric, localized or evolving hyperdensities with convex contours
Indeterminate microcalcifications appearing amorphous and indistinct particularly
if in a cluster or heterogeneous and pleomorphic
Round or oval non cystic opacities with microlobulated or obscured contours

Positive predictive value of BI-RADS 4B for breast cancer is 36%

This category (BIRADS 4) is reserved for findings that do not have the classic
appearance of malignancy but are sufficiently suspicious to justify a
recommendation for biopsy.

Raza, S., Goldkamp, A., Chikarmane, S., Birdwell, R. (2010). US of Breast Masses
Categorized as BI-RADS 3, 4, and 5: Pictorial Review of Factors Influencing
Clinical Management. Radiology Society of North America
BI-RADS 4: US

INTRO:
The US lexicon includes six morphologic features of solid breast masses: shape,
orientation, margin, lesion boundary, internal echo pattern, and posterior acoustic
features. Shape is described as oval, round, or irregular; and the orientation of a
mass can be described as parallel or not parallel (often described as “taller-than-
wide” or “vertical,” which includes round). Margins. The margins of solid breast
masses on US images should be categorized as either circumscribed or
noncircumscribed. (a) Circumscribed margins (arrows) are well defined, with an
abrupt transition between the lesion and the surrounding tissue. Noncircumscribed
margins include microlobulated, indistinct, angular, and spiculated. A mass with
noncircumscribed margins should be categorized as either BI-RADS 4 or 5, with a
recommendation for biopsy.Internal echo pattern. The echo pattern, or echotexture,
of a lesion on US images is described in reference to the echo pattern of the
subcutaneous fat within the breast. The lesion (arrows) is described as hypoechoic
(a), isoechoic (b), or hyperechoic (c) relative to the fat (arrowheads). Posterior
acoustic features (Fig 4) may or may not be seen when imaging solid masses.
Posterior acoustic shadowing is a suspicious finding and may be seen in cases of
invasive carcinoma, postoperative scar, complex sclerosing lesion, or
macrocalcifications and may even be seen in patients with dense breast tissue.
RIGHT: US image of a 47-year-old woman with a vague right breast density on a
screening mammogram (not shown) shows a hypoechoic mass (arrows). Histologic
findings from core-needle biopsy disclosed ductal carcinoma in situ. Pathologic
concordance is particularly important for category 4B lesions, given that both
malignant and benign lesions can be evenly distributed in this group. Recommended
BI-RADS description is a hypoechoic irregular mass with indistinct margins, a
heterogeneous internal echo pattern, and parallel orientation: BI-RADS 4B.

BIOETHICS
Jimenez - Juan Loa

Ethical Issues
How will breast cancer affect:
Pregnancy of the mother
Should she undergo chemotherapy/radiotherapy?
What will happen to the pregnancy?
Will it affect the health of the mother?
Health of the baby
Effects of chemotherapy/radiotherapy on the baby?
Health of mother VS health of baby?
Lactation
Is it safe to breastfeed? If not, how will the baby receive sustenance for the
first months of life?
Principles Involved
Pregnant mother
Autonomy
Totality
Double effect
Mother VS unborn child
Nonmaleficence
Beneficence
Unborn child
Inviolability of life

Autonomy
Self governance
Allow the pregnant mother to make decision
Free and informed consent. It is her body.
Breast cancer
Should I undergo treatment?
Chemotherapy or Radiotherapy or Surgery?
Will it affect my pregnancy?
Pregnancy
What will be the effect of cancer treatment on my unborn child?
Priority: Treat cancer or protect pregnancy?
Best options for the mother?

Totality
Surgery: Mastectomy
The principle of totality → care for all parts of the human body (Whole > Parts)
Sacrifice a part ONLY if:
It harms the whole human body
No alternative
Removal does not destroy intrinsic nature effort to compensate
Conflicts: Breastfeeding

Double Effect
According to the principle of double effect, it is morally permissible to perform
an act that has both a good effect and bad effect if all of the following
conditions are met:
The act to be done must be good in itself or at least indifferent
The good effect must not be obtained by means of the bad effect
The bad effect must not be intended for itself, but only permitted
There must be a proportionately grave reason for permitting the bad effect

Double Effect
Mastectomy
“In the absence of metastatic disease, either a wide excision or a modified or
total mastectomy - each with axillary node staging - can be performed (Rosenkranz,
2006 & Woo, 2003)”
Breast feeding
“There are also no data indicating that lactation adversely affects the course of
previously diagnosed breast cancer. Also, lactation and breastfeeding are possible
after conservative surgery and radiation of the treated breast (Higgins, 1994)” -
William’s Obstetrics

Nonmaleficence
DO NO HARM
Chemotherapy
“Chemotherapy is usually given with either positive or negative node breast
cancers. In pre-menopausal women, survival is improved even if lymph nodes are
cancer free.”
Radiotherapy
Mammography
“Mammography is appropriate if indicated, and fetal radiation risk is negligible
with appropriate shielding.”
Pregnancy following breast cancer
“After breast cancer treatment, chemotherapy will render some women infertile, and
options for childbearing are limited (Kim, 2011)”
For those who became pregnant, there appear to be no adverse effects on long-term
maternal survival rates (Avarette, 1999 & Velentgas, 1999)”

Beneficence
DO GOOD
What’s best for BOTH the mother and the unborn child

Inviolability of life
If treatment modalities of the breast cancer affects the fetus,
“Life is sacred” (from conception to natural death)
PROTECT LIFE
Life of baby = Life of mother
Choose the best treatment option that will contribute least harm to unborn child!
“Most evidence does not suggest increased maternal survival following therapeutic
abortion” - SOGC Clinical Practice Guidelines

Ethical Considerations
ALWAYS balance maternal and fetal interests
Consider cancer type, stage, age of gestation, maternal and fetal risks
Discuss situation with pregnant patient AND family, providing all treatment
alternatives
Have a multidisciplinary team:
Family physician, hematologist and/or oncologist, OB-GYN, social worker,
psychologist, and in some cases, a religious advisor
Cancer Chemotherapy and Pregnancy, SOGC Clinical Practice Guidelines

Summary:
41yo, Female, nulligravid
Chief complain: Bloody nipple discharge
PE: Right breast mass (2cmx1.5) irregular, 2cm firm movable mass at right axilla
Workup→ Ultrasound (if suspect malignancy: Mammogram with abdominal shield)
Important to establish Benign vs Malignant, Staging, Grade, Hormonal panel
(HER2/Neu, ER, PR +/-)
Mammography, BIRADS
Management: Modified radical mastectomy
Definitive for Stage 1-3
Safe in pregnancy
Ethical principles: Autonomy, Totality, Double effect, Non-maleficence,
Beneficence, Inviolability of life
BIRADS
standardized classification for mammographic studies
Risk assessment and quality assurance tool to make the reporting of mammograms
comprehensible to the non-radiologist reading the report
ALWAYS balance maternal and fetal interests
Consider cancer type, stage, age of gestation, maternal and fetal risks
Discuss situation with pregnant patient AND family, providing all treatment
alternatives
Have a multidisciplinary team:
Family physician, hematologist and/or oncologist, OB-GYN, social worker,
psychologist, and in some cases, a religious advisor