BREAST CANCER Specific situations. Dr.Ayşenur Oktay Med School Ege University, Izmir, TR

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1 BREAST CANCER Specific situations Dr.Ayşenur Oktay Med School Ege University, Izmir, TR

2 Breast cancer: Specific situations Pregnant women/ lactation Young/ old patients Occult breast cancer Inflammatory breast cancer Male cancer Paget disease Malignant filloid tm Sarcomas

3 Pregnancy associated breast ca During pregnancy or first postpartum year Most common malignancy during pregnancy ( 1/ 3000 ) Accounting for 1-3% of all breast cancers Poor prognosis ( late diagn, delayed tratment, agrr hist ) Genetic screening recommended Most common symptom: Mass 70-80% of all masses are benign

4 Breast in pregnancy- lactation Proliferative changes Volume, parenchymal density/ ekojenite/ vascularity - Difficult clinical exam Sensitivity; MG: 63-90% US: %

5 Breast imaging in pregnant/ lactating women Breast US first line imaging modality Suspicious US / suspicious clinical findings / risk / malign bx MG MG X-ray dose: without abdominal protection Gy ( Fetal deterministic effect > Gy ) Recommendation: Don t do MG in first trimestr of pregn Single position MLO view Digital MG NCCN ; mammography of the breast with shielding can be safely done

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7 37 yo women With history of 2 months of lactation R breast mass

8 BİRADS 4C Which biopsy method? Local staging/ surgery planning- MRI?

9 Histologic diagnosis FNA insufficient (false positive/ negative results) Cor bx- sensitivity 90% Local anestesia- safe Milk fistulas- rare Bleeding/ infection

10 MRI in pregnancy- lactation Limited role in pregnancy- Accuracy? Safety? IV Gd cross placenta / difficult positioning MRI not typically done In pregnancy +C MRI only benefit/ risk ( Therapy planning ) In lactating breast can be used

11 Use if it is considered critical Potential benefits are higher than risks Low risk contrast media for NSF (Gadobenate dimeglumine and Gadoterate meglumine) Not use in first trimestr In lactating patients, stop breast feeding 24 hr ACR Committee on Drugs and Contrast Media. ACR Manual on Contrast Media Version

12 2 months of lactation T2 +C

13 Diffusion MRI MR-spectroscopy

14 Screening for metastasis: Chest x-ray, abdominal US, bone MRI/ scintigraphy (in cases of uncertain MRI findings) Risk after delivery

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16 Breast cancer in young women: young women under the age of 40 7%-8.8% of all breast cancers More aggressive and worse outcomes Early diagnosis remains a challenge (screening mg not recommended) Gene mutations more frequent

17 30 yo women R breast pain US recommended

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23 Inflammatory carcinoma 1-6% of all breast cancers Tm emboli in dermal lymphatics Clinical findings; Distant metastasis in 20-30% cases at time of diagnosis Imaging; Demonstrate primary tumor bx / planning NACT Screening metastasis PET-CT

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25 NAC

26 Lepori D. Diagn Interv Imaging 2015

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28 51 yo women Skin thickening after 8 years of breast conserving surg+ Rth

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30 Skin biopsy: Angiosarcoma (secondary to Rth)

31 Secondary angiosarcoma Following Rth to breast Most common after 5-10 years of Rth Typically involve skin, parenchma may be normal Clinical exam difficult DD: IBC, fibrous histiocytoma, cellulitis MG and US are not patognomonic Progressive skin thickening bx

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33 Occult karsinom 0.3-1% of all breast cancer Occult on clinical exam, MG and US (TXN1M0) (TXN0M1) MRI sensitivity % spesifity % MRI detected lesion MRI bx

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35 Multidiciplinary conference - Ege University Medical School