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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 2  |  Page : 46-48

Clinicopathological features, treatment, and outcome of pregnancy-associated breast cancer in Ahmadu Bello University Teaching Hospital, Zaria, Northwestern Nigeria


Department of Surgery, Breast and Endocrine Unit, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Submission02-Feb-2019
Date of Decision16-Apr-2019
Date of Acceptance02-May-2019
Date of Web Publication20-Jan-2020

Correspondence Address:
Peter Pase Abur
Department of Surgery, Breast and Endocrine Unit, Ahmadu Bello University Teaching Hospital, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/archms.archms_5_19

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  Abstract 


Background: Pregnancy-associated breast cancer (PABC) is breast cancer diagnosed during pregnancy or within 1 year of delivery. It is the most frequent malignancy diagnosed during pregnancy or lactation. There is a paucity of information on PABC in our hospital. Aim: The aim of the study is to highlight the clinicopathological features, treatment, and outcome of PABC in the center. Materials and Methods: It was a 6-year prospective study of PABC from January 2007 to December 2012 at our hospital. Information documented included patient's biodata, clinical features, pathological types, receptor status, staging, treatment, and outcome of PABC patients. Results: A total of 1344 patients had breast cancer during the study period. 31 patients (2.3%) had PABC. Age ranged 20–43 years, median 31 years. Common clinical features were: breast lump/mass – 27 (87.1%) patients, skin thickness – 10 (32.3%), nipple retraction – 9 (29.0%), and inflammation – 6 (19.4%). 19 (61.3%) patients were diagnosed in pregnancy: first trimester – 4 (12.9%), second trimester – 7 (22.6%), third trimester – 8 (25.8%), while 12 (38.7%) were within 1 year of delivery. Twenty-two patients (71.0%) had advanced disease. Twenty-four (77.4%) patients had invasive ductal carcinoma. Thirteen (59.1%) patients were ER/PR positive, 6 (27.3%) were triple negative, and 3 (13.6%) were HER2 positive. Twenty-four patients (77.4%) had vaginal delivery. Three patients (9.7%) had spontaneous abortion and 1 patient (3.2%) had still birth. 25 babies (80.6%) were alive and well. 17 patients (54.8%) had modified radical mastectomy (2 patients in second trimester and 15 patients after delivery), 25 (80.6%) had chemotherapy, 14 (45.2%) had radiotherapy, and 1 (3.2%) received trastuzumab. Mortality was 8 (25.8%). Conclusion: PABC constituted 2.3% of all breast cancer patients in our hospital. Majority (71%) presented with advanced disease. 3 out of every 4 were invasive ductal carcinoma, while 1 in 4 were triple negative. The mortality was 25.8%.

Keywords: Clinicopathological features, outcome, pregnancy-associated breast cancer, treatment


How to cite this article:
Abur PP, Yusufu LM, Odigie VI. Clinicopathological features, treatment, and outcome of pregnancy-associated breast cancer in Ahmadu Bello University Teaching Hospital, Zaria, Northwestern Nigeria. Arch Med Surg 2019;4:46-8

How to cite this URL:
Abur PP, Yusufu LM, Odigie VI. Clinicopathological features, treatment, and outcome of pregnancy-associated breast cancer in Ahmadu Bello University Teaching Hospital, Zaria, Northwestern Nigeria. Arch Med Surg [serial online] 2019 [cited 2020 Feb 23];4:46-8. Available from: http://www.archms.org/text.asp?2019/4/2/46/276184




  Introduction Top


Pregnancy-associated breast cancer (PABC) is breast cancer diagnosed during pregnancy or within 1 year of delivery.[1] It is the most frequently diagnosed cancer that coexists with pregnancy and lactation.[2],[3],[4],[5],[6] Most of the women of PABC present with larger tumors and have a higher incidence of lymph node metastasis at diagnosis.[7] The reason might be due to a delay in diagnosis, secondary to wrong attribution of the symptoms to normal physiological changes of the pregnant or lactating breast. Treatment of PABC poses specific challenges as the regimen may harm the fetus [8] and while delayed or under-treatment may be less harmful to the fetus, treatment efficacy for the mother may be suboptimal.[9] Due to delay in diagnosis, PABC patients tend to present at a more advanced stage at the initial diagnosis and have a higher risk of metastatic disease than nonpregnant women, resulting in worse prognosis.[7],[8],[9] In contrast, some previous studies reported that pregnancy was not found to be an independent factor for biologically more aggressive cancer and poorer survival among breast cancer patients, after controlling for cancer stage and age.[9] There is a paucity of the literature of PABC in this hospital.

The aim of this study was to highlight the clinicopathological features, treatment, and outcome of PABC.


  Materials and Methods Top


The study was conducted prospectively from January 2007 to December 2012 at our hospital. Patients who had breast cancer in pregnancy or within 1 year of delivery were studied. Information documented included patients biodata, clinical features, staging, histological types, receptor status, treatment, and outcome. Patients were followed up for 3 years and outcome of events concerning patients and their pregnancies were documented. Excluded from the study were patients that had some form of treatment for PABC before referral to our center. The data obtained were analyzed using SPSS Version 19.0, (IBM, 2010., Armonk, New York) and results were presented as simple percentages and charts.


  Results Top


A total of 1344 women had breast cancer during the study period. Thirty-one patients (2.3%) had PABC. The median age at diagnosis was 31 years (range: 20–43 years). Four patients (12.9%) had family history of breast cancer. Seven patients (22.6%) were carrying their first pregnancy in life, while the remaining were multiparous. [Table 1] shows the clinical features with breast lump/mass occurring in 27 patients (87.10%). Four patients (12.9%) were diagnosed in the first trimester, seven patients (22.6%) in the second trimester, eight patients (25.8%) in the third trimester, and 12 patients (38.7%) diagnosed within 1 year of delivery. Two patients (6.5%) had Stage I, 7 (22.6%) patients had Stage II, 15 patients (48.4%) had Stage III disease, and 7 patients (22.6%) had metastatic disease (Stage IV) at presentation. Invasive ductal carcinoma was the histological type in 24 patients (77.4%), invasive lobular in 3 patients (9.7%), and inflammatory carcinoma in 4 patients (12.9%). Complete hormonal profile was available in 22 (71%) cases. Staining for ER/PR receptor was positive in 13 patients (59.1%), triple negativity in 6 patients (27.3%), and HER-2/Neu was positive in 3 patients (13.6%). Twenty-four patients (77.4%) had normal vaginal delivery, three cesarean sections, three spontaneous abortion, and one stillbirth. [Table 2] summarized the treatment, 17 patients (54.8%) had modified radical mastectomy, 9 patients for Manchester Stage 1 and 2 disease, and 8 patients for Stage 3 disease. Twenty-five patients had chemotherapy (cyclophosphamide, epirubicin, and 5-fluorouracil [CEF]) 15 patient's neoadjuvant for Manchester stage 3 disease, 7 patients' palliative chemotherapy, and 3 patients' adjuvant chemotherapy. Fourteen patients had radiotherapy, 12 patients adjuvant radiotherapy for locoregional disease, and 2 patients palliative radiotherapy for metastatic disease. At 3 years of follow-up, 10 patients (32.3%) were dead, 21 patients (67.7%) were alive, 10 patients were doing well, and 11 patients were at different stages of local recurrence and or distant metastasis. Twenty-four babies were alive at 3 years of follow-up, while three died within the period. One child died from pneumonia, the second from severe malaria, and the third died at home from a febrile illness.
Table 1: Clinical features

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Table 2: Treatment

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  Discussion Top


PABC is breast cancer diagnosed during pregnancy or within 1 year of delivery. PABC is relatively rare and its incidence is 0.2%–3.8%.[10]

In this study, PABC constitutes 2.3% of breast cancer patients in women. It constitutes 8.2% of breast cancer in young women <40 years. One of the previous studies had suggested that approximately 10% of breast cancers diagnosed in patients' aged ≤40 years were diagnosed during the pregnancy.[11] In another study, PABC constitutes 0.7% of total cases and 8% of young breast cancer patients (<35 years).[12] The incidence, however, is lower than that of 26.3% of PABC in young women <50 years reported in our center 22 years ago.[13] This may be explained by the difference in definition of PABC in the young women, <50 years in the previous study compared to <40 years in the present study and also by the increasing awareness of breast cancer treatment making patients whom initially were reluctant in seeking orthodox treatment now presenting for treatment. In the past, patients with breast cancer were reluctant to seek treatment preferring to carry the disease, in the process, becoming pregnant, thereby increasing the incidence. In our study, majority of the patients (70.1%) presented with advanced breast disease, this is similar to earlier report from this center; however, in this study, most of the patients presented with locally advanced breast cancer compared to 64% Stage IV disease reported 22 years ago.[13] This suggests that there has been some improvement at the stage of presentation of PABC in our Centre more need to be done by routinely examining the breast during antenatal and postnatal clinics visit and also teaching pregnant women self-breast examination. These will help in early detection and presentation. Invasive ductal carcinoma constitutes 77.4%, and this is also similar to the previous report of 72% from this center.[13] In the previous studies, PABC has been associated with a genetic predisposition and a strong family history.[14] In this study, we found only four patients have a positive family history of breast cancer. Modified radical mastectomy was done in 54.8% of the patients and most of the surgeries were done after delivery, the few surgeries performed in pregnancy were in the second trimester and were uneventful. None of the patients had breast-conserving surgery because of the large tumor size at presentation. The administration of chemotherapy in pregnancy was classically dogged by controversy due to the fear of possible induction of teratogenicity in the fetus. Current evidence showing the safety of chemotherapy has been successfully illustrated in several series.[15],[16] In this study, standard doses of chemotherapy CEF were given from the second trimester. Out of 14 patients who had intrapartum chemotherapy, 13 had uneventful pregnancies and delivered normal babies at term, while 1 patient had stillbirth. This suggests that intrapartum chemotherapy from the second trimester is safe. There are conflicting data on outcomes after PABC. Some authors showed similar survival outcome with nonpregnant patients with breast cancer, whereas others have come out with poor outcome with nonpregnant patients.[16],[17],[18],[19]

In this study, the mortality was 32.3% at 3 years of follow-up. Half of the patients who were alive were at different stages of local recurrence and/or distant metastasis; the remaining half were alive and doing well. The poor outcome may be as a result of delay in presentation for most patients presented with advanced breast disease. Out of the 27 deliveries, 24 babies were alive and doing well at 3 years follow-up; this suggests that treatment of PABC does not adversely affect the outcome of the pregnancy.


  Conclusion Top


PABC constituted 2.3% of all breast cancer patients in our hospital. Majority (71%) presented with advanced disease. Three out of every four were invasive ductal carcinoma and 1 in every 4 were triple negative. The high mortality and morbidity could be reduced by early presentation and commencement of treatment.

Routine breast examination during the antenatal and postnatal period would help in early detection of PABC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Schedin P. Pregnancy-associated breast cancer and metastasis. Nat Rev Cancer 2006;6:281-91.  Back to cited text no. 9
    
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Wallack MK, Wolf JA Jr., Bedwinek J, Denes AE, Glasgow G, Kumar B, et al. Gestational carcinoma of the female breast. Curr Probl Cancer 1983;7:1-58.  Back to cited text no. 10
    
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Nugent P, O'Connell TX. Breast cancer and pregnancy. Arch Surg 1985;120:1221-4.  Back to cited text no. 11
    
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Gogia A, Deo SV, Shukla NK, Mohanti BK, Raina V. Pregnancy associated breast cancer: An institutional experience. Indian J Cancer 2014;51:167-9.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Hassan I, Muhammed I, Attah MM, Mabogunje O. Breast cancer during pregnancy and lactation in Zaria, Nigeria. East Afr Med J 1995;72:280-2.  Back to cited text no. 13
    
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Shen T, Vortmeyer AO, Zhuang Z, Tavassoli FA. High frequency of allelic loss of BRCA2 gene in pregnancy-associated breast carcinoma. J Natl Cancer Inst 1999;91:1686-7.  Back to cited text no. 14
    
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Berry DL, Theriault RL, Holmes FA, Parisi VM, Booser DJ, Singletary SE, et al. Management of breast cancer during pregnancy using a standardized protocol. J Clin Oncol 1999;17:855-61.  Back to cited text no. 15
    
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Hahn KM, Johnson PH, Gordon N, Kuerer H, Middleton L, Ramirez M, et al. Treatment of pregnant breast cancer patients and outcomes of children exposed to chemotherapy in utero. Cancer 2006;107:1219-26.  Back to cited text no. 16
    
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Bonnier P, Romain S, Dilhuydy JM, Bonichon F, Julien JP, Charpin C, et al. Influence of pregnancy on the outcome of breast cancer: A case-control study. Societe francaise de senologie et de pathologie mammaire study group. Int J Cancer 1997;72:720-7.  Back to cited text no. 18
    
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