Breast cancer at pregnant women
Breast cancer at pregnant women — the malignant neoplasia of a breast revealed against the background of a gestation, a lactation or within 12 months after the delivery. It is shown by nodal or diffusion consolidation of chest glands, their weight and morbidity, discomfort, pain in the field of an areola, allocations from a nipple, local changes of skin, increase in axillary lymph nodes. Trepanobiopsiya, MRT of mammary glands is diagnosed by means of ultrasonography. In the period of a gestation surgical methods of treatment (usually modified options of a radical mastectomy), chemotherapy according to the scheme AC are used. After the delivery therapy is supplemented with hormonal medicines and beam techniques.
Breast cancer at pregnant women
Malignant tumors of mammary glands — a type of the neoplaziya, the second for prevalence, diagnosed for pregnant women. Their occurrence makes 1:3 000 — 1:10 000 gestation. Average age of women for whom cancer of chest gland associated with pregnancy is diagnosed — makes 33 years. To 82% of patients reveal a new growth independently in the I trimester, at the same time practically in 3/4 cases late stages of a neoplasia with sizes of tumor from 6 to 15 cm are diagnosed, and metastasises in internals are found in every fifth pregnant woman. Because of untimely diagnosis of a disease the delay of an initiation of treatment averages 2-3,5 months.
The reasons of a breast cancer at pregnant women
The etiology of malignant neoplaziya at a gestation is same, as at not pregnant women. In 5-10% of cases development of cancer is caused by the inherited mutation of genes of BRCA1/BRCA2. At other patients the new growth arises against the background of disgormonalny conditions, influences of adverse factors of the environment (mutagen chemicals, radiation and so forth), insufficiency of immunity. As a rule, the tumors revealed in chest glands of pregnant women arise before conception, however their growth can accelerate against the background of physiological gestational changes. According to experts in the sphere of oncology, obstetrics and gynecology, specific provocative factors of a bystry onkogenez at pregnancy are:
- Hormonal reorganization. More than in 70% of cases breast cancer at pregnant women is estrogen - dependent (ER+). At a gestation the level of estrogen increases in blood almost by 30 times. Under the influence of hormones there is a preparation of mammary glands for a lactation: the breast bulks up, in it the quantity of alveoluses, dairy channels increases. Hyper estrogenic stimulation can promote more bystry development of cancer cells.
- Decrease in immunity. As genetically the fruit is alien to a maternal organism, physiological changes in immune system of pregnant women are directed to decrease in the general reactivity. For the account increase in number T-supressorov, reduction of the T-helperov level, emergence of the blocking antibodies is suppressed an effector link of immunity. As a result the immune system reveals worse and destroys own regenerating cages.
The probable mechanism of development of a breast cancer in pregnant women is based on stimulation of growth of the transformed cages by estrogen and progesterone. The strengthened estrogenic influence induces synthesis of factors of growth under the influence of which proliferirut epitelialny cells of chest glands, including a malignant tumor. Cellular apoptosis is at the same time braked, at the expense of the induced transcription of a factor of growth vascular the endoteliya begins a pathological neovaskulyarization.
As estrogen is capable to level action of the inhibiting growth factors, the negative feedback stimulating a cellular giperplaziya joins. One of estrogenic effects is the bystry increase in number of micrometastasises caused by stimulation of the so-called sleeping metastatic educations. The progesterone role in an onkogeneza of neoplaziya of mammary glands is still specified. Its effects can be connected with maintenance of cyclic proliferation of ferruterous cages at a gestation and stimulation of growth with potential modification of the answer of the normal and regenerated ferruterous epithelium.
Systematization of forms of breast cancer during pregnancy is based on the same criteria, as out of the gestational period — an anatomic arrangement of a neoplasia, its sizes, features of metastasis in lymph nodes and the remote bodies, a histologic structure, level of a cellular differentiation, type of expressiruyemy receptors of malignizirovanny cages. The most significant role in development of optimum tactics of maintenance of pregnancy is played by classification of a tumor by development stages. Onkomammolog are distinguished:
- Noninvasive cancer (in situ carcinoma). The neoplasia is localized in a dairy channel or a segment. Intaktna lymph nodes. The clinic is absent. Cancer becomes a casual find at planned inspection. Optimum form. Continuation of a gestation after expeditious treatment is possible.
- Cancer of the I stage. The maximum diameter of a new growth does not exceed 2 cm. The neoplasia sprouts in surrounding tissues of a breast, but does not spread. Can clinically be defined in the form of nodal consolidation. Carrying out surgical intervention allows to keep pregnancy.
- Cancer of the II stage. At IIA of a stage the tumor has the sizes to 2 cm with metastasis in axillary lymph nodes on the party of defeat or to 5 cm without metastasises. At IIB cancer of a stage the sizes of a neoplasia make 2-5 cm in the presence of metastasises in lymph nodes or from 5 cm and more — at their absence. For preservation of a gestation the radical mastectomy is shown.
- Cancer of the III stage. The tumor expands to 5 and more centimeters or conglomerates of the soldered axillary lymph nodes, germination of cancer in skin of a mammary gland, thorax tissue, damage of subclavial and supraclavicular lymph nodes are noted. The remote metastasises are possible.
- Cancer of the IV stage. Massive damage of a mammary gland with germination of surrounding fabrics, a dissemination in skin, ulcerations is noted. Involvement in process of the second breast, axillary lymph nodes on the opposite side is possible. The multiple remote metastasises are characteristic.
At the III-IV stages of an onkoprotsess at the request of the patient and her relatives preservation of a gestation with an early rodorazresheniye in terms of sufficient viability of the child is admissible. In such cases performance of radical surgery allows to suspend spread of a tumor and to begin active therapy in the postnatal period. Purpose of some himiopreparat is possible from 15th week of a gestation.
Symptoms of a breast cancer at pregnant women
Though gestational physiological changes of fabrics complicate identification of malignant volume education, there are marker signs raising an onkonastorozhennost. Emergence in one of mammary glands of knot or not properly executed consolidation, morbidity and weight can demonstrate development of cancer. At some patients against the background of the general nagrubaniye the form of the struck chest gland asymmetrically changes, on skin there are roughnesses, sites of retractions or local puffiness.
The pricking, pains in a mamillar areolyarnoy of area is often noted, the nipple can be pulled in, sanious allocations appear. In the presence of regionarny metastasises in an armpit on the struck party the increased lymph nodes are defined, in more hard cases lymph nodes are probed over and under a clavicle, in an opposite axillary hollow. Symptoms of the general intoxication in the form of loss of appetite, weight reduction, the increasing weakness and bystry fatigue are characteristic only of terminal stages of a disease.
Cancer of chest glands arising at pregnant women can quickly progress and be complicated by metastasis. Common forms of a disease come to light at 72-85% of patients, at 20% of women internals are affected with metastasises. In certain cases the inflammation of the fabrics surrounding a tumor develops. According to most of obstetricians-gynecologists, breast cancer does not make negative impact on the child, however at late stages of a disease in the presence of tumoral intoxication the fruit hypoxia is possible. Application in the II-III trimesters of chemotherapeutic medicines is capable to provoke premature birth, a miyelosupressiya at the woman and the child, a fruit arrest of development, a still birth, massive postnatal bleedings, infectious complications (the endometritis, horioamnionit, etc.).
As pregnant women often regard initial symptoms of a tumor as specific changes of mammary glands before a lactation, breast cancer at a gestation is usually diagnosed at later stages. Diagnostic significant radiological methods of a research at pregnancy are applied restrictedly because of possible negative impact on a fruit, however other modern techniques allow to reveal a tumor and it is correct to estimate a stage of an onkoprotsess. The most informative at detection of a malignant neoplasia of a breast are:
- Ultrasonography of mammary glands. An optimum method of screening diagnosis of malignant tumors at pregnant women and the lactating women. Informational content of the ultrasonografiya added with color and power doppler sonography reaches 97%. Usually on ultrasonography cancer looks as gipervaskulyarizirovanny gipoekhogenny formation of irregular shape and non-uniform structure. By means of ultrasound it is convenient to investigate regionarny lymph nodes.
- Trepanobiopsiya of a mammary gland. The material received by means of the biopsiyny gun is used for definition of morphological structure of a new growth and its immunohistochemical profile (the receptor status, amplification of a gene of Her2-neu, the proliferative Ki-67 index, etc.). The method has bigger informational content, than the punktsionny biopsy, allows to verify the diagnosis in 99,0-99,8% of cases.
- MRT of chest glands. Examination is conducted when obtaining ambiguous results of a sonografiya. Layer-by-layer visualization gives the chance most precisely to estimate the sizes and prevalence of a neoplasia. MRT of all body is recommended for identification of metastasises. In the I trimester scanning is carried out with care because of possible cavitation and overheating of an embryo. Contrasting is allowed in exceptional cases.
Mammography to pregnant women with suspicion of breast cancer is appointed seldom that is connected with the possible damaging impact on a fruit and receiving in 25% of cases of false-negative results. As additional methods of inspection definition of an onkomarker of CA 15-3, cytology of dab received from a nipple of the affected mammary gland, assessment of risk of development of the BRCA associated cancer, a duktoskopiya, breast radio thermometry, electroimpedance mammography is recommended. The disease is differentiated with mastitis, good-quality neoplaziya (cysts, adenomas, fibroadenoma, lipomas, listovidny tumors), to the galaktotsela, gamartoma, lymphoma, sarcomas, tuberculosis. Except an onkomammolog the patient according to indications is advised by the oncologist, , the surgeon, the phthisiatrician, the infectiologist.
Cancer therapy of a mammary gland at pregnant women
If earlier identification of a malignant new growth of a breast formed the sufficient basis for termination of pregnancy, in the last decades apply the strategy assuming the early beginning of therapy and preservation of a gestation. The choice of medical tactics in each case of cancer is carried out individually taking into account a stage of process, gestational term and the decision of the pregnant woman. In the 1st trimester at identification of invasive forms of a tumor pregnancy is recommended to be interrupted with medical abortion, in the 2-3rd — at desire of the patient to prolong up to minimum possible term of the birth of a viable fruit. After artificial interruption of a gestation treatment is made under standard protocols of the oncological help. At the decision to keep the child the following options can be used:
- Surgical treatment. The most justified intervention at early stages of cancer is the radical mastectomy if necessary added with an axillary dissektion without the subsequent radiation therapy. Lumpectomy, a kvadrantektomiya, a sectoral resection of a breast are carried out less often. Onkoplastichesky operations are not recommended. The volume and term of carrying out intervention at late stages of a disease are defined individually.
- Purpose of himiopreparat. Anti-neoplastic means can be applied after the 14th week of gestational term. The later drug treatment is begun, the probability of emergence of uglinesses at a fruit is less. Medicines of the choice are alkiliruyushchy cytostatics and antratsiklinovy antibiotics. At common forms of cancer the neoadjyuvantny polychemotherapy as a preparatory stage before radical operation is used.
Hormonal therapy, the most effective at retseptoro-positive forms of cancer, to pregnant women is not carried out because of teratogenny influence of antagonists of estrogen. Purpose of radiation therapy is possible only after end of a gestation. The recommended way of a rodorazresheniye is natural childbirth. Cesarean section is performed only in the presence of obstetric indications or the heavy ekstragenitalny pathology incompatible with patrimonial loadings.
Forecast and prevention
Indicators of survival of patients for which during pregnancy the malignant new growth of a mammary gland was diagnosed do not differ from not pregnant women given on groups. Interruption of a gestation does not influence a disease outcome. However in general the forecast is more serious as at pregnant women common forms of cancer often come to light. The minimum safe interval from the moment of completion of treatment before the following pregnancy, according to different authors, makes from 6 months to 5 years. The main objective of prevention of cancer of chest glands — detection of a tumor at early stages by means of screening methods (ultrasonography, mammographies).