Breast imaging of the pregnant and lactating patient: imaging modalities and pregnancy-associated breast cancer

Breast cancer screening in BRCA1/2 pathogenic sequence variant carriers during pregnancy and lactation

OBJECTIVES

Women harboring germline BRCA1/BRCA2 pathogenic sequence variants (PSVs) are at an increased risk for breast cancer. There are no established guidelines for screening during pregnancy and lactation in BRCA carriers. The aim of this study was to evaluate the utility of whole-breast ultrasound (US) screening in pregnant and lactating BRCA PSV carriers.

METHODS

Data were retrospectively collected from medical records of BRCA PSV carriers between 2014 and 2020, with follow-up until 2021. Associations between imaging intervals, number of examinations performed and pregnancy-associated breast cancers (PABCs) were examined. PABCs and cancers diagnosed at follow-up were evaluated and characteristics were compared between the two groups.

RESULTS

Overall 212 BRCA PSV carriers were included. Mean age was 33.6 years (SD 3.93, range 25-43 years). During 274 screening periods at pregnancy and lactation, eight (2.9 %) PABCs were diagnosed. An additional eight cancers were diagnosed at follow-up. Three out of eight (37.5 %) PABCs were diagnosed by US, whereas clinical breast examination (n = 3), mammography (n = 1) and MRI (n = 1) accounted for the other PACB diagnoses. One PABC was missed by US. The interval from negative imaging to cancer diagnosis was significantly shorter for PABCs compared with cancers diagnosed at follow-up (3.96 ± 2.14 vs. 11.2 ± 4.46 months, P = 0.002).

CONCLUSION

In conclusion, pregnant BRCA PSV carriers should not delay screening despite challenges like altered breast tissue and hesitancy towards mammography. If no alternatives exist, whole-breast ultrasound can be used. For lactating and postpartum women, a regular screening routine alternating between mammography and MRI is recommended.

MRI of the Lactating Breast

The breasts undergo marked physiologic changes during lactation that can make conventional imaging evaluation with mammography and US challenging. MRI can be a valuable diagnostic aid to differentiate physiologic and benign processes from malignancy in patients who are lactating. In addition, MRI may allow more accurate delineation of disease involvement than does conventional imaging and assists in locoregional staging, screening of the contralateral breast, assessment of response to neoadjuvant chemotherapy, and surgical planning. Although the American College of Radiology recommends against patients undergoing contrast-enhanced MRI during pregnancy because of fetal safety concerns, contrast-enhanced MRI is safe during lactation. As more women delay childbearing, the incidence of pregnancy-associated breast cancer (PABC) and breast cancer in lactating women beyond the 1st year after pregnancy is increasing. Thus, MRI is increasingly being performed in lactating women for diagnostic evaluation and screening of patients at high risk. PABC is associated with a worse prognosis than that of non-PABCs, with delays in diagnosis contributing to an increased likelihood of advanced-stage disease at diagnosis. Familiarity with the MRI features of the lactating breast and the appearance of various pathologic conditions is essential to avoid diagnostic pitfalls and prevent delays in cancer diagnosis and treatment. The authors review clinical indications for breast MRI during lactation, describe characteristic features of the lactating breast at MRI, and compare MRI features of a spectrum of benign and malignant breast abnormalities. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Chikarmane in this issue.

Choosing the appropriate pharmacotherapy for breast cancer during pregnancy: what needs to be considered?

INTRODUCTION

Breast cancer is the most commonly diagnosed malignancy during pregnancy. Breast cancer during pregnancy is a challenging clinical condition requiring proper and timely multidisciplinary management.

AREAS COVERED

This review focuses on the management of breast cancer during pregnancy with a focus about the current state-of-the-art on the feasibility and safety of pharmacotherapy approaches in this setting.

EXPERT OPINION

Multidisciplinary care is key for a proper diagnostic-therapeutic management of breast cancer during pregnancy. Engaging patients and their caregivers in the decision-making process is essential and psychological support should be provided. The treatment of patients with breast cancer during pregnancy should follow the same recommendations as those for breast cancer in young women outside pregnancy but taking into account the gestational age at the time of treatment.Anthracycline-, cyclophosphamide-, and taxane-based regimens can be safely administered during the second and third trimesters with standard protocols, preferring weekly regimens whenever possible. Endocrine therapy, immune checkpoint inhibitors, and targeted agents are contraindicated throughout pregnancy, also due to the very limited data available to guide their administration in this setting. During treatment, careful fetal growth monitoring is mandatory, and even after delivery proper health monitoring for the children exposed in utero to chemotherapy should be continued.

Gestational Breast Cancer - a Review of Outcomes, Pathophysiology, and Model Systems

The onset of pregnancy marks the start of offspring development, and represents the key physiological event that induces re-organization and specialization of breast tissue. Such drastic tissue remodeling has also been linked to epithelial cell transformation and the establishment of breast cancer (BC). While patient outcomes for BC overall continue to improve across subtypes, prognosis remains dismal for patients with gestational breast cancer (GBC) and post-partum breast cancer (PPBC), as pregnancy and lactation pose additional complications and barriers to several gold standard clinical approaches. Moreover, delayed diagnosis and treatment, coupled with the aggressive time-scale in which GBC metastasizes, inevitably contributes to the higher incidence of disease recurrence and patient mortality. Therefore, there is an urgent and evident need to better understand the factors contributing to the establishment and spreading of BC during pregnancy. In this review, we provide a literature-based overview of the diagnostics and treatments available to patients with BC more broadly, and highlight the treatment deficit patients face due to gestational status. Further, we review the current understanding of the molecular and cellular mechanisms driving GBC, and discuss recent advances in model systems that may support the identification of targetable approaches to block BC development and dissemination during pregnancy. Our goal is to provide an updated perspective on GBC, and to inform critical areas needing further exploration to improve disease outcome.

MRI can accurately diagnose breast cancer during lactation

OBJECTIVE

To test the diagnostic performance of breast dynamic contrast-enhanced (DCE) MRI during lactation.

MATERIALS AND METHODS

Datasets of 198 lactating patients, including 66 pregnancy-associated breast cancer (PABC) patients and 132 controls, who were scanned by DCE on 1.5-T MRI, were retrospectively evaluated. Six blinded, expert radiologists independently read a single DCE maximal intensity projection (MIP) image for each case and were asked to determine whether malignancy was suspected and the background-parenchymal-enhancement (BPE) grade. Likewise, computer-aided diagnosis CAD MIP images were independently read by the readers. Contrast-to-noise ratio (CNR) analysis was measured and compared among four consecutive acquisitions of DCE subtraction images.

RESULTS

For MIP-DCE images, the readers achieved the following means: sensitivity 93.3%, specificity 80.3%, positive-predictive-value 70.4, negative-predictive-value 96.2, and diagnostic accuracy of 84.6%, with a substantial inter-rater agreement (Kappa = 0.673, p value < 0.001). Most false-positive interpretations were attributed to either the MIP presentation, an underlying benign lesion, or an asymmetric appearance due to prior treatments. CAD's derived diagnostic accuracy was similar (p = 0.41). BPE grades were significantly increased in the healthy controls compared to the PABC cohort (p < 0.001). CNR significantly decreased by 11-13% in each of the four post-contrast images (p < 0.001).

CONCLUSION

Breast DCE MRI maintains its high efficiency among the lactating population, probably due to a vascular-steal phenomenon, which causes a significant reduction of BPE in cancer cases. Upon validation by prospective, multicenter trials, this study could open up the opportunity for breast MRI to be indicated in the screening and diagnosis of lactating patients, with the aim of facilitating an earlier diagnosis of PABC.

KEY POINTS

• A single DCE MIP image was sufficient to reach a mean sensitivity of 93.3% and NPV of 96.2%, to stress the high efficiency of breast MRI during lactation. • Reduction in BPE among PABC patients compared to the lactating controls suggests that several factors, including a possible vascular steal phenomenon, may affect cancer patients. • Reduction in CNR along four consecutive post-contrast acquisitions highlights the differences in breast carcinoma and BPE kinetics and explains the sufficient conspicuity on the first subtracted image.

Cancer in pregnancy: breast cancer

Breast cancer is the most common malignancy in women, and for women under 40, it is the leading cause of cancer-related deaths. A specific type of breast cancer is pregnancy-associated breast cancer, which is diagnosed during pregnancy, the first-year postpartum, or during lactation. Pregnancy-associated breast cancer is seen in 3/1000 pregnancies and is increasing in incidence as women delay pregnancy. This type of breast cancer is more aggressive, and not infrequently, there is a delay in diagnosis attributed to physiologic changes that occur during pregnancy and a lack of awareness among physicians. In this review, we discuss the demographics of pregnancy-associated breast cancer, provide differential considerations, and illustrate the multimodality imaging features to bring attention to the radiologist about this aggressive form of breast cancer.

Management of breast cancer diagnosed during pregnancy: global perspectives

INTRODUCTION

Pregnancy-associated breast cancer (PABC) encompasses breast cancer diagnosed during pregnancy (BCP) or postpartum (PPBC). BCP is especially challenging with concerns regarding maternal and fetal safety synchronously. This review provides a comprehensive global view to optimize care of this unique entity. Areas covered Published literature and practices across the globe including real world published data from the first Indian registry are thoroughly reviewed to derive inferences. Diagnostic delays are common with resultant upstaging and inferior outcomes. Sonography-mammography and a biopsy with immunohistochemistry for estrogen, progesterone and HER-2neu receptors is mandatory. Multidisciplinary specialist teams are critical for trimester dependent management. Stage-wise surgical and systemic treatment remains largely similar to that of the nonpregnant women. Anthracyclines- and taxane-based chemotherapy is found to be safe after the 1st trimester. Frequent fetal and maternal monitoring is required to minimize complications. Chemotherapy should stop three weeks prior to the delivery to prevent peripartum infection/bleeding. Anti- Her-2 targeted therapy, endocrine therapy and radiation therapy are administered post-delivery. Iatrogenic premature delivery leads to poor neurocognition and should be avoided. Expert opinion Stage-wise outcomes are similar to that of non-pregnant patients with breast cancer, and underscores the importance of early detection especially in low- and middle-income countries. Global collaborations are warranted.

AREAS COVERED

Published literature and practices across the globe including real world published data from the first Indian registry are thoroughly reviewed to derive inferences. Diagnostic delays are common with resultant upstaging and inferior outcomes. Sonography-mammography and a biopsy with immunohistochemistry for estrogen, progesterone and HER-2neu receptors is mandatory. Multidisciplinary specialist teams are critical for trimester dependent management. Stage-wise surgical and systemic treatment remains largely similar to that of the nonpregnant women. Anthracyclines- and taxane-based chemotherapy is found to be safe after the 1st trimester. Frequent fetal and maternal monitoring is required to minimize complications. Chemotherapy should stop three weeks prior to the delivery to prevent peripartum infection/bleeding. Anti- Her-2 targeted therapy, endocrine therapy and radiation therapy are administered post-delivery. Iatrogenic premature delivery leads to poor neurocognition and should be avoided.

EXPERT OPINION

Stage-wise outcomes are similar to that of non-pregnant patients with breast cancer, and underscores the importance of early detection especially in low- and middle-income countries. Global collaborations are warranted.

Ultrasound features of pregnancy-associated breast cancer: A retrospective observational analysis

Pregnancy-associated breast cancer (PABC) is a poor prognosis in women, and the mortality rate is higher in this subgroup of patients than in non-PABC. This study aims to assess clinicopathological and ultrasound features of patients with PABC. Of 75 patients with breast cancer, 31 cases were in lactating, or pregnancy phase and 44 patients had no recent history of pregnancy/lactation at the time of cancer detection. The available pathological characteristics and ultrasound findings of the PABC and non-PABC groups were compared. The analysis of ultrasound findings demonstrated that the percentages of antiparallel orientation (p = 0.04) and heterogeneous internal echo pattern (p = 0.002) were higher in the PABC group. The final Breast Imaging Reporting and Data System (BI-RADS) assessment in the two groups was significantly different (p = 0.008). In this study, most PABCs were BI-RADS 4c or 5; compared with age-matched non-PABC cases. There were significant differences in ER (p = 0.03), receptor groups (p = 0.007), and tumor grade (p = 0.02) in PABC compared to non-PABC group. To conclude, radiologists should be careful about ultrasound findings of PABC and recommend core needle biopsy in suspected cases.

Breast MRI during pregnancy and lactation: clinical challenges and technical advances

The breast experiences substantial changes in morphology and function during pregnancy and lactation which affects its imaging properties and may reduce the visibility of a concurrent pathological process. The high incidence of benign gestational-related entities may further add complexity to the clinical and radiological evaluation of the breast during the period. Consequently, pregnancy-associated breast cancer (PABC) is often a delayed diagnosis and carries a poor prognosis. This state-of-the-art pictorial review illustrates how despite currently being underutilized, technical advances and new clinical evidence support the use of unenhanced breast MRI during pregnancy and both unenhanced and dynamic-contrast enhanced (DCE) during lactation, to serve as effective supplementary modalities in the diagnostic work-up of PABC.

MRI in Pregnancy and Precision Medicine: A Review from Literature

Magnetic resonance imaging (MRI) offers excellent spatial and contrast resolution for evaluating a wide variety of pathologies, without exposing patients to ionizing radiations. Additionally, MRI offers reproducible diagnostic imaging results that are not operator-dependent, a major advantage over ultrasound. MRI is commonly used in pregnant women to evaluate, most frequently, acute abdominal and pelvic pain or placental abnormalities, as well as neurological or fetal abnormalities, infections, or neoplasms. However, to date, our knowledge about MRI safety during pregnancy, especially about the administration of gadolinium-based contrast agents, which are able to cross the placental barrier, is still limited, raising concerns about possible negative effects on both the mother and the health of the fetus. Contrast agents that are unable to cross the placenta in a way that is safe for the fetus are desirable. In recent years, some preclinical studies, carried out in rodent models, have evaluated the role of long circulating liposomal nanoparticle-based blood-pool gadolinium contrast agents that do not penetrate the placental barrier due to their size and therefore do not expose the fetus to the contrast agent during pregnancy, preserving it from any hypothetical risks. Hence, we performed a literature review focusing on contrast and non-contrast MRI use during pregnancy.

Lapses in breast cancer screening for highly penetrant mutation carriers during pregnancy and lactation

BACKGROUND AND OBJECTIVES

Screening for breast cancer in highly penetrant mutation carriers during pregnancy and lactation is challenging and consensus guidelines are lacking. This study evaluates the lapse in screening and the interval pregnancy-associated breast cancer rate.

METHODS

A single-institution retrospective cohort study of pregnant and lactating patients with known pathogenic germline mutations was performed. Lapse in screening was defined as the interval between the last screening imaging exam obtained before last menstrual period and the subsequent screening imaging.

RESULTS

Out of 685 patients, 42 had 1-3 evaluable pregnancies (54 total - 28 managed in High Risk Breast Clinic and 26 by OB/GYN). Mutations were observed in patients in BRCA1 (49%), BRCA2 (36%), CDH1 (5%), CHEK2 (2%), ATM (2%), NF1 (3%), and MSH2 (3%). The average screening lapse was 25 [19, 30] months for patients followed in the High Risk Clinic versus 32.5 [21, 65.75] months for patients followed with Routine Care (p = 0.035). We identified three cases of pregnancy-associated breast cancer (interval cancer rate 6%).

CONCLUSIONS

Patients with highly penetrant mutations are at risk for the development of interval pregnancy-associated breast cancer. Development of consistent screening guidelines and adherence to those guidelines is needed for this patient population.

MRI of the Lactating Breast: Computer-Aided Diagnosis False Positive Rates and Background Parenchymal Enhancement Kinetic Features

RATIONALE AND OBJECTIVES

To investigate the application of computer-added diagnosis (CAD) in dynamic contrast-enhanced (DCE) MRI of the healthy lactating breast, focusing on false-positive rates and background parenchymal enhancement (BPE) coloring patterns in comparison with breast cancer features in non-lactating patients.

MATERIALS AND METHODS

The study population was composed of 58 healthy lactating patients and control groups of 113 healthy premenopausal non-lactating patients and 55 premenopausal non-lactating patients with newly-diagnosed breast cancer. Patients were scanned on 1.5-T MRI using conventional DCE protocol. A retrospective analysis of DCE-derived CAD properties was conducted using a commercial software that is regularly utilized in our routine radiological work-up. Qualitative morphological characterization and automatically-obtained quantitative parametric measurements of the BPE-induced CAD coloring were categorized and subgroups' trends and differences between the lactating and cancer cohorts were statistically assessed.

RESULTS

CAD false-positive coloring was found in the majority of lactating cases (87%). Lactation BPE coloring was characteristically non-mass enhancement (NME)-like shaped (87%), bilateral (79%) and symmetric (64%), whereas, unilateral coloring was associated with prior irradiation (p <0.0001). Inter-individual variability in CAD appearance of both scoring-grade and kinetic-curve dominance was found among the lactating cohort. When compared with healthy non-lactating controls, CAD false positive probability was significantly increased [Odds ratio 40.2, p <0001], while in comparison with the breast cancer cohort, CAD features were mostly inconclusive, even though increased size parameters were significantly associated with lactation-BPE (p <0.00001).

CONCLUSION

BPE was identified as a common source for false-positive CAD coloring on breast DCE-MRI among lactating population. Despite several typical characteristics, overlapping features with breast malignancy warrant a careful evaluation and clinical correlation in all cases with suspected lactation induced CAD coloring.

Clinical Decision Making in the Management of Breast Cancer Diagnosed During Pregnancy: A Review and Case Series Analysis

Purpose: To highlight the various options available for the management of breast cancer diagnosed during pregnancy by describing the investigations, treatment, and outcomes in relation to these women. Methods: This is a narrative review of the literature to describe the issues related to pregnancy and obstetric management in patients with breast cancer. It incorporates a description of six cases of women (aged 29-39 years) with a first-time diagnosis of breast cancer during pregnancy to illustrate a number of issues that need to be considered during different trimesters. Results: Of the six cases, two were diagnosed in each pregnancy trimester. A painless breast mass was the presenting symptom in five cases (83%). In all cases, breast ultrasound was the primary diagnostic imaging procedure. Chest X-ray was performed in 3 (50%) and computed tomography in 2 (33%). A core needle biopsy was performed in all cases, and sentinel lymph node biopsy in 3 (50%) cases. Four women had grade 3 tumor; five had estrogen receptor-positive tumors. Four women had breast surgery during pregnancy. Five women gave birth after the induction of labor and/or cesarean section. In all six cases, a multidisciplinary team was involved in the delivery of health care. Conclusion: Regular breast examinations are needed for all pregnant woman during prenatal visits. Breast ultrasonography should be offered if a breast lump or other symptoms are detected. Breast surgery can be safely performed during all pregnancy trimesters, and some systemic therapeutic agents can be administered safely in the second and third trimesters.

Surgical excision of a lactating adenoma with rapid enlargement: A case report

Introduction and importance

A lactating adenoma is a benign breast tumor occurring in young women during pregnancy or lactation. Its growth is usually slow but, occasionally, can become rapid, resulting in a giant mass. This case report outlines an example of the rapid growth of a lactating adenoma, which was surgically excised. In this case, malignancy could not be ruled out, and biopsy and surgical excision were considered.

Case presentation

We present the case of a 28-year-old woman referred to us owing to the presence of a left breast mass with progressive enlargement. She initially presented with a left breast mass of approximately 20-mm in size, which increased to an approximate size of 70 mm during pregnancy. The patient's mammogram showed an equal-density lobular mass in the left breast. Ultrasonography and magnetic resonance imaging revealed a circumscribed lobular mass with cystic regions in the upper lateral quadrant. The patient was diagnosed with adenosis using core needle biopsy. However, it did not shrink during follow-up, and resection was performed. Histologically, the proliferation of the cystic ducts containing eosinophilic secretions and dilated tubules consisting of cuboidal or hobnail-shaped cells were observed.

Clinical discussion

Lactating adenoma, phyllodes tumor, and breast cancer are essential differential diagnoses when the size of breast masses increases rapidly. Ultrasonography is the first choice to examine lactating adenomas. Echogenic bands and pseudocapsules are characteristics of lactating adenomas.

Conclusion

Surgical excision is a notable treatment option when a lactating adenoma exhibits rapid growth or increase in mass, as it could be malignant.

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A lactating adenoma is a benign breast tumor.

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It rarely grows rapidly resulting in a giant mass.

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When this occurs, differentiation from malignancy is important.

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If malignancy cannot be ruled out, surgical excision becomes a feasible alternative.

Breast imaging screening in a BRCA1-mutated lactating patient: A potential pitfall mimicking malignancy

Breast imaging screening during lactation poses a real clinical challenge, especially in high-risk patients. We presented the case of a 34-year-old BRCA1-mutated woman showing marked, asymmetric background parenchymal enhancement on the right breast suspicious for malignancy in the context of annual screening magnetic resonance imaging. The patient revealed that she was still occasionally breastfeeding her two-year-old child only from right side. Ultrasound evaluation reported typical benign lactational findings on the right enhancing breast. An in-depth understanding of expected/ physiologic breast changes during lactation and an accurate clinical-radiological correlation are required to appropriately guide patient management and avoid misdiagnosis.

Pregnancy-associated breast cancer: evaluating maternal and foetal outcomes. A national study

PURPOSE

Pregnancy-associated breast cancer (PABC) is defined as breast cancer diagnosed during the gestational period (gp-PABC) or in the first postpartum year (pp-PABC). Despite its infrequent occurrence, the incidence of PABC appears to be rising due to the increasing propensity for women to delay childbirth. We have established the first retrospective registry study of PABC in Ireland to examine specific clinicopathological characteristics, treatments, and maternal and foetal outcomes.

METHODS

This was a national, multi-site, retrospective observational study, including PABC patients treated in 12 oncology institutions from August 2001 to January 2020. Data extracted included information on patient demographics, tumour biology, staging, treatments, and maternal/foetal outcomes. Survival data for an age-matched breast cancer population over a similar time period was obtained from the National Cancer Registry of Ireland (NCRI). Standard biostatistical methods were used for analyses.

RESULTS

We identified 155 patients-71 (46%) were gp-PABC and 84 (54%) were pp-PABC. The median age was 36 years. Forty-four patients (28%) presented with Stage III disease and 25 (16%) had metastatic disease at diagnosis. High rates of triple-negative (25%) and HER2+ (30%) breast cancer were observed. We observed an inferior 5-year overall survival (OS) rate in our PABC cohort compared to an age-matched breast cancer population in both Stage I-III (77.6% vs 90.9%) and Stage IV disease (18% vs 38.3%). There was a low rate (3%) of foetal complications.

CONCLUSION

PABC patients may have poorer survival outcomes. Further prospective data are needed to optimise management of these patients.

Imaging during pregnancy: What the radiologist needs to know

During the last decades, there has been a growing demand for medical imaging in gravid women. Imaging of the pregnant woman is challenging as it involves both the mother and the fetus and, consequently, several medical, ethical, or legal considerations are likely to be raised. Theoretically, all currently available imaging modalities may be used for the evaluation of the pregnant woman; however, in practice, confusion regarding the safety of the fetus often results in unnecessary avoidance of useful diagnostic tests, especially those involving ionizing radiation. This review article is focused on the current safety guidelines and considerations regarding the use of different imaging modalities in the pregnant population; also presented is an imaging work-up for the most common medical conditions of pregnant women, with emphasis on fetal and maternal safety.

Point-of-care Ultrasound to Evaluate Breast Pathology in the Emergency Department

Introduction

As physician-performed point-of-care ultrasound (POCUS) becomes more prevalent in the evaluation of patients presenting with various complaints in the emergency department (ED), one application that is significantly less used is breast ultrasound. This study evaluates the utility of POCUS for the assessment of patients with breast complaints who present to the ED and the impact of POCUS on medical decision-making and patient management in the ED.

Methods

This was a retrospective review of ED patients presenting with breast symptoms who received a POCUS examination. An ED POCUS database was reviewed for breast POCUS examinations. We then reviewed electronic health records for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, and impact of the POCUS study on patient care and disposition.

Results

We included a total of 40 subjects (36 females, 4 males) in the final analysis. Most common presenting symptoms were breast pain (57.5%) and a palpable mass (37.5%). “Cobblestoning,” ie, dense bumpy appearance, was the most common finding on breast POCUS, seen in 50% of the patients. Simple fluid collections were found in 37.5% of patients.

Conclusion

Our study findings illustrate the utility of POCUS in the evaluation of a variety of breast complaints in the ED.

Mammographic density changes following BC treatment

BACKGROUND

Mammographic density (MD) reduction is associated with lower risk of breast cancer (BC) recurrence and may be used as a marker of treatment outcome; however, trends in MD following BC therapies and the factors associated with such trends are poorly understood. The aim of this study was to investigate MD changes following BC treatment and the factors associated with these changes.

METHODS

A total of 226 BC-affected patients who received BC treatments were examined. MD was assessed by the Laboratory for individualized Radiodensity Assessment (LIBRA) software. A Wilcoxon ranked signed test was used to investigate the differences in MD before and after treatment and median independent test to assess the associated factors.

RESULTS

Significant differences in MD between baseline and follow-up mammograms were observed for all MD measures: percent density (p ≤ 0.005), dense area (p ≤ 0.004), and nondense area (p ≤ 0.02). After adjustment, these differences were more pronounced among younger at BC diagnosis (p ≤ 0.001), premenopausal (p ≤ 0.003), and obese women (p ≤ 0.05). Changes in MD were evident regardless of the treatment regimen. MD reduction was observed among patients with high baseline MD (p < 0.001), younger at BC diagnosis (p ≤ 0.04), premenopausal (p < 0.001), and normal body mass index (p = 0.04). Patients who experienced an increase in nondense area had high percent density at baseline (p ≤ 0.001).

CONCLUSION

Two different MD changes were observed over time: MD increase and decrease. Baseline MD, menopausal status, age at BC diagnosis, and body mass index influenced these changes.

Clinical Presentation, Diagnosis and Prognosis of Pregnancy-Associated Breast Cancer

Breast cancer in pregnancy is a rare entity generally presenting as a persistent breast mass, but is often a delayed finding due to the expected physiologic changes in the breast related to pregnancy and lactation. The preferred diagnostic workup of a persistent breast mass involves a combination of mammographic and ultrasonographic evaluation in addition to tissue diagnosis via core biopsy ; breast MRI is not recommended. Surgical excision should be reserved for definitive treatment in order to minimize fetal exposure to anesthesia. Evaluation for distant metastatic spread can be performed using radiographs and ultrasound to limit fetal radiation exposure . Similar to the non-pregnant patient, prognosis is primarily driven by tumor biology, however, there is limited and conflicting data regarding the impact of pregnancy on breast cancer outcomes with a distinct difference in survival among patients with breast cancer during pregnancy compared to those diagnosed postpartum.

Breast Imaging in Pregnancy and Lactation

All breast disorders found during pregnancy and lactation should be carefully evaluated. Most of them are benign, but it is essential to exclude pregnancy-associated breast cancer (PABC), which is too often diagnosed late. The first-line imaging technique is ultrasound (US), which must be completed by mammography if there is any clinical or US suspicious sign . In lactating patients with PABC , breast magnetic resonance imaging (MRI) can be useful for local assessment.Management depends on the precise analysis and BI-RADS classification of the lesion. During pregnancy and lactation, there is an overlap in imaging: many benign lesions can grow, infarct, become heterogeneous and thus suspicious, and on the other hand, PABC does not always present with typical malignant features. That is why biopsy must be performed if after the clinical and radiological evaluation the doubt persists, i.e. for all BI-RADS 4 and 5 lesions, and for some BI-RADS 3 lesions.

Current Recommendations for Breast Imaging of the Pregnant and Lactating Patient

During pregnancy and lactation, the breast undergoes unique changes that manifest as varied clinical and imaging findings. Understanding the expected physiologic changes of the breast as well as recognizing the best imaging modalities for a given clinical scenario can help the radiologist identify the abnormalities arising during this time. Discussion with the patient about the safety of breast imaging can reassure patients and improve management. This article reviews the physiologic changes of the breast during pregnancy and lactation; the safety and utility of various imaging modalities; upto-date consensus on screening guidelines; recommendations for diagnostic evaluation of breast pain, palpable abnormalities, and nipple discharge; and recommendations regarding advanced modalities such as breast MRI. In addition, the commonly encountered benign and malignant entities affecting these patients are discussed.

Breast lesions during pregnancy and lactation: a pictorial essay

A wide range of breast lesions can arise during pregnancy and lactation, from benign or Epub ahead of print inflammatory diseases to malignant tumors. Hormone-influenced physiological changes of the breast make the radiological evaluation of breast lesions challenging. Knowledge of the imaging features of normal physiological changes and common breast lesions during this period can help radiologists accurately diagnose and appropriately manage conditions. As such, this pictorial essay illustrates normal physiological changes related to pregnancy and lactation, as well as common benign and malignant breast lesions encountered during those periods.

Pregnancy associated breast cancer

Pregnancy associated breast cancer (PABC) defined as breast cancer occurring during pregnancy or within the first 1-2 years postpartum. Delay in diagnosis is common. Treatment is timed around gestational age. Surgery and chemotherapy are considered safe after the first trimester. Radiation, anti-her-2, and endocrine therapy are delayed until after delivery due to adverse fetal effects. Iatrogenic prematurity likely causes most long-term fetal sequelae. Multi-disciplinary care and social support are critical for patients and families with PABC.

Breast Imaging During Pregnancy and Lactation

Breast imaging during pregnancy and lactation is important in order to avoid delays in the diagnosis and treatment of pregnancy-associated breast cancers. Radiologists have an opportunity to improve breast cancer detection by becoming familiar with appropriate breast imaging and providing recommendations to women and their referring physicians. Importantly, during pregnancy and lactation, both screening and diagnostic breast imaging can be safely performed. Here we describe when and how to screen, how to work up palpable masses, and evaluate bloody nipple discharge. The imaging features of common findings in the breasts of pregnant and lactating women are also reviewed. Finally, we address breast cancer staging and provide a brief primer on treatment options for pregnancy-associated breast cancers.

Ultrasound Imaging Characteristics of Breast Lesions Diagnosed During Pregnancy and Lactation

Background and Objectives: The breast undergoes extensive physiologic changes during pregnancy/lactation. We aimed to review the ultrasound (US) imaging characteristics of breast lesions during pregnancy/lactation and to demonstrate ultrasonography as an excellent imaging modality in this patient population. Materials and Methods: We performed a retrospective study involving 195 patients with 206 pathologically confirmed breast lesions during pregnancy/lactation over the period of January 2010 to December 2018; 51 were diagnosed with breast cancer, including 50 invasive ductal carcinomas and 1 low malignant potential phyllodes tumor, whereas 144 were diagnosed with 155 benign lesions, including 103 mastitis/abscesses, 45 fibroadenomas, 2 intraductal papillomas, 2 sclerosing lesions, and 3 benign phyllodes tumors. The patients' age, lesion diameter, and US characteristics were analyzed. Results: The breast lesions of patients during pregnancy/lactation were compared with those during nonpregnancy/lactation. Patients with breast cancer or fibroadenomas during pregnancy/lactation were younger than those during nonpregnancy/lactation. The average lesion diameter was significantly higher among pregnant/lactating patients compared with controls of childbearing age for fibroadenomas, but not for malignant lesions. The fibroadenomas and mastitis/abscesses during pregnancy/lactation usually have higher BI-RADS categories than those during nonpregnancy/lactation. Conclusions: The imaging features of breast cancer during pregnancy/lactation did not differ much from those of nonpregnancy/lactation; however, some benign lesions had suspicious sonographic features, and US-guided core biopsies were necessary for differentiating benign from malignant lesions.

Breast Cancer during Pregnancy-Current Paradigms, Paths to Explore

Breast cancer is the most common form of malignancy in pregnant women. The prevalence of pregnancy-associated breast cancer (PABC) is up to 0.04% of pregnancies and is expected to rise in developed countries. PABC represents a unique clinical scenario which requires a delicate balance of risks and benefits for both maternal and fetal well-being. Currently, there is paucity of data regarding the short- and long-term outcomes of in-utero exposure to anti-neoplastic agents. In general, when possible, treatment for PABC should follow the same guidelines as in non-pregnant patients. Surgery, including sentinel lymph node biopsy, is possible during all trimesters of pregnancy. Radiotherapy is contraindicated during pregnancy, although it might be considered in highly selected patients based on risk-benefit assessment. Evidence supports that administration of chemotherapy may be safe during the second and third trimesters, with cessation of treatment three weeks prior to expected delivery. Currently, hormonal therapy and anti-HER2 agents are contraindicated during pregnancy and should be postponed until after delivery. Prematurity is associated with worse neonatal and long-term outcomes, and thus should be avoided. While current data on the long-term effects of anti-neoplastic treatments are reassuring, grade of evidence is lacking, hence additional large prospective studies with long-term follow-up are essential to rule out any treatment-induced adverse effects.

Pregnancy-associated breast cancer: A review of 47 women

PURPOSE

Pregnancy-associated breast cancer (PABC) is a rare disease. However, its expected incidence tends to be increased because of delayed maternal age. The purpose of this study was to describe the clinical, radiological, and histopathological characteristics of PABC cases diagnosed in our center.

METHODS

The clinical-radiological findings and histopathological characteristics of patients diagnosed and treated with PABC at our institution between January 2011 and January 2017 were retrospectively evaluated.

RESULTS

Mammography and ultrasonography were performed in all patients. MRI examination was performed in 18 patients. Nine (19.1%) out of 47 patients were diagnosed with breast cancer during pregnancy, and 38 (80.9%) were in their first year after delivery. The most frequent finding (95.7%) during imaging was one or more masses. Mammography-detected pure or accompanying microcalcifications were found in 12 (25.5%) patients. MRI detected additional multifocal and multicentric disease in 14 (29.8%) patients and contralateral cancer in one (2.1%) patient.

CONCLUSIONS

Pregnancy-related breast cancer tends to be diagnosed in an advanced stage with poor prognosis. Any breast abnormalities observed in this period should alert clinicians, and a meticulous radiological evaluation is mandatory. The early diagnosis of this disease would increase the chances of successful treatment.

Imaging of Lactating Adenoma: Differential Diagnosis of Solid Mass Lesion in a Lactating Woman

Lactating adenoma is an uncommon palpable breast lesion occurring in the late pregnancy or lactation period and is commonly found in young primiparous women in the second or third decade of life. Although a benign condition, sometimes, core biopsy is required to exclude malignancy. Approximately 3% of all breast cancers occur in women who are pregnant; and hence, a breast mass in this group of women must be investigated. The main differential diagnosis for a palpable solid breast mass is lobular hyperplasia which is a normal physiological event, fibroadenoma, focal mastitis, lactating adenoma, tubular adenoma, phyllodes tumor, and breast carcinoma. Here, we present a case of lactating adenoma of the breast at 6 months’ postpartum in a 24-year-old primiparous woman.

Breastfeeding and Breast Cancer: Managing Lactation in Survivors and Women with a New Diagnosis

BACKGROUND

Supporting breastfeeding is a global health priority, yet few clinical guidelines exist to guide surgical oncologists in managing lactation during or after breast cancer treatment.

METHODS

The literature was reviewed to identify evidence-based strategies for managing lactation during multidisciplinary breast cancer treatment or among breast cancer survivors.

RESULTS

The majority of the evidence is from observational studies, with some higher levels of evidence, including systematic reviews and meta-analyses. Several significant gaps in knowledge remain.

CONCLUSIONS

This review serves as a comprehensive resource of evidence-based recommendations for managing lactation in breast cancer survivors and breastfeeding women with a new breast cancer diagnosis.

Breast Cancer Screening in High-Risk Patients during Pregnancy and Breastfeeding: A Systematic Review of the Literature

There are currently no clear guidelines for high-risk breast cancer screening during the pregnancy and breastfeeding periods. The objective of this systematic review (SR) was to assess the available evidence pertaining to breast cancer screening recommendations in this population with the aim of supporting future guidelines. We performed a SR of the literature using the electronic databases MEDLINE and Embase. Predetermined inclusion and exclusion criteria were used during the abstract screening and full-text data extraction phases. We retrieved 2,274 abstracts after removal of duplicates, from which 16 studies were included based on predetermined eligibility criteria. Most of the studies found were narrative reviews and expert opinions. Clinical breast exam (CBE) was recommended by 12 studies during pregnancy and by 6 studies in the breastfeeding period. Mammography was recommended in the breastfeeding period by 2 studies. Magnetic resonance imaging was recommended in the breastfeeding period by 2 studies. Ultrasound was considered not appropriate for screening in this population. The information extracted from this SR is based primarily on expert opinion and anecdotal evidence, which explains the lack of standardized guidelines for high-risk breast cancer screening in this population. However, expert opinion may be a surrogate outcome for high-risk breast cancer screening recommendations in this subset of patients, and as such, may justify the clinical management to be tailored accordingly. This SR summarizes the evidence pertaining to high-risk breast cancer screening during pregnancy and breastfeeding, which could serve as a catalyst for future research on the topic.

Young Women with Breast Cancer: Fertility Preservation Options and Management of Pregnancy-Associated Breast Cancer

BACKGROUND

Breast cancer is the most common malignancy diagnosed in women of childbearing age. A breast cancer diagnosis in this young patient population can be uniquely complex to navigate when considering the potential impact of fertility loss associated with specific gonadotoxic therapies. Another unique challenge for young breast cancer patients is pregnancy-associated breast cancer (PABC), which occurs in approximately 1 of every 3000 pregnancies. Pregnancy adds a layer of complexity to breast cancer treatment planning as many therapies can affect the developing fetus. These two clinical challenges require nuanced multidisciplinary approaches to facilitate optimal treatment outcomes. We sought to review and summarize the management strategy options for both fertility preservation and PABC.

METHODS

A guideline and literature review was performed for fertility preservation, young patients with breast cancer, and pregnancy-associated breast cancer.

RESULTS

Fertility preservation options, both established and experimental, are detailed. Suggested clinical practice guidelines for PABC are also presented, which delineate breast cancer treatment recommendations based on pregnancy trimester.

CONCLUSION

A multidisciplinary approach to patient care, including oncologists and early referral to reproductive specialists, can provide young breast cancer patients with options for fertility preservation. Under the guidance of a multidisciplinary treatment team, PABC can also be diagnosed and treated to permit the best possible outcomes for the mother and the developing fetus.

Diffuse optical spectroscopic imaging for the investigation of human lactation physiology: a case study on mammary involution

Relatively few imaging and sensing technologies are employed to study human lactation physiology. In particular, human mammary development during pregnancy as well as mammary involution after lactation have been poorly described, despite their importance for breast cancer diagnosis and treatment during these phases. Our case study shows the potential of diffuse optical spectroscopic imaging (DOSI) to uniquely study the spatiotemporal changes in mammary tissue composition during the involution of the lactating breast toward its pre-pregnant state. At nine time intervals over a period of eight months after the cessation of breastfeeding, we reconstructed 2-D maps of mammary water content, lipid content, total hemoglobin (THb) concentration, oxygen saturation (StO2), and tissue optical scattering. Mammary lipid content in the nonareolar region showed a significant relative increase of 59%, whereas water content and THb concentration showed a significant relative decrease of 50% and 48%, respectively. Significant changes were also found in StO2 and tissue optical scattering. Our findings are consistent with the gradual replacement of fibroglandular tissue by adipose tissue and vascular regression during mammary involution. Moreover, our data provide unique insight into the dynamics of breast tissue composition and demonstrate the effectiveness of DOSI as a technique to study human lactation physiology.

Breast Ultrasound during Lactation: Benign and Malignant Lesions

Background

Structural changes during lactation make breast physical examination difficult. When breast problems occur, patients are often referred for an ultrasound (US) scan. Most breast lesions diagnosed in these patients are benign, but the diagnosis of breast cancer is a challenge. We aim to demonstrate the spectrum of US imaging findings in lactating women.

Methods

77 breastfeeding patients who underwent breast US in our department between February 2012 and March 2017 were evaluated. Patients' electronic medical records were reviewed for the presenting complaint, US reports, pathology results if available, and clinical/radiologic follow-up. All examinations were performed by 2 radiologists.

Results

28 of the 77 patients had normal US findings. Cysts were seen in 16 patients. 4 patients had stable fibroadenomas. 6 patients had US imaging findings suggestive of mastitis, 5 patients had galactoceles, 1 patient had an abscess, and 1 patient had unilateral hypertrophy without any accompanying lesion. In 13 patients, BI-RADS 3 solid masses were diagnosed. Invasive breast cancer was diagnosed in 3 patients.

Conclusion

US can demonstrate or exclude a true mass against the background of a nodular breast parenchyma. Radiologists must be aware of malignant US features to avoid delays in the diagnosis of pregnancy-associated breast cancer.

ACR Appropriateness Criteria® Breast Imaging of Pregnant and Lactating Women

Breast imaging during pregnancy and lactation is challenging due to unique physiologic and structural breast changes that increase the difficulty of clinical and radiological evaluation. Pregnancy-associated breast cancer (PABC) is increasing as more women delay child bearing into the fourth decade of life, and imaging of clinical symptoms should not be delayed. PABC may present as a palpable lump, nipple discharge, diffuse breast enlargement, focal pain, or milk rejection. Breast imaging during lactation is very similar to breast imaging in women who are not breast feeding. However, breast imaging during pregnancy is modified to balance both maternal and fetal well-being; and there is a limited role for advanced breast imaging techniques in pregnant women. Mammography is safe during pregnancy and breast cancer screening should be tailored to patient age and breast cancer risk. Diagnostic breast imaging during pregnancy should be obtained to evaluate clinical symptoms and for loco-regional staging of newly diagnosed PABC. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Imaging in pregnancy-associated breast cancer: a case report

BACKGROUND

PABC (pregnancy-associated breast cancer) is a rare condition that appears as a malignancy in 1 per 3000 pregnant women and is one of the most common cancers diagnosed during pregnancy or the postpartum period. If a woman who is pregnant or within a year after delivery has complaints of a palpable breast mass, it could undeniably be a malignant mass of the breast. That is why an ultrasound should be performed for all pregnant or lactating women who detect a palpable breast mass that persists for two or more weeks.

CASE REPORT

Our case report presents a pregnant 40-year-old previously healthy female at 36 weeks gestational age with a complaint of a palpable left breast mass for two months period. The initial ultrasound showed a breast tumour of irregular shape, solid and hypervascular mass.

CONCLUSIONS

Early diagnostics of PABC is of crucial importance in order to offer the best possible outcomes for the patient and foetus.

A Review of Pregnancy-Associated Breast Cancer: Diagnosis, Local and Systemic Treatment, and Prognosis

The incidence of pregnancy-associated breast cancer (PABC) increases as more women choose to delay childbearing and the population-based incidence of breast cancer rises. Reliably and safely staging PABC is necessary to choose between starting with local or systemic therapy. With regard to local therapy, both lumpectomy and mastectomy can be considered depending on gestational age and the stage at diagnosis. By mirroring nonpregnant treatment regimens as much as possible, chemotherapy may improve long-term oncologic outcomes while allowing for surgical downstaging during pregnancy. Delaying treatment due to misconceptions regarding risk of local and systemic therapy most certainly worsens oncologic outcomes, and most neonatal morbidity is related to gestational age at delivery and not in utero exposures. Pregnancy itself was once considered an independent risk factor for worse outcome, but the prognosis of these patients is not significantly different than nonpregnant counterparts of a similar age.

Intravoxel incoherent motion (IVIM) and non-Gaussian diffusion MRI of the lactating breast

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Breastfeeding significantly affects IVIM and non-Gaussian diffusion parameters.

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The distribution of ADC₀ values becomes more heterogeneous after breastfeeding.

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Care needs to be taken in interpreting DWI data in lactating breasts.

Purpose

To investigate the effect of breastfeeding on IVIM and non-Gaussian diffusion MRI in the breast.

Materials and methods

An IRB approved prospective study enrolled seventeen volunteers (12 in lactation and 5 with post-weaning, range 31–43 years; mean 35.4 years). IVIM (f_IVIM and D*) and non-Gaussian diffusion (ADC₀ and K) parameters using 16 b values, plus synthetic apparent diffusion coefficients (sADCs) from 2 key b values (b = 200 and 1500 s/mm²) were calculated using regions of interest. ADC₀ maps of the whole breast were generated and their contrast patterns were evaluated by two independent readers using retroareolar and segmental semi-quantitative scores. To compare the diffusion and IVIM parameters, Wilcoxon signed rank tests were used between pre- and post-breastfeeding and Mann-Whitney tests were used between post-weaning and pre- or post-breastfeeding.

Results

ADC₀ and sADC values significantly decreased post-breastfeeding (1.90 vs. 1.72 × 10⁻³ mm²/s, P < 0.001 and 1.39 vs. 1.25 × 10⁻³ mm²/s, P < 0.001) while K values significantly increased (0.33 vs. 0.44, P < 0.05). f_IVIM values significantly increased after breastfeeding (1.97 vs. 2.97%, P < 0.01). No significant difference was found in D* values. There was significant heterogeneity in ADC₀ maps post-breastfeeding, both in retroareolar and segmental scores (P < 0.0001 and =0.0001).

Conclusion

IVIM and non-Gaussian diffusion parameters significantly changed between pre- and post-breastfeeding status, and care needs to be taken in interpreting diffusion-weighted imaging (DWI) data in lactating breasts.

Is there any relationship between adc values of diffusion-weighted imaging and the histopathological prognostic factors of invasive ductal carcinoma?

OBJECTIVE

MRI is being used increasingly as a modality that can provide important information about breast cancer. Diffusion-weighted imaging (DWI) is an imaging technique from which apparent diffusion coefficient (ADC) values can be calculated in addition to obtaining important structural information which cannot be obtained from other imaging studies. We did not find any significant relationships between ADC values and prognostic factors, but did provide some explanations for conflicting results in the literature.

METHODS

The ADC results of 61 females with invasive ductal carcinomas were evaluated. DWI was performed and ADC values were calculated from the area in which restriction of diffusion was the highest in ADC mapping. B value was 500 and region of interest (ROI) was designated between 49 and 100 mm². Calculations were performed automatically by the device. Tissue samples were obtained for prognostic factor evaluation. The relationships between ADC and prognostic factors were investigated. Comparisons between groups were made with one-way ANOVA and Kruskal Wallis test. Pairwise comparisons were made with Dunn's test. Analyses of categorical variables were made with Chi-square test.

RESULTS

We found a weak negative correlation between ADC and Ki-67 values (r = -0.279; p = 0.029). When we compared ADC values in regard to tumour type, we found no significant differences for tumour grade, Ki-67 positivity, estrogen receptor positivity, progesterone receptor positivity, C-erb B2, lymphovascular invasion and ductal carcinoma in situ or lobular carcinoma in situ component. On a side note, we found that mean ADC values decreased as tumour grade increased; however, this was not statistically significant.

CONCLUSION

The literature contains studies that report conflicting results which may be caused by differences in B values, ROI area and magnetic field strength. Multicentre studies and systematic reviews of these findings may produce crucial data for the use of DWI in breast cancer. Advances in knowledge: To determine if any significant relationship exists between DWI findings and prognostic factors of breast cancer.