Breast diseases during pregnancy and lactation

Pregnancy and Breast Cancer: A Challenge for the Multidisciplinary Team. A Single Center Experience and Narrative Review

Purpose

The diagnosis of breast cancer during pregnancy is a rare event, but it is more frequent in our daily clinical practice due to the progressing aging of pregnant women. The management of a woman affected by pregnancy-associated breast cancer (PABC) remains a challenge for the clinician as it is related to ethical and psychological decisions.

Patients and Methods

Here, we retrospectively described 10 cases of PABC in women treated at our Institution. All cases were discussed in the multidisciplinary team. We reviewed available literature data on the topic.

Results

Nine out 10 patients were diagnosed with localized breast cancer. The remaining patients were presented with metastatic de novo disease. Median age was 37.5 years (range 26-42). Seven patients presented with grade 3 tumor and 9 patients had Ki-67 value higher than 30%. All but 2 patients received neoadjuvant chemotherapy consisting of sequential anthracyclines and cyclophosphamide followed by weekly paclitaxel during pregnancy. No safety concerns or complications during delivery for both the mothers and the babies were reported.

Conclusion

Breast cancer during pregnancy is a challenging clinical situation and all the decisions need to consider both the patients and the fetus safety. Data from our series and from literature confirm the safety of standard chemotherapy approach starting from the second trimester of gestation. More research and effort are needed to offer these patients excellent outcomes and it is mandatory that cases should be closely followed up by a multidisciplinary team.

Graduate Student Literature Review: Mammary gland development in dairy cattle - quantifying growth and development

Mammary gland development research in dairy cattle has improved tremendously over the years, ranging from palpation to methods such as DNA/RNA sequencing, histological imaging, and medical imaging. Despite these advancements, there is limited evidence relating milk production with early mammary development due to incomplete and conflicting data. Further, data is typically not collected longitudinally in the same animals allowing for repeated measures analysis. Additional research is necessary to better understand development of the mammary gland and its direct relationship with subsequent ability to produce milk. As ultrasound has been shown to be a reliable method of visualizing mammary gland structure and parenchymal composition throughout the different stages of development in dairy cattle, it is possible that ultrasound technology can be used in future research to monitor and visualize longitudinal mammary development in dairy cattle noninvasively, and identify quantitative features indicative of milk production potential without culling. Identification of features indicative of higher milk production potential would not only aid in the selection of replacement heifers, but also has potential applications to human medicine with possible prediction of lactation potential in humans.

A case of phyllodes tumor with rapid growth during pregnancy and lactation period: a case report

BACKGROUND

The age of onset of the phyllodes tumor is generally in the late 40 s, and diagnosis and treatment during pregnancy and lactation are rare. We herein present a case of a phyllodes tumor that rapidly increased in size during the pregnancy and lactation period.

CASE PRESENTATION

A 39-year-old woman was referred to our hospital with a mass in the right breast that increased in size during the pregnancy and lactation period. On ultrasound (5 week postpartum), a well-defined lobulated mass with internal septations and fluid retention was observed. Magnetic resonance imaging of the breast at 8 week postpartum revealed a 70-mm-sized smooth-margin mass with multilocular cystic components. Marked proliferation of stromal cells with high cell density was observed in a biopsy specimen taken at the previous hospital. We diagnosed the mass as a phyllodes tumor of borderline malignancy and excised it at 13 week postpartum. The excised tumor was 85 mm in diameter and its interior was filled with a milk-like substance. Histologically, there was only a mild increase in stromal cell density but fibrosis with associated degeneration was prominent. The final diagnosis was benign phyllodes tumor with degeneration.

CONCLUSIONS

We report a case of a phyllodes tumor that rapidly increased in size during pregnancy and the lactation period. The accumulation of a milk-like substance was thought to be responsible for the rapid growth of the tumor.

Gestational Gigantomastia: Case Report and Review of Treatment Options

Gestational gigantomastia is a rare and devastating condition involving rapid and excessive enlargement of the breast tissue during pregnancy or postpartum. We review the workup, assessment, and care of a patient with gestational gigantomastia with superimposed mastitis. Conservative treatment, medical management, and surgical options should be explored with patients. It is also important for providers to be cognizant of the psychological impact of this condition.

Surgical management of a giant fibroadenoma during lactation

Fibroadenomas are the most common breast lesion in women of reproductive age. During pregnancy and lactation, fibroadenomas can undergo rapid growth in response to hormonal stimulus. These changes may prompt further investigation and/or intervention due to the risk of an underlying phyllodes tumour. We present a case of a female patient who underwent surgical excision of a giant fibroepithelial lesion at 4 months post partum while continuing to breastfeed. The lesion was successfully excised while maintaining lactation. A postoperative milk fistula resolved with non-operative management. There is limited literature on the surgical management of breast lesions in lactating women. This case illuminates the surgical management of breast lesions in an often well informed group of patients who may choose to have surgery while lactating in spite of the increased risk of complications. This case also highlights the need for a holistic approach to maintain the overall health of mother and child.

Pregnancy-Associated Breast Changes after Nipple-Sparing Mastectomy

BACKGROUND

Women of reproductive age are chronically underrepresented in breast cancer studies. Recent studies suggest that almost 40% of patients diagnosed with breast cancer who are of reproductive age want to have children after completing treatment. In this study, the authors evaluated patients of reproductive age who had undergone nipple-sparing mastectomy (NSM) and implant-based reconstruction. The authors compared those who became pregnant with those who did not with respect to clinical and radiologic changes that are reported at follow-up.

METHODS

Any patient 45 years of age or younger at the time of NSM was determined to be of reproductive age, selected for evaluation, and followed prospectively. The presence or absence of breast examination changes in the setting of pregnancy after NSM was recorded.

RESULTS

A total of 36 patients became pregnant after NSM, and 158 patients did not become pregnant after NSM. Of those who became pregnant, nearly half reported some clinical change just before or immediately after delivery. These changes included color change and discharge at the residual nipple-areola complex and palpable nodularity elsewhere. For those with palpable changes, an ultrasound was performed and hypoechoic lesions with variable vascularity were identified. For those who went on to excision, lactational hyperplasia was the most common diagnosis.

CONCLUSIONS

Ultrasound is an appropriate first-line investigation of breast changes, which can include hyperplasia of remaining ductal and glandular tissue. Patients who became pregnant after NSM commonly had clinical breast examination changes, but the majority of these changes were found to be benign on further evaluation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Single cell profiling of female breast fibroadenoma reveals distinct epithelial cell compositions and therapeutic targets

Fibroadenomas (FAs) are the most common breast tumors in women. No pharmacological agents are currently approved for FA intervention owing to its unclear mechanisms and a shortage of reproducible human models. Here, using single-cell RNA sequencing of human FAs and normal breast tissues, we observe distinct cellular composition and epithelial structural changes in FAs. Interestingly, epithelial cells exhibit hormone-responsive functional signatures and synchronous activation of estrogen-sensitive and hormone-resistant mechanisms (ERBB2, BCL2 and CCND1 pathways). We develop a human expandable FA organoid system and observe that most organoids seem to be resistant to tamoxifen. Individualized combinations of tamoxifen with ERBB2, BCL2 or CCND1 inhibitors could significantly suppress the viability of tamoxifen-resistant organoids. Thus, our study presents an overview of human FA at single-cell resolution that outlines the structural and functional differences between FA and normal breast epithelium and, in particular, provides a potential therapeutic strategy for breast FAs.

Factors associated with breast disorders detected by clinical breast examination during pregnancy and six months postpartum in Ibadan, South-western Nigeria

Background

Breast disorders (BD) during pregnancy and postpartum cause anxiety and reduce women's quality of life. The study examined BD risk factors during pregnancy and six months after delivery.

Methods

Women attending antenatal clinics at 26 weeks gestation were recruited. 1248 pregnant women were followed six months postpartum. During recruitment, a validated questionnaire was used to collect participant characteristics and risk factors. Palpable lumps, inflammation, persistent pain, and abnormal nipple discharge were classified breast disorders. Statistical analysis used multiple logistic and cox regression models at p<0.05.

Results

Women with benign breast disease were more likely to develop BD (aOR = 2.63, 95% CI = 1.50-4.88). One pregnancy increases the risk of BD more than three times (aOR=0.52, 95%CI: 0.29-0.95). History of breast trauma (aHR=3.59, 95%CI: 1.40-9.17) and 3 miscarriages vs. none (aHR=2.23, 95%CI: 1.04-4.23) were also risk factors for BD. The second quartile of physical activity was associated with a lower risk of BD (aHR=0.35, 95%CI: 0.15-0.78).

Conclusion

Women with breast trauma and miscarriage are more likely to develop breast disorders during pregnancy and six months after delivery. Our findings highlight the need for additional longitudinal research to validate these findings and plans for prevention and control. Keywords: Breast disorders, pregnancy, postpartum, predictors, longitudinal study.

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.

Crystallizing galactocele of the breast masquerading as a malignancy: Report of a rare case with cytological diagnosis

Galactoceles are the common benign cystic breast lesions during pregnancy and lactation. This report describes the cytological findings of a case of long standing galactocele which underwent crystallization and mimicked carcinoma clinically as well as on sonography. A young woman presented with a hard painless lump in the right breast. She noticed the lump during her pregnancy 2.5 years back. Clinically the lesion was hard and sonography was equivocal in categorizing the lesion. An FNAC was performed which showed granular amorphous material along with crystals of various shapes and sizes. A diagnosis of crystallizing galactocele was made and woman was assured about the benign nature of the lesion. The cytological findings of crystallizing galactocele have been reported in very few cases. In the present case, a detailed history and clinical examination followed by fine needle aspiration established the diagnosis of crystallizing galactocele.

Fluid Flow Stimulation Modulates Expression of S100 Genes in Normal Breast Epithelium and Breast Cancer

INTRODUCTION

S100 proteins are intracellular calcium ion sensors that participate in cellular processes, some of which are involved in normal breast functioning and breast cancer development. Despite several S100 genes being overexpressed in breast cancer, their roles during disease development remain elusive. Human mammary epithelial cells (HMECs) can be exposed to fluid shear stresses and implications of such interactions have not been previously studied. The goal of this study was to analyze expression profiles of S100 genes upon exposing HMECs to fluid flow.

METHODS

HMECs and breast cancer cell lines were exposed to fluid flow in a parallel-plate bioreactor system. Changes in gene expression were quantified using microarrays and qPCR, gene-gene interactions were elucidated using network analysis, and key modified genes were examined in three independent clinical datasets.

RESULTS

S100 genes were among the most upregulated genes upon flow stimulation. Network analysis revealed interactions between upregulated transcripts, including interactions between S100P, S100PBP, S100A4, S100A7, S100A8 and S100A9. Overexpression of S100s was also observed in patients with early stage breast cancer compared to normal breast tissue, and in most breast cancer patients. Finally, survival analysis revealed reduced survival times for patients with elevated expression of S100A7 and S100P.

CONCLUSION

This study shows that exposing HMECs to fluid flow upregulates genes identified clinically to be overexpressed during breast cancer development, including S100A7 and S100P. These findings are the first to show that S100 genes are flow-responsive and might be participating in a fundamental adaptation pathway in normal tissue that is also active in breast cancer.

Pregnancy-lactation cycle: how to use imaging methods for breast evaluation

Pregnancy and lactation constitute states of intense hormonal variation with secretory and structural changes in the breast parenchyma. These changes translate into important features on breast imaging, as well as the emergence of specific benign and malignant lesions. This literature review aims to discuss the safety of the use of breast imaging methods (mammography, ultrasound, and magnetic resonance imaging) during the pregnancy-lactation cycle, and to present the expected physiological changes and imaging appearance of the main breast diseases that may occur in this period, such as galactocele, lactating adenoma, fibroadenoma, puerperal mastitis, and pregnancy-associated breast cancer.

Nipple Ultrasound: A Pictorial Essay

Ultrasound (US) is an attractive diagnostic approach to identify both common and uncommon nipple pathologies, such as duct ectasia, nipple abscess, nipple leiomyoma, nipple adenoma, fibroepithelial polyp, ductal carcinoma in situ (restricted to nipple), invasive carcinoma, and Paget's disease. US is the reliable first-line imaging technique to assess nipple pathologies. It is useful to identify and characterize nipple lesions. Additionally, we have presented the mammography and MRI outcomes correlated with histopathologic features for the relevant cases.

Mastitis, Breast Abscess, and Granulomatous Mastitis

Breastfeeding is immunoprotective and World Health Organization recommends exclusive breastfeeding for about six months with continuation of breastfeeding for one year or longer as mutually desired by mother and infant. But the target for duration of exclusive breastfeeding has not been reached in a significant number of women. It may be due to inflammatory breast disease such as milk stasis or lactational mastitis.In this chapter we discuss the most common complications of breastfeeding including milk stasis, mastitis, and breast abscess. Also idiopathic granulomatous mastitis, a less common condition, is discussed due to its confusing characteristics and not universally-accepted treatment strategies .Breastfeeding mastitis is inflammation of the breast that can be infectious or non-infectious. With proper diagnosis and treatment of this condition, more severe complications like breast abscess could be avoided, so that breastfeeding could be continued in some circumstances.

Breast Cytology and Pathology in Pregnancy and Lactation

Breast tissue reveals some physiologic changes during pregnancy and lactation due to hormonal alterations. Whole range of breast diseases including inflammatory, benign and malignant neoplasms can be seen in pregnancy but due to concurrent physiologic changes, may lead to diagnostic challenges. This chapter reviews sampling methods and histologic features of common benign breast lesions in pregnancy and lactation periods.

A Systematic Review of Milk Fistula in Nursing Mothers: Modifying the Perspective Toward Maintenance of Breastfeeding

Introduction

Milk fistula is rare, and cessation of nursing has been recommended for treatment. We performed a comprehensive review of all existing literature to explore the causes of milk fistulae and the necessity of discontinuing breastfeeding, and mention our recommendations given our present practice.

Method

Google Scholar, Pubmed, Ovid Medline, and Scopus were thoroughly investigated by using relevant keywords. After screening by reading titles, abstracts, and full texts of returned studies, pertinent articles were included and data extracted.

Results

Seventeen studies including 27 cases were included. Lactation ceased in 16 patients, but this was generally done without awaiting results of conservative management.

Conclusion

We recommend measures for preventing milk fistulae, conservative measures for treatment, and continuation of breastfeeding throughout the process until healing occurs.

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.

Clinical Presentations of Breast Disorders in Pregnancy and Lactation

The breast tissue undergoes significant physiological change during pregnancy and lactation. These changes can give rise to some unique disorders during pregnancy , puerperium and lactation or exaggerate pre-existing conditions. Clinical examination becomes less reliable due to textural change and density of breast tissue as a result of hormonal changes. The main symptoms during pregnancy and lactation are breast pain, mastitis, lactational abscess, breast lump, and blood- stained nipple discharge.Lactational mastitis/ abscess must be treated without delay. Open incision and drainage of lactational abscess is rarely required, any lactational abscess should be treated with appropriate antibiotics and ultrasound guided aspiration of the pus.Any breast lump during pregnancy and lactation should be investigated with triple assessment. Pregnancy associated breast cancer (PABC ) must be ruled out. The choice of investigations and treatment needs careful consideration. While ultrasound is the investigation of choice, mammography can be performed with abdominal shielding if malignancy is suspected. Core biopsy is necessary for evaluation of any breast pathology but it comes with risk of infection, bleeding, hematoma and even milk fistula.The treating clinical specialist must be aware of certain unusual unique clinical conditions in pregnancy and lactation including accessory axillary breast tissue, gigantomastia and Raynaud's phenomenon.

Benign Disorders of the Breast in Pregnancy and Lactation

Benign cystic or solid lumps frequently occur in the breasts of young women, and consequently can also be seen during pregnancy and lactation. Simple cysts do not increase the risk of malignancy. The current management is routine follow-up. Complex cysts are thick walled or contain a mass, and should be followed by a US-guided biopsy and then treated similar to any non-gravid, non-lactating patient.Galactoceles can be detected during the last trimester of pregnancy and during or after stopping lactation. Aspiration can be done to confirm the content. Co-existence of galactocele and malignancy is extremely rare, and the key is to follow up until it resolves.Fibroadenoma is the most frequent lesion found during pregnancy and lactation. Management is usually conservative after triple assessment. Surgery is usually not recommended in pregnant and lactating women unless rapid increase in size occurs or there is discordance in the triple assessment.Lactating adenomas are sometimes interpreted as a variant of fibroadenoma . They can naturally disappear at the end of pregnancy or lactation. Management is usually conservative, and an excisional biopsy is only mandated if it is rapidly enlarging or if there is discordance in the triple assessment.Gestational gigantomastia is a rare condition consisting of diffuse severe hypertrophy of both breasts during pregnancy . Mastectomy and reconstruction may rarely be required in such cases.

Atypical Lesions of the Breast and Lobular Carcinoma in Situ in Pregnancy - Surgeons' Practice

Objective

Approach to precancerous and high-risk breast lesions occurring in pregnancy has received little attention in the literature. We carried out a study to investigate the practice of surgeons in the management of these cases.

Materials and Methods

A short survey was sent to surgeons, including a multiple-choice questionnaire about their practice for atypical hyperplasia or lobular carcinoma in situ presenting in each trimester of pregnancy or at time of breastfeeding. Answer options included observation, immediate vacuum biopsy, immediate surgery, surgery in next trimester, surgery after delivery, and surgery after end of breastfeeding; based on the time of presentation.

Results

Out of the 671 practitioners invited, 97(14.5 %) responded to the survey. Participants were from 23 countries. Answers showed that management of gestational Atypical Ductal Hyperplasia (ADH) and Lobular Neoplasia (LN) was readily postponed by surgeons in favor of fetus safety while being cautious about risks of conservative management alone.

Conclusion

Various methods of treatment are selected by surgeons for managing high-risk breast lesions during pregnancy. In the absence of relevant literature, decision making in a multidisciplinary team would be the best approach in these cases.

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.

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.

Pitfalls in Fine-Needle Aspiration Cytology Diagnosis of Ductal Carcinoma in a Lactating Breast

Breast undergoes hormonal changes, especially during pregnancy and postpartum period and may be associated with benign and malignant lesions. These lesions can arise either de novo or can be an exacerbated change occurring in a preexisting breast lesion. The benign lesion in the lactating breast can show some degree of atypia due to the high levels of progesterone and prolactin which can mimic malignant features microscopically and can be overdiagnosed with breast cancer. On the other hand, breast cancer in the lactating breast can be underdiagnosed when the atypical cytological features are considered as hormonal changes. A few case reports are published in the literature regarding lactating adenoma undergoing malignant transformation. We present a case in 23 years postpartum lactating female with mass in bilateral breasts. Initially, the lesions were diagnosed with hormonal changes on cytology. On follow-up by fine-needle aspiration cytology and biopsy, it was diagnosed with infiltrating ductal carcinoma in both breasts. As far as our knowledge goes, this is the first-case report in the English literature of ductal carcinoma in the bilateral lactating breast arising de novo.

A longitudinal study of the prevalence and characteristics of breast disorders detected by clinical breast examination during pregnancy and six months postpartum in Ibadan, Southwestern Nigeria

Background

Breast disorders cause great anxiety for women especially when they occur in pregnancy because breast cancer is the most common cause of cancer related deaths in women. Majority of the disorders are Benign Breast Diseases (BBD) with various degrees of associated breast cancer risks. With increasing breast cancer awareness in Nigeria, we sought to determine the prevalence and characteristics of breast disorders among a cohort of pregnant women.

Methods

A longitudinal study of 1248 pregnant women recruited in their first trimester- till 26 weeks gestational age consecutively from selected antenatal clinics (ANCs), in Ibadan, Southwest Nigeria. A pretested interviewer- administered questionnaire was used to collect information at recruitment. Clinical Breast Examination (CBE) using MammaCare® technique was performed at recruitment and follow up visits at third trimester, six weeks postpartum and six months postpartum. Women with breast disorders were referred for Breast Ultrasound Scan (BUS) and those with Breast Imaging Reporting and Data System (BIRADS) ≥4 had ultrasound guided biopsy. Statistical analysis was performed using Stata version 14.

Results

Mean age of participants was 29.7 ± 5.2 years and mean gestational age at recruitment was 20.4 ± 4.4 weeks. Seventy-two participants (5.8%) had a past history of BBD and 345 (27.6%) were primigravidae. Overall, breast disorder was detected among 223 (17.9%) participants and 149 (11.9%) had it detected at baseline. Findings from the CBE showed that 208 (69.6%) of 299 breast disorders signs found were palpable lumps or thickenings in the breast, 28 (9.4%) were persistent pain, and 63 (21.1%) were abscesses, infection and mastitis. Twenty out of 127 (15.7%) participants who had BUS performed were classified as BIRADS ≥3. Lesions found by BUS were reactive lymph nodes (42.5%), prominent ducts (27.1%), fibroadenoma (9.6%), breast cysts (3.8%) and fibrocystic changes (2.5%). No malignant pathology was found on ultrasound guided biopsy.

Conclusions

Breast lump is a major breast disorder among pregnant women attending antenatal clinics in Ibadan. Routine clinical breast examination and follow up of pregnant women found with breast disorders could facilitate early detection of pregnancy associated breast cancer in low resource settings.

Pregnancy-associated breast cancer: the risky status quo and new concepts of predictive medicine

The paper is motivated by severe concerns regarding currently applied care of the pregnancy-associated breast cancer (PABC) characterised by particularly poor outcomes of the disease. Psychological and ethical aspects play a crucial role in PABC: the highest priority not to damage the foetus significantly complicates any treatment generally, and it is quite usual that patients disclaim undergoing any breast cancer treatment during pregnancy. Although, due to global demographic trends, PABC is far from appearing rarely now, severe societal and economic consequences of the disease are still neglected by currently applied reactive medical approach. These actualities require creating new strategies which should be better adapted to the needs of the society at large by advancing the PABC care based on predictive diagnostic approaches specifically in premenopausal women, innovative screening programmes focused on young female populations, targeted prevention in high-risk groups, and optimised treatment concepts. The article summarises the facts and provides recommendations to advance the field-related research and medical services specifically dedicated to the PABC care.

Genetics and genomics of breast fibroadenomas

Fibroadenomas of the breast are benign fibroepithelial tumours most frequently encountered in women of reproductive age, although they may be diagnosed at any age. The fibroadenoma comprises a proliferation of both stromal and epithelial components. The mechanisms underlying fibroadenoma pathogenesis remain incompletely understood. In the clinical setting, distinguishing cellular fibroadenomas from benign phyllodes tumours is a common diagnostic challenge due to subjective histopathological criteria and interobserver differences. Recent sequencing studies have demonstrated the presence of highly recurrent mutations in fibroadenomas, and also delineated the genomic landscapes of fibroadenomas and the closely related phyllodes tumours, revealing differences at the gene level, which may be of potential adjunctive diagnostic use. The present article provides an overview of key studies uncovering genetic and genomic abnormalities in fibroadenomas, from initial karyotype reports revealing myriad cytogenetic aberrations to next-generation sequencing-based approaches that led to the discovery of highly recurrent MED12 mutations. A thorough understanding of these abnormalities is important to further elucidate the mechanisms by which fibroadenomas arise and to refine diagnostic assessment of this very common tumour.

Galactocele in the Axillary Accessory Breast Mimicking Suspicious Solid Mass on Ultrasound

Galactoceles are the most common benign breast lesions during breastfeeding period that can mimic carcinomas. We report a galactocele with malignant appearance on ultrasound in the accessory breast. The patient was a 32-year-old lactating woman presented to our hospital for considerable swelling in the left axilla. Ultrasound examination revealed a hypoechoic mass with heterogeneous echogenicity and irregular shape and margins. Sonography-guided aspiration was performed. Aspiration of milky fluid and resolution of the axillary lump after aspiration confirmed the diagnosis of galactocele. Galactocele can present as a suspicious tumoral lesion in the axillary accessory breast and diagnostic aspiration can help in correct diagnosis of this rare lesion in the accessory breast.

Giant fibroadenoma with massive infarction masquerading as malignancy: a case report

Fibroadenoma is a common benign breast lesion that usually affects women in their second and third decade of life and usually present as small mobile painless lump. However, it is important to recognize that a small percentage have been shown to progress to giant fibroadenomas. Giant fibroadenomas can undergo infarction leading to significant morbidity and difficulty to distinguish from the more aggressive phyllodes tumors or carcinoma. We report an interesting case of giant fibroadenoma (17 × 11 × 7 cm) with massive infarction during lactation, further complicated by lactational mastitis with close resemblance to cystosarcoma phyllodes. Detailed clinical evaluation and proper investigation in the form of USG breast and PET-CT scan helped us to delineate the nature of pathology. Simple excision of lesion with curvilinear incision was done with excellent cosmetic outcome. Histopathologic features were consistent with fibroadenoma (giant) with large areas of infarction. Fibroadenoma breast has varied clinical presentations. The course of disease may be complicated by pregnancy, lactation and inflammatory processes. Massive infarction may make the picture more dubious and masquerade with malignant transformation altering our treatment decision. The presence of necrosis on core biopsy or intra-operative finding should be cautiously interpreted and is not itself a sign of malignancy. Detailed clinical evaluation and comprehensive workup should be done before embarking on radical treatment.

A Qualitative Study on Negative Emotions Triggered by Breastfeeding; Describing the Phenomenon of Breastfeeding/Nursing Aversion and Agitation in Breastfeeding Mothers

Background:

Breastfeeding aversion and agitation (BAA) while breastfeeding is anecdotally known to occur in some women who breastfeed while pregnant or those who tandem feed a newborn and a toddler. However, it is a little-researched area and the paucity of published literature around BAA reveals a significant gap in the literature.

Materials and Methods:

This study presents the findings and responses of 694 women who filled in an anonymous survey questionnaire that collected data on their basic demographics and their experiences with breastfeeding. It uses thematic and inductive content analysis, with qualitative interpretive description to present the findings.

Results:

The findings of this study shed light on an experienced phenomenon of aversion and agitation whilst breastfeeding, which varies in form, severity, and duration. It is characterised by feelings of anger or rage, a skin crawling sensation and an urge to remove the suckling infant, but can also be feelings of agitation and irritability whilst the infant is latched. A number of mothers who experience aversion still continue to breastfeed, but have feelings of guilt and shame while also experiencing confusion around those feelings.

Conclusions:

BAA is a phenomenon that occurs in some women who breastfeed, whereby breastfeeding triggers negative emotions. The reason women experience it is not clearly known. Research is needed to understand its cause, triggers, and strategies to minimise the experience in breastfeeding mothers.

Ultrasound findings of the physiological changes and most common breast diseases during pregnancy and lactation

Because of the physiological changes that occur during pregnancy and lactation, diagnostic ultrasound of the breast during these periods is a challenge for physicians. Therefore, a comprehensive understanding of imaging, anatomy, and physiology of the breast is important to effectively diagnosing diseases that can arise in women who are pregnancy or lactating. The aim of this article was to review the physiological changes that occur in the breasts during pregnancy and lactation, as well as to describe the main features of the breast diseases that occur most frequently during these periods.

Variation in Galactocele Location and Sonographic Appearance

A galactocele is a cyst that forms from the obstruction of a lactiferous duct within the breast. These cysts typically form when a woman is pregnant or lactating and are usually of periareolar location. Mammography and sonography are common imaging modalities used to detect these cysts. This case study presents the sonographic detection of a galactocele with an abnormal location and appearnace in the left axilla.

Autophagy mediated by arginine depletion activation of the nutrient sensor GCN2 contributes to interferon-γ-induced malignant transformation of primary bovine mammary epithelial cells

Autophagy has been linked to the regulation of both the prevention and progression of cancer. IFN-γ has been shown to induce autophagy in multiple cell lines in vitro. However, whether IFN-γ can induce autophagy and whether autophagy promotes malignant transformation in healthy lactating bovine mammary epithelial cells (BMECs) remain unclear. Here, we provide the first evidence of the correlation between IFN-γ treatment, autophagy and malignant transformation and of the mechanism underlying IFN-γ-induced autophagy and subsequent malignant transformation in primary BMECs. IFN-γ levels were significantly increased in cattle that received normal long-term dietary corn straw (CS) roughage supplementation. In addition, an increase in autophagy was clearly observed in the BMECs from the mammary tissue of cows expressing high levels of IFN-γ. In vitro, autophagy was clearly induced in primary BMECs by IFN-γ within 24 h. This induced autophagy could subsequently promote dramatic primary BMEC transformation. Furthermore, we found that IFN-γ promoted arginine depletion, activated the general control nonderepressible-2 kinase (GCN2) signalling pathway and resulted in an increase in autophagic flux and the amount of autophagy in BMECs. Overall, our findings are the first to demonstrate that arginine depletion and kinase GCN2 expression mediate IFN-γ-induced autophagy that may promote malignant progression and that immunometabolism, autophagy and cancer are strongly correlated. These results suggest new directions and paths for preventing and treating breast cancer in relation to diet.

Pregnancy Associated Breast Cancer: Awareness is the Key to Diagnosis -A Case Report

Pregnancy-associated breast cancer (PABC) is defined as breast cancer that occurs during pregnancy or within one year of delivery. PABCs are typically found at advanced stage and are reported to have higher recurrence and mortality rates as compared to non PABC. Although it is said to be rare its incidence is increasing. Very little data is available on PABC among Indian women. Delay in diagnosis is one of the major causes of aggressive presentation of PABC. This is due to the fact that most of the lesions presenting during this period are benign and lactational changes hamper the detection of mass clinically as well as by various investigative methods. Paget's disease of breast, usually reported in elderly woman, when occurs in lactating breast may mimic benign eczematous lesion. Increased awareness among patients as well as clinicians is required to detect this highly aggressive form of breast cancer at an early and treatable stage. Treatment is by multidisciplinary approach and depends upon the gestational stage. Here we report a case of PABC in a lactating woman presenting with Paget's disease because such case may be under diagnosed as breast feeding related lesion leading to delayed diagnosis.