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CASE REPORTS
Breast Cancer and Pregnancy
Ashok Kumar Shukla, Asha R Dalal, Poornima Ranka
30 yrs old Mrs. XYZ married since 1 yr came with c/o of lump in right breast and primary infertility for which she was getting herself investigated. FNAC of the lump was done on 25.08.01. The report came as Benign breast disease followed by which patient underwent lumpectomy on 20.10.01. Histopathological report came as infiltrating duct carcinoma. Patient missed her menses which was due on 26.10.01. Urine pregnancy test was done which came positive. Patient refused to get the pregnancy terminated and was explained all the risks and consequences of continuing this pregnancy. Patient underwent right modified radical mastectomy on 6.11.01 and delivered vaginally a full term male child 2.9 kgs on 30.06.02.
INTRODUCTION
Breast carcinoma is a condition whose incidence is on the rise. Currently a modern tendency is observed among young women to postpone conception to a late period of life on account of a number of socioeconomical reasons, which tendency tangibly augments the number of women affected with breast cancer during the pregnancy period.1 Approximately 3% of breast cancers are associated with pregnancy or lactation.
CASE REPORT
Mrs. XYZ 30 yr old married since 10 yrs a case of primary infertility under investigation came with complains of lump in right breast since 3 to 4 wks. FNAC of the lump was done on 25.08.01. The report came as benign breast disease followed by which patient underwent lumpectomy on 20.10.01. The histopathological report came as infiltrating duct carcinoma. Patient was advised radical mastectomy. She missed her menses. The urine pregnancy test was done which came positive. Patient was advised termination as surgery was mandatory as early as possible to avoid spread. But since she had conceived after 10 yrs of marriage patient refused to undergo medical termination of pregnancy. With high risk informed consent patient underwent right sided modified radical mastectomy on 6.11.01. Patient was on progesterone support till 18 wks of pregnancy. Histopathological report came as infiltrating ductal carcinoma with tumour infiltrating into adjacent fatty tissue. There was no evidence of residual tumour. The margins, lymph nodes and lymphovascular structures were free. Patient was advised postpartum radiation. Patient was subjected to level 2 scan to rule out any congenital anomaly at 20 wks and was repeated at 36 wks pregnancy. Patient went in to spontaneous labour and delivered 2.9 kg male child on 30.06.02 vaginally. Mother and baby were discharged on day 3 postpartum and were advised to follow up in oncology department for radiation and also for reconstruction of right breast.
DISCUSSION
Approximately 3% of breast cancers are associated with pregnancy or lactation. Prognosis was thought to be much worse than for non pregnant patients.2 Theoretical considerations for why pregnancy could be associated with more severe disease include: a) increased level of circulating stimulatory hormones. b) Delay in diagnosis, c) Expanded extravascular and lymphatic capacity in the engorged breast, and d) a relative maternal immunoincompetence. Chances of spontaneous abortion are 1% due to general anaesthesia.
Management options available are1 modified radical mastectomy in the 1st and 2nd trimester (radiation contraindicated); no immediate reconstruction.2 Tumorectomy with axillary dissection and delayed (postpartal) radiotherapy in 3rd trimester. Chemotherapy is generally permissible in the 2nd half of the pregnancy, provided specific cytotoxic drugs are avoided. However there is high rate of growth-retarded foetuses, preterm births and low birth weight may be expected.3 Conservative surgery with postpartum radiation therapy has been used for breast preservation. An analysis has been performed which helps to predict the risk of waiting to have radiation.4
REFERENCES
1. Dimitrov G, Ivochev I. Breast cancer and pregnancy Khirurgija (sofia) 1997; 50 (3) : 39-41.
2. Guinee VF, Olsson H, Moller T, et al. Effect of pregnancy on prognosis for young women with breast cancer. Lancet 1994; 343 (8913) : 1587-89.
3. Giacalone PL, Laffargue F, Benos P. Chemotherapy for breast carcinoma during pregnancy. A French National Survey. Cancer 1999; 86 (11) : 2266-72.
4. Nettleton J, Long J, Kuban D, et al. Breast cancer during pregnancy: quantifying the risk of treatment delay. Obstetrics and Gynaecology 1996; 87 (3) : 414-18.
ASPIRIN WITH BYPASS SURGERY - FROM TABOO TO NEW STANDARD OF CARE
In patients undergoing bypass surgery, an elevated base-line C-reactive protein value has been shown to have an important relation to ischaemic events.
Numerous studies have emphasized that aspirin administered before surgery leads to more mediastinal blood loss, transfusion, and repeated operations. The consensus has been that aspirin should be avoided before surgery in order to minimize the risk of bleeding complications and particularly the need for emergency reoperation to control mediastinal bleeding. There is also widespread agreement about the vital need for long-term aspirin use after CABG to prevent closure of the graft. But the use of aspirin in the early hours after CABG has been controversial, and in many centres, it is considered taboo.
Mangano and colleagues present their global registry data on the use of aspirin during the 48 hours after CABG. The findings are quite striking. Among the patients who received aspirin during the first 48 hours, the rate of death was more than 60 per cent lower than that among those who did not receive aspirin during that period (1.3 per cent vs. 4.0 per cent), and the rates of nonfatal ischaemic complications, including myocardial infarction, stroke, renal failure, and bowel infarction, were each reduced by a similar magnitude.
The extent and scope of the influence of aspirin are most likely a reflection of its anti-inflammatory effect rather than its antithrombotic effect. The pathophysiology of many of the ischaemic complications that are averted by early aspirin use does not invoke thrombosis; inflammation seems like a more probable explanation.
Early aspirin use after bypass surgery should become standard practice.
Eric J Topol, N Engl J Med, October 2002; 347 : 1359-60.
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