Rosen's Breast Pathology, 4e

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C h a p t e r

Unusual Clinical Presentation of Carcinoma SYED A. HODA

Breast carcinoma can have myriad clinical presentations. In this chapter, the salient clinical and pathologic aspects of breast carcinomas that present during pregnancy or lactation, in patients at relative extremes of ages, within ­fibroepithelial tumors, in ectopic breast tissue, with an ­“inflammatory” ­appearance, with axillary nodal involve­ ment, or in transverse rectus abdominus muscle (TRAM) flaps, are presented.

mammography may be ­reduced during ­pregnancy because of increased parenchymal density. 10 ­Liberman et al. 11 re­ ported that the sensitivity of mammography for detecting carcinoma during pregnancy or within 1 year postpartum was 78%. In one study, ultrasound was 100% sensitive as a method for detecting solid tumors in a series of pregnant women, and is now regarded as the preferred initial diag­ nostic procedure in this setting. 12,13 Ultrasound is also essen­ tial for monitoring response to neoadjuvant chemotherapy during pregnancy and for evaluating axillary lymph nodes (ALNs). 14 Invasive carcinomas can be identified in lactating breast tissue by magnetic resonance imaging (MRI), 15 but uncertainty about the effects of gadolinium on the fetus and issues related to positioning the pregnant patient have raised concern about this diagnostic procedure. 16 Pathology A diagnosis of carcinoma during pregnancy and lactation can be made by fine-needle aspiration (FNA) biopsy. 17 How­ ever, caution should be exercised when interpreting cytol­ ogy specimens in this setting, because physiologically altered non-neoplastic mammary epithelial cells can appear atypical in cytologic preparations in this setting, and the material of­ ten consists of abundant dyscohesive cells. 18 For these rea­ sons, needle core biopsy or excisional biopsy are preferable for definitive diagnosis. The histologic spectrum of pregnancy-associated breast carcinoma is not significantly different from breast carci­ noma unrelated to pregnancy in women of a comparable age. 7,16,19–21 Invasive ductal carcinoma (IDC) is present in about 90% of both groups. There were small numbers of patients with invasive lobular, mucinous, medullary, and other types of carcinoma. Tumors are significantly larger, and vascular invasion as well as axillary nodal in­ volvement is more frequent in the pregnancy group. In one case-control study, intraductal carcinoma was pres­ ent in 4.8% of control patients and in 1.6% of women with pregnancy-related carcinoma. 19 ALN metastases are pres­ ent in 60% to 70% of women with pregnancy-related breast carcinoma. 7,19,22

CARCINOMA IN PREGNANCY AND LACTATION

Breast carcinoma is the most common malignant neo­ plasm encountered during pregnancy, afflicting one in 3,000 pregnancies. 1 The frequency of coincident pregnancy in women with breast carcinoma is 1% to 3%. 2 The average age of women who have breast cancer in pregnancy is in the mid- to late 30s. 2 About 6% of women with breast car­ cinoma diagnosed by age 35 are pregnant when the tumor is detected. 3 With the trend for women in some sociocul­ tural groups to delay pregnancy to their late 30s and 40s, it is likely that coincident pregnancy and breast carcinoma will be increasingly encountered. 1 Breast carcinoma has been reported in pregnant teenage girls. 4,5 Data from one study suggest that women from BRCA1-positive families may be at increased risk of developing breast carcinoma during and after pregnancy. 6 Clinical Presentation The usual presenting symptom is a painless mass that may be obscured by pregnancy-associated physiologic changes in the breast. This factor can contribute to delay in seeking medical attention on the part of the patient, as well as physician delay in recognizing the presence of a neoplasm and obtaining a bi­ opsy. In one study, more than 50% of patients with breast car­ cinoma diagnosed postpartum had a palpable mass detected and followed during pregnancy. 7 With appropriate precautions, mammography can be performed during pregnancy. 8,9 The effectiveness of

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