894
Chapter 33
had a poorer survival (85%) at 10 years than women with
non–pregnancy-associated breast carcinoma (93%), but the
outcomes for both groups were favorable.
19
The same series
reported a greater discrepancy in node-positive cases, with
survival of 62% and 37% in the nonpregnant and pregnant
groups, respectively. Others also found the prognosis of
pregnancy-associated breast carcinoma to be relatively un
favorable after adjustment for tumor size and nodal status.
45
The impact of subsequent pregnancy on prognosis in
women previously treated for breast carcinoma remains un
certain.
46
Most studies of this subject conducted retrospec
tively appear to indicate that the prognosis for such patients
is the same as or better than for patients who do not become
pregnant.
47,48
Women who have received chemotherapy are
generally advised to delay pregnancy for at least 6 months
before attempting to conceive.
49
One case-control study
compared 53 women who became pregnant after treat
ment of breast carcinoma with a cohort without subsequent
pregnancy, matched for stage of disease at diagnosis and a
disease-free survival (DFS) at least as long as the interval to
pregnancy in the study individual.
50
There were 5 deaths due
to breast carcinoma among 53 women (9.6%) with subse
quent pregnancies and 34 deaths among 265 controls (13%).
The relative risk (RR) of death due to breast carcinoma in
the subsequent pregnancy group was 0.8 (95% confidence
interval [CI], 0.3 to 2.3), a result indicative of no increase
in risk associated with subsequent pregnancy. A prospective
study will be required to fully evaluate this issue, especially
in the context of current management practices.
An unusual complication of pregnancy concurrent with
or subsequent to the diagnosis of breast carcinoma is the
development of placental metastases. This is most likely
to occur in women who have disseminated metastatic tu
mors.
51–53
Gross evidence of metastatic carcinoma is usually
apparent on the placental surface, and microscopic exami
nation discloses tumor cells in the intervillous spaces, rarely
with villous invasion (Fig. 33.1).
BREAST CARCINOMA IN “YOUNGER”
AND “OLDER” WOMEN
The average age at diagnosis of patients with breast carci
noma is in the mid-50s. The ages of the majority of affected
women are within two decades above or below this mid
point. Within this framework, the extremes of age may be
considered younger than 35 years and older than 75 years.
Breast carcinoma is widely thought to have a relatively
poor prognosis in women younger than 35 years of age,
whereas in those older than 75 it has been described as an
indolent disease. Many published studies of this issue are not
easily compared because of differences in defining age ex
tremes or in the treatment that patients received. These are
important considerations, especially when comparing data
from the era when therapy consisted of surgery alone with
recent data including neoadjuvant and adjuvant therapy,
breast conservation, and radiation therapy. Data obtained
Prognostic Markers
Estrogen receptors (ER) and progesterone receptors (PR)
are significantly more often negative in carcinomas from
pregnant and lactating women than in tumors from non
pregnant age-matched controls.
16,19,22–26
A substantial pro
portion of such carcinomas, ranging from 44% to 58%, are
HER2-positive.
24–26
Treatment and Prognosis
Although the primary treatment has generally been surgical,
the use of adjuvant chemotherapy and breast conservation is
an increasingly exercised option, depending on the circum
stances in a particular case.
16
Surgery and chemotherapy are
relatively safe treatment options after the fetal organogenesis
period of the first 16 weeks has elapsed. Therapeutic irradia
tion ought to be delayed until after completion of pregnancy.
27
However, the use of chemotherapy at any time during preg
nancy has been linked to underdevelopment of placenta.
28
The most significant obstetrical outcome in women who
have received chemotherapy during pregnancy is low birth
weight.
29
Although no long-term complications have been
reported in children whose mothers received chemotherapy
for hematologic neoplastic diseases during pregnancy, the
effects of fetal
in utero
exposure to maternal chemotherapy
for breast carcinoma have not been well studied.
30
In the past, a modified radical mastectomy was performed
in most cases for local control, in part to avoid radiation of
the fetus during breast conservation therapy.
16,31–34
Radia
tion should be delayed until after pregnancy.
16
Results in 9
patients treated by breast conservation in pregnancy were
reported by Kuerer et al.
35
The patients were all stage I and
stage II, with a median fetal gestation of 7 months. After a
median follow-up of 24 months, there were no recurrences
in the breast, although three women had distant recurrences.
Thus far, no adverse effects have been reported with the
use of either lymphoscintigraphy or methylene blue in preg
nancy for the detection of sentinel lymph nodes (SLNs),
36–41
although the use of lymphoscintigraphy alone has been rec
ommended in this setting.
16
In general, breast carcinoma in
pregnancy can now be safely and effectively treated; how
ever, management needs to be guided by duration of preg
nancy and stage of breast cancer.
32
The overall prognosis of women with breast carcinoma
diagnosed in pregnancy and lactation is relatively poor ow
ing to the high proportion of patients with nodal metasta
ses.
31,42
In one study, axillary nodal metastases were present
in 74% of patients younger than 40 years of age with breast
carcinoma diagnosed during pregnancy, whereas 37% of
nonpregnant patients in the same age group had posi
tive nodes.
43
When stratified by stage, some investigators
reported no significant difference in outcomes between
pregnancy-related and non–pregnancy-related patients of
comparable age.
7,20,22,44
In a number of reports, 75% to 80%
of node-negative patients remained alive or recurrence free
with follow-up of 5 to 10 years. In one case-control study,
node-negative women in the pregnancy and lactation group
