Breast Cancer Diagnosed During Pregnancy

Background: Pregnancy-associated breast cancers are cancers diagnosed during pregnancy or within 1 year of delivery. It is rare, occurring in 2.5-7.5/100,000, but these numbers continue to rise as maternal age increases. As a result, prospective studies evaluating diagnosis and treatment are limited. Case Description: Patient is a P1G0 35 yo woman who presented with a new breast mass at 26 wga. Diagnostic workup including core biopsy revealed invasive ductal carcinoma, ER 70%, PR 40%, her-2 negative. After multidisciplinary discussion with the breast team and the patient’s obstetrician, the patient underwent mastectomy with sentinel node biopsy at 28 wga. Pathology showed a 1.9 cm tumor with 5 negative sentinel nodes. Genomic evaluation of her tumor using 21-gene recurrence score revealed significant risk of distant recurrence without chemotherapy. Patient will initiate chemotherapy after delivery. Conclusion: The treatment regimen should be as close to standard of care as possible for a non-pregnant woman with the same cancer. Diagnostic workup should include ultrasound and possible mammogram with shielding of the fetus. Core biopsy can provide definitive diagnosis. Surgery is the mainstay of treatment during pregnancy, and decisions regarding breast conservation are dependent on gestational age at presentation. Adjuvant treatments can be performed with modifications and avoidance of radiotherapy during pregnancy. Decisions regarding treatment require multidisciplinary input between the oncology and obstetric teams to provide effective care with minimal toxicity to the fetus. Clinical Significance: Physiological changes of the breast during pregnancy make diagnosis of new breast cancer difficult. Furthermore, lack of diagnostic suspicion delays diagnosis. Further research is needed to determine the best diagnostic and therapeutic methods to ensure the best prognosis for mother and baby as the prevalence of breast cancer during pregnancy continues to rise

The Implications of Insurance Status on Presentation, Surgical Management and Mortality among Non-Metastatic Breast Cancer Patients in Indiana

Background The National Breast and Cervical Cancer Early Detection Program seeks to reduce health care disparities by providing uninsured and underinsured women access to screening mammograms. The objective of this study is to identify the differences in presentation, surgical management, and mortality among nonmetastatic uninsured patients diagnosed through Indiana's Breast and Cervical Cancer Program compared with patients with private and government (Medicare or Medicaid) insurance. Methods Study data were obtained using the Indiana state cancer registry and Indiana's Breast and Cervical Cancer Program. Women aged 50 to 64 with an index diagnosis of stage 0 to III breast cancer from January 1, 2006 to December 31, 2013, were included in the study. Bivariate intergroup analysis was conducted. Kaplan-Meier estimates between insurance types were compared using the log rank test. All-cause mortality was evaluated using a mixed effects model. Results The groups differed significantly for sociodemographic and clinical variables. Uninsured Indiana Breast and Cervical Cancer Program patients presented with later disease stage (P < .001) and had the highest overall mortality (hazard ratio 2.2, P = .003). Surgical management only differed among stage III patients (P = .012). Conclusion To improve insurance-based disparities in Indiana, implementation of the Breast and Cervical Cancer Program in conjunction with expansion of insurance coverage to vulnerable low-income populations need to be optimized

Phyllodes Tumor vs Fibroadenoma: Diagnosis and Management

Case: The patient is a 71 year-old woman who presented with enlarging painful breast mass. She had history of previous excision of a fibroadenoma in her left breast in 1993. She underwent menopause at 52 and does not take estrogen. Diagnostic imaging revealed 4.7cm breast mass, which had increased from prior measurement of 2.8cm to 4.7cm. Core biopsy demonstrated a fibroepithelial neoplasm areas of hypercellular stroma and occasional stromal mitotic figures most consistent with phyllodes tumor. Lumpectomy was performed. Final pathology showed a 4.8cm well-demarcated tumor with mildly pleomorphic spindled cells in the stroma and up to 1 per 10 mitoses per high powered field, consistent with benign phyllodes. The patient was followed every 6 months with imaging for 2 years without recurrence. Conclusions: Phyllodes tumors are rare fibroepithelial tumors of varying metastatic potential that can be mistaken for benign fibroadenomas. Phyllodes tumors should be surgically excised with wide margins, needing radiation or chemotherapy only if recurrent or large (>10cm), whereas fibroadenomas can be managed expectantly if asymptomatic (Gnerlich, 2014). Phyllodes tumors are often diagnosed in women ages 35-55. The patient in this case was diagnosed at a more advanced age with benign disease, although older age is more often associated with increased histologic grade (Mishra, 2013) (Karim, 2009). Borderline and malignant tumors are more likely to recur within two years of resection; there is less data on recurrence rates of benign tumors. Clinical Significance: Phyllodes tumors should be suspected with rapid growth of a known fibroadenoma. Core biopsy should be performed rather than fine needle aspiration for accurate diagnosis. Although phyllodes tumors comprise less than 1% of all breast neoplasms, it is crucial that uncommon pathologies are diagnosed correctly so that patients receive appropriate treatment

Breast Cancer Cell Detection and Characterization from Breast Milk-Derived Cells

Radiologic techniques remain the main method for early detection for breast cancer and are critical to achieve a favorable outcome from cancer. However, more sensitive detection methods to complement radiologic techniques are needed to enhance early detection and treatment strategies. Using our recently established culturing method that allows propagation of normal and cancerous breast epithelial cells of luminal origin, flow cytometry characterization, and genomic sequencing, we show that cancer cells can be detected in breast milk. Cells derived from milk from the breast with cancer were enriched for CD49f+/EpCAM-, CD44+/CD24-, and CD271+ cancer stem-like cells (CSC). These CSCs carried mutations within the cytoplasmic retention domain of HDAC6, stop/gain insertion in MORF4L1, and deletion mutations within SWI/SNF complex component SMARCC2. CSCs were sensitive to HDAC6 inhibitors, BET bromodomain inhibitors, and EZH2 inhibitors, as mutations in SWI/SNF complex components are known to increase sensitivity to these drugs. Among cells derived from breast milk of additional ten women not known to have breast cancer, two of them contained cells that were enriched for the CSC phenotype and carried mutations in NF1 or KMT2D, which are frequently mutated in breast cancer. Breast milk-derived cells with NF1 mutations also carried copy-number variations in CDKN2C, PTEN, and REL genes. The approach described here may enable rapid cancer cell characterization including driver mutation detection and therapeutic screening for pregnancy/postpartum breast cancers. Furthermore, this method can be developed as a surveillance or early detection tool for women at high risk for developing breast cancer. SIGNIFICANCE: These findings describe how a simple method for characterization of cancer cells in pregnancy and postpartum breast cancer can be exploited as a surveillance tool for women at risk of developing breast cancer

Referral process to further evaluate poor sleep in breast cancer survivors

Objective: Breast cancer survivors (BCS) are twice as likely to report symptoms of poor sleep as those without cancer. However, sleep disorders are under-assessed and under-treated among BCS. The purpose of this study was to determine the portion of BCS who completed referral visits to a sleep specialist and identify the acceptability, facilitators, and barriers to the screening and referral process. Methods: BCS, who reported having sleep problems, completed questionnaires to screen for symptoms suggestive of sleep disorders. Those with symptoms suggestive of sleep apnea, movement disorders, narcolepsy, insomnia syndrome, or circadian disorders, they were referred to a sleep medicine physician or behavioral sleep medicine psychologist. Two months after the referral, participants were interviewed about their perceptions of the acceptability, barriers, and facilitators to sleep screenings and referrals. Results: Of 34 BCS assessed for eligibility, 29 were eligible and had sleep problems. Only eight of 29 participants (27.6%) completed the sleep referral process. Most thought the screening and referral process was acceptable. However, BCS identified barriers to completing the referral visit, including time, not seeing the need for treatment, insurance/sick leave concerns, and distance/transportation. Conclusion: Adequate evaluation and treatment of sleep disorders in BCS are rare. Creative solutions to address barriers to timely sleep referrals are needed to reduce long-term negative consequences of inadequate sleep

Pain Control in Breast Surgery: Survey of Current Practice and Recommendations for Optimizing Management—American Society of Breast Surgeons Opioid/Pain Control Workgroup

Introduction: The opioid epidemic in the United States is a public health crisis. Breast surgeons are obligated to provide good pain control for their patients after surgery but also must minimize administration of narcotics to prevent a surgical episode of care from becoming a patient's gateway into opioid dependence. Methods: A survey to ascertain pain management practice patterns after breast surgery was performed. A review of currently available literature that was specific to breast surgery was performed to create recommendations regarding pain management strategies. Results: A total of 609 surgeons completed the survey and demonstrated significant variations in pain management practices, specifically within regards to utilization of regional anesthesia (e.g., nerve blocks), and quantity of prescribed narcotics. There is excellent data to guide the use of local and regional anesthesia. There are, however, fewer studies to guide narcotic recommendations; thus, these recommendations were guided by prevailing practice patterns. Conclusions: Pain management practices after breast surgery have significant variation and represent an opportunity to improve patient safety and quality of care. Multimodality approaches in conjunction with standardized quantities of narcotics are recommended

Racial-ethnic variations in phyllodes tumors among a multicenter United States cohort.

BACKGROUND AND OBJECTIVES: Previous studies have identified racial-ethnic differences in the diagnostic patterns and recurrence outcomes of women with phyllodes tumors (PT). However, these studies are generally limited in size and generalizability. We therefore sought to explore racial-ethnic differences in age, tumor size, subtype, and recurrence in a large US cohort of women with PT. METHODS: We performed an 11-institution retrospective review of women with PT from 2007 to 2017. Differences in age at diagnosis, tumor size and subtype, and recurrence-free survival according to race-ethnicity. RESULTS: Women of non-White race or Hispanic ethnicity were younger at the time of diagnosis with phyllodes tumor. Non-Hispanic Other women had a larger proportion of malignant PT. There were no differences in recurrence-free survival in our cohort. CONCLUSIONS: Differences in age, tumor size, and subtype were small. Therefore, the workup of young women with breast masses and the treatment of women with PT&nbsp;should not differ according to race-ethnicity. These conclusions are supported by our finding that there were no differences in recurrence-free survival

Prophylactic Absorbable Antibiotic Beads for High-risk, Implant-based Prepectoral Reconstruction

Summary:. Infections are problematic in postmastectomy implant-based reconstruction with infection rates as high as 30%. Strategies to reduce the risk of infection have demonstrated various efficacies. A prolonged course of systemic, oral antibiotics has not shown evidence-based benefit. Although absorbable antibiotic beads have been described for orthopedic procedures and pressure wounds, their use has not been well studied during breast reconstruction, particularly for prepectoral implant placement. The purpose of this study was to evaluate the selective use of prophylactic absorbable calcium sulfate antibiotic beads during high-risk implant-based, prepectoral breast reconstruction after mastectomy. Patients who underwent implant-based, prepectoral breast reconstruction between 2019 and 2022 were reviewed. Groups were divided into those who received antibiotic beads and those who did not. Outcome variables included postoperative infection at 90 days. A total of 148 patients (256 implants) were included: 15 patients (31 implants) who received biodegradable antibiotic beads and 133 patients (225 implants) in the control group. Patients who received antibiotic beads were more likely to have a history of infection (66.7%) compared with the control group (0%) (P < 0.01). Surgical site infection occurred in 3.2% of implants in the antibiotic bead group compared with 7.6%, but this did not reach statistical significance. The incidence of infection in high-risk patients who have absorbable antibiotic beads placed during the time of reconstruction seems to be normalized to the control group in this pilot study. We present a novel use of prophylactic absorbable antibiotic beads in prepectoral breast implant reconstruction

Germline Genetic Mutations in a Multi-center Contemporary Cohort of 550 Phyllodes Tumors: An Opportunity for Expanded Multi-gene Panel Testing

BackgroundA paucity of data exists regarding inherited mutations associated with phyllodes tumors (PT); however, some are reported (TP53, BRCA1, and RB1). A PT diagnosis does not meet NCCN criteria for testing, including within Li-Fraumeni Syndrome (TP53). We sought to determine the prevalence of mutations associated with PT.MethodsWe performed an 11-institution review of contemporary (2007-2017) PT practice. We recorded multigenerational family history and personal history of genetic testing. We identified patients meeting NCCN criteria for genetic evaluation. Logistic regression estimated the association of select covariates with likelihood of undergoing genetic testing.ResultsOf 550 PT patients, 59.8% (n = 329) had a close family history of cancer, and 34.0% (n = 112) had ≥ 3 family members affected. Only 6.2% (n = 34) underwent genetic testing, 38.2% (n = 13) of whom had only BRCA1/BRCA2 tested. Of 34 patients tested, 8.8% had a deleterious mutation (1 BRCA1, 2 TP53), and 5.9% had a BRCA2 VUS. Of women who had TP53 testing (N = 21), 9.5% had a mutation. Selection for testing was not associated with age (odds ratio [OR] 1.01, p = 0.55) or PT size (p = 0.12) but was associated with grade (malignant vs. benign: OR 9.17, 95% CI 3.97-21.18) and meeting NCCN criteria (OR 3.43, 95% confidence interval 1.70-6.94). Notably, an additional 86 (15.6%) patients met NCCN criteria but had no genetic testing.ConclusionsVery few women with PT undergo germline testing; however, in those selected for testing, a deleterious mutation was identified in ~ 10%. Multigene testing of a PT cohort would present an opportunity to discover the true incidence of germline mutations in PT patients