0:00

We can't really cover every possible scenario

0:04

of every type of patient that would come in

0:06

during a diagnostic day, but there are two

0:08

groups of patients that we see regularly.

0:11

Um, and I put these into the special populations

0:13

category and that is the pregnant and

0:17

lactating uh, women and also male patients.

0:20

So we'll discuss those next.

0:23

So pregnant and lactating women, um,

0:25

there's a whole ACR appropriateness

0:28

criteria dedicated to these patients.

0:30

So that's something good to check out.

0:33

Our imaging modalities,

0:35

for these patients are basically ultrasound

0:39

and mammography and contrast-enhanced MRI for

0:42

the lactating patient, but not for the pregnant

0:45

patient because we don't want to inject

0:47

gadolinium in a pregnant patient.

0:50

So ultrasound is going to be the first

0:52

line exam in pregnant and lactating women.

0:55

It has a high sensitivity and negative

0:58

um, predictive value for PABC,

1:00

which is pregnancy-associated breast cancer.

1:03

Mammography is considered safe

1:05

during pregnancy and lactation.

1:07

The radiation dose is very low.

1:10

So from a bilateral to view mammogram, it's about

1:12

three milligray, and that's similar to eight

1:15

weeks of background radiation, and the estimated

1:18

dose to the uterus is even lower than that.

1:21

It's less than 0.03 milligray.

1:23

33 00:01:24,875 --> 00:01:27,735 And a dose less than 50 mg is unlikely to

1:27

cause fetal harm, and we can see that the

1:30

0.03 mg is substantially less, so unlikely to

1:34

cause any kind of harm to the developing fetus.

1:40

So the most common Presentation of pregnancy

1:42

associated breast cancer is a palpable

1:44

mass, and we know this is a young patient

1:47

population with denser breast tissue.

1:50

We want to use ultrasound as our first line

1:52

examination and then additional imaging with

1:54

mammography or tomosynthesis if we need to.

1:58

And MRI can be performed,

2:00

as I mentioned, if the patient is lactating.

2:03

There are a lot of reasons for palpable mass in

2:05

a pregnant or lactating woman, and they include

2:09

normal breast tissue, cysts, and fibrocystic

2:12

change, fibroadenoma, galactocele, which is

2:15

basically just a collection of milk, mastitis,

2:19

or abscess, lactating adenoma, adenopathy,

2:24

unfortunately, pregnancy-associated breast

2:26

cancer, and then other, um, malignancies

2:30

such as lymphoma, sarcoma, or metastasis.

2:35

Just a few words about pregnancy

2:36

associated breast cancer.

2:38

This is defined as breast cancer

2:40

diagnosed during pregnancy and up to

2:42

one year postpartum or during lactation.

2:46

It occurs in 1 in 3,000 to 1 in 10,000

2:49

pregnancies and represents up to 3%

2:51

of all newly diagnosed breast cancer.

2:54

Interestingly, up to 10 percent of newly

2:56

diagnosed breast cancer in patients under age 40.

3:01

Um, most patients present with a painless lump.

3:04

The diagnosis tends to be delayed,

3:07

and we think that may be because the

3:08

breast tissue is lumpy and bumpy anyway.

3:11

There's a lot of changes that go on in

3:13

the breast and the shape and feel of the

3:15

breast with pregnancy and with lactation.

3:18

So sometimes the patient may

3:19

feel a little bit of pain.

3:20

Um, not be aware of a certain lump or their

3:24

provider may not think anything of it.

3:27

So, um, you know, the diagnosis

3:29

tends to be a little bit delayed.

3:31

Most of these are invasive ductal

3:33

carcinomas, and there's a tendency toward

3:35

high grade, poorly differentiated tumors.

3:37

Also a tendency toward larger tumor size,

3:40

increased LVI, which is lymphovascular

3:43

invasion, increased nodal involvement,

3:46

and more advanced stage at diagnosis.

3:48

And all of these factors lead

3:50

to a poorer overall prognosis.

3:53

The imaging features are similar

3:54

to a non-pregnant patient.

3:56

A mass is most common.

3:58

Um, so it's really important to consider biopsy of

4:00

any new solid mass to avoid a delay in diagnosis

4:04

and masses can have a pseudo-benign appearance.

4:07

And what I mean by that is that they

4:09

may be quickly growing so that they

4:11

can have sort of pushing borders.

4:13

They push the surrounding tissue away from them

4:16

so that you have more of an oval-looking mass

4:18

rather than an infiltrating irregular mass.

4:22

Um, we may see suspicious

4:23

calcifications without a mass,

4:25

or skin thickening and generalized

4:27

increased tissue density.

4:30

Nipple discharge, um, bloody nipple

4:32

discharge can occur in up to 20 percent

4:35

of pregnant women or in early lactation.

4:38

It's referred to as the rusty pipe syndrome.

4:41

Um, and this may be due to proliferative

4:43

epithelial changes and increased vascularity that

4:46

occurs in patients with pregnancy or lactation.

4:50

Persistent unilateral

4:51

proliferative epithelial changes,

4:52

bloody nipple discharge can be due to

4:54

infection, papilloma, or breast cancer.

4:56

So that's worth investigating.

4:58

We want to image with ultrasound first and

5:00

then mammogram with chomosynthesis if needed.

5:05

Um, for patients with pain, we would do

5:07

ultrasound first, mammography or DBT if needed,

5:11

and we use the ACR appropriateness criteria

5:13

for breast pain, which we talked about earlier.

5:17

Imaging is usually normal, but we may find

5:19

a cause for the patient's pain, such as

5:21

a cyst or mastitis, uh, slash abscess.