Zusammenfassung
Die Inzidenz eines Mammakarzinoms während der Schwangerschaft oder bis zu einem Jahr post partum ist gering. Hormonelle Einflüsse spielen eine wesentliche Rolle in der Karzinogenese des Mammakarzinoms, dennoch scheint die Prognose für Frauen in und außerhalb der Schwangerschaft identisch zu sein. Die Diagnose ist aufgrund vielfältiger Veränderungen der Brustdrüse intra graviditatem deutlich erschwert. Die sehr häufig verspätete Diagnosestellung erklärt zu einem gewissen Teil die schlechten Überlebensdaten. Die Therapie darf sich nicht nur an den möglichen Nebenwirkungen für die Mutter ausrichten, sondern muss ebenso die Kurz- und Langzeittoxizität für das ungeborene Leben berücksichtigen. Die operative Therapie folgt den bekannten Empfehlungen. Die adjuvante Bestrahlung sollte nach der Geburt erfolgen. Eine (neo-)adjuvante, anthrazyklinhaltige Chemotherapie scheint im zweiten und dritten Trimenon für Mutter und Kind ohne wesentliche Nebenwirkungen möglich zu sein. Die angewandten Therapien können einen negativen Einfluss auf die Fertilität der jungen Frauen haben. Eine Schwangerschaft nach einem behandelten Mammakarzinom verändert die Prognose der Patientinnen nicht.
Abstract
Breast cancer during pregnancy or the first year postpartum is rare. While hormonal factors play an important role in the carcinogenesis of breast cancer, the prognosis of pregnant patients appears to be identical to that of nonpregnant women. The physiologic changes the breast undergoes with pregnancy can make it difficult to diagnose cancer and delayed diagnosis may contribute to unfavorable survival. Treatment plans need to consider potential immediate and long-term toxicity for the fetus. Surgical treatment should be the same as for nonpregnant women. Adjuvant radiation should be deferred until after delivery. Neoadjuvant anthracycline-based chemotherapy in the second and third trimester appears to be without significant side effects for mother or fetus. Certain treatment modalities can impair future fertility. Pregnancy after breast cancer does not affect the prognosis.
Literatur
-
1
Gemignani M L, Petrek J A, Borgen P I.
Breast cancer and pregnancy.
Surg Clin North Am.
1999;
79
1157-1169
-
2
Smith L H, Dalrymple J L, Leiserowitz G S. et al .
Obstetrical deliveries associated with maternal malignancy in California, 1992 through 1997.
Am J Obstet Gynecol.
2001;
184
1504-1512
-
3 Engel J. IBE München, persönliche Mitteilung 8/2002. 2002
-
4
Pavlidis N A.
Coexistence of pregnancy and malignancy.
Oncologist.
2002;
7
279-287
-
5
Helewa M, Levesque P, Provencher D, Lea R H, Rosolowich V, Shapiro H M.
Breast cancer, pregnancy, and breastfeeding.
J Obstet Gynaecol Can.
2002;
24
164-180
-
6
Kilgore A R, Bloodgood J C.
Tumors and tumor like lesions of the breast in association with pregnancy.
Arch Surg.
1929;
18
2079
-
7
Haagensen C D, Stout A P.
Carcinoma of the breast: criteria of operability.
Ann Surg.
1943;
118
859
-
8
White T T.
Carcinoma of the breast and pregnancy.
Ann Surg.
1954;
139
9
-
9
Harrington S W.
Carcinoma of the breast: results of surgical treatment when the carcinoma occurred in the course of pregnancy or lactation and when pregnancy occurred subsequent to operation, 1910 - 1933.
Ann Surg.
1937;
106
690
-
10
Byrd B F, Bayer D S, Robertson J C. et al .
Treatment of breast tumors associated with pregnancy or lactation.
Ann Surg.
1962;
155
940
-
11
Miller H K.
Cancer of the breast during pregnancy and lactation.
Am J Obstet Gynecol.
1961;
1
471
-
12
Gemignani M L, Petrek J A.
Breast cancer during pregnancy: diagnostic and therapeutic dilemmas.
Adv Surg.
2000;
34
273-286
-
13
Petrek J A, Dukoff R, Rogatko A.
Pregnancy-associated breast cancer.
Cancer.
1991;
67
869-872
-
14
Ribeiro G, Jones D A, Jones M.
Carcinoma of the breast associated with pregnancy.
Br J Surg.
1986;
73
607-609
-
15
Zemlickis D, Lishner M, Degendorfer P. et al .
Maternal and fetal outcome after breast cancer in pregnancy.
Am J Obstet Gynecol.
1992;
166
781-787
-
16
Tretli S, Kvalheim G, Thoresen S. et al .
Survival of breast cancer patients diagnosed during pregnancy or lactation.
Br J Cancer.
1988;
58
382-384
-
17
Bonnier P, Romain S, Dilhuydy J M. et al .
Influence of pregnancy on the outcome of breast cancer: a case control study. Societe Francaise de Senologie et de Pathologie Mammaire Study Group.
Int J Cancer.
1997;
72
720-727
-
18
Liberman L, Giess C S, Dershaw D D, Deutsch B M, Petrek J A.
Imaging of pregnancy-associated breast cancer.
Radiology.
1994;
191
245
-
19
Ishida T, Yokoe T, Kasumi F. et al .
Clinicopathologic characteristics and prognosis of breast cancer patients associated with pregnancy and lactation: Analysis of case control study in Japan.
J Cancer Res.
1992;
83
1143-1149
-
20
Moore H C, Foster Jr R S.
Breast cancer and pregnancy.
Sem Oncol.
2000;
27
646-653
-
21
Elledge R M, Ciocca D R, Langone G, McGuire W L.
Estrogen receptor, progesterone receptor, and HER-2/neu protein in breast cancers from pregnant patients. Cancer 1993; 71: 2499 - 2506.
Comment in: Cancer.
1993;
72
2291-2292
-
22
Shousa S.
Breast carcinoma presenting during or shortly after pregnancy and lactation.
Arch Pathol Lab Med.
2000;
124
1053-1060
-
23
King R M, Welch J S, Martin J L. et al .
Carcinoma of the breast associated with pregnancy.
Surg Gynecol Obstet.
1985;
160
228-232
-
24
Nugent P, O'Connell T X.
Breast cancer and pregnancy.
Arch Surg.
1985;
120
1221-1224
-
25
Nettleton J, Long J, Kuban D. et al .
Breast cancer during pregnancy: quantifying the risk of treatment delay.
Obstet Gynecol.
1996;
87
414-418
-
26 Bauerfeind I, Baltzer J, Konecny G, Sittek H, Untch M. Mammakarzinom und Schwangerschaft. Sauer HJ Manual Mammakarzinome: Empfehlungen zur Diagnostik, Therapie und Nachsorge. 8. Aufl. München; Zuckschwerdt Verlag 2001
-
27
Schackmuth E M, Harlow C L, Norton L W.
Milk fistula: a complication after core biopsy.
AJR.
1993;
161
961
-
28
Max M H, Klamer T W.
Pregnancy and breast cancer.
South Med J.
1983;
76
1008
-
29
Samuels T H, Liu F, Yaffe M, Haider M.
Gestational breast cancer.
Can Assoc Radiol J.
1998;
49
172
-
30 Wagner L K, Lester R G, Saldana L. Exposure of the Pregnant Patient to Diagnostic Radiation: A Guide to Medical Management. - The Amount of Radiation Absorbed by the Conceptus. Philadelphia; JB Lipincott 1985: 40
-
31
Sabel M, Aichinger U, Schulz-Wendlandt R.
Radiation exposure in x-ray mammography.
Rofo Fortschr geb Rontgenstr Neue Bildgeb Verfahr.
2001;
173
79-91
-
32
Kal H B, Struikmans H.
Pregnancy and medical irridiation: summary and conclusions from the International Commission on Radiological Protection, Publication 84.
Ned Tijdschr Geneeskd.
2002;
146
299
-
33
Kuerer H M, Gwyn K, Ames F C, Theriault R L.
Conservative surgery and chemotherapy for breast carcinoma during pregnancy.
Surgery.
2002;
131
108-110
-
34
Schwartz G F, Giuliano A E, Veronesi U. Consensus Conference Committee .
Proceedings of the consensus conference on the role of sentinel lymph node biopsy in carcinoma of the breast, April 19 - 22, 2001, Philadelphia, Pennsylvania.
Cancer.
2002;
94
2542-2551
-
35
Miller R, Mulvihill S.
Small head size after atomic radiation.
Teratology.
1976;
14
355
-
36
Kimler B F.
Prenatal irridiation: a major concern for the developing brain.
Int J Radiat Biol.
1998;
73
423-434
-
37
Wakeford Doll R.
Risk of childhood cancer from fetal irridiation.
Br J Radiol.
1997;
70
130-139
-
38 Kommentare zu [37] in: Br J Radiol 1997; 70: 769-770; discussion 771. Br J Radiol 1997; 70: 770-771; Br J Radiol 1998; 71: 460-461. 1997
-
39
Wong G C.
Management of haematologic malignancies in pregnancy.
Ann Acad Med Singapore.
2002;
31
303-310
-
40
Doll D C, Ringenberg S, Yarbro J W.
Antineoplastic agents and pregnancy.
Semin Oncol.
1989;
16
337-346
-
41
Giannakopoulou C, Manoura A, Hatzidaki E. et al .
Multimodal cancer chemotherapy during the first and second trimester of pregnancy.
Eur J Obstet Gynecol Repord Biol.
2000;
91
95-97
-
42
Petrek J A.
Breast cancer during pregnancy.
Cancer.
1994;
74
518-527
-
43
Bunker M L, Peters M V.
Breast cancer associated with pregnancy or lactation.
Am J Obstet Gynecol.
1963;
85
312-321
-
44
Berry D L, Theriault R L, Holmes F A. et al .
Management of breast cancer during pregnancy using a standardized protocol.
J Clin Oncol.
1999;
17
855-861
-
45
De Santis M, Lucchese A, De Carolis S, Ferrazani S, Caruso A.
Metastatic breast cancer in pregnancy: first case of chemotherapy with docetaxel.
Eur J Cancer Care.
2000;
9
235-237
-
46
Bueckers T E, Lallas T A.
Chemotherapy in pregnancy.
Obstet Gynecol Clin N Am.
1998;
25
323-329
-
47
Isaacs R J, Hunter W, Clark K.
Tamoxifen as systemic treatment of advanced breast cancer during pregnancy - case report and literature review.
Gynecol Oncol.
2001;
80
405-408
-
48
Halakivi-Clarke L, Cho E, Onojafe I, Liao D J, Clarke R.
Maternal exposure to tamoxifen during pregnancy increases carcinogen-induced mammary tumorigenesis among female rat offspring.
Clin Cancer Res.
2000;
6
305-308
-
49
Sutton R, Buzdar A, Hortobagyi G N.
Pregnancy and offspring after adjuvant chemotherapy in breast cancer patients.
Cancer.
1990;
65
847-850
-
50
Cobleigh M A, Bines J, Harris J, Lofolette S S. et al .
Amenorrhoea following adjuvant chemotherapy for breast cancer.
Proc Am Soc Clin Oncol.
1995;
14
(Abstract 158)
-
51
Hensley M L, Reichmann B S.
Fertility and pregnancy after adjuvant chemotherapy for breast cancer.
Oncol Hematol.
1998;
28
121-128
-
52
Hershlag A, Schuster M W.
Return of fertility after autologous stem cell transplantation.
Fertil Steril.
2002;
77
419-421
-
53
Aisner J, Wiernik P H, Pearl P.
Pregnancy outcome in patients treated for Hodgkin disease.
J Clin Oncol.
1993;
11
507-512
-
54
Jordan V C, Fritz N F, Langan-Fahey S. et al .
Alteration of endocrine parameters in premenopausal women with breast cancer during long term adjuvant therapy with tamoxifen as the single agent.
J Natl Cancer Inst.
1992;
83
1488
-
55
Ruiz-Velasco V, Rosas-Arceo J, Matute M M.
Chemical inducers of ovulation: comparative results.
Int J Fertil.
1979;
24
61
-
56
Sunderland M C, Osborne C K.
Tamoxifen in premenopausal patients with metastatic cancer: a review.
J Clin Oncol.
1991;
9
1283
-
57
Averette H E, Mirhasemi R, Moffat F L.
Pregnancy after breast carcinoma. Editorial.
Cancer.
1999;
85
2301-2304
-
58
Gemignani M L, Petrek J A.
Pregnancy after breast cancer.
Cancer Control.
1999;
6
272-276
-
59
Sankila R, Heinavaara S, Hakulinen T.
Survival of breast cancer patients after subsequent term pregnancy: “Healthy mother effect”.
Am J Obstet Gynecol.
1994;
170
818-823
-
60
von Schoultz E, Johansson H, Wilking N. et al .
Influence of prior and subsequent pregnancy on breast cancer prognosis.
J Clin Oncol.
1995;
13
430-434
-
61
Kroman N, Jensen M B, Melbye M. et al .
Should women be advised against pregnancy after breast cancer treatment?.
Lancet.
1997;
350
319-322
-
62
Gelber S, Coates A S, Goldhrisch A. et al .
Effect of pregancy on overall survival after the diagnosis of early-stage breast cancer.
J Clin Oncol.
2001;
19
1671-1675
-
63
Harvey J C, Rosen P P, Ashikari R. et al .
The effect of pregnancy on the prognosis of carcinoma of the breast following radical mastectomy.
Surg Gynecol Obstet.
1981;
153
723-725
-
64
Mignot L, Morvan F, Berdah J, Querleu D, Laurent J C, Verhaeghe M, Fontaine F, Marin J L, Gorins A, Marty M.
Pregnancy after treated breast cancer. Results of a case-control study.
Presse Med.
1986;
15
1961-1964
-
65
Mignot L.
Pregnancy after treated cancer of the breast. Results of a case-control.
Pathol Biol.
1989;
37
1002
-
66
Ariel I M, Kempner R.
The prognosis of patients who become pregnant after mastectomy for breast cancer.
Int Surg.
1989;
74
185-191
-
67
Clark R M, Chua T.
Breast cancer and pregnancy: the ultimate challenge.
Clin Oncol (R Coll Radiol).
1989;
1
11-18
-
68
Dow K H, Harris J R, Roy C.
Pregnancy after breast-conserving surgery and radiation therapy for breast cancer.
J Natl Cancer Inst Monogra.
1994;
16
131-137
-
69
Clark F M, Reid J M.
Carcinoma of the breast in pregnancy and lactation.
Int J Radiat Oncol Biol Phys.
1978;
4
693-698
-
70
Mignot L, Morvan F, Sarrazin D.
Breast carcinoma and subsequent pregnancy.
Proc Am Soc Clin Oncol.
1986;
5
57
-
71
Higgins S, Haffty B G.
Pregnancy and lactation after breast conserving therapy for early stage breast cancer.
Cancer.
1994;
73
2175-2180
-
72
Giacalone P L, Laffargue F, Benos P.
Chemotherapy for breast carcinoma during pregnancy: A French national survey.
Cancer.
1999;
86
2266-2272
-
73
Jakesz R, Hausmaninger H, Samonigg H.
Chemotherapy versus hormonal adjuvant treatment in premenopausal patients with breast cancer.
Eur J Cancer.
2002;
38
327-332
-
74
Moore H C.
Fertility and the impact of systemic therapy on hormonal status following treatment for breast cancer.
Curr Oncol Rep.
2000;
2
587-593
-
75
Poikonen P, Saarto T, Elomaa A. et al .
Prognostic effect of amenorrhoea and elevated serum gonadotropin levels induced by adjuvant chemotherapy in premenopausal node-positive breast cancer patients.
Eur J Cancer.
2000;
36
43-48
-
76
Del Mastro L, Venturini M, Sertoli M R.
Amenorrhea induced by adjuvant chemotherapy in early breast cancer patients: prognostic role and clinical implications.
Breast Cancer Res Treat.
1997;
43
183-190
-
77
Aziz S, Pervez S, Khan S. et al .
Case control study of novel prognostic markers and disease outcome in pregnancy/lactation associated breast carcinoma.
Pathol Res Prac.
2003 (in press);
-
78
Sorosky J I, Scott-Conner C E.
Breast disease complicating pregnancy.
Obstet Gynecol Clin North Am.
1998;
25
353-363
-
79
Smythe A R, Underwood Jr P B, Kreutner Jr A.
Metastatic placental tumors: report of three cases.
Am J Obstet Gynecol.
1976;
125
1149-1151
-
80
Lehner R, Strohmer H, Jirecek S, Goharkhay N, Tringler B, Barrada M.
Placental insufficiency and maternal death caused by advanced stage of breast cancer in third trimester.
Eur J Obstet Gynecol Reprod Biol.
2001;
99
272-273
-
81
Keleher A J, Theriault R L, Gwyn K M, Hunt K K, Stelling C B, Singletary S E, Ames F C, Buchholz T A, Sahin A A, Kuerer H M.
Multidisciplinary management of breast cancer concurrent with pregnancy.
J Am Coll Surg.
2002;
194
54-64
-
82
Tewari K, Cappuccini F, Gambino A, Kohler M F, Pecorelli S, DiSaia P J.
Neoadjuvant chemotherapy in the treatment of locally advanced cervical carcinoma in pregnancy: a report of two cases and review of issues specific to the management of cervical carcinoma in pregnancy including planned delay of therapy.
Cancer.
1998;
82
1529-1534
-
83
Ballast A, Hellmeyer L, Emons G, Ramaswamy A, Förster B, Schmidt S.
Chemotherapie mit Adriamycin und Cyclophosphamid beim Mammakarzinom in der Schwangerschaft: Ein Fallbericht.
Geburtsh Frauenheilk.
1999;
59
531-534
-
84
Michniewicz K, Elling D.
Genitalmalignome in der Gravidität - Eine Literaturrecherche.
Geburtsh Frauenheilk.
2002;
62
125-130
-
85
Fornier M N, Modi S, Hudis C A.
Incidence of amenorrhea (A) in breast cancer (BC) patients (pts) ≤ 40 years of age after paclitaxel (T)-based adjuvant chemotherapy (CT).
Breast Cancer Res Treat.
2002;
Abstr. 645
Dr. Ingo Bauerfeind
Oberarzt der Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe der LMU München, Klinikum Großhadern
Marchioninistraße 15
81377 München
Email: ingo.bauerfeind@med.uni-muenchen.de
