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Carcinoma of the breast and pregnancy
CARCINOMA OF THE BREAST AND PREGNANCY A REPORT OF THREE CASES ALEXANDER
H.
ROSENTHAL,
M.D.
Assistant in Obstetrics and GynecoIogy, Long IsIand CoIIege of Medicine BROOKLYN, NEW YORK
T
HREE cases of carcinoma of the breast associated with pregnancy have occurred on the obstetrica service of the Long IsIand CoIIege HospitaI during the past two years. One wouId ordinariIy expect some effect of pregnancy on a neopIasm of the mammary gIand, an organ which normaIIy undergoes marked hyperpIasia during pregnancy. A survey of the Iiterature, however, shows a marked difference of opinion as to the effects of pregnancy on cancer of the breast. Presentation of these three cases may aid in formuIating a more definite opinion. CASE I. Miss S. I., a 34 year oId white spinster, was admitted on May 8, 1930. She had frrst noticed a smaII Iump in the right breast one year prior to admission. The tumor was excised by her physician during August rgzg and a course of x-ray therapy given. Examination on admission showed a recurrent tumor mass beneath the oId scar. A radicaI mastectomy was then performed. Pathologic examination reveaIed chronic interstitia1 mastitis and a duct ceII carcinoma. The wound heaIed by primary union and she was discharged on the eighteenth day foIIowing operation. The patient was readmitted on January 13, rg35, because of a recurrence in the other breast. This was frrst noted as a smaI1, hard mass the size of which remained stationary for nearIy two years and then increased. Examination showed a firm, immobiIe, nodmar, ova1 mass in the left breast. An amputation of the Ieft breast was performed after a preliminary course of twenty-six x-ray treatments were given. The pathoIogic diagnosis was aIveoIar carcinoma of duct origin. She was discharged on May 26, 1934, with the Ieft breast wound healing by primary union. The patient was again readmitted on December IO, 1933, when she stated that she had feIt we11 and strong since her last admission and
had gained in weight. The Iast menstruaI period was during September 1933. At the beginning of December, the patient suffered vagina1 bIeeding and Iower abdomina1 cramps which continued intermittently unti1 the time of admission. A preoperative diagnosis of incompIete .abortion was made and a curettage performed. The pathoIogic diagnosis was decidua1 endometritis and incompIete abortion. It was estimated that the patient was about three months pregnant. During the two week period after her return home the patient’s general condition rapidly became worse. She suffered from continued weakness and soon became bed-ridden. Examination revealed marked swelling of the abdomen, generalized jaundice, dehydration and dyspnea. She was readmitted at this time and died two days later. Post-mortem examination showed generaIized carcinomatosis. In the opinion of the attending physician who saw her from the onset and in a11 stages of her iIIness, the growth and spread of the tumor were markedIy increased by the occurrence of the pregnancy. CASE II. Mrs. M. N., 42 years of age, gravida v, para IV, was admitted on June 29, 1937, for recurrent carcinoma of the breast and pregnancy. Six years previousIy the patient had noticed a smaI1 Iump in her right breast. Two years later she gave birth to her fourth chiId and faiIed to observe any change in the tumor during pregnancy or Iactation. In 1934, the tumor became Iarger and a radical mastectomy was done. This was folIowed by six x-ray treatments and the appIication of radium. Her condition was surprisingIy good up to the third month of the present pregnancy, at which time she came under our observation. Within the next few months, the patient grew rapidIy worse, suffered from a persistent cough and Iost 33 pounds. she was emaciated and On admission, cyanotic. The veins of the neck and face were distended and three recurrent carcinomatous 142
NEW SERIES VOL. XLIII,
No. I
Rosenthal-Breast
ulcers were observed at the site of the old mastectomy scar. X-ray examination revealed a moderate amount of &rid in the pIeura1 cavities. The uterus was the size of a six months’ pregnancy and the fetal heart was heard distinctly. X-ray therapy according to the Coutard technique was given. The patient is still pregnant and expects to be confined within a short time.* The attending physician, who has folIowed this patient from the onset of her ilhress, states that a marked change for the worse wasnoted in the patient soon after the beginning of her present pregnancy. This is contrary to the observation made in the course of her pregnancy four years previously, at which time little change in the tumor was noted. This case, however, may represent an instance of carcinomatous change in a hbroadenoma. CASE III. Mrs. F. C., a 35 year old Puerto Rican, para III, was admitted to the prenata1 cIinic on August 30, 1935. She was about six months pregnant. Physical examination of the breast was negative save for the usual signs of pregnancy. She was admitted to the hospital on January 7, 1936, and deIivered spontaneousIy a norma full term infant. At this time, two Iarge tumor masses were palpated in the left breast. Two weeks Iater, one of these was excised. Histologic examination revealed the tumor to be an extremely maIignant and rapidly growing meduIIary carcinoma. The patient refused permission for a radical mastectomy and Ieft the hospital against advice. She was readmitted on October 22, 1936. During the interim of nine months, she had lost considerabIe weight, had aged considerably, and became too weak to perform her ordinary househoId duties. The tumor mass left in the breast had become very extensive. On October 28, 1936, a radica1 mastectomy was performed. The pathologic examination revealed essentialIy the same type of tumor as noted previousIy. She was discharged from the hospital on November 18, 1936, and is at the present time receiving a course of x-ray therapy. Examination recently showed improvement in her general condition and a recurrence of the tumor at the site of the operation. This case is an instance of rapidly growing cancer of the breast associated with pregnancy. * This patient has since carried to term and delivered an infant spontaneously. She died within one week post-partum. The child is alive.
Cancer
American
Journal
of Surgery
‘43
WhiIe it is conceivable that a small tumor may have been present at the time the patient first visited the prenatal clinic, it is hardIy IikeIy that a tumor of any Iarge size would be missed. However, on admission to the hospital four months Iater, examination showed two Iarge tumors. Her refusal to permit a radical mastectomy after one of the tumors was excised for diagnosis gave us a good opportunity to observe its rapid growth. The recent genera1 improvement of the patient may be ascribed not only to the treatment but possibIy to the fact that there is no Ionger the inff uence of pregnancy or lactation.
It was formerIy universaIIy agreed that pregnancy has a stimuIating effect on a11 tumor growth and especiaIIy on the growth of mammary carcinoma. Reference to the Iiterature demonstrates many case reports where it appears unquestioned that pregnancy and Iactation stimuIated the growth of the neopIasm and were responsibIe for early fataIities. In some instances, the patient survived onIy a few months after a smaI1 tumor was paIpated.ls2T3 These authors beIieved that the abundant vascuIar and Iymphatic circuIation of the breast during pregnancy and Iactation offered pecuIiarIy widespread channeIs for extension. WhiIe it is aIso suggestive that direct hormona1 stimuIation of the growth of the cancer occurs in the same manner in which norma mammary gIand ceIIs proIiferate during the premenstruai phase of the sexua1 cycIe and during pregnancy, there is no direct evidence for this beIief. According to Loeb,4 mammary gIand ceIIs that have undergone definite carcinomatous transformation are no Ionger responsive to norma hormona1 stimuIation. On the other hand, one of the . Iarger series of cases presents a number of five years survivak that corresponds very cIoseIy with that of the nonpregnant group.5 It must aIso be remembered that in the age group in which pregnancy usuaIIy occurs, nameIy the young, cancer of the breast has generaIIy been regarded as having a notoriousIy bad prognosis.
I44
American Journal of Surgery
RosenthaI-Breast
A consideration of the three cases reported here confirms the generaIIy accepted beIief that pregnancy stimuIates the growth of cancer of the breast and hastens a fata outcome. A safe view wouId be to regard pregnancy and Iactation as probabIe aggravating factors in a11 cases of cancer of the breast which especiaIIy caI1 for earIy diagnosis and treatment. SUMMARY
AND
CONCLUSIONS
Three cases of cancer of the breast associated with pregnancy have occurred on the obstetrica service of the Long Isiand CoIIege HospitaI during the past two years. 2. Survey of the Iiterature shows a divergence from the universaIIy heId beIief that pregnancy markedIy stimuIates the growth of mammary carcinoma. I.
Cancer 3. CIinicaI anaIysis of the three cases herein reported shows a definite stimuIating effect of pregnancy on cancer of the breast. 4. The differentia1 diagnosis of a Iump in the breast during pregnancy and Iactation is of the greatest importance. Any reasonabIe doubt caIIs for biopsy and microscopic diagnosis. I am deepIy indebted to Drs. Vincent P. MazzoIa and Grover C. Emery for their kind permission here.
to publish
two of the cases reported
REFERENCES I. 2.
WACHSMUTH,W. Cbirurg, 5: 585,Ig33. RUBINACCI,G. Rossegna internaz. di clin. e. terap.,
11: 753, 1930. 3. LEE, B. J. Am. J. Obst. ti Gynec., 20: 775, 1930. 4. LOEB, L. In COWDRY, E. V. SpeciaI CytoIogy, 3: 1667. New York, 1932. PauI B. Hoeber.
J. C. Trans. Sect. 5. KILGORE,A. R., and BLOODGOOD, Surg. Gen. @ Abdom., A.M.A.,
p. 333, 1928.
H.
ROSENTHAL,
M.D.
Assistant in Obstetrics and GynecoIogy, Long IsIand CoIIege of Medicine BROOKLYN, NEW YORK
T
HREE cases of carcinoma of the breast associated with pregnancy have occurred on the obstetrica service of the Long IsIand CoIIege HospitaI during the past two years. One wouId ordinariIy expect some effect of pregnancy on a neopIasm of the mammary gIand, an organ which normaIIy undergoes marked hyperpIasia during pregnancy. A survey of the Iiterature, however, shows a marked difference of opinion as to the effects of pregnancy on cancer of the breast. Presentation of these three cases may aid in formuIating a more definite opinion. CASE I. Miss S. I., a 34 year oId white spinster, was admitted on May 8, 1930. She had frrst noticed a smaII Iump in the right breast one year prior to admission. The tumor was excised by her physician during August rgzg and a course of x-ray therapy given. Examination on admission showed a recurrent tumor mass beneath the oId scar. A radicaI mastectomy was then performed. Pathologic examination reveaIed chronic interstitia1 mastitis and a duct ceII carcinoma. The wound heaIed by primary union and she was discharged on the eighteenth day foIIowing operation. The patient was readmitted on January 13, rg35, because of a recurrence in the other breast. This was frrst noted as a smaI1, hard mass the size of which remained stationary for nearIy two years and then increased. Examination showed a firm, immobiIe, nodmar, ova1 mass in the left breast. An amputation of the Ieft breast was performed after a preliminary course of twenty-six x-ray treatments were given. The pathoIogic diagnosis was aIveoIar carcinoma of duct origin. She was discharged on May 26, 1934, with the Ieft breast wound healing by primary union. The patient was again readmitted on December IO, 1933, when she stated that she had feIt we11 and strong since her last admission and
had gained in weight. The Iast menstruaI period was during September 1933. At the beginning of December, the patient suffered vagina1 bIeeding and Iower abdomina1 cramps which continued intermittently unti1 the time of admission. A preoperative diagnosis of incompIete .abortion was made and a curettage performed. The pathoIogic diagnosis was decidua1 endometritis and incompIete abortion. It was estimated that the patient was about three months pregnant. During the two week period after her return home the patient’s general condition rapidly became worse. She suffered from continued weakness and soon became bed-ridden. Examination revealed marked swelling of the abdomen, generalized jaundice, dehydration and dyspnea. She was readmitted at this time and died two days later. Post-mortem examination showed generaIized carcinomatosis. In the opinion of the attending physician who saw her from the onset and in a11 stages of her iIIness, the growth and spread of the tumor were markedIy increased by the occurrence of the pregnancy. CASE II. Mrs. M. N., 42 years of age, gravida v, para IV, was admitted on June 29, 1937, for recurrent carcinoma of the breast and pregnancy. Six years previousIy the patient had noticed a smaI1 Iump in her right breast. Two years later she gave birth to her fourth chiId and faiIed to observe any change in the tumor during pregnancy or Iactation. In 1934, the tumor became Iarger and a radical mastectomy was done. This was folIowed by six x-ray treatments and the appIication of radium. Her condition was surprisingIy good up to the third month of the present pregnancy, at which time she came under our observation. Within the next few months, the patient grew rapidIy worse, suffered from a persistent cough and Iost 33 pounds. she was emaciated and On admission, cyanotic. The veins of the neck and face were distended and three recurrent carcinomatous 142
NEW SERIES VOL. XLIII,
No. I
Rosenthal-Breast
ulcers were observed at the site of the old mastectomy scar. X-ray examination revealed a moderate amount of &rid in the pIeura1 cavities. The uterus was the size of a six months’ pregnancy and the fetal heart was heard distinctly. X-ray therapy according to the Coutard technique was given. The patient is still pregnant and expects to be confined within a short time.* The attending physician, who has folIowed this patient from the onset of her ilhress, states that a marked change for the worse wasnoted in the patient soon after the beginning of her present pregnancy. This is contrary to the observation made in the course of her pregnancy four years previously, at which time little change in the tumor was noted. This case, however, may represent an instance of carcinomatous change in a hbroadenoma. CASE III. Mrs. F. C., a 35 year old Puerto Rican, para III, was admitted to the prenata1 cIinic on August 30, 1935. She was about six months pregnant. Physical examination of the breast was negative save for the usual signs of pregnancy. She was admitted to the hospital on January 7, 1936, and deIivered spontaneousIy a norma full term infant. At this time, two Iarge tumor masses were palpated in the left breast. Two weeks Iater, one of these was excised. Histologic examination revealed the tumor to be an extremely maIignant and rapidly growing meduIIary carcinoma. The patient refused permission for a radical mastectomy and Ieft the hospital against advice. She was readmitted on October 22, 1936. During the interim of nine months, she had lost considerabIe weight, had aged considerably, and became too weak to perform her ordinary househoId duties. The tumor mass left in the breast had become very extensive. On October 28, 1936, a radica1 mastectomy was performed. The pathologic examination revealed essentialIy the same type of tumor as noted previousIy. She was discharged from the hospital on November 18, 1936, and is at the present time receiving a course of x-ray therapy. Examination recently showed improvement in her general condition and a recurrence of the tumor at the site of the operation. This case is an instance of rapidly growing cancer of the breast associated with pregnancy. * This patient has since carried to term and delivered an infant spontaneously. She died within one week post-partum. The child is alive.
Cancer
American
Journal
of Surgery
‘43
WhiIe it is conceivable that a small tumor may have been present at the time the patient first visited the prenatal clinic, it is hardIy IikeIy that a tumor of any Iarge size would be missed. However, on admission to the hospital four months Iater, examination showed two Iarge tumors. Her refusal to permit a radical mastectomy after one of the tumors was excised for diagnosis gave us a good opportunity to observe its rapid growth. The recent genera1 improvement of the patient may be ascribed not only to the treatment but possibIy to the fact that there is no Ionger the inff uence of pregnancy or lactation.
It was formerIy universaIIy agreed that pregnancy has a stimuIating effect on a11 tumor growth and especiaIIy on the growth of mammary carcinoma. Reference to the Iiterature demonstrates many case reports where it appears unquestioned that pregnancy and Iactation stimuIated the growth of the neopIasm and were responsibIe for early fataIities. In some instances, the patient survived onIy a few months after a smaI1 tumor was paIpated.ls2T3 These authors beIieved that the abundant vascuIar and Iymphatic circuIation of the breast during pregnancy and Iactation offered pecuIiarIy widespread channeIs for extension. WhiIe it is aIso suggestive that direct hormona1 stimuIation of the growth of the cancer occurs in the same manner in which norma mammary gIand ceIIs proIiferate during the premenstruai phase of the sexua1 cycIe and during pregnancy, there is no direct evidence for this beIief. According to Loeb,4 mammary gIand ceIIs that have undergone definite carcinomatous transformation are no Ionger responsive to norma hormona1 stimuIation. On the other hand, one of the . Iarger series of cases presents a number of five years survivak that corresponds very cIoseIy with that of the nonpregnant group.5 It must aIso be remembered that in the age group in which pregnancy usuaIIy occurs, nameIy the young, cancer of the breast has generaIIy been regarded as having a notoriousIy bad prognosis.
I44
American Journal of Surgery
RosenthaI-Breast
A consideration of the three cases reported here confirms the generaIIy accepted beIief that pregnancy stimuIates the growth of cancer of the breast and hastens a fata outcome. A safe view wouId be to regard pregnancy and Iactation as probabIe aggravating factors in a11 cases of cancer of the breast which especiaIIy caI1 for earIy diagnosis and treatment. SUMMARY
AND
CONCLUSIONS
Three cases of cancer of the breast associated with pregnancy have occurred on the obstetrica service of the Long Isiand CoIIege HospitaI during the past two years. 2. Survey of the Iiterature shows a divergence from the universaIIy heId beIief that pregnancy markedIy stimuIates the growth of mammary carcinoma. I.
Cancer 3. CIinicaI anaIysis of the three cases herein reported shows a definite stimuIating effect of pregnancy on cancer of the breast. 4. The differentia1 diagnosis of a Iump in the breast during pregnancy and Iactation is of the greatest importance. Any reasonabIe doubt caIIs for biopsy and microscopic diagnosis. I am deepIy indebted to Drs. Vincent P. MazzoIa and Grover C. Emery for their kind permission here.
to publish
two of the cases reported
REFERENCES I. 2.
WACHSMUTH,W. Cbirurg, 5: 585,Ig33. RUBINACCI,G. Rossegna internaz. di clin. e. terap.,
11: 753, 1930. 3. LEE, B. J. Am. J. Obst. ti Gynec., 20: 775, 1930. 4. LOEB, L. In COWDRY, E. V. SpeciaI CytoIogy, 3: 1667. New York, 1932. PauI B. Hoeber.
J. C. Trans. Sect. 5. KILGORE,A. R., and BLOODGOOD, Surg. Gen. @ Abdom., A.M.A.,
p. 333, 1928.