Hamza Arabiyat, Oncoplastic Breast and General Surgeon at Royal Cornwall Hospital NHS Trust, shared on LinkedIn:
“A challenging breast cancer case during early pregnancy. Seeking colleagues’ opinions.
I would appreciate the thoughts of my colleagues, particularly breast and medical oncologists, regarding a challenging case encountered in my clinic.
Clinical Scenario
A young lady who is 32 years old, currently 9 weeks pregnant with her first pregnancy, has been diagnosed with multifocal HER2-positive invasive breast cancer involving the upper outer quadrant.
- Multiple tumour foci, each measuring less than 1 cm on current assessment.
- Clinically node-negative (cN0).
- No evidence of distant disease on available staging.
- The patient strongly wishes to preserve her breast and is requesting wide local excision (WLE) with sentinel lymph node biopsy (SLNB) and strongly against mastectomy.
I have 2 main concerns.
1. Timing of adjuvant systemic treatment
If final pathology reveals pT1c disease or higher, adjuvant chemotherapy and HER2-directed treatment would generally be indicated.
Although pregnancy-compatible chemotherapy can be administered during the second and third trimesters, trastuzumab and other HER2-directed agents would need to be deferred until after delivery.
Given that she is only 9 weeks pregnant, this potentially creates a prolonged delay in initiating anti-HER2 therapy.
How would you approach this situation? Would you favour upfront surgery followed by pregnancy-compatible chemotherapy, accepting delayed anti-HER2 treatment, or consider an alternative strategy?
2. Proceeding with breast conservation before genetic testing
Given her young age, germline genetic testing is indicated, but results are not yet available and she will not wait another four weeks for the results.
Would you proceed with WLE and SLNB based on her preference, or recommend waiting for genetic results, particularly considering the implications of a possible BRCA1/2 or TP53 pathogenic variant for surgical decision-making?
I would particularly value colleagues’ perspectives on balancing maternal oncological safety, treatment timing, hereditary risk, and the patient’s strong preference for breast conservation.
How would you manage this patient in your MDT?”
In the comments section, different specialists shared thoughts around this case, so you can also read the comments part.
You can also read: Pregnancy and Recent Childbirth Do Not Independently Worsen Outcomes in Young Women With Early Breast Cancer.
