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Breast cancer

bloating, tightness, and narrowing in her stool caliber 9 years after the diagnosis of a stage I breast cancer. Note the diffuse thickening of the rectal and colonic wall, peritoneal carcinomatosis, and ascites. A colonoscopy was performed, and biopsy confirmed diffuse involvement with metastatic adenocarcinoma consistent with a breast primary. On restaging, she was also noted to have multiple osseous metastases. (Image courtesy of Drs. Pamela Dipiro and Wendy Chen, Dana Farber Cancer Institute, Boston, MA.) D, In an ultrasound-guided needle biopsy, the ultrasound probe is used to localize the lesion that was identified either on physical examination or on mammogram. A biopsy needle is passed through the lesion several times to obtain tissue. Compared to a stereotactic biopsy, an ultrasound-guided biopsy is faster and better tolerated by most patients. However, not all lesions may be amenable to an ultrasound-guided biopsy. (Image courtesy of Robyn L. Birdwell, MD, Brigham and Women’s Hospital, Boston, MA, and Diagnostic Imaging Breast, Amirsys, Inc., Salt Lake City, UT, 2006.) E, The premise behind stereotactic needle biopsy is that a lesion can be localized in three dimensions by evaluating its changes in position in a series of angled radiographic views. First, a radiograph localizes the suspicious area; then two additional views, angled 15 degrees to either side of the lesion, are obtained. A computer calculates how much the lesion’s position appears to have changed on each of the angled views and uses these data to estimate the lesion’s location within three-dimensional space. With the advent of digital mammography, these images are commonly acquired digitally. (Image courtesy of Robyn L. Birdwell, MD, Brigham and Women’s Hospital, Boston, MA, and Diagnostic Imaging Breast, Amirsys, Inc., Salt Lake City, UT, 2006). F, Positron emission tomography (PET) involves injection of a substance labeled with a positron-emitting isotope (commonly, fluorine-18 bound to D-glucose, called FDG for 2-([18F]fluoro-2-deoxy-D-glucose)). Metabolically active cells, especially malignant ones, preferentially take up glucose and therefore FDG, as compared with non-neoplastic tissue. Sensitivity of PET can vary considerably by tumor type and size. False-positive results can occur in areas of inflammation or infection. Many machines now acquire CT images in tandem with PET images, which can then be fused together to provide anatomic correlation by CT with metabolic activity measurements by PET. This patient presented with palpable axillary adenopathy and a large breast mass with associated erythema, skin edema, and nipple retraction. Note the extremely intense areas of uptake within the right breast and axilla corresponding to the patient’s known locally advanced breast cancer. Also note the intense uptake in the right supraclavicular, paratracheal, prevascular, precarinal, and hilar lymph nodes suspicious for metastatic disease. Uptake in the kidney, bladder, and ureters is physiologic and due to FDG excretion. Uptake in the right adnexa and jaw is most likely physiologic and benign. G, Panels 1 and 2: Accelerated partial breast irradiation (APBI) encompasses techniques including intracavitary and interstitial brachytherapy as well as 3D-conformal, intensity-modulated, and intraoperative external-beam radiation therapy. One of the more commonly used brachytherapy methods in the U.S., the MammoSite Brachytherapy System (Hologic, Massachusetts), involves insertion of a catheter with a balloon tip into the lumpectomy cavity at the time of surgery or shortly thereafter (panel 1). The balloon is filled with saline, and a high-dose-rate radioactive source is introduced twice per day for 5 days by computed axial tomography scan–based treatment planning, permitting a highly conformal dose to be delivered to the first centimeter of remaining breast tissue with optimal sparing of the remaining tissue and other regional organs (panel 2). The balloon catheter is removed upon completion. APBI is an option only for selected patients, mainly older women with smaller, node-negative “low-risk” tumors and with negative margins. (Courtesy of Phillip M. Devlin, MD, Dana Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Boston, MA.) H, The HER family of receptors (human epidermal growth factor receptor, also called ErbB) is a group of transmembrane tyrosine kinase receptors that regulate cell growth, survival, and differentiation via a variety of pathways, including RAS (rat sarcoma), RAF (receptor activation factor), MAPK (mitogen-activated protein kinase), and MEK (mitogen extracellular signal kinase). The tyrosine kinase domains are activated by dimerization. Current therapeutics involve tyrosine kinase inhibitors (e.g., lapatinib) and antibodies directed against the HER2 protein and VEGF (vascular endothelial growth factor) (e.g., trastuzumab and bevacizumab). (Skarin AT: Atlas of diagnostic oncology, ed 4, Philadelphia, 2010, Elsevier.) BASIC INFORMATION DEFINITION Breech presentation occurs when fetal longitudinal axis is such that the cephalic pole occupies the uterine fundus (Fig. E1). Three types exist: frank (48%-73%, flexed hips, extended knees), complete (4.6%-11.5%, flexed hips and knees), and footling (12%-38%, hips extended). ICD-10CM CODES O83 Breech extraction O32.1 Maternal care for breech extraction P03.0 Newborn (suspected to be) affected by breech delivery and extraction EPIDEMIOLOGY & DEMOGRAPHICS INCIDENCE: Gestational age dependent: 3% to 4% overall, 14% at 29 to 32 wk, 33% at 21 to 24 wk PERINATAL MORTALITY: Three to five times increase over vertex presentation at term, regardless of delivery route. When corrected for associated increase in congenital anomalies and complications of prematurity, morbidity and mortality rates approach those of vertex presentation at term regardless of delivery route. PHYSICAL FINDINGS & CLINICAL PRESENTATION • Lack of presenting part on vaginal examination • Fetal heart tones heard above the umbilicus • Leopold maneuvers revealing mobile fetal part in the uterine fundus ETIOLOGY • Abnormal placentation (fundal), uterine anomalies (fibroids, septa), pelvic or adnexal masses, alterations in fetal muscular tone, or fetal malformations • Associated conditions: trisomy 13, 18, 21; Potter syndrome; myotonic dystrophy; prematurity DIAGNOSIS DIFFERENTIAL DIAGNOSIS Vertex, oblique, or transverse lie WORKUP • Determine reason for breech presentation, history of uterine anomalies, gestational age, or associated fetal congenital anomalies. • Assess fetal status by continuous FHR monitoring. • Perform ultrasound to confirm position and presenting part (see “Imaging Studies”). • Assess pelvis to determine feasibility of vaginal delivery. • Assess risk for safety of vaginal versus abdominal delivery. IMAGING STUDIES Ultrasound to evaluate for: • Fetal anomalies • Placental location • Position of fetal head relative to spine (check for hyperextension) • Estimated fetal weight (2500-3800 g for attempt of vaginal delivery) • Type of breech (frank, complete, footling) TREATMENT ACUTE GENERAL Rx • Vaginal delivery in breech position ○ Vaginal delivery in selected patients (see “Comments” section): Allow maternal expulsive forces to deliver fetus until scapula visible (avoiding traction); with flexion and/or Piper forceps, deliver fetal head. • Cesarean delivery ○ Perform cesarean section (see “Comments”). • External cephalic version followed by induction of labor and attempt at vaginal delivery in vertex position ○ Improved success if >37 weeks. Success rates 16% to 100%. Adequate pelvic or cervical relaxation essential. Use of tocolytic (terbutaline) and epidural anesthesia improves success rates. Data are not adequate to establish absolute or relative contraindications; must individualize. Contraindicated if vaginal delivery is not appropriate. In general, contraindicated with placental abruption, placenta previa, fetal anomalies, multiple gestations, or nonreassuring fetal status. Other relative contraindications: perform with caution with low-lying placenta, prior uterine incision, and preterm gestation. Informed consent includes risks of abruption, cord prolapse, rupture of membranes, stillbirth, and hemorrhage (<1%). COMPLICATIONS • Head entrapment: leading cause of death (with the exception of anomalous fetuses); 88 cases per 1000 deliveries; avoid by maintaining flexion of fetal head (Mauriceau Smellie Veit maneuver), use of Piper forceps or Dührssen’s incisions. Avoid hyperextension of head during delivery. • Cord prolapse: usually occurs late in labor. Incidence depends on type of breech: frank (0.5%), complete (4%-5%), footling (10%). • Nuchal arm: arm extended above fetal head; occurs when there is undue traction before delivery of fetal scapulas. Treatment: Bring trapped arm across infant’s face (Lovset’s maneuver). DISPOSITION If confounding variables are corrected for (prematurity, associated congenital anomalies [6.3% of breeches vs. 2.4% in general population]), route of delivery plays less important role in fetal outcome than previously believed if the obstetrician performing the delivery is experienced in breech delivery. As fewer providers perform breech deliveries and seasoned obstetricians retire, fewer new physicians learn the technique of breech delivery. REFERRAL An obstetrician trained in vaginal breech delivery is prerequisite for attempt; explain to the patient that with cesarean section, certain risks (i.e., hyperextension of the fetal head with resultant spinal cord injury) may be minimized but not eliminated. Cesarean section also comes with its own risks and requires informed consent as well. PEARLS & CONSIDERATIONS COMMENTS For planned vaginal delivery of the breech presentation, mortality rate increased 13-fold and morbidity 7-fold, mainly because of an increase in congenital anomalies, perinatal hypoxia, birth injury, and prematurity. However, although planned cesarean delivery reduced perinatal/neonatal death as well as composite outcomes of death or neonatal morbidity, this is at the expense of an increase in maternal morbidity. No contraindication to induction of labor in breech presentation; labor not prohibited even in primigravidas. Planned vaginal delivery of term singleton breech fetus is reasonable under hospital-specific protocol and with an experienced provider and informed consent of the patient. CRITERIA FOR TRIAL OF LABOR • Gestational age >37 weeks (proceed with caution in preterm delivery of the breech fetus; consider Maternal-Fetal Medicine consultation in these situations) • Estimated fetal weight, 2500 to 4000 g (recognizing inherent error in estimated

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