# Breast Cancer During Pregnancy: A Single Surgery for Cesarean Delivery, Mastectomy, and Breast Reconstruction Pregnancy-associated breast cancer (PABC) is the most common cancer diagnosed during pregnancy, affecting approximately 1 in 3,000 to 1 in 10,000 pregnancies. This case report describes a 37-year-old woman diagnosed with breast cancer at 36 weeks of pregnancy who underwent a groundbreaking combined procedure: cesarean delivery, nipple-sparing mastectomy (removal of breast tissue while preserving the nipple and skin), and immediate breast reconstruction — all in a single surgical session. The surgery was completed without complications for either mother or baby, and after 6 years of follow-up, the patient remains alive and free of disease. This innovative approach may offer a new treatment pathway for carefully selected patients with PABC in the third trimester. # Breast Cancer During Pregnancy: A Single Surgery for Cesarean Delivery, Mastectomy, and Breast Reconstruction ## Table of Contents - Key Points - What Is Pregnancy-Associated Breast Cancer? - The Patient's Story: A Diagnosis at 34 Weeks - Planning a Combined Surgical Approach - The Day of Surgery: How It Unfolded - What the Pathology Report Revealed - Recovery and Follow-Up Treatment - Six Years Later: The Outcome - Why This Approach Matters - Important Caveats and Limitations - What This Means for Patients - Frequently Asked Questions - Source Information ## Key Points - Pregnancy-associated breast cancer is diagnosed during pregnancy or within one year after birth, occurring in about 1 in 3,000 to 10,000 pregnancies. - In a single reported case, a 37-year-old woman had cesarean delivery, nipple-sparing mastectomy, and immediate breast reconstruction in one session at 36 weeks. - This combined approach is only applicable to PABC diagnosed in the late third trimester, when the fetus is mature enough for delivery. - Previous reports of breast surgery during pregnancy highlight risks including preterm delivery, miscarriage, and fetal distress. - After 6 years of follow-up in the reported case, the patient remained alive and disease-free, but single case reports cannot establish how often this approach works. ## What Is Pregnancy-Associated Breast Cancer? Pregnancy-associated breast cancer (PABC) is defined as breast cancer diagnosed either during pregnancy or within 1 year after giving birth. It is relatively uncommon — occurring in 1 out of every 3,000 to 10,000 pregnancies — but it is the most frequent type of cancer found during pregnancy, representing 0.2% to 3.8% of all breast cancer cases. The authors note that although the current incidence is low, the burden of PABC will likely increase in the coming years. Many developed countries are seeing a trend of postponing pregnancy until after age 40. Research by Robertson and colleagues, cited in this paper, found that older-age pregnancy carries a significantly increased risk, with a **5.3% rise per year beyond age 25**. Several biological factors may explain why breast cancer develops during pregnancy. Hormonal changes and increased levels of insulin-like growth factor-1 — a hormone that can promote cell growth — have been linked to a higher incidence of PABC. Pregnancy also triggers immunological changes, including cellular immunosuppression and immune tolerance, which may allow cancer cells to take hold. Diagnosing breast cancer during pregnancy is uniquely challenging. Pregnancy causes normal breast changes — hypertrophy (enlargement), increased gland density, and nipple changes — that can mask a tumor. Both patients and clinicians tend to focus on the pregnancy itself, which means PABC is often discovered at a more advanced and aggressive stage. Although the overall prognosis of PABC is similar to that of non-pregnant breast cancer of the same stage, delayed diagnosis frequently leads to more advanced disease at onset. PABC tumors often show unfavorable features: higher rates of hormone-receptor-negative tumors, HER2 overexpression, and lower levels of tumor-infiltrating lymphocytes — all of which contribute to a worse outlook. ## The Patient's Story: A Diagnosis at 34 Weeks A 37-year-old woman, pregnant for the first time, was found to have a **7-cm firm mass in her right breast** during an ultrasound examination at the 34th week of pregnancy. The patient had no significant previous medical, family, or psycho-social history. Physical examination revealed a firm nodule in the upper lateral pole (the outer upper area) of the right breast. Importantly, palpation of the axillary (armpit) lymph nodes found no signs of lymphadenopathy — meaning no enlarged lymph nodes could be felt. A 14-gauge semi-automated core biopsy (a needle biopsy that removes a small cylinder of tissue) was performed using a device called Precisa®. The biopsy confirmed the diagnosis: **invasive carcinoma** with the following characteristics: - **Estrogen receptor (ER)-positive**: 90% of cells tested positive for estrogen receptors - **Progesterone receptor (PgR)-positive**: 70% of cells tested positive for progesterone receptors - **Ki67 index**: 25% (a marker indicating the rate of cell division — higher means more aggressive growth) - **HER2-positive**: score 3+ (the cancer overproduces the human epidermal growth factor receptor 2 protein) When the care team discussed the diagnosis and treatment options with the patient, her perspective was clear: she wanted to protect the fetus, even at the expense of her own health. This powerful statement shaped the entire treatment planning process. ## Planning a Combined Surgical Approach The medical team took a multidisciplinary approach, bringing together a breast surgeon, gynecologist, plastic surgeon, oncologist, psychologist, and neonatologist (a specialist in newborn care). Together, they planned a bold strategy: to perform a **concomitant cesarean delivery, nipple-sparing mastectomy, sentinel lymph node biopsy, and immediate breast reconstruction** — all at the 36th week of pregnancy, after first inducing fetal lung maturation. The surgical timing was carefully chosen to balance several priorities: - Avoiding general anesthesia exposure for the fetus during the breast surgery - Limiting the risks of an excessively premature birth - Allowing adequate fetal lung maturation - Ensuring appropriate and timely management of the oncological threat This approach was made possible because the baby was already close to full term, so delivery could be safely expedited. The team emphasized that this strategy takes advantage of a diagnosis made in the late third trimester, when the fetus is mature enough for delivery. ## The Day of Surgery: How It Unfolded On the second day of the 36th week, the surgical team executed the planned sequence. First, the **cesarean delivery was performed under spinal anesthesia** — the standard approach that numbs the lower body without putting the baby to sleep. Fetal monitoring was conducted prior to the delivery using cardiotocography, which tracks the baby's heart rate and uterine contractions. As soon as the newborn was delivered, the baby was taken care of by the neonatologists and was in good health, with an **APGAR index of 9/9/10** (a standard scoring system that assesses the newborn's heart rate, breathing, muscle tone, reflexes, and color — scores of 7 to 10 are considered normal). Immediately after delivery, general anesthesia was induced in the mother — now safe, since the baby was no longer in the womb — and the breast surgery began. The procedure included: 1. **Nipple-sparing mastectomy**: removal of all breast tissue while preserving the nipple and overlying skin 1. **Sentinel lymph node biopsy with intraoperative frozen section**: the first lymph node(s) draining the breast were removed and examined under a microscope immediately during surgery 1. **Radical ipsilateral axillary dissection**: because the frozen section revealed macro-metastases (visible cancer deposits) in the sentinel lymph node, the surgeon removed additional lymph nodes from the armpit on the affected side 1. **Immediate breast reconstruction (IBR)**: the breast was rebuilt in the same session using a breast implant For the reconstruction, the surgical team used a technique called **partial submuscular coverage**. The upper part of the implant was covered by the pectoral major muscle (the large chest muscle), and the lower part was reinforced using an **acellular porcine dermal matrix** — a biological mesh derived from pig skin that helps support the implant and define the natural breast shape. Surgical drains were placed as is routine practice in the authors' experience. The entire surgical sequence, including anesthesia times, lasted **240 minutes (4 hours)**. The cesarean section itself took just 25 minutes, while the nipple-sparing mastectomy, axillary lymph node dissection, and breast reconstruction together took 140 minutes. ## What the Pathology Report Revealed The pathology results confirmed a more extensive disease than the initial biopsy suggested. The tumor was classified as a **multifocal and multicentric no-special-type G3-infiltrating ductal carcinoma** — meaning there were multiple separate tumor sites within the breast, and the cancer cells were grade 3 (the most aggressive grade on a 1-to-3 scale). The tumor also showed vascular and lymphatic infiltration, meaning cancer cells had invaded blood and lymph vessels. Of the **18 lymph nodes removed** from the armpit, **4 contained cancer**. According to the TNM 2017 (8th edition) staging classification, the cancer was staged as **pT2(m) (50 mm) and pN2a (4/18)** — indicating a primary tumor of 50 mm (5 cm) with multiple involved lymph nodes. This corresponds to **stage IIIA** in the American Joint Committee on Cancer (AJCC) TNM 8th edition staging system. Immunohistochemical staining of the surgical specimen showed: - **ER-positive**: 90% - **PgR-positive**: 90% - **Ki67 index**: 50% (higher than the 25% seen on the initial biopsy, confirming a highly proliferative tumor) - **HER2-positive**: score 3+ Genetic testing found **no pathologic BRCA1 or BRCA2 mutations**, and no other abnormal findings were detected. Skeletal scintigraphy (a bone scan) and a total body CT scan found **no distant metastases** — meaning the cancer had not spread to other organs or bones. ## Recovery and Follow-Up Treatment The patient's recovery was smooth. She was **discharged on the fourth postoperative day**. The breast drains were removed on the sixth postoperative day, once drainage fell below 20 cc per day, while the axillary drain was removed earlier, on the fourth postoperative day. **No major or minor complications** were reported during recovery for either the mother or the newborn. Because chemotherapy was going to be administered, lactation (milk production) had to be suppressed. This was achieved with a **single oral dose of 1 mg of cabergoline**, a medication that stops milk production. Adjuvant treatment (therapy given after surgery to reduce the risk of recurrence) began **4 weeks after delivery** and included all of the following components: - **Chemotherapy**: four cycles of intravenous AC (doxorubicin and cyclophosphamide) given every 3 weeks, followed by 12 weekly doses of Taxol (paclitaxel) - **Targeted therapy**: trastuzumab (Herceptin) given every 21 days for 18 months to target the HER2-positive cancer - **Hormone therapy**: triptorelin 3.75 mg (one injection every 28 days for 3 years) to suppress ovarian function, plus tamoxifen 20 mg (one tablet per day for 2 years), later replaced with exemestane 25 mg (one tablet per day) - **Radiotherapy**: 40 Gy plus a 15 Gy boost to the operated breast/chest wall Her follow-up schedule was rigorous. Every 6 months, she underwent clinical examination with blood tests for tumor markers **Ca-15.3** (cancer antigen 15-3) and **CEA** (carcinoembryonic antigen). Every year, she had a breast ultrasound, mammography, and total body CT scan. ## Six Years Later: The Outcome At the time of the case report, after a **6-year follow-up period, the patient is alive and disease-free**. The authors note that the post-operative photograph taken 1 year after the right breast reconstruction showed a good aesthetic result. ## Why This Approach Matters This case is notable because, to the best of the authors' knowledge, it is the **first reported case** of a concurrent cesarean delivery, PABC mastectomy, axillary dissection, and immediate breast reconstruction performed in a single surgical session. Previous studies have explored immediate breast reconstruction during pregnancy, but with important caveats. Lohsiriwat and colleagues, in 2013, were the first to propose IBR during pregnancy using an expander device. Caragacianu and colleagues reported a series of 10 patients who underwent IBR during pregnancy, one of whom developed an intraoperative uterine contraction that required tocolysis (medication to stop contractions). These reports, while favorable overall, highlight the potential risks of performing breast surgery during pregnancy, including **preterm delivery, miscarriage, and fetal distress**. The strategy used in this case elegantly sidesteps those risks. By delivering the baby first under spinal anesthesia, the team avoided exposing the fetus to general anesthesia or the stress of surgery. Then, with the baby safely delivered, the mother could undergo a complete, guideline-compliant breast cancer operation in the same session. This single-step approach offers several meaningful advantages: - Avoidance of a second, separate surgical procedure - Reduced psychological distress for the patient - Lower overall healthcare costs and shorter waiting lists - Better aesthetic outcomes, because placing the implant while respecting the natural inframammary fold (the crease under the breast) optimizes the final appearance - A reduced need for a future surgery to symmetrize (balance) the opposite breast The authors also emphasize that this approach aligns with the most accredited guidelines, which recommend that surgical treatment for breast cancer during pregnancy should be as close as possible to the standard treatment for non-pregnant patients. Current guidelines support immediate breast reconstruction whenever feasible, and this case demonstrates that it can be done safely in the PABC setting with careful planning. Another key element was the strong collaboration within the multidisciplinary Breast Unit team. The authors note that, in their hospital, the Breast Unit and the Obstetrics and Gynecology Department work closely together — and in this case, the breast surgeon was also a gynecologist, which further ensured that both oncologic and obstetric concerns were given appropriate weight. ## Important Caveats and Limitations The authors are clear about the limitations of this approach. The main drawback is that the strategy is only applicable to PABC cases diagnosed in the **late third trimester**. Performing a cesarean delivery too early would expose the fetus to well-known risks of prematurity, including: - Respiratory distress - Intraventricular hemorrhage (bleeding in the brain) - Other complications associated with premature birth Because this is a single case report, the authors acknowledge that further research is needed to confirm the feasibility, safety, and appropriate timing of this surgical sequence in a larger group of patients. Single case reports can demonstrate that a procedure is possible, but they cannot establish how often it works or what complications might arise in a broader population. Additionally, the patient's tumor was HER2-positive and hormone-receptor-positive, which permitted the use of targeted and hormonal therapies. The approach may not generalize to all PABC subtypes, and each case must be individualized. ## What This Means for Patients For patients diagnosed with breast cancer during pregnancy, especially in the third trimester, this case report offers several important takeaways: 1. **Treatment is possible during pregnancy.** Breast cancer surgery is commonly performed during all trimesters of pregnancy, and treatment should follow standard breast cancer guidelines as closely as possible. 1. **A multidisciplinary team is essential.** This case involved breast surgeons, gynecologists, plastic surgeons, oncologists, psychologists, and neonatologists all working together. Patients with PABC should seek care at a center with this level of coordination. 1. **Immediate breast reconstruction may be an option.** When mastectomy is required and the pregnancy is far enough along, immediate reconstruction — rather than delayed reconstruction — may be feasible and can improve both psychological recovery and aesthetic outcomes. 1. **Your priorities matter.** In this case, the patient's strong desire to protect her baby shaped the treatment plan. The medical team listened and designed a strategy that honored her wishes while still providing guideline-compliant cancer care. 1. **Long-term follow-up is critical.** Even after successful treatment, patients with PABC need ongoing surveillance with regular imaging and tumor marker testing to ensure early detection of any recurrence. It is important to note that this is a single case report, not a clinical trial. While the outcome was excellent for this patient, every PABC case is unique. Patients should discuss all available options — including the timing of delivery, surgical approach, and reconstruction method — with their full medical team to make the best decision for their individual situation. ## Frequently Asked Questions ### What is pregnancy-associated breast cancer (PABC)? Pregnancy-associated breast cancer is breast cancer diagnosed during pregnancy or within one year after giving birth. It is uncommon, occurring in about 1 in 3,000 to 10,000 pregnancies, but it is the most frequent cancer found during pregnancy. Diagnosis can be delayed because normal pregnancy breast changes may hide a tumor, so it is often found at a more advanced stage. ### Can breast cancer be treated during pregnancy? Yes. Breast cancer surgery is commonly performed during all trimesters of pregnancy, and treatment should follow standard breast cancer guidelines as closely as possible. In the reported case, a 37-year-old woman had cesarean delivery, nipple-sparing mastectomy, and immediate breast reconstruction in one surgical session at 36 weeks. A multidisciplinary team is essential for coordinating care. ### What is a single-session combined procedure for PABC? It is a planned approach where cesarean delivery, nipple-sparing mastectomy, sentinel lymph node biopsy, and immediate breast reconstruction are performed in one surgical session. In the reported case, this was done at 36 weeks of pregnancy after inducing fetal lung maturation. The baby was delivered first under spinal anesthesia, then the mother received general anesthesia for the breast surgery. ### Who might be eligible for this combined approach? This strategy is only applicable to pregnancy-associated breast cancer diagnosed in the late third trimester, when the fetus is mature enough for delivery. Performing cesarean delivery too early would expose the fetus to risks of prematurity, such as respiratory distress and intraventricular hemorrhage. Each case must be individualized, and the approach may not generalize to all PABC subtypes. ### What are the risks of breast surgery during pregnancy? Previous reports of immediate breast reconstruction during pregnancy highlight potential risks including preterm delivery, miscarriage, and fetal distress. One series of 10 patients reported an intraoperative uterine contraction that required medication to stop it. The combined approach used in the reported case avoids these risks by delivering the baby first under spinal anesthesia, so the fetus is not exposed to general anesthesia or surgical stress. ### What does a Ki67 index of 25% or 50% mean? The Ki67 index is a marker indicating the rate of cell division; a higher number means more aggressive growth. In the reported case, the initial biopsy showed a Ki67 index of 25%, and the surgical specimen showed 50%, confirming a highly proliferative tumor. This information helps the medical team plan treatment. ### What follow-up is needed after treatment for PABC? Long-term follow-up is critical. In the reported case, the patient had clinical examination with blood tests for tumor markers every 6 months, and yearly breast ultrasound, mammography, and total body CT scan. After 6 years of follow-up, she remained alive and disease-free. Regular surveillance helps ensure early detection of any recurrence. ### When should a patient diagnosed with breast cancer in the third trimester of pregnancy seek a second opinion about combining cesarean delivery, mastectomy, and breast reconstruction in one surgery? This combined single-session approach applies only to pregnancy-associated breast cancer diagnosed in the late third trimester, when the fetus is mature enough for delivery. A second opinion can help confirm whether the timing of delivery, the mastectomy, and immediate reconstruction are appropriate for your tumor subtype and stage, since the reported case involved a HER2-positive, hormone-receptor-positive tumor and each case must be individualized. A multidisciplinary team including breast surgeons, gynecologists, plastic surgeons, oncologists, and neonatologists is essential. Diagnostic Detectives Network provides independent expert second opinions. ## Source Information This patient-friendly article is based on the following peer-reviewed research: - **Original article title**: "Breast cancer in pregnancy: concurrent cesarean section, nipple-sparing mastectomy, and immediate breast reconstruction — case report" - **Authors**: Alessandro Innocenti, Pietro Susini, Luca Grimaldi, and Tommaso Susini - **Journal**: Frontiers in Oncology - **Publication date**: January 8, 2024 - **DOI**: 10.3389/fonc.2023.1332862 - **Affiliations**: Careggi University Hospital, Florence, Italy; University of Siena, Italy; University of Florence, Italy *Note: This patient-friendly article is based on peer-reviewed research. It is intended for informational purposes and does not constitute medical advice. Patients with questions about breast cancer during pregnancy should consult their healthcare provider.* --- Publisher: Diagnostic Detectives Network (https://diagnosticdetectives.com) — independent multi-expert medical second opinions, worldwide, private-pay. Author byline: Anton Titov, MD, PhD. Contact: https://diagnosticdetectives.com/pages/contact Canonical page: https://diagnosticdetectives.com/products/breast-cancer-during-pregnancy-a-single-surgery-for-cesarean-delivery-mastectomy-and-breast-reconstruction