Unexpected association between breast cancer and molar pregnancy in a 52-year-old woman: A case report

Abstract

Introduction

There was no prior discussion about the association between breast cancer and molar pregnancy, particularly at an advanced age. Through our case and a systematic review, we will discuss the relevance of ovarian castration in hormone-receptor-positive breast cancer.

Case presentation

We reported the case of a 52-year-old woman, not yet menopausal, who was diagnosed with a right breast tumor classified as BI-RADS category 4. The anatomopathological analysis of mammary biopsy revealed an invasive ductal carcinoma of no special type (grade 2). Hormone receptors were positive. It was a HER2-negative Breast cancer. It was then decided to treat the patient with radical surgery followed by chemotherapy, radiotherapy, and hormonotherapy. The patient had a “Patey operation”. The postoperative course was without significant complications. No medical or surgical castration was indicated in the expectation that chemotherapy would cause ovarian failure. Unlikely, during chemotherapy course our patient developed a molar pregnancy.

Clinical discussion

Our case illustrates the possibility of pregnancy in non-menopausal women with estrogen-receptor-positive breast cancer. The combination of tamoxifen or aromatase inhibitors with ovarian suppression as standard adjuvant therapy may be recommended in such cases.

Conclusions

Ovarian function suppression in non-menopausal women with hormone receptor-positive breast cancer seems to be necessary. So that, we can avoid unexpected manifestations like molar pregnancy.

Highlights

• •Suspicion of gestational trophoblastic disease in a premenopausal women with abnormal vaginal bleeding
• •Chemotherapy does not systematically induce ovarian failure.
• •The importance of suppressing ovarian function in non-menopausal women with hormone receptor-positive breast cancer
• •The multidisciplinary approach for breast cancer

1. Introduction

Breast cancer is the most common cancer diagnosed in women, mainly over the age of 50 (80 %) [1]. Similarly, the incidence of molar pregnancy is higher in this population [2]. The association between these two pathologies has never been reported before. In fact, in premenopausal women with breast cancer, ovarian dysfunction is often the most important long-term side effect of adjuvant chemotherapy. Therefore, it appears that these women are unable to become pregnant. Here, we present the case of a molar pregnancy in a 52-year-old female who was treated with chemotherapy for breast cancer.

2. Case presentation

This was a 52-year-old woman who was not yet menopausal. She was a housewife and had a medium socio-economic level. She didn't smoke. Her husband was a smoker and taxi driver. She was a third gesture, a second part with spontaneous abortion. As for her medical history, she had a thyroid nodule surgically removed 30 years ago. Histological analysis revealed a benign tumor. Postoperative thyroid function was normal. There was no history of illness in the family. A movable mass was found during the physical examination in the right breast's lower outer quadrant. It had a 5 cm diameter and straight lines throughout. The axillary lymph nodes were unaffected. Except for a body mass index of 30 kg/m², the rest of the physical examination was normal. The BI-RADS classification assigned this breast tumor a category of 4. A core needle biopsy guided by ultrasonography was performed. The anatomo-pathological examination identified a grade 2 invasive ductal carcinoma of no particular type. Positive hormone receptors were found. The malignancy was HER2-negative (Fig. 1, Fig. 2, Fig. 3). Ki67 was 30 %. The diagnosis of luminal a subtype Breast cancer without secondary localization was confirmed.

Fig. 1.

Non-specific infiltrating carcinoma of the breast.

Fig. 2.

Breast carcinoma proliferation arranged in trabeculae and glandular structures.

Fig. 3.

a) Intense and diffuse nuclear labeling to estrogen receptors.

b) Intense and diffuse nuclear staining to progesterone receptors.

The case was discussed at a multidisciplinary committee. Therapeutic management was started with radical surgery followed by chemotherapy and hormonotherapy. The patient received a thorough explanation of the procedure. She approved of the proposed course of treatment. A psychologist supported her during the therapy period.

She underwent a right “Patey operation” without significant postoperative complications.

The micro biopsy analysis supported the diagnosis with no foci of carcinoma in situ and no vascular emboli, and of the 15 excised nodes, 3 were impacted. In our instance, neither medicinal nor surgical castration was recommended because chemotherapy was expected to make an irreversible ovarian failure. The patient received the FEC protocol (fluorouracil-epirubicin-cyclophosphamide).

Three months later, the patient experienced abnormal uterine bleeding while undergoing chemotherapy. Upon examination, it was discovered that the patient had blackish discharge but was hemodynamically stable (Blood Pressure = 140/80 mmHg, Pulse rate = 83 bpm). The ultrasound exam revealed a normal-sized uterus, a thick endometrium that measured 40 mm in thickness without adnexal abnormalities. The B-HCG level was 132,700 IU/ml. The blood test findings were normal. A molar pregnancy was strongly suspected. There was a negative extension assessment. A meticulous ultrasound-guided aspiration was carried out, returning a vesicular product that was sent for an anatomopathological study. The anatomopathological analysis confirmed the molar pregnancy diagnosis (Fig. 4, Fig. 5). The surgery was successful with an endometrium at 8 mm and a negativation of B-HCG after two months. Surgical castration associated with a total hysterectomy was then suggested.

Fig. 4.

Molar pregnancy: large chorionic villi with hydropic axis and anfractuous contours with trophoblast hyperplasia.

Fig. 5.

Cistern and trophoblast hyperplasia.

3. Discussion

Our case indicates that ovarian function can be preserved in breast cancer patients receiving chemotherapy, and pregnancy is always possible, even in premenopausal patients who were at high risk of molar pregnancies.

In fact, the toxicity of chemotherapy on ovarian function depends on the dose and protocol applied and varies from patient to patient. The likelihood of ovarian failure increases with age in most cases [3]. The age of the patient was an independent factor predicting its occurrence [4]: ovarian failure is five times more likely to occur in women over the age of 40 compared to women under that age [5]. In order to prevent the ovaries from secreting estrogen, premenopausal women may benefit from ovarian castration. It can either be irreversible (laparoscopic surgery or radiotherapy) or reversible (hormone therapy with LHRH analogues) [6]. In premenopausal women with estrogen receptor-positive breast cancer, recent international consensus statements advise using tamoxifen or aromatase inhibitors in conjunction with ovarian suppression as conventional adjuvant therapy [7]. In non-menopausal women, LH-RH analogues for two years have been suggested as an alternative to castration and it seems to be an effective mutilating procedure [8]. Ovarian suppression reduces or eliminates endogenous estrogen production. As a result, the rates of disease relapse, progression or mortality in premenopausal women with breast cancer will be reduced [9].

In our situation, because of our patient's advanced age and in the expectation of chemotherapy-induced ovarian failure, neither analogues nor surgical castration were suggested. Especially considering that fertility reduces with age and that beyond the age of 30, the likelihood of becoming pregnant decreases by 3.5 % annually.

Although fertility decreases with age, pregnancy still possible in premenopausal women [8]. Our patient's case illustrates well this fact. It is rare for women over 50 to become pregnant, and when it does, abnormal characteristics are discovered. An older-age pregnancy may result in a molar pregnancy or an abortion [10]. Few perimenopausal women have a gestational trophoblastic disease (GTD) [11]. The two main risk factors are patient age and prior hydatidiform mole history [12]. Our patient was 52 years old and not yet menopausal. Rare cases of benign hydatidiform pregnancy in postmenopausal women over 50 years have been reported in the literature up to now [10]. Following suction curettage, this population's risk of developing postmolar malignancy is reported to be 56.3 % [11]. Therefore, it may be reasonable to assess for GTD even in perimenopausal women with abnormal uterine bleeding. [13].

4. Conclusions

Due to the variety of breast cancer treatments, multidisciplinary management must be set up for each patient and at each stage of the disease. It must be personalized to ensure the patient's compliance. Although, breast cancer women over 50 years rarely become pregnant, GTD should be taken into account in the differential diagnosis of pre- and postmenopausal abnormal vaginal bleeding [13].

Therefore, in premenopausal women with hormone receptor-positive breast cancer, ovarian suppression may be recommended to prevent unexpected results (molar pregnancy) and to improve the prognosis.

Consent

The patient has given permission for the case to be published.

Ethical approval

The case report is exempt from ethnical approval in our institution. It is only necessary to obtain the patient's consent.

Funding

The authors declare that there are no funding sources for their research.

Author contribution

Karima Mekni: has substantially contributed to the conception and substantively revised it.

Oumayma Mejri: has assisted in data collection.

Ayadi Aida: has provided us with the histological diagnosis and photos of the slides.

Chiraz El Fekih: has provided final approval of the work.

Guarantor

Dr Karima Mekni.

Research registration number

• 1.Name of the registry: Unusual Association of a Molar Pregnancy to a Breast Cancer.
• 2.Unique identifying number or registration ID: Molar.
• 3.Hyperlink to your specific registration (must be publicly accessible and will be checked): https://register.clinicaltrials.gov/prs/app/action/ViewOrUnrelease?uid=U0006HES&ts=58&sid=S000D1DT&cx=uw6qmt.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Declaration of competing interest

The authors declare that they have no competing interests.