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Hello everyone and welcome to Noon conferences hosted by MRI Online.

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In response to changes happening around the world right now and the shutting

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down of in person events, we've decided to provide free daily Noon conferences

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to all radiologists worldwide. Today we're joined by Dr. Amy Patel for a

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lecture on the pregnant and lactating patient. Dr. Amy K. Patel is a

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Breast Radiologist and Medical Director of the Women's Imaging Center at

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Liberty Hospital. She's also an Assistant Professor of radiology at the

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University of Missouri Kansas City School of Medicine.

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A reminder, there will be a Q&A session at the end of the

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lecture, so please use the Q&A feature to ask your questions and we'll

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get to as many as we can before time's up. That being said,

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thank you all so much for joining us today. Dr. Patel,

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I'll let you take things from here. Okay.

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So today I'm going to be discussing the pregnant and lactating patient.

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So briefly, we're going to discuss physiologic changes during pregnancy

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and lactation. We're also going to look from a radiographic, radiologic

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standpoint of the breast and the changes that occur during pregnancy and

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lactation. I will be showing you some benign disorders

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and tumors, as well as inflammatory and infectious diseases, and briefly

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touch a little bit on pregnancy associated breast cancer.

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So when a woman is pregnant, as we all know, there are physiologic

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changes involved, and the hormonal changes during pregnancy lead to increased

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breast size, firmness, nodularity, and parenchymal density. And these lead

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to challenges during clinical and radiological evaluation in these patients.

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Oftentimes these are very challenging patients that we have to

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encounter and in terms of management and how we diagnose these

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patients and manage these patients. Now it's important to note that these

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changes steadily return to a pre pregnancy state approximately three months

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after the cessation of breastfeeding. So that's one of the important takeaway

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points I have for you today and this lecture is remember that changes

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of the breasts steadily return to pre pregnancy state approximately three

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months after the cessation of breastfeeding. So this is just an illustrative

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example of how we produce milk. So these are illustrations of the nipple

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areolar complex, and essentially during lactation milk is produced in lobules

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which are denoted by these little pink blobs here, and then transported

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via the ducts that's denoted by this open black arrow

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to the nipple orifices to essentially expel the milk.

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Now at the histopathology level, these are two images just illustrate,

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particularly on the left hand side, here with the black arrows we see

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acinar cells with a vacuolated cytoplasm and then some occasional luminal

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cytoplasmic buds which this overall does represent lactational changes.

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Now it's important to note that histology and cytology smears from lactational

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change can overlap with carcinomas. It's important to be able to distinguish

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the two on histopathology. Here on the right hand side you can see

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that this is a patient in their first trimester of pregnancy and you

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have quite an expansion here of the number of lobules compared with the

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pre pregnancy state, and an example of that would be here with the

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black arrow is. So your lobules are really expanding during pregnancy,

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of course, gearing up for the production of milk.

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And then like we discussed particularly three months after the cessation

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of breastfeeding the essentially the breast composition returns to normal

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and so you're more likely to see obviously a picture of

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your lobules decreased in the expansion like this area of lobules demonstrates

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here. As far as hormonal changes go, as we know during pregnancy we

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have increased estrogen, and that stimulates growth of the breasts mostly

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through the development and arborization of the ductal system and to a lesser

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extent through increased stromal adipose tissue. We have increased progesterone

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and it acts synergistically with estrogen and leads to ductal and lobular

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growth and provides secretory capability to our alveolar cells that's needed

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for that milk synthesis. However, both estrogen and progesterone inhibit

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milk production and that's where our prolactin comes in.

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We have increased prolactin it starts after childbirth when prolactin works

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unopposed by the inhibitory effects of placental estrogen and progesterone

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in milk production can act at full capacity.

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So in terms of mammography, what do we see? So we see increased

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breast size, increased breast density, most prominent during early lactation

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and the late third trimester. So these are important. It's important to

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know sort of where the patient is along their pregnancy.

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It's also helpful to have the lactating patient nurse or pump before the

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mammogram to decrease breast density. For those of you out there who are

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breast imagers we know that these women who are lactating tend have a

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very dense appearance on mammography or the increased whiteness denoting

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the density, the fibroglangial tissue it's very prominent in these patients.

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So it's important for us to ensure the patient has

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nursed or pumped before their mammogram so we can reduce that breast density

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as best as we can. So this is an example here on the

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left hand side this is a 32 year lactating woman and

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she was having some nipple discharge, and here you can see that the

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breast is really increased in size, coarse nodular dense parenchymal pattern

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and this is the same patient a year later where you really see

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a reduction in that really expanded breast density nodular pattern

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where she is back to baseline. Again, here on the left side you

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have a 36 year old breastfeeding woman you have a very diffuse nodular

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coarse parenchymal pattern, here bilaterally. And then the same patient

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six months after she stopped breastfeeding you see nearly complete resolution

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of that lactational change. You can see that that diffuse nodular appearance

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has really decreased in prominence.