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Oral Boards > Breast > Flashcards

Breast Flashcards

1
Q

What is the current USPSTF task force mammo recommendation?

A

Screen women between 50-75

q2 year screening

For women >40, consider q2y screening weighing risks/benefits

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2
Q

When should women with history of thoracic RT get breast screening?

A

10 years after RT or starting at age 40 (whichever sooner)

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3
Q

How should women with prior thoracic RT get screened for BC?

A
  • Annual mammogram and.or MRI
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4
Q

The axillary regions are defined with respect to what landmark?

A

Pec minor

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5
Q

Where does pec minor insert?

A

coracoid process

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6
Q

where does pec minor connect to?

A

Ribs 3-5

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7
Q

How to define Level I axilla

A

Inferior and lateral to pec minor

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8
Q

How to define Level II axilla

A

Beneath pec minor

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9
Q

How to define level III axilla?

A

superior and medial to pec minor

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10
Q

Superior edge of SCV field

A

below cricoid cartilage

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11
Q

Inferior edge of SCV field

A

caudal edge of clavicular head

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12
Q

Anterior edge of SCV field

A

SCM muscle

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13
Q

Posterior edge of SCV field

A

Anterior aspect of scalene muscle

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14
Q

Lateral edge of SCV field

A

Cranial: lateral edge of SCM

Caudal: junction of clavicular head and 1st rib

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15
Q

Medial edge of SCV field

A

Excludes thyroid and trachea

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16
Q

Superior edge of level I

A

Axillary vessels cross lateral edge of pec minor

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17
Q

Inferior edge of Level I axillary field

A

Pec major inserts into ribs

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18
Q

Anterior edge of level I axilla

A

Anterior surface of pec major and lat dorsi

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19
Q

Posterior border of level I axilla

A

Anterior surface of subscapularis muscle

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20
Q

Lateral border of level I axilla

A

medial edge of lat dorsi

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21
Q

Medial edge of level I axilla

A

lateral edge of pec minor

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22
Q

Superior edge of Level II axilla

A

Axillary vessels cross medial edge of pec minor

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23
Q

Inferior edge of level II axilla

A

Axillary vessels cross lateral edge of pec minor

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24
Q

Anterior border of level II axilla

A

Anterior surface of pec minor

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25
Q

Posterior border of Level II axilla

A

Ribs and chest wall

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26
Q

Lateral border of level II axilla

A

Lateral border of pec minor

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27
Q

Medial border of level II axilla

A

medial border of pec minor

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28
Q

Superior border of level III axilla

A

Pec minor inserts to coracoid

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29
Q

Inferior border of level III axilla

A

Axillary vessels cross medial edge of pec minor

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30
Q

Anterior edge of level III axilla

A

posterior surface of pec major

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31
Q

Posterior edge of level III axilla

A

Ribs and intercostal muscles

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32
Q

Lateral edge of level III axilla

A

Medial border of pec minor

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33
Q

Medial edge of level III axilla

A

Thoracic inlet

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34
Q

Superior edge of IMN field

A

Superior aspect of medial 1st rib

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35
Q

Inferior aspect of the IMN field

A

Top of 4th rib

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36
Q

What is the markers of Luminal A

A

ER/PR+

HER2-

Low Ki-67

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37
Q

What is the marker profile of Luminal B?

A

ER/PR+

HER2+ or HER2-

High Ki-67

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38
Q

Marker profile of basal breast cancers

A

Triple negative

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39
Q

How is Her2+ defined?

A

IHC 3+

FISH amplification of at least 2

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40
Q

How is extensive intraductal component defined?

A

DCIS > 25% of specimen

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41
Q

Rate of LR if extensively positive margin?

A

27%

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42
Q

Rate of LR if focally positive margin

A

8-15%

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43
Q

How is positive margin defined for invasive BC?

A

no tumor on ink

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44
Q

What is the ramification of positive margin per ASTRO consensus

A

>2 fold increase in IBRT, not overcome by boost, chemo or subtype

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45
Q

What is the definition of negative margin for DCIS

A

>2 mm

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46
Q

If LCIS is found at margin of surgical specimen, what is next step?

A

no need for re-excision

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47
Q

Patient comes with concern on screening mammo, what history should be asked?

A
  • Presence and duration of breast symptoms including palpable mass
  • Skin changes
  • Nipple inversion
  • Discharge
  • Lymphadenopathy
  • Adbominal pain, weight loss
  • Bone pain or neuro sx
  • Risk factors
    • FHx of breast/ovarian ca
    • Gyn history and excess hormone exposure
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48
Q

What is the typical breast physical exam

A

Bilateral breast exam looking for

  • Symmetry
  • Palpable masses
  • Satellite nodules
  • Skin or chest wall changes
  • Nipple retraction or inversion
  • Axillary, IMN, SCV nodes
  • Abdominal and neuro exam
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49
Q

Patient comes with concerning mammo, what should you ask about?

A

Prior mammos

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50
Q

What does a CC mammo stand for

A

Craniocaudal

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51
Q

What does a CC mammo show?

A

Inner or outer quadrants

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52
Q

How to tell medial from lateral on CC mammo?

A

Convention is that top is lateral

CC marker is placed on lateral

Clip in axilla

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53
Q

How can you tell a good CC image

A

Nipple should be present

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54
Q

What does MLO mammo stand for?

A

Medial lateral oblique

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55
Q

What does MLO show?

A

Superior (upper) or Inferior (lower)

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56
Q

What dictates a good MLO image?

A

Visualize inframammary fold

Visualize pec major

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57
Q

How to tell sup/inf on MLO scan

A

Pec major is sup

convention is superior on top

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58
Q

BIRADS 0

A

Incomplete

Perform spot compression, mag views or US ASAP

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59
Q

BIRADS 1

A

Negative

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60
Q

BIRADS 2

A

Benign finding

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61
Q

BIRADS 3

A

Probably benign –> new mammo in 6 months

2% risk of malignancy

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62
Q

BIRADS 4

A

Suspicious abnormality –> biopsy recommended

3-95% risk

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63
Q

BIRADS 5

A

Highly suggestive of malignancy - perform bx right away

>95% risk

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64
Q

BIRADS 6

A

Biopsy proven malignancy

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65
Q

What is the imaging workup for abnormal screening mammo

A

Send for diagnostic mammo and US

Digital breast tomo

Breast MRI as needed

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66
Q

What kind of extra imaging needed for spiculated mass

A

compression views

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67
Q

What kind of mammo imaging needed for suspicious calcs

A

magnification view

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68
Q

What type of calcs are more likely to be malignant

A

finer, granular

linear, branching

pleomorphic

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69
Q

How do tumors looks on Ultrasound

A

hypoechoic mass with uneven borders and posterior shadowing

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70
Q

What is the best workup approach to a palpable mass

A
  1. Bilateral diagnostic mammo with spot compression views
  2. Correlative diagnostic US of breast and axilla
  3. If there is a visible mass –> recommend proceeding to US-guided core needle biopsy
    1. stain for ER/PR/HER2
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71
Q

If there is no palpable mass and unable to visualize mass on US, what is the best biopsy approach

A

Stereotactic guided core needle biopsy with clip placement (especially if small lesion that could be removed with biopsy or with neoadjuvant chemo)

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72
Q

Surgical approach if there is DCIS in biopsy

A
  • Radiology places wire into area of calcs
  • 2 cm margin is taken around wire at the time of surgery
  • Specimen mammo then taken to assure calcs have been removed
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73
Q

What if lesion is very close to CW or difficult to visualize calcs

A

Stereotactic wire-localized excisional biopsy

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74
Q

What if core biopsy shows atypical ductal hyperplasia?

A

Needle-localized excision with specimen mammo

Referral for possible tamoxifen

Ensure DCIS has been adequately removed (at least 2 mm margins)

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75
Q

How should suspicious nodes be handled?

A

US-guided FNA, especially if neoadjuvant chemo planned

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76
Q

What labs should be drawn for breast cancer?

A

CBC

CMP

LFTs

PREGNANCY TEST

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77
Q

If T3N1 or greater also consider getting what imaging?

A

CT CAP

PET or bone scan

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78
Q

What other studies should be obtained?

A

A few could be obtained as guided by symptoms:

CT imaging

MRI brain

Bone scan if sx or elevated alk phos

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79
Q

What other referrals should be potentially made?

A

Fertility if young woman

Genetics if meeting criteria

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80
Q

What patients should be referred for genetics?

A
  • Triple negative < 60 years
  • Any breast cancer < 50
  • Family member BRCA+
  • Multiple breast primaries
  • Male breast cancer
  • 1+ blood relative with breast ca <50y
  • 1+ blood relative with ovarian ca
  • 2+ blood relatives with breast or panc ca
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81
Q

What is risk of Br cancer with BRCA

A

50%

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82
Q

What is risk of ovarian ca with BRCA

A

25%

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83
Q

How much does prophylactic b/l mastectomy and BSO reduce breast and ovarian cancer risk for BRCA?

A

90%

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84
Q

What is alternative to bilateral mastectomies and BSO

A

BCS+RT

Prophylactic TAH/BSO

Tamoxifen for contralateral risk reduction by 30-40%

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85
Q

How do outcomes for women with BRCA compare to non BRCA

A

same

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86
Q

Tis breast

A

DCIS

LCIS

Pagets

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87
Q

T1 breast

A

<2 cm

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88
Q

T2 breast

A

2.1-5 cm

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89
Q

T3 breast

A

>5 cm

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90
Q

T4a breast

A

chest wall (not including only pec muscle alone)

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91
Q

T4b breast

A

Edema/ peau d’orange

Ulceration

Ipsilateral satellite skin nodules

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92
Q

T4c breast

A

T4a (chest wall)

and

T4b (edema, ulceration, skin nodules)

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93
Q

T4d breast

A

inflammatory

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94
Q

cN1 breast

A

Ipsi, mobile axillary I/II

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95
Q

cN2a breast

A

Ipsi fixed level I/II

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96
Q

cN2b breast

A

IMN only

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97
Q

cN3a breast

A

Ipsi level III (IMN) with or without level I/II

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98
Q

cN3c breast

A

Ipsi SCV

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99
Q

pN1mic

A

>0.2 mm but < 2mm

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100
Q

pN1a breast

A

1-3 nodes

At least one with met > 2mm

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101
Q

pN1b breast

A

IMN+ only by SLNBx

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102
Q

pN1c

A

N1a (1-3 axillary nodes)

and

N1b (IMN detected via SLNBx)

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103
Q

pN2a

A

4-9 LN

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104
Q

pN3a

A

>10 LN

or Level III involvement

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105
Q

pN3b

A

clinically detected IMN and axillary nodes

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106
Q

pN3c

A

ipsi SCV nodes

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107
Q

Stage IA

A

T1N0

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108
Q

Stage IB

A

T1N1mic

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109
Q

Stage IIA

A

T1N1 or T2N0

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110
Q

Stage IIB

A

T2N1 or T3N0

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111
Q

Stage IIIA

A

T3N1 or T1-3N2

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112
Q

Stage IIIB

A

T4N+

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113
Q

Stage IIIC

A

N3

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114
Q

How to determine if pec invasion vs. CW invasion

A

If on flexing mass is fixed but mobile on relaxing then pec only

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115
Q

What conditions are inoperable?

A

arm edema

satellite skin nodules (T4b)

SCV disease

Inflammatory (T4d)

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116
Q

Interpretation of IHC for Her2 on core bx

A

If 1+ –> negative

If 3+ –> positive

If 2+ –> get FISH

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117
Q

Which cases require SLNBx

A
  • All invasive carcinoma
    • UNLESS clinically positive axilla –> Ax Dissection of levels 1 and 2
  • DCIS getting mastectomy
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118
Q

If SLNBx is positive, which cases can ignore axillary dissection

A
  • T1 or T2
  • Clinically node negative
  • 1 or 2 SLN positive
  • BCT and WBRT planned
  • No neoadjuvant chemo
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119
Q

Absolute contraindications to BCT

A
  • PREGNANCY
  • Diffuse or suspicious microcalcs
  • widespread breast disease that cannot be resected through single incision that achieves neg margins with acceptable cosmesis
  • Positive path margin
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120
Q

Relative contraindications to BCT

A
  • Prior RT to chest wall or breast
  • Active connective tissue disease involving skin (scleroderma)
  • Tumors >5 cm
  • Focally positive margin (tumor at margin in 3 or fewer LPFs)
  • Women with known or suspected predisposition to breast cancer (i.e., BRCA)
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121
Q

OUTCOMES

Stage I

A

<5% local failure

95% OS at 8 years

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122
Q

OUTCOMES

Stage II/III

A

<10% LF at 5 years

<30% BC mortality at 15 years per EBCTMA

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123
Q

How does outcome compare for ILC vs IDC

A

similar

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124
Q

What is prognosis of micromets

A

between pN0 and pN1

0.2 mm to 2 mm

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125
Q

Risk of skin tox

A

30-50%

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126
Q

Risk of late cosmesis issues

A

20%

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127
Q

Risk of pneumonitis

A

Tangents: <1%

3 field: 3%

RT + ACT: 9%

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128
Q

Risk of cardiac toxicity

A

1-4% (depends on dose, approach, LAD dose, chemo)

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129
Q

What is the relative risk of cardiotoxicity for breast RT

A

Increase of 7% for each mean heart dose increase of 1 Gy

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130
Q

Risk of lymphedema with tangents and SLNBx

A

5%

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131
Q

Risk of lymphedema with tangents and RNI`

A

10%

132
Q

Risk of lymphedema with ALND

A

10%

133
Q

Risk of lymphedema with ALND + tangent RT

A

15-20%

134
Q

Risk of lymphedema with ALND and RNI

A

25%

135
Q

What is overall complication rate after PMRT

A

30%

136
Q

When should mammo be performed after breast RT

A

4-6 months

Then annually

137
Q

If patient is on tam, what needs to be scheduled?

A

annual gyn exam

138
Q

If patient is on AI, what needs to be scheduled

A

assessment of bone density

139
Q

What class of medication is tamoxifen

A

SERM - binds to estrogen receptor and blocks estrogen binding

140
Q

What is the dose of tamoxifen?

A

20 mg qd

141
Q

What is the benefit of tamoxifen for invasive disease

A

5-10% OS benefit

Reduces local failure as well

142
Q

What is benefit of tamoxifen for DCIS

A

Small absolute reduction of 3%

Decreases risk of ipsilateral recurrences and in situ recurrences

Decreases incidence of ipsilateral new breast events - no effect on contralateral disease

143
Q

Side effects of Tamoxifen

A
  • Hot flashes
  • Vaginal atrophy and bleeding 5-10%
  • Thromboembolic events 2-5%
  • Rare risk of endometrial ca
  • Decreased bone fracture risk
144
Q

What class of meds given to women postmenopausal with HR+ cancers

A

aromatase inhibitors

Blocks androgen to estradiol conversion

145
Q

Common AI medication

A

anastrozole 1 mg daily

146
Q

AI side effects

A

Osteoporosis

Joint pain

Fractures (5-7%)

147
Q

What is the benefit of chemotherapy for premenopausal women?

A

10-15% OS benefit at 15 years

148
Q

What is the benefit for chemo for post menopausal women?

A

5% OS benefit at 15 years

149
Q

What is Oncotype

A

21 gene assay developed and validated from NSABP studies to predict risks of distant recurrence with Tam alone (and thus benefit of adjuvant chemo)

150
Q

Which patients should get oncotype?

A

T1, T2

N0

ER/PR+

Her2-

151
Q

What is considered low risk for Oncotype?

A

1-18

152
Q

What is considered intermediate risk Oncotype

A

19-30

153
Q

What is considered high risk Oncotype

A

>30

154
Q

What is the common breast cancer chemo regimen?

A
  • AC x 4 –> Tx4
    • AC
      • Dose AC q3 weeks if normal
      • Dose AC q2 weeks if dose dense
    • T
      • Dose T q2 weeks x 4
      • T weekly x 12 weeks
155
Q

What is ACT

A

Adriamycin

Cytoxan

Paclitaxel

156
Q

What is the advantage of dose dense chemo

A

Increased efficacy

157
Q

Doses of ACT

A

Adriamycin: 60 mg/m2

Cytoxan: 600 mg/m2

Paclitaxel: 175 mg/m2 (q2w) or 80 mg/m2 (q1w)

158
Q

What is the chemo regimen for to avoid adriamycin

A

Docetaxel

Cytoxan

or Docetaxel Carboplatin

159
Q

What is the chemo regimen for HER2+

A

AC –> THP

160
Q

How long shoudl patients be on Herceptin?

A

1 year

161
Q

What is benefit of Herceptin

A

Decreased recurrence, increased survival

162
Q

What monitoring is needed for women on herceptin

A

Cardiac monitoring

Baseline, 3, 6, 9 months

163
Q

What is main side effect of ACT

A

myelosuppression

hair loss from adria

cardiotox from adria

164
Q

What is a radical mastectomy?

A

Breast including skin

Areola/nipple

Pec Major and Pec minor

Levels I-III

165
Q

What is a modified radical mastectomy?

A

Removes breast and skin, nipple, areola

Removes level I and II

Spares pec muscle

166
Q

Total mastectomy

A

AKA simple

Spares pec and nodes

167
Q

Which patients get simple mastectomies

A

DCIS

prophylactic for risk reduction

168
Q

Skin sparing mastectomy

A

Removes biopsy scar, skin over tumor, nipple-areolar complex, breast parenchyma

169
Q

Quadrantectomy

A

Tumor + 1.5-2 cm with overlying skin and deep muscle fascia

170
Q

SLNBx accuracy

A

90-95%

171
Q

What is the false neg rate for a SLNBx

A

5-15%

172
Q

Which patients cannot get SLNBx

A

Clinically positive axilla (should get dissection)

Inflammatory

T4

173
Q

Which patients need AXLND

A
  • Clinically LN+
  • 3+ SLNBx
  • T4+
  • Inflammatory
174
Q

If the patient has an axillary dissection, what does that mean for Ax RT

A

Typically do not need to cover levels I and II

175
Q

After ax dissection, which women should have coverage of level I and II with RT

A

Gross ECE

Extranodal tumor deposits

Inflammatory

176
Q

What is the concern with LCIS

A

Marker of bilateral breast cancer, 9x risk of BC in both breasts

177
Q

What is best management of classic LCIS

A
  • If core needle biopsy only –> surgical excision
    • If just LCIS –> observe or chemoprevention
    • If DCIS/invasive –> manage per those pathways
  • Can consider Tam for chemoprevention
    • Can consider bilaterral prophylactic mastectomy
178
Q

What to do if LCIS margins positive after lumpectomy

A

No need to re-excise

179
Q

Which women should consider prophylactic bilateral mastectomies for LCIS?

A

Young with strong FHx

Genetic predisposition

180
Q

What is the risk of DCIS transformation to invasive cancer at 10 years

A

30%

181
Q

Types of DCIS

A

Comedonecrosis

Solid

Cribiform

Papillary

Medullary

182
Q

Which is the most aggressive type of DCIS

A

comedo

183
Q

What are high risk factors for DCIS

A
  • Close/positive margins (<2 mm)
  • Age <40
  • Grade
  • Size > 4cm
  • Comedonecrosis
  • Multifocality
184
Q

What questions should we ask about path specimen for DCIS

A

Size

Margin status

ER+

Grade

Extensiveness in sample

185
Q

What is extensive intraductal component?

A

25%+ of primary tumor is DCIS and DCIS is present in normal breast tissue

186
Q

Core biopsy shows LCIS or ADH, what is the next step?

A

Excisional biopsy or lumpectomy because 20% will be associated with DCIS

187
Q

Do women with DCIS need genetics consultation?

A

Yes, same guidelines as invasive

age <50

FHx of BRCA

1+ family member with young breast cancer

188
Q

What are the broad treatment options for DCIS?

A
  • Lumpectomy w/o SLNB –> post excision mammo –> WBRT +/- boost –> endocrine therapy if ER+
  • Total mastectomy + SLNB –> endocrine if ER+
  • Lumpectomy –> observation
  • Lumpectomy –> APBI –> endocrine therapy if ER+
189
Q

If woman with DCIS opts for mastectomy, what type?

A

Total mastectomy

No ALND

Do a SLNB in case invasive

190
Q

DCIS woman opts for BCT, what to do if margin < 2mm

A

Re-resection

191
Q

DCIS woman as persistently positive margin or cannot achieve good cosmesis, next step

A

total mastectomy

192
Q

What is the RT approach for DCIS after lumpectomy?

A

Whole breast RT +/- boost

Hypofractionated (2.66 x 16 = 42.6 Gy)

Boost of 250 x 4 = 10 Gy

193
Q

Which women should get boost after DCIS

A

Age < 50

Close/positive margin

High grade

194
Q

What is the advantage of boost

A

Local control benefit (3%)

195
Q

What is the downside of a boost for DCIS

A

Increased toxicity (fibrosis, telangiectasia)

196
Q

Patient is ER+, what else could be done?

A

Chemoprevention

  • Tamoxifen (20 mg qd) x 5 years
  • Anastrozole (1mg qd) x 5 years if POSTMENOPAUSAL and <60 years old
197
Q

What is the benefit of RT after lumpectomy for DCIS?

A

Reduces ipsilateral breast events by 50%

No OS benefit

198
Q

What is the ipsilateral recurrence risk after DCIS?

A

Low-Risk: 1% per year

High-Risk: 2% per year

Half of recurrences will be DCIS and half will be invasive

199
Q

What is the “good risk” DCIS criteria?

A
  • Mammogram detected disease
  • Size <2.5 cm
  • Margins >3mm
  • Low or intermediate grade
  • NOT AGE
200
Q

Which women could be considered for obs after lumpectomy for DCIS

A

Good risk profile

Need to council on 1% annual risk of ipsi breast events

So older age more suitable

Willing to take 5 years Tam if ER+

201
Q

What patients are suitable for APBI after lumpectomy for DCIS

A
  • Age >50
  • Screen detected DCIS
  • Low intermediate grade
  • Size < 2.5 cm
  • Margins >3 mm
  • ER+
  • No LVSI
202
Q

If offering APBI, what is the dose?

A

6 Gy x 5 QOD

203
Q

What is the best approach to deliver APBI

A

Fixed field IMRT

204
Q

What is the approach to contour for APBI

A
  • Contour lumpectomy cavity
  • Expand by 1.5 cm to make a CTV
    • Carve back to 5 mm from skin surface
    • Bring off chest wall/pec/non breast tissue
  • Expand by 5 mm to make a PTV and pull back 5 mm from skin
205
Q

What is the objective for PTV of APBI with respect to rest of the breast?

A

Should not exceed 30-35% of whole breast volume

206
Q

What is the constraint for nontarget breast for APBI?

A

No more than 50% of nontarget breast getting 50% of dose

207
Q

What needs to happen after lumpectomy for DCIS?

A

post lumpectomy mammo

Mag views

Specimen mammo

208
Q

What is the advantage of tamoxifen above lumpectomy+RT in DCIS?

A

Improves LR by 3%

209
Q

If woman getting tamoxifen or AI, when should it start with respect to breast RT?

A

1 week later

210
Q

What stages should be managed as early stage invasive?

A

T1-3

N0-1

211
Q

How to manage N1mic

A

“Soft N1”

Can consider a high tangent but no need for SNI

Don’t necessarily need chemo if Oncotype low

But don’t do PBI

212
Q

What are the treament options for early stage invasive carcinoma?

A
  • Lumpectomy + nodal eval –> chemo if indicated –> RT –> hormones if indicated
  • Total mastectomy + SLNBx +/- ALND –> chemo if indicated –> RT if indicated –> hormones if indicated
  • Lumpectomy + SLNBx –> Tamoxifen but no RT
213
Q

What is acceptable lumpectomy margin for invasive

A

No tumor on ink

214
Q

What is the appropriate strategy for nodal evaluation for early invasive

A
  • If cN1 –> FNA
    • If positive –> ALND
    • If negative –> SLNBx
    • If preop chemo given
      • If still cN+ –> ALND
      • If cN- –> SLNBx (but ensure 3 nodes removed, clipped node removed, dual tracer study)
  • If cN0 –> SLNBx
215
Q

How to manage early invasive if SLNBX negative

A
  • No ALND
216
Q

How to manage early invasive if SLNB shows micromet

A

No ALND

217
Q

How to manage early invasive if SLNBx positive

A
  • Can exclude ALND if
    • T1/T2
    • cN0
    • 1 or 2 positive nodes
    • Non matted nodes
    • Planned for adjuvant RT
    • No prior neoadjuvant chemo
  • Otherwise –> ALND
218
Q

Which early patients should get adjuvant chemo?

A
  • If N+ –> all should get chemo
  • If Node negative, depends on histology
    • ER/PR+, HER2- :
      • <0.5 no chemo
      • >0.5 use Oncotype
    • TNBC: >0.5 cm
    • Any Her2+: >0.5 cm
219
Q

What Oncotype scores need adjuvant chemo

A
  • Age > 50: Oncotype >25
  • Age < 50: Oncotype >15
220
Q

What is the chemo regimen for Her2- tumors

A

ddAC (4 cycles, q2 weeks)

Taxol (4 cycles q2 weeks)

or: cytoxan + docetaxel if cardiotox

221
Q

What is the chemo regimen for Her2+

A

AC (4 cycles q3w)

Taxol (80 mg/m2, q1w) with weekly Herceptin

Continue herceptin x 1 year total

If concern about cardiotox: docetaxel, carboplatin, herceptin

222
Q

When should XRT begin after adjuvant chemo

A

1 month

223
Q

Which early stage patients should be offered hypofrac

A

All, unless covering nodes

224
Q

What is acceptable MPD for breast tangents?

A

<110%

225
Q

What the homogenity goal for breast tangents

A

Vol 105% < 10-15%

226
Q

What is RT field if SLNB is negative

A

Breast tangents only

Tumor bed boost

Consider APBI if meeting criteria

227
Q

Are there any pN0 patients who should get RNI?

A

Consider for high risk patients

  • T3 tumors
  • Medial tumors
  • Young age
  • Extensive LVSI
228
Q

Which patients can we consider for APBI?

A
  • Age > 50
  • Tumor < 2 cm
  • Negative margins
  • ER+
  • Any grade
  • No LVSI
  • N0
  • No BRCA
  • Only low risk DCIS
229
Q

What is the RT field if 1-3 positive nodes?

A
  • Most will get RNI
    • If patient had Ax Dissection - Cover Level III + SCV + IMN
    • If not Z11 candidate and no Ax Dissection - Cover levels I-III + SCV + IMN
    • If prior Ax Dissection - cover level I/II only if ECE, high burden of nodal disease
  • If meeting criteria for Z11 consider WBRT or high tangents
230
Q

RT fields if 1-2 positive sentinel nodes

A
  • If Z11 candidate (cT1, ER+, no LVSI)
  • Consider WBRT plus high tangent (sup border is inferior humeral head)
  • If not Z11 candidate or other higher risk features (2+ nodes, young, LVSI, ER neg etc.)
  • Should get WBRT + RNI
231
Q

What is the RT field if 4+ nodes for early disease?

A

Whole breast RT + boost

RNI

232
Q

Indications to intentionally cover the axilla after ALND

A

Gross ECE

>50% nodal ratio

<10 LN resected

233
Q

Which patients do not need breast boost?

A

Age >70

ER+

Low/low intermediate grade

Widely negative margins (>2 mm)

234
Q

What is the benefit of RT after lumpectomy?

A

4% improvement in OS

235
Q

If cN0 how often is SLNB positive?

A

30-40%

236
Q

If patient opts for mastectomy, how should axilla be assessed?

A
  • Start with SLNB
    • If negative can stop
    • If positive –> ALND
237
Q

What are the indications for PMRT?

A

At least 1 positive node

Positive margin

Maybe T3N0

238
Q

What is the PMRT field for T3N0 or T2 with positive margin

A

If everything else is favorable (ER+, no LVSI, low grade, older patient) then can consider treating CW only (not RNI)

239
Q

For which early stage patients can adjuvant RT be excluded?

A
  • Age >70
  • T1N0
  • ER+
  • Negative margin
  • Willing to take 5 years tam
  • Willing to accept higher local recurrence risk
240
Q

What is the rate of local recurrence if RT is omitted after lumpectomy

A

1% per year

241
Q

What is the boost dose?

A
  • If negative margin
    • 250 x 4 = 1000
    • 200 x 5 = 1000
  • If positive margin
    • 200 x 8 = 1600
242
Q

If a woman has T1-3N0-1 disease but cannot get BCT due to size, what is the best plan

A
  • Do a core needle biopsy with placement of an imaging marker if not already done
  • If clinically negative axilla
    • Axillary ultrasound
    • Sample suspicious nodes by FNA and place clips
  • If clinically positive axilla
    • Sample suspicious nodes with FNA and place clips
  • Give neoadjuvant systemic therapy
243
Q

What is the preferred treatment strategy for stage III breast cancer

A
  • Ultrasound for concerning nodes–> place clips for primary and nodes
  • Neoadjuvant chemo as guided by markers
  • Mastectomy or BCS
  • RT as guided by risk profile
  • Adjuvant endocrine +/- Her2-directed therapy
244
Q

If a patient is cN+ and has clips placed how is axilla managed after NAC

A

ALND

245
Q

How is the RT decided if patient received NAC

A

Treat as if they went straight to surgery

246
Q

If patient got NAC and had BCS, what are the treatment fields?

A
  • If cN0, ypN0 –> tangents
  • If cN+, ypN0 –> tangents + RNI
  • If cN+, ypN+ –> tangents + RNI
247
Q

What is the dose for PMRT

A

50 Gy in 25 fractions of 2 Gy

Boost of 200 x 5 = 10 Gy (neg margins)

Boost of 200 x 8 = 16 Gy (positive margins)

248
Q

How to treat SCV or IMN which are not resected?

A

Boost to 60 Gy if any response to chemo

Boost to 66 Gy if no response to chemo

249
Q

what is pCR rate of neoadjuvant AC-TH for Her2+ tumors

A

50-60%

250
Q

What is the PTV margin on affected nodes?

A

5 mm

251
Q

What other workup does stage III BC need?

A

CT CAP

Bone scan or PET

MRI brain if symptoms

252
Q

After neoadjuvant chemo for TNBC ypT1-T4 or ypN1 what else should be considered?

A

6 months of capecitabine

253
Q

What is the dose of capecitabine for TNBC?

A

1250 mg/m2 BID

Days 1-14

q3w cycles

254
Q

If residual disease after neoadjuvant AC-TH(P) for Her2+, what is next step?

A

T-DM1 for 14 cycles

255
Q

If CR to neoadjuvant AC-THP for Her2+ BC, what is adjuvant therapy

A

Complete 1 year of herceptin and/or pertuzumab

256
Q

What is the diagnostic criteria for inflammatory breast cancer?

A
  • It is a clinical diagnosis of symptoms which occur RAPIDLY in preceeding 3-6 months
    • Erythema
    • Peau d’orange covering >1/3 of breast
    • Ridging (palpable border of erythema)
    • Path confirmation of breast cancer
257
Q

What is the stage of inflammatory breast cancer

A

cT4d

258
Q

What is the workup for inflammatory BC?

A
  • First check diagnostic bilateral mammo/ultrasound
    • If abnormal node or mass –> bx to confirm BC
  • If none, consider MRI breast
    • If abnormality –> biopsy
  • If no other findings do a full thickness skin biopsy
    *
259
Q

Does BC need to be in skin to confirm IBC?

A

No, but do need some path confirmation of breast cancer before proceeding to chemo

260
Q

What additional workup does IBC need?

A

CT CAP or PET

261
Q

What is the general treatment approach to inflammatory BC?

A
  • Neoadjuvant chemo
  • Modified radical mastectomy and ALND
  • PMRT + RNI
  • Endocrine therapy ER+
262
Q

If there is limited response to neoadjuvant chemo for IBC what is the next step?

A

Consider either switching chemo or pre-op RT (bolus every day)

263
Q

What is the reconstruction option for IBC?

A

No immediate reconstruction

264
Q

What is the dose of RT for IBC

A

If pCR to NAC –> 50 Gy in 25 fractions to CW and RNI

If boost scar + 3 cm to 60 Gy

If really bad response or +margin –> boost to 66 Gy

265
Q

What bolus should be used for IBC?

A

0.5 cm bolus DAILY

Should consider continuing even if moist desquamation

266
Q

What does Paget’s disease look like?

A

Nipple or areola involvement of tumor, usually from underlying carcinoma

Presents as crusting or eczema, ulceration, bleeding or itching

267
Q

What percentage of Pagets of breast will have palpable mass

A

50%

268
Q

What is the workup for Pagets of breast

A

Full thickness skin biopsy of nipple and bx any other underlying lesion

269
Q

If found to have underlying breast lesion (DCIS or invasive) how should Paget’s be managed

A

Treat as underlying condition

Lumpectomy needs to resect nipple/areolar

270
Q

If the breast is negative but nipple is positive, what are the options

A
  • Lumpectomy but removing nipple areola complex –> SLN –> WBRT
  • Total mastectomy +/- SLN
271
Q

Approach to BrCa in First Trimester

A
  • Discuss termination
  • Mastectomy + axillary staging
  • Begin adjuvant chemo in 2nd trimester
  • Consider adjuvant RT postpartum
  • Consider adjuvant endocrine therapy postpartum
272
Q

Approach to BrCa in 2nd trimester

A
  • Mastectomy or BCS + axillary staging
    • Adjuvant chemo
    • +/- adjuvant RT and endocrine therapy postpartum
  • Neoadjuvant chemo–> surgery, RT, endocrine therapy postpartum
273
Q

What is the chemo used for pregnancy?

A

Doxorubicin

Cyclophosphamide

Fluorouracil

274
Q

When should RT be used during pregancy

A

NEVER

275
Q

How should axilla be staged during preganncy

A

Only ALND

No SLN dye or radiation

276
Q

How to workup recurrent breast cancer?

A

Imaging - mammo/US/MRI

Consider systemic imaging

277
Q

Treatment options for in breast recurrences

A
  • If initial treatment was BCS+RT
    • Total mastectomy + ALND and consider systemic therapy
  • If initial treatment was mastectomy + PMRT
    • Surgical resection if possible and consider systemic therapy
  • If initial treatment was mastectomy
    • Surgical resection and RT (CW+RNI)
278
Q

How to approach axillary recurrence

A

Surgical resection if possible

+ RT to CW + RNI if possible

279
Q

How to approach SCV reccurence

A

Radiation if possible, respecting total MPD of 60-66 Gy to brachial plexus

Consent to plexopathy

280
Q

How to approach IMN recurrence

A

RT if possible to CW and RNI

281
Q

If required to do reRT what dose should be used?

A

45 Gy in 1.5 BID fractions (30 fractions)

282
Q

How to simulate breast patient – SUPINE

A
  • Supine immobilized in an alpha cradle or on a breast board
  • Arms up
  • Ipsidalteral arm abducted and externally rotated
  • Turn patient’s head and neck facing away from the breast we are treating
  • Wire the estimated field borders and any surgical scars
  • CT simulation w/o contrast
  • Consider DIBH if left sided tumor
283
Q

Where to place wires for tangents?

A

Inferior aspect of SCV head

2cm inferior to inframammary fold

Mid axillary line (~2 cm beyond breast tissue)

Midline sternum

If post-mastectomy, wire scar, drains

284
Q

What is the RT approach for WBRT?

A

Conventionally opposed wedged tangents to whole breast

285
Q

How to approach setting tangents for WBRT

A
  • Set the medial tangent first using wired landmarks as a guide to confirm no overlap with the contralateral breast
  • Next, match a lateral tangent
  • Rotate the gantry to create a non-divergent back border (half beam block)
  • Collimate to align with the chest wall in the sagittal plane with goal to have <2cm of lung
  • Top of field at axillary vessels
  • Anterior border is 2 cm flash
  • Inferior border is 2 cm inferior to inframammary fold
286
Q

Superior border of normal tangent field

A

axillary vessels (inferior clavicular head)

287
Q

Superior edge of high tangent field

A

Humeral head

288
Q

Where is the isocenter for breast tangents

A

Typically set at midline and midaxilla which become “reference isos”

These are shifted to a virtual iso within the breast which determines the calc point

Virtual iso is 5 mm above lung/breast inferface

289
Q

Any special tangent considerations for left sided breasts

A

Utilize DIBH or heart block to minimize cardiac exposure

290
Q

What is acceptable V105 for tangent

A

<10%

291
Q

What is acceptable hotspot for breast tangent

A

<107-110%

292
Q

What are strategies to minimize hot spots

A

Wedges

Field in field

IMRT

293
Q

Where is hotspot in underwedged tangent field?

A

narrow, anterior portion of the breast

294
Q

Where is the hotspot in an overwedged tangent field

A

Two posterior corners

295
Q

What is the lumpectomy GTV?

A

Cavity + archiectural distortion + seroma + clips

296
Q

Lumpectomy CTV expansion

A

1 cm excluding pec major and 5 mm in from skin

297
Q

Lumpectomy CTV to PTV expansion

A

5 mm excluding heart

298
Q

How should the boost be planned?

A

Direct en face electrons prescribed to 85-90% IDL

299
Q

What is the formula for electron energy for boost

A

E/3

300
Q

What is the preferred setup if RNI is being performed

A

Monoisocentric technique

301
Q

Strategies for boost if breast cavity is too deep for electrons

A

Switch to mini tangents

302
Q

Ipsilateral lung constraint for tangent

A

V20 < 15% (normal tangent)

V20 < 20% (high tangent)

303
Q

Ipsilateral lung constraint for 3 field

A

V20 < 30-35%

304
Q

Heart constraint

A

Mean heart dose ALARA, ideally mean of 1-2 Gy but can go up to 4-5 Gy if treating IMNs

305
Q

What is the V20 goal to heart for L sided breast cancer

A

<5%

306
Q

Ways to reduce heart dose if needed

A

Change gantry and collimator angles

Sim prone

Mixed field approach (electrons/photons)

DIBH

IMRT

307
Q

Describe approach for PMRT or RNI

A
  • Attempt to use 3 fields including 2 breast tangents and a SCV field
  • Set the isocenter at the match line which is the superior edge of the trangent field and the inferior border of the SCV field - usually below clavicular head midway between medial and lateral tangent border
  • Contour the levels I, II, III and SCV nodal volumes
  • First set the SCV field
    • Anterior oblique field
    • Half beam block inferiorly at the match line
    • Angle anterior oblique field off cord 10-15 degree to avoid esophagus and cord
    • Use MLCs to block humeral head
  • Next set tangent fields
    • Half beam block at match line
    • Flash breast 2 cm
    • Use MLCs to block lung and heart if left sided
308
Q

What is the superior border of SCV field

A

cricoid

309
Q

What is the inferior border of SCV field

A

Inferior edge of clavicular head

310
Q

What is the medial edge of SCV field

A

Vertebral bodies

Avoid thyroid

311
Q

Lateral edge of SCV field

A

Lateral to humeral head if high risk

Coracoid process if lower risk

312
Q

What is the limitation of monoiso technique

A

Tangent field can only be 20 cm, so if taller, need dual isocenter technique

313
Q

For dual isocenter technique - what is necessary strategy?

A

Kick couch AWAY from the gantry

314
Q

What are the options to cover IMN nodes?

A
  • Partially wide tangents - include IMN in 1st-3rd interspaces and then use blocks to cover heart and lung lower down
  • If unable to cover in tangent use electron strip
315
Q

How to approach IMN for setting electron field

A

Start by contouring IM vessels

Add 1 cm expansion for CTV

Match electron field to my shallower tangent field

316
Q

Which patients should have SCV field extend to medial edge of humeral head

A

Not fully dissected axilla

SLN+ only

N+ with ECE

High nodal ratio

317
Q

Hypofractionation dose

A

42.5 in 16 fractions

318
Q

Describe approach to setting up tangent beams

A
  • Start with medial tangent, adjust gantry so off the contralateral breast but good coverage of ipsi breast without significant lung
  • Top of field should be axillary vessels or inferior head of clavicle
  • Use collimation to align field with CW and minimize lung in sagittal plane (<2 cm maximum)
  • Oppose the field with a lateral beam and ensure non divergent into lung
  • Set calc point 5 mm above the breast/CW interface midway in the breast
319
Q

Approach to 3 field/RNI

A
  • Attempt to approach using a monoisocentric technique
  • FIRST CONTOUR nodal areas of levels I-III, SCV, IMN
  • Set the SCV field
    • Superior- cricoid
    • Inferior- Inferior edge of clavicular head
    • Lateral - either coracoid process (if dissected axilla) or lateral to humeral head (if undissected axilla)
    • Medial - adjacent to vertebral pedicles
  • Angle SCV AP field 10-15 degrees to avoid esophagus and cord
  • Set SCV field blocks
    • small triangular block to block vertebral bodies
    • Block AC joint
    • Block partial humeral head as tolerable
    • Inferior half beam block
  • Set calc point to depth of 3 cm
  • Evaluate coverage and if suboptimal, consider adding PAB
  • Set tangents
    • Use MLCs to block heart and lungs since collimation
320
Q

Where to set calc point for SCV field

A

3 cm depth

321
Q

Borders of a PAB

A
  • Superior: Bisecting the clavicle
  • Inferior: SCV match line
  • Medial: Inside chest wall, including 1 cm of lung
  • Lateral: block humeral head
322
Q

How much does PAB contribute

A

30-60 cGy per day

323
Q

Options for IMN field

A
  • Partial wide tangents
  • Matching electron field with shallower tangents
324
Q

What is the angle of the IMN field

A

5 degrees less than medial tangent

325
Q
A

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