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
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)
3
Q
How should women with prior thoracic RT get screened for BC?
A
- Annual mammogram and.or MRI
4
Q
The axillary regions are defined with respect to what landmark?
A
Pec minor
5
Q
Where does pec minor insert?
A
coracoid process
6
Q
where does pec minor connect to?
A
Ribs 3-5
7
Q
How to define Level I axilla
A
Inferior and lateral to pec minor
8
Q
How to define Level II axilla
A
Beneath pec minor
9
Q
How to define level III axilla?
A
superior and medial to pec minor
10
Q
Superior edge of SCV field
A
below cricoid cartilage
11
Q
Inferior edge of SCV field
A
caudal edge of clavicular head
12
Q
Anterior edge of SCV field
A
SCM muscle
13
Q
Posterior edge of SCV field
A
Anterior aspect of scalene muscle
14
Q
Lateral edge of SCV field
A
Cranial: lateral edge of SCM
Caudal: junction of clavicular head and 1st rib
15
Q
Medial edge of SCV field
A
Excludes thyroid and trachea
16
Q
Superior edge of level I
A
Axillary vessels cross lateral edge of pec minor
17
Q
Inferior edge of Level I axillary field
A
Pec major inserts into ribs
18
Q
Anterior edge of level I axilla
A
Anterior surface of pec major and lat dorsi
19
Q
Posterior border of level I axilla
A
Anterior surface of subscapularis muscle
20
Q
Lateral border of level I axilla
A
medial edge of lat dorsi
21
Q
Medial edge of level I axilla
A
lateral edge of pec minor
22
Q
Superior edge of Level II axilla
A
Axillary vessels cross medial edge of pec minor
23
Q
Inferior edge of level II axilla
A
Axillary vessels cross lateral edge of pec minor
24
Q
Anterior border of level II axilla
A
Anterior surface of pec minor
25
Posterior border of Level II axilla
Ribs and chest wall
26
Lateral border of level II axilla
Lateral border of pec minor
27
Medial border of level II axilla
medial border of pec minor
28
Superior border of level III axilla
Pec minor inserts to coracoid
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29
Inferior border of level III axilla
Axillary vessels cross medial edge of pec minor
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30
Anterior edge of level III axilla
posterior surface of pec major
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31
Posterior edge of level III axilla
Ribs and intercostal muscles
32
Lateral edge of level III axilla
Medial border of pec minor
33
Medial edge of level III axilla
Thoracic inlet ![]()
34
Superior edge of IMN field
Superior aspect of medial 1st rib
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35
Inferior aspect of the IMN field
Top of 4th rib
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36
What is the markers of Luminal A
ER/PR+
HER2-
Low Ki-67
37
What is the marker profile of Luminal B?
ER/PR+
HER2+ or HER2-
High Ki-67
38
Marker profile of basal breast cancers
Triple negative
39
How is Her2+ defined?
IHC 3+
FISH amplification of at least 2
40
How is extensive intraductal component defined?
DCIS \> 25% of specimen
41
Rate of LR if extensively positive margin?
27%
42
Rate of LR if focally positive margin
8-15%
43
How is positive margin defined for invasive BC?
no tumor on ink
44
What is the ramification of positive margin per ASTRO consensus
\>2 fold increase in IBRT, not overcome by boost, chemo or subtype
45
What is the definition of negative margin for DCIS
\>2 mm
46
If LCIS is found at margin of surgical specimen, what is next step?
no need for re-excision
47
Patient comes with concern on screening mammo, what history should be asked?
* 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
48
What is the typical breast physical exam
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
49
Patient comes with concerning mammo, what should you ask about?
Prior mammos
50
What does a CC mammo stand for
Craniocaudal
51
What does a CC mammo show?
Inner or outer quadrants ![]()
52
How to tell medial from lateral on CC mammo?
Convention is that top is lateral
CC marker is placed on lateral
Clip in axilla
53
How can you tell a good CC image
Nipple should be present
54
What does MLO mammo stand for?
Medial lateral oblique
55
What does MLO show?
Superior (upper) or Inferior (lower)
56
What dictates a good MLO image?
Visualize inframammary fold
Visualize pec major
57
How to tell sup/inf on MLO scan
Pec major is sup
convention is superior on top
58
BIRADS 0
Incomplete
Perform spot compression, mag views or US ASAP
59
BIRADS 1
Negative
60
BIRADS 2
Benign finding
61
BIRADS 3
Probably benign --\> new mammo in 6 months
2% risk of malignancy
62
BIRADS 4
Suspicious abnormality --\> biopsy recommended
3-95% risk
63
BIRADS 5
Highly suggestive of malignancy - perform bx right away
\>95% risk
64
BIRADS 6
Biopsy proven malignancy
65
What is the imaging workup for abnormal screening mammo
Send for diagnostic mammo and US
Digital breast tomo
Breast MRI as needed
66
What kind of extra imaging needed for spiculated mass
compression views
67
What kind of mammo imaging needed for suspicious calcs
magnification view
68
What type of calcs are more likely to be malignant
finer, granular
linear, branching
pleomorphic
69
How do tumors looks on Ultrasound
hypoechoic mass with uneven borders and posterior shadowing
70
What is the best workup approach to a palpable mass
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
71
If there is no palpable mass and unable to visualize mass on US, what is the best biopsy approach
Stereotactic guided core needle biopsy with clip placement (especially if small lesion that could be removed with biopsy or with neoadjuvant chemo)
72
Surgical approach if there is DCIS in biopsy
* 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
73
What if lesion is very close to CW or difficult to visualize calcs
Stereotactic wire-localized excisional biopsy
74
What if core biopsy shows atypical ductal hyperplasia?
Needle-localized excision with specimen mammo
Referral for possible tamoxifen
Ensure DCIS has been adequately removed (at least 2 mm margins)
75
How should suspicious nodes be handled?
US-guided FNA, especially if neoadjuvant chemo planned
76
What labs should be drawn for breast cancer?
CBC
CMP
LFTs
_PREGNANCY TEST_
77
If T3N1 or greater also consider getting what imaging?
CT CAP
PET or bone scan
78
What other studies should be obtained?
A few could be obtained as guided by symptoms:
CT imaging
MRI brain
Bone scan if sx or elevated alk phos
79
What other referrals should be potentially made?
Fertility if young woman
Genetics if meeting criteria
80
What patients should be referred for genetics?
* 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
81
What is risk of Br cancer with BRCA
50%
82
What is risk of ovarian ca with BRCA
25%
83
How much does prophylactic b/l mastectomy and BSO reduce breast and ovarian cancer risk for BRCA?
90%
84
What is alternative to bilateral mastectomies and BSO
BCS+RT
Prophylactic TAH/BSO
Tamoxifen for contralateral risk reduction by 30-40%
85
How do outcomes for women with BRCA compare to non BRCA
same
86
Tis breast
DCIS
LCIS
Pagets
87
T1 breast
\<2 cm
88
T2 breast
2.1-5 cm
89
T3 breast
\>5 cm
90
T4a breast
chest wall (not including only pec muscle alone)
91
T4b breast
Edema/ peau d'orange
Ulceration
Ipsilateral satellite skin nodules
92
T4c breast
T4a (chest wall)
and
T4b (edema, ulceration, skin nodules)
93
T4d breast
inflammatory
94
cN1 breast
Ipsi, mobile axillary I/II
95
cN2a breast
Ipsi fixed level I/II
96
cN2b breast
IMN only
97
cN3a breast
Ipsi level III (IMN) with or without level I/II
98
cN3c breast
Ipsi SCV
99
pN1mic
\>0.2 mm but \< 2mm
100
pN1a breast
1-3 nodes
At least one with met \> 2mm
101
pN1b breast
IMN+ only by SLNBx
102
pN1c
N1a (1-3 axillary nodes)
and
N1b (IMN detected via SLNBx)
103
pN2a
4-9 LN
104
pN3a
\>10 LN
or Level III involvement
105
pN3b
clinically detected IMN and axillary nodes
106
pN3c
ipsi SCV nodes
107
Stage IA
T1N0
108
Stage IB
T1N1mic
109
Stage IIA
T1N1 or T2N0
110
Stage IIB
T2N1 or T3N0
111
Stage IIIA
T3N1 or T1-3N2
112
Stage IIIB
T4N+
113
Stage IIIC
N3
114
How to determine if pec invasion vs. CW invasion
If on flexing mass is fixed but mobile on relaxing then pec only
115
What conditions are inoperable?
arm edema
satellite skin nodules (T4b)
SCV disease
Inflammatory (T4d)
116
Interpretation of IHC for Her2 on core bx
If 1+ --\> negative
If 3+ --\> positive
If 2+ --\> get FISH
117
Which cases require SLNBx
* All invasive carcinoma
* UNLESS clinically positive axilla --\> Ax Dissection of levels 1 and 2
* DCIS getting mastectomy
118
If SLNBx is positive, which cases can ignore axillary dissection
* T1 or T2
* **_Clinically node negative_**
* 1 or 2 SLN positive
* BCT and WBRT planned
* No neoadjuvant chemo
119
Absolute contraindications to BCT
* 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
120
Relative contraindications to BCT
* 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)
121
OUTCOMES
Stage I
\<5% local failure
95% OS at 8 years
122
OUTCOMES
Stage II/III
\<10% LF at 5 years
\<30% BC mortality at 15 years per EBCTMA
123
How does outcome compare for ILC vs IDC
similar
124
What is prognosis of micromets
between pN0 and pN1
0.2 mm to 2 mm
125
Risk of skin tox
30-50%
126
Risk of late cosmesis issues
20%
127
Risk of pneumonitis
Tangents: \<1%
3 field: 3%
RT + ACT: 9%
128
Risk of cardiac toxicity
1-4% (depends on dose, approach, LAD dose, chemo)
129
What is the relative risk of cardiotoxicity for breast RT
Increase of 7% for each mean heart dose increase of 1 Gy
130
Risk of lymphedema with tangents and SLNBx
5%
131
Risk of lymphedema with tangents and RNI`
10%
132
Risk of lymphedema with ALND
10%
133
Risk of lymphedema with ALND + tangent RT
15-20%
134
Risk of lymphedema with ALND and RNI
25%
135
What is overall complication rate after PMRT
30%
136
When should mammo be performed after breast RT
4-6 months
Then annually
137
If patient is on tam, what needs to be scheduled?
annual gyn exam
138
If patient is on AI, what needs to be scheduled
assessment of bone density
139
What class of medication is tamoxifen
SERM - binds to estrogen receptor and blocks estrogen binding
140
What is the dose of tamoxifen?
20 mg qd
141
What is the benefit of tamoxifen for invasive disease
5-10% OS benefit
Reduces local failure as well
142
What is benefit of tamoxifen for DCIS
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
Side effects of Tamoxifen
* Hot flashes
* Vaginal atrophy and bleeding 5-10%
* Thromboembolic events 2-5%
* Rare risk of endometrial ca
* Decreased bone fracture risk
144
What class of meds given to women postmenopausal with HR+ cancers
aromatase inhibitors
Blocks androgen to estradiol conversion
145
Common AI medication
anastrozole 1 mg daily
146
AI side effects
Osteoporosis
Joint pain
Fractures (5-7%)
147
What is the benefit of chemotherapy for premenopausal women?
10-15% OS benefit at 15 years
148
What is the benefit for chemo for post menopausal women?
5% OS benefit at 15 years
149
What is Oncotype
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
Which patients should get oncotype?
T1, T2
N0
ER/PR+
Her2-
151
What is considered low risk for Oncotype?
1-18
152
What is considered intermediate risk Oncotype
19-30
153
What is considered high risk Oncotype
\>30
154
What is the common breast cancer chemo regimen?
* 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
What is ACT
Adriamycin
Cytoxan
Paclitaxel
156
What is the advantage of dose dense chemo
Increased efficacy
157
Doses of ACT
Adriamycin: 60 mg/m2
Cytoxan: 600 mg/m2
Paclitaxel: 175 mg/m2 (q2w) or 80 mg/m2 (q1w)
158
What is the chemo regimen for to avoid adriamycin
Docetaxel
Cytoxan
or Docetaxel Carboplatin
159
What is the chemo regimen for HER2+
AC --\> THP
160
How long shoudl patients be on Herceptin?
1 year
161
What is benefit of Herceptin
Decreased recurrence, increased survival
162
What monitoring is needed for women on herceptin
Cardiac monitoring
Baseline, 3, 6, 9 months
163
What is main side effect of ACT
myelosuppression
hair loss from adria
cardiotox from adria
164
What is a radical mastectomy?
Breast including skin
Areola/nipple
Pec Major and Pec minor
Levels I-III
165
What is a modified radical mastectomy?
Removes breast and skin, nipple, areola
Removes level I and II
Spares pec muscle
166
Total mastectomy
AKA simple
Spares pec and nodes
167
Which patients get simple mastectomies
DCIS
prophylactic for risk reduction
168
Skin sparing mastectomy
Removes biopsy scar, skin over tumor, nipple-areolar complex, breast parenchyma
169
Quadrantectomy
Tumor + 1.5-2 cm with overlying skin and deep muscle fascia
170
SLNBx accuracy
90-95%
171
What is the false neg rate for a SLNBx
5-15%
172
Which patients cannot get SLNBx
Clinically positive axilla (should get dissection)
Inflammatory
T4
173
Which patients need AXLND
* Clinically LN+
* 3+ SLNBx
* T4+
* Inflammatory
174
If the patient has an axillary dissection, what does that mean for Ax RT
Typically do not need to cover levels I and II
175
After ax dissection, which women should have coverage of level I and II with RT
Gross ECE
Extranodal tumor deposits
Inflammatory
176
What is the concern with LCIS
Marker of bilateral breast cancer, 9x risk of BC in both breasts
177
What is best management of classic LCIS
* 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
What to do if LCIS margins positive after lumpectomy
No need to re-excise
179
Which women should consider prophylactic bilateral mastectomies for LCIS?
Young with strong FHx
Genetic predisposition
180
What is the risk of DCIS transformation to invasive cancer at 10 years
30%
181
Types of DCIS
Comedonecrosis
Solid
Cribiform
Papillary
Medullary
182
Which is the most aggressive type of DCIS
comedo
183
What are high risk factors for DCIS
* Close/positive margins (\<2 mm)
* Age \<40
* Grade
* Size \> 4cm
* Comedonecrosis
* Multifocality
184
What questions should we ask about path specimen for DCIS
Size
Margin status
ER+
Grade
Extensiveness in sample
185
What is extensive intraductal component?
25%+ of primary tumor is DCIS and DCIS is present in normal breast tissue
186
Core biopsy shows LCIS or ADH, what is the next step?
Excisional biopsy or lumpectomy because 20% will be associated with DCIS
187
Do women with DCIS need genetics consultation?
Yes, same guidelines as invasive
age \<50
FHx of BRCA
1+ family member with young breast cancer
188
What are the broad treatment options for DCIS?
* 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
If woman with DCIS opts for mastectomy, what type?
Total mastectomy
No ALND
Do a SLNB in case invasive
190
DCIS woman opts for BCT, what to do if margin \< 2mm
Re-resection
191
DCIS woman as persistently positive margin or cannot achieve good cosmesis, next step
total mastectomy
192
What is the RT approach for DCIS after lumpectomy?
Whole breast RT +/- boost
Hypofractionated (2.66 x 16 = 42.6 Gy)
Boost of 250 x 4 = 10 Gy
193
Which women should get boost after DCIS
Age \< 50
Close/positive margin
High grade
194
What is the advantage of boost
Local control benefit (3%)
195
What is the downside of a boost for DCIS
Increased toxicity (fibrosis, telangiectasia)
196
Patient is ER+, what else could be done?
Chemoprevention
* Tamoxifen (20 mg qd) x 5 years
* Anastrozole (1mg qd) x 5 years if POSTMENOPAUSAL and \<60 years old
197
What is the benefit of RT after lumpectomy for DCIS?
Reduces ipsilateral breast events by 50%
No OS benefit
198
What is the ipsilateral recurrence risk after DCIS?
Low-Risk: 1% per year
High-Risk: 2% per year
Half of recurrences will be DCIS and half will be invasive
199
What is the "good risk" DCIS criteria?
* Mammogram detected disease
* Size \<2.5 cm
* Margins \>3mm
* Low or intermediate grade
* ***_NOT AGE_***
200
Which women could be considered for obs after lumpectomy for DCIS
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
What patients are suitable for APBI after lumpectomy for DCIS
* Age \>50
* Screen detected DCIS
* Low intermediate grade
* Size \< 2.5 cm
* Margins \>3 mm
* ER+
* No LVSI
202
If offering APBI, what is the dose?
6 Gy x 5 QOD
203
What is the best approach to deliver APBI
Fixed field IMRT
204
What is the approach to contour for APBI
* 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
What is the objective for PTV of APBI with respect to rest of the breast?
Should not exceed 30-35% of whole breast volume
206
What is the constraint for nontarget breast for APBI?
No more than 50% of nontarget breast getting 50% of dose
207
What needs to happen after lumpectomy for DCIS?
post lumpectomy mammo
Mag views
Specimen mammo
208
What is the advantage of tamoxifen above lumpectomy+RT in DCIS?
Improves LR by 3%
209
If woman getting tamoxifen or AI, when should it start with respect to breast RT?
1 week later
210
What stages should be managed as early stage invasive?
T1-3
N0-1
211
How to manage N1mic
"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
What are the treament options for early stage invasive carcinoma?
* 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
What is acceptable lumpectomy margin for invasive
No tumor on ink
214
What is the appropriate strategy for nodal evaluation for early invasive
* 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
How to manage early invasive if SLNBX negative
* No ALND
216
How to manage early invasive if SLNB shows micromet
No ALND
217
How to manage early invasive if SLNBx positive
* 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
Which early patients should get adjuvant chemo?
* 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
What Oncotype scores need adjuvant chemo
* Age \> 50: Oncotype \>25
* Age \< 50: Oncotype \>15
220
What is the chemo regimen for Her2- tumors
ddAC (4 cycles, q2 weeks)
Taxol (4 cycles q2 weeks)
or: cytoxan + docetaxel if cardiotox
221
What is the chemo regimen for Her2+
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
When should XRT begin after adjuvant chemo
1 month
223
Which early stage patients should be offered hypofrac
All, unless covering nodes
224
What is acceptable MPD for breast tangents?
\<110%
225
What the homogenity goal for breast tangents
Vol 105% \< 10-15%
226
What is RT field if SLNB is negative
Breast tangents only
Tumor bed boost
Consider APBI if meeting criteria
227
Are there any pN0 patients who should get RNI?
Consider for high risk patients
* T3 tumors
* Medial tumors
* Young age
* Extensive LVSI
228
Which patients can we consider for APBI?
* Age \> 50
* Tumor \< 2 cm
* Negative margins
* ER+
* Any grade
* No LVSI
* N0
* No BRCA
* Only low risk DCIS
229
What is the RT field if 1-3 positive nodes?
* 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
RT fields if 1-2 positive sentinel nodes
* 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
What is the RT field if 4+ nodes for early disease?
Whole breast RT + boost
RNI
232
Indications to intentionally cover the axilla after ALND
Gross ECE
\>50% nodal ratio
\<10 LN resected
233
Which patients do not need breast boost?
Age \>70
ER+
Low/low intermediate grade
Widely negative margins (\>2 mm)
234
What is the benefit of RT after lumpectomy?
4% improvement in OS
235
If cN0 how often is SLNB positive?
30-40%
236
If patient opts for mastectomy, how should axilla be assessed?
* Start with SLNB
* If negative can stop
* If positive --\> ALND
237
What are the indications for PMRT?
At least 1 positive node
Positive margin
Maybe T3N0
238
What is the PMRT field for T3N0 or T2 with positive margin
If everything else is favorable (ER+, no LVSI, low grade, older patient) then can consider treating CW only (not RNI)
239
For which early stage patients can adjuvant RT be excluded?
* Age \>70
* T1N0
* ER+
* Negative margin
* Willing to take 5 years tam
* Willing to accept higher local recurrence risk
240
What is the rate of local recurrence if RT is omitted after lumpectomy
1% per year
241
What is the boost dose?
* If negative margin
* 250 x 4 = 1000
* 200 x 5 = 1000
* If positive margin
* 200 x 8 = 1600
242
If a woman has T1-3N0-1 disease but cannot get BCT due to size, what is the best plan
* 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
What is the preferred treatment strategy for stage III breast cancer
* 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
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If a patient is cN+ and has clips placed how is axilla managed after NAC
ALND
245
How is the RT decided if patient received NAC
Treat as if they went straight to surgery
246
If patient got NAC and had BCS, what are the treatment fields?
* If cN0, ypN0 --\> tangents
* If cN+, ypN0 --\> tangents + RNI
* If cN+, ypN+ --\> tangents + RNI
247
What is the dose for PMRT
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
How to treat SCV or IMN which are not resected?
Boost to 60 Gy if any response to chemo
Boost to 66 Gy if no response to chemo
249
what is pCR rate of neoadjuvant AC-TH for Her2+ tumors
50-60%
250
What is the PTV margin on affected nodes?
5 mm
251
What other workup does stage III BC need?
CT CAP
Bone scan or PET
MRI brain if symptoms
252
After neoadjuvant chemo for TNBC ypT1-T4 or ypN1 what else should be considered?
6 months of capecitabine
253
What is the dose of capecitabine for TNBC?
1250 mg/m2 BID
Days 1-14
q3w cycles
254
If residual disease after neoadjuvant AC-TH(P) for Her2+, what is next step?
T-DM1 for 14 cycles
255
If CR to neoadjuvant AC-THP for Her2+ BC, what is adjuvant therapy
Complete 1 year of herceptin and/or pertuzumab
256
What is the diagnostic criteria for inflammatory breast cancer?
* 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
What is the stage of inflammatory breast cancer
cT4d
258
What is the workup for inflammatory BC?
* 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
Does BC need to be in skin to confirm IBC?
No, but do need some path confirmation of breast cancer before proceeding to chemo
260
What additional workup does IBC need?
CT CAP or PET
261
What is the general treatment approach to inflammatory BC?
* Neoadjuvant chemo
* Modified radical mastectomy and ALND
* PMRT + RNI
* Endocrine therapy ER+
262
If there is limited response to neoadjuvant chemo for IBC what is the next step?
Consider either switching chemo or pre-op RT (bolus every day)
263
What is the reconstruction option for IBC?
No immediate reconstruction
264
What is the dose of RT for IBC
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
What bolus should be used for IBC?
0.5 cm bolus DAILY
Should consider continuing even if moist desquamation
266
What does Paget's disease look like?
Nipple or areola involvement of tumor, usually from underlying carcinoma
Presents as crusting or eczema, ulceration, bleeding or itching
![]()
267
What percentage of Pagets of breast will have palpable mass
50%
268
What is the workup for Pagets of breast
Full thickness skin biopsy of nipple and bx any other underlying lesion
269
If found to have underlying breast lesion (DCIS or invasive) how should Paget's be managed
Treat as underlying condition
Lumpectomy needs to resect nipple/areolar
270
If the breast is negative but nipple is positive, what are the options
* Lumpectomy but removing nipple areola complex --\> SLN --\> WBRT
* Total mastectomy +/- SLN
271
Approach to BrCa in First Trimester
* Discuss termination
* Mastectomy + axillary staging
* Begin adjuvant chemo in 2nd trimester
* Consider adjuvant RT postpartum
* Consider adjuvant endocrine therapy postpartum
272
Approach to BrCa in 2nd trimester
* Mastectomy or BCS + axillary staging
* Adjuvant chemo
* +/- adjuvant RT and endocrine therapy postpartum
* Neoadjuvant chemo--\> surgery, RT, endocrine therapy postpartum
273
What is the chemo used for pregnancy?
Doxorubicin
Cyclophosphamide
Fluorouracil
274
When should RT be used during pregancy
NEVER
275
How should axilla be staged during preganncy
Only ALND
No SLN dye or radiation
276
How to workup recurrent breast cancer?
Imaging - mammo/US/MRI
Consider systemic imaging
277
Treatment options for in breast recurrences
* 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
How to approach axillary recurrence
Surgical resection if possible
+ RT to CW + RNI if possible
279
How to approach SCV reccurence
Radiation if possible, respecting total MPD of 60-66 Gy to brachial plexus
Consent to plexopathy
280
How to approach IMN recurrence
RT if possible to CW and RNI
281
If required to do reRT what dose should be used?
45 Gy in 1.5 BID fractions (30 fractions)
282
How to simulate breast patient -- SUPINE
* 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
Where to place wires for tangents?
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
What is the RT approach for WBRT?
Conventionally opposed wedged tangents to whole breast
285
How to approach setting tangents for WBRT
* 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
Superior border of normal tangent field
axillary vessels (inferior clavicular head)
287
Superior edge of high tangent field
Humeral head
288
Where is the isocenter for breast tangents
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
Any special tangent considerations for left sided breasts
Utilize DIBH or heart block to minimize cardiac exposure
290
What is acceptable V105 for tangent
\<10%
291
What is acceptable hotspot for breast tangent
\<107-110%
292
What are strategies to minimize hot spots
Wedges
Field in field
IMRT
293
Where is hotspot in underwedged tangent field?
narrow, anterior portion of the breast
294
Where is the hotspot in an overwedged tangent field
Two posterior corners
295
What is the lumpectomy GTV?
Cavity + archiectural distortion + seroma + clips
296
Lumpectomy CTV expansion
1 cm excluding pec major and 5 mm in from skin
297
Lumpectomy CTV to PTV expansion
5 mm excluding heart
298
How should the boost be planned?
Direct en face electrons prescribed to 85-90% IDL
299
What is the formula for electron energy for boost
E/3
300
What is the preferred setup if RNI is being performed
Monoisocentric technique
301
Strategies for boost if breast cavity is too deep for electrons
Switch to mini tangents
302
Ipsilateral lung constraint for tangent
V20 \< 15% (normal tangent)
V20 \< 20% (high tangent)
303
Ipsilateral lung constraint for 3 field
V20 \< 30-35%
304
Heart constraint
Mean heart dose ALARA, ideally mean of 1-2 Gy but can go up to 4-5 Gy if treating IMNs
305
What is the V20 goal to heart for L sided breast cancer
\<5%
306
Ways to reduce heart dose if needed
Change gantry and collimator angles
Sim prone
Mixed field approach (electrons/photons)
DIBH
IMRT
307
Describe approach for PMRT or RNI
* 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
What is the superior border of SCV field
cricoid
309
What is the inferior border of SCV field
Inferior edge of clavicular head
310
What is the medial edge of SCV field
Vertebral bodies
Avoid thyroid
311
Lateral edge of SCV field
Lateral to humeral head if high risk
Coracoid process if lower risk
312
What is the limitation of monoiso technique
Tangent field can only be 20 cm, so if taller, need dual isocenter technique
313
For dual isocenter technique - what is necessary strategy?
Kick couch AWAY from the gantry
314
What are the options to cover IMN nodes?
* 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
How to approach IMN for setting electron field
Start by contouring IM vessels
Add 1 cm expansion for CTV
Match electron field to my shallower tangent field
316
Which patients should have SCV field extend to medial edge of humeral head
Not fully dissected axilla
SLN+ only
N+ with ECE
High nodal ratio ![]()
317
Hypofractionation dose
42.5 in 16 fractions
318
Describe approach to setting up tangent beams
* 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
Approach to 3 field/RNI
* 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
Where to set calc point for SCV field
3 cm depth
321
Borders of a PAB
* Superior: Bisecting the clavicle
* Inferior: SCV match line
* Medial: Inside chest wall, including 1 cm of lung
* Lateral: block humeral head
![]()
322
How much does PAB contribute
30-60 cGy per day
323
Options for IMN field
* Partial wide tangents
* Matching electron field with shallower tangents
324
What is the angle of the IMN field
5 degrees less than medial tangent
325
