Breast Flashcards
Indications for neoadjuvant chemo
- Locally advanced (T3/4) tumour
- cN1 nodes (try and avoid ALND)
- Increase chance of BCS
- Triple neg or ER/PR- HER2+
- Temporary contraindication to surgery (pregnancy, anticoagulation)
- Delay surgery while genetic testing undertaken (that may affect surgery chosen)
Indications for MRI
- Dense breast tissue/young women
- Lobular carcinoma
- Assess disease extent (esp if multicentric)
- Assess deep nodal involvement
- Assess chest wall invasion
- Assess response to neoadjuvant therapy
Disadvantages of MRI
Higher rates of false positives
No improvement in outcomes according to studies
Indications for adjuvant chemo?
Node + disease
Tumour >20mm (T2+)
Triple neg
High risk according to PREDICT or Adjuvant! calculators
High risk according to Oncotype DX or Mammaprint calculators
Indications for adjuvant radiotherapy?
Post wide local excision
- whole breast irradiation with boost to tumour bed
Nodes:
• Irradiate “regional nodes” (supra- and infraclavicular) if nodes positive at SLNB/ALND
• Irradiate axilla as well if no ALND performed (AMAROS trial)
• Irradiate axilla, supra and infraclavicular nodes post ALND if extensive axillary involvement (extranodal spread, >50% nodes involved)
After mastectomy, give if high chance of local recurrence
• Tumour >5cm (T3 - T4)
• >4 positive nodes - controversial, some say less
• Stage III disease
• Chest wall invasion/margin involvement
Adjuvant chemo after neo adj?
Not always necessary.
Give if:
- Residual disease post surgery (give Capecitabine)
- Didn’t complete neo adj regime -> continue regime (AC-T)
How do you assess grade of breast ca?
Bloom and Richardson classification
“TNM”
- Tubule formation
- Nuclear pleomorphism
- Mitotic count
How do you assess prognosis of breast ca?
Nottingham prognostic index
“SiNG”
- Size
- Nodal involvement
- Grade
The index is calculated using the formula:
NPI = [0.2 x S] + N + G
Where:
• S is the size of the index lesion in centimetres
• N is the node status: 0 nodes = 1, 1-3 nodes = 2, >3 nodes = 3
• G is the grade of tumour: Grade I =1, Grade II =2, Grade III =3
Gives survival at 10 years • 2 – 2.4 = 93% • 2.4 – 3.4 = 85% • 3.4 – 5.4 = 73% • >5.4 = 50%
Definition of ALH?
Atypical proliferation of monomorphic dyscohesive epithelial cells in a breast lobule
- with no/minor distortion of lobule (this is how it differs from LCIS)
Risk of ALH or LCIS on biopsy being upgraded to invasive cancer on excision?
<3%
Risk of ADH being upgraded to DCIS?
30%
Risk of DCIS being upgraded to invasive ductal carcinoma?
30%
Risk of overall malignancy in either breast when ALH or LCIS found?
ALH: 4-fold
LCIS: 8-fold
Types of LCIS? Why do these matter?
Classic
Pleomorphic
Mass-forming
Classic LCIS alone does not require excision but can be observed. Pleomorphic or mass-forming should be excised.
How does ADH differ from DCIS?
Both = atypical proliferation of epithelial cells arising from breast ducts, with no invasion of basement membrane
In DCIS the abnormal cells FILL the ducts