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Rad Onc Oral Boards > Breast > Flashcards

Breast Flashcards

1
Q

Breast Borders

A
  • sup: inferior clavicle
  • inf: 2 cm below inf-mamm fold
  • lat: mid-axillary line
  • medial: mid-sternum
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2
Q

DCIS subtypes, low, high grade

A

Subtypes:
Lower grade: papillary, cribiform

Higher grade: solid, comedo

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3
Q

Breast Screening mammo

A

Screening mammo:
(USPSTF) -every 2 years, age 50-74 individualized decision 40-49

American Cancer Society: 40 individualized, 45-74 annual
** For hx of thoracic RT at age 10-30: annual mammogram and/or MRI yearly starting 8 years after RT or age 40 (whichever earlier)

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4
Q

Screening MRI who needs it

A 
Screening MRI for: (ACS)
•Lifetime risk > 20%
•Known BRCA +
•1st degree relative BRCA+ with pt status unknown
•PTEN/p53 mutation
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5
Q

Types of Mastectomy:

A

Types of Mastectomy:

  • Radical: pec major/minor Levels I, II & III
  • MRM: Level I & II
  • Total: breast Only (only used for prophy, DCIS)
  • Skin Sparing: biopsy scar, skin over tumor, breast parenchyma, and typically also remove NAC (nipple areolar complex)
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6
Q

Supraclav borders

A 
Cranial: Cricoid
Caudal: Caudal edge of clavicle
Anterior: SCM
Posterior: Scalene Muscle
Lateral: lateral SCM
Medial: Thyroid/Trachea
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7
Q

Axillary lvl I borders

A 
Cranial:    Ax vessels cross lateral edge of Pec Min
Caudal:    Pec major insert on ribs
Anterior:  Ant surface of Pec Maj to Lat
Posterior: Subscapularis Muscle
Lateral:     Lat
Medial:     Pec minor
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8
Q

Axillary lvl II borders

A

Cranial: Ax vessels cross medial edge of Pec Min
Caudal: Ax vessels cross lateral edge of Pec Min
Anterior: Ant surface Pec Minor
Posterior: Ribs
Lateral: Lat Pec Minor
Medial: Med Pec Minor

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9
Q

Axillary lvl III borders

A 
Cranial:    Coracoid Process
Caudal:    Ax vessels cross medial edge of Pec Min
Anterior:  Pec Major
Posterior: Ribs
Lateral:     Medial edge Pec Minor
Medial:     Thoracic Inlet
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10
Q

IMN borders

A

Cranial: Cranial 1st rib
Caudal: Cranial 4th rib

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11
Q

Luminal A:

A

Luminal A: ER+/HER2-, low grade

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12
Q

Luminal B:

A

Luminal B: ER+/H2N- or +, high grade

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13
Q

Basal:

A

Basal: triple negative

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14
Q

Her2-like:

A

Her2-like: ER-, Her2+

Her2 pos defined as:
•IHC 3+ (2+ equivocal)
•FISH amplification of ≥ 2.0

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15
Q

Extensive intraductal component (EIC):

A

Extensive intraductal component (EIC): DCIS > 25% of IDC specimen

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16
Q

Want to know from pathologist:

A

Want to know from pathologist:

  • Size
  • Grade
  • LVI
  • Margins
  • EIC
  • LNs (and ECE)
  • Receptors
  • Oncotype Dx
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17
Q

Pec invasion vs true CW invasion:

A

Pec invasion vs true CW invasion: if on flexing, the mass is fixed but on relaxing it’s movable - then it’s pec only. If true CW invasion it’s always fixed

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18
Q

IMN involvement %’s
if lateral primary and -ALNs
if +ALNs or medial primary
if both medial primary and +ALNs

A

IMN involvement
- 5% if lateral primary and -ALNs
- 15-20% if +ALNs or medial primary
- 30-40% if both medial primary and +ALNs
=> usually limited to first 3 intercostal spaces

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19
Q

CC View

A

CC: shows lat vs. medial

  • should show nipple
  • marker on lateral side
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20
Q

MLO view

A

MLO: shows sup vs. inf

  • need to see pec maj on film down to level of nipple
  • includes axillary tail
  • if abnlty, get b/l dx mam
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21
Q

BIRADS:

A

BIRADS: breast imaging reporting and data system (0-6):

0: incomplete - additional imaging needed
1: negative – routine screening
2: benign – routine screening
3: probably benign - 6 month follow-up (<2% risk)
4: suspicious - biopsy (3-95% risk)
5: highly suggestive of malignancy - biopsy (>95% risk)
6: known malignancy

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22
Q

Breast history/Physcial

A

History: prior mammos, pain, nipple discharge, gyn hx (PG status, age menarche, first brith, age menopause, OCPs, HRT), Ashkenazi,

-Physical: bilateral, bipositional (supine and sitting) breast exam, nodes

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23
Q

Workup

A
  • Imaging:
  • diagnostic mammo and ultrasound
  • spot compression for mass
  • magnified view for calcs
  • Biopsy:
  • Core biopsy: stereotactic (see on mammogram) vs US guide (see on ultrasound); leave clip
  • FNA any clinically positive nodes
  • Determine receptor status

Systemic w/u (symptoms, N+, Stage IIIA+):

  • CT C/A/P
  • bone scan or PET/CT
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24
Q

When Genetic referral:

A 
Genetic referral: 
- Both breast and ovarian primaries
- Family member with BRCA
- Any breast CA <50 
- Triple neg any age
- Multiple breast primaries
- Breast CA in pt and then cancer in family (>1 relative breast <50 or any age ovarian, >2 relative with breast, prostate, or pancreatic cancer)
- Ashkenazi Jew
- Male breast CA
(Consider p53, ATM testing if BRCA negative)
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25
Q

When to get MRI for workup

A

MRI for:

  • extremely dense breast tissue
  • ILC
  • assessing feasibility of breast conservation
  • before NACT
  • unknown primary
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26
Q

TNM

A

Tis: DCIS, LCIS, pagets

T1mic: ≤ 1mm 
T1a: 1-5 mm
T1b: > 5-10 mm
T1c: > 10-20 mm
T2: > 2-5 cm
T3: > 5 cm
T4:
T4a: chest wall not including pec 
T4b: 
•skin
•edema
•ulceration
•skin nodules or peau d’orange
T4c: T4a and b
T4d: inflammatory
cN1:   moveable
cN2a: fixed
cN2b: IMN only
cN3a:  infraclav (III)
cN3b: IMN and axilla
cN3c: supraclav

cM0(i+) – circulating metastatic tumor cells in blood or found in other tissue < 0.2mm

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27
Q

pN stage

A 
pN1mi: >0.2-2mm or >200 cells
pN1a: 1-3 ax nodes (one >2mm)
pN1b: IM by SLN bx
pN1c: both N1a + N1b
pN2a: 4-9 nodes
pN2b: clin IMN only
pN3a: >10 or infraclav
pN3b: clin IMN + ax; or IM by SLN + >3 ax
pN3c: supraclav

ITC: < 0.2 mm; behave like pN0

NEVER N2c in breast

28
Q

Overall Stage

A 
IA: T1N0
IB: T1N1mi
IIA: T1N1, T2N0
IIB: T2N1, T3N0
IIIA: T3N1, N2
IIIB: T4
IIIC: N3
29
Q

ASTRO PBI consensus guidelines:

A 
ASTRO PBI consensus guidelines:
Suitable:
->50 y/o
---
-Tis/T1 only (≤ 2cm)
-Marg >2mm
-pN0
---
-DCIS <2.5cm, gr1-2, >3mm margins

Cautionary:

  • 40-49yo
  • 50+ if one path criteria
  • –
  • T2
  • Invasive lobular
  • ER-
  • Focal LVSI
  • Close margins
  • –
  • Pure DCIS < 3 cm

Unsuitable:

  • Age <40
  • BRCA positive
  • –
  • T3, T4
  • Multicentric/focal
  • Extensive LVSI
  • Margins +
  • pN+ or NX
30
Q

Hormonal therapy

A

Hormonal therapy
SERM: premenopausal
- Tamoxifen 20mg po qd x 5 yrs
- Can also consider Lupron + AI

Tam: (HATE) – less in younger individuals 
Hot flashes
VAginal bleeding
Thomboembolic
Endometrial ca

AI: postmenopausal

  • Blocks androgen to estrone+ estradiol
  • Nonsteroidal: Letrozole 2.5mg, Anastrozole 1mg
  • Steroidal: Exemestane

Arimidex/AI (post-meno): osteoporosis, thromboembolic (lower than TAM), endometrial cancer (lower than TAM)

31
Q

DCIS Managment

A

1) Lumpectomy (wire-localized) -> specimen mammo (post-excision mammo if clip not in specimen) -> XRT + boost -> tam for 5-10 yrs for ER+
•Boost – retro data, extrapolate from IDC
•More important in: young, high grade, close margin

2) Simple mast -> tam for 5 yrs for ER+
* *(if widespread or pt choice)**
- should do SLNB (can’t go back to do if invasive disease found)

*if find invasive cancer at DCIS surgery -> get ER/PR/Her2, do SLNBx

Omit Boost

  • Age>70
  • HR+
  • Grade 1-2, >2 mm margins

BCT: contraindications:

  • Pregnancy
  • Multicentric (>1 quadrant)
  • Persistent + margins
  • Diffuse microcalcs
32
Q

Early IDC management BCS

A

1) Lumpectomy + SLNB -> Chemo if indicated -> XRT -> hormone tx if indicated
42. 5/16 + 10 Gy boost (12.5 Gy if + margins)

=> definitely do boost for age <=50, or age 51-70 w/ high grade or positive margins

33
Q

Early IDC management BCS: + SLNBx

A 
For + SLNB, can omit ALND if ALL met:
•T1-2, cN0
•<= 2 positive SLN, not matted, no ECE
•No neoadj chemo administered
•BCT w/ whole breast RT planned

or

N1mi only

34
Q

BCS Omission of RT

A

3) Omission of RT
- T1, ER+, Older age (65-70+), No ink on tumor, cN0 (don’t need pN0), Willing to take anti-estrogen

-higher LRR (10% vs. 2% at 10 yrs): consider for pts w/ comorbidities limiting life expectancy

35
Q

APBI dose and quick WBRT

A

4) APBI dose
3.4 Gy bid x 10 (brachy)
30 Gy in 5 fractions QOD (external beam)

28.5 in 5 fractions weekly

36
Q

Indications for adjuvant Chemo:

A

Indications for Chemo:

(1) Node positive even N1mi -> oncotype for post menopausal to decide if pN1: 1-3
(2) Triple negative > 0.5 cm
(3) Her2 positive > 0.5 cm consider for <0.5 if HR-
(4) Oncotype score >=26 (>=16 for premenopausal)

37
Q

For clinically N+

A

For clinically N+

  • biopsy of +LN to confirm cancer
  • basically all need ALNDx can consider SLN for neoadjuvant chemo cat 2b
38
Q

Pre-op chemo

A

Her2/TNBC T1c+ (>1cm) definitely for T2+
N+
inoperable
large tumor desiring BCS

39
Q

Adjuvant systemic therapy after pre-op therapy

BRCA1/2 + ypT or N+ :

A

BRCA1/2 + ypT or N+ : Olaparib

40
Q

Adjuvant systemic therapy after pre-op therapy
Her2+ pCR
Her2+ ypT or N +

A

Her2+ pCR : Transtuzumab 1y +/- pertuzumab
-add endocrine if HR+

Her2+ ypT or N+: Kadcyla for 14 cycles
-add endocrine if HR+

41
Q

Adjuvant systemic therapy after pre-op therapy

TNBC

A

pCR: adjuvant pembro if given pre-op for Stage II-III

yp+: Capecitabine 6 cycles or pembro if given pre-op

42
Q

DCIS RT benefit

A

50% reduction of 10-yr IBTR with RT (30% vs. 15%), no diff in OS
-30% reduction in any breast event (ipsi or contra) with tam; no diff in OS

43
Q

Breast Simulation

A

“I would simulate the patient supine immobilized on breast board. I would place the patient’s ipsilateral arm abducted and externally rotated and patient’s head/neck facing away from the breast that we are treating. I would also consider treating the patient on an incline so that the sternum is parallel to the chest floor. I would wire the estimated field borders as well as surgical scars.” Specifically, I would place wires at:
• At inferior aspect of the supraclavicular head
• 2 cm inferior to inframammary fold
• At mid-axillary line
• on sternum

44
Q

Volumes and treatment design

A

Breast CTV= breast tissue, extends to ant surface of pec posteriorly then cropped 5 mm from skin (pec and serratous excluded from CTV)
Breast PTV= breast CTV +7mm
Breast PTV_eval = PTV cropped 5mm from skin and at anterior ribs (includes muscle)

“I would set the medial tangent first rotating the gantry to making sure the volumes are covered and minimizing heart, lung and contralateral breast dose. I would rotate the collimator to align with the chest wall. Apply a couch kick away from the gantry to allow for alignment of the superior edge of the field. I would then set the lateral tangent aligned to the medial field with a non-divergent deep field border”

  • Borders: generally top of field is at level of axillary vessels (used to be humeral head) inferior clavicular head; flash 2 cm of breast; medial inside chest wall <2cm of lung; inferior 1.5-2 cm flash
  • limit hot spot to < 110% (<107% if hypofx), 115% if 3rd field. Use field in field (also beam weigthing, changing calc point, change energy; wedge is last resort)
  • isocenter set centrally at midline and mid axilla – shifted to within breast for treatment
  • normalization/calc point 0.5 cm anterior to lung/breast interface
  • prescription vs. normalization/calc pt – 1.5 cm
45
Q

Boost design

A

Boost: 10/2 Gy (16 for positive margins) – (10 Gy in 4 fx hypofx)
- electrons: energy which allows 90% IDL to cover target (if too deep, mini-tangents)
Boost GTV = tumor bed, clips, scar
Boost CTV = (GTV + 1 cm), cropped 5 mm from skin and post at ant pec
Boost PTV=CTV + 7 mm
Boost PTV eval = Boost PTV cropped 5 mm from skin and at pec/serratus
9Mev: 2.8, 12MeV: 3.75

46
Q

RNI sim and setup

A

Supine slant board, arm up, chin up and away. Markers.

I would plan to use a dual isocenter technique.

I would contour the nodal levels, OARs, and matchline at the clavicular head. Start the set up with the SCL field iso along the match line to allow for half beam block. laterally at the coracoid process if good dissection, lat humeral head if not or ECE, med vertebral pedicals with field angled 10-15 to reduce divergence into cord.

I would then setup the tangents with a z shift on the iso, I would start with the medial field with the gantry rotated to allow for target coverage and minimizing dose to OARs. Collimator aligned to the chest wall. Couch kick would be applied AWAY from the gantry to align with the SCL field. Medial tangent would then be placed matching posterior divergence.

Supraclav + level III: (50/2 Gy or 45 Gy)

  • monoisocentric technique
  • same pt set-up, tilt chin away
  • set SC field first: sup cricoid (or top 1st rib), inf clavicular head, lat coracoid process if good dissection, lat humeral head if not or ECE (block 2/3 of humeral head and AC joint), med vertebral pedicals with field angled 10-15 to reduce divergence into cord
  • half beam block caudal edge of SCV field and cranial edge of tangents
  • set tangent fields
  • rotate gantry to align deep borders of tangent fields – with MI, can rotate gantry but NOT collimators! Means you have to use MLCs to block heart, etc
  • if breast is too large (tangents > 20 cm – thus 40 cm total), can try dual isocenter technique. Half beam block SCV but not tangents, then kick couch AWAY from gantry to match divergence of tangents to SCV field. Can rotate collimators. Place iso at CW/lung interface.
  • R breast = LAO

IMN:
1) partially wide tangents if favorable anatomy; not too much heart and lung (if lung dose too high  electron match)

PAB: (0.4-0.5 Gy daily)

  • used to supplement levels I-II
  • use for ECE, 10/10+ nodes, gross disease, or inadequate dissection
  • prescribed to midplane of axilla
  • borders: inf matched to tangent, sup parallel to clavicle (diagonal), medial just inside chest wall, lateral humeral head.
  • in modern practice, I would contour my nodes that need coverage. If adequate nodal coverage isn’t obtained with tangents, I would consider adding a posterior field
47
Q

Cardiac protection:

A

Cardiac protection:

1) Change gantry/collimator angle
2) Sim prone
3) Mixed field approach (electrons/photons – like for IMNs)
4) Deep inspiration breath hold
5) IMRT / Protons

48
Q

Partial breast RT technique

A

Partial breast RT:

  • CT after device placement on all patients to determine conformance
  • < 10% air or fluid in PTV-eval
  • Typical balloon diameter of 4 to 5 cm and a final fill volume of 35 to 70 mL
  • Min balloon-to-skin surface distance of 5 mm is required
  • 3.4 Gy bid x 10 rx’ed to 1 cm from the surface using HDR 192Ir separated by at least 6 hours
  • Max dose to skin/chest wall: 150%
  • Want ≥ 90% of PTV_eval getting ≥ 90% of dose

-PTV eval = balloon + 1 cm cropped 5 mm from skin and at pectoralis sub central balloon
– partial breast (brachy or EBRT) vs. whole breast stand frac
EBRT – 3.85 x 10 BID (make sure surgeon places clips)
Brachy – 3.4 x 10 BID

49
Q

Breast constraints

A 
Ipsi lung: 
V20 < 15% 
High tangent V20< 20%
3-field 
V20 < 35%

Heart:
V20 < 5%
mean < 4 Gy (per RCTs, ALARA, try <1-2 Gy)

For every increase of 1 Gy on mean heart dose, risk of CVD increases by 7%

Contralat lung V5 < 10%

Contralateral breast
Max 3 Gy

95% PTV gets 95% dose
V100%< 30%
hotspots under 10%
(less than 115 in SCV)

Electrons – don’t want more than 12mEV

Tamoxifen reduces contralateral breast cancer by 1/2

50
Q

OS and LR

A 
5-yr OS:
I: >90%
II: 80 %
IIIA: 70%
IIIB (T4): 40%
IIIC (N3): 50%

Stage I: <5% local failure and 95% OS at 8 years
Stage II/III: < 10% local failure at 5 yrs and < 30% BC mortality at 15 yrs per the early breast cancer trialists meta-analysis

51
Q

Axillary recurrence: risk

A

Axillary recurrence:
In the undissected breast, the risk is 20% per B04.
If > 10 nodes taken, the risk is <1% per B04
If suboptimal dissection, the risk is 8% -> 2% after RT

52
Q

Lymphedema risk

A

-Lymphedema:
SLNbx: 5%
ALND: 10%
ALND + RT: 15-20%

53
Q

Chemo toxicity

A

ACT – myelosuppresion
Adria – hair loss, cardiac

Tam: (HATE) – less in younger individuals 
Hot flashes
VAginal bleeding
Thomboembolic
Endometrial ca

Arimidex/AI (post-meno): osteoporosis, thromboembolic (lower than TAM), endometrial cancer (lower than TAM)

Herceptin:

  • Cardiotoxic – watch heart, no IMNs
  • Decreases recurrence and improves survival
  • Do cardiac monitoring at baseline, 3, 6, and 9 months
54
Q

BRCA risk of cancer

A

BRCA

  • risk of breast cancer 50-60%
  • risk of ovarian 20-40% (BRCA2>1)
  • PPX B/L mast & BSO reduces risk of these CAs by 90%
  • can do BCS+RT w/ PPX TAH/BSO&tam for 30-40% C/L BTR risk reduction
  • CSS similar to non-BRCA pts
55
Q

Indications for PMRT

A 
N+, Stage III
consider for T3N0 and <1mm margins especially with another risk factor:
        a.  Premenopausal
	b.  LVSI
	c.  High grade
	d.  Triple negative tumor
	e.  Her2+ tumor
	f.  Extracapsular extension
	h.  T4
        k. Genomic assay (oncotype or higher) – intermediate or higher

RNI for most

+ margins -> re-excision if not possible CW+RNI

Level I/II intentional nodal coverage

1. Gross undissected nodal disease (100% of prescribed dose)
2. Extracapsular extension
3. > 20% of lymph nodes removed are positive for cancer
4. at least 1 positive lymph node but < 10 lymph nodes removed
56
Q

predictors of LR for BCT and MRM

A

Age, Stage(cN+) and response to chemo

  • predictors of LR for BCT: age, pre-chemo clinical node status, path nodal status/response
  • predictors of LR in MRM: pre-chemo tumor size, cN, pN
57
Q

Inflammatory Diagnostic criteria:

A

Diagnostic criteria:

  1. Erythema/edema (peau d’orange) > 1/3 of breast (w/ palpable border to erythema)
  2. Rapidly occurring (< 3 months)
  3. Path confirmation of breast CA

Ddx: mastitis, cellulitis, neglected breast cancer if >3 months

58
Q

Inflammatory workup

A

-Full thickness skin biopsy
-Tumor in dermal lymphatics typical, but not required
-T4d
Clinical diagnosis, but malignancy requires path confirmation
- if node+ and FNA neg, do core
- if skin punch neg, do incisional bx

Full labs (pregnancy, CBC, chem/LFTs) and imaging (B/L mammos, bone scan, CT C/A/P, PET-CT)

59
Q

Inflammatory managment

A

Neoadj chemo -> MRM -> PMRT

-If no response to chemo, consider switching chemo, or pre-op RT (50 Gy with bolus every third day)

If PR or NR, 51 GY at 1.5 Gy BID followed by boost of 15 Gy BID at 1.5Gy Bid, total of 66 Gy then (5mm bolus x 15 fractions, more if no erythema)

If CR, then 50 Gy at 2 Gy per fxn, followed by 10 Gy boost at 2 Gy per fxn (5mm bolus x 15 fractions, more if no erythema):

60
Q

Inflammatory OS and LR

A

5yr OS 50%
5 yr DFS- 40%
5yr LR- 16% (with 66 Gy BID technique) vs 42%

61
Q

ADH

A

consider wire loc or incisional Bx

Ask for re-excision b/c on lump find DCIS or IDC 15 – 30%

Lumpectomy alone
(no RT needed)

62
Q

LCIS about

A

Incidental finding on biopsy – not detectable on mammogram

Marker of bilateral BC - 9x increased risk of breast cancer in both breasts (1%/year)

Pleomorphic LCIS more aggressive

63
Q

LCIS managment

A

1) Confirm site biopsied is concordant w/ site sampled -> if so, risk reduction (see below)
2) If not concordant, multifocal or extensive, or pleomorphic LCIS, consider excisional bx -> observation (yearly mammo) or chemoprevention
(no RT needed)

Bilateral prophy: total mastectomy
Chemoprevention:
     Pre-meno: Tam
     Post-meno: Tam, Ral, Exemestane, or  
                         Anastrozole

** 25% associated w DCIS or invasive – treat as per those paradigms

review in multiD, if area biopsied is cw with biopsy, then observe

-if not or pleomorphic->excision

No RT

64
Q

Phyllodes

A

Rapidly growing fibroadenoma
Path: benign, borderline, malignant

Breast exam and bilateral mammogram
Excisional bx (not core needle)

Lumpectomy alone with wide margins (>1 cm)
(no ALND or RT needed)
If recurrence, then can add RT

65
Q

Recurrence

A

If had prior BCS: do mastectomy +/- chemo +/- focal RT

If had prior mastectomy (no RT): excise if possible  chemo  RT to chest wall and regional nodes

If had prior mastectomy and prior RT: excise if possible  chemo  RT to small volume with electrons. Consider hyperfractionation (51/1.5 BID)

For nodal recurrence: dissection  chest wall and nodal RT (qday if not previously given, BID if previously given)

66
Q

Pregnancy

A

•No Tam/AI, RT, SLNBx, Herceptin!
- 1st trimester: discuss termination
Mastectomy +ALND chemo in 2nd trimester delivery RT  tam
- 2nd trimester: Surgery (can include BCS +ALND (no SNLB)  chemo as needed  delivery XRT  tamoxifen
- 3rd trimester: BCS or mastectomy deliver  chemo as needed  XRT  tamoxifen

67
Q

Chemotherapy

A

Chemotherapy:
N+: AC-> T (or TC if frail, elderly, cardiac history)
- dd AC (every 2 weeks), dd paclitaxel q2weeks, or weekly

N-, ER+/HER2-:
Tumor <0.5 cm (T1a): endocrine therapy alone
Tumor >0.5 cm (≥T1b): Get Oncotype DX and AC chemo if high
– 21-gene assay yields a recurrence score, which relates to 10-yr risk of systemic recurrence with Tamoxifen alone
– If <50 yo 16+ -> chemo
• 26+ -> chemo

N-, -/-/-:
Tumor >0.6-1.0cm (i.e. T1b): Consider chemotherapy
Tumor >1 cm (≥T1c): Chemotherapy (usually AC then T)
HER2+:
Tumor >0.6-1.0cm (i.e. T1b): Consider multiagent chemo with Herceptin
Tumor >1 cm (≥T1c) or N+: Multiagent chemo with Herceptin (usually TCH)

ddAC x 4 ->ddTaxol x 4
- doxorubicin 60mg/m2 d1
- cyclophosphamide 600mg/m2 d1 q2wks x 4
- then paclitaxel 175mg/m2 q2weeks x 4
Herceptin (Trastuzumab)
– Begin Herceptin with Taxol
– 4 mg/kg loading dose  2 mg/kg weekly x1 y –OR- 6 mg/kg q3wks after Taxol
– Can give RT with Herceptin
– Cardiac monitoring at baseline, months 3, 6, 9 (4% risk of CHF)
Or THCP for Her2+ - docetaxel, carboplatin, Herceptin, pertuzumab – only done NACT
ACTH or Adria, Cycophos, Paclitaxel, Herceptin, Pertuzumab – can do NA alone

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