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Breast Flashcards

1
Q

What is the margin for DCIS?

A

2mm according to Morrow et al 2016 Society of Surgical Oncology recommendation

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2
Q

What is the local recurrence rate of DCIS with excision alone?

A

30% NSABP B-17 study

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3
Q

What is Van Nguyen’s prognostic indicator?

A

For DCIS after BCS
Score 1,2,3
Based on size, margin, pathological classification, age
Low risk is VNPI score of 4-6 where it showed no difference in local recurrence rate with radiotherapy.

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4
Q

When should boost be offered to DCIS after BCS?

A

for non-low-risk DCIS. A boost lowered the 5-year local recurrence rate from 7·3% to 2·9%, resulting in 4% fewer salvage mastectomies compared with the no-boost group; however, this was at the cost of an increase of 15% acute and 11% late grade 2 or more events.

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5
Q

What is the local fecurrence

A
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6
Q

What is CTS 5?

A
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7
Q

What is the benefit of adjuvant abrmaciclib in early breast cancer?

A

Increase in absolute IDFS, DRFS at 4 years
Ki67 remains prognostic but not predictive as abemaciclib is similar regardless of Ki67 index

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8
Q

What is the benefit of abemaciclib plus ET compared to ET alone? What is main concerning side effect?

A

OS data immature
Diarrhoea is significant side effects

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9
Q

What is the benefit of adjuvant bisphosphonate?

A

Cost associated with treatment
Vitamin D as alternative for bone preservation

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10
Q

What is the benefit of adjuvant abemaciclib?

A

HR+, Her2-, node positive, high risk EBC

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11
Q

When would you consider omitting adjuvant radiation therapy after lumpectomy?

A

As per NCCN 2023 guideline
Age > 70
ER+ , pT1pN0 based on CALBG9343
PRIME II and CALGB 9343 did not show an overall survival benefit with adjuvant radiation therapy there was a significant decrease in local breast recurrence

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12
Q

What is the local recurrence rate after adjuvant radiation therapy for Stage 1A IDC, ER/PR+, HER2- ?

A

PRIME II study
10 year local breast recurrence without radiation is 9.5% vs 0.9% with radiation

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13
Q

What is the Whelan Trial?

A

Comparing 50Gy/25# vs 42.5Gy /16#
10 year local recurrence rate were comparable 6.7% vs 6.2%
Cosmetic outcome similar 71.3% vs 69.8%
Subgroup analysis, high grade tumour 10 year LR = 4.7% vs 15.6% (hypofractionation)

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14
Q

What are the ultra-hypofractionation constraints?

A

As per FAST: Breast PTV Dmax < 107%
Breast PTV 105% < 5%

Per FAST FORWARD:
Ipsilateral lung V8Gy < 15%
Heart V1.5Gy <30% and V7Gy < 5%
Breast PTV105% < 5%
PTV 107% <2%
Dmax < 110%

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15
Q

What are the 2 main trials for boost in invasive cancer?

A

Lyon and EORTC trial shows long term benefit of serial tumour bed boost after lumpectomy
Improvement in local control
Smaller benefit in older patient

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16
Q

What is the trial for boost in DCIS?

A

BIG 3-07 trial (serial boost)

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17
Q

What are the study for integrated boost?

A

IMPORT HIGH (hypo + sequential vs hypo integrated)
RTOG 1005 (50Gy/25# + sequentiall 10Gy/5# vs 40Gy/15# + concurrent boost to 48Gy)

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18
Q

What are the study for hypofractionation?

A

FAST
FAST-FORWARD

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19
Q

What are the study for hypofractionation for DCIS?

A

BIG03
DBCG HYPO

20
Q

What are the study for ABPI?

A

ELIOT (whole breast vs intraoperative electron)
TARGIT (intraoperative vs EBRT) - when higher risk factors found post-op, EBRT should be added
IMPORT LOW (partiall breast 40Gy/15# non inferior, less side effect )
RAPID (DCIS and invasive, non inferiority, 38.5Gy/10# BD, similar outcome, less toxicities, increase in late cosmesis at 5 years)
NSABP B-39 (BID, 38.5Gy/10#)
FLORENCE (30Gy/5#, <2.5 cm)
ACCEL (27Gy/5#)

21
Q

What are the study for ABPI?

A

ELIOT (whole breast vs intraoperative electron)
TARGIT (intraoperative vs EBRT) - when higher risk factors found post-op, EBRT should be added
IMPORT LOW (partiall breast 40Gy/15# non inferior, less side effect )
RAPID (DCIS and invasive, non inferiority, 38.5Gy/10# BD, similar outcome, less toxicities, increase in late cosmesis at 5 years)
NSABP B-39 (BID, 38.5Gy/10#, less acute and long term)

22
Q

What are the study for moderate hypofractionation?

A

MRC START A&B (40Gy/15#, 10Gy boost allowed)
OCOG Ontario Canada (42.5Gy/16#, no boost) Whelan

23
Q

Who should get APBI?

A

Low grade disease
Less than 2cm
ER positive
30Gy/5#
Either DCIS or IDC

24
Q

What is the trial for re-irradiation with APBI?

A

RTOG 1014
45Gy BID 30#
For recurrences in preventing mastectomy

25
What are trial for PMRT?
Node positive cancers British Columbia study 37.5Gy/16# Reduced LRR Increase survival, OSS, BCS Danish 82b and C Mastectomy + ALND 50Gy/25# Tumour > 5cm, N+, invasion of skin or fascia
26
What is the local failure rate in post-matectomy node positive?
Increases with N stage ECOG 13 - 30% NSABP 13 - 24% MDACC 14 - 25%
27
What is the meta-analysis for PMRT?
EBCTG 2014 (Oxford overview) N0 no benefit 1-3 N and >4N => LRR and mortality benefit
28
What is the study for PMRT in stage 2 breast cancer?
SUPREMO trial Stage II with 1-3N+ or pT2N0 or T3N0 Data maturing Also using hypofractionation 40Gy/15#, at 2 year minimal cosmetic
29
What are the risk factors for risk of recurrence?
Age, Grade, LVI, margins, tumour size, N, ENE, response to neoadjuvant, tumour biology
30
What is the study for breast cancer for RNI?
MA20 Node positive or high risk node negative Mostly stage 2, mostly node positive patient Significant improvement in DFS, local regional DFS, distant disease survival OS not different No change to cardiac toxicity and pneumonitid EORTC 2292 Mastectomy 25% rest BCS Majority stage 2 Stage I-III 50Gy/25# vs 50Gy/25# to cw and RNI (medial SCV and IMN) No OS Reduce recurrence and Breast cancer mortality
31
What are the study for whether to include IMN in RNI?
KROG 08-06 No overall improvement in DFS However, subanalysis, mediocentral tumour Comparable rates of adverse effect Pneumonitis higher in IMN DBCG (Danish) Left side received no IMN, right side received IMN 4.7% improvement in OS Decrease risk of distant Mets No different from cause of death from other
32
What is the meta-analysis for RNI?
EBCTG2023 (also included T1-2N0) RNI improve disease free survival in N1 No increase in cardiopulmonary toxicity when IMN treated IMN RT in pt w axillary nodes, central or inner quadrant, ER-
33
What are the trial for ALND vs SLNB/RT?
Z0011 AMAROS Lymphoedema 44.2% ALND vs 28.6% ART OTOASAR 15% ALND, 5%RNI
34
What is the trial for PMRT/ RNI hypofractionation?
Chinese NCC Trial 50Gy/25# vs 43.5Gy/15#, similar FABREC PMRT with reconstruction RT-CHARM
35
What does NSABP B18/27 show LRT after neoadjuvant therapy?
BCS + RT Mastectomy with no RT Recurrence highest in those with no complete response Those with nodes that remains after neoadjuvant - highest risk for recurrence
36
What is the rationale for RNI for pN to ypN?
Persistent nodal disease after neoadjuvant systemic therapy, even if limited (micrometastatic disease), is both indicative of systemic therapy resistance and predictive of additional non-sentinel lymph nodes and regional nodal irradiation is appropriate
37
What rationale for RNI in neoadjuvant complete response patient?
NSABP 51 T1-3N1 Among patients who are initially node positive and become pathologically node negative after neoadjuvant systemic therapy, 5 year follow up data suggest limited benefit to regional nodal irradiation in this sitting
38
What is the study for adjuvant RT post lumpectomy for DCIS?
NSABP B-17 32% vs 16% 12 year ipsilateral breast tumour recurrence Improvement in event free survival
39
What rate of major coronary events increases per Gray?
7.4% per gray with no threshold. Darby et al NEJM2013
40
What is the management approach for pure LCIS?
LCIS bilateral breast process Tamoxifen reduces 5-year rate of disease development by one half
41
What does the EBCTCG meta-analysis show?
pN0 = pN+ = 20% reduction in locoregional recurrence, 5% overall survival
42
What is the benefit of RNI if there is pCR in nodes from neoadjuvant chemo?
RTOG 1304/NSABP-B51 cT1-3N1, WLE or mastectomy + SLNbx(some ALND) RNI = IMN 1-3, SCV, axillary, Very few recurrences 80% had pCR in breast No benefit in RNI in setting of pCR Still need WBRT for WLE
43
44
What study suggest micrometastais and ITC may not require aggressive treatment ?
IBCSG 23-01 trial This multicenter, randomized trial compared outcomes in patients with micrometastases in sentinel lymph nodes (SLNs) who either underwent ALND or had no further axillary surgery. The results showed no significant difference in 5-year disease-free survival (DFS) between the two groups: 87.8% in the no-ALND group versus 84.4% in the ALND group. Axillary recurrence rates were also extremely low (around 1% in both arms). The study concluded that avoiding ALND in patients with SLN micrometastases, particularly those receiving adjuvant therapies like radiation or systemic treatment, did not compromise outcomes.
45
46
What are the indications for neoadjuvant radiation for breast cancer?
Locally advanced TNBC HER2+ High risk HR+ Downstage and BCS desired
47
When is adjuvant chemotherapy recommended for breast cancer ?
Hormone positive

Phase 2 (12 decks)

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