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FRCR2 > Breast > Flashcards

Breast Flashcards

1
Q

What are the molecular subtypes of breast cancer

A

Luminal A - ER+, HER2-
Luminal B - two types
ER+/HER2- and PR- or KI67 high
ER+/HER2+
Non-luminal HER2+ - ER-/HER2+
Triple negative (ER-/PR-/HER2-)

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2
Q

How is DCIS risk assessed
What factors are included

A

Van Nuys Prognostic index
Size (<15mm, >40mm), margin (>10mm, <1mm), grade/histology (Gr1-2 no necrosis, grade 3), age (<40, >60)

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3
Q

What is the management of DCIS

A

Based on Van Nuys prognostic index
4-6 -> WLE only

7-9 -> WLE + SLNB if large (5cm) or high risk
+/- Adjuvant whole breast RT (26Gy/5#, or tamoxifen if decline)

> 10 -> Mastectomy & SLNB

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4
Q

When is a mastectomy indicated for DCIS

A

Disease in ≥2 quadrants, or if clear margins can’t be obtained with WLE (curative if clear margins)

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5
Q

What is the follow up after DCIS

A

annual mammogram for 5yrs

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6
Q

Who gets adjuvant endocrine therapy

A

All ER+ pts, regardless of HER2 status and stage, after adj ChT. improves OS

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7
Q

Indications for adjuvant bisphosphonates in breast cancer

A

Post-MP women receiving neo-adjuvant or adjuvant chemotherapy
Pre-MP pts receiving OFS

For up to 5yrs

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8
Q

Duration of endocrine treatment in post-MP pts

A

High risk (Gr3, Node positive, T3) - 10yrs
Med/low risk - 5yrs

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9
Q

Duration of endocrine treatment in pre-MP pts

A

10yrs (5yrs minimum)

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10
Q

Indications for breast conserving surgery (WLE)
And what is the acceptable margin

A

T2 disease or less (<5cm tumour)
Operable multifocal disease in single quadrant

Acceptable margin - 1mm (2mm for DCIS) -> re-excision or mastectomy (or consider RT + boost)

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11
Q

Indications for mastectomy

A

Pt related: Patient choice, Pregnancy

RT CI: scleroderma, pre-existing cardiac/lung disease, reduced shoulder movement
Or previous RT to breast

Site: Multifocal, Central tumour

Tumour: > 5cm (T3-4), Inflammatory breast cancer, Extensive DCIS

Prophylactic in BRCA carrier

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12
Q

Indications for post-operative RT
What is the benefit of post-op breast RT?
What is the dose

A

All breast conserving surgery (unless low risk - T1, node negative, Gr1, ER+, and 5yrs endocrine therapy and 10yrs mammogram)

Benefit
N+ pts: Decrease in local recurrence risk 21%; 15yr risk of death reduced by 8%
N- pts: Decrease in local recurrence risk 15%; 15yr risk of death reduced by 3%

26Gy/5# (can consider 28.5Gy/5# over 5wks if frail / co-morbid)

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13
Q

When can post-op whole breast RT be avoided?

A

> 70yrs, T1N0 (stage 1A), ER+/PR+, Gr1-2 and pt will take endocrine therapy for 5yrs and have mammograms for 10yrs

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14
Q

Indications for tumour bed boost RT
Dose
Benefit

A

Positive margins (<1mm) and further resection not possible
All <50yrs
Consider for high risk - G3, DCIS, TNBC

Dose: SIB - 48Gy/15# with 40Gy/15 to whole breast
Or sequential boost of 13.35Gy/5# or 16Gy/8# following 26Gy/5#

Reduction in risk of local recurrence by 4%
No benefit on OS.

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15
Q

Indications for chest wall RT after mastectomy
Dose
Benefit

A

Absolute indications:
T3-4, ≥4 LNs (N2), positive margin (<1mm) or residual disease after NACT in the axilla or breast

Relative indications:
High risk T2 or N1 (1-3 LNs) - Gr3 or LVSI;
Multifocal with largest tumour >2cm (T2)

26Gy/5#

Reduces local recurrence by 20% in high risk groups
8% survival benefit at 10yrs
No benefit for node negative pts

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16
Q

When is internal mammary nodal RT indicated

A

T4 disease,
N2 - ≥4 axillary LN

N1 (1-3 axillary nodes) & INNER/CENTRAL quadrant tumour

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17
Q

When is SCF RT indicated in breast cancer

A

N2 disease (>4 axillary LNs)
N1 (1-3 axillary nodes), and G3 / LVI+ / T3 disease, age <50, TNBC
≥ypN1 following NACT

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18
Q

What is the indication for olaparib in breast cancer adjuvant setting

A

Adjuvant monotherapy for ER+ HER2- or triple negative breast cancer, treated with NACT or adjuvant chemotherapy, in those with BRCA1/2 mutations and PS 0-1

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19
Q

What is the indication for abemeciclib in breast cancer adjuvant setting
Benefit

A

Adjuvant treatment of hormone receptor positive, HER-2 negative, node-positive breast cancer at high risk of recurrence, defined as either:
N2 (>4 pALN) , or N1 (1-3 pALN) and either tumour ≥5cm (T3) or Gr3

given for 2yrs with AI

6% increase in invasive disease free survival at 4yrs

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20
Q

When is an oncotype score done in breast cancer

A

If >T1a and node negative, ER+ HER2- disease
Or Nottingham prognostic index >3.4

Over 50yrs: if oncotype <25 - no chemo; >26 - chemo
<50yrs: 21-25 - consider chemo, >26 - chemo

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21
Q

What are the indications for Neo-adjuvant chemotherapy?

A

HER2+ and ≥T2 (≥2cm) or node positive
T3-4 disease
Node positive disease
Triple negative breast cancer
Inflammatory breast cancer

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22
Q

What Neo-adjuvant regime is given to HER2+ breast cancer ≥T2 or node positive

A

Acc EC x3 followed by docetaxel x4
Or carboplatin/docetaxel x6
With Phesgo (trastuzumab/pertuzumab)

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23
Q

When is TDM-1 (Kadcyla) indicated
Based on what trial

A

For residual disease, up to 14 cycles, after NACT and HER2-directed treatment and surgery/RT, in HER2+ early breast cancer
Based on Katherine trial - decreased risk of death and 10% improvement in invasive disease free survival

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24
Q

When is neratinib indicated

A

For the extended adjuvant treatment of stage 2-3B (T2 or N+) HR+/HER2+ EBC in those who completed adjuvant trastuzumab monotherapy less than one year previously
AND did not receive NACT
OR still had residual invasive disease in the breast or axilla following NA-treatment

Given orally for one year

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25
Q

What is the benefit of trastuzumab and based on what trial

A

Hera trial
1yr trastuzumab reduces risk of recurrence by 50% vs observation
8% absolute survival benefit

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26
Q

When can a shorter duration of trastuzumab be considered and based on what trial

A

HER2+ EBC, post NACT with pCR
6mth can be considered instead of 12mths for T1-2 disease with no aggressive characteristics
Based on Persephone trial

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27
Q

When is Phesgo (trastuzumab/pertuzumab indicated)

A

With neoadjuvant ChT for HER2+ EBC, continued for 6-12mths adjuvantly if initially node positive disease
6mth can be considered instead of 12mths for T1-2 disease with no aggressive characteristics

Given adjuvantly for those found to be node positive (pN+) but who did not receive NACT

Metastatic setting - given until progression

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28
Q

BRCA1
Chr & Inheritance
What cancers are increased in risk and by how much

A

Chr 17 - AD inheritance
Lifetime risk of breast cancer 45-60%, typically TNBC
Ovarian cancer 15%

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29
Q

BRCA2
Chr & Inheritance
What cancers are increased in risk and by how much

A

Chr 13 - AD inheritance
Breast cancer lifetime risk 55-85%, usually ER+
Ovarian cancer risk 60%

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30
Q

What is the risk of contralateral breast cancer with BRCA mut?
What is the monitoring

A

60% (vs 7% in general population).
Annual MRI from age 30yrs

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31
Q

Breast cancer screening criteria
and what is the outcome

A

Between 50-70yrs - every 3yrs
Can request if >70yrs, but not routinely invited
10% are recalled, 1% require biopsy and 0.5% have cancer

32
Q

What is the screening for those with a BRCA mutation

A

Annual MRI age 30-39
Annual mammogram age 40-69
As per population screening >70yrs

33
Q

What is the screening for those with a TP53 mutation

A

Annual MRI age 20-49
Consider MRI age 50-69

34
Q

When is a staging CT abdo/pelvis indicated for breast cancer

A

N2 (≥4 LNs)
Tumour >5cm (T3)
Aggressive biology
Suspicion of mets

35
Q

What are the axillary lymph nodes

A

Level 1: Lateral to pec minor
Level 2: Deep to pec minor
Level 3: Superior or medial to pec minor

36
Q

What is the CTV for chest wall RT

A

CTV - skin flaps and scar, extending to deep fascia posteriorly, and excluding muscle and rib cage

37
Q

What is the CTV for a tumour bed boost
CTV-PTV margin

A

CTV - clips and tumour bed
PTV margin = CTV +5-10mm

38
Q

What is the dose constraint for breast RT - ipsilateral lung

A

V30Gy <17%
V18Gy <15% for two fields & <30% for 3 fields

39
Q

What is the dose constraint for breast RT - heart

A

V13Gy <10%
V25Gy <5%
Mean dose ≤2Gy

40
Q

What is the dose constraint for breast RT - brachial plexus

A

Max dose <40Gy (as 2.67Gy/#)

41
Q

What is the dose constraint for breast RT - spinal cord

A

Max dose <37Gy (as 2.67Gy/#)

42
Q

What techniques exist to minimise cardiac dose / toxicity

A

DIBH
MLC cardiac shielding
Wide tangent technique

43
Q

What test must be sent in metastatic TNBC, and why

A

PDL1
If >1% - give abraxane and atezolizumab (de novo metastatic disease only)
or Pembrolizumab-ChT if CPS >10
ChT - nab-paclitaxel, paclitaxel, gemcitabine or carbo/gem, if de-novo mBC or progression after >6mths of adjuvant tx

44
Q

What is given in metastatic TNBC for gBRCA-mut

A

PARP inhibitor - tucatinib or olaparib

45
Q

What would a skin biopsy show for inflammatory breast cancer

A

Dermal lymphatic invasion

46
Q

Where do phylloides tumours typically metastasise to
How are they typically treated

A

Lungs
Referral to sarcoma unit
WLE with wide margins, or mastectomy (preferred)
No need for ALND (don’t spread to LNs)

47
Q

The rates of what are higher with the addition of pertuzumab to trastuzumab & docetaxel in metastatic HER2+ breast cancer

A

Febrile neutropaenia
≥Gr 3 Diarrhoea

48
Q

When is internal mammary node irradiation indicated

A

T4 disease
≥4 axillary nodes positive

Or 1-3 axillary nodes AND inner quadrant tumour

49
Q

How should doxorubicin be dosed in liver impairment

A

Serum Bilirubin 20 – 50 micromol/L use 50% normal dose
Serum Bilirubin 50-85 micromol/L use 25% normal dose
Serum bilirubin >85 micrimol/L avoid use

50
Q

When should staging be considered

A

T3 or N2 disease in general

51
Q

What is needed at diagnosis of lobular breast cancer
Where do they tend to recur
How does the prognosis compare

A

Bilateral MRI as it can be bilateral involvement in 20-30%
Tend to recur at pleural / pericardial surfaces

Survival curves cross at 10yrs and then lobular does worse

52
Q

who receives a boost in adjuvant RT

A

All pts <50
positive margins
high risk (Gr 3 or intraductal components)

53
Q

DCIS management

A

If untreated, 30-50% develop invasive breast cancer within 10 years

WLE +/- RT (If Van Nuys prognostic index score 7-9)
Surgery - Aim for margin ≥1mm; NICE guidelines = ≥2mm
Adjuvant whole breast RT - 26Gy/5#
Reduces local recurrence following BCS but no effect on OS (2013 systematic review)
Not for SLNB unless large (>5cm) or high risk DCIS
Consider omitting in low grade DCIS - (<10mm, low / intermediate nuclear grade, adequate surgical margins)

Mastectomy & SLNB
Indication: disease in ≥2 quadrants, or if clear margins can’t be obtained with WLE
Total mastectomy with clear margins in DCIS is curative

Endocrine therapy
Offer Tamoxifen/AI (post-MP) to pts who have WLE and decline adjuvant RT
Consider for patients having WLE alone (i.e. RT not recommended) - small reduction in ipsilateral / contralateral recurrence

Follow-up: Post DCIS tx, annual mammogram for 5yrs

54
Q

what is the Nottingham prognostic indicator calculation

A

Prognosis following surgery and RT
0.2 x Size + Grade + Nodes (0 LN = 1, 1-3LN = 2, 4+ LN = 3)

55
Q

Does doxorubicin need to be dose reduced in renal impairment

A

no

56
Q

What are the referral criteria due to breast cancer in relatives

A

Age at diagnosis <40
 Bilateral breast cancer or ipsilateral second primary breast cancer
 Personal history of ovarian cancer (any age)
 First degree relative with breast or ovarian cancer (any age)
 Second degree relative with male breast cancer (any age)
 Two or more first or second degree relatives with breast and/or ovarian cancer (any age)
 Male sex

57
Q

What numbers for breast staging

A

2 & 5
T1 <2cm
T2 2-5cm
T3 >5cm
T4 - local invasion - chest wall or skin

58
Q

What is the absolute risk reduction for whole breast RT in node positive disease & node negative disease

A

N+: 10yr recurrence - 20% improvement from 60% to 40%

N-: local recurrence rate halved from 30% to 15%

59
Q

What is the indication for partial breast RT

A

> 50yrs, Gr1-2, ER+/HER2-, N0, <3cm, clear margins, LVSI negative and will have endocrine therapy for 5yrs

60
Q

What is the side effect of Enhertu (trastuzumaab deruxtecan)

A

ILD

61
Q

Draw out axillary management diagram

A

x

62
Q

Draw out HER2+ early breast cancer management diagram

A

x

63
Q

Draw out ER+ HER2- early breast cancer management diagram

A

x

64
Q

Draw out triple negative early breast cancer management diagram

A

x

65
Q

Draw out HER2+ metastatic breast cancer management diagram

A

x

66
Q

what determines 1st line management for metastatic HER2+ breast cancer

A

suitability for docetaxel

67
Q

Draw out TN metastatic breast cancer management diagram

A

x

68
Q

What are the borders for Chest wall RT

A

midline to mid axillary line
sternal notch or 2cm above contralateral breast tissue
2cm below inferior mammary fold contra laterally

69
Q

What are the borders for axillary RT

A

Ipsilateral vertebral bodies to humeral head (inclusive) laterally
3cm above medial head of clavicle
0.5cm below

70
Q

What are the borders for SCF RT

A

Ipsilateral vertebral bodies to medial 2/3 of clavicle
3cm above medial head of clavicle
0.5cm below

71
Q

What are the borders for internal mammary chain RT

A

Outline mammary vessels
Grow by 5mm to form CTV
Grow further 5mm for PTV
First 3 intercostal spaces

72
Q

what is given adjuvantly for a recurrence of breast cancer

A

Adjuvant taxane following surgery for recurrence

73
Q

When is neoadjuvant treatment not given in early TNBC

A

T1a-b (<1cm)
Straight to surgery +/- RT

74
Q

When is neoadjuvant treatment given in early TNBC, and what is the regimen

A

≥T1c or N+
If T1c - carbo/taxol & EC, then surgery +/- RT
If T2 or N+ - carbo/taxol & EC, with pembro, then surgery +/- RT

75
Q

when should a genetic referral be done

A

<40yrs
male
bilateral breast cancer or sequential contralateral primary
hx of ovarian cancer

First degree relative with breast or ovarian cancer (any age)
Second degree relative with male breast cancer (any age)
two or more first or second degree relatives with breast and/or ovarian cancer (any age)

FRCR2 (38 decks)

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