Breast Flashcards
What are contraindications for breast conserving therapy?
Dose and constraints for RT CHARM?
Plan eval (for hypofractionated Rx 42.56Gy/16):
V115%<0.3cc (Dmax)
V107% <10cc
Contra breast V3Gy<10% (preferred), V5Gy<10% (acceptable)
Lung V18Gy≤35% (≤40% acceptable)
Heart mean≤3Gy (preferred), ≤5Gy (acceptable)
Heart V22.5Gy<10% (Left-sided), V22.5Gy<2% (Right-sided)
Hypofract breast constraints 40/15fx?
Heart (left): V16<5%, V8<30%
Heart (right): V16<0% and V8<10%
Ipsi lung: V16<15%
Contra Lung: V4<10%
Contra breast: Max 2.4Gy
APBI dose constraints?
Ipsi breast: V15<50%
Ipsi lung: V10<20%
Contra lung: V5<10%
Conta breast: Dmax <1Gy
Heart V3<10%
Who needs ALND after SLNB?
3+ LN+
T3/T4 primary
Preop chemo
WBRT not planned
Sentinal LN not identified
MA20 trial (NEJM 2015)?
NCIC MA20 (NEJM 2015): lump+ALND then: WBRT +/- RNI (IM, SCV, ax)
pN+ on ALND or N0 + “high risk features” (T3N0 or T2N0 AND < 10 nodes removed AND ER- or grade 3 or +LVI)
10yr DFS: 82% vs 77% (SS), distant DFS: 86% vs 82% (SS), isolated LRR-free survival: 95% vs 92% (SS)
No Diff 10yr OS: ~82%
EORTC 22922 (NEJM 2015)?
+/- RNI (IM, SCV)
pN+ or central/medial tumor, 75% BCS, 25% mastectomy; 45% LN+
10 yr: DFS: 72% vs 69% (SS), distant DFS 78% vs 75% (SS), BCM 12.5% vs 14.4% (SS)
No diff 10yr OS (80%)
If planning neoadj chemo what do you need to do beforehand?
Clip primary and nodes
MRI breast
What are preop chemo regimens?
ddAC: adriamycin/cyclophosphamide –> paclitaxel q2 weeks each for 4 cycles
Chemo for high risk TNBC? What if no CR?
pembro+carbo/taxel followed by pembro+cyclophosphamide/adriamycin(doxorubicin), followed by adj pembro.
neoadjuvant phase lasts about 24 weeks (6 months), and Keytruda continues for a total of 1 year when including the adjuvant phase.
High-risk TNBC = T1c N1-2, or T2-4 N0-2 (Keynote 522) 65% pCR w/ this regimen (vs 51% w/o pembro)
Capecitabine for patients w/o pCR to NAC capecitabine AFTER RT (not concurrent!) CREATE-X Trial showed OS benefit to adding capecitabine in TNBC pts w/o pCR.
Capecitabine 1000-1250mg/m2 BID d1-14 Q3wks for 6-8 cycles to start after RT
Who gets adjuvant abemaciclib with endocrine tx?
HR+ Her2- high risk (> 4 +LN or 1-3 +LN, and grade 3 or > 5 cm: 2 years abemaciclib (CDK 4/6 inhibitor) with endocrine tx (The absolute improvements in 3-year IDFS and DRFS rates were 5.4% and 4.2%)
What chemo for HER-2+? What if no CR?
TCHP: docetaxel, carboplatin, herceptin, pertuzumab. If CR then 1yr of HP. Given q3 weeks x6c.
If residual disease after NAC: Ado-trastuzumab emtansine aka Kadcyla aka TDM-1 ( category 1)
What makes you stage IIIA, IIIB, and IIIC breast staging?
N2 or T3N1; T4; N3.
What breast pts get neoadjuvant chemotherapy?
TNBC and HER-2+ if >=T2 or N+
IBC
cN2 bulky or matted nodes
cN3
cT4
Hypofract breast constraints 40/15fx?
Heart (left): V16<5%, V8<30%
Heart (right): V16<0% and V8<10%
Ipsi lung: V16<15%
Contra Lung: V4<10%
Contra breast: Max 2.4Gy
What is a modified radical mastectomy?
Modified radical mastectomy = remove breast , pec fascia, lvl I-II.
What is cN2a, cN2b, cN3a, cN3b, and cN3c?
N2a: clinically fixed or matted
N2b: clincally detected IMN without axillary LNs
N3a: ICV nodes
N3b: IMN and axillary nodes
N3c: SCV nodes
What % convert to BCT with neochemo? pCR rate?
2/3
25%
When do you give CDK4/6 inh?
4+LNs; N+ and G3 or >5cm
How is ddACT-T and TCHP given? Ribociclib? Olarparib? Capecitabine?
q2wks x4 cycles-q2weeksx4cycles
q3wks x 6 cycles; HP q3wks for complete 1 year
q3wks for 3yrs
q28d for 1yr
q21d for 6-8 cycles
Who needs ALND?
Palpable node at dx or 3+ suspicious nodes on imaging or not meeting Z11. So, T3/4 get dissection.
Phylloydes managment?
Tumors >2cm after lumpectomy or >10cm after mastectomy have LC <85% so consider RT.
