Breast Flashcards
Breast Cancer:
Early stage and Locally advanced definition
●Early stage – This includes patients with clinical stage I, IIA, or a subset of stage IIB disease (T2N1).
●Locally advanced – This includes a subset of patients with clinical stage IIB disease (T3N0) and patients with stage IIIA to IIIC disease.
Breast Cancer - percent of patients presenting with metastatic disease
5%
Criteria that preclude Breast Conserving therapy (6)
●Multicentric disease
●Large tumor size in relation to breast
●Presence of diffuse malignant-appearing calcifications on imaging (ie, mammogram or magnetic resonance imaging [MRI])
●Prior history of chest RT (eg, mantle radiation for Hodgkin disease)
●Pregnancy
●Persistently positive margins despite attempts at re-excision
EBCTCG “Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials” Lancet 2014 PMID 24656685
Based upon the Early Breast Cancer Trialists’ Collaborative Group meta-analysis of 3786 women with invasive breast cancer undergoing an axillary dissection and mastectomy, there was a reduction in recurrences for node-positive women ([n = 1314, one to three nodes positive] and [n = 1772, four or more nodes positive]) undergoing postmastectomy radiation, but not for node-negative women
ACOSOG Z0011
Giuliano Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA 2011
PMID 21304082
Patients who have one or two pathologically involved sentinel nodes may not require a complete axillary node dissection [11]. However, whether or not patients with three or more pathologically involved sentinel nodes should undergo an axillary node dissection is best determined on an individualized basis, taking into account all other tumor risk factors and the patient’s performance status and comorbidities.
Size cutoff for chemo based on Breast Cancer receptor type:
ER/PR+ : >5mm with high risk onclotype Dx
HER2+ : >1cm definitly (smaller is controversial)
-/-/- : >5mm
National Surgical Adjuvant Breast and Bowel Project (NSABP) 18 trial
administration of the same chemotherapy in the neoadjuvant versus adjuvant setting is associated with similar outcomes
Rastogi J Clin Oncol 2008 PMID 18258986
Adjuvant Chemo if a full neoadjuvant chemotherapy course was completed for Breast Cancer:
ER/PR+: endocrine alone
-/-/-: none
HER2+: one year of transtuzumab
Adjuvant therapy if a full neoadjuvant endocrine therapy course was completed for Breast Cancer:
Completion of adjuvant endocrine therapy (5 years or more)
Hamaker - Omission of surgery in elderly patients with early stage breast cancer - Eur J Cancer 2013
For some patients with estrogen receptor (ER)-positive breast cancer, in whom surgery is not an option or life expectancy is limited, primary hormonal treatment with either tamoxifen or an aromatase inhibitor without surgery or radiation therapy (RT) can be used [14]. We prefer to individualize treatment based on the presence of medical comorbidities and patient and clinician preference
management of a simple breast cyst
observation
definition of a simple breast cyst (4)
anechoic
well-circumscribed
smooth walls
posterior enhancement
Management of a complex breast cyst
repeat US in 6 months
Management of a breast cyst with a solid component
needs biopsy;
23% risk of malignancy
management of ADH on needle biopsy
Needs needle loc biopsy; 15% cancer or dcis
10 year risk of breast cancer after ADH is excised
17%
NSABP P1 trial
tamoxifen reduces the risk of developing breast cancer for patients with ADH by 86%
STAR trial (NSABP P2)
Study of tamoxifen and raloxifene - raloxifen provides similar risk-reduction as tamoxifen with less toxicity (endometrial cancer)
first step to work-up bloody nipple discharge
ductogram
what do you do if there is a persistent concern for malignancy with blood nipple discharge and a negative ductogram
excision
sensitivity of nipple discharge cytology
34-46% (poor)
NCCN recommended screening after breast cancer treatment?
Mammograms only
No evidence to support what screening for breast cancer survivors?
tumor markers CT Bone Scans PET (Part of Choosing Wisely Campaign)
Mechanism of Taxanes
Inhibit the spindle cell apparatus needed for mitosis
Mechanism of Cyclophosphamide
alkylating agent - forms DNA cross-linkages
Mechanism of Doxorubicin
interferes with topoisomerase II
mechanism of 5-FU
nucleotide analog
mechanism of trastuzumab
antibody against EGFR
When do you do metastatic work-up for Breast Cancer
for clinical stage III disease; ASCO guidelines; even for other bad prognostic factors like triple negative tumors
Treatment for recurrent breast cancer?
do metastatic work-up Excise RT - if it hasn't been given yet hormonal therapy if receptors there Consideration of adjuvant chemotherapy
Treatment order for stage III breast cancer when pregnant?
Neoadjuvant Chemo
lumpectomy with SLNB +/- ALND
Deliver baby
XRT
Treatment for occult primary breast cancer
Get MRI first; if still occult then need
Modified Radical Mastectomy (Breast and ALND)
some in Europe would just do total breast XRT
Key molecular marker of Lobular carcinoma
lacks e-cadherin
Treatment for inflammatory breast cancer
Neoadjuvant Chemo
Modified Radical Mastectomy
Chest Wall Radiation
Endocrine Therapy (if receptor positive)
Can you do a SLNB for inflammatory breast cancer?
No! high False negative rate, and nearly all patients will have nodal involvement at the time of diagnosis.
Can you do brachytherapy or partial breast irradiation for a patient with positive SN?
No
ASTRO consensus on accelerated partial breast irradiation?
look up
Guidelines for nipple sparring mastectomy
look-up
Which has higher rate of flap loss TRAM or DIEP flap?
TRAM
Use of acellular dermal matrix in breast reconstruction increases risk of
seroma infection and reconstruction failure
Did ACOSOG Z011 include men?
no, so can’t apply criteria, and all SN+ men should get ALND for breast cancer
gynecomastia and a testicular mass?
Sertoli cell tumor until proven otherwise
High penetrance genes for breast cancer
PTEN and p53
moderate risk genes for breast cancer
CHEK
ATM
PALB2
risk reduction for lymphedema
lift weights
early arm mobilization
lose weight
distal surgery after ALND ok?
yes, no increased risk in lymphedema rates
Role of lymphedema sleeves
Help control symptoms but don’t prevent before it develops.
Family history of breast cancer work-up
Test the effected members first. If a gene (BRCA) is identified, then prophylactic surgery on gene positive individuals only
If no gene found, then can council on prophylactic surgery for all.
screening after prophylactic mastectomy?
Physical exam only.
Relative indications for breast MRI
BRCA (these tumors are often missed on mammo)
dense breasts
primary peritoneal carcinoma
associated with BRCA; treated like ovarian cancer
NCCN guidelines for screening BRCA patients (if no surgery)
Mammography and MRI yearly, staggered by 6months (complimentary tests)
Black women and breast cancer
higher incidence after age 40
higher mortality even when matched for stage
more likely to be ER negative or triple negative
