Breast Flashcards

1
Q

ASTRO APBI “Suitable” Criteria

A

age ≥50

Tis or T1

margins ≥3 mm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

ASTRO APBI “Cautionary” Criteria

A

40-49 years and all other suitable criteria are met

OR age ≥50 and at least one of:

size 2.1-3.0 cm

T2

margin <2mm

limited/focal LVSI

ER-

ILC

any DCIS ≤3 cm if suitable criteria not met

EIC ≤3 cm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

ASTRO APBI “Unsuitable” Criteria

A

age <40

positive margins

DCIS >3cm

age 40-49 and does not meet cautionary criteria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Breast: Workup

A

H&P with breast/node exam (extra history: prior RT, collagen vascular dz, menopausal status, pregnancy status) Labs: CBC, LFTs, alk phos, beta-HCG. BRCA for young age or direct family history Imaging primary: diagnostic mammogram (magnification for calcs, spot compression for questionable mass), US with core needle bx. Evaluation of ER/PR/Her2. If invasive breast cancer patients with ER/PR+ and tumor size 0.5 cm or greater, order Oncotype MRI potential indications: DCIS, unknown primary (axillary node or pageats), neoadjuvant chemo planned, dense breasts, to assess for extent of multicentric or multifocal disease especially if unsure about lumpectomy Imaging staging: CXR. Bone scan and CT only for Stage III. PET scan increasing in use

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Breast: Contraindications to lumpectomy (RT)

A

Absolute: pregnancy, large surgery that would result in poor cosmesis, diffusely/persistent positive margins, diffuse calcifications

Relative: prior RT, active connective tissue disease (esp scleroderma and lupus), T3 category 2B, positive margin (prefer re-excision), BRCA or other genetic predisposition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Breast: 3D conformal tangents

A

Supine, breast board, wire scar and both breasts, bolus if skin involvment. Set tangents in middle of field, put iso in middle of tangents. Add 0.7cm for breast PTV and crop breast PTV eval off chest wall and 0.5cm off skin.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Breast: Boost setup

A

Seroma plus clips, 1 cm CTV, 0.7cm PTV. Use 2-3 field photons or electrons to 80-90% idodose line.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Breast: when to treat nodes post-lumpectomy

A

One way: 4 nodes positive or 1-3 nodes and medial tumor

Another way: any nodes positive

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Breast: indications for chemo

A

Her2+

triple negative

ER/PR+ that is >0.5 cm and had high Oncotype

node positive

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Breast: considerations for each case

A

Should I check BHCG?

Should I do neoadjuvant chemo?

Is lumpectomy or mastectomy indicated?

Is chemo indicated?

Special Her2+ chemo?

Is RT indicated?

Should I boost?

Is RNI indicated?

Is adjuvant HT indicated?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Breast: DCIS treatment paradigm

A

Lumpectomy or total mastectomy (consider SLNBx if mastectomy) Strongly favor XRT for grade 3, ER/PR negative, or young age 40Gy/15fxs +/- boost (grade 3, <2mm margin, comedonecrosis, age<50, ER/PR negative) Adjuvant Tam. Aromatase inhibitor if postmenopausal and age 50-60 (NSABP-35)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Breast:conventional whole breast dosimetry (coverage, max hot spot, lung V20, heart mean, contralateral breast max)

A

95/95 coverage of PTV eval

max hot spot 107%

no large 105% hotspots

lung V20<30%

heart mean <4Gy

contra breast max <4Gy

BOOST:

50% of breast gets at least 90% dose <1/3 breast gets 100%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Breast: follow up

A

imaging and/or exam every 6 months for two years then anually annual GYN exam if on tamoxifenimaging and/or exam every 6 months for two years then anually annual GYN exam if on tamoxifen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Breast: indications for hormones

A

ER+ Premenopausal: tamoxifen 10 years OR tam then AI for 5+5 years if becomes postmenopausal

Postmenopausal: AI for 5 years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Breast: hypofractionation dosimetry

A

95/95 coverage

105% volume should be minimized

contralateral breast <2.4 Gy

<15% ipsi lung>16 Gy

<10% contra lung>4 Gy

<5% of heart >16 Gy if left sided

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Breast: outcomes for early stage

A

10yr LR 6%

10yr OS 85%

(EBCTCG)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Breast: chemo regimens

A

Her2-: ddAC (q 2 weeks x 4 cycles) + Taxol, neulasta support

Her2 +: AC/paclitaxol/herceptin (not dose dense) give taxol 4mg starting dose with first day of taxol, and continue weekly x 1yr

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Breast: APBI brachy dose, volumes, dosimetry

A

34Gy/10fxs BID over 5 days

If using SAVI then may need to place dummy at time of surgery CT simulation with breast board.

CT sim or scout prior to each treatment to confirm position of device. 1.5cm expansion, crop 0.5cm from skin

Mammosite/SAVI (NSABP-B51)

skin<145% V90>90% V200<20cc V150<50cc no criteria for lung no criteria for rib

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Breast: APBI EBRT dose, volumes, dosimetry

A
  1. 5Gy/10fxs BID over 5 days
  2. 5cm CTV
  3. 0cm PTV

crop PTV eval off chest wall and 0.5cm skin

EBRT (NSABP-B51)

ipsi lung: V30% dose<15%

contra lung: V5% dose<30%

Heart, right: V5%<5%

Heart, left: V5%<40%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Breast: double isocenter narrative

A

The patient would be placed in the supine position with breast board. A supraclavicular field would be created using a half beam block at the inferior edge with the isocenter placed at this level. For the tangent field, a second isocenter would be placed at the midpath of the tangents, about 1 cm anterior to the chest well. For the tangents, the couch would be moved away from the gantry and collimator rotated to align the cranial edge of the tangents with the supraclavicular field. The lung would be blocked using MLCs. Alternatively, can rotate the collimator so that the jaw of the collimator blocks the lung in the tangent field, then use MLCs to block the portion of the tangents overlapping the SCV field.

21
Q

Inflammatory breast cancer: workup, treatment paradigm

A

PET and CT C/A/P neoadjuvant chemo -> mastectomy -> PMRT with regional node irradiation 50 Gy plus 10-16 Gy boost, bolus skin!

For poor response to neoadjuvant chemo, consider pre-op treatment with 51 Gy in 1.5 BID plus 15 Gy boost OS 50%

22
Q

Breast: ddAC+T dose and schedule

A

Doxo 60mg/m2 and Cyclophosphamide 600mg/m2 on day 1. q14 days x 4 cycles with neulasta support.

Paclitaxel 80 mg/m2 weekly x 12 week.

Or Paclitaxel 175 mg/m2 day 1, Q14 days x 4 cycles.

23
Q

Breast: chemo regimen for Her2+

A

AC (60/600) q 3 weeks x 4 followed by paclitaxel weekly (80) x 12.

Start Trastuzumab 4mg/kg with the first dose of paclitaxel then 2 m2/kg weekly during paclitaxel. Then every 3 weeks (6mg/kg) for 1 year.

If doing pertuzumab: Loading dose of 840 mg pert and 8 mg/kg tratuzumab followed by 420 pert and 6 mg/kg tratuzumab every 3 weeks, with 80 mg/m2 paclitaxel weekly for FOUR CYCLES then back to q3 week tratuzumab until 1 year tratuzumab TNBC or BRCA mutation: use platinum regimen

24
Q

Breast T1a

A

>1mm - ≤5mm

25
Breast T1b
\>5mm - ≤10mm
26
Breast T1c
\>10mm - ≤20mm
27
Breast T2
\>2cm - ≤5cm
28
Breast clinical N1
mobile axillary nodes
29
Breast clinical N1mi
micrometastases (aprox 200 cells, 0.2mm-2mm)
30
Breast clinical N2a
fixed axillary nodes
31
Breast clinical N2b
IMN nodes without axillary nodes
32
Breast clinical N3a
infraclavicular nodes
33
Breast clinical N3b
IMN and axillary nodes
34
Breast clinical N3c
supraclavicular nodes
35
Breast path N1a
1-3 axillary lymph nodes (at least one \>2mm)
36
Breast path N1b
positive IMN sentinel node (excluding ITCs)
37
Breast path N1c
1-3 axillary nodes with positive IMN sentinel node (N1a + N1b)
38
Breast path N2a
4-9 axillary lymph nodes
39
Breast path N2b
clinically detected IMN nodes
40
Breast path N3a
10 or more axillary nodes
41
Breast path N3b
axillary nodes and IMN involvement (either clinical or pathological)
42
Breast path N3c
supraclavicular nodes
43
Breast anatomic IA
T1N0
44
Breast anatomic IB
T0-1 N1mic
45
Breast anatomic IIA
T0-1N1 or T2N0
46
Breast anatomic IIB
T2N1, T3N0
47
Breast anatomic IIIA
T3 or N2
48
Breast anatomic IIIB
T4
49
Breast anatomic IIIC
N3