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Oral Boards > Breast > Flashcards

Breast Flashcards

1
Q

ASTRO APBI “Suitable” Criteria

A

age ≥50

Tis or T1

margins ≥3 mm

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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

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3
Q

ASTRO APBI “Unsuitable” Criteria

A

age <40

positive margins

DCIS >3cm

age 40-49 and does not meet cautionary criteria

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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

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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

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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.

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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.

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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

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9
Q

Breast: indications for chemo

A

Her2+

triple negative

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

node positive

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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?

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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)

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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%

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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

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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

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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

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16
Q

Breast: outcomes for early stage

A

10yr LR 6%

10yr OS 85%

(EBCTCG)

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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

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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

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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%

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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
Q

Breast T1b

A

>5mm - ≤10mm

26
Q

Breast T1c

A

>10mm - ≤20mm

27
Q

Breast T2

A

>2cm - ≤5cm

28
Q

Breast clinical N1

A

mobile axillary nodes

29
Q

Breast clinical N1mi

A

micrometastases (aprox 200 cells, 0.2mm-2mm)

30
Q

Breast clinical N2a

A

fixed axillary nodes

31
Q

Breast clinical N2b

A

IMN nodes without axillary nodes

32
Q

Breast clinical N3a

A

infraclavicular nodes

33
Q

Breast clinical N3b

A

IMN and axillary nodes

34
Q

Breast clinical N3c

A

supraclavicular nodes

35
Q

Breast path N1a

A

1-3 axillary lymph nodes (at least one >2mm)

36
Q

Breast path N1b

A

positive IMN sentinel node (excluding ITCs)

37
Q

Breast path N1c

A

1-3 axillary nodes with positive IMN sentinel node (N1a + N1b)

38
Q

Breast path N2a

A

4-9 axillary lymph nodes

39
Q

Breast path N2b

A

clinically detected IMN nodes

40
Q

Breast path N3a

A

10 or more axillary nodes

41
Q

Breast path N3b

A

axillary nodes and IMN involvement (either clinical or pathological)

42
Q

Breast path N3c

A

supraclavicular nodes

43
Q

Breast anatomic IA

A

T1N0

44
Q

Breast anatomic IB

A

T0-1 N1mic

45
Q

Breast anatomic IIA

A

T0-1N1 or T2N0

46
Q

Breast anatomic IIB

A

T2N1, T3N0

47
Q

Breast anatomic IIIA

A

T3 or N2

48
Q

Breast anatomic IIIB

A

T4

49
Q

Breast anatomic IIIC

A

N3

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