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Breast Flashcards

1
Q

Breast anatomic IA

A

T1N0

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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

Breast clinical N2a

A

fixed axillary nodes

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4
Q

Breast: outcomes for early stage

A

10yr LR 6%

10yr OS 85%

(EBCTCG)

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5
Q

Breast T1c

A

>10mm - ≤20mm

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6
Q

Breast T2

A

>2cm - ≤5cm

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7
Q

Breast anatomic IIIA

A

N2, T3N1

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8
Q

Breast path N3b

A

axillary nodes and IMN involvement (either clinical or pathological)

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9
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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10
Q

ASTRO APBI “Suitable” Criteria

A

age ≥50

Tis or T1

margins ≥3 mm

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11
Q

Breast path N1c

A

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

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12
Q

Breast: Workup

A

H&P, family history, menopausal status, pregnancy, collagen vascular disease breast/node exam

Labs: CBC, LFTs, alk phos, beta-HCG, consider genetic testing

Imaging primary: diagnostic mammogram (magnification for calcs, spot compression for questionable mass), US with core needle bx (receptor status)

Oncotype if ER/PR+ and tumor >5mm

MRI potential indications: DCIS, unknown primary (axillary node or pageats), neoadjuvant chemo planned, dense breasts, assess multicentric or multifocal disease

Imaging staging: CXR. Bone scan and CT only for Stage III. PET scan increasing in use

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13
Q

Breast anatomic IIB

A

T2N1, T3N0

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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 path N3c

A

supraclavicular nodes

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16
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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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

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%

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19
Q

Breast anatomic IIIC

A

N3

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20
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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21
Q

Breast clinical N2b

A

IMN nodes without axillary nodes

22
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?

23
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. 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.

24
Q

Breast clinical N1mi

A

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

25
Breast: ddAC+T dose and schedule
Doxourbicin 60mg/m2, Cyclophosphamide 600mg/m2, q14 days x 4 cycles, neulasta support Paclitaxel 80 mg/m2, weekly, 12 cycles
26
Breast clinical N1
mobile axillary nodes
27
Breast: chemo regimen for Her2+
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
28
Breast path N1a
1-3 axillary lymph nodes (at least one \>2mm)
29
Breast: APBI EBRT dose, volumes, dosimetry
38. 5Gy/10fxs BID over 5 days 1. 5cm CTV 1. 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%
30
Breast: Clinical Tangents
wire at clavicle, midline, mid axillary, and 1 cm from inferior. Wire scar. Place calc point at midpoint of beams and 1 cm anterior to chest wallwire at clavicle, midline, mid axillary, and 1 cm from inferior. Wire scar. Place calc point at midpoint of beams and 1 cm anterior to chest wall
31
Breast clinical N3c
supraclavicular nodes
32
Breast: hypofractionation dosimetry
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
33
Breast path N3a
10 or more axillary nodes
34
Breast: double isocenter narrative
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.
35
Breast anatomic IB
T0-1 N1mic
36
Breast clinical N3b
IMN and axillary nodes
37
Breast anatomic IIA
T0-1N1 or T2N0
38
Breast: APBI brachy dose, volumes, dosimetry
34Gy/10fxs BID over 5 days CT sim or scout prior to each treatment to confirm position of device. Target volume is baloon +1.5cm expansion, crop 0.5cm from skin skin V200\<20cc V150\<50cc
39
Breast path N1b
positive IMN sentinel node (excluding ITCs)
40
Breast:conventional whole breast dosimetry (coverage, max hot spot, lung V20, heart mean, contralateral breast max)
95/95 coverage of PTV eval max hot spot 107% no large 105% hotspots ipsi lung V20\<30% (3 field) ipsi lung V20\<15% (tagents only) heart mean \<4Gy contra breast max \<4Gy BOOST: \<30% breast receiving 100% boost dose \<50% breast receiving 50% boost dose
41
Breast anatomic IIIB
T4
42
Breast T1b
\>5mm - ≤10mm
43
Breast path N2a
4-9 axillary lymph nodes
44
Breast: Contraindications to lumpectomy (RT)
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
45
Breast clinical N3a
infraclavicular nodes
46
Breast path N2b
clinically detected IMN nodes
47
Breast: Boost setup
Seroma plus clips, 1 cm CTV, 0.7cm PTV. Use 2-3 field photons or electrons to 80-90% idodose line.
48
ASTRO APBI "Unsuitable" Criteria
age \<40 positive margins DCIS \>3cm age 40-49 and does not meet cautionary criteria
49
Breast: follow up
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
50
Breast T1a
\>1mm - ≤5mm

OB2 (10 decks)

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