Breast cancer Flashcards
(28 cards)
What is management of DCIS?
Lumpectomy + radiation +/- hormone therapy (if ER positive)
OR mastectomy
If bilateral mastectomy - dont need follow up endocrine therapy
What is the management of invasive breast cancer?
Surgical excision + radiation
- WLE for cancers < 5cm, with clear margins and no skin involvement
- Mastectomy for high risk: > 5cm, inflammatory, BRCA1/2 positive, strong family history or when radiation is contraindicated
- Sentinel LN biopsy - if < 2 nodes involved and pt getting chemo + endocrine + radio tx no need for axillary LN clearance
- Can do neoadjuvant chemo or endocrine tx for breast conservation
- Radiation post op - recommended when tumour size > 5cm, positive margins, 4 or more LN involved, inflammatory breast cancer
What are some side effects of axillary LN clearance?
Lymphoedema
Sensory loss
Shoulder abduction defects
What is the management for invasive breast cancer women > 70 years ?
If tumour <2cm and ER+ve - WLE and endocrine therapy only
What is Paget’s disease of the breast?
- A rare type of breast cancer that affects the lactiferous ducts and the skin of the nipple and areola
- Associated with underlying IDC or DCIS in 80-90% cases
- Clinical features: erythematous, scaly rash, nipple retraction and ulceration, blood tinged nipple discharge
How is Paget’s disease of the breast diagnosed and treated?
- Diagnosed with punch /wedge biopsy of nipple tissue
- Followup imaging to look for IDC/ DCIS
Treatment:
Mastectomy OR breast conserving surgery with radiation
What is inflammatory breast cancer ?
A rare form of advanced, aggressive invasive carcinoma characterized by dermal lymphatic invasion of tumor cells
What are the clinical features of inflammatory breast cancer?
Peau d’orange
- erythematous, oedematous skin plaques with prominent hair follicles resembling orange skin peel –> caused by blocked lymphatics by the tumour
- Tenderness, burning sensation
- Blood-tinged nipple discharge
- Signs of metastatic disease (e.g., axillary lymphadenopathy
- Usually no palpable tumour
What are the diagnostic criteria for inflammatory breast cancer?
All 4 criteria must be met:
1) Rapid onset of breast erythema, edema, warmth, and peau d’orange, with or without palpable mass on breast examination
2) Erythema involving at least one-third of the breast
3) Symptoms have been present for < 6 months
4) Core needle biopsy confirming the presence of invasive carcinoma
What is the diagnostic workup for inflammatory breast cancer?
Patients who meet the diagnostic criteria should undergo at least two full-thickness skin punch biopsies
Further testing
Imaging: bilateral mammogram and ultrasound of regional lymph node
Receptor testing
What is the management of inflammatory breast cancer?
modified radical mastectomy + ANLD with neoadjuvant and adjuvant systemic therapy and adjuvant radiation therapy
What are some ddx of inflammatory breast cancer?
Mastitis
Paget’s disease of the breast
Breast abscess
What are the 3 types of breast cancer depending on hormone and HER-2 status ?
ER/PR positive, HER-2 neg (65% of breast cancers)
HER-2 positive , variable ER/PR status (~20% of breast cancers)
Triple negative (ER/PR and HER-2 negative) - ~15% of breast cancers
Note: ER/PR positive if >= 1% cells have hormone receptors
What are some features of ER/PR positive breast cancer in terms of prognosis and relapse?
Indolent course
Late recurrence with bone metastases
Responsible for the highest mortality of all breast cancer subtypes
What are the general principles of therapy for the 3 molecular subtypes of breast cancer?
HR positive, HER-2 neg: endocrine tx +/- chemotx
HER-2 pos, HR pos or neg: HER-2 targeted tx + chemotx +/- endocrine tx
Triple neg: chemotherapy + immunotherapy
What is the treatment for early stage breast cancer?
Curative intent
Surgery (mastectomy or WLE) +/- LN biopsy +/- ALND
Neoadjuvant therapy: Triple neg, HER-2 positive or large tumour size
Adjuvant therapy: can be Chemo +/- HER-2
Endocrine +/- CKD4/6 inhibitors
Radiotherapy
Bisphosphonates
How does nodal status affect management?
Nodal involvement : neo or adj chemotx
No nodal involvement: role of chemotx (neo or adj) unclear and depends on other prognostic factors
What did the TAILORx study show?
Study with 21 panel gene assay in HR positive, HER2 neg and node neg BC
Gave recurrence score estimates that were used to guide need for chemo
Post menopausal with recurrence score < 25 - only endocrine tx is enough
What has been the change in delivery of neoadjuvant chemotx for breast cancer?
Usually nodal disease treated with anthracycline and taxane
Dose escalation not beneficial, better to shorten dose interval (2 weeks vs 3 weeks) with GCSF cover for myelosuppression
What is the targeted therapy for HER-2 positive breast cancer?
Transtuzumab for 12 months (in early BC, and as maintenance in metastatic disease)
No benefit of addition of lapatinib and minimal benefit of adj addition of pertuzumab
Main SE: heart failure, compounded if co-administered with anthracycline drugs
2nd line : lapatinib with capecitabine chemo
Main SE: diarrhoea, hand–foot syndrome, anaemia and nausea
What is the KATHERINE trial?
Failure with neoadj chemo and HER2 therapy and ongoing residual disease - did better with TDM-1 (anti -body with drug conjugate vs HER-2 ab alone)
Improvement in DFS and freedom from distant recurrence
What are the endocrine therapies available for ER/PR +ve breast cancer, their duration of tx and side effects?
SERMS: tamoxifen and raloxifene
Aromatase inhibitors: anastrozole, letrozole, exemestane
Given for 5 - 10 years (ATLAS and ATTOM trial)
Common SE : hot flushes, arthralgias and vaginal atrophy
SERMs: VTE and endometrial ca
AI: osteoporosis
Small absolute benefit of AI> SERMs
SERMs: pre and post menopausal
AI: post menopausal or pre with ovarian suppression (otherwise causes paradoxical rise in oestrogen from ovaries if used premenopausal)
Adj BBP - zolendronic acid
Fertility preservation - cryopreservation
CDK 4/6 inhibitors (not PBS approved in HR pos BC)
What is the treatment for metastatic breast cancer?
Palliative intent
- prolongation of life, QoL and symptom management
Consider re-biopsy as metastases may be discordant to primary tumour (HR, HER-2 status)
HR positive:
- endocrine +/- CDK4/6 inhibitors (abemaciclib, palbociclib, ribociclib)
- Chemo - sequential single agent
- bisphosphonates
HER-2 positive
- dual HER-2 - transtuzumab, pertuzumab
- chemotx
- ab- drug conjugates - transtuzumab emtansine and transtuzumab deruxtecan)
Triple neg
- chemotherapy + immunotherapy
- ab - drug conjugates - sacituzumab govitecan
What are some examples of CDK4/6 inhibitors?
MONARCH: Abemaciclib
PALOMA: Palbociclib
MONALEESA: Ribociclib
All three showed PFS benefit in HR+, HER-2 neg advanced BC but only abemaciclib and ribociclib showed OS benefit - drug of choice
SE:
palbociclib: myelosuppression and fatigue
Ribociclib : myelosuppression, liver toxicity QTc
Abemaciclib: myelosuppression and diarrhoea
