Breast Cancer Flashcards
SLNB localisation
SENTINA trial - dual localisation minimised risk of false negatives
Complete pathological response
surrogate end point for improved overall and disease free survival
NSABP B-18
Post op would continue on anti-Her2 tx (trastuzamab for 12 months.
If residual disease then eligible for TDM-1 (Kadcyla) as per Katherine Study
Neoadjuvent Tx
Can consider to allow breast conserving surgery
If post-menopausal and ER +ve then can consider Aromatase inhibitor for 6-9 months to downsize
BCS vs mastectomy
Equivalent long term outcomes
Reduced paient satisfaction and psycho-social wellbeing in mastectomy group.
MILAN -1 and NSABP B6 trials. - outcomes of 20yrs FU and Netherlands population study
Adjuvent Radiotherapy
Oxford overview
Radiotherapy reduced local recurrences by 2/3 with a survival benefit between 5-7%
For every 4 recurrences prevented, 1 death is avoided.
PRIME 2 and CALGB 9343 - looked at omitting in small ER positive tumours - concluded small improvement in local reoccurrence risk but no survival benefit
NPI
Nottingham Prognostic Index - measure that predicts operable breast cancer survival
Calculated based on size, number of LNs +ve and grade.
(0.2 x S) + N + G
N 0nodes-1, 1-3nodes =2 >3 nodes=3
2-2.4 - 93% 5yr survival
2.4-3.4 - 85%
3.4.5.4 - 70 %
>5.4 - 50
Oncotpye Dx
Tumour gene profiling test - 21 genes tested
Predicts benefit of chemo and risk of distant disease recurrence
Used in ER+ve HER2 -ve
1) Node negative patient and intermediate risk of distant recurrence using NPI/PREDICT
2)Node positive (1-3 LN) who re not pre- menopausal
Validated by NSABP B14 study
Technetium 99m
Half life 6hrs
Staging the Axilla
US at time of assessment
SLNB at time of surgery - dual technique
NSABP B-32 and ALMANAC trials - low false negative rate with SLNB and non difference in survival, disease fee survival or axillary recurrence compared to clearance
Rates of Lymphoma ws significantly less with SLNB
SLNB contraindicated in:
1)Inflammatory of locally advanced cancers
2) Patients with DCIS undergoing breast conserving surgery (except in mass forming DCIS)
3)Pregnant patients (relative and emerging evidence says its safe)
LN staging
Isolated tumour cells <0.2mm
Micromets 0.2-2mm Macromets >2mm
ABS consensus Isolated tumour cells and micrometers do not require further treatment to axilla
If <3macromets and having whole breast radio and T1 grade 1/2 Er=ve Her2-ve doesn’t need Tx.
If >3 or T3grade 3, Er-ve Her2 +ve does need more Tx - possible axillary radio
Axilla treatment trials
RCT ACOSOG Z0011 and EORTC Amaros trials randomised patients to clearance or axillary radio. Concluded radiotherapy offered comparable regional control and no differences at 6.3yrs and 5yrs respectively
DCIS grading and behaviour
Low and intermediate - Tend to be ER+ve and HER-ve - reflected in cancers they form
High grade
Usually ER-veHER+ve (represented sign alight pathway (epidermal growth factor) - Higher progression rate to cancer
Do you need SLND in DCIS
No unless performing a mastectomy or mass forming DCIS
Margins in resecting DCIS
ASCO and Association of Brest surgeons suggest 2mm margin
Significantly reduces risk of ipsilateral recurrence (Odds ration 0.51)
Radiotherapy in DCIS
NSABP B17, EORTC 10853, UKANZ DCIS and SWEDCIS showed signdifanct reduction in ipsilateral recurrence for pre-invasive and invasive disease
No effect on survival
Likely to benefit high grade lesions more and could be avoided in certain low and intermediate grades
Endocrine Tx in DICS
NICE guidance recommends discussion around adjacent endocrine therapy - useful is radiotherapy offered but declined
Staging of T3 Tumour
FBC, UE, LFTs, Serum bone profile
Also
CT C/A/P
Isotope bone scan
Palbocicclib
CD4-5 inhibitor approved for use with aromatase inhibitors for ‘previously untreated’ hormone receptor positive ER-ve locally advance/met cancer
Denosumab
monoclonal antibody preferred option in presence of skeletal mets to reduce risk of pathological fractures
Screening program
Started in 1988
50-70 registered with a GP
Screened with mammogram every 3yrs
Designed to detect early breast cancer and improve outcome and survive
Approx 9in1000 women screened have BC
Women at moderate or high risk based on genetics or FH are invited for high risk screening from earlier age
B3 lesions
Discuss at MDT
Recommend larger volume vacuum assisted excision removing at least 4g of tissue
If not upgraded to B5 then annual surveillance for 5yrs
Papillary lesions with atypic, spindle cell lesions and firboepithelial lesions should undergo surgical excision
LCIS
Lobular carcinoma in situ
Classical or atypical lobular hyperplasia is B3
Pleomorphic or fluid LCIS is regarded as comparable to DCIS - precursor lesions conferring 8-10x increased relative risk of developing breast cancer
Assessment for reconstruction (immediate)
Hx including job, lifestyle and sports activities. PMH, medications and smoking status
Advise to stop smoking and provide support
Record breast: Size, symmetry, nipple to notch distance, inframamary fold to nipple distance, grade of ptosis
Post mastectomy Radiotherpy
NICE recommends should be considered in Node positive invasive breast cancer
or
Involved margins
or
Node negative T3 or T4
Triple Negative Breast Cancer
If under 40 should council for genetic testing - 7 gene panel (R208)
Initial recommendation would be NACT - Neoadjuvent Chemo.
High change of pCR in triple negative and confers excellent prognosis.
If residual disease on NACT then givens info on treatment plan and can use other treatments such as capecitabine or olabparib (in BRCA mutations)
Also gives option of WLE and targeted axillary direction rather than mastectomy and clearance
ATNEC trial
For patients who have had complete pathological response to Neoadjuvant theatre.
Randomised radio vs no radio to axilla
Pembrolizumab
Can cause a silent inflammatory thyroiditis
