Breast Cancer

Question 1

SLNB localisation

Answer 1

SENTINA trial - dual localisation minimised risk of false negatives

Question 2

Complete pathological response

Answer 2

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

Question 3

Neoadjuvent Tx

Answer 3

Can consider to allow breast conserving surgery

If post-menopausal and ER +ve then can consider Aromatase inhibitor for 6-9 months to downsize

Question 4

BCS vs mastectomy

Answer 4

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

Question 5

Adjuvent Radiotherapy

Answer 5

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

Question 6

NPI

Answer 6

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

Question 7

Oncotpye Dx

Answer 7

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

Question 8

Technetium 99m

Answer 8

Half life 6hrs

Question 9

Staging the Axilla

Answer 9

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)

Question 10

LN staging

Answer 10

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

Question 11

Axilla treatment trials

Answer 11

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

Question 12

DCIS grading and behaviour

Answer 12

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

Question 13

Do you need SLND in DCIS

Answer 13

No unless performing a mastectomy or mass forming DCIS

Question 14

Margins in resecting DCIS

Answer 14

ASCO and Association of Brest surgeons suggest 2mm margin

Significantly reduces risk of ipsilateral recurrence (Odds ration 0.51)

Question 15

Radiotherapy in DCIS

Answer 15

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

Question 16

Endocrine Tx in DICS

Answer 16

NICE guidance recommends discussion around adjacent endocrine therapy - useful is radiotherapy offered but declined

Question 17

Staging of T3 Tumour

Answer 17

FBC, UE, LFTs, Serum bone profile
Also
CT C/A/P
Isotope bone scan

Question 18

Palbocicclib

Answer 18

CD4-5 inhibitor approved for use with aromatase inhibitors for ‘previously untreated’ hormone receptor positive ER-ve locally advance/met cancer

Question 19

Denosumab

Answer 19

monoclonal antibody preferred option in presence of skeletal mets to reduce risk of pathological fractures

Question 20

Screening program

Answer 20

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

Question 21

B3 lesions

Answer 21

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

Question 22

LCIS

Answer 22

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

Question 23

Assessment for reconstruction (immediate)

Answer 23

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

Question 24

Post mastectomy Radiotherpy

Answer 24

NICE recommends should be considered in Node positive invasive breast cancer
or
Involved margins
or
Node negative T3 or T4

Question 25

Triple Negative Breast Cancer

Answer 25

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

Question 26

ATNEC trial

Answer 26

For patients who have had complete pathological response to Neoadjuvant theatre.

Randomised radio vs no radio to axilla

Question 27

Pembrolizumab

Answer 27

Can cause a silent inflammatory thyroiditis