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Hematology, oncology > Breast cancer 2 > Flashcards

Breast cancer 2 Flashcards

1
Q

biopsy type for breast mass

A

core needle biopsy

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2
Q

HER2 scoring system

A

0 to 1+ = “HER2 negative.”
2+ = “borderline,” requiring FISH
3+ = “HER2 positive.”

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3
Q

Classic features of cancerous breast lesion on exam

A

Hard + immobile + irregular borders

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4
Q

Skin findings that suggest inflammatory breast cancer

A

Erythema, thickening, or dimpling of overlying skin

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5
Q

Classic mammography findings of breast cancer

A

Soft tissue mass or density + grouped micro calcifications

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6
Q

MRI features of breast cancer

A

Irregular or spiculated mass + heterogeneous internal enhancement + enhancing internal septa

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7
Q

Other malignancies that can occur in the breast outside of breast cancer

A

(think about other tissue types in the breast)

  • breast sarcoma
  • paget disease
  • phyllodes tumors
  • lymphoma
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8
Q

Definition of ER-positivity

A

IHC for ER and PR in more than 1% of tumor cells

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9
Q

Definition of multifocal and multicentric disease

A 
Multifocal = several areas within a single quadrant (so prob represents disease along an entire duct)
Multicentric = multiple areas within different quadrants (so disease prob involves multiple ducts)
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10
Q

notation of clinical stage

A 
cTNM = clinical stage
pTNM = pathologic stage
ypTNM = final pathologic stage after undergoing NAC
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11
Q

Test characteristics of physical exam for lymph node staging + why

A

Poor NPV (metastatic lymph nodes are often not palpable and reactive lymph nodes may be mistaken for mets)

  • PPV = 61-84%
  • NPV = 50-60%
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12
Q

Tamoxifen mechanism

A

SERM – selective estrogen receptor modulator

- Mixed ER antagonistic and agonistic properties

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13
Q

Palbociclib/ribociclib/abemaciclib mechanism

A

CDK 4/6 inhibitors

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14
Q

Targeted therapies for metastatic breast cancer?

A
  • CDK 4/6 inhibitors
  • PI3K
  • mTOR
  • EGFR
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15
Q

First line *regimens for HER2-negative, hormone receptor positive Stage IV BC

A

Endocrine therapy + targeted therapy typically
AI + CDK4/6 inhibitor
OR
Fulvestrant + CDK4/6 inhibitor
OR
Selective ER down-regulator + non-steroidal AI

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16
Q

Lapatinib mechanism

A

TKI of HER2 and EGFR pathways

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17
Q

Axillary imaging modality

A

US or MRI

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18
Q

Workup of stage IV disease

A
  • Chest CT/abdomen/pelvis with contrast
  • IF CNS symptoms – brain MRI
  • IF back pain or cord compression symptoms – spine MRI
    ER/PR/HER2 status of metastatic tumor
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19
Q

Definition of visceral crisis in breast cancer

A

Severe organ dysfunction

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20
Q

Preferred regimen for hormone receptor negative, HER2 positive stage IV

A

pertuzumab + trastuzumab + taxane

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21
Q

median overall survival of metastatic breast cancer

A

??

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22
Q

2 major phenotypes in metastatic breast cancer

A

1) Visceral metastases (aggressive phenotype)

2) Bone metastases (indolent phenotype)

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23
Q

Management of stage IV hormone receptor positive, HER2 negative BC

A

Initial treatment with endocrine therapy, unless visceral crisis, in which case chemo is used

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24
Q

Tumor markers that can be trended for response assessment in MBC (if elevated)?

A

CA 15-3
CA 27.29
CEA

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25
Q

What are the standardized criteria for determining response to therapy in solid tumors called?

A

Response Evaluation Criteria in Solid Tumors (RECIST)

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26
Q

Management of AI-induced arthralgia

A

Switch to a different AI, if persistent, then start tamoxifen

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27
Q

Receptor status of most BRCA 1 tumors

A

Triple negative

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28
Q

Receptor status of most BRCA 2 tumors

A

ER+

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29
Q

who needs genetic testing per NCCN

A

1) triple negative BC
2) male
3) Younger than age 45
4) over 51 + close relative with breast, ovarian, pancreatic cancer
5) some other indications

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30
Q

Adjuvant for ER+ with negative surgical margins

A

???

- no indication for tamoxifen (no remaining breast tissue)

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31
Q

Margin size to be considered negative for DCIS

A

2 mm (optimal surgical margin for DCIS)

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32
Q

Indications for post mastectomy radiation

A

More than 3 lymph nodes involved OR involved margins

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33
Q

First step following disease progression

A

ALWAYS BIOPSY (receptor status can change)

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34
Q

TDM drug type

A

HER2 ADC

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35
Q

Problem with breast MRI

A

high false positive rate

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36
Q

Surveillance modality

A

Mammography

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37
Q

Management points for localized breast cancer arising from radiation from previous treatment (Eg hodgkin’s)

A
  • can’t reirradiate
  • so have to do mastectomy (lumpectomy requires RT)
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38
Q

Relative contraindications to RT for breast cancer

A
  • SLE

- scleroderma and other - connective tissue disease

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39
Q

negative margins broadly speaking with lumpectomy or mastectomy

A

*Unlike DCIS, you don’t need 2 mm of negative margins

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40
Q

No ink on tumors means

A

negative margins

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41
Q

Management of HER2+ via IHC

A

FISH testing (HER2 is intermediate so you need confirmatory testing)

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42
Q

Management of ER/PR positive BC after mastectomy in old patient who values quality of life + intermediate oncotype

A

Anastrozole, no chemo (noninferior in trials to chemo in terms of disease free survival and OS at 9 years)

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43
Q

When oncotype 21 is used

A

ER/PR positive AND node negative

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44
Q

Indications for RT in breast cancer

A 
>5cm
T4 disease
Inflammatory breast cancer
nodal involvement 
positive margins after mastectomy
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45
Q

Breast cancer management in pregnant woman

A
  • Radiation is contraindicated
  • Can give chemo during second trimester
  • Can’t give tamoxifen
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46
Q

To know about workup in pregnant women

A

Blue dye is contraindicated during SLNB

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47
Q

ER/PR positive management in men after mastectomy

A

Tamoxifen (you can’t given an AI because it won’t inhibit testicular production)

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48
Q

Most common phenotype

A

ER+ (70-80% of breast cancer)

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49
Q

What is the goal of neoadjuvant systemic therapy?

A

Treat occult micrometastatic disease + surgical minimization

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50
Q

Why is neoadjuvant chemo important?

A

Surgical minimization (50% of people with node positive disease will be converted to node negative, therefore won’t need axillary dissection)

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51
Q

Why is neoadjuvant endocrine therapy not standard?

A

Can reduce tumor size, but pCR is rare so it’s not standard

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52
Q

Management of triple negative residual disease

A

chemo escalation (add capecitabine)

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53
Q

Therapy with more activity for ER+, HER2- negative

A
  • Endocrine therapy has a greater impact than chemo
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54
Q

Neoadjuvant chemo for ER+, HER2-?

A

Less commonly used since pCR is rare (hence little surgical benefit)

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55
Q

What are the prognostic genomic assays available?

A
  • oncotype
  • mammaprint
  • prosigna
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56
Q

What is the point of oncotype?

A
  • ER+ derives more benefit from endocrine therapy. Oncotype predicts recurrence + response to chemo, so it is used to determine patients that will benefit and those who derive minimal benefit from chemo and for whom toxicity outweighs benefit
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57
Q

Supportive care for hair loss

A
  • cold caps or scalp cooling device (highly effective in 50-60% of women)
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58
Q

Definition of hormone receptor positive

A

ER or PR greater than 1% on IHC

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59
Q

Management of vaginal dryness from AI’s

A

topical moisturizers/lubricants

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60
Q

Main reason for discontinuation of AI’s

A

MSK symptoms

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61
Q

Phenotype in which late relapse is more commonly seen?

A

ER+, seldomly seen in ER-

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62
Q

When to extend adjuvant endocrine therapy after 5 years?

A
  • Stage 3 and many Stage 2
  • Stage 1 on an individual basis and considering secondary prevention
    • patient has tolerated treatment
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63
Q

How long do you extend endocrine therapy?

A

Typically not longer than 10 years total

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64
Q

How long is trastuzumab given?

A

1 year (duration given in trial)

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65
Q

Adjuvant treatment of hormone receptor positive breast cancer

A
  • Leuprolide + aromatase inhibitor (exemestane) (ovarian suppression + an aromatase inhibitor has been shown to have a survival benefit over ovarian suppression alone)
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66
Q

When is breast cancer screening recommended after chest wall radiation?

A

25 or 8 years after completion of radiation therapy, whichever is last
*correct answer
*MRI before 30, only start mammograms at age 30

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67
Q

Management of woman requiring chemo who wants to preserve fertility

A

Delay chemo until patient can meet with fertility specialist

68
Q

Fulvestrant generic name

69
Q

Role for fulvestrant

A
  • HR+ metastatic breast cancer with disease progression

- HR+, HER2 negative advanced BC in combination with palbociclib

70
Q

Denosumab mechanism of action

A

RANKL inhibitor

71
Q

atezolizumab indication

A

Stage IV, PD-L1 expression greater than 1%

72
Q

Diagnosis of inflammatory breast cancer

A

CLINICAL (dermal lymphatic involvement not needed)

- erythema and edema of more than a third of the breast

73
Q

Clinical course of inflammatory breast cancer

A
  • very aggressive, rapidly proliferates
74
Q

First step in management of inflammatory BC

A
  • Neoadjuvant chemo (athracyclines and taxanes)
75
Q

Why you can’t give AI’s in male breast cancer

A
  • won’t inhibit testicular estrogen production
76
Q

adjuvant hormonal treatment of early stage favorable histology BC

A

consider/offer adjuvant tamoxifen or AI

77
Q

What are the favorable histology breast cancers?

A
  • papillary
  • tubular
  • mucinous
78
Q

Phyllodes tumor management

A

Primary surgery: Wide excision of the tumor (greater than 1), no axilla staging needed (no lymphatic spread)

79
Q

Stage IV HER2+, ER+ treatment

A

Triplet therapy – docetaxel + trastuzumab + pertuzumab

  • then typically drop docetaxel, and transition to hormonal therapy
  • HER2 therapy markedly improves outcomes
  • Currently unclear as to whether it is better to use HER2-directed therapy + chemo vs. endocrine therapy first-line
80
Q

Oncotype testing is only indicated

A

ER+ AND *HER2 negative AND node negative

81
Q

Stage IV management of ER+/HER2 -

A

IF no visceral crises –> initial anti estrogen therapy with letrozole +

82
Q

letrozole mechanism

83
Q

SE to know about with CDK4/6 inhibitors

A

neutropenia

84
Q

Treatment of patient with residual invasive breast cancer after NAC plus HER2+ targeted therapy

85
Q

Adjuvant treatment of triple negative early stage

A

IF less than 0.5 cm – no adjuvant chemo

IF greater than 1 cm – adjuvant chemo

86
Q

Utility of MRI for screening

A
  • Reserved for those at high risk (Known BRCA carriers, first degree relatives of BRCA carriers, Li-Fraumeni syndrome, a few others)
  • Per ASCO – Not indicated for dense breasts on exam
87
Q

leuprolide MOA

A
  • GNRH agonist (thus inhibits gonadotrope secretion of LH and fFSH, subsequently suppresses gonadal sex steroid production) (this is why used in both breast and prostate)
88
Q

Treatment of cold agglutinin disease

A
  • Cold avoidance

- rituximab

89
Q

Treatment of early stage laryngeal cancer

90
Q

Why do you test for RAS in metastatic CRC?

A

Candidacy for EGFR inhibitors (cetuximab or panitumumab)

91
Q

Palbociclib mechanism

A

CDK4, CDK6 inhibitor

92
Q

Patients who need NAC

A

1) IBC
2) bulky or matted cN2 axillary nodes (cN3, CT4)
3) HER-2 positive disease
4) TNBC, if cT greater than 2 or cN greater than 1
5) large primary tumor relative to breast size in a patient who desires breast conservation
6) cN+ disease likely to become cN0 with preoperative systemic therapy

93
Q

what are the CDK4/6 inhibitors

A
  • abemaciclib
  • palbociclib
  • ribociclib
94
Q

fulvestrant mechanism

A

SERM (selective ER down-regulator)

95
Q

Regimens for stage IV HER2-positive disease

A
  • pertuzumab + trastuzumab + taxane (docetaxel or paclitaxel)
96
Q

IBC is

A

inflammatory breast cancer

97
Q

Neoadjuvant management of locally advanced endocrine positive BC

A

Chemo rather than neoadjuvant endocrine therapy (associated with higher response rates in a shorter time period)

98
Q

Role for PARP inhibitors in locally advanced

A

Adjuvant for triple negative with residual disease

99
Q

Fulvestrant mechanism vs. tamoxifen or raloxifene

A
  • tamoxifen or raloxifene are SERMS, fulvestrant down-regulates estrogen receptor
100
Q

Why CDK4-6, PIK3CA inhibitors, and mTOR inhibitors are given with estrogen therapy

A
  • trials have shown they mechanistically work in different ways and can enhance benefit of ET aloen
101
Q

Criteria for ER positivity based on IHC

A

0-1% = negative
1-9% = positive BUT may be less likely to be effective
Greater than 10% = positive

102
Q

Drug approved for PIK3CA positive BC

103
Q

Taxotere generic name

104
Q

when to extend ET in ER+ breast cancer

A
  • node-positive
  • node-negative patients at higher recurrence risk
  • benefits are modest in lower risk node-negative or limited node-positive cancers, so approach is individualized
105
Q

high risk features of early stage hormone receptor-positive cancers

A
  • high grade
  • large tumor size (greater than 2 cm)
  • nodal involvement
  • high 21-gene recurrence score
106
Q

prognostic factors for recurrence after 5 years of ET

A
  • nodal status
  • tumor size
  • higher grade
  • low levels of ER expression
  • higher score on genomic assays
107
Q

Margin required for DCIS

108
Q

Typical recurrence pattern of ER positive

A
  • often bone recurrence
109
Q

Late recurrence in breast cancer?

A
  • not uncommon
110
Q

Tumor type that develops as secondary malignancy from radiation

111
Q

extension of endocrine therapy has been shown to be beneficial in what disease state?

A

locally advanced

112
Q

Benefit of tamoxifen for DCIS

A

Reduces ipsilateral recurrence risk, no OS benefit

113
Q

First line for stage IV hormone AND HER2 positive

A

Taxane + pertuzumab + trastuzumab
*no endocrine therapy

114
Q

CPS warranting addition of pembro to NAC in triple negative BC

A

None, irrespective in trial
*CPS greater than 10 in setting of metastatic disease

115
Q

IBC diagnosis

A

Clinical
*negative skin biopsy does not rule it out

116
Q

Inflammatory breast cancer management

A

NAC
Mastectomy w/ axillary lymph node dissection
Adjuvant radiation therapy

117
Q

management of adenoid cystic carcinoma

A

Local therapy alone (surgery)
No adjuvant chemo

118
Q

Adjuvant management of hormone receptor positive tumor with high Ki-67 (greater than 20%)

A

AI + abemaciclib

119
Q

Third line regimens for HER2+

A

T-DM1 (very well tolerated. Used to be standard second line) (EMILIA trial – OS 30.9 months)
Given brain mets, tucatinib/capecitabine/trastuzumab (HER2 climb)

120
Q

DCIS primary management

A

BCS (lumpectomy with radiation) vs. mastectomy

121
Q

First line for triple negative MBC management

A

single agent chemotherapy – docetaxel, platinum, capecitabine

122
Q

Management of locoregionally recurrent triple negative breast cancer

A

NAC + surgery

123
Q

Common toxicity seen with pertuzumab

124
Q

Common cause of diarrhea after chemotherapy

A

Bacterial overgrowth

125
Q

Benefit of adjuvant radiation and endocrine therapy for DCIS

A

Reduced recurrence risk, NO proven survival benefit

126
Q

BI-RADS scores

A

1-2 = normal or benign
3 = probable benign
4 = suspicious for malignancy
5 = highly suggestive of malignancy

127
Q

Staging of newly diagnosed breast cancer

A

Given absence of cough or hemoptysis on ROS and pulmonary exam within normal limits, no indication for CT abdomen/pelvis w/ contrast
Given LFT’s and alk phos within normal limits and absence of abdominal pain per ROS, no indication for CT abdomen/pelvis w/ contrast
Given ROS negative for bone pain and alkaline phosphatase within normal limits, no indication for bone scan
Stage IIIA or higher OR inflammatory:
Cross sectional imaging (CT C/A/P w/ contrast)
Bone scan (inpatient) vs. PET/CT (outpateint) (Preferred but limits of sensitivity as may miss very small mets)

128
Q

Management of hormone receptor positive MBC in premenopausal woman

A

ovarian suppression + AI + CDK4/6 inhibitor

129
Q

Contraindication to aromatase inhibitor

A

osteoporosis

130
Q

contraindications to tamoxifen

A
  • history of CVA
  • fluoxetine use
131
Q

Second line for hormone receptor positive MBC without PIK3CA

A

single-agent endocrine therapy, everolimus with endocrine therapy, or chemotherapy.

132
Q

Evidence for tamoxifen for breast cancer chemoprevention

A
  • reduces incidence of invasive breast cancer by 30%
  • reduces fractures by 34%
  • NO effect on mortality
133
Q

Adjuvant for triple negative with residual disease

A

Capecitabine

134
Q

T3 disease

A

Tumor greater than 5cm in greatest dimension

135
Q

T4 disease

A

Tumor with extension to chest wall and or skin (ulceration or macroscopic skin nodules(

136
Q

cN1 disease

A

Met to movable ipsilateral level I or II axillary lymph nodes

137
Q

cN2 disease

A

Met to ipsilateral level I or II axillary lymph nodes that are clinically fixed or matted

138
Q

cN3 disease

A

Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s) with or without level I, II axillary lymph node involvement; or in ipsilateral internal mammary lymph node(s) with clinically evident level I, II axillary lymph node metastases; or metastases in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement.

139
Q

pN1 disease

A

Micrometastases, or metastases in one to three axillary lymph nodes, and/or clinically negative internal mammary nodes with micro- or macrometastases detected by sentinel lymph node biopsy.

140
Q

pN2 disease

A

Metastases in four to nine axillary lymph nodes, or positive ipsilateral internal mammary lymph nodes by imaging in the absence of axillary lymph node metastases.

141
Q

pN3 disease

A

Metastases in 10 or more axillary lymph nodes; or in infraclavicular (level III axillary) lymph nodes; or in ipsilateral internal mammary lymph nodes by imaging in the presence of one or more positive level I, II axillary lymph nodes; or in more than three axillary lymph nodes and in internal mammary lymph nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected; or in ipsilateral supraclavicular lymph nodes.

142
Q

What are the luminal subtypes?

A

Histologic subtype associated with hormone receptor positive

143
Q

Breast sarcoma subtype associated with radiation

A

Radiation-induced angiosarcoma

144
Q

What is ovarian suppression?

A

Either GNRH agonist OR oophorectomy

145
Q

Systemic therapy you can’t give in second and third trimester

A

HER-2 targeted drugs (oligohydramnios, pulmonary hypoplasia, skeletal abormalities, neonatal death)

146
Q

CDK4-6 inhibitor that requires ECG monitoring

A

ribociclib

147
Q

Second line preferred for metastatic triple negative

A

sacituzumab

148
Q

ADH management

A

Surgical excision (exclude malignancy, excisional biopsy can diagnose DCIS or invasive carcinoma in around 30% of cases)

149
Q

Management of locally advanced triple negative with pathCR

A

Surveillance (even including BRCA patients)

150
Q

CDK4/6 inhibitor with highest rate of neutropenia + QTc prolongation

A

Palbociclib

151
Q

Calcifications good or bad on imaging in breast?

152
Q

Role for PARP inhibitors in metastatic disease for BRCA mutant patients

A

second line

153
Q

When are PARP inhibitors indicated adjuvantly

A

High risk (Node positive or T2 TNBC)

154
Q

Drug used to treat hot flashes for breast cancer patients

A

oxybutynin

155
Q

Adjuvant for HER2+, node negative

A

Taxol-trastuzumab

156
Q

When is TCHP used for HER2+?

A

Larger tumors or Node positive

157
Q

Firstline regimens for metastatic triple negative PDL1+

A

pembro + gem-carbo or taxane

158
Q

BRCA mutation associated with male breast cancer

159
Q

IBC histologically

A

Clinical diagnosis based on skin findings. Still have tumor that is invasive ductal histology

160
Q

NAC for inflammatory breast cancer

A

anthracycline and taxane based regimen

161
Q

Screening interval and modality for high risk patients

A

annual mammogram + breast MRI

162
Q

first line for metastatic HER2+

A

Trastuzumab + pertuzumab + taxane (docetaxel)

163
Q

adjuvant for BRCA mutant TNBC with residual disease

A

Olaparib (NOT capecitabine)

164
Q

Pathologic staging in hormone receptor includes

165
Q

When continuation of endocrine therapy is needed to 10 years

A

high-risk, node positive disease

166
Q

Management of papilloma

A

Surgical excision (commonly copresent with other premalignant features (ADH, DCIS) so need to cut out)

167
Q

Adjuvant management of HER2 with path CR

A

continue trastuzumab with pertuzumab (Dual HER2 blockade) for total 1 year

Hematology, oncology (218 decks)

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