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BREAST CANCER > BREAST CANCER > Flashcards

BREAST CANCER Flashcards

1
Q

Histopathology

A
  • infiltrating ductal carcinoma (>70%)
  • invasive lobular carcinoma (5-10%)
  • inflammatory (orange, worst prognosis)
  • DCIS (ductal carcinoma in situ)
  • LCIS (lobular carcinoma in situ)
  • Medullary
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2
Q

Important anatomical landmarks (no bony structures)

A
  • Xiphoid process
  • Sternal angle
  • Tail of Spence
  • Nipple
  • Areola
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3
Q

Epidemiology

A
  • the most common malignant disease in women
  • 1/9 chance of developing it in lifetime
  • more frequent in left breast
  • more frequent in the upper-outer (triangle of Spence)
  • 10% of cases are bilateral
  • <1% affect men
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4
Q

Etiology

A
  • F 100 : 1 M
  • BRCA1 and BRCA2
  • Age 60-79 yrs x2, medial age onset 55 yrs
  • Family history of breast ca, 1st line relatives
  • Nulliparity
  • Early menarche
  • Late Menopause
  • Oophorectomy < 50yrs
  • Diet high in fats, alcohol
  • Previous cancer in one breast
  • Early exposure to Radiation
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5
Q

Detection/Diagnosis tools

A
  • Breast self examination
  • Clinical Breast examination
  • Mammography screening (although controversial)
  • US (Ultrasound) which differentiates between cystic or solid tumors
  • Thermotherapy (with high false +) uses infrared to detect high blood circulation
  • MRI (for silicone implants)
  • Fine Needle biopsy (small gauge)
  • Core Needle biopsy (large gauge)
  • Incisional biopsy
  • Excisional biopsy
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6
Q

American Cancer Society (ACS) and Canadian Cancer Society (CCS) mammography recommendations

A

American Cancer Society (ACS) starting at 40 years old

Canadian Cancer Society (CCS) starting at 50 years old

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7
Q

Clinical presentation

A
  • Breast mass
  • nipple discharge
  • skin changes in color and texture
  • alteration breast contour
  • lymphadenopathy (enlargement of axillary LNs)
  • small lesions found on mammography
  • distant METS
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8
Q

Lymphatic drainage

A
  • Axillary LNs (70%)
  • Internal mammary LNs (30%)
  • Supraclavicular LNs (METS)
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9
Q

Sentinel Node Biopsy

A 
Radioactive dye (Blue dye) used to stain lymph node involvement directly injected inside the tumor.
This procedure reports the first nodal involvement and the requirement of a LN dissection.
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10
Q

Prognostic factors

A
  • LN involvement (# of Axillary LN is the most significant prognostic factor)
  • Tumor extent
  • Histopathology
  • ER/PR status
  • HER2 protein receptors
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11
Q

Lymphatic channels

A
  • Superficial (draining to skin covering breast)

- Deep (draining to internal breast tissues)

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12
Q

Hormonal Therapy for Breast cancer by using Tamoxifen.

A

Breast cancer cells can have receptors for Estrogen or Progesterone (ER/PR), therefore it’s possible to block these receptors nourishing cancer cells by using Tamoxifen (Nolvadex). Tamoxifen blocks the binding of Estrogen or Progesterone into the ER and PR. This blocks breast cell growth because the tumor cells usually nourish on these two hormones.
Tamoxifen is used in pre-menopausal women. It is important to understand Estrogen can be produced by 2 mechanism systems: produced by the ovaries or the adrenal glands (androgen to estrogen conversion). Tamoxifen can only be used for pre-menopausal women because it can block the receptors for estrogen but cannot block the androgen to estrogen conversion by adrenal glands.Whereas post-menopausal women do not produce estrogen by the ovaries anymore, Arymidex, would have to be used to cancel the nourishment of tumor cells on androgen to estrogen conversion.

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13
Q

How is HER2 gene protein a prognostic factor for Breast cancer?

A

Each healthy breast cell has two copies of HER2 gene for normal cell function
Breast cancer cells have too many copies of HER2 gene, therefore associated with higher aggressiveness of tumor, making it to grow faster!

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14
Q

5 year-survival rates

A
  • Generally 89%
  • If Regional spread 77%
  • Distant METS 21%
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15
Q

First treatment of choice

A

-Surgery (Radical,modified mastectomy,lumpectomy)
Radical mastectomy:
Removal of breast, overlying skin, all axillary lymph nodes, pectoralis major and minor muscles
Popular in the 70s but brought high complication rates
Women had weak arm. shoulder stiffness, lymphedema (arm swelling)

Modified mastectomy:
Removal of breast, overlying skin, SOME axillary lymph nodes, pectoralis minor muscle removed, leave pectoralis major intact!!!
Reduces arm swelling and increases arm strength

Lumpectomy:
Excisional biopsy of tumor + margins of small masses (early stages)

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16
Q

Role of Chemotherapy

A

To treat the microscopic cells around the system and lymphatics as a systemic treatment.
Usually chemotherapy is given POST-OPERATIVE, especially for advanced stages like stages 2 - 4.

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17
Q

Common chemotherapy agents

A
  • 5 FU
  • Adriamycin (doxorubicin), heart toxicity
  • Vinblastine
  • Methotrexate
  • Cytoxan (cyclophosphamide)
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18
Q

Ovarian ablation

A 
Ovaries produce estrogen in pre-menopausal women (at least much more than post-menopausal women). Therefore, an oophorectomy is performed to treat the ER/PR + women.
An LHRH (lutenizing hormone releasing hormone) agonist inhibits the pituitary gland to stop ordering for the production of estrogen by the ovaries. 
Ex. ZOLADEX (used actually in breast and prostate cancer.
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19
Q

Hormonal Therapy for Breast cancer by using Arimidex.

A

Compared to Tamoxifen which can be used in pre or post menopausal women, Arimidex can only be used in POST-MENOPAUSAL women.
Arimidex inhibits the conversion of androgen (produced by adrenal glands) into estrogen. Because post-menopausal do not produce estrogen by their ovaries (usually removed or non-producing), the only pathway left is the androgen-estrogen pathway. In order to inhibit that conversion (usually activated by an enzyme) Arimidex can be used.
Giving Arimidex to a pre-menopausal woman would not help in preventing ER/PR+ tumor cells from nourishing of estrogen because although Arimidex can block the conversion, her ovaries will be still producing estrogen normally.

20
Q

Side effects of using Tamoxifen

A
  • Increased risk of developing uterine cancer!
  • Hot flashes
  • Vaginal dryness
  • Weight gain
21
Q

Side effects of using Arimidex

A
  • bone and joint pain
  • osteoporosis
  • decrease in bone density
22
Q

Herceptin treatment for Breast cancer.

A

Herceptin (Trastuzumab) interferes with the HER2/neu receptor and in two days stop cancer cells to continue growing! This type of treatment is expensive 100 000$/year but can be effective in late stages of breast cancer.

Requires the patient to be Her2 +, meaning the receptor gene is present therefore we have a treatment available for it

23
Q

role of Radiotherapy in treating Breast cancer

A
  • Conservative breast cancer management!
  • Therefore, a lumpectomy is done instead of a mastectomy. An ipsilateral axillary node dissection is performed if node involvement is positive after a sentinel node biopsy.
  • After the dissection surgery 2-4 POST OPERATIVE recovery, Radiotherapy is given.
24
Q

typical dose prescription for Breast cancer

A
  • 50 Gy / 25 fx
  • used when >26 cm separation on the breast
  • when Mcgill technique is used
  • when the heart is in the field and is an OAR (left breast)
  • 42.4 Gy / 16 fx (hypofractionation) o 42.56 /16 fx
  • used when need to accelerate waiting list
  • used commonly for smaller breast <26 cm
25
Q

minimum # of MUs for a wedge configuration to be used

A

-minimum 20 MUs

26
Q

rationale to use either 6 MV alone, 6MV and 18 MV or 18MV alone photon energy in breast cancer treatment

A

-It all comes down to the SEPARATION of the breast
6 MV used when separation is < 22 cm
6 and 18 MV Bi-energy when separation is 22-26 cm
18 MV used when separation is >26 cm

27
Q

electron boost used for breast cancer

A

To treat the tumor bed in 10 Gy / 4 fx or 10 Gy/ 5 fx using electron or photon energy beams.
The tumor bed is treated to prevent recurrence of disease.
Photon beam is used as a boost when the breast is too big.
Otherwise, an electron boost is used with the energy depending of the depth of prescription by the doctor. Recall the penetration efficiency is approx, 1/3 of the electron beam energy.
Ex: a 12 MeV electron beam can penetrate up to 4 cm in tissue.

If the depth required is < 4cm use electron
If the depth required is > 4 cm use photon

28
Q

Isodose curves to be respected when treating breast cancer

A

-between the 95% and 107% isodose curves to respect what ICRU proposes.

29
Q

In some cases, what is required to bring the 95% isodose curve closer to the skin

A

Bolus is what is required to bring the 95% isodose curve closer to the skin (usually for 18 MV)
Bolus is used when need to bring the dose more superficial, to compensate for missing tissue or to make a more homogenous surface

30
Q

What are the two techniques used to treat Breast cancer?

A

-Tangential
used to treat the chest wall

-Mcgill
used to treat the chest wall + supraclavicular Lymph nodes

31
Q

In a Mcgill breast technique, why is the ANT and POST fields at a off-0 degree angle?

A

The answer is to be OFF-CORD, if the Ant and Pot fields were to be treating at ) and 180 degrees, the spinal cord would be in the field. Therefore, the spinal cord is skipped.

32
Q

What are the two tangential techniques for Breast cancer?

A

-Coplanar
most used in JGH and MGH
the idea of the posterior margins of the tangential beams to be coplanar is to share the same plane, so that NO DIVERGENCE of the beam occurs.

-Coaxial, on the other hand the posterior margins of tangential beams are not on the same plane but rather share the same central axis, where some beam divergence would take place on the posterior margins, that could eventually create hot spots or overdose into the lung tissue.

33
Q

What are the 4 treatment modalities for Breast cancer?

A

1-Surgery
2-Chemotherapy
3-Radiotherapy (includes Brachytherapy)
4-Hormonal Therapy

34
Q

In what cases is Chemotherapy an option for Breast cancer?

A

If the tumor site is 2 cm and + in size

If there is lymph node involvement

35
Q

Why is radiation Therapy given only 2 weeks after Chemotherapy for Breast cancer?

A

The patient is left to:

  • recover and take back some energy
  • prevent heart toxicity by irradiating right away after chemotherapy.
  • especially for left breast case, the heart will be in the field, it will be better to let the patient recover from the systemic treatment so no stress on the heart.
36
Q

What is the SHIFT HORMONAL THERAPY in Breast cancer?

A

This treatment is used when the patient is not pre-menopausal but not quite post-menopausal yet. a CBC confirms when menopause is SET ON by seeing if ovaries still produce estrogen (low level of estrogen will mean menopause is set on)

37
Q

What is the staging system for Breast cancer?

A

the TNM system is commonly used.

T1 <2cm tumor size
T2 >2 cm but < 5 cm tumor size
T3 > 5 cm tumor size
T4 Invasion through the chest wall

N0 No lymph node involvement
N1 1-3 lymph nodes
N2 4-8 lymph nodes
N3 >9 lymph nodes

Mx Distant METS cannot be assessed
M0 No distant METS
M1 Distant METS

38
Q

When is Brachytherapy an option for Breast cancer?

A
  • When no Lymph node involvement
  • Early stage, small lesion
  • Superficial tumor
39
Q

What are the most common organs for METS spread in Breast cancer?

A
  • Bone
  • Brain
  • Lung
  • Liver
40
Q

Give the pathway of an electron beam starting at the bending magnet.

A
  • Bending magnet
  • Pencil sharp tool
  • 1-collimation
  • Scattering filter carroussel
  • Ion chamber
  • 2-collimation
  • Patient
41
Q

What are the OARs in Breast cancer treatment?

A
  • Contra-lateral Breast
  • Heart
  • Lung
  • Spinal cord
  • Humeral head
42
Q

What are the SIDE EFFECTS of Radiation when treating Breast cancer?

A
  • Erythema
  • Dry Desquamation
  • Moist Desquamation
  • Necrosis
43
Q

What are the different Patient care options to help with the side effects of radiation in Breast cancer?

A
  • Use of FLAMAZINE for skin care

- Dressings done by Nurses or Technologists

44
Q

What are some of the recommendations of DAY 1 for a Breast cancer patient?

A
  • Start applying Aveeno or glaxalbase hydrating creams as starting on day 1
  • Non-scented products
  • No shaving on side being treated
  • No deodorant on the side being treated
  • No perfume or alcohol-based around the area of treatment
  • If taking shower, no rubbing on marks,pad dry gently
  • No cold to hot abrupt changes
  • No solar exposure anymore since skin will become sensitive to radiation
  • Not to remove marks, neither to remark their marks, this is done at the clinic
  • No application of cream 4 hours PRIOR to treatment because it can create a BOLUS effect.
  • to use loose clothes, no wired bras, dark cloths to not stain with marks and ink
45
Q

In a Breast setup, why is the collimator angle not at 0 degrees?

A

It is to be parallel to the chest wall

BREAST CANCER (9 decks)

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