Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Ph RadOnc Residency PBRROE2-3 Review 2021 > Breast Cancer: Locally Advanced > Flashcards

Breast Cancer: Locally Advanced Flashcards

1
Q

Breast Cancer: Locally Advanced

Epidemiology

Why is there a high incidence of mortality in Blacks?

A

ER(-)

high nuclear grade

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Breast Cancer: Locally Advanced

Pathology

What are the most common histology of locally advanced breast cancer?

A

Invasive ductal and lobular carcinoma

However, those subtypes considered to behave less aggressively (e.g., tubular
carcinoma, mucinous carcinoma, and medullary carcinoma) are unlikely to
present at advanced clinical stages unless the breast mass has been present for a
long time.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Breast Cancer: Locally Advanced

Biology

What is the most common biologic/molecular profile of locally advanced breast cancer that has developed between annual interval screening mammograms?

A

ER-negative
high nuclear grade
high proliferative index

(luminal B, nonluminal HER-2, or triple negative)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Breast Cancer: Locally Advanced

Clinical Presentation

What is the most common presentation of locally advanced breast cancer?

A

palpable breast mass

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Breast Cancer: Locally Advanced

Diagnostic Workup

Aside from physical examination, and laboratory tests, what other staging procedures should be requested prior to initiation of therapy?

A

chest CT
abdominal CT
pelvic CT
bone scan (with radiographs of symptomatic areas or areas of increased uptake)

a brain MRI is not routinely done for all patients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Breast Cancer: Locally Advanced

Diagnostic Workup

What subsets of patient will benefit from a contrast-enhanced brain MRI?

A

those with higher risk

  • HER2-positive
  • triple-negative
  • inflammatory breast cancer

those with symptoms suspicious of cerebral metastases

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Breast Cancer: Locally Advanced

Treatment

This landmark trial compared neoadjuvant and adjuvant 4 cycles of AC in operable breast cancer in 1,523 patients.

Results showed no difference in OS and DFS but showed higher percentage of patients that are able to undergo BCS after neoadjuvant therapy.

What is this trial?

A

NSABP B-18

Another trial with same findings is the EORTC 10902

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Breast Cancer: Locally Advanced

Treatment

Those who achieve a pCR with neoadjuvant chemotherapy have a higher DFS compared to those who did not.

TRUE or FALSE?

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Breast Cancer: Locally Advanced

Which of the following is/are chemosensitive and associated with higher pCR over the other/s?

highly proliferative (luminal B, nonluminal/HER2-positive, and triple-negative)

or

low proliferative subtypes with high expression of hormone receptors (luminal A).

A

highly proliferative (luminal B, nonluminal/HER2-positive, and triple-negative)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Breast Cancer: Locally Advanced

Treatment

When comparing neoadjuvant tamoxifen vs. anastrozole vs. tamoxifen+anastrozole for 12 weeks, there were no differences in clinical or radiographic response, but a higher percentage of women receiving ________ were eligible for BCS compared to the rest.

A

Anastrozole.

The IMPACT trial randomized 330 postmenopausal patients with clinical stage II or III HR+ breast cancer to receive tamoxifen versus anastrozole versus tamoxifen plus anastrozole for 12 weeks.
There was no difference in clinical and radiographic response rates among the three groups, but a higher percentage of women receiving anastrozole were eligible for BCS compared with those receiving tamoxifen (44% vs. 22%, P = .022).
The authors also found that higher expression of ER was associated with increased response rates.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Breast Cancer: Locally Advanced

Treatment

What chemotherapy agents are usually administered in the neoadjuvant setting for HER2 negative LABC?

A

4 cycles
anthracycline-based (doxorubicin) + cyclophosphamide

with or without additional 4 cycles of taxane

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Breast Cancer: Locally Advanced

Treatment

What drugs/agents are usually added to chemotherapy in both the neoadjuvant setting and adjuvant setting for HER2 positive LABC?

A

Trastuzumab +/- Pertuzumab

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Breast Cancer: Locally Advanced

Epidemiology

IBC tends to occur in older patients than non-IBC.

A

False

More common in young, also in blacks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Breast Cancer: Locally Advanced

Natural History of IBC

Inflammatory breast cancer, as defined by the AJCC, is a composite clinical–pathologic entity characterized by diffuse edema and erythema of the breast with acute/subacute onset and pathologic demonstration of invasive breast cancer.
The erythema and skin changes must involve at least _______ (how much?) of the breast, and duration of symptoms must be <6 months.

A

1/3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Breast Cancer: Locally Advanced

Natural History of IBC

the presence of invasive cells in the
dermal lymphatics is the confirmatory findings in IBC.

TRUE or FALSE?

A

False.
One hallmark of IBC is extensive lymphovascular invasion of the superficial
plexus of vessels in the papillary and high reticular dermis by tumor emboli.
These emboli can be demonstrated with skin punch biopsies directed to areas of
erythema in up to 75% of cases.
However,

the presence of invasive cells in the
dermal lymphatics alone is neither sufficient nor necessary for the diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Breast Cancer: Locally Advanced

Natural History of IBC

How do you clinically differentiate skin findings from IBC to that of advanced non-IBC skin findings due to lympathic compression?

A

Duration of symptoms.

IBC is rapid.
Non-IBC skin changes are usually due to neglect and time factors.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Breast Cancer: Locally Advanced

Diagnostic Workup of IBC

What is the imaging study that is considered the most accurate test for identifying primary breast lesions in IBC?

A

MRI

MRI, with dynamic contrast enhancement studies, is the most accurate test for identifying primary breast lesions in IBC.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Breast Cancer: Locally Advanced

Treatment

What is the general management of IBC?

A

Trimodality therapy

Neoadjuvant chemo (FAC)
Mastectomy
PMRT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Breast Cancer: Locally Advanced

Treatment

RT prescription for IBC?
(both postop and preop and definitive)

A

-Popstop
50/2/25 or 51/.15 BID
with or without bolus
Subsequently, the chest wall and any areas of gross disease that has not been resected should be boosted to 60 to 66 Gy.

-Preop
Same, but if not rendered operable, may be given definitively to 72 Gy

20
Q

Breast Cancer: Locally Advanced

Which has a worse prognostic factor?
A second breast primary? or a recurrence?

A

Recurrence

21
Q

Breast Cancer: Locally Advanced

Patients with recurrent disease should undergo all of the following:

restaging
biopsy
reevalation of hormone receptor and HER2 status

TRUE or FALSE?

A

True syempre

22
Q

Breast Cancer: Locally Advanced

What is the standard-of-care management for patients who have in-breast recurrence after BCT?

A

Salvage mastectomy

23
Q

Breast Cancer: Locally Advanced

What are the indications for PMRT in the recurrent setting?

A

positive nodes (who did not receive initial regional nodal irradiation as a part of initial therapy),

tumors larger than 5 cm,

or multiple adverse risk factors, particularly in patients in whom their initial radiation was many years prior to the recurrence.

24
Q

Breast Cancer: Locally Advanced

What are the major risk factors for postmastectomy recurrence?

A

number of axillary lymph nodes positive at surgery

younger age

higher-grade histology

receptor-negative disease

LVI

25
Q

Breast Cancer: Locally Advanced

Patients with recurrent disease after initial mastectomy may have a worse prognosis than those with recurrent disease after initial breast conservation therapy.

TRUE or FALSE?

A

True

In the Canadian and the Danish postmastectomy radiation randomized control trials, patients who developed locoregional recurrence had very high rates of subsequently developing metastatic disease.
In the Vancouver trial, of the 39 patients who developed a locoregional recurrence, 37 eventually developed metastatic disease.
In the Danish trial, the 5-year rate of distant metastatic disease development after an isolated locoregional recurrence was 73%.

26
Q

Breast Cancer: Locally Advanced

What is the general management strategy for an isolated locoregional recurrence after mastectomy?

A

The general management strategy for an isolated locoregional recurrence after mastectomy requires input from a multidisciplinary team, but whenever possible should be wide local excision.

27
Q

Breast Cancer: Locally Advanced

An occult primary breast cancer is a contraindication for breast conservation therapy.
The primary treatment in this setting should be mastectomy with PMRT.

TRUE or FALSE?

A

False

In one of the largest series, investigators from MD Anderson evaluated 45 patients treated over a 47-year period and compared the outcome of those treated with mastectomy (n = 13) to those treated with breast conservation (n = 32).
These authors found equivalent rates of locoregional control, DFS, and OS between the mastectomy and breast conservation cohorts.
With a median follow-up of 7 years, only 2 of the 25 breast conservation patients who received breast irradiation developed a local recurrence.
Similar results have been reported from The Royal Marsden Hospital.
In a series of 48 patients, they found a 14% locoregional recurrence rate after breast radiation and an unacceptable rate of 80% if breast radiation was omitted.
These data suggest that microscopic/undetectable primary lesions can successfully be sterilized with the combination of systemic therapy and radiation therapy.
One can feel particularly reassured with this strategy for lesions treated in the MRI age (i.e., for lesions below the threshold for MRI detectability).
Patients presenting with an occult breast primary and axillary disease should receive regional nodal RT, whether as a part of PMRT or breast conservation therapy.

28
Q

Breast Cancer:

What is the most common presentation of male breast cancer?

A

Breast/axillary mass

29
Q

Breast Cancer:

What BRCA mutation is more common in male breast cancer?

A

BRCA2

30
Q

Breast Cancer: Locally Advanced

In the early meta-analysis by J. Cuzick, it was found out that radiation therapy was associated with reduced breast cancer-specifc mortality, but was counterbalanced by an increased risk of _____?

A

cardiovascular death.

Although these trials were conducted in an
era that predated effective systemic therapies and many of the surgical and
radiation practices used are no longer applied in modern practice, the work by
Cuzick et al. provided relevant early lessons in the association between
locoregional control and improved breast cancer–specific survival and the
importance of using heart-sparing radiation techniques to mitigate the risks of
cardiac injury and cardiac death.

31
Q

Breast Cancer: Locally Advanced

What group presented a meta-analysis in 1995 that studied 36 trials comparing surgery alone versus surgery plus radiation therapy.

Among 17,273 women enrolled in these trials, the use of radiation therapy after
surgery was associated with a threefold reduced rate of local recurrence
compared with surgery alone.

A

EBCTCG

32
Q

Breast Cancer: Locally Advanced

In the EBCTCG 2000 reanalysis by Gebski et al, what is the definition of “optimal” radiation therapy?

A

doses ranging between 40
and 60 Gray (Gy) in 2 Gy fractions or a biologically equivalent dose to the chest
wall, axilla, and supraclavicular fossa with or without the IMN

33
Q

Breast Cancer: Locally Advanced

Addressing the benefit of RT in the context of systemic therapy, a meta-analysis was conducted by Whelan et al.

What are the results of this study published in 2000?

A

significant reductions in LR and overall mortality.

Postmastectomy radiation was associated with significant reductions in
local recurrence (odds ratio [OR] 0.25; 95% CI, 0.19 to 0.34) and overall
mortality (OR 0.83; 95% CI, 0.74 to 0.94)

34
Q

Breast Cancer: Locally Advanced

In the most recent fifth update of the EBCTCG meta-analysis, published in
2014, that analyzed the benefit of PMRT in node-positive women,
how did they stratify the patients in the study? :)

A

by nodal status.

1-3 and 4 or more.

reduced LRR, overall recurrence, and breast cancer mortality for both groups.

35
Q

Breast Cancer: Locally Advanced

What are the randomized landmark trials which evaluated PMRT and showed not only locoregional control but also OS benefit?

A 
DBCG 82b (Overgaard)
DBCG 82c (Overgaard)
British Columbia PMRT trial
36
Q

Breast Cancer: Locally Advanced

The DBCG 82b and 82c showed benefits in their outcomes.
What was the difference in the two study populations?

A

82b - premenopausal women
CMF chemo +/- PMRT

82c - postmenopausal women
tamoxifen +/- PMRT

37
Q

Breast Cancer: Locally Advanced

The British Columbia PMRT trial is almost similar to the DBCG 82b trial.
What was the difference?

A

BC employed hypofractionated RT

37.5/16 chestwall and IMN
35/16 midaxilla

38
Q

Breast Cancer: Locally Advanced

Discuss the MA20 trial “by heart” hahaha

A

In 2015, the National Cancer Institute of Canada Clinical Trial Group (NCICCTG) MA20 trial was published after a median follow-up time of 9.5 years.
In this multicenter trial, 1,832 patients who underwent breast-conserving surgery and systemic therapy were randomized to receive radiation therapy to the whole breast alone (50 Gy in 25 fractions) versus radiation therapy to the whole breast (50 Gy in 25 fractions) plus regional nodes (45 Gy in 25 fractions).
Axillary dissection was performed in 96% of subjects.
Overall, 85% had 1 to 3 positive nodes, 5% had 4 or more positive nodes, and 10% had high-risk node-negative disease, defined as tumors >2 cm with ≤10 nodes removed, plus one or more of the following features: grade 3 histology, lymphovascular invasion, or estrogen receptor (ER)-negative disease.
LABC, defined as stage IIB to III disease, was represented by 45% of subjects.
RNI included the ipsilateral IMN in the first 3 intercostal spaces and the supraclavicular and level III axillary nodes.
For patients with fewer than 10 nodes removed or 4 or more positive nodes, the target volume also included level I and II axillary nodes.
At 10 years, RNI was associated with improved locoregional disease-free survival (95.2% vs. 92.2%, P = .009) and distant disease-free survival (86.3% vs. 82.4%, P = .03), but no difference in overall survival (82.8% and 81.8%, P = .38).
In a planned subset analysis, women with ER-negative disease randomized to RNI had improved disease-free survival and overall survival compared to no RNI.
The majority of regional recurrences occurred in the axilla (63% of patients) or the supraclavicular nodes (27%).
The rate of lymphedema was higher in the RNI group (8.4% vs. 4.5%, P = .001). The rates of grade 2 or higher cardiac and pulmonary toxicities were low (<1%) and were similar in the two study groups.

39
Q

Breast Cancer: Locally Advanced

Discuss the EORTC 22922 trial “by heart” hahaha

A

The European Organisation for Research and Treatment of Cancer (EORTC) 22922 trial evaluated elective radiation to the IMN and medial supraclavicular fossa in conjunction with whole-breast radiation after breast-conserving surgery or chest wall radiation after mastectomy.
Between 1996 and 2004, 4,004 patients with stage I to III breast cancer with a central or inner quadrant tumor with node-negative or node-positive disease or an outer quadrant tumor with node-positive disease were enrolled after breast-conserving surgery (76%) or mastectomy (24%).
In this trial, the majority of patients had early-stage breast cancer (34% stage I and 32% stage IIA disease).
33% of subjects had LABC, including 19% stage IIB and 14% stage III disease.
Systemic therapy was used in 99% of node-positive and 66% of node-negative subjects.
Subjects were randomized to radiation to the IMN and supraclavicular nodes: 50 Gy in 25 fractions, 26 Gy with photons (ranging from Co60 to 10 MV photons), and 24 Gy with electrons or no IMN–supraclavicular radiation.
Radiation was delivered to the IMN in the first three intercostal spaces, up to and including the first five intercostal spaces in patients with lower inner quadrant tumors.
Among subjects who underwent mastectomy, 76% had chest wall radiation in conjunction with RNI.
The axillary nodes were included in the target volume in 8.3% of the IMN– supraclavicular radiation group and 7.4% in the control (no IMN–supraclavicular radiation) group.
At 10 years, the RNI group had lower rate of any first recurrence (19.4% vs. 22.9%, P = .02) and higher rates of distant disease-free survival (78% vs. 72%, P = .02).
Overall survival was 82.3% in the RNI group and 80.7% in the control groups (P = .06).
As in the MA20 trial, the EORTC trial demonstrated that RNI was beneficial for women with node-positive disease with respect to breast cancer–specific outcomes, but the difference in overall survival at 10 years was small and did not reach statistical significance.
The rate of lung fibrosis was higher in the RNI group (4.4% vs. 1.7%, P < .001), whereas the rate of cardiac disease was comparable in the two groups (6.5% vs. 5.6%, P = .25).

40
Q

Breast Cancer: Locally Advanced

What are the traditional clinical borders for chest wall RT especially when using 2D-fluoroscopic planning?

A

superior: inferior edge of the clavicular head
inferior: 2 cm below the contralateral inframammary fold
lateral: midaxillary line
medial: midsternum
anterior: 2 to 3 cm of air over the chest wall
posterior: 1 to 3 cm of air

41
Q

Breast Cancer: Locally Advanced

What are the dose-volume constraints as recommended by the DBCCG?

Heart

A

LAD V20 Gy = 0%
V20 Gy = 10%
V40 Gy = 5%

42
Q

Breast Cancer: Locally Advanced

What are the dose-volume constraints as recommended by the DBCCG?

Lung

A

V20 Gy = 25% (no SCNI)

V20 Gy = 35% (with SCNI)

43
Q

Breast Cancer: Locally Advanced

RT sequelae.

What are the four categories of cardiac toxicity after breast RT?

A

pericarditis
myocardial fibrosis
pericardial fibrosis
CAD

44
Q

Breast Cancer: Locally Advanced

What are the dose-volume constraints as recommended by the QUANTEC?

Heart

A

V25 = 10%

45
Q

Breast Cancer: Locally Advanced

What is the main purpose of treating breast cancer in supine position?

A

lessen the dose the heart and lungs.

46
Q

Breast Cancer: Locally Advanced

Anatomically speaking, what subsets of patients will benefit the most from a supine position?

A

pendulous breasts,

pectus excavatum

47
Q

Breast Cancer: Locally Advanced

Discuss reconstruction

autologous vs implant
delayed vs. immediate
timing
types
sequencing
outcomes
A

:)

Ph RadOnc Residency PBRROE2-3 Review 2021 (57 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions