Breast Cancer Part 2 Flashcards
Distinct from skin-sparing in that nipple and/or nipple areola complex are conserved
Nipple-Sparing Mastectomy
breast-conserving surgery by wide local excision of the tumor followed by definitive irradiation to the intact breast
Lumpectomy
When the surgical procedure was less than a complete lumpectomy, such as an initial incisional biopsy or core biopsy
When pathologic margins on the initial excisional biopsy are shown to be involved by tumor
When there are residual suspicious microcalcifications on a postlumpectomy mammogram.
Recommendations for re-excision of primary tumor
Modified radical mastectomy may be preferable
for some patients who wish to avoid radiation
for those in whom removal of clinical and radiographically apparent disease will result in a suboptimal cosmetic result
for those with diffusely positive margins which cannot be cleared with re-excision those with diffuse suspicious microcalcifications
personal preference for mastectomy over breast conserving therapy
In Axillary Node Dissection, what are the landmarks for each level of axillary lymph nodes?
Level 1
between axillary vein and latisimuss dorsi
Level 2
between lateral and medial borders of pectoralis minor muscle
Level 3
between medial border of pectoralis minor and Halsted’s ligament
Iwasaki et al.
Identified subgroup of patients who may not undergo axillary lymph node dissection. What are the histologies with lower rates of LN involvement
Medullary, mucinous, and tubular
Although the current standard for patients with a positive sentinel node is to undergo completion axillary dissection, the necessity of this has been questioned and was the subject of this trial which showed:
No significant differences in local recurrence or regional recurrences in SLND and ALND versus ALND alone
What is the name of the trial?
ACOSOG Z0011
What is the conclusion of the ALMANAC trial comparing standard ALND versus Sentinel lymph node dissection with respect to the Primary outcome measure: Arm and shoulder morbidity and QOL
Conclusion: SLNB treatment of choice for patients who have early-stage breast cancer and clinically negative nodes
Most acceptable standard of care for the majority of women with early-stage invasive breast CA
Breast-conserving surgery followed by RT to the intact breast
Journal of National Cancer Institute
Appropriate treatment for Stage I or II breast CA
Preferable because:
Equivalent survival to that of total mastectomy and axillary dissection while preserving the breast
Breast-Conserving Therapy is ideal for?
Unicentric primary tumors and
Relative contraindications for BCT:
Collagen vascular disease Patients with germline mutations that predisposes to breast CA dev’t Positive margins More advanced disease Multicentric disease Pregnancy Prior RT
Based on the NSABP 06 trial,
Disease-free survival among patients in the three cohorts who were treated by total mastectomy, lumpectomy, or lumpectomy and breast irradiation (20yr ff-up). What is the conclusion?
20-year follow-up period – no significant difference in all 3 arms with regards to survival
Remains among the strongest factors for local relapse
Age and margin
What trial showed tamoxifen improved local control rates in pxs with LN (-) breast tumors
NSABP B-21 trial
MD Anderson Cancer Center
use of systemic therapy was the most powerful clinical, pathologic, or treatment predictor of local control, producing a ___-fold reduction in the risk of local recurrence.
3.3
________ is a humanized monoclonal antibody
against the human EGFR-2 (HER2), which is amplified or
overexpressed in about 15% to 20% of invasive breast cancers;
these tumors are known to be more aggressive and more susceptible
to recurrence than HER2-negative tumors
Trastuzumab (Herceptin)
Based on the mature data from the well-conducted randomized trials outlined above and on long-term follow-up from the several large retrospective series, it is apparent that breast-conserving surgery followed by radiation therapy is a safe and effective modality for the majority of women with early-stage invasive breast cancer.
True or false?
True
Collectively, the randomized studies to date consistently demonstrate an approximately threefold greater local relapse rate in the unirradiated
cohorts.
According to Vinh-Hung and Verschraegen in
Meta-analysis of survival and local control in randomized trials comparing breast conserving surgery with or without radiation
What is the conclusion?
Demonstrates a threefold reduction in local relapse and a small but significant increase in survival with the use of radiation therapy following lumpectomy
What is the Benefit of RT in elderly women with early breast CA?
associated with a lower risk of a second ipsilateral breast cancer and subsequent mastectomy
Most likely to benefit
Patients aged 70-79 yrs with minimal comorbidity
Least likely to benefit
Older patients with substantial comorbidity
For women with favorable T1N0, receptor (+) breast CA
Tamoxifen alone is a reasonable option that should be discussed
Patients with low comorbidity and long life expectancy
Offer radiation even in those over age 70 with ER-positive tumor
What is the standard RT technique?
45-50.4 Gy / 1.8-2.0 Gy / Fx (25-28 days )
Followed by 5-8 fraction boost (10-16Gy) for a total of 60-66 Gy
Delivered for 6-7.5 weeks
In the UK Standardization of Breast Radiotherapy (START) - Trial A on the hypofractionated whole breast irradiation concludes ______
Lower total dose in a smaller number of fractions could offer similar rates of tumor control as standard fractionation
Based on ASTRO, the hypofractionated whole breast irradiation likely equivalent to conventional fractionation in patients who meet ALL criteria:
Age over 50 yrs
Pathologic state T1-2N0 treated with lumpectomy
Has not received systemic chemotherapy
Minimum and maximum dose along the central axis is not 107% of the prescription dose
is now the most common method of axillary management in
women with early-stage breast cancer
Sentinel node sampling, with or without full axillary dissection
NSABP-04, operable negative disease. What is the conclusion?
Comparable Radi Mast and Simpl Mast with RT
(
Yarnold
advised elective RT of the axilla and the supraclavicular fossa in selected patients, such as:
> 4 metastatic axillary lymph nodes,
involvement of the apex of the axilla
gross extracapsular tumor extension, even if the patients are to receive adjuvant chemotherapy
In MD Anderson Cancer Center
Retrospective analysis of sequencing chemotherapy and RT in patient with lymph node (-) treated with breast conserving therapy
What is the conclusion?
Supports an adjuvant-therapy schedule in which chemotherapy is delivered first
Chemotherapy vs RT
Local ctrl rate: 100% vs 94%
Recurrence free survival 92% vs 77%
Sartor et al. (CALGB)
More recently, with the addition of taxane-based chemotherapy to adriamycin-based regimens, concerns have arisen regarding the additional delays in initiating radiation therapy in conservatively managed patients.
What is the effect?
patients in the adriamycin plus taxane arm had radiation
delayed by an additional 84 days
Despite this added delay, local-regional relapses were lower in
the adriamycin plus taxane
In the study of Arcangelli et al., Concurrent Chemoradation in Breast-Conserving Therapy. How long is the acceptable delay of Rt?
Patients with negative surgical margins receiving adjuvant chemotherapy, radiotherapy can be delayed to up to 7 months.
In Sequencing Tamoxifen / Hormonal Therapy and RT in Conservatively Managed Patient, why is it proposed to have a delayed tamoxifen use during RT course?
Optimal scheduling of hormonal therapy and RT due to theoretical concerns:
Tamoxifen causes arrest of breast cancer cells in relatively radioresistant G0/G1 phases of the cell cycle
Clinical studies suggested:
Increase pulmonary fibrosis and breast fibrosis
Possible related to increased concentrations of transforming growth factor-B with concurrent tamoxifen use
What are the corresponding chromosomes for BRCA 1 and 2 respectively?
BRCA1
Chromosome 17q21
BRCA2
Chromosome 13q12-13
Seynaeve et al. (Dutch Cancer Society),
Investigated LR after Breast Conservation Therapy in patients with 3 or more 1st degree relatives with breast or ovarian CA or BRCA1/2 families
What is the result?
Local recurrence rates
Initially similar
Longer follow up: higher rate in hereditary group vs age-matched sporadic patients
In NSABP-P1, Analysis from Tamoxifen vs Placebo Prevention trial
Identified BRCA1/2 mutations who developed breast CA
What is the conclusion?
BRCA2 carriers: 62% reduction in breast CA incidence with tamoxifen
BRCA1 carriers: no benefit with tamoxifen
most common cancer diagnosed during pregnancy
Breast CA
Zemlickis et al., compared pregnant and non pregnant breast ca patients. What are characteristics of breast ca pregnant patients?
2.5 times more likely to have metastatic disease
Had significantly lower chance of having stage I disease
T or F?
With a history of breast CA, subsequent pregnancy does not increase the risk of recurrence.
True
What is the dose of RT associated with mental retardation? What is the most susceptible trimester?
0.1 – 0.9 Gy during 1st trimester
What is the safest period to do the MRM in pregnant patients?
Potentially harmful interventions carry greatest risk during period of organogenesis; safest during final trimestser
Patient with operable disease
Surgery can be safely performed after 12th week of pregnancy
What is the Estimated dose to fetus from breast/chest wall RT?
0.5 Gy Equivalence:
- 02 Gy (1st trimester)
- 022 - 0.246 Gy (2nd trimester)
- 02 - 0.586 Gy (3rd trimester)
According to Hall, what is the dose in which therapeutic abortion may occur?
Suggested that 0.1 Gy in utero exposure be used as a dose beyond which a therapuetuc abortion should be considered
Patients receiving adjuvant chemotherapy, a minimum of ___ months between treatment and conception is advised
Breastfeeding contraindicated in patient receiving chemotherapy
12
Mantle field irradiation
Associtated with ___ fold increase in developing breast CA vs mediastinal irradiation alone
2.7
recommended as the preferred treatment option for breast cancer patients with previously irradiated hodgkins lymphoma
Mastectomy – recommended as the preferred treatment option
Lumpectomy followed by irradiation is considered to be contraindicated due to cumulative radiation dose to breast
Can multicentric disease be a candidate for BCS?
It depends!
Considered by some as a contraindication to BCS
Suggest mastectomy as the preferred option
BCS may be acceptable for 2-3 lesions provided these lesions are surgically excised with negative margins and there are no residual areas of suspicion
What are the risk factors for contralateral breast carcinomas?
Younger age Family history of breast CA Lobular carcinoma Multicentric disease Histologic differentiation of the primary tumor PR-positive status
Heron et al, compared outcomes with in patients with unilateral, with metachronous, with synchronous breast carcinoma treated with either mastectomy or BCT. What is the conclusion?
Synchronous and metachronous bilateral CA had a worse 8-year DFS vs unilateral breast CA, as well as increased risk of distant metastasis
Multivariate analysis
Local tumor control and overall survival – not statistically significant
What are the borders for chest wall irradiation?
Borders:
Upper margin
head of the clavicle
Medial margin
Without internal mammary portal: at or 1 cm over the midline
With internal mammary field: lateral margin of the internal mammary field
Lateral-posterior margin
2 cm beyond all palpable breast tissue (usually near the mid-axillary line)
Inferior margin
2 to 3 cm below the inframammary fold
Best predictor of percentage of ipsilateral lung would be included in tangential field
Central lung distance (CLD)
Usually up to 2-3cm of underlying lung maybe included in tangential portals
___% breast recurrence after BCS and RT occur around primary tumor site
65% - 80%
Most institutions: prefer electron beam boost:
Most institutions: prefer electron beam boost
Relative ease in setup Outpatient setting Lower cost Decreased time demands on the physician Excellent results compare with 192Ir implants
90% prescription isodose line is limited to the chest wall to decrease lung dose
Clinical set-up involves marking the projection of the postlumpectomy volume on the skin and adding 2-3cm in all directions
Electron boost
Seroma Cavity contouring
Seroma Clarity Scale (British Columbia Cancer Agency)
Cavity Visualization Score (Stanford Group)
What is the difference between the two?
SCS – 0-5 scoring
0: no visible seroma 1: scar or shadow
CVS – 1-5
1: no visible seroma, omits scar or shadow, 2-5similar
Borders, dose and technique of supraclavicular LN irradiation
Borders:
Inferior: matched to the tangential field, usually just below the clavicular head.
Medial: 1 cm across the midline, extending upward following medial border of SCM to the thyrocricoid groove
Lateral: vertical line at the level of the coracoid process, just medial to the humerus head.
Field angled 10-15 degrees
Typical width: 7-9cm
Total dose delivered to SCF: 46-50.4 Gy/1.8 to 2.0 Gy/fx
Treated when (+) nodes, inadequate, or undissected axillare SCF extended laterally to cover at least 2/3 of humeral head
Axillary LN irradiation
Dose of midplane of axilla from SCF is calculated at a point approximately 2 cm inferior to the midportion of the clavicle
Borders, dose and technique of posterior axillary boost.
Borders
Medial: drawn to allow 1.5-2cm of lung to show on the portal film
Inferior: level of inferior border of SCF
Lateral: blocks fall-off across post. Axillary fold
Superior: splits clavicle
Superolateral: shields/splits humeral head
Additional dose to axilla midplane usually administered to complete 46-50Gy when indicated
A boost of 10-15Gy is delivered with reduced fields
With tangential fields: Caudal border: within 2cm of humeral head 2cm deep to the chest wall-lung interface (includes majority of level I and II LN)
Borders and Dose of IMN RT.
Borders:
Median: midline
Lateral: 5-6cm lateral to midline
Superior: abuts the inferior border of SCF
first intercostal space (if only IMNs are to be treated)
Inferior: xiphoid or higher
Dose:
45-50Gy/1.8-2Gy/fx
Calculated at point 4-5cm beneath the skin surface
To spare underlying lung, mediastinum, and spinal cord:
Electron beam (12-16MeV) preferred
Single isocenter is set at the match between the supraclavicular and tangential fields. The inferior portion of the beam is blocked for the supraclavicular treatment and the superior blocked for the tangential field, with no movement of the isocenter, resulting in an ideal match. Blocks are drawn as indicated to shield lung and heart. The field should be viewed clinically to ensure that the blocks drawn to shield the heart and lungs to not block target tissue on the breast–chest wall. Projection of fields onto patient surface demonstrates perfect match of the supraclavicular and tangential fields.
Monoisocentric matching technique.
Vicini et al.
Reported on patients treated with WB-IMRT using multiple static MLC segments:
Use of intensity modulation with a static MLC technique for tangential WBRT is an efficient method for achieving a uniform and standardized dose throughout the whole breast.
standard mastectomy, with minimal skin sacrifice at the mastectomy site
this is often performed when immediate reconstruction is planned
This technique attempts to remove all breast tissue, but the preservation of skin provides cosmetic and reconstructive advantages.
The procedure is oncologically sound, and patients undergoing skin-sparing mastectomy do not require postmastectomy radiation unless they have risk factors that place them at higher risk
Skin-Sparing Mastectomy
