Breast Early Stage Part 3

Question 1

Give the four Accelerated Partial Breast Irradiation techniques.

Answer 1

Multicatheter Interstitial Techniques
MammoSite
External-Beam Conformal Radiation
Intraoperative Partial Breast Irradiation

Question 2

In multicatheter technique:

Total No. of catheters and planes are dependent on the:

Answer 2

Total No. of catheters and planes: dependent on the:
 size
extent, and 
shape of the target
Due to complexity:  less widely used

Question 3

Employs a single balloon catheter introduced into the lumpectomy site either at the time of lumpectomy or percutaneously after the procedure

Answer 3

Mammosite

Question 4

Dose of the mammosite?

Answer 4

Dose: 3.4 Gy, 1 cm 2x daily (34 Gy for 5 days)

Question 5

In APBI,

Over 70% of patients in randomized trial are opting for 3D-CRT due to?

Answer 5

Non-invasiveness

Homogeneous Dose Distribution

Question 6

Challenges in EBRT APBI?

Answer 6

Daily positioning of the target
Movement with breathing
Delivery of higher doses to surrounding normal breast tissue than with the brachytherapy

Question 7

Dose of EBRT APBI

Answer 7

Dose: 38.5 Gy in 3.85 Gy/fx delivered twice daily

Question 8

RT: delivered in a single intraoperative dose to the lumpectomy site at the time of surgery
Intraoperative electrons or intraoperative photons

Answer 8

Intraoperative Accerlerated Partial Breast Irradiation

Question 9

What is the dose for IORT APBI?

Answer 9

Single fraction of 21 Gy is equivalent to 60Gy/2Gy/fx

Question 10

ASTRO Recommendations on suitability of patients receiving APBI?

Answer 10

Suitable for patients: (2009)
≥60yrs
Node (-)
Invasive ductal tumors
≤2cm
(-) margins
ER (+)
(-) lymphovascular space involvement

Question 11

What are the four important factors that can affect cosmesis?

Answer 11

1. Surgical factors to be considered include extent of surgical resection, re-excision, orientation and length of the scar, closure or not of the tylectomy cavity, separate or continuous axilla–tylectomy scars, extent of the axillary dissection, and whether an ellipse of skin over the tumor was removed.
2. Radiation therapy factors are doses to the whole breast with tangential portals, homogeneity of dose throughout the breast (use of wedge or compensating filters), use of bolus, fractionation, overall duration of therapy including breaks, type and dose of boost, beam energy, and volume treated (whether peripheral lymphatic irradiation is administered).
3. Chemotherapy issues include cytotoxic agents used, timing and sequence relative to radiation therapy, and doses and combinations of drugs.
4. Host factors include size and shape of the breast, age, race, compliance with care and hygiene, concurrent medical illnesses (e.g., hypertension, diabetes, CVD), and intrinsic sensitivity to radiation

Question 12

In surgical aspect what are the factors Associated with lower rates of excellent/good cosmesis:

Answer 12

Reexcision of primary site
>100cm3 breast tissue resection
Skin resection area >20cm2

Question 13

Axillary surgery DOES NOT affect Breast Cosmesis

T or F?

Answer 13

True

Question 14

Radiation factors affecting cosmesis?

Answer 14

Treatment volume (tangential breast fields only vs. three fields or more)
Whole breast dose (>50 Gy)
Total dose to the tumor site (>65 Gy)
Optimum dose distribution created with use of compensating filters

NOT FACTORS:
Daily fractions size (1.8 vs 2 Gy)
Boost vs No boost
Use and type of boost  (brachytherapy vs. electrons)
Total irradiation dose
Use of bolus

Question 15

In EORTC trial, what are the factors showing worse cosmetic outcomes

Answer 15

Factors associated with worse cosmesis:
Inferior tumor location
Large excision volume
Presence of postoperative complications
Radiation therapy boost

Question 16

Most frequent findings in imaging after BCS in early stage Breast CA

Answer 16

parenchymal distortion and fibrosis
at the tumor excision site (secondary to surgical scar and irradiation)

skin thickening
seen in 90% of patients, which may be diffuse or more prominent at the surgical excision site

calcifications
due to fat necrosis, which are coarse and round and have radiolucent centers

Question 17

drew et al compared MRI vs Mammo and Clin exam

What is the conclusion?

Answer 17

CONCLUSION: When combined, clinical examination and mammography are as sensitive as MRI of the breast for the detection of locoregional recurrence, but MRI has greater specificity.

Question 18

Risk of arm edema increases when axillary dissection and axillary radiation therapy are used

What is the most common presentation of lymphedema?

Answer 18

Swelling

Question 19

Factors associated with arm edema?

Answer 19

More extensive axillary dissection (Beyond Level II - Midline)
Axillary Surgery plus irradiation
Younger women with axillary node dissection
> 13 LN dissected

Question 20

Unusual variant of panniculitis thickened sclerotic septa:
thick and thin collagen bundles
lobular panniculitis

Answer 20

Pseudosclerodermatosus panniculitis

Question 21

Tamoxifen has been shown to induce secretion of ________, which has been implicated in pathogenesis of radiation fibrosis.

Answer 21

tumor growth factor-β

Question 22

True or false?

Skin effects after postlumpectomy radiation therapy may be affected more significantly by the increase in the dose of radiation per fraction rather than by the total dose

Answer 22

True

Question 23

incidence of brachial plexopathy was significantly higher when the axillary dose was ______ Gy

Answer 23

> 50 Gy

Question 24

Most common presentation of pneumonitis

Answer 24

Dry cough

Question 25

High incidence of pneumonitis seen in?

Answer 25

Higher incidence of pneumonitis: paclitaxel (Taghian et al.)

Higher incidence: with concurrent use of weekly paclitaxel (Burstein et al.)

Question 26

Increase cardiotoxicity noted in the concurrent use of RT (left sided) and cardiotoxic regimens

What are some of the cardiotoxic drugs?

Answer 26

Adriamycin
Epirubicin
Trastuzumab

Trastuzumab can be used concurrently with Rt

Question 27

Two factors associated with transient ischemic attacks and CVA?

Answer 27

Age and hypertension remained significant predictors of cardiovascular accident or transient ischemic attack

Question 28

True or false

By 5 years, the overall cost for breast-conservation therapy was higher than for a mastectomy

Answer 28

False

By 5 years, the overall cost for breast-conservation therapy was lower than for a mastectomy

Question 29

Common goal of APBI techniques?

Answer 29

GOAL: COMMON STRATEGY

Delivering RT to a smaller vol. of breast tissue around lumpectomy site

Fewer larger fractions, over shorter period of time