Breast Oncology Flashcards
Aetiology and risk factors for breast cancer?
Increasing age Family history Endogenous hormones (early Period and late menopause) High socio economic status Alcohol BRCA 1/2 Hormonal therapy IR
What is the Breast anatomy?
Epithelial-ducts and lobules
Stromal- connective tissue
What is the Lymph drainage of breast
Laterally to axilla
Medially to IM
From axillary to supraclavicular nodes
What are the three groups of axilla LN?
1-Lateral to pec minor
2-under pec minor
3-medial to pec minor
What is ductal carcinoma in situ?
Proliferation of malignant cells that does not breach the basement membrane
What is lobular carcinoma in situ
Proliferation of malignant cells that does not breach the basement membrane
What is a ductal carcinoma?
Proliferation of malignant cells that does breach the basement membrane
What is lobular carcinoma
Proliferation of malignant cells that does breach the basement membrane
poorly defined
Natural spread of breast cancer?
Carcinoma in situ, invasion of basement membrane, LN then blood vessels
Signs and symptoms of breast cancer?
Lumps-benign changes
Asymmetry
changes in size shape
skin and nipple changes
Clinical presentation of cancer?
Pain
Nodal disease:oedema, palpable
After mammogram
Early detection
Breast checks independent
Mammogram
Checks from doctor
What is the screening group for mammograms?
50-69
younger age breast is too dense
older other co morbidities
can display false positives
What is the workup for breast cancer?
Mammgram
Ultrasound/mammogram
Surgery
then staging using CT
Staging of breast cancer?
Carcinoma in situ
Early stage breast cancer
Locally advanced
Metastatic
Early breast cancer treatment?
Surgery
XRT
Chemo
Hormone therapy
What is the benefits of surgery?
Primary treatment
Excise all tumour
What are the two types of surgery?
Lumpectomy-BCS
Mastectomy- removing whole breast tisuue, fascia and LN.
Is there much difference in survival between mastectomy and BCS?
No
Who is BCS not suitable for?
Cancer too big
Multifocal disease
Nipple or skin involvement
Locally advanced disease.
What was the standard axillary dissection?
level 1 and 2 nodes
What were some morbidity from Axilla surgery?
Lymphoedema, wound seroma, haemotoma, infection
What is the sentinel node?
First node cancer drains to
lower rates of lymphoedema and false posiives.
What is adjuvant treatment?
treatment of potential microscopic disease
Local regional or distant
What do oestrogen and progesterone do?
Oest-stimulate ductal growth
Prog-stimulate lobular development
are overexpressed in breast cancer
What is HER 2
Growth factor gene
gene amplification in breast cancer
What can radiotherapy used for in early breast cancer?
Following BCS Following mastectomy reduce local recurrence by 70% reduce overall recurrence by 50% reduce death by 17%
Do all women who have BCS require RT?
Yes reduction in local recurrence
Older late not much clinically better depends on stage of life.
Should post masectomy patient undertake RT/
YES if large tumour, number of nodes and positive margins.
What are the radiotherapy volumes?
Whole breast after BCT
Chest wall after masectomy
LN
What are the margins for chest wall/breast
Med-midline
Sup-clavicle
Inf-1cm inferior to breast tissue
Lat-1cm lateral to breast tissue
When should nodal RT be undertaken?
High suspicion of cancer
Whn should SCF RT be undertaken?
If there is a high number of axillary LN present.
What is the SCF technique?
Tangents to breast
Heavy weight anterior field
in accordance to SCF margins
Is axillary RT indicated and what would change?
Not if there has been prior surgery may increase lymphoedema
Just extend lateral margin to neck of humerus
What indicates Axillary RT?
Residual disease in axilla
sentinel node in axilla
less extensive surgery
What is the role of IM RT and when is it indicated?
No clear evidence
Maybe for high rates of involvement
if sentinel node is IM
What are the arguments of IM
Technically difficult
Increased toxicity
Isolated IM recurrence is rare
No proven benefit
What are the techniques for IM RT?
Extend tangents
Match with electron field and move medial border
Highly conformal-IMRT/VMAT
When is regional Nodal irradiation indicated?
SCF>4 LN
Axilla- high likelihood
IM-medial axillary node where feasible
What is the standard fractionation regime?
50 in 25 to whole breast and chest wall
What are some hypofraction prescriptions?
42.5 in 16
40 in 15
41.6 in 13
What are the arguments for Hypofractionation?
reduction in treatment time
low alpha beta ratio
What is the rationale for electron boost?
Local recurrence around tumour bed
10 in 5
16 in 8
What are some acute toxicities of RT
Oedema
skin changes
Fatigue
Pharyngitis
What are some late toxicities of RT
fibrosis, change in pigmentation, telangiectasia-high dose to skin nipple retraction. Rib osteitis Interstitiual pneumonitis heart disease. Brachial plexopathy Secondary malignancies
How can you reduce toxicities?
Ensure surgical wound healed and cellulitis treated
consider fraction size
CT plan
DIBH
When can the prone technique be used?
Patients with large pendulous breasts/late seps
remove folds
reduce folds
What are some prone technique limitations?
Not suitable for deep tumours-posterior legions
Heart falls towards the chest wall
Dont treat regional LN
Advantages of IMRT breast?
Reduces heterogeneities
Conform complex target volumes
May allow treatment of LN with greater sparing
Can treat odd shapes
Disadvantages of IMRT
Complexity
Respiratory cycle
greater dose to contralateral breast
What is the rationale for PBI:
Treatment of whole breast
Occurs within 2cm of tumour bed
can hypofractionate it even more reduce dose to lungs and heart.
What are some PBI techniques?
3DCRT
Brachytherapy
Intra-operative RT-TARGIT
What are the PBI results to date?
Suggests higher local recurrence
concern fat necrosis, telangiectsia
Under investigation
only for low risk patients
What are the main surgeries for early breast cancer?
Mastectomy
Wide local excision
Nodes
When is adjuvant radiotherapy indicated?
For women after a wide local excision
High risk mastectomy women
tangents across nodes if high risk
