Breast Oncology

Question 1

Aetiology and risk factors for breast cancer?

Answer 1

Increasing age
Family history
Endogenous hormones (early Period and late menopause)
High socio economic status
Alcohol
BRCA 1/2
Hormonal therapy
IR

Question 2

What is the Breast anatomy?

Answer 2

Epithelial-ducts and lobules

Stromal- connective tissue

Question 3

What is the Lymph drainage of breast

Answer 3

Laterally to axilla
Medially to IM
From axillary to supraclavicular nodes

Question 4

What are the three groups of axilla LN?

Answer 4

1-Lateral to pec minor
2-under pec minor
3-medial to pec minor

Question 5

What is ductal carcinoma in situ?

Answer 5

Proliferation of malignant cells that does not breach the basement membrane

Question 6

What is lobular carcinoma in situ

Answer 6

Proliferation of malignant cells that does not breach the basement membrane

Question 7

What is a ductal carcinoma?

Answer 7

Proliferation of malignant cells that does breach the basement membrane

Question 8

What is lobular carcinoma

Answer 8

Proliferation of malignant cells that does breach the basement membrane
poorly defined

Question 9

Natural spread of breast cancer?

Answer 9

Carcinoma in situ, invasion of basement membrane, LN then blood vessels

Question 10

Signs and symptoms of breast cancer?

Answer 10

Lumps-benign changes
Asymmetry
changes in size shape
skin and nipple changes

Question 11

Clinical presentation of cancer?

Answer 11

Pain
Nodal disease:oedema, palpable
After mammogram

Question 12

Early detection

Answer 12

Breast checks independent
Mammogram
Checks from doctor

Question 13

What is the screening group for mammograms?

Answer 13

50-69
younger age breast is too dense
older other co morbidities
can display false positives

Question 14

What is the workup for breast cancer?

Answer 14

Mammgram
Ultrasound/mammogram
Surgery
then staging using CT

Question 15

Staging of breast cancer?

Answer 15

Carcinoma in situ
Early stage breast cancer
Locally advanced
Metastatic

Question 16

Early breast cancer treatment?

Answer 16

Surgery
XRT
Chemo
Hormone therapy

Question 17

What is the benefits of surgery?

Answer 17

Primary treatment

Excise all tumour

Question 18

What are the two types of surgery?

Answer 18

Lumpectomy-BCS

Mastectomy- removing whole breast tisuue, fascia and LN.

Question 19

Is there much difference in survival between mastectomy and BCS?

Answer 19

No

Question 20

Who is BCS not suitable for?

Answer 20

Cancer too big
Multifocal disease
Nipple or skin involvement
Locally advanced disease.

Question 21

What was the standard axillary dissection?

Answer 21

level 1 and 2 nodes

Question 22

What were some morbidity from Axilla surgery?

Answer 22

Lymphoedema, wound seroma, haemotoma, infection

Question 23

What is the sentinel node?

Answer 23

First node cancer drains to

lower rates of lymphoedema and false posiives.

Question 24

What is adjuvant treatment?

Answer 24

treatment of potential microscopic disease

Local regional or distant

Question 25

What do oestrogen and progesterone do?

Answer 25

Oest-stimulate ductal growth Prog-stimulate lobular development are overexpressed in breast cancer

Question 26

What is HER 2

Answer 26

Growth factor gene | gene amplification in breast cancer

Question 27

What can radiotherapy used for in early breast cancer?

Answer 27

``` Following BCS Following mastectomy reduce local recurrence by 70% reduce overall recurrence by 50% reduce death by 17% ```

Question 28

Do all women who have BCS require RT?

Answer 28

Yes reduction in local recurrence | Older late not much clinically better depends on stage of life.

Question 29

Should post masectomy patient undertake RT/

Answer 29

YES if large tumour, number of nodes and positive margins.

Question 30

What are the radiotherapy volumes?

Answer 30

Whole breast after BCT Chest wall after masectomy LN

Question 31

What are the margins for chest wall/breast

Answer 31

Med-midline Sup-clavicle Inf-1cm inferior to breast tissue Lat-1cm lateral to breast tissue

Question 32

When should nodal RT be undertaken?

Answer 32

High suspicion of cancer

Question 33

Whn should SCF RT be undertaken?

Answer 33

If there is a high number of axillary LN present.

Question 34

What is the SCF technique?

Answer 34

Tangents to breast Heavy weight anterior field in accordance to SCF margins

Question 35

Is axillary RT indicated and what would change?

Answer 35

Not if there has been prior surgery may increase lymphoedema | Just extend lateral margin to neck of humerus

Question 36

What indicates Axillary RT?

Answer 36

Residual disease in axilla sentinel node in axilla less extensive surgery

Question 37

What is the role of IM RT and when is it indicated?

Answer 37

No clear evidence Maybe for high rates of involvement if sentinel node is IM

Question 38

What are the arguments of IM

Answer 38

Technically difficult Increased toxicity Isolated IM recurrence is rare No proven benefit

Question 39

What are the techniques for IM RT?

Answer 39

Extend tangents Match with electron field and move medial border Highly conformal-IMRT/VMAT

Question 40

When is regional Nodal irradiation indicated?

Answer 40

SCF>4 LN Axilla- high likelihood IM-medial axillary node where feasible

Question 41

What is the standard fractionation regime?

Answer 41

50 in 25 to whole breast and chest wall

Question 42

What are some hypofraction prescriptions?

Answer 42

42.5 in 16 40 in 15 41.6 in 13

Question 43

What are the arguments for Hypofractionation?

Answer 43

reduction in treatment time | low alpha beta ratio

Question 44

What is the rationale for electron boost?

Answer 44

Local recurrence around tumour bed 10 in 5 16 in 8

Question 45

What are some acute toxicities of RT

Answer 45

Oedema skin changes Fatigue Pharyngitis

Question 46

What are some late toxicities of RT

Answer 46

``` fibrosis, change in pigmentation, telangiectasia-high dose to skin nipple retraction. Rib osteitis Interstitiual pneumonitis heart disease. Brachial plexopathy Secondary malignancies ```

Question 47

How can you reduce toxicities?

Answer 47

Ensure surgical wound healed and cellulitis treated consider fraction size CT plan DIBH

Question 48

When can the prone technique be used?

Answer 48

Patients with large pendulous breasts/late seps remove folds reduce folds

Question 49

What are some prone technique limitations?

Answer 49

Not suitable for deep tumours-posterior legions Heart falls towards the chest wall Dont treat regional LN

Question 50

Advantages of IMRT breast?

Answer 50

Reduces heterogeneities Conform complex target volumes May allow treatment of LN with greater sparing Can treat odd shapes

Question 51

Disadvantages of IMRT

Answer 51

Complexity Respiratory cycle greater dose to contralateral breast

Question 52

What is the rationale for PBI:

Answer 52

Treatment of whole breast Occurs within 2cm of tumour bed can hypofractionate it even more reduce dose to lungs and heart.

Question 53

What are some PBI techniques?

Answer 53

3DCRT Brachytherapy Intra-operative RT-TARGIT

Question 54

What are the PBI results to date?

Answer 54

Suggests higher local recurrence concern fat necrosis, telangiectsia Under investigation only for low risk patients

Question 55

What are the main surgeries for early breast cancer?

Answer 55

Mastectomy Wide local excision Nodes

Question 56

When is adjuvant radiotherapy indicated?

Answer 56

For women after a wide local excision High risk mastectomy women tangents across nodes if high risk