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Radiation therapy 2 > Breast Oncology > Flashcards

Breast Oncology Flashcards

1
Q

Aetiology & Risk Factors?

A

increasing age
Family history
Endogenous hormone factors
Reproductive – lower age at menarche, older age at menopause, nulliparous, older at time of first birth. (Breast feeding protective)
Obesity in post-menopausal women
Exogenous hormone factors
Hormone replacement therapy (combined oestrogen/progesterone)
Higher socio-economic status
Moderate alcohol intake
Genetic (BRCA 1 & 2, p53, ATM)
Proliferative fibrocystic changes in breast, especially with atypia
Personal history of DCIS or invasive breast ca or endometrial ca
Previous exposure to ionising radiation – eg Hodgkin’s

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2
Q

Lymphatic drainage of the breast?

A

Laterally –> axillary lymph nodes – levels I-III
From here –>supraclavicular nodes
Medially –> internal mammary nodes (deep to 1st 3 intercostal spaces within 4cm of midline)

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3
Q

Pathology of breast cancer? (epithelial)

A

Carcinoma in situ

Ductal carcinoma in situ – proliferation of malignant cells in the ducts that does not breach the basement membrane.

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4
Q

Pathology of breast cancer? (Lobular)

A

Lobular carcinoma in situ – proliferation of malignant cells in the lobules that does not breach the basement membrane

Often more poorly defined
Greater risk of multifocality and bilaterality cf IDC
Others – including medullary, colloid (mucinous), tubular, Paget’s disease, adenoid cystic

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5
Q

Pathology of breast cancer? (Ductal)

A

Ductal (intraductal) carcinoma (infiltrating carcinoma of no special type)

Proliferation of malignant cells that breach the basement membrane

Grade 1 – 3 depending on malignant cells look and how arranged

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6
Q

Routes of spread?

A

Invasion of lymphatics  risk of spread to lymph nodes (axilla, supraclavicular fossa, internal mammary nodes) & subsequent vascular spread & distant mets

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7
Q

Symptoms & signs of breast cancer?

A

• Lump – most commonly related to benign disease
• Change in size or shape
• Nipple discharge, itching, bleeding or retractions
• Skin changes
–>Fungation or ulceration from direct invasion
–>Dimpling from underlying tumour fixation
–>Lymphoedema due to invasion of dermal lymphatics (peau d’ orange)
–>Erythema and warm from inflammatory breast cancer

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8
Q

How does the Her 2 gene cause breast cancer?

A
  • Cell which leads to cell proliferation
  • Gene amplification → overexpression → uncontrolled activation → proliferation and metastasis
  • Overexpression in 25% of breast cancers
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9
Q

Clinical presentation of breast cancer includes?

A

• Pain (uncommon)
• Nodal disease – palpable nodes, arm oedema, nerve
• Distant metastases
• Usually asymptomatic mammographic abnormality
o Soft tissue mass
o Miro calcifications

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10
Q

What is the aim of early screening methods?

A

o Aim – get tumour while still small and confined in breast

o Breast self-examination, clinical breast examination, screening mammography

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11
Q

What does mammography screening involve?

A

o Every 2 years for women 50-69 age group reduces mortality 20-35%
o False -ve and +ves can occur → higher in young women due to dense breasts
o No need in older women as co-morbid conditions compete for high risk of mortality
• After screening biopsy → definitive surgery → high risk metastatic disease CT head, chest, abdo and pelvis scans and bone scans

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12
Q

TNM stage 1 for breast cancer?

A 
Stage O 
non invasive (DCIS or LCIS)
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13
Q

TNM stage2 for breast cancer?

A

Stage 2 = primary >2 but <5cm, 1-3 nodes or >5cm no nodes

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14
Q

TNM stage 3 for breast cancer?

A

Stage 3 = primary >5cm with nodes or involves skin or chest wall or >4 axillary nodes

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15
Q

TNM stage 4 for breast cancer?

A

Stage 4 = tumour spread distantly usually to lung, liver and bone

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16
Q

Early breast cancer management?

A

Surgery, radiotherapy, chemotherapy, endocrine therapy → better outcome using full range of treatment options

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17
Q

Possible treatment sequences after surgery?

A

Chemo → RT
RT → chemo
Chemo → RT → Chemo
Concurrent

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18
Q

What does sentinel node biopsy involve?

A

Ist draining node within a LN basin to receive lymphatic drainage from a tumour site
<10% false -ve rate

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19
Q

What is the aim of breast cancer surgery?

A

Aim is to excise all tumour

20
Q

What is a modified radical mastectomy?

A

Removal of whole breast and underlying fascia over pectoralis major muscle with axillary dissection

21
Q

What does breast conversing surgery involve?

A

Wide local excision +/- axillary dissection and RT to whole breast

22
Q

Why might breast conserving surgery not be suitable for all patients?

A 
Multicentric disease, 
diffuse microcalcifications, 
inflammatory, 
previous RT, 
pregnancy, 
persistently +ve margins after re-excision
23
Q

Why might we use adjuvant radiotherapy?

A

o Either as part of breast conserving therapy or following mastectomy
o Reduces risk of local recurrence by 70% and all recurrence by 50%
o Even small no nodal cancers show benefit from radiation therapy
o Tamoxifen alone following lumpectomy is a realistic choice only for women >70 with small completely resected ER +ve tumour
o RT to supraclavicular, axilla and internal mammary nodes if regional nodal involvement and risk of relapse

24
Q

What are the field inclusion margins for the breast? (supine)

A

WHOLE BREAST: Medial, 1cm lat, 1cm inf, sup to include all breast tissue (lower edge of clavicular head to base of axilla)
CHEST WALL: entire mastectomy scar with bolus (may by alternate days on and off or full and scar)
NODAL: if high suspicion of occult nodal disease
SUPRA CLAV: >4 axillary nodes involved (inf to 2nd costal cartilage, medial, lat at coracoid process, sup at cricoid cartilage)
AXILLARY: increase risk of lymphoedema and not usually done if dissection has been performed, treated if residual disease
INTERNAL MAMMARY: involvement increase with medial tumours however very hard area to irradiate and can use either extended tangents, matched electron field, IMRT/VMAT

25
Q

Early side effects of breast cancer?

A
  • GI (nausea, vomiting, diarrhoea)
  • Hair loss
  • Myelosuppression
  • Fatigue
26
Q

Late side effects of breast cancer?

A
  • Heart failure
  • Premature menopause and infertility
  • Cognitive dysfunction
27
Q

What is inflammatory breast cancer defined by?

A

• Defined by
o Oedema >1/3 breast
o Erythema >1/3 breast
o Palpable border to erythema
• Usually Her2, node negative and younger
• Treatment same as LABC with Herceptin if Her2 +ve or HT if ER/PR +ve

28
Q

Where is the inflammatory breast cancer most breast likely to spread to?

A

Lung, bong and liver

29
Q

What is the chance of survival after having inflammatory breast cancer for 5 years?

A

5-10%

30
Q

Treatment of inflammatory breast cancer?

A

• Surgery, RT, HT, chemo, Her2, bisphosphonates (inhibit osteoclasts which slows down bone resorption around metastases in bone)

31
Q

How does the use of chemotherapy benefit cancer patients?

A

Significantly reduces risk of death from breast cancer for all patients with greater benefit in young women or with nodal involvement

32
Q

What is the traditional chemotherapy regime?

A

CMF (cyclophosphamide, methotrexate, 5FU)

33
Q

Late side effects of breast cancer?

A
  • Breast/arm oedema or Shrinkage
  • Pain and tenderness
  • Rib fracture
  • Skin telangiectasia
  • Symptomatic lung fibrosis and Cardiac morbidity
34
Q

OAR for the breast?

A
  • Heart
  • Lung
  • Contralateral breast
35
Q

Acute affects of breast irradiation treatment?

A
  • Skin changes (Erythema, dry/moist desquamation)
  • Oedema
  • Fatigue
  • Pharyngitis (SCF)
36
Q

Late side effects of breast irradiation treatment?

A
  • Cosmesis (Fibrosis, pigmentation change, telangiectasia)
  • Lung (Pneumonitis)
  • Cardiac (Ischaemic heart disease)
  • Rib osteitis
  • Lymphoedema
  • Brachial plexopathy
  • Second malignancy (lung, sarcomas)
37
Q

What is the standard dose for breast treatment?

A

50Gy in 25#

38
Q

What is the standard dose for hypo-fractionated treatment?

A

42.5Gy in 16#

39
Q

How does hypo-fractionated dose improve treatment?

A
  • a/b ratio is low and thus bigger fraction sized may be more effective
  • trials showed similar local control and cosmesis
40
Q

Electron boost to tumour bed fractionation? Why is this beneficial?

A

16Gy in 8#, 10Gy in 5#•

Shows small but significant reduction in local recurrence especially in women <50

41
Q

Why do we use IMRT for breast?

A
  • Reduces heterogeneity
  • Conformal target volumes
  • Reduced heart and lung dose
  • Regional node improvement
  • Odd shaped chest
42
Q

What do we need to consider for IMRT plans?

A

can be used to improve plans but need to consider respiratory motion and increased dose to contralateral breast

43
Q

Partial breast irradiation techniques?

A
  • 3D conformal or IMRT
  • Brachytherapy (interstitial or intracavitary)
  • Intra-operative RT
44
Q

What is a negative of partial breast irradiation?

A

o Show a higher local recurrence with no trials to confirm equivalent to standard treatment

45
Q

What are two examples of hormone therapy?

A

Tamoxifen

Aromatase Inhibitor

Radiation therapy 2 (3 decks)

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