Early-stage (I-II) Breast Cancer Flashcards
What histologic subtypes of IDC are associated with favorable outcomes?
Tubular, medullary, mucinous (colloid), papillary
What is a phyllodes tumor of the breast?
Ranges from benign to malignant. Rare tumor, leaflike, lobulated appearance on microscopic section. Treated with surgery, wide local excision or total mastectomy. No role for RT
What is Paget disease of the breast?
Malignant epithelial cells infiltrating the epidermis of the nipple-areolar complex. Presents with crusting, scaling, itching, and redness of the skin. 80-90% is associated with underlying DCIS or invasive breast cancer
What percent of invasive breast cancers are invasive lobular carcinomas?
10-15%
What percentage of women with clinically negative axilla were found to have axillary metastases on LND in NSABP B04?
40% of clinically node negative patients had positive nodes on LND
In NSABP B04, what percentage of women with a clinically negative axilla who did not undergo LND eventually developed a clinically positive axilla?
20% of women with initially negative nodes developed positive nodes
Workup for early-stage invasive breast cancer?
H&P (hormone use, ob/gyn hx, family or personal hx of breast/ovarian ca), diagnostic bilateral mammogram +/- ultrasound, pathology w/ ER/PR and HER2 status, CBC/CMP
When should bone scan or CT abdomen/pelvis be performed?
Bone scan only if localized bone pain or elevated alk phos
CT a/p if elevated alk phos or LFTs, abdominal sx, abnormal exam
When should breast MRI be used in screening/workup?
Women with >20% increased lifetime breast cancer risk based on family history and genetics
How should ER/PR and HER2 status be determined and reported?
ER/PR is positive if >1% of tumor cell nuclei are reactive via IHC
HER2 is positive if evidence of protein overexpression (3+) or gene amplification. If 2+, should get reflex testing using ISH
How should axilla and primary be evaluated prior to surgery or preoperative systemic thearpy?
If detected radiologically (mammo or axillary US), should get core biopsy
If LN-, SLNBx
If LN+, ALND if surgery planned or SLNBx following systemic therapy
Which trial shows SLNBx as an alternative to ALND for sentinel node negative patients?
NSABP B32: randomized 5611 patients to SLNBx + immediate completion axillary LND vs. SLN Bx alone; OS, DFS and regional control were similar between groups. Also shows decreased risk for lymphedema and arm numbness with SLNBx
What should be done is SLNBx is positive?
If T1/T2 or 1-2+ SLN, WBI after lumpectomy is appropriate without systemic chemo. ACOSOG Z0011 randomized ALND vs. no dissection for SLNBx+ treated with WBI and found noninferior 5yr OS, DFS, and LRR; 10yr OS also noninferior
What can be done in high risk patients with 1-2+ axillary SLNBx who do not undergo ALND?
High tangents (cranial tangent border >2cm from humeral head)
List the T-staging cutoffs for T1 and T2 breast cancers per 8th edition of AJCC
(c/p)T1mi: ≤1 mm (c/p)T1a: >1 mm but ≤5 mm (c/p)T1b: >5 mm but ≤10 mm (c/p)T1c: >10 mm but ≤20 mm (c/p)T2: >20 mm but ≤50 mm
What is clinical nodal staging for N1 disease?
cN1: mets to movable ipsilateral level I and level II axillary nodes
cN1mi: micromets (>0.2mm but <2.0mm)
What is the pathologic staging for N0-N1 disease?
pN0(i+): ITCs only (malignant cell clusters ≤0.2 mm)
pN0(mol+): Pos molecular findings by RT-PCR; no ITCs detected
pN1mi: Micromets (<0.2 mm but ≤2.0 mm)
pN1a: Mets in 1–3 axillary LNs, at least 1 with >2.0 mm
pN1b: Mets in ipsi IM SLNs, excluding ITCs
pN1c: pN1a and pN1b combined
What T and N groupings make up stage IA, IB, IIA, IIB?
IA: T1N0
IB: T0N1mi, T1N1mi
IIA: T0N1, T1N1, T2N0
IIB: T2N1, T3N0
What is the bioscore incorporated into the AJCC 8th edition staging system>
Multivariate model that incorporates grade, ER status, HER2 status and pathologic stage to assess DSS which ranges from 0 to 7
Which biomarker panel has level I evidence for breast cancer and what is it used for?
Oncotype DX recurrence score. A low oncotype DX score downgrades a biologically low-risk T2N0 from stage II to stage I
What percentage of breast cancer patients are diagnosed with stages 0 to II disease?
80%
What are the management options for early stage breast cancers?
- Lumpectomy w/ surgical axillary staging + RT
- Total mastectomy w/ surgical axillary staging +/- reconstruction
- If T2 or T3 and otherwise meets criteria for BCS can consider systemic chemo
When do you use adjuvant chemotherapy for early stage node negative breast cancer?
Triple negative or Her2+ with tumor > 1cm
ER+, Her2- with tumor > 0.5cm, consider oncotype
What does oncotype dx score tell you?
Risk of distant recurrence within 10 years of diagnosis with 5 years of endocrine therapy alone in ER+, N0 patients that undergo upfront surgery
Low <18, adjuvant endocrine alone
Intermediate 18-30, adjuvant endocrine +/- chemo
High >=31, adjuvant endocrine + chemo
