Intraining - Breast Flashcards
2019-286. According to 2018 NCCN Guidelines, which newly diagnosed breast cancer patient does NOT meet criteria for further genetic risk assessment assuming no additional risk factors?
(A) 75-year-old female with triple negative breast cancer
(B) 70-year-old female of Ashkenazi Jewish ancestry
(C) 45-year-old female with DCIS
(D) 55-year-old male with negative LNs
Key: A
Citations: NCCN guidelines, multiple, January 2018, BR/OV-1.
Rationale: A: Patients with triple negative breast cancer diagnosed at <= 60 years of age should be referred for genetic risk assessment.; B: Patients of Ashkenazi Jewish ancestry with a personal history of breast or high-grade prostate cancer should be sent for genetic risk assessment.; C: Patients diagnosed with breast cancer, invasive and DCIS, at <= 50 years of age should be sent for genetics risk assessment.; D: Male breast cancer patients should be sent for genetics risk assessment.
2019-282. Regarding use of hypofractionation for PMRT:
(A) nearly half of patients on the START A and B trials received PMRT.
(B) is associated with worse chest wall appearance and increased fibrosis versus conventional fractionation.
(C) is contraindicated following autologous reconstruction.
(D) the ongoing Alliance A221505 phase III PMRT trial compares 42.56 Gy in 16 fractions to 50 Gy in 25 fractions.
Key: D
Citations: Haviland et al, Lancet Oncol, 2013: 14, 1086-94. Badiyan et al, Radiotherapy and Oncology, 2014: 110, 39-44.
Rationale: START A included 15% pts s/p mastectomy, START B had 8%; with 14% and 7% respectively receiving RNI. Worse chest wall appearance and fibrosis with hypofractionation have not be reported on prior trials using and will be further evaluated on the Alliance phase III RCT of hypofractionated PMRT (Alliance A221505: Hypofractionated radiation therapy after mastectomy in preventing recurrence in patients with stage IIa-IIIa breast cancer). This trial compares 42.56 Gy in 16 fractions with conventional fractionation and evaluates the rates of breast reconstruction complications, acute and late toxicities, and recurrence.
2019-275. According to the 2018 ASTRO guideline update, what is a preferred dose fractionation schema for whole breast irradiation? (A) 40 Gy in 15 fx (B) 42.5 Gy in 20 fx (C) 50 Gy in 25 fx (D) 50.4 Gy in 28 fx
Key: A
Citations: Smith et al., PRO, 2018: 8(3), 145-152.
Rationale: According to the recent ASTRO guideline update, the preferred dose fractionation scheme for whole breast radiation with or without the low axilla but without additional nodal fields is 40 Gy in 15 fractions or 42.5 Gy in 16 fractions. The guideline addresses whether various clinicopathologic factors affect this recommendation, the role for boost, and dose and treatment planning recommendations.
2019-268. According to the 15-year update of the EORTC 10853 trial of RT versus no RT following breast conserving surgery in DCIS, what was the relative reduction in any local recurrence with RT? (A) By one quarter (B) By one third (C) By one half (D) By two thirds
Key: C
Citations: American College of Radiology Appropriateness Guidelines for DCIS, 2014. Donker et al, JCO, 2013:31(32, p. 4054-9.
Rationale: While no differences were seen in breast cancer specific survival or overall survival in the 15-year update for the EORTC 10853 trial, the risk of local recurrence after radiation was reduced by 48%. The local recurrence free rate increased from 69% to 82%.
2019-262. On the NCIC MA-20 study of WBI +/- regional nodal irradiation, what grade 2 or higher treatment related toxicity was increased with regional nodal irradiation? (A) Fatigue (B) Cardiac events (C) Neuropathy (D) Lymphedema
Key: D
Citations: Whelan TJ, Olivotto IA, Parulekar WR, et al., Regional Nodal Irradiation in Early-Stage Breast Cancer, NEJM, July 23, 2015, p. 314.
Rationale: There was no difference in the rates of grade 2 or higher fatigue, pain, neuropathy, or cardiac events between both groups (WBI +/- RNI). The risk of pneumonitis was 0.2% with WBI and 1.2% with the addition of RNI, p=0.01. The risk of grade 2 lymphedema was 4.5% in the breast alone group compared to 8.4% in the group receiving nodal irradiation with a p-value of 0.001.
2019-260. Which feature is associated with increased risk of developing breast cancer? (A) Atypical hyperplasia (B) Breast feeding (C) Exercise (D) Oophorectomy before age 45
Key: A
Citations: NCCN Breast Cancer Risk Reduction Guidelines, Version 2.2018.
Rationale: According to the NCCN Guidelines on breast cancer risk reduction, for a woman who does not have familial risk or genetic predisposition, atypical (ductal and lobular) hyperplasia is associated with increased risk. Prior oophorectomy before age 45 years, prior risk-reducing therapy, exercise, and breast feeding are associated with decreased risk.
2019-242. According to recent ACR breast cancer screening recommendations, what would be appropriate annual screening for women with calculated lifetime breast cancer risk of 20% or more?
(A) MRI with IV contrast starting at age 20
(B) Digital breast tomosynthesis starting at age 20
(C) Ultrasound of the breast starting at age 25
(D) Digital mammography starting at age 30
Key: D
Citations: Monticciolo et al, American College of Radiology, J Am Coll Radiol, 2018:15, p. 408-414.
Rationale: The updated ACR breast cancer screening recommendations for women at higher-than-average risk state the following: “For women with genetics-based increased risk (and their untested first-degree relatives) or with a calculated lifetime risk of 20% or more, DM, with or without DBT, should be performed annually beginning at age 30. For women with histories of chest radiation therapy before the age of 30, DM, with or without DBT, should be performed annually beginning at age 25 or 8 years after radiation therapy, whichever is later. For women with genetics-based increased risk (and their untested first-degree relatives), histories of chest radiation (cumulative dose of 10 Gy before age 30), or a calculated lifetime risk of 20% or more, breast MRI should be performed annually beginning at age 25 to 30. For women with personal histories of breast cancer and dense breast tissue, or those diagnosed before age 50, annual surveillance with breast MRI is recommended. For women with personal histories not included in the above, or with ADH, atypical lobular hyperplasia, or LCIS, MRI should be considered, especially if other risk factors are present. All women, especially black women and those of Ashkenazi Jewish descent, should be evaluated for breast cancer risk no later than age 30, so that those at higher risk can be identified and can benefit from supplemental screening.”
2019-229. What are the appropriate regional nodal treatment volumes for a pT2N1 breast cancer following modified radical mastectomy?
(A) Supraclavicular, infraclavicular, and dissected axilla
(B) Supraclavicular, axillary apical, and ipsilateral IMNs
(C) Supraclavicular and bilateral IMNs
(D) Infraclavicular and ipsilateral IMNs
Key: B
Citations: Recht et al, JCO, 2016: 34(36), 4431-4442.
Rationale: According to a focused guideline update on PMRT from ASCO/ASTRO/SSO: RNI should include the IMNs and supraclavicular-axillary apical nodes. Axillary LND is included in MRM. The dissected axilla should not be included for N1 disease.
2019-208. What were the doses for WBI and APBI used on the NSABP B-39/RTOG 0413 clinical trial for women with stage 0, I, II breast cancers?
(A) WBI 42 Gy in 16 fx; APBI 34 Gy in 10 fx bid brachy; APBI 38.5 Gy in 10 fx bid 3D CRT
(B) WBI 42 Gy in 16 fx; APBI 38.5 Gy in 10 fx bid brachy; APBI 34 Gy in 10 fx bid 3D CRT
(C) WBI 50 Gy in 25 fx; APBI 34 Gy in 10 fx bid brachy; APBI 38.5 Gy in 10 fx bid 3D CRT
(D) WBI 50 Gy in 25 Fx; APBI 38.5 Gy in 10 fx bid brachy; APBI 34 Gy in 10 fx bid 3D CRT
Key: C
Citations: Julian TB et al., IJROBP, 2001, 81(2), S7 (abstract). NSABP B-39/RTOG 0413 protocol.
Rationale: On NSABP B-39/RTOG 0413 women with stage 0, I, or II breast cancers with tumor size less than 3 cm and no more than 3 LNs positive were stratified by disease stage, menopausal status, hormone receptor status, and intention to receive chemotherapy. They were randomized to either WBI as 50 Gy (2 Gy/fx) or 50.4 Gy (1.8 Gy/fx) with optional boost versus 34 Gy (3.4 Gy/fx bid) with multicatheter or intracavitary brachytherapy or 38.5 Gy (3.85 Gy/fx bid) with 3D conformal EBRT.
2019-195. A 70-year-old female with normal renal function and no other significant co-morbidity presents with a cT2N2M1 triple negative breast cancer with an asymptomatic bone metastasis. What is the next MOST appropriate step in treatment?
(A) Chemotherapy + RT
(B) Endocrine therapy + RT
(C) Chemotherapy + denosumab
(D) Endocrine therapy + ovarian suppression
Key: C
Citations: NCCN Guidelines, Breast Cancer, April 23, 2018, BINV-19.
Rationale: Denosumab, zoledronic acid, or pamidronate should be added to endocrine or chemotherapy in the treatment of stage IV breast cancer with bone disease present, provided life expectancy is greater than 3 months and patient has normal renal function. Given that patient is asymptomatic from bone metastasis, there is no immediate need for palliative radiation.
2019-189. For DCIS, which feature is associated with an elevated risk of in-breast recurrence? (A) Clinical detection (B) Intermediate grade (C) Presence of ADH (D) Tumor-to-ink margin of 0.3 cm
Key: A
Citations: Donker M, J Clin Oncol, 2013, 31(22):4054-4059. Wapnir IL, JNCI, 2011, 103:478-488.
Rationale: In the EORTC 10853 trial, the risk factors associated with IBTR were: age<40, clinical detection (non-mammographic), + margins, and solid type. This finding was replicated in the pooled analysis of NSABP B-17 and B-24 which found that the risk factors associated with IBTR were: age <45, clinical detection, comedonecrosis, and margin status (positive/unknown vs. negative).
2019-137. Using modern chemotherapy regimens, which molecular subtype is associated with the highest rates of pCR after neoadjuvant chemotherapy? (A) Hormone receptor HR (+) / Her-2 (-) (B) Hormone receptor HR (+) / Her-2 (+) (C) Hormone receptor HR (-) / Her-2 (-) (D) Hormone receptor HR (-) / Her-2 (+)
Key: D
Citations: Swisher SK, Vila J, Tucker SL et al, Locoregional Control According to Breast Cancer Subtype and Response to Neoadjuvant Chemotherapy in Patients Undergoing Breast-conserving Therapy, Ann Surg Oncology, March 2016, 749-56, 23(3).
Rationale: In the publication by Swisher et al the pCR rates following neoadjuvant chemotherapy for the different subgroups were as follows:
HR (+)/Her-2(-) – 16.5%
HR (+)/Her-2 (+) – 45.7%
HR (-)/Her-2 (-) – 42%
HR (-)/Her-2(+) – 72.4%
- Which statement is TRUE regarding the recent 2018 ASTRO guideline on fractionation for WBI?
(A) The use of hypofractionation in patients < 40 years of age should be avoided
(B) The use of adjuvant chemotherapy should not affect the decision regarding fractionation
(C) For patients in whom the inclusion of the low axilla is intended, conventional fractionation is preferred
(D) The guideline applies to early stage invasive breast cancer and not DCIS
Key = C; Citations: Smith BD, Bellon JR, Blitzblau R, et al., Radiation therapy for the whole breast: Executive summary of an ASTRO evidence-based guideline., Practical Radiation Oncology, Vol 8, May-June 2018, 148.
Rationale: In table 1, page 148, the 2018 guideline stated that the panel supports the use of hypofractionation in patients of any age in whom the intent is to treat the whole breast without additional fields to cover regional lymph nodes and applies to both invasive cancer and DCIS. Use of adjuvant chemotherapy is not an exclusion for use of hypofractionation.
- In the ACOSOG Z0011 study of axillary dissection (AxLND) vs. no AxLND in women with positive sentinel lymph nodes (SLN):
(A) less than 5% of patients did not receive protocol specified radiation treatment.
(B) there was an imbalance of Her2+ patients between the arms favoring the SLN alone group.
(C) nearly 30% of patients who underwent AxLND had additional lymph nodes containing macrometastases beyond the SLNs.
(D) more patients on the AxLND arm received adjuvant chemotherapy due to the additional nodal disease found versus patients on the SLN alone arm.
Key: C
Citations: Giuliano AE, Ballman KV, McCall L, et al. , Effect of Axillary Dissection vs. No axillary Dissection on 10-year overall survival among women with invasive breast cancer and Sentinel node metastasis. The ACOSOG Z0011 (Alliance) Randomized clinical trial, JAMA, Sept 12, 2017, 918-926, 318(10).
Rationale: A: 18.9% of patients received protocol-prohibited nodal irradiation and 11% of patients did not receive radiation. B: The treatment groups were well balanced with respect to patient and disease characteristics including hormone receptor status. Her2 status was not reported. C: 27.3% of patients in the ALND group had macrometastases (>2mm) in nonsentinel lymph nodes removed during ALND. D: There was no difference in the type of chemotherapy or the proportion receiving endocrine therapy, chemotherapy or both among the two groups.
2019-120. Historically for locally advanced breast cancer, what signs were associated with low likelihood of negative margins and high recurrence rates if patients proceeded directly to resection?
(A) Multicentric disease and nipple retraction
(B) Extensive skin edema and satellite skin nodules
(C) ER negativity and palpable mobile axillary nodes
(D) Palpable breast mass and nipple discharge
Key: B
Citations:
Haagensen, CD and Stout, AP. Annals of Surgery. 1942 Dec: 116(6), 801-815. Haagensen, CD and Stout, AP. Annals of Surgery. 1951 Dec: 118(6), 1032-1051. Haagensen, CD and Stout, AP. Annals of Surgery. 1943 Dec: 118(6), 1032-1051.
Rationale: Haagensen and Stout published their surgical results in the treatment of advanced breast cancers and proposed criteria of operability based on the extent of carcinoma. The following features were among those considered as inoperable as radical resection was not likely to result in disease control or cure: extensive skin edema, skin satellite nodules, intercostal or parasternal nodules, arm edema at presentation, supraclavicular nodal disease, inflammatory breast cancer.
