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Locoregional Treatment of IDC Flashcards

1
Q

NSABP B17

A

RCT: BCS vs BCS + RT for localised DCIS
Conclusion: addition of RT after BCS significantly reduces ipsilateral breast cancer recurrence

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2
Q

NSABP B24

A

Tamoxifen after BCS + RT in DCIS patients
Conclusion: reduced incidence of invasive breast cancer

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3
Q

Evidence for BCT + RT treatment in IDC

A

NSABP B17
EORTC 10853
ECOG E5194

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4
Q

Indications for Mastectomy in IDC

A
  • >4cm
  • Multicentric disease
  • Local recurrence following BCS
  • Contraindications / do not want RT
  • Male
  • Inflammatory carcinoma
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5
Q

Contraindications to radiotherapy

A
  • Absolute
    • Pregnancy
    • Previous RT
  • Relative
    • Active connective tissue disease
    • Known BRCA
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6
Q

Radiotherapy regimen in BCS + RT

A
  • 50 Gy to whole breast
  • 10Gy boost over operative site
  • daily for 5-6 weeks
  • 2-3 weeks after surgery
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7
Q

Types of positive SLNB and associated management

A
  • Isolated Tumor cells → no need ALND
  • Micrometastasis → no need ALND
  • Macrometastasis
    • ≤2 → no further dissection if T2 or less
    • 3 or more → ALND
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8
Q

Definition of isolated tumor cells

A

≤ 0.2mm tumor cells

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9
Q

Definition of micrometastasis

A

0.2-2mm tumor cells

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10
Q

Definition of macrometastasis

A

>2mm tumor cells in SLNB

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11
Q

Why use dual tracer technique for SLNB?

A
  • increased accuracy
  • Radioactive colloid → accuracy 90%
  • blue dye → accuracy 80%
  • dual agent → accuracy 97-98%
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12
Q

Evidence of SLNB for axillary management in clinically node negative

A

ALMANAC

  • level 1 evidence
  • improved quality of life outcomes
  • improved arm morbidity
  • no difference in overall survival
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13
Q

What is Z0011 eligibiltiy criteria

A
  • Refers to subset of patient with early stage IDC that may not require further axillary surgery
  • Criteria:
    • T1/T2
    • Clinically node negative
    • Less than 3 metastatic SLN
    • Will undergo BCS + RT
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14
Q

What is the Z0011 trial

A
  • multicenter non-inferiority RCT
  • Patients: T1/T2 clinical node negative
  • Intervention: (BCT + RT) +ALND vs SLNB only
  • Outcome: 10 year survival
  • Conclusion: ALND not necessary for 1-2 nodes
  • Criticism: low accrural, premature study termination
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15
Q

Evidence for axillary management in early IDC cancer

A

Z0011

AMAROS

IBCSG 23-01

POSNAC (pending)

ALLIANCE

SOUND

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16
Q

Indications for ALND

A
  • 3 more metastatic sentinel LN
  • 1-2 SLN metastastsis in patients who do not want or cannot have whole breast irradiation
17
Q

Indication for adjuvant radiotherapy

A
  • skin and chest wall involvement
  • Inflammatory cancers
  • >4 axillary LN met
18
Q

Principle of Breast Conservative Surgery

A
  • WLE + RT
  • Titanium clips should be attached to pectoral muscle at base fo tumorectomy site
  • Specimen shoudl be oriented by suture/ clips
  • Eclipse of skin should be excised if attached to skin
  • No ink tumor margin
19
Q

Definition of Modified Radical Masectomy

A

Removal of

  • all breast tissue (total mastectomy)
  • ALND Level I + II
  • preservation of pectoralis major + minor and overlying skin
20
Q

Describe the MRM procedure

A
  • Supine with ipsilateral arm secure to arm board
  • Transverse elliptical incision encompassing NAC and lump
  • Elevate superior and inferior skin flaps in plane between subcutaneous and breast tissue
    • superior: until lower border of clavicle
    • inferior: superior border of rectus sheath
    • medial: periphery of the breast disc
    • lateral: latissimus dorsi
  • Dissect down to chest wall to pectoralis fascia then along fascia from medial to lateral to lift breast tissue enbloc from the chest wall
  • Identify the border of pectoralis major and clear axillary tail
  • Wash cavity with water to eliminate any solitary tumor cells & unvascularize fat globules
21
Q

Boundaries of dissection for ALND

A
  • Superior: axillary vein
  • Inferior: upper lateral breast tissue/axillary fascia
  • Medial: lateral border of pectoralis major + clear LN posterior to pect minor
  • Lateral: anterior of LD
  • Anterior: clavicopectoral fascia
  • Posterior subscapularis
22
Q

Intra-operative methods for SLN assessment

A
  • Frozen section
  • Touch imprint cytology
  • Molecular technique (OSNA- one step nucleic acid amplification)
23
Q

LocoPros and cons of intraoperative assessment techniques

A
  • Frozen section:
    • +tissue retained for future reference, + sensitive (55-75%) and specific
    • -requires on hand pathologist, -
  • Touch imprint cytology
      • high specificity, +retained tissued for future reference
    • -pathologist on hand, - low sensitivity
  • OSNA
    • +high specificity and sensitivity, + able to quantify between macro/micro/ITC
    • -expensive equipment, -no tissue left for furthre assessment
24
Q

When would you perform Level 3 axillary clearance?

A

Only in melanoma

Breast (5 decks)

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