Red Book Early Stage

Question 1

What mutations are involved in breast cancer?

Answer 1

1. Ataxia-telangiextasia
2. BRCA1: 60-80% risk
3. BRCA2: 50-60% risk
4. Cowden
5. Li-Fraumeni

Question 2

What’s the most common location for breast cancer?

Answer 2

UOQ

Greatest volume of glandular elements

Question 3

What are the common location for breast cancer

Answer 3

UOQ > Central > UIQ > LOQ > LIQ

Question 4

What’re the anatomical margins of the breast?

Answer 4

1. Overlaying pec major
2. 2nd to 6th rib
3. Sternum to anterior axillary fold
4. Axillary tail of spencer extends into low axilla

Question 5

What’re the location of IM nodes?

Answer 5

Along IM vessels
First three intercostal spaces
2-3 cm lateral to midline
2-3 cm deep

Question 6

What % of tumors drain to IMN?

Answer 6

Medial: 30%
Lateral: 15%

Question 7

What % of breast cancers are triple negative?

Answer 7

15%, and most commonly associated w/ BRCA mutations

Question 8

What’re the common histologic types?

Answer 8

IDC: 80%
ILC: 5-10% (less visible on mammo, more on MRI)
Tubular
Medullary
Mucinous
Colloid
Papillary
Cribriform

Question 9

What’s extensive intraductal component (EIC)?

Answer 9

> 25% DCIS within invasive cancer

Question 10

Which pt’s do we use Oncotype DX for?

Answer 10

LN -ve
ER +ve
Receiving tamoxifen

Question 11

What does Oncotype DX tell us?

Answer 11

Benefit from chemotherapy in addition to hormonal therapy

Question 12

What’re the Oncotype DX scores?

Answer 12

<18: Low risk
18-30: Intermediate risk
>30: High risk

Question 13

What’re the rates of distant recurrence for different Oncotype DX groups?

Answer 13

Low: ~7%
Intermediate: ~14%
High: ~30%

Question 14

What’re the 4 main intrinsic (molecular) subtypes of breast cancer?

Answer 14

Luminal A
Luminal B
Triple -ve
HER2 enriched
Normal-like

Question 15

What defines Luminal A subtypes of breast cancer? What does Luminal A signify?

Answer 15

Hormone Receptor + (ER+ and/or PR+)
HER2-
Low Ki-67

Slow growing w/ the best prognosis

Question 16

What defines Luminal B subtypes of breast cancer? What does Luminal B signify?

Answer 16

Hormone Receptor + (ER+ and/or PR+)
+/- HER2+
High Ki-67

Grow faster than Luminal A w/ worse prognosis

Question 17

What defines HER2 enriched subtypes of breast cancer? What does HER2 enriched signify?

Answer 17

Hormone receptor -
HER2 +

Grow faster than luminal cancers w/ worse prognosis

Question 18

What’s the SN/SP of mammogram?

Answer 18

> 90%

Question 19

What’re the USPS recs for mammograms

Answer 19

40-49: No routine screening
50-72: Yearly mammograms
High-risk women: 10 yrs before dx of relative
No evidence for benefit/harm of clinical exam
Recommend against teaching self-exam

Question 20

How’re breast cancers detected?

Answer 20

Mammogram 90%

Self-exam 10% (usually painless. Rarely (~5%) painful)

Question 21

If a mass changes w/ menstrual cycles, what’s the likelihood of it being cancerous?

Answer 21

Low

Question 22

What % of women have b/l cancers?

Answer 22

1-3%

Question 23

What’s the risk of developing contralateral breast cancer after primary dx?

Answer 23

0.75% per year

Question 24

What’s multifocal breast cancer?

Answer 24

2 or more foci in the same quadrant

Question 25

What's multi-centric breast cancer?

Answer 25

2 or more foci in di quadrants OR 2 foci > 5 cm apart NOT eligible for breast conservation

Question 26

What's BI-RADS?

Answer 26

Classification System 0: Incomplete. 1 % risk 1: -ve. <1% risk 2: Benign. <1% risk 3: Probably benign: <2% risk 4a: Low suspicion for malignancy. 2-10% risk > Bx 4b: Mod suspicion for malignany. 10-50% risk > Bx 4c: High suspicion for malignancy. 50-95% risk > Bx 5: Highly suggestive of malignancy. >95% risk > Bx 6: Bx proven malignancy

Question 27

For which stages ca we skip systemic imaging for breast cancer pts?

Answer 27

Stage I-II w/o suspicious sx

Question 28

What're some suspicious sx/findings in a low stage breast cancer pt that would warrant systemic imaging?

Answer 28

Elevated LFTs | Elevated alk phos

Question 29

What're some suspicious findings on mammography?

Answer 29

Calcifications | Spiculated lesions

Question 30

How does spot compression distinguish between benign vs. malignant lesions on mammography?

Answer 30

Benign (dense breast tissue) spreads out w/ compression.

Question 31

Why do we do US w/ mammography?

Answer 31

Distinguish solid from cystic lesions, and evaluate nonpalpable masses identified on mammogram

Question 32

What're the different types of bx?

Answer 32

Core: Preferred FNA: Cannot distinguish invasive cancer vs DCIS, or hormone/receptor status Punch bx: For Paget's disease/inflammatory breast cancer

Question 33

What're some poor prognostic factors associated w/ breast cancer?

Answer 33

``` LN +ve Young age ER/PR -ve HER +ve (in the absence of HER2 directed tx) High Grade LVSI + Basal-like subtype ```

Question 34

What's the T staging for breast cancer?

Answer 34

Tis: Carcinoma in situ T1mic: <0.1 cm T1a: 0.1-0.5 cm T1b: 0.5-1 cm T1c: 1-2 cm T2: 2-5 cm T3: > 5 cm T4a: Extension into the chest wall (not pec major) T4b: Extension into the skin T4c: T4a + T4b T4d: Inflammatory breast cancer

Question 35

What's the cN staging for breast cancer?

Answer 35

N0: No palpable LNs N1: Mobile ipsilateral I/II Ax. LNs N2a: Fixed/matted ipsilateral Ax LNs N2b: Ipsilateral IM LNs w/o Ax LNs N3a: Ipsilateral infraclavicular LNs N3b: IM + Ax LNs N3c: Ipsilateral Supraclav LNs

Question 36

What're the pN staging for breast cancer?

Answer 36

N0 (i-) -ve by IHC N0 (i+) +ve by IHC N0 (mol-) -ve by PCR N0 (mol+) +ve by PCR N1 (mi) >0.2 mm and/or >200 cells, but <2mm N1 (a) 1-3 Ax LNs N1 (b) IM +ve by pathology, -ve be exam N1 (c) pN1a + pN1b N2 (a) 4-9 axillary LNs N2 (b) IM +ve pathologically and clinically, but -ve Ax LNs N3 (a) >10 Ax LNs + or infraclav + N3 (b) Pathologically and clinically +ve IM + +Ax LNs N3 (c) Ipsilateral Supraclav LNs +ve

Question 37

What's the M staging for breast cancer?

Answer 37

M0 (i+) Circulating tumor cells in BM | M1 Distant Mets

Question 38

What's the treatment paradigm for low-risk breast caner?

Answer 38

MRM BCT: Lumpectomy + RT CHT: If desired, done either neoadjuvantly or adjuvantly Endocrine: For hormone-receptor +ve cancers. Done after all other tx.

Question 39

Therapies to prevent BCa or reduce risk of recurrence?

Answer 39

Tamoxifen: ER antagonist in Breast, ER agonist in endometrium. Reduces risk by 50% Raloxifene: ER antagonist in breast and endometrium. Less thromboembolic effects than tamoxifen. Vitamin D + Ca: May reduce risk in premenopausal women Ppx mastectomy: Reduces risk by 90% in predisposed populations No conclusive evidence from special dietary changes

Question 40

What are the different types of mastectomies?

Answer 40

RM: Removes pec major + Level I/II/III LNs MRM: Removal of Level I/II LNs +/- Pec minor. Preserves Pec major and Level III LNs TM: Removal of breast tissue only Skin-sparing M: Removal of breast + scar skin Nipple-sparing M: Preservation of nipple-areolar complex

Question 41

How many LNs are removed in ALND vs SLNBx?

Answer 41

Complete ALND: 20-22 LNs Level I and II LND: ~15 LNs SLNBx: Cariable

Question 42

Which women typically receive CHT for early-stage breast cancer?

Answer 42

``` LN+ ER- HER2+ Young Age (unclear benefit in > 70 yrs) Multiple adverse features High Oncotype DX ```

Question 43

Timing of CHT?

Answer 43

Typically, post-op | Neoadjuvant equivalent to adjuvant, but neo may allow for a less extensive surgery

Question 44

Which CHT has an OS benefit for HER2+ pt's? How much is the benefit?

Answer 44

Trastuzumab | OS benefit 1 yr

Question 45

What's the benefit of dose-dense (q2 wks) instead of standard regimens?

Answer 45

OS advantage for high-risk pt's

Question 46

Which pts benefit from hormone therapy?

Answer 46

All hormone-receptor +ve pts w/o contraindications

Question 47

What're the common hormone therapies? When are they used? What do they do?

Answer 47

All are typically given for 5 yrs Tamoxifen: Decrease recurrence by 1/3 at 10 yrs, 1/2 subsequently. Carries risk of thromboembolic events (1%) and endometrial cancer. Anastrozole: Prevents conversion of androgens to estrogen in peripheral tissue. Ineffective in premenopausal women. Less risk of thromboembolic events and endometrial cancer.