[ROQs] Breast Flashcards
What are the borders of the breast when treating w/ tangential fields?
- Ant: 2 cm flash on breast
- Sup:
– 1 cm margin (superiorly) on the palpable breast tissue
– radiographically, the inferior edge of the sternoclavicular junction. This is also the match line when using a 3 field technique - Inf: 2-3 cm inferior to IM fold
- Med: midline
- Lateral:
– 1 cm margin on all the breast tissue
– Usually, mid-axillary line to posterior axillary line
What are the known side effects of tamoxifen?
- ↑ risk Endometrial Ca 2/2 agonist acitivity in the endometrial tissue
- ↑ risk of PE
- ↑ risk of cataracts
- Trend towards ↑ risk of DVT/Stroke
Note: Fracture risk actually ↓ in women on tamoxifen
What are the known side effects of anastrozole?
- ↑ risk of MSK effects (Arthralgias + Myalgias)
- trend to ↑ fracture risk 2/2 ↓ bone mineral density
- ↑ risk of ischemic heart disease
What is the rule of thumb for the depths of various IDLs for e-?
- Rule of 5, 4, 3, 2, 1
– Dmax → 1/5 x e- energy
– 90% IDL → 1/3.2 x e- energy
– 80% IDL → 1/2.8 x e- energy
– Range → 1/2 x e- energy
Is pure LCIS considered benign or malignant? How is it treated?
- Benign; no longer considered a true premalignant lesion
– Per NCCN, observation and close follow-up alone; 15% risk of developing inv ca
– Risk reduction w/ chemoprevention: tamoxifen or raloxifene to reduce 5 yr risk fo disease
– No role for upfront surgery, WBRT or CHT
– If several risk factors (young age, diffuse disease, FH of breast ca, BRCA mutations) → can consider b/l mast
In the past, LCIS was considered a rare pre-malignant lesion and thus was treated accordingly.
What were the findings of the TAILORx trial for breast cancer?
Breast cancer, ER/PR+, Her2-, LN-
- Randomization:
– Oncotype Intermediate risk (score 11-25) →chemo+endocrine therapy vs.🏆 endocrine therapy
– Oncotype high risk (score > 25) → chemo+endocrine therapy
Results:
- Intermediate risk (score 11-25)
– No change in 9-yr OS, DM, DFS, FFDM, FF LRR/DM
– 9-yr OS 94%, DFS ~83%, FFDM 95%, FF LRR/DM ~92%
– Benefit in age <50 in DFS, LRR+DM, but not DM or OS
- High risk (score >25)
– 5-yr DM 7%, FF LRR/DM 91%, OS 96%
- Cognitive QOL
– Chemo+ET causes cognitive decline.
– ET alone also causes cognitive decline, though less so.
- Post-hoc subanalysis of “Lower” vs. “higher” risk (low risk: grade 1 size ≤3 cm, grade 2 ≤2 cm, grade 3 ≤1 cm): CHT + ET vs. ET alone
– 9-yr DM in age <50, lower risk: <5% both
– 9-yr DM in age <50, higher risk: 12% vs. 6% - Conclusions:
– Women older than 50 years with hormone-receptor positive, HER2-negative, lymph node-negative breast cancer and a 21-gene recurrence score of 0 to 25.
– Women 50 years or younger with hormone-receptor positive, HER2-negative, node-negative breast cancer and a 21-gene recurrence score of 0 to 15.
What were the results of the KATHERINE trial?
- Breast cancer, Her2+, who had PR after neoadjuvant taxane-based chemo & trastuzumab and surgery
- trastuzumab-emtansine (TDM-1) vs. trastuzumab”
– 3-yr Invasive LC 88% vs. 77%
– Invasive DFS improved, HR 0.50
– 3-yr DM 11% vs. 16%
– ↑ pneumonitis: 1.5% vs. 0.7%
Conclusion: Trastuzumab-emtansine improves invasive LC and DFS in partial responders to neoadjuvant chemo in HER2+.
What were the results of the Create X trial?
Breast cancer, HER2-, who had PR after neoadjuvant chemo and surgery
- →capecitabine vs. none
- Capecitabine improved DFS
– 5-yr DFS 74% vs. 68%
– 5-yr OS 89% vs. 84%
– Among triple negative:
– 5-yr DFS 70% vs. 56%
– 5-yr OS 79% vs. 70%”
Conc:
- Capecitabine improves DFS and OS in Her2- breast cancer with PR after neoadjuvant chemo.
- The effect is primarily in triple-negative patients.
What are the systemic therapy tx options for women w/ PR to their neoadj CHT for their HER2+ or TNBC?
- KATHERINE: T-DM1 improves 3y DFS by 10% over trastuzumab for HER2+ breast cancer wresidual dz after NAC.
- CREATE-X: Capecitabine improves 5y OS by ~5% for HER2- (10% for TNBC) breast cancer w residual dz after NAC.
Upon local recurrence of breast ca after tx, which factors predict a ↑ risk of concurrent distant mets?
Per Shen et al, Ca ‘05, the MDACC experience
- Initial LN+
- Skin involvement at IBTR
Per Galper et al, IJROBP ‘05:
- Invasive histology at the time of recurrence
- Local therapy for the recurrence (mastectomy vs. breast-conserving surgery vs. none)
- Shorter time to recurrence
- Age at initial diagnosis
What were the results of the NSABP B-27 trial for breast cancer?
- T1c-T3 N0-1 or T1-3 N1. It must be palpable.
- Randomization: Lumpecomty + ALND or masectomy, TAM in all
– neoadjuvant AC vs.
– neoadj ACT, then surg vs.
– neoadj AC, then surg, then T - Results: AC vs. ACT vs. AC-Surg-T:
– pCR 13% vs. 26% vs. 13% → Neoadj ACT led to best pCR
– ↑ Gr 4 tox: 10% vs. 23.4% (AC vs AC-T)
– negative nodes 51% vs. 58% (AC vs AC-T)
– Did not improve DFS or OS - Conc: addition of T improves cCR and pCR rates, but does not improve DFS and OS
What are the findings of the UK FAST FORWARD trial?
- pT1-3, N0-1, M0 s/p BCS or mastectomy (93% had BCS)
- Noninferiority
– 40 Gy/ 15 fx QD vs. 27 Gy/ 5 fx QD →🏆 26 Gy/ 5 fx QD
– Boost of 10 or 16 Gy in ~25% - Results: 40/15 vs. 27/5 vs. 26/5 → Recurrence and survival were noninferior
– 5-yr IBTR 2.3% vs. 2.0% vs. 1.5%
– 5-yr LRR 3.2% vs. 2.6% vs. 2.1%
– 5-yr DM 4.3% vs. 5.0% vs. 5.6%
– Any breast ca event 8.7% vs. 8.2% vs. 8.3%
– All cause mortality 6.8% vs. 7.7% vs. 6.6% - Tox: 40/15 vs. 27/5 vs. 26/5
– cosmetic effects worse in 27 Gy
– moderate/marked skin & CW effects: 9.9% vs. 15.4% vs. 11.9%
– Patient and photo assessments:: Worse in 27 Gy, noninf in 26 Gy vs. 40 Gy - Conc:
– 26/5 fractions to the whole breast/CW is noninferior to 40/15.
– 27/5 was noninferior in LC, but cosmetic effects were worse.
What are the findings of the UK FAST trial?
- pT1-2 pN0 s/p BCS, excluded: boost, RNI, mastectomy, chemo
- 50 Gy/ 25 fx vs. 30 Gy or 28.5 Gy/ 5 fx once weekly
- Outcomes: longer fu compared to FAST FORWARD
– LR 1% with all doses (at 9.9 yrs f/u)
– 10-yr cosmetic effects were worse with 30 Gy, and not different between 50 Gy and 28.5 Gy - Conc:
– At 10 year f/u, there is no difference in cosmetic effects between 50 Gy and 28.5 Gy/ 5 fx in once weekly fractions. Cosmesis with 30 Gy was worse. Local recurrence was very low in all arms.
What are the findings of the UK START A&B trials for breast cancer?
- pT1-3a, N0-1, s/p BCS and/or mastectomy
- START A:
– 50 Gy/25fx vs. 39 Gy/13 fx vs. 41.6 Gy/13 fx - START B: 50 Gy/25 fx vs. 🏆 40 Gy/15 fx
– 10 Gy boost allowed (given in 61%)
– Nodal and CW RT allowed - Results:
– 10-yr LRR 4-6% (NS)
– Less cosmetic changes in 39 Gy and 40 Gy group (HR 0.77).
– In the 15% receiving RT to LNs, there was no difference in arm and shoulder toxicity at 10 years. No difference in lung or heart toxicity. - Conclusion:
– Hypofx results in favorable outcomes and low toxicity compared to conventional RT.
– Late cosmetic effects are reduced.
What are the findings of the Canadian hypofx trial (Whelan et al. NEJM 2010) for breast cancer?
- pT1 or T2, N0, -margin, s.p BCS and ALND
– 🏆 42.5 Gy / 16 fx vs. 50 Gy / 25 fx
– No boost - Outcomes:
– 5-yr LR ~3%
– 10-yr LR ~6% - Eq cosmetic outcomes
- Grade 3 tox favored conventional RT (contrast w/ START Α/Β, which did not show this)
What are the findings of the Univ of Florence trial of PBI for early stage BCa?
- Age >40, size <2.5cm, IDC or DCIS
- 30 Gy/ 5 fx QOD IMRT PBI vs. WBRT 50 Gy/ 25 fx + 10 Gy boost
- Results:
– 5-yr IBTR ~1.5% (NS)
– 10-yr IBTR 3.7% vs. 2.5% (NS)
– 10-yr OS ~92% (NS)
– 10-yr BCSS 98% (NS) - Tox:
– ABPI had improved acute toxicity, late toxicity, and patient and physician assessed cosmesis
What +LN ratio for pts w/ 1-3 +LNs is considered a cut-off point for delivering RNI for breast cancer?
- 20%, per Katz et al, IJORBP 2001
- 25%, per Truong et al, Cancer 2005
What were the results of the TEXT-SOFT trials investigating adjuvant ET for breast cancers
- Premenopausal primary breast cancer
- SOFT:
– TAM vs. TAM+ovarian suppression (OS) vs. exemestane+OS
– TEXT was similar w/o the TAM only arm - SOFT: TAM vs. TAM+ovarian suppression (OS) vs. exemestane+OS
– 8-yr DFS 79% vs. 83% vs. 86% (SS)
– 8-yr OS 91.5% vs. 93.3% vs. 92.1% (SS for TAM vs. TAM+OS)
if still premenopausal, 85% vs. 89% vs. 87% - Combine results: exem + OS vs. TAM vs. OS
– 8-yr DFS: 87% vs. 83%
– 8-yr freedom from distant recurrence: 92% vs. 90%
– 8-yr OS: 93% vs. 93% - Conc: In premenopausal breast cancer, adding ovarian suppression to TAM improved DFS and OS. Adding exemestane leads to an even better FFR. The highest risk patients may receive up to 10-15% reduction in DM. However, ovarian suppression has notable adverse effects.
What are the findings of the NSABP B-04 trial, NEJM 2002?
- Clinically (-) axilla and clinically (+) axilla
– cN- axilla: Rad mastectomy vs.🏆 TM+RT to axilla vs.TM + ALND
– cN+ axilla: Rad mastectomy vs. TM+RT to axilla 🏆 - Results: no diff in LF, DFS, or OS
- Conc: There is no benefit to radical mastectomy compared to total mastectomy.
What is the difference between radical and total mastectomy?
A radical mastectomy, also known as the Halsted mastectomy, involves the removal of the entire breast, the pectoralis major and minor muscles, and the axillary lymph nodes. This procedure was historically the standard treatment for breast cancer but has largely been replaced by less extensive surgeries due to advancements in understanding the disease and its spread.
In contrast, a total mastectomy (also known as a simple mastectomy) involves the removal of the entire breast tissue, including the nipple-areolar complex, but does not include the removal of the underlying chest muscles or the axillary lymph nodes unless a separate axillary dissection is performed.
Per the Taghian et al. JCO 2004 analysis, how does 10-yr LRF depend on the # of LNs and tumor size for patients who undergo mastectomy and systemic therapy w/o adjuvant RT?
Compare w/ the EBCTCG MA
Per the EBCTCG MA Lancet 2014, how are 10 and 20-yr outcomes for post-mastectomy patients affected by PMRT when broken down by pathologic LN staging and # of LNs?
- Conc:
– no benefit with RT for recurrence or BCM
– PMRT improves LRR and BCM in those with 1-3 nodes and ≥4 nodes.
What is the NCCN def. for a post-menopausal female?
- History of bilateral oophorectomy
- Age >60 years
- Age <60 and amenorrheic for ≥12 months in the absence of chemotherapy, tamoxifen, toremifene, or ovarian suppression
– women < 60 who are on tamoxifen or toremifene must have FSH and estradiol in the post-menopausal range
What were the results of the EBCTCG MA for DCIS, JNCI 2010 w/ respect to ipsilateral breast tumor recurrence, BCM, and overall mortality?
BCS alone vs BCS + RT for DCIS
- 10-yr risk of ipsilateral breast tumor recurrence: 28.1% → 12.9% (SS)
– ↓ 50%!
- 10-yr breast cancer mortality: 4.1% vs. 3.7% (NS)
- 10-yr overall mortality: 8.2% vs. 8.4% (NS)
