Workup/Staging Flashcards
What is the workup for early-stage invasive breast cancer (stage I–IIB)?
Per NCCN 2018, H&P (inc. hormone use, ob/gyn Hx, family or personal Hx of breast/ovarian ca), diagnostic bilat mammogram +/– US, pathology review w/ determination of ER/PR and HER2 status, CBC/CMP (inc. LFTs and alk phos)
When should a bone scan or CT abdomen/pelvis be performed per NCCN 2018?
Bone scan should only be done for localized bone pain or elevated alk phos. CT Abd/pelvis w/ contrast should be done if elevated alk phos or LFTs, abdominal Sx, or abnl physical exam. CT chest w/ contrast should only be done if pulmonary Sx are present.
When should breast MRI be used in screening or workup per NCCN 2018?
Screening MRI is indicated in women with a >20% increased lifetime breast cancer risk. Risk models are largely dependent on family Hx and including Claus BRCAPRO, BOADICRA, Tyrer–Cuzick, etc. Screening annual breast MRI is also recommended in women >25 yrs who undergo thoracic RT b/t 10 and 20 yrs.
Diagnostic MRI can be used if there is concern for multifocal/multicentric Dz, Bx is possible, and it would change management (i.e., lobectomy vs. mastectomy or concern for contralat Dz).
MRI should be done in a high quality center, with a dedicated breast coil, experienced radiologist, and the ability to perform Bx under MR guidance if a lesion is identified.
What type of counseling should be provided up front?
Genetic counseling if pt high risk, fertility counseling if premenopausal (NCCN 2018)
How should ER/PR and HER2 status be determined and reported?
ER/PR status is positive if ≥1% of tumor cell nuclei are reactive via IHC (CAP 2014; Template for Reporting Results of Biomarker Testing of Specimens From Pts With Carcinoma of the Breast)
HER2 status is positive when there is evidence of protein overexpression (IHC 3+) or gene amplification (HER2 single probe ISH, copy number ≥6.0 signals/cell or dual probe ISH assay with HERs/CEP17 ratio ≥2.0 with ≥4 signals/cell). If results for IHC are equivocal (IHC 2+), reflex testing should be performed using ISH. (CAP 2015; Wolff et al., NCCN 2018)
How should the axilla and primary be evaluated prior to Sg or preop systemic therapy?
If radiologically identifiable primary lesion, should have core Bx and placement of fiducial prior to systemic therapy
Axillary US w/ Bx of suspicious or clinically pos nodes
If axillary LN neg, can have SLNB prior to systemic Tx or Sg
If axillary LN pos, can have ALND if going straight to Sg, or potentially SLNB if preop systemic therapy and nodes become negative prior to Sg. If axillary LN pos and planned for preop systemic therapy, should have clip placed in +LN prior to systemic therapy.
Which major trials showed SLND Bx as an alternative to ALND for sentinel node neg pts?
The NSABP B-32 trial randomized 5,611 pts undergoing mastectomy or lumpectomy to SLN Bx + immediate completion axillary LND vs. SLN Bx alone. The OS, DFS, and regional control were statistically similar b/t groups. The 10-yr OS was 87.8% vs. 88.9%, DFS 76.9% for both, and LR rate 4.3% vs. 4.0%, for SLND alone vs. SLND + ALND, respectively (Krag DN et al., Lancet Oncol 2010; 10-yr update ASCO 2013). The ALMANAC trial (Mansel RE et al., JNCI 2006) and Milan trial (Veronesi U et al., NEJM 2013; Lancet Oncol 2006; 10-yr update Ann Surg 2010) also showed comparable outcomes. Both NSABP B32 and ALMANAC showed a decreased risk of lymphedema and arm numbness with SLN Bx.
What should be done if the SLND is positive?
If T1 or T2 tumor, 1 or 2 + SLN, WBI is planned after lumpectomy and no neoadj systemic therapy was given, no further Sg may be considered (NCCN 2018). ACOSOG Z0011 randomized ALND (n = 445) vs. no dissection (n = 445) for +SLND Tx with WBI (tangents) but no dedicated axillary RT. Study closed (891 of 1,900) early b/c of low accrual and no expected change in results with full accrual. SLND alone did not result in inf 5-yr OS (91.8% vs. 92.5%), DFS (83.9% vs. 82.2%), or LRR-free survival (96.7% vs. 95.7%) (Giuliano AE et al., JAMA 2011). 10-yr updated results also did not show any difference in OS (86.3% vs. 83.6%). (Giuliano et al., JAMA 2017)
What can be done in high-risk pts with 1 or 2 positive axillary SLNs who don’t undergo ALND?
High tangents (cranial tangent border ≥2 cm from humeral head). 50% of pts in ACOSOG Z0011 assigned to SLND were treated with high tangents. Another 20% rcvd directed nodal RT using ≥3 fields (Jagsi et al., JCO 2014)
List the T staging of T1 and T2 breast cancers per the 8th edition of AJCC (2017).
T-stage (all greatest dimension):
(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 the clinical nodal staging for N1 Dz?
cN1: Mets to movable ipsi level I and level II axillary nodes
cN1mi: Micromets (>0.2 mm but ≤2.0 mm)
What is the pathologic staging for N0–N1 Dz?
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, and IIB?
IA: T1N0
IB: T0N1mi, T1N1mi
IIA: T0N1, T1N1, T2N0
IIB: T2N1, T3N0
When is the anatomic stage groups used alone per AJCC 8th edition?
Only in global regions where biomarker tests are not routinely available.
What is the bioscore incorporated into the AJCC 8th edition staging system?
The bioscore is a multivariate model incorporating grade, ER status, HER2 status and AJCC pathologic stage (Mittendorf et al., Ann Surg Onc, 2017) to assess DSS. Points are assigned for each of these factors, ranging from 0 to 7. A bioscore of 1 is consistent with a 99.4% DSS, while a bioscore of 7 is associated with 33.3% DSS. This is consistent with data that pts with triple-negative tumors have DSS in line with 1 pathologic stage above.
