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Flashcards in Breast Deck (53)
1

Breast Cancer:
Early stage and Locally advanced definition

●Early stage – This includes patients with clinical stage I, IIA, or a subset of stage IIB disease (T2N1).

●Locally advanced – This includes a subset of patients with clinical stage IIB disease (T3N0) and patients with stage IIIA to IIIC disease.

2

Breast Cancer - percent of patients presenting with metastatic disease

5%

3

Criteria that preclude Breast Conserving therapy (6)

●Multicentric disease

●Large tumor size in relation to breast

●Presence of diffuse malignant-appearing calcifications on imaging (ie, mammogram or magnetic resonance imaging [MRI])

●Prior history of chest RT (eg, mantle radiation for Hodgkin disease)

●Pregnancy

●Persistently positive margins despite attempts at re-excision

4

EBCTCG "Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials" Lancet 2014 PMID 24656685

Based upon the Early Breast Cancer Trialists’ Collaborative Group meta-analysis of 3786 women with invasive breast cancer undergoing an axillary dissection and mastectomy, there was a reduction in recurrences for node-positive women ([n = 1314, one to three nodes positive] and [n = 1772, four or more nodes positive]) undergoing postmastectomy radiation, but not for node-negative women

5

ACOSOG Z0011

Giuliano Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA 2011

PMID 21304082

Patients who have one or two pathologically involved sentinel nodes may not require a complete axillary node dissection [11]. However, whether or not patients with three or more pathologically involved sentinel nodes should undergo an axillary node dissection is best determined on an individualized basis, taking into account all other tumor risk factors and the patient’s performance status and comorbidities.

6

Size cutoff for chemo based on Breast Cancer receptor type:

ER/PR+ : >5mm with high risk onclotype Dx
HER2+ : >1cm definitly (smaller is controversial)
-/-/- : >5mm

7

National Surgical Adjuvant Breast and Bowel Project (NSABP) 18 trial

administration of the same chemotherapy in the neoadjuvant versus adjuvant setting is associated with similar outcomes

Rastogi J Clin Oncol 2008 PMID 18258986

8

Adjuvant Chemo if a full neoadjuvant chemotherapy course was completed for Breast Cancer:

ER/PR+: endocrine alone
-/-/-: none
HER2+: one year of transtuzumab

9

Adjuvant therapy if a full neoadjuvant endocrine therapy course was completed for Breast Cancer:

Completion of adjuvant endocrine therapy (5 years or more)

10

Hamaker - Omission of surgery in elderly patients with early stage breast cancer - Eur J Cancer 2013

For some patients with estrogen receptor (ER)-positive breast cancer, in whom surgery is not an option or life expectancy is limited, primary hormonal treatment with either tamoxifen or an aromatase inhibitor without surgery or radiation therapy (RT) can be used [14]. We prefer to individualize treatment based on the presence of medical comorbidities and patient and clinician preference

11

management of a simple breast cyst

observation

12

definition of a simple breast cyst (4)

anechoic
well-circumscribed
smooth walls
posterior enhancement

13

Management of a complex breast cyst

repeat US in 6 months

14

Management of a breast cyst with a solid component

needs biopsy;
23% risk of malignancy

15

management of ADH on needle biopsy

Needs needle loc biopsy; 15% cancer or dcis

16

10 year risk of breast cancer after ADH is excised

17%

17

NSABP P1 trial

tamoxifen reduces the risk of developing breast cancer for patients with ADH by 86%

18

STAR trial (NSABP P2)

Study of tamoxifen and raloxifene - raloxifen provides similar risk-reduction as tamoxifen with less toxicity (endometrial cancer)

19

first step to work-up bloody nipple discharge

ductogram

20

what do you do if there is a persistent concern for malignancy with blood nipple discharge and a negative ductogram

excision

21

sensitivity of nipple discharge cytology

34-46% (poor)

22

NCCN recommended screening after breast cancer treatment?

Mammograms only

23

No evidence to support what screening for breast cancer survivors?

tumor markers
CT
Bone Scans
PET
(Part of Choosing Wisely Campaign)

24

Mechanism of Taxanes

Inhibit the spindle cell apparatus needed for mitosis

25

Mechanism of Cyclophosphamide

alkylating agent - forms DNA cross-linkages

26

Mechanism of Doxorubicin

interferes with topoisomerase II

27

mechanism of 5-FU

nucleotide analog

28

mechanism of trastuzumab

antibody against EGFR

29

When do you do metastatic work-up for Breast Cancer

for clinical stage III disease; ASCO guidelines; even for other bad prognostic factors like triple negative tumors

30

Treatment for recurrent breast cancer?

do metastatic work-up
Excise
RT - if it hasn't been given yet
hormonal therapy if receptors there
Consideration of adjuvant chemotherapy

31

Treatment order for stage III breast cancer when pregnant?

Neoadjuvant Chemo
lumpectomy with SLNB +/- ALND
Deliver baby
XRT

32

Treatment for occult primary breast cancer

Get MRI first; if still occult then need
Modified Radical Mastectomy (Breast and ALND)
some in Europe would just do total breast XRT

33

Key molecular marker of Lobular carcinoma

lacks e-cadherin

34

Treatment for inflammatory breast cancer

Neoadjuvant Chemo
Modified Radical Mastectomy
Chest Wall Radiation
Endocrine Therapy (if receptor positive)

35

Can you do a SLNB for inflammatory breast cancer?

No! high False negative rate, and nearly all patients will have nodal involvement at the time of diagnosis.

36

Can you do brachytherapy or partial breast irradiation for a patient with positive SN?

No

37

ASTRO consensus on accelerated partial breast irradiation?

look up

38

Guidelines for nipple sparring mastectomy

look-up

39

Which has higher rate of flap loss TRAM or DIEP flap?

TRAM

40

Use of acellular dermal matrix in breast reconstruction increases risk of

seroma infection and reconstruction failure

41

Did ACOSOG Z011 include men?

no, so can't apply criteria, and all SN+ men should get ALND for breast cancer

42

gynecomastia and a testicular mass?

Sertoli cell tumor until proven otherwise

43

High penetrance genes for breast cancer

PTEN and p53

44

moderate risk genes for breast cancer

CHEK
ATM
PALB2

45

risk reduction for lymphedema

lift weights
early arm mobilization
lose weight

46

distal surgery after ALND ok?

yes, no increased risk in lymphedema rates

47

Role of lymphedema sleeves

Help control symptoms but don't prevent before it develops.

48

Family history of breast cancer work-up

Test the effected members first. If a gene (BRCA) is identified, then prophylactic surgery on gene positive individuals only

If no gene found, then can council on prophylactic surgery for all.

49

screening after prophylactic mastectomy?

Physical exam only.

50

Relative indications for breast MRI

BRCA (these tumors are often missed on mammo)
dense breasts

51

primary peritoneal carcinoma

associated with BRCA; treated like ovarian cancer

52

NCCN guidelines for screening BRCA patients (if no surgery)

Mammography and MRI yearly, staggered by 6months (complimentary tests)

53

Black women and breast cancer

higher incidence after age 40
higher mortality even when matched for stage
more likely to be ER negative or triple negative