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CGSO oral boards > Breast > Flashcards

Breast Flashcards

1
Q

Choosing wisely recommendation on SLNB?

A

Do not do for age >70

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2
Q

Ever exclude chest wall radiation for PMRT?

A

generally no. N+ patients have a very high risk of chest wall recurrence and morbidity of chest wall radiation is limited.

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3
Q

Can you get pregnant on tamixifen?

A

yes!

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4
Q

Management of a simple breast cyst?

A

observation and reassurance.

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5
Q

Additional nodal basins that get RT during PMRT

A

All three levels of the axilla, Supraclavicular nodes and internal mammary chain.

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6
Q

Risk of infertility after breast cancer chemo?

A

rises with age and patient risk factors.

Most women <40 remain fertile.

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7
Q

Agents for SLNB during pregnancy?

A

radioactive tracer is safe
methylene blue is not
lymphazurin is labelled “not safe”

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8
Q

does ypCR correlate with OS for all agents (breast)?

A

No!
Bevacizumab - high ypCR rate but small change in OS
endocrine therapy - no ypCRs but big improvement in OS

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9
Q

Lifetime risk of Ovarian cancer with BRCA?

A

40% lifetime

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10
Q

Breast cancer chemo and fertility?

A

Anthracyclines are safe

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11
Q

Alliance A011202 - completes 2024

A

patients who go from N+ to cN- butt pN+ after NeoAdj

randomizes ALND v axillary RT

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12
Q

OK to use short HRT if oopherectomy has been done for BRCA?

A

appears safe.

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13
Q

How do you follow-up lymphedema?

A

get bilateral arm circumference at first follow-up with tape measure.
Follow the ratio to account for changes in weight.

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14
Q

Screening for women with previous chest wall radiation?

A

Automatically high risk so need alternating mammography and MRI.

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15
Q

How are most lymphedema procedures done?

A

Inject IcG distally, find areas of pooling and do microsurgical lymphovenous anastomosis (11-0 proline)
Repeat IcG to confirm patency

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16
Q

Are there any positive RCTs for adding more systemic chemo after neoadjuvant chemo and resection for breast cancer patients with residual disease?

A

at least 5 RCTs have shown negative results.

One positive CREATE-X, used capcitabine.

Was predominantly in Japan and Korea and may not be generalizable to western patients.

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17
Q

Definition of Inflammatory breast cancer?

A

Inflammation/erythema involving >1/3 of breast skin

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18
Q

Is there benefit for q6 month mammography after resection of breast cancer?

A

there is randomized data that proves no benefit.

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19
Q

management of pleomorphic LCIS

A

need to excise to negative margins, unlike typical LCIS.

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20
Q

When to do genetic testing for -/-/- breast cancer patient

A

all under 60 [NCCN guidelines]

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21
Q

What stage is inflammatory breast cancer?

A

T4d

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22
Q

TAYLORx quick summary

A

for recurrence score between 11-25, hormonal therapy alone is non-inferior to hormonal therapy with chemotherapy for ER/PR+,HER2-

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23
Q

Sensitivity of mammogram for low density breasts v high density breasts?

A

low 80-90%

high 60-70%

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24
Q

Herceptin during pregnancy?

A

No, associated with oligohydramnios

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25
Q

Three models of breast cancer risk

A

Claus
Gail
Tyler-Cuzick

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26
Q

Minimal nodes needed on SLNB and ALND combined for trial eligibility?

A

8

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27
Q

What is utility of mammography for a breast skin lesion?

A

poor! do a punch/incisional biopsy.

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28
Q

How does Alliance A011202 stage the axilla?

A

TAD: SLN biopsy and excision of the clipped preclinical node.

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29
Q

Difficulties with Lobular breast cancer and neoadjuvant therapy?

A

generally has a lower rate of pCR.

staging after neoadjuvant is tricky since generally has a diffuse pattern.

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30
Q

What to do about high breast density patient?

A

calculate lifetime risk
if lifetime risk >20% then do MRI
if lifetime risk <20% then tomosynthesis is adequate

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31
Q

5 Major Breast Axillary trials in order

A

Z0011 - no ALND for <3+SN (got some RT)
Z1071
AMAROS
A11202 - do you need RT if doing ALND for ypN+
NRG/BST - do you need ALND if doing RT for ypN-

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32
Q

False negative rate for clipped node

A

6.8%

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33
Q

Future tech in breast screening?

A

low dose MRI

contrast enhanced mammography

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34
Q

Randomized studies for radiation after neoadjuvant therapy?

A

none yet!

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35
Q

RxPonder trial - results 2023

A

randomizes ER+ patients with <3+LN with recurrence score <23 to chemo/hormonal v hormonal alone

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36
Q

Problems with breast density data

A

Birads density scoring was updated in 2013

Sensitivity data has not been fully explored post tomosynthesis

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37
Q

Medical therapy for ADH and trial?

A

tamoxifen

NSABP 1 and 2

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38
Q

What tissue do radiation induced angiosarcomas arise from?

A

Skin/soft tissue, not residual breast.

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39
Q

Tyler-Cuzick risk model of breast cancer

A

most extensive details
Includes breast density
overestimates compared to other models

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40
Q

Did USPSTF look at 5 year incriments for mammography reccomendations?

A

no, 10 year incriments

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41
Q

Safe chemo for breast cancer in pregnancy?

A

AC is safe,

no taxane

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42
Q

False negative rate with TAD

A

If you do SLNB and take clipped node:

FNR = 2%

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43
Q

Proposed best definition of pCR for breast cancer?

A

most meaningful pCR is patient who is negative in breast and nodes ypT0ypN0

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44
Q

Poor candidates for lymphedema operation?

A

BMI > 30

venous insufficiency

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45
Q

Have RCTs ever looked at screening mammography after 75 years?

A

no

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46
Q

Is there an added survival benefit to prophylactic mastectomy after oopherectomy has been done for BRCA carriers?

A

minimal.

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47
Q

Disadvantages of Gail model of breast cancer?

A

ignores male relatives

ignores second degree relatives

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48
Q

Is there a difference between ypTis and ypT0 overall survival for breast cancer?

A

no

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49
Q

Screening after resection of breast cancer?

A

need annual mammography

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50
Q

ACOSOG Z1071

A

measures sensitivity of SLNB after NeoAdj, with and without clip for positive node

51
Q

ACS mammogram reccomendations

A

40-44 individualized
45-54 annual
55+ annual or every 2 years
stop when life expectancy <10 years

52
Q

Two trials to test deescalation of surgery/RT after NeoAdj therapy?

A

NSABP B51 - reducing radiation - expected 2023

Alliance A011202 - reducing surgery - expected 2024

53
Q

Surveilance for BRCA carriers before proph. Mastectomy

A

Alternating 6 month MRI and mammography

54
Q

PET/Gamma imaging for breast cancer screening?

A

Don’t do! abandoned due to high doses of radiation

55
Q

Proven survival benefit for alternating MRI/mammogram for BRCA carriers?

A

No

56
Q

Who is best candidate for lymphedema operations?

A

Best to catch at early stage;
Stage I is detectable by measurement only and is completely reversable after surgery.
Stage II has pitting edema and will not completely resolve

57
Q

Rate of ypCR by marker subtype?

A

ER/PR+ HER2- = 15%
ER/PR+ HER2+ = 30%
ER/PR- HER2+ = 50%
-/-/- = 30 %

58
Q

SWOG S1418

A

Pembro for patients with residual breast cancer after neoadjuvant/resection.

59
Q

What is dose dense AC

A

Doxorubicin (topoisomerase inhibitor)
Cyclophosphamide (crosslinking agent)
every 2 weeks for 6 cycles

60
Q

TAYLORx - resulted 2018

A

prospective trial involving 10k women with ER/PR+ HER2- LN- breast cancer. 6k had a midrange recurrence score of 11 to 25 and were randomly assigned to receive either chemoendocrine therapy or endocrine therapy alone.

61
Q

Proven advantages of alternating MRI/mammogram for BRCA carriers?

A

Higher sensitivity and catches tumors at earlier stage

62
Q

Would you ever irradiate a breast angiosarcoma?

A

there is evidence if they occur outside of previous radiation fields.

63
Q

perform reconstruction after mastectomy for inflammatory breast cancer?

A

no! too high a rate of local recurrence

64
Q

5 criteria for a simple breast cyst

A
  1. asymptomatic
  2. anechoic
  3. well circumscribed
  4. smooth walled
  5. posterior enhancement
65
Q

Who should definitely get post mastectomy radiation therapy? (PMRT?)

A

all ycN+, always irradiate the chest wall and axilla with PMRT.

66
Q

best chance of pCR for breast cancer?

A

Her2+ ER/PR-

67
Q

hormonal supplementation for infertility after breast cancer?

A

estrogens are unsafe, tamoxifen can be used.

68
Q

workup for bloody nipple discharge?

A

mammogram
ultrasound
then ductogram if no evidence of cancer

69
Q

Differences between RxPonder and TAYLORx?

A

RxPonder includes HER+ and SN1-3+

70
Q

treatment for stage IV lymphedema?

A

“elaphantitis” is generally irreversible with lymphatic procedures.
“debulking” liposuction is palliative

71
Q

Granulomatous lobar mastitis?

A

usually a postpartum patient, observe.

72
Q

Management of non-axillary nodes in Alliance 11202

A

all patients get radiation to the “nonsurgical” nodes

i.e. level III, supraclav and IM

73
Q

How do you do an ultrasound/palpation guided core biopsy?

A

local anesthesia
14-18 G needle
6-8 cores
leave a clip and confirm with ultrasouns

74
Q

When to get a breast MRI (6)

A 
occult primary
Paget's with negative mammography
Extent of disease
Dense breasts
Stage before and after neoadjuvant therapy
genetic/high risk screening
75
Q

Information to check on breast biopsy path report?

A

all markers and grade.

76
Q

Are AJCC prognostic stage groups helpful after neoadjuvant therapy?

A

no

77
Q

Quick cheat for breast tumor markers and staging?

A

+/+/- will be one letter less

-/-/- will be one letter worse

78
Q

When to order Oncotype DX (or other panel)?

A

+/+/-; LN- and <5cm

board answer unti RxPonder, but many already generalizing to limited node+

79
Q

What is stage III breast cancer?

A

tumor > 5 cm

fixed LN or infraclavicular LN

80
Q

When to do systemic staging for breast cancer?

A

PET/CT for all stage III

81
Q

> 30% lifetime risk of breast cancer genes?

A 
BRCA
P53
pTEN
CDH
STK11
82
Q

Screening for breast cancer gene carriers starts at age?

A

25

83
Q

Hard Contraindications for lumpectomy?

A

inflammatory Breast Ca
scleroderma/lupus
persistent positive margins
multicentric disease

84
Q

relative contraindications for lumpectomy?

A 
pregnancy
prior radiation (RTOG 1014)
85
Q

Contraindication for nipple sparring mastectomy?

A

need a 1-2 cm margin

86
Q

Whole breast RT doses?

A

hypofractionated 40 Gy in 15 fx

standard 50 gy in 25 fx

87
Q

Who gets boost RT?

A

high grade tumor or patient <50

high grade DCIS <50 yo

88
Q

boost dose for breast?

A

6-16 Gy

89
Q

size cutoff for neoadjuvant for -/-/- breast cancer?

A

5 mm

90
Q

size cutoff for neoadjuvant for HER2+ breast cancer?

A

2 cm

91
Q

tamoxifen dose?

A

20mg daily

92
Q

Letrozole dose?

A

5 mg daily

93
Q

Re-excise ALH on a stereotactic biopsy?

A

no as of 2019 NCCN guidelines

94
Q

When do you do systemic staging for an inflammatory breast cancer?

A

its automatically stage III so do for all!

95
Q

Work up of a breast nodule in a breastfeeding patient?

A

can get an FNA instead of a core to avoid milk fistula.

96
Q

Any evidence of improved breast cancer outcomes with pregnancy termination?

A

no evidence

97
Q

When can chemo start in pregnancy?

A

week 11-12

organogenesis ends at week 10

98
Q

How big is a stereotactic biopsy needle?

A

9-11G

99
Q

chemo for HER2+ breast cancer

A

TCHP

docetaxel, carboplatin, trastuzumab, and pertuzumab

three week cycles,

need 1 year of trastuzumab

trying to avoid adriamycin for the cardiotoxicity

100
Q

What else to consider before starting chemo?

A

fertility preservation

101
Q

Isolated tumor cells in LN after neoadjuvant therapy?

A

Still have to go direct to ALND.

102
Q

Patient got neoadjuvant, can only find 2 SLN, what next?

A

if you cannot find a third LN then accuracy of your SLNB is not sufficient and need to do the ALND.

103
Q

HER2 positive tests

A

IHC staining 3+

FISH ratio >2.2 or copy # >6.0

104
Q

When to resect an intraductal papilloma?

A

atypia
1 cm
bloody nipple discharge

105
Q

When to resect radial scar?

A

generally do, especially with atypia.

106
Q

Early breast cancer in pregnancy?

A

1st trimester - Mastectomy and SNB then chemo

2nd trimester - can do lumpectomy and give RT after delivery

107
Q

Advanced breast cancer in pregnancy?

A

start neoadjuvant at week 11. Start surgery after delivery.

108
Q

Mammogram safe during pregnancy?

A

yes

109
Q

maximum delays of systemic chemotherapy?

A

good retrospective evidence of worse outcomes if >3 month delay.

110
Q

Side effects of chemo in 2/3 trimester?

A

generally acceptable,

50% of pregnancies will have premature delivery and low birth weight.

111
Q

Timing of delivery when on chemo?

A

try to end chemo 3-4 weeks before expected delivery

give tocolytics to delay delivery if mom is neutropenic

112
Q

breastfeeding on chemo/targeted/hormonal therapy?

A

no

113
Q

Antibiotics while breastfeeding?

A

generally all are safe including keflex, bactim and cipro.
tetracycline and levaquin are sometimes avoided for bone/tendons
no adverse effects ever noted with flagyl

114
Q

Giving AC during pregnancy?

A

generally safe with most short term data

more safety data with traditional course v. dose dense, but can use either regimen to try and time delivery best

115
Q

Which has higher mortality, peripartum breast cancer or post-partum breast cancer?

A

post-partum breast cancer

Mechanism not yet known

116
Q

Advanced HER2+ breast cancer in early second trimester?

A

Give chemo without Herceptin/Progetta, then surgery, then Herceptic post-partum

117
Q

radial scar of core needle?

A

can upstage, need to do excisional biopsy

also increases lifetime risk of cancer 2-3x.

118
Q

PASH

A

mimics cancer/inflammatory cancer
no actual cancer risk
can excise for symptoms

119
Q

LCIS and calcifications?

A

either rad/path discordance and needs excision

or

pleomorphic and needs excision

120
Q

ALND is performed for:

A

> 3 +LN with small (≤5 cm) tumors (T1 or T2).
Any +LN with large (>5 cm) tumors (T3).
Any +LN with extranodal extension
Any +LN if patient will not get RT

121
Q

operation for recurrent breast cancer?

A

Mastectomy v chest wall resection

ALND

122
Q

chemo for recurrent breast cancer?

A

would generally give

123
Q

adjuvant treatment fora phylloides tumor?

A

give RT
15% chance of local recurrence
No well established systemic treatments

CGSO oral boards (7 decks)

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