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Radiation Oncology Factoids > Early-stage (I-II) Breast Cancer > Flashcards

Early-stage (I-II) Breast Cancer Flashcards

1
Q

What histologic subtypes of IDC are associated with favorable outcomes?

A

Tubular, medullary, mucinous (colloid), papillary

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2
Q

What is a phyllodes tumor of the breast?

A

Ranges from benign to malignant. Rare tumor, leaflike, lobulated appearance on microscopic section. Treated with surgery, wide local excision or total mastectomy. No role for RT

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3
Q

What is Paget disease of the breast?

A

Malignant epithelial cells infiltrating the epidermis of the nipple-areolar complex. Presents with crusting, scaling, itching, and redness of the skin. 80-90% is associated with underlying DCIS or invasive breast cancer

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4
Q

What percent of invasive breast cancers are invasive lobular carcinomas?

A

10-15%

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5
Q

What percentage of women with clinically negative axilla were found to have axillary metastases on LND in NSABP B04?

A

40% of clinically node negative patients had positive nodes on LND

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6
Q

In NSABP B04, what percentage of women with a clinically negative axilla who did not undergo LND eventually developed a clinically positive axilla?

A

20% of women with initially negative nodes developed positive nodes

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7
Q

Workup for early-stage invasive breast cancer?

A

H&P (hormone use, ob/gyn hx, family or personal hx of breast/ovarian ca), diagnostic bilateral mammogram +/- ultrasound, pathology w/ ER/PR and HER2 status, CBC/CMP

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8
Q

When should bone scan or CT abdomen/pelvis be performed?

A

Bone scan only if localized bone pain or elevated alk phos

CT a/p if elevated alk phos or LFTs, abdominal sx, abnormal exam

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9
Q

When should breast MRI be used in screening/workup?

A

Women with >20% increased lifetime breast cancer risk based on family history and genetics

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10
Q

How should ER/PR and HER2 status be determined and reported?

A

ER/PR is positive if >1% of tumor cell nuclei are reactive via IHC
HER2 is positive if evidence of protein overexpression (3+) or gene amplification. If 2+, should get reflex testing using ISH

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11
Q

How should axilla and primary be evaluated prior to surgery or preoperative systemic thearpy?

A

If detected radiologically (mammo or axillary US), should get core biopsy
If LN-, SLNBx
If LN+, ALND if surgery planned or SLNBx following systemic therapy

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12
Q

Which trial shows SLNBx as an alternative to ALND for sentinel node negative patients?

A

NSABP B32: randomized 5611 patients to SLNBx + immediate completion axillary LND vs. SLN Bx alone; OS, DFS and regional control were similar between groups. Also shows decreased risk for lymphedema and arm numbness with SLNBx

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13
Q

What should be done is SLNBx is positive?

A

If T1/T2 or 1-2+ SLN, WBI after lumpectomy is appropriate without systemic chemo. ACOSOG Z0011 randomized ALND vs. no dissection for SLNBx+ treated with WBI and found noninferior 5yr OS, DFS, and LRR; 10yr OS also noninferior

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14
Q

What can be done in high risk patients with 1-2+ axillary SLNBx who do not undergo ALND?

A

High tangents (cranial tangent border >2cm from humeral head)

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15
Q

List the T-staging cutoffs for T1 and T2 breast cancers per 8th edition of AJCC

A 
(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
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16
Q

What is clinical nodal staging for N1 disease?

A

cN1: mets to movable ipsilateral level I and level II axillary nodes
cN1mi: micromets (>0.2mm but <2.0mm)

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17
Q

What is the pathologic staging for N0-N1 disease?

A

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

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18
Q

What T and N groupings make up stage IA, IB, IIA, IIB?

A

IA: T1N0
IB: T0N1mi, T1N1mi
IIA: T0N1, T1N1, T2N0
IIB: T2N1, T3N0

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19
Q

What is the bioscore incorporated into the AJCC 8th edition staging system>

A

Multivariate model that incorporates grade, ER status, HER2 status and pathologic stage to assess DSS which ranges from 0 to 7

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20
Q

Which biomarker panel has level I evidence for breast cancer and what is it used for?

A

Oncotype DX recurrence score. A low oncotype DX score downgrades a biologically low-risk T2N0 from stage II to stage I

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21
Q

What percentage of breast cancer patients are diagnosed with stages 0 to II disease?

A

80%

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22
Q

What are the management options for early stage breast cancers?

A
  1. Lumpectomy w/ surgical axillary staging + RT
  2. Total mastectomy w/ surgical axillary staging +/- reconstruction
  3. If T2 or T3 and otherwise meets criteria for BCS can consider systemic chemo
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23
Q

When do you use adjuvant chemotherapy for early stage node negative breast cancer?

A

Triple negative or Her2+ with tumor > 1cm

ER+, Her2- with tumor > 0.5cm, consider oncotype

24
Q

What does oncotype dx score tell you?

A

Risk of distant recurrence within 10 years of diagnosis with 5 years of endocrine therapy alone in ER+, N0 patients that undergo upfront surgery
Low <18, adjuvant endocrine alone
Intermediate 18-30, adjuvant endocrine +/- chemo
High >=31, adjuvant endocrine + chemo

25
Q

When should you use adjuvant endocrine therapy in early stage breast cancer?

A

ER+ and tumor > 0.5cm

26
Q

General principles for administering adjuvant endorine therapy?

A

If premenopausal, tamoxifen x 5 yrs (consider additional 5 yrs vs. switching to AI)
If postmenopausal, AI x 5 yrs

27
Q

Major contraindication to using AI

A

Premenopausal status as AIs are ineffective in women with estrogen producing ovaries

28
Q

Major side effects of tamoxifen and AIs

A

Tamoxifen: blood clots, strokes, uterine cancer, cataracts
AIs: bone loss, osteoporosis, joint pain, stiffness

29
Q

Major chemo agents used in breast cancer

A

Doxorubicin (A), epirubicin (E), cyclophosphamide or carboplatin (C), paclitaxel or docetaxel (T), 5FU (F), trastuzumab (H)

30
Q

Major chemo regimens for HER2- tumors

A

ddAC = doxorubicin + cyclophosphamide, q2w x 4
followed by
paclitaxel q2 wk x4

31
Q

Major chemo regimens for HER2+ tumors

A

AC (doxorubicin + cyclophosphamide) plus trastuzumab followed by single agent trastuzumab

32
Q

What data support the equivalence of BCT (lumpectomy +RT) vs mastectomy with regard to survival?

A 
Several RCTs (NSABP B06, Milan III, Ontario, Royal Marsden, EORTC 10801). 
B06: No difference in 20 year DFS, OS or DM
33
Q

What percentage of patients are eligible for BCT for early stage breast cancers?

A

75-80%

34
Q

What are the contraindications for BCT for patients with early stage breast cancer?

A

Prior RT to the chest, disease extent that makes excision difficulty, diffuse microcalcifications, pregnancy, persistently positive margin, homozygous ATM mutation

35
Q

Is there a contraindication for BCT in patients with a positive family history of breast cancer?

A

No

36
Q

What are the dose fractionation schedules for WBI?

A

Standard 50Gy in 2 Gy fx or 45-50.4 Gy in 1.8 Gy fx

Hypofractionated: 42.56 in 2.66 Gy fx or 40.05 in 2.67 Gy fx

37
Q

What data support the use of hypofractionated WBI?

A

4 RCT with >10 year f/u suggest same outcomes with potentially better side effect profile (Canadian, START pilot, START A/B trials)
Canadian (Whelan) - 42.56/16fx vs 50/25fx, T1-2N0, excluded women with >25cm breast width - no difference in LR, DFS or cosmesis
British (START A/B): 40/15fx vs 50/25fx, T1-3N0-1, no difference in IBTR, better cosmesis with hypofractionation

38
Q

Per ASTRO guidelines, who can be offered hypofractionated WBI?

A

> 50y, pT1-2N0, treated with BCS, no systemic chemo, good dose homogeneity

39
Q

What data support the use of a tumor bed boost?

A

2 studies demonstrate improved LC rate with 10-16 Gy boost after initial 45-50 Gy WBI
EORTC boost trial: RCT 50 Gy vs. 50+16 Gy (-margins) or 26 Gy (+margins). 10yr LF rate 6.2% boost vs. 10% w/o boost. No difference in 20yr OS
Lyon boost trial: RCT 50Gy vs 50+10Gy, 3y LF rate 3.6% vs. 4.5%

40
Q

Should you boost to higher dose in patients with incomplete excision after BCS?

A

No. EORTC boost trial showed no difference in LC or survival between 10 Gy and 26 Gy boosts

41
Q

What is next step in management of patient who has lumpectomy with focal positive margin?

A

Ideally, re-excision in order to decrease LR risk to baseline

42
Q

Is there a subset of women whose LR risk is not influenced by margin positivity after BCS?

A

Age < 40 y/o women have worse 5 yr LR rate (37%) if margins are positive

43
Q

Should T1-2N0 women treated with mastectomy found to have +margin be treated with adjuvant RT?

A

British Columbia retrospective study had 94 women with positive mastectomy margins, half treated with RT. Suggests women >50, T2 tumor, grade III, and +LVI may have LR benefit with PMRT

44
Q

What is EIC?

A

Extensive intraductal component: DCIS both admixed and adjacent to invasive disease and comprising 25% of total tumor mass

45
Q

Does EIC have prognostic significance in the LR risk of patients treated with BCT?

A

Yes, but dependent on margin status. If there is a close or positive margin, EIC is associated with higher risk of recurrence

46
Q

What data suggests that the results of BCT can be further improved with tamoxifen?

A

NSABP B21 - 3 arm RCT tam alone vs. RT alone vs. tam + R. 8 yr IBTR 16.5% tam alone, 9.3% RT alone, 2.8% RT + tam

47
Q

Are there patient subgroups with low risk of LR that can be treated with BCS and systemic therapy alone without radiation?

A

Yes. Age > 65-70, ER+, T1N0
Toronto: >60 w/ <1cm tumor, risk 1.2% vs. 0% with RT
CALGB 9343/Intergroup: >70y, T1, cN0, ER+ tamoxifen vs. tamoxifen + RT - no difference in time to mastectomy, DM, OS
Prime II: >65y T1-T2N0 ER+ on tamoxifen WBI vs. no RT, IBTR 1.3% vs. 4.1%

48
Q

Can RT be used for treating axillary nodes in place of surgery in ALND not performed?

A

AMAROS trial randomized SLN+ to completion ALND vs nodal RT. No significant difference in LRR, DM or OS and better arm function in the RT group

49
Q

Are there data supporting WBI + RNI for early stage breast cancer after BCS?

A

2 RCTs (MA.20 and EORTC 22922/10925)
MA.20 - Whelan - LN+ or high risk LN- patients, decreased regional recurrence (2.7 vs. 0.7%) with addition of nodal irradiation
EORTC - decreased regional recurrence (4.2 vs. 2.7%) and decreased DM rate (19.6% vs. 15.9%)
no OS benefit in either

50
Q

How should chemo be sequenced with radiotherapy after BCS?

A

JCRT sequencing trial (“upfront-outback” trial)
5yr results better in chemo 1st arm but 11yr results show no difference in DFS, LR, DM, or OS
Either sequence is acceptable

51
Q

What US trial investigated the role of accelerated partial breast irradiation?

A

NSABP B39/RTOG 0413 - randomized women with stage 0, 1 or 2 with tumors <3cm and <3 LN+ to WBI vs APBI (interstitial, intracavitary or EBRT)
PUBLICATION PENDING

52
Q

What is the dose and duration of treatment for APBI from B39/RTOG0413?

A

All given BID over 5 days
34Gy in 3.4Gy BID fractions for interstitial/intracavitary treatment
38.5 Gy in 3.85 Gy BID fx for EBRT

53
Q

Who can be offered PBI?

A

> 50y, Tis, T1, with DCIS allowed if low/intermediate grade, <2cm and margins >3mm

54
Q

Is there evidence to support using IMRT for WBI for early stage breast cancer?

A

Data suggests benefit in acute effects and late cosmesis
Canadian study: reduced moist desquamation
British study: cosmesis improved (OR 0.68) and reduced skin telangiectasia

55
Q

Are there subsets of women who undergo mastectomy for early stage breast cancers that may benefit from PMRT?

A

NCCN guidelines: no RT if -axillary nodes, tumor <5cm, margins >1mm
Otherwise, risk factors including close/+ margins, extensive LVSI, central/medial tumors, young age can be taken into consideration

56
Q

How do you manage breast cancer in pregnant woman?

A

Chemo can be used to delay surgery until after delivery - non-taxane chemos (FAC) are appropriate in 2nd and 3rd trimesters. Chemo is held 3 weeks before due date to reduce risk of infetion and bleeding. RT must be deferred until pospartum

Radiation Oncology Factoids (44 decks)

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