Breast Flashcards
(123 cards)
1
Q
Choosing wisely recommendation on SLNB?
A
Do not do for age >70
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.
3
Q
Can you get pregnant on tamixifen?
A
yes!
4
Q
Management of a simple breast cyst?
A
observation and reassurance.
5
Q
Additional nodal basins that get RT during PMRT
A
All three levels of the axilla, Supraclavicular nodes and internal mammary chain.
6
Q
Risk of infertility after breast cancer chemo?
A
rises with age and patient risk factors.
Most women <40 remain fertile.
7
Q
Agents for SLNB during pregnancy?
A
radioactive tracer is safe
methylene blue is not
lymphazurin is labelled “not safe”
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
9
Q
Lifetime risk of Ovarian cancer with BRCA?
A
40% lifetime
10
Q
Breast cancer chemo and fertility?
A
Anthracyclines are safe
11
Q
Alliance A011202 - completes 2024
A
patients who go from N+ to cN- butt pN+ after NeoAdj
randomizes ALND v axillary RT
12
Q
OK to use short HRT if oopherectomy has been done for BRCA?
A
appears safe.
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.
14
Q
Screening for women with previous chest wall radiation?
A
Automatically high risk so need alternating mammography and MRI.
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
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.
17
Q
Definition of Inflammatory breast cancer?
A
Inflammation/erythema involving >1/3 of breast skin
18
Q
Is there benefit for q6 month mammography after resection of breast cancer?
A
there is randomized data that proves no benefit.
19
Q
management of pleomorphic LCIS
A
need to excise to negative margins, unlike typical LCIS.
20
Q
When to do genetic testing for -/-/- breast cancer patient
A
all under 60 [NCCN guidelines]
21
Q
What stage is inflammatory breast cancer?
A
T4d
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-
23
Q
Sensitivity of mammogram for low density breasts v high density breasts?
A
low 80-90%
high 60-70%
24
Q
Herceptin during pregnancy?
A
No, associated with oligohydramnios
25
Three models of breast cancer risk
Claus
Gail
Tyler-Cuzick
26
Minimal nodes needed on SLNB and ALND combined for trial eligibility?
8
27
What is utility of mammography for a breast skin lesion?
poor! do a punch/incisional biopsy.
28
How does Alliance A011202 stage the axilla?
TAD: SLN biopsy and excision of the clipped preclinical node.
29
Difficulties with Lobular breast cancer and neoadjuvant therapy?
generally has a lower rate of pCR.
| staging after neoadjuvant is tricky since generally has a diffuse pattern.
30
What to do about high breast density patient?
calculate lifetime risk
if lifetime risk >20% then do MRI
if lifetime risk <20% then tomosynthesis is adequate
31
5 Major Breast Axillary trials in order
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-
32
False negative rate for clipped node
6.8%
33
Future tech in breast screening?
low dose MRI
| contrast enhanced mammography
34
Randomized studies for radiation after neoadjuvant therapy?
none yet!
35
RxPonder trial - results 2023
randomizes ER+ patients with <3+LN with recurrence score <23 to chemo/hormonal v hormonal alone
36
Problems with breast density data
Birads density scoring was updated in 2013
| Sensitivity data has not been fully explored post tomosynthesis
37
Medical therapy for ADH and trial?
tamoxifen
NSABP 1 and 2
38
What tissue do radiation induced angiosarcomas arise from?
Skin/soft tissue, not residual breast.
39
Tyler-Cuzick risk model of breast cancer
most extensive details
Includes breast density
overestimates compared to other models
40
Did USPSTF look at 5 year incriments for mammography reccomendations?
no, 10 year incriments
41
Safe chemo for breast cancer in pregnancy?
AC is safe,
| no taxane
42
False negative rate with TAD
If you do SLNB and take clipped node:
| FNR = 2%
43
Proposed best definition of pCR for breast cancer?
most meaningful pCR is patient who is negative in breast and nodes ypT0ypN0
44
Poor candidates for lymphedema operation?
BMI > 30
| venous insufficiency
45
Have RCTs ever looked at screening mammography after 75 years?
no
46
Is there an added survival benefit to prophylactic mastectomy after oopherectomy has been done for BRCA carriers?
minimal.
47
Disadvantages of Gail model of breast cancer?
ignores male relatives
| ignores second degree relatives
48
Is there a difference between ypTis and ypT0 overall survival for breast cancer?
no
49
Screening after resection of breast cancer?
need annual mammography
50
ACOSOG Z1071
measures sensitivity of SLNB after NeoAdj, with and without clip for positive node
51
ACS mammogram reccomendations
40-44 individualized
45-54 annual
55+ annual or every 2 years
stop when life expectancy <10 years
52
Two trials to test deescalation of surgery/RT after NeoAdj therapy?
NSABP B51 - reducing radiation - expected 2023
| Alliance A011202 - reducing surgery - expected 2024
53
Surveilance for BRCA carriers before proph. Mastectomy
Alternating 6 month MRI and mammography
54
PET/Gamma imaging for breast cancer screening?
Don't do! abandoned due to high doses of radiation
55
Proven survival benefit for alternating MRI/mammogram for BRCA carriers?
No
56
Who is best candidate for lymphedema operations?
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
Rate of ypCR by marker subtype?
ER/PR+ HER2- = 15%
ER/PR+ HER2+ = 30%
ER/PR- HER2+ = 50%
-/-/- = 30 %
58
SWOG S1418
Pembro for patients with residual breast cancer after neoadjuvant/resection.
59
What is dose dense AC
Doxorubicin (topoisomerase inhibitor)
Cyclophosphamide (crosslinking agent)
every 2 weeks for 6 cycles
60
TAYLORx - resulted 2018
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
Proven advantages of alternating MRI/mammogram for BRCA carriers?
Higher sensitivity and catches tumors at earlier stage
62
Would you ever irradiate a breast angiosarcoma?
there is evidence if they occur outside of previous radiation fields.
63
perform reconstruction after mastectomy for inflammatory breast cancer?
no! too high a rate of local recurrence
64
5 criteria for a simple breast cyst
1. asymptomatic
2. anechoic
3. well circumscribed
4. smooth walled
5. posterior enhancement
65
Who should definitely get post mastectomy radiation therapy? (PMRT?)
all ycN+, always irradiate the chest wall and axilla with PMRT.
66
best chance of pCR for breast cancer?
Her2+ ER/PR-
67
hormonal supplementation for infertility after breast cancer?
estrogens are unsafe, tamoxifen can be used.
68
workup for bloody nipple discharge?
mammogram
ultrasound
then ductogram if no evidence of cancer
69
Differences between RxPonder and TAYLORx?
RxPonder includes HER+ and SN1-3+
70
treatment for stage IV lymphedema?
"elaphantitis" is generally irreversible with lymphatic procedures.
"debulking" liposuction is palliative
71
Granulomatous lobar mastitis?
usually a postpartum patient, observe.
72
Management of non-axillary nodes in Alliance 11202
all patients get radiation to the "nonsurgical" nodes
| i.e. level III, supraclav and IM
73
How do you do an ultrasound/palpation guided core biopsy?
local anesthesia
14-18 G needle
6-8 cores
leave a clip and confirm with ultrasouns
74
When to get a breast MRI (6)
```
occult primary
Paget's with negative mammography
Extent of disease
Dense breasts
Stage before and after neoadjuvant therapy
genetic/high risk screening
```
75
Information to check on breast biopsy path report?
all markers and grade.
76
Are AJCC prognostic stage groups helpful after neoadjuvant therapy?
no
77
Quick cheat for breast tumor markers and staging?
+/+/- will be one letter less
| -/-/- will be one letter worse
78
When to order Oncotype DX (or other panel)?
+/+/-; LN- and <5cm
| board answer unti RxPonder, but many already generalizing to limited node+
79
What is stage III breast cancer?
tumor > 5 cm
| fixed LN or infraclavicular LN
80
When to do systemic staging for breast cancer?
PET/CT for all stage III
81
>30% lifetime risk of breast cancer genes?
```
BRCA
P53
pTEN
CDH
STK11
```
82
Screening for breast cancer gene carriers starts at age?
25
83
Hard Contraindications for lumpectomy?
inflammatory Breast Ca
scleroderma/lupus
persistent positive margins
multicentric disease
84
relative contraindications for lumpectomy?
```
pregnancy
prior radiation (RTOG 1014)
```
85
Contraindication for nipple sparring mastectomy?
need a 1-2 cm margin
86
Whole breast RT doses?
hypofractionated 40 Gy in 15 fx
| standard 50 gy in 25 fx
87
Who gets boost RT?
high grade tumor or patient <50
| high grade DCIS <50 yo
88
boost dose for breast?
6-16 Gy
89
size cutoff for neoadjuvant for -/-/- breast cancer?
5 mm
90
size cutoff for neoadjuvant for HER2+ breast cancer?
2 cm
91
tamoxifen dose?
20mg daily
92
Letrozole dose?
5 mg daily
93
Re-excise ALH on a stereotactic biopsy?
no as of 2019 NCCN guidelines
94
When do you do systemic staging for an inflammatory breast cancer?
its automatically stage III so do for all!
95
Work up of a breast nodule in a breastfeeding patient?
can get an FNA instead of a core to avoid milk fistula.
96
Any evidence of improved breast cancer outcomes with pregnancy termination?
no evidence
97
When can chemo start in pregnancy?
week 11-12
| organogenesis ends at week 10
98
How big is a stereotactic biopsy needle?
9-11G
99
chemo for HER2+ breast cancer
TCHP
docetaxel, carboplatin, trastuzumab, and pertuzumab
three week cycles,
need 1 year of trastuzumab
trying to avoid adriamycin for the cardiotoxicity
100
What else to consider before starting chemo?
fertility preservation
101
Isolated tumor cells in LN after neoadjuvant therapy?
Still have to go direct to ALND.
102
Patient got neoadjuvant, can only find 2 SLN, what next?
if you cannot find a third LN then accuracy of your SLNB is not sufficient and need to do the ALND.
103
HER2 positive tests
IHC staining 3+
| FISH ratio >2.2 or copy # >6.0
104
When to resect an intraductal papilloma?
atypia
1 cm
bloody nipple discharge
105
When to resect radial scar?
generally do, especially with atypia.
106
Early breast cancer in pregnancy?
1st trimester - Mastectomy and SNB then chemo
| 2nd trimester - can do lumpectomy and give RT after delivery
107
Advanced breast cancer in pregnancy?
start neoadjuvant at week 11. Start surgery after delivery.
108
Mammogram safe during pregnancy?
yes
109
maximum delays of systemic chemotherapy?
good retrospective evidence of worse outcomes if >3 month delay.
110
Side effects of chemo in 2/3 trimester?
generally acceptable,
| 50% of pregnancies will have premature delivery and low birth weight.
111
Timing of delivery when on chemo?
try to end chemo 3-4 weeks before expected delivery
| give tocolytics to delay delivery if mom is neutropenic
112
breastfeeding on chemo/targeted/hormonal therapy?
no
113
Antibiotics while breastfeeding?
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
Giving AC during pregnancy?
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
Which has higher mortality, peripartum breast cancer or post-partum breast cancer?
post-partum breast cancer
| Mechanism not yet known
116
Advanced HER2+ breast cancer in early second trimester?
Give chemo without Herceptin/Progetta, then surgery, then Herceptic post-partum
117
radial scar of core needle?
can upstage, need to do excisional biopsy
| also increases lifetime risk of cancer 2-3x.
118
PASH
mimics cancer/inflammatory cancer
no actual cancer risk
can excise for symptoms
119
LCIS and calcifications?
either rad/path discordance and needs excision
or
pleomorphic and needs excision
120
ALND is performed for:
>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
operation for recurrent breast cancer?
Mastectomy v chest wall resection
| ALND
122
chemo for recurrent breast cancer?
would generally give
123
adjuvant treatment fora phylloides tumor?
give RT
15% chance of local recurrence
No well established systemic treatments
