Breast Cancer

Question 1

What is primary breast cancer?

Answer 1

Local tumour presented only in breast tissue with no extension to lymph nodes or distant metastases

Clinical sense early BC is tumour < 2cm or T1 stage

Question 2

What are the risk factors of Primary BC?

Answer 2

• early menarche late menopause
• nullparity
• absence of breastfeeding
• BRCA1 mutation
• female and advanced age (>65)

Question 3

Early diagnosis methods of BC?

Answer 3

• anamnesis
• clinical examination of breast and axilla
• echo with doppler of breast, clavicle and axilla region
• Mammography X ray

Question 4

How is BC definitively diagnosed?

Answer 4

• Mamotom biopsy- vacuum assisted
• core needle biopsy

Question 5

What are early cancer lesions of BC?

Answer 5

• Ductal carcinoma in situ (DCIS) > 80%
• Lobular Neoplasia in situ 15%
• Ductal-lobular carcinoma
• Rare types: medullar, adenoid cystic etc

Question 6

What aspects of immunohistochemistry and receptor status is important?

Answer 6

ER & PgR: intensity of hormone expression

HER2 expression

Ki67 proliferative index

Question 7

Why is plasminogen activator inhibitor (uPA-PAI-1) important?

Answer 7

• Tissue levels help predict metastatic spread of BC
• Useful to aid treatment decision making in early BC

Question 8

TNM classification of BC?

Answer 8

T1: > 1mm and < 20mm (a,b,c)
T2: > 20mm and < 50mm
T3: > 50mm
T4a: extension to chest wall w/o Pec.major invasion
T4b: edema of skin (P’eau de orange)
T4c: a and b
T4d: inflammatory BC

N1: regional axillary LN
N2: IMA, ipsilateral axillary LN deeper involvement
N3: supraclavicular ipsilateral LN and M1

Question 9

ESMO recommendation for treating primary BC?

Answer 9

Tumour < 2cm (BCS)

Tumour > 2cm (potential for BCS)
- Systemic induction tx
- + then BCS
- - then mastectomy

Breast conserving not an issue/aggressive
- Mastectomy

• all followed by postop chemo tx (if HER2+, trastuzumab) and RT (mandatory after BCS)

Question 10

When is adjuvant RT absolutely indicated?

Answer 10

• age < 50
• after BCS
• > 5cm
• Extensive DCIS
• vascular invasion
• non radical tumour excision

45-50 Gy

Whole body RT (WBRT) after BCS for CIS reduces risk of recurrence, where survival is = to as after a mastectomy

Question 11

What is the protocol with adjuvant hormonotherapy?

Answer 11

Indicated ER + expression irrespective of the use of chemo or target tx

Premenopausal women
- tamoxifen
- LHRH agonist e.g. goserelin

Reaching menopause women (first 5 years)
- switch tamoxifen to letrozole (Aromatase inhibitor)

Postmenopausal women
- Aromatase inhibitor
- letrozole
- Exernestan

*adjuvant tx must be administered 2-6 weeks after surgery, if after 12 week, efficacy reduces

Question 12

What are the neoadjuvant chemotherapy protocols for BC?

Answer 12

• used to downstage a tumour e.g. > 2cm before resection (can be BCS)

Anthracyclines e.g. doxirubicin (not to be used at the same time as trastuzumab) - due to high cardiotoxicity

Taxanes e.g. Pacliataxel
*Sequential use > concomitant use

Neratinib after 1 year of Neoadj Tx may be used with trastuzumab to prolong DFS and improve outcomes

Question 13

When is surgery indicated in early BC?

Answer 13

• T1a for local surgery
• 80% of EU women undergo BCS
• Mastectomy with LN axilla dissection in metastatic in regional LN BC
• Bilateral mastectomy for prophylaxis in BRCA1,2 mutation

Question 14

What is metastatic BC?

Answer 14

• Incurable disease
• survival 2-3 years (25% survive after 5 years)
• beyond breast tissue with extension to LN and other organs

Question 15

What are the tx aims of MBC?

Answer 15

• Prolongue progression free survival
• Extension of overall survival
• CR/PR
• QOL

Question 16

What are the critical factors for tx of MBC?

Answer 16

• age
• disease free interval
• extension of disease e.g. number of metastatic deposits
• upfront adjuvant tx
• performance status

Question 17

St Gallens

Question 18

What can be used as chemotherapy for MBC?

Answer 18

• Doxorubicin
• Pacliataxel
• Platinum
• Kapactabin
• Vinorelbin

Question 19

What can be used as hormonotherapy for MBC?

Answer 19

• Ovary ablation, surgery
• AI e.g. letrozole
• ER blockade e.g. tamoxifen
• Fluvestrant

Question 20

St Gallen recommendation for premenopause women?

Answer 20

• SERM (Selective ER modulator) e.g. tamoxifen for 5 years
• w or w/o surgery or LHRH agonist

Question 21

St Gallen recommendation for postmenopause women?

Answer 21

• AI e.g. letrozole
• assess bone density before administration due to risk of osteoporosis

Question 22

What does HER2+ MBC mean?

Answer 22

• more aggressive
• shorter PFS
• Poor survival

Question 23

First line treatment according to ESMO for MBC HER2 -/+?

Answer 23

HER2+

No contraindication for Cht
At least 6 cycles
- pacliataxel
- trastuzumab
- endocrine therapy

Cht Contraindicated:
- trastuzumab
- endocrine therapy

HER2-
No contraindication for Cht
At least 6 cycles
- pacliataxel
- trastuzumab, can be used

Cht Contraindication :
- trastuzumab until progression
- pertuzumab may be used