Early Stage Breast Cancer
Order by
75 terms
Terms | Definitions |
|---|---|
 What histologic subtypes of IDC are associated with favorable outcome? | Tubular Medullary Mucinous (colloid) Papillary |
| What are classic histologic features of of medullary carcinoma? | syncytial growth pattern of poorly differentiated tumor with high mitotic rate - Often prominent lymphoplasmacytic reaction involving at least 75% of periphery & present diffusely throughout the tumor. - Manages same as IDC |
| What is phylloides tumor of the breast? | Rare tumor with leaf-like, lobulated appearance on micro section. Has both malignant epithelial & stromal components (stromal has potential for mets) |
| What percent of phylloides tumor has LN involvement? | 10% (pts should get axillary dissection) |
| What is managment of phylloides tumor? | - Surgery is preferred - RT only for rare +margin & possible large tumors (>2cm) tx by breast conservation surgery |
| What is Paget dz of the breast? | - Malignant epithelial cells (Paget cells) infiltrating the epidermis through mammary ductal epithelium - Presents with crusting, scaling, itching, & redness on the skin of the nipple that can progress to ulceration & bleeding |
| What percent of Paget's dz is associated with underlying breast cancer (IDC or DCIS)? | >95% (90% IDC, 10% DCIS) |
| What percent of invasive cancer are lobular carcinomas? | 5-10% |
| What percent of lobular carcinomas are associated with contralat & synchronous primaries? | Up to 30% |
| Of pts with early stage breast cancers who will ultimately have recurrence, what percent recurs after 5 years? | 25% of women fail distantly after 5 yrs 50% fail in contralat breast According to NSABP B04 (Fisher, NEJM 2002) |
| According to NSABP B04, what percent of women with clinically (-) axilla were found to have axillary mets at LND? | 40% |
| Of the women with clinically (-) axilla and did not have LND what percent eventually developed a clinically (+) axilla? | 20% |
| What is the size to be considered microinvasive dz in the primary breast tumor? | < 0.1cm |
| What are the subsets of Stage I breast cancer? | T1mic: < 0.1 cm T1a: > 0.1 but < 0.5 T1b: > 0.5 cm but < 1 cm T1c: > 1 cm but < 2 cm ** All Stage I are LN (-) |
| What is TNM staging for Stage II breast cancer? | T2N0 T1-2N1 T3N0 - T2: > 2cm but < 5cm - T3: > 5 cm - N1: 1-3 LN+ |
| How are pN1(i+) & Pn1mi defined for involvement of breast cancer cells in axillary LN? | based on size of micromet - pN1(i+): isolated cells IHC or H&E (+) but <0.2mm pN1mi: > 0.2mm &/or >200 cells but < 2mm |
| Are pN1(i+) counted for total number of positive involved LNs? | No. |
| What percent of breast cancer pts are diagnosed with Stage I-II dz? | 75% |
| What is T Stage for Paget dz? | Tis (but only if it is associated with underlying cancer) |
| How should Paget dz associated with underlying cancer be staged? | According to T stage of underlying cancer |
| What are managment options for early stage breast cancers? | 1. MRM +/- chemo +/- RT 2. BCT (BCS + RT) +/- chemo * Consider endocrine tx for all women with ER+ tumors |
| When should adjuvant chemo be utilized in the management of early stage breast cancer? | - Tumor > 1cm - T1b tumors that are ER(-), +/- HER2 - 0.6-1cm tumor that are Gr2/3 or +LVI - For ER+ tumor with > T1c (incl T2/3) consider Oncotype DX to determine risk score for benefit of chemo. Benefit of chemo for pts > 70 yrs uis uncertain |
| What systemic tx is recommended for pts with ER+ tumors that are < 1cm? | Endocrine tx |
| What are some general guidelines for administration of adj endocrine therapy? | 1. Pre-menopausal: tamoxifen (20mg/d) x 5yrs. If pt remains premenopausal tx end. If pt becomes postmenopausal then AI x 5yrs 2. Post-menopausal: AI x 5yrs or tamoxifen x 2-3yrs or 4.5-6yrs >> AI x 5yrs 3. Tamoxifen x 5yrs in unable to take AI's |
| What are contraindications for AI's? | 1. Pre-menopausal 2. Use of HRT In post-menopausal |
| What are major side effects of Tamoxifen? | 1. Small increase in blood clots 2. Stroke 3. Uterine cancer 4. Cataracts |
| What are major side effects of AI's? | 1. Bone loss & osteoporosis 2. Joint pain & stiffness 3. Hypercholesterolemia * Consider bisphosphonates, statins to counter effects |
| When should paclitaxel be added to AC? | LN+ - Can use ACx4 for >1cm, LN- - If adding paclitaxel then dose dense (Q2wks) or AC Q3wks >> Taxol x 12wks |
| What systemic tx is recommended for HER2+ tumors? | 1. Endocrine tx (<5mm, LN-, ER+) 2. Combo chemo +/- Herceptin (0.6-1cm, LN-) 3. Combo chemo + Herceptin (>1cm, LN+) *Combo chemo = Taxotere/Carbo/Herceptin (TCH) * AC-TH not used due to cardiotoxicity |
| How should Herceptin be used in management of early stage breast cancer? | HER2+ tumor > 1cm - T1a-bN0 have good prognosis even with HER2 amp;must weigh potential cardiotoxicity of chemo in this group |
| If Herceptin is added to tx how is it administered? | - After completion of Adr-based chemo - Can be given with Taxol or Taxotere - Given Qwk x 1yr. Can give with RT - If capecitabine given as radiosensitizer then Herceptin can be given concurrently |
| What data support BCT (lumpectomy + RT) having equivalent OS to mastectomy +/- LND? | NASPB B06 (Fisher, NEJM 2002; n = 1851, Stage I/II) - TM vs. lumpectomy vs. lumpectomy + RT(50) - No diff in DFS, OS, DM - IPSI recurrence 14 vs. 39% in favor of RT arm EBCTCG (Lancet 2005; n = 7300, 10 trials BCS +/- RT) - LR5 7 vs. 26% in favor of RT - 15yr breast cancer mort: 30.5 vs. 35.9% favoring RT - 15yr overall mortality: 35.2 vs. 40.5 favoring RT - *for every 4 LR prevented, 1 life saved |
| What percent of patients are eligible for BCT for early stage breast cancer? | 75-80% |
| What is rate of BCT for invasive lobular carcinoma compared with IDC? | 75 vs. 80% due to propensity for multi-focality |
| What are some absolute contraindications for BCT? | 1. Prior RT 2. Multicentricity 3. Diffuse microcalcs 4. 1st or 2nd trimester pregnancy 5. Persistently +margin |
| What are relative contraindications for BCT? | 1. Ratio of tumor to breast size (suboptimal cosmesis) 2. Locally adv dz (can consider for large tumors after chemo) 3. Collagen vascular dz (scleroderma, mixed connective tissue dz, CREST syndrome) 4. Pregnancy (can delay RT until delivery) |
| What is CREST syndrome? | Calcinosis Raynaud Esophageal dysfunction Sclerodactyly Telangiectasia |
| Is LN involvement contraindication for RT? | No. - May determine extent of LN RT - 1-3 LN consider breast & axillary RT - > 4 LN consider comprehensive LN RT |
| Is BCT contraindicated for BCT in pts with positive hx of breast cancer? | No. - No evidence of increased IPSI or CONTRA breast cancers after BCT |
| Are BRCA mutations contraindication for BCT? | No. - IPSI recurrence may be higher but this becomes indistinguishable after oophorectomy in BRCA carriers - CONTRA recurrence higher (26 vs. 3%, 39 vs. 7%) at 10/15 yrs; reduced with tamoxifen or tamoxifen + oophorectomy |
| What is typical whole breast RT dose? | 45-50 Gy |
| Is there data to support benefit of boost? | Yes. - EORTC & French studies - In general boost of 10-16 Gy should be considered for pts at higher risk for LR (age < 50, +axillary LN, LVSI, close margin) |
| Describe EORTC boost trial. | (Bartelink,JCO 2007; n = 5318 pts with BCT) - 50 vs. 50+16 (margin-) vs. 50+26 (margin+) - LF10 (6.2 vs. 10.2) favoring boost - Absolute benefit highest in women <50 due to higher risk of LR (24 vs. 13.5%) favoring boost |
| Describe Lyon boost trial. | (Romestiang, JCO 1997; n = 1024) - 50 vs. 50+10 - LF3 (3.6 vs. 4.5%) favoring boost |
| Is there a need for a higher boost dose in pts with incomplete tumor excision after BCS? | No. - In EORTC boost trial 251 pts with micro +margins were randomized to 10 vs. 26 Gy boost. No diff in LRC or OS though high dose arm had much more fibrosis |
| Can RT be used to tx axilla in place of surgery if axillary LN dissection not performed? | Possibly NSABP B04 (Fisher, NEJM 2002) - Subset 1: cLN- randomized to RM vs. simple mastectomy vs. simple mastectomy + RT - Subset 2: cLN+ randomized to RM vs. simple mastectomy + RT - No diff in LF, DFS, OS at 25 yrs *Caveat: ~1/3 pts who should not have had LN dissection had some LN removed |
| What is next step for pt who undergoes lumpectomy with focal +margin? | Most would advocate for re-excision - May diminish 10yr LR to baseline levels |
| Is there a subset of women whose LR risk may not be substantially influenced by +margin after BCS? | Possibly. - Some data suggest margin+ status dependent on age<40 (29% increased risk vs. 0% increase if >40) |
| Should women with T1-2N0 tx with mastectomy to a +margin be tx with adjuvant RT to chest wall? | British Columbia Retrospective (n = 2570) - Of 94 pts with +margin 41 had post-mastectomy RT - Trend toward improvement in pts <50, T2, Gr3, LVSI |
| What is more important factor in LR: margins or LN? | Margins - LN more predictive of distant recurrence & OS |
| What is EIC? | Extensive Intraductal Component - DCIS comprising 25% of tumor mass & foci of DCIS separate from invasive dz - DCIS with areas of focal invasion |
| Does EIC have prognostic significance in recurrence risk of pts tx with BCT? | Yes - Largely dependent on margin status. If close or positive then EIC associated with high risk of recurrence |
| What data suggests BCT can be improved with addition of Tamoxifen? | NSABP B21 (Fisher, JCO 2002; n = 1009, < 1cm tumor) - lumpectomy >> tamoxifen vs. RT(50) vs. RT+tamoxifen - IPSI recurrence 16.5 vs. 9.3 vs. 2.8% - CONTRA recurrence 0.9 vs. 4.2 vs. 3% - No OS benefit or benefit in ER- tumors |
| Are there pt subgroups with low risk recurrence that can be tx with BCS + systemic tx and no RT? | Possible - based on data from PMH & Intergroup trial that showed risk of recurrence low for pts >70 & with small tumors (< 1cm) |
| Describe details of PMH / Canadian trial. | Fyles, NEJM 2004 (n = 769 > 50yrs, T1/2N0) - lumpectomy >> Tamox vs. Tamox + RT (40/16 + 12.5) - LR8 (17.6 vs. 3.5%) in favor of RT - In tumors < 1cm relapse risk 2.6 vs. 0% - In pts > 60, < 1cm tumor no difference in risk between arms (1.2 vs. 0%) |
| Describe details of Intergroup trial | Hughes, NEJM 2004 (n = 636 >70 yrs, T1N0, ER+) - lumpectomy >> Tamox vs. Tamox + RT (45 + 14) - LF5 (4 vs. 1%) in favor of RT - LF8 (7 vs. 1%) |
| What are some alternative fx regimens for whole breast RT? | Canadian - 42.5 in 16 fx (2.65 Gy/fx) British (START B) - 40 in 15 fx |
| Describe trial the reported results of Canadian regimen | Whelan, JNCI 2002 (n = 1234 T1/2N0, - margin, <25cm breast) - 42.5/16 vs. 50/25 - No diff in LC, OS, cosmesis at 69 months - LR 6.2 vs. 6.7% |
| Describe START B trial | Lancet 2008 (n = 2215 pT1-3N0-1) - 50/25 vs. 40/15 - No diff in IPSI recurrence between arms (3 vs. 2%) |
| How should chemo be sequenced with RT after BCS? | JCRT sequencing trial (Upfront-Outback trial) - Distant recurrence at 5 yrs better with chemo upfront (20 vs. 32%) - At 11 yrs no diff in DFS, LR, DM, OS - With -margin LR 6 vs. 13% favoring chemo 1st *Study underpowered so either is acceptable but convention is chemo 1st |
| What is max length of time RT can be delayed after BCS before impacting clinical outcome? | No more than 20 wks - Data suggests that in pts who get chemo delay > 20 wks results in increase in DFS & breast cancer mortality (British Columbia Study, JCO 2009) |
| Can accelerated partial breast RT (PBI) be considered an option for BCT? | Not an option as of 2010 NSAPBP B39 / RTOG 0413 testing this - whole breast vs. PBI (interstitial, mammosite, EBRT) |
| What are ASTRO guidelines for PBI off-trial? | >60, ER+, IDC < 2cm (no DCIS, ILC), N0, unicentric, > 2mm margin, -LVSI, -EIC, BRCA1/2 (-) - Several retrospective studies show excellent ctrl in pts with short follow-up |
| What are PBI doses done off protocol? | EBRT: 38.5 in 10 fx (target = tumor bed +1-1.5cm) Brachy / Interstitial: 34 in 10 fx (target = tumor bed + 1cm) |
| Are there subsets of women who undergo mastectomy for early stage dz (T1/2N0) who may benefit from post-mastectomy RT? | Yes - PMRT recommended with T3/4N+ (>4LN) - PMRT may not be necessary if margins clear (> 1cm); consider for margins < 1mm |
| What data suggests some pts who receive PMRT for early stage dz benefit? | Vancouver Retrospective data - pts with LVSI, Gr3, no chemo, T2 tumors may benefit - In presence of 2-3 risk factors LR 21-23% without RT Harvard - Close margins, >T2, premenopausal, LVSI predicted for increased risk of recurrence - LRR10 (0 vs. 1.2% margins), (1 vs. 10% >T2), (2 vs. 18% premenopausal), (3 vs. 41% LVSI) |
| How should breast cancer be managed in pregnant woman? | 1st trimester: termination, mastectomy + axillary staging. If chemo needed add in 2nd trimester. RT, hormones (if needed post-partum) 2nd - 3rd trimester: BCT or mastectomy. Can consider neoadj chemo. RT, adj hormones (if needed) post-partum |
| For pts with large breasts with large medial to lateral separation (>22-24 cm) what techniques will improved dose homogeneity? | - Photon energy > 10 MV to keep max inhomogeneity <10% - Field segmentation techniques (IMRT) - Avoid medial wedges to reduce scatter to CONTRA breast in pts < 45 yrs |
| Which RCT showed superiority of IMRT over 2D techniques for minimizing cosmetic changes? | Royal Marsden (Donovan, RO 2007) - n = 306. 3D vs. 2D (50 +11 e-) - Cosmesis better with IMRT (40 vs. 58%) - Less palpable induration in IMRT - No diff in QOL Pignol, JCO 2008 - IMRT vs. 2D - IMRT had less moist desquam (31 vs. 48%) & better dose dist |
| What is risk of 2nd malignancy in pts tx for early breast cancer with RT? | WECARE study - RR 3 in pts < 40 getting > 1 Gy to CONTRA breast - No excess risk in pts > 40 - Sarcoma (angiosarc) within RT field < 1% within 10-30 yrs |
| What is risk of lymphedema in pts tx for breast cancer? | <5% if RT alone, SLN bx alone, level I/II dissection 10% with complete axillary dissection >15% with axillary dissection + RT |
| What is risk of brachial plexopathy in pts tx for breast cancer? | ~1% with conventional fx & dose Highly dependent on fx dose & total dose - median time = 10-12 months - Hypofx (2.2 - 4.6 Gy/fx) & dose 43.5-60 Gy increase risk from 1.7 - 73% (normally 1%) - According to JCRT data if dose < 50 risk 1% without chemo, 4.5% with chemo. If dose > 50 Gy risk 5.6%. |
| What is risk of pulm tox (fibrosis, symp pneumonitis) after BCT? | Fibrosis in everyone Clinical pneumonitis rare (1%) |
| How does symptomatic pneumonitis present? | cough, fever, non-specific infiltrate on CT 3-9 months after RT |
| What is long-term risk of fibrosis in tx breast? | EORTC boost trial - Good cosmesis at 3 yrs 86% (no boost) vs. 71% (boost) - Risk of fibrosis dependent on max whole breast dose + concomittant chemo & post-op breast edema/hematoma - Risk decreased if RT given with >6MV photons |
First Time Here?
Welcome to Quizlet, a fun, free place to study. Try these flashcards, find others to study, or make your own.