Chpt 9 Breast W&L 38 – Flashcards

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1. At what age should women of normal risk begin having regular annual screening mammograms? a. 20 b. 30 c. 40 d. 50
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ANS: C Starting at age 40, all women should have a mammogram done every year. REF: Chapter 38, Breast Cancer, p. 874
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2. DCIS is classified as which stage? a. stage 0 b. stage 1 c. stage 2 d. stage 3
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ANS: A Ductal carcinoma in situ is defined as the earliest stage of breast cancer and is associated with a stage 0 denotation. REF: Chapter 38, Breast Cancer, pp. 877-878, Box 38-7
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3. Inflammatory breast cancer is always classified as which T stage? a. T4a b. T4b c. T4c d. T4d
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ANS: D Inflammatory carcinoma of the breast is classified as T4d. REF: Chapter 38, Breast Cancer, p. 877, Box 38-7
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4. Which treatment field arrangement is used to increase the midaxillary dose to the prescribed level in some patients? a. intact breast tangents b. chest wall tangents c. supraclavicular field d. PAB
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ANS: D The posterior axillary boost field (PAB) is used when midplane radiation dose from an anterior supraclavicular field alone is not sufficient. REF: Chapter 38, Breast Cancer, p. 887
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5. In which quadrant do most breast cancers occur? a. upper outer b. upper inner c. lower outer d. lower inner
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ANS: A Approximately 48% of breast cancers arise in the upper-outer quadrant. REF: Chapter 38, Breast Cancer, p. 872, Fig. 38-5
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6. The lower border of the breast extends to which rib? a. 5th b. 6th c. 7th d. 8th
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ANS: B The protuberant portion of the adult breast is located between the second and sixth ribs in the sagittal plane. REF: Chapter 38, Breast Cancer, p. 870
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7. What T stage is a breast cancer that is a 9-cm tumor with skin invasion? a. Tis b. T1 c. T2 d. T3 e. T4
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ANS: E Skin invasion depicts a T-stage that is extensive, T4. REF: Chapter 38, Breast Cancer, p. 877, Box 38-7
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8. What T stage is a breast cancer that is a 3.5-cm tumor near the nipple? a. Tis b. T1 c. T2 d. T3 e. T4
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ANS: C As defined by the AJCC Staging System for Breast Cancer, a tumor more than 2 cm but less than 5 cm is denoted as a T2.
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9. What T stage is a breast cancer that is a 1-cm tumor in the upper outer quadrant? a. Tis b. T1 c. T2 d. T3 e. T4
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ANS: B As defined by the AJCC Staging System for Breast Cancer, a tumor 2 cm or less in any dimension is denoted as a T1. REF: Chapter 38, Breast Cancer, p. 877, Box 38-7
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10. What T stage is a breast cancer that is a 7-cm tumor in the upper outer quadrant with extension to the skin? a. Tis b. T1 c. T2 d. T3 e. T4
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ANS: D As defined by the AJCC Staging System for Breast Cancer, a tumor of any size with direct extension to the chest wall or skin is denoted as a T4.
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11. What T stage is a breast cancer that is a 1.5-cm tumor near the nipple? a. Tis b. T1 c. T2 d. T3 e. T4
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ANS: B As defined by the AJCC Staging System for Breast Cancer, a tumor 2 cm or less in any dimension is denoted as a T1. REF: Chapter 38, Breast Cancer, p. 877, Box 38-7
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12. What T stage is a breast cancer that is a 3-cm tumor invading the chest wall? a. Tis b. T1 c. T2 d. T3 e. T4
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ANS: E As defined by the AJCC Staging System for Breast Cancer, a tumor of any size with direct extension to the chest wall or skin is denoted as a T4. REF: Chapter 38, Breast Cancer, p. 877, Box 38-7
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13. What is the ligament holding the breast in place? a. Cooper b. Montgomery c. Stoop d. Paget
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ANS: A The superficial pectoral fascia encompasses the breast tissue and is attached to the deep fascia by bands of connective tissue called Cooper suspensory ligaments, which support the breast.
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14. What is the standard dose delivered to the tumor bed following tangential treatments? a. 4500 to 5000 cGy b. 5000 to 5600 cGy c. 6000 to 6600 cGy d. 7000 to 7600 cGy
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ANS: A Fields are treated daily with standard fractionation (180 to 200 cGy per fraction) to a total dose of 4500 to 5000 cGy. A boost dose may be delivered with a reduced photon field electron beam or interstitial technique, increasing the total dose to the primary tumor site to 6000 to 6600 cGy. REF: Chapter 38, Breast Cancer, p. 882
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15. What is the medial treatment border when the internal mammary lymph nodes are to be included in the tangential field? a. midline b. 1 cm beyond midline to the contralateral side c. 3 cm beyond midline to the contralateral side d. 3 cm beyond midline to the ispalateral side
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ANS: C Rather than placing the edge of the medial tangential field at the patient's midline, the field is extended beyond the midline to the contralateral side by approximately 3 cm. REF: Chapter 38, Breast Cancer, p. 889
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16. What is the standard dose delivered to the SCV field? a. 4000 to 4600 cGy b. 4500 to 5000 cGy c. 5000 to 5600 cGy d. 6000 to 6600 cGy
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ANS: B Peripheral (supraclavicular and/or axillary) lymphatic irradiation may also be required. Fields are treated daily with standard fractionation (180 to 200 cGy per fraction) to a total dose of 4500 to 5000 cGy
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17. What is the stage of a breast cancer that is 3 cm in greatest diameter with three positive axillary lymph nodes? a. IIA b. IIB c. IIIA d. IIIB
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ANS: B Stage IIB is defined as a T2N1M0 or T3N0M0. In this case, the tumor is greater than 2 cm but less than 5 cm making it a T2, and it is N1 because there are 1-3 lymph nodes involved.
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18. What is the stage of a breast cancer that has grown into the chest wall and has eight positive axillary lymph nodes? a. IIA b. IIB c. IIIA d. IIIB
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ANS: D Stage IIIB is defined as a T4N0M0, T4N1M0, or T4N2M0. In this case, the tumor extends to the chest wall, making it a T4, and it is N2 because there are 4-9 lymph nodes involved.
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19. What stage is a inflammatory breast cancer that has not spread to distant organs but has distant lymph node involvement? a. stage I b. stage IIA c. stage IIIA d. stage IV
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ANS: D Stage IV is defined as any T, any N, and metastatic node involvement distantly.
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20. What stage is a 6-cm breast cancer in the upper inner quadrant? a. Tis b. T1 c. T2 d. T3
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ANS: D T3 is defined by AJCC as a tumor more than 5 cm in greatest dimension.
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21. Which of the following techniques may be used to adequately irradiate the internal mammary lymph nodes while limiting the exposure to other organs? a. AP 6 MV only b. AP photon/electron combination c. AP 6 MeV only d. extended medial tangent
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ANS: B An alternative method of irradiating the IM nodes involves the use of an en face (perpendicular to the skin surface with a slight angle toward the patient) IM field with a combination of electrons and photons. REF: Chapter 38, Breast Cancer, p. 889
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1. A woman's risk of developing breast cancer is 1 in 8.
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ANS: T Current data indicate that every woman has approximately a 1-in-8 chance of developing breast cancer over her lifetime.
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2. Breast implants at an early age increase a woman's risk of developing breast cancer.
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ANS: F Breast implants do not increase a woman's risk of breast cancer.
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3. Breast cancer risk is influenced by hormonal variables; early menarche and late menopause increase the risk while oophorectomy before age 50 decreases the risk
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ANS: T The assumption that the overall length of ovarian function is related to breast cancer risk is supported by the increased activity associated with early menarche and late menopause as well as early cessation associated with removal of one or both ovaries before the age of 50.
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4. Breast cancer is the most common cancer in women.
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ANS: T Breast cancers affect an estimated 178,480 new patients each year in the United States.
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5. External beam radiotherapy for breast cancer irradiates the entire breast regardless of the tumor size.
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ANS: F Accelerated partial breast irradiation (APBI) has been investigated as a possible alternative treatment option for women undergoing breast-conserving therapy. Instead of treating the whole breast, partial breast irradiation targets the tumor bed with a margin.
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6. Inverted nipples are always an indication of breast cancer.
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ANS: F Inverted nipples are not necessarily an indication of breast cancer.
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7. Most breast lumps feel hard and have irregular edges.
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ANS: T The assessment of a breast mass must address the size, shape, consistency, mobility, pain or tenderness, location in the breast, and relation to skin and surrounding tissues. REF: Chapter 38, Breast Cancer, p. 873
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8. Most breast cancers are infiltrating ductal carcinoma.
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ANS: T More than 70% of invasive breast cancers are infiltrating ductal carcinoma. REF: Chapter 38, Breast Cancer, p. 875
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9. Radiation therapy is the only treatment necessary for T1 and T2 breast cancers.
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ANS: F All breast cancers will be removed either via mastectomy or lumpectomy.
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10. The posterior axillary boost (PAB) field delivers 180 cGy to the axillary lymph
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ANS: F A PAB field is sometimes used to increase the midaxillary dose to the prescribed level in a subset of patients whose axillary fossa requires radiation. REF: Chapter 38, Breast Cancer, pp. 887-888
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what is the most common malignancy in women?
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breast cancer
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how many women will be diagnosed with breast cancer?
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1 in 8 women
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How many cases will be men?
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1%
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Breast cancer is second to what cancer in mortality?
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lung cancer is first in mortality for both men and women
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What makes up the breast tissue?
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fat, glands, and ducts
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What are the four quadrants of the breast?
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upper outer quadrant (UOQ) upper inner quadrant (UIQ) lower outer quadrant (LOQ) lower inner quadrant (LIQ)
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Where is the most common location?
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upper outer quadrant
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What is a rare location?
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central
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What is the minimum size for a palpable lump?
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1 cm
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What is the overall prognosis?
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good overall even with positive nodes
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What are high risk factors associated with breast cancer?
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female gender family history history of benign breast disease early menarche late menopause nulliparity children at late age oral contraceptives
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What are low risk factors associated with breast?
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asian ancestry early pregnancy (by age 18) early menopause late menarche oophorectomy by age 37
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What other factors have a strong influence on breast cancer?
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genetics exposure to estrogen
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What are the Invasive/Infiltrating histologies of breast cancer?
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ductal lobular tubular medullary (usually well circumscribed) papillary mucinous inflammatory
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What are the noninvasive histologies of breast cancer?
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lobular or ductal carcinoma in situ (LCIS or DCIS) Paget disease (from underlying in situ or invasive disease)
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What is the most common breast cancer?
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Infiltrating ductal carcinoma - 70% 0f invasive beast cancers
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What is Paget disease?
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Paget's disease of the nipple is an uncommon type of cancer that forms in or around the nipple and accounts for about 1% of all breast cancers.
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What is the lymphatic drainage of the breast?
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contiguous pattern through axillary, internal mammary, and supraclavicular
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How does cancer of the breast metastasize?
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through the blood and Batson plexus to skin, bone, (especially thoracic spine) liver, and brain
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What is the Batson plexus?
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A network of valveless veins in the human body that connect the deep pelvic veins and thoracic veins(draining the inferior end of the urinary bladder, breast and prostate) to the internal vertebral venous plexuses. Because of their location and lack of valves, they are believed to provide a route for the spread of cancer metastases.
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What % of cases will have positive axillary nodes?
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55 to 70%
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What node dissections are common for staging?
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axillary nodes
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Internal mammary nodes are positive depending on location of the mass-where?
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central or inner quadrants
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What is the workup done for breast cancer?
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physical exam history needle-guided biopsy with mammogram, ultrasound, or CT open biopsy (lumpectomy and node dissection) Sentinel node biopsy (removal of nodes first containing mets using radioactive tracer and blue colored dye) CT chest and abdomen bone scan and liver scan for suspected mets
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What does tissue need evaluation for?
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estrogen and progesterone receptors (ER, PR)
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How is breast cancer staged?
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TNM; clinical staging in office, pathologic staging required. positive supraclavicular nodes classified as M1
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What M will positive supraclavicular nodes be classified as?
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M1
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What is the primary treatment of breast cancer?
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removal of tumor by surgery is preferred with lumpectomy
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What is a radical mastectomy?
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removal of breast, pectoralis muscles and regional lymph nodes-three levels of axillary)
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What is partial excision?
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also known as wide excision (removal of lump and axillary nodes dissected through separate incision)
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What is total mastectomy?
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removes breast and axillary tail, leaving the pectoralis muscles behind
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What is a modified radical mastectomy?
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a total mastectomy with axillary nodes dissected and pectoralis minor
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What happens when too many lymph nodes are removed?
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chronic lymphadema
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What is the recurrence rate for radical vs total mastectomies?
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slightly lower for radical
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What is the advantage of partial mastectomy/lumpectomy?
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psychological
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How can surgery be used for reconstruction?
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silicone implants, grafts using autologous tissue from abdomen and upper thigh for areola
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When would surgery be used prophylactically?
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for patients with high risk for developing cancer in opposite breast
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Who would be at risk of developing cancer in opposite breast?
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family history, HER2neu, BRCA1 and 2 genes
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Radiation is used definitively to irradiate the entire breast following?
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a lumpectomy
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Radiation is used definitively to irradiate the chest wall following?
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mastectomy
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What RT is done for those who had large tumors, positive surgical margins, or at least four positive lymph nodes?
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chest wall RT en face electron fields or photon tangential fields
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What RT is done following lumpectomy for low risk patients? (older age, small tumors, negative nodes)
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local radiation, accelerated breast therapy with brachytherapy
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When will chemotherapy have a role?
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following surgery
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What type of chemotherapy?
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cytotoxic and hormonal therapy
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What is used if ER and/or PR positive?
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hormonal therapy to maintain remission
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What are common cytotoxic combinations?
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CMF or CAF- cyclophosphamide, methotrexate, 5-FU, adriamycin (doxorubicin)
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What chemo drug has cardiac toxicity?
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Adriamycin (doxorubicin) so cardiac gating procedures may be employed for patients receiving radiation to the left breast especially
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When is concomitant cytotoxic chemotherapy and RT used?
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is the standard following surgery for candidates not suited for accelerated brachytherapy
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What is the common order of treatment?
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surgery, chemotherapy then radiation
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What are radiation treatment fields for an intact breast?
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medial border at midline, lateral border beyond breast tissue, upper border above the superior tail of the breast (about the second intercostal space), lower border about 2 cm inferior to breast fold
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What nodes at minimum are included in the tangential fields?
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first level axillary nodes
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What fields are used if third level axillary nodes (apical nodes) found positive or if no axillary dissection, or if tumor was extracapsular?
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another field may be added and treated AP/PA or posterior only with a posterior axillary boost (PAB)
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What is the field for the supraclavicular nodes if positive?
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medial border at midline, lateral border about two thirds of the clavicle and upper border about 2 to 3 cm above the clavicle; lower border carefully matched to tangential fields
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What would a combination supraclavicular and apical nodes field show?
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an extended field down to the second rib
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If treating internal mammary nodes what would the field look like?
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a wider tangential field or separate anterior field if tumor was located near midline
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Where are the internal mammary nodes located?
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lateral of sternum about 2 cm on each side and from the level of the 3rd to 8th rib; border should be carefully matched to medial tangent and/or supraclavicular field
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What is total dose for intact breast?
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50 Gy in 5 to 6 weeks
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What fields are used for intact lung?
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tangents to avoid underlying lung
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What is used for uniform dose distribution within the breast?
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wedge or compensators
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what will the lumpectomy site be boosted to?
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10 to 20 Gy depending on tumor size and margins at surgery time electron energy depending on depth of tumor bed
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What can be used for accelerated breast irradiation?
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Iridium for 1 week using hyperfractionated twice daily
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When is brachytherapy used?
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for low recurrence risk patients instead of entire breast radiation
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What will the chest wall be dosed to following lumpectomy?
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45 to 60 Gy with photons; bolus scar or entire chest wall
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Can the chest wall radiation be delivered with electrons?
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yes
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How is the supraclavicular field treated?
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AP only to depth of 3.0 cm to 45 Gy at 2Gy per day
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When treating the supraclav field what needs to be protected?
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Cerrobend or MLC beam shaping to protect the head of the humerus and larynx; gantry angle may facilitate sparing of larynx
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How are apical axillary fields treated?
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AP/PA or PAB treated to midline to 45 Gy
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How will matching the tangential and supraclav fields be done?
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likely a half-beam technique and/or couch angles to prevent overlap at junction
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How are internal mammary fields treated?
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with single anterior photon field or en face electrons or a combination; IM nodes at depth of 3 cm; careful planning to avoid overdose at junction
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How is patient positioned?
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supine, with affected arm or both up, chin turned away from the affected side
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How might large breasted patients be positioned?
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prone to pull breast away from the chest wall
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What is a breast board used for?
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decrease the slope of the chest
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What organ must be watched dose wise?
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the lung, so make sure match lines between tangents and supraclavicular are on
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What reactions will occur with breast RT?
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skin reactions so educate on skin care.
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The posterior Axillary Boost (PAB) field is intended to irradiate a. level 1 axillary nodes b. level 2 axillary nodes c. level 3 axillary nodes d. supraclavcular nodes
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c. level 3
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lymphatic drainage of the breast is primarily to the a. axillary b. supraclavicular c. internal mammary
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all of them
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For estrogen receptor positive cases, an antiestrogen may be used to maintain remission known as a. taxol b. tamoxifen c. megace d. prednisone
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b. tamoxifen
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What are the two common cytotoxic drug combinations for management of breast carcinoma?
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CMF and CAF
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What is the CAF combination?
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C: cyclophosphamide alkylating agent myelosupression, alopecia, nausea, vomiting, diarrhea A: Adriamycin (doxorubicin) anti-tumor antibiotic myelosupression, cardiotoxicity, alopecia, nausea/vomiting F: 5-fluourocail anti-metabolite oral and intestinal ulcers, nausea/vomiting, mild alopecia, radiation recall
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What is the CMF combination?
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C: cyclophosphamide alkylating agent myelosupression, alopecia, nausea, vomiting, diarrhea M: methotrexate anti-metabolite mucositis, myelosuppression, mild alopecia F: 5-fluourocail anti-metabolite oral and intestinal ulcers, nausea/vomiting, mild alopecia, radiation recall
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What is myelosuppression?
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the bone marrow making too few blood cells to replace the blood cells that have worn out. It doesn't hurt—a person with myelosuppression does not feel any specific pain from this condition. However, myelosuppression can lead to fatigue, excessive bleeding, or an increased vulnerability to certain infections. Fatigue: This results from a shortage of red blood cells. It is also known as Anemia. -- Bleeding: This results from a shortage of platelets. It is also known as Thrombocytopenia. -- Infection risk: This results from a shortage of white blood cells, notably neutrophils. It is also known as Neutropenia.
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Special care must be taken to limit dose to the heart when treating left breast patients who have undergone CAF chemotherapy. Why?
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a unique toxicity associated with adriamycin is cardiac toxicity. radiation dose should be limited so as not to compound the potential latent injury to the heart
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What is the difference between clinical staging and pathological staging?
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Clinical staging: includes physical exam taking survey of the skin of the breast and the status of palpable lymph nodes. imaging studies may also be used for clinical staging Pathological staging: includes everything necessary for clinical staging but adds surgical exploration and resection with pathological evaluation of tissue sample
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If the lumpectomy bed is located in the right upper outer quadrant of the right breast what possible patient table and gantry positions would adequately deliver uniform dose distribution to the site?
answer
the objective is to have the horizontal plane of the beam be parallel to the patients tumor bed area 1. The patient may be positioned in left lateral oblique position and slightly inclined to flatten the area 2. The patient may continue in the same arm up position and the couch and gantry could be rotated to bring the horizontal axis parallel to the skin
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look at question 10 in Mosbys for couch angles look at questions 11 and 12 calculations questions 20 and 24
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The most common symptom of breast cancer is a. painless lump b. clear nipple discharge c. dimpling of the skin d. inverted nipple
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a. painless lump
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What is a radical mastectomy?
answer
resection of the breast, pectoralis muscles and regional lymph nodes
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What is the HER2neu?
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an oncogene expression seen in certain breast cancer patients; an epidermal growth factor
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What is the BRCA1?
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a tumor suppressor gene whose failed type is associated with elevated risk for breast cancer
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What is Peau d-orange?
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an orange coloring of the skin of the breast indicating infiltration of cancerous cells into the dermal layers of the breast; skin feels thick and leathery
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When using a breast board for positioning the optimal incline angle is influenced by a. the angle of the elbow when it is raised b. the ability of patient to raise arms c. the slope of the patients chest d. the gantry angle on the medial tangent
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c. slope of the patients chest
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When the supraclavicular fossa is treated along with opposing tangents, the supraclavicular field is best treated using? a. AP/PA ports b. wedged pairs c. rotational beam d. half beam technique
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d. half beam technique
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The total radiation dose received by the lumpectomy bed in standard whole breast irradiation followed by lumpectomy site boost is a. 40 to 50 Gy b. 50 to 60 Gy c. 60 to 70 Gy d. 70 to 80 Gy
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c. 60 to 70 Gy entire breast treated to 50 Gy and scar boosted 10 to 20 Gy
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The most common histologic type of breast cancer is a. infiltrating ductal b. lobular insity c. paget disease d. medullary
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a. infiltrating ductal
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The acceptable amount of lung tissue included in tangential breast fields is 2 cm in order to decrease the chance of latent a. pneumonia b. lung fibrosis c. pleural effusion d. atelectasis
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b. lung fibrosis
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an en face electron boost to the lumpectomy bed is accidentally treated at 105cm instead of 100 cm SSD. the error in dose delivered is about a. 5% overdose b. 5% underdose c. 10% overdose d. 10% underdose
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d. 10% under dose
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ductal carcinoma in situ (DCIS) is classified as a.stage 0 b. stage I c. Stage II d. stage II
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a. stage 0
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A breast cancer classified as T3 N1 M1with the metastasis to the supraclavicular nodes only would be grouped as? a. stage I b. Stage II c. Stage III d. Stage IV
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d. Stage IV
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a sentinel lymph node biopsy involves the injection of a blue dye and radioactive: a. iridium 92 b. technetium 99m c. strontium 89 d. samarium 137
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b. technetium 99m
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The hinge angle between two half-beam tangential ports is 180 degrees. The medial tangent gantry angle is 310 degrees. What is the gantry angle for the lateral tangent? a. 230 b. 140 c. 130 d. 50
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c. 130
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The pathologic staging system for breast cancer incorporates a. lymph node status b. tumor extent c. distant mets
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all of them
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The most common presenting symptom of early stage breast cancer is a. nipple discharge b. pain c. palpable mass d. ulceration
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c. palpable mass
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Which of the following is proper advice for a patient receiving RT to the breast? a. do not wear restrictive clothing b. avoid using commercial deodorant c. avoid sun exposure to the skin of the treated area
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All of them
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TD 5/5 refers to a. minimal tolerance dose b. maximum tolerance dose c. tumor dose of 5 Gy in 5 days d. tumor dose of 5cGy in 5 days
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a. minimal tolerance dose the TD 50/5 would be maximal dose
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The TD 5/5 for the spinal cord delivered through standard fractionation is a. 1500 cGy b. 3000 cGy c. 4500 cGy d. 6000 cGy
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c. 4500
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Which of the following is not currently a standard technique for breast surgery? a. radical mastectomy b. modified radical mastectomy c. lumpectomy d. tylectomy
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a. radical mastectomy (tylectomy is aka lumpectomy)
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Chemotherapy for breast cancer may consist of a. drug therapy b. endocrine therapy c. immunotherapy
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a and b
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In treating a breast cancer patient via tangential fields plus an electron field boost, the usual total dose to the tumor bed delivered through standard fractionation is a.4000-4600 cGy b. 5000 to 5600 cGy c. 6000 to 6600 cGy d. 7000 to 7600 cGy
answer
c. 6000 to 6600
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The technique that may be used to adequately irradiate the internal mammary nodes with left breast cancer and simultaneously deliver the least cardiac dose is a. anterior photon field 50 Gy in 5 weeks b. anterior photon-electron fields, equally weighted 50 Gy in5 weeks c. wide tangential fields, extending 5 cm across the midline 50 Gy in 5 weeks d. anterior electron field 50 Gy in 5 weeks
answer
b. anterior photon-electron fields, equally weighted 50 Gy in 5 weeks
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The skin usually reacts in a pattern that is dose dependent. which of the following would you expect to see first for radiation administered using standard fractionation a. dry desquamation b. erythema c. moist desquamation d. radiation pneumontis
answer
b. erythema
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question
1. At what age should women of normal risk begin having regular annual screening mammograms? a. 20 b. 30 c. 40 d. 50
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ANS: C Starting at age 40, all women should have a mammogram done every year. REF: Chapter 38, Breast Cancer, p. 874
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2. DCIS is classified as which stage? a. stage 0 b. stage 1 c. stage 2 d. stage 3
answer
ANS: A Ductal carcinoma in situ is defined as the earliest stage of breast cancer and is associated with a stage 0 denotation. REF: Chapter 38, Breast Cancer, pp. 877-878, Box 38-7
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3. Inflammatory breast cancer is always classified as which T stage? a. T4a b. T4b c. T4c d. T4d
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ANS: D Inflammatory carcinoma of the breast is classified as T4d. REF: Chapter 38, Breast Cancer, p. 877, Box 38-7
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4. Which treatment field arrangement is used to increase the midaxillary dose to the prescribed level in some patients? a. intact breast tangents b. chest wall tangents c. supraclavicular field d. PAB
answer
ANS: D The posterior axillary boost field (PAB) is used when midplane radiation dose from an anterior supraclavicular field alone is not sufficient. REF: Chapter 38, Breast Cancer, p. 887
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5. In which quadrant do most breast cancers occur? a. upper outer b. upper inner c. lower outer d. lower inner
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ANS: A Approximately 48% of breast cancers arise in the upper-outer quadrant. REF: Chapter 38, Breast Cancer, p. 872, Fig. 38-5
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6. The lower border of the breast extends to which rib? a. 5th b. 6th c. 7th d. 8th
answer
ANS: B The protuberant portion of the adult breast is located between the second and sixth ribs in the sagittal plane. REF: Chapter 38, Breast Cancer, p. 870
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7. What T stage is a breast cancer that is a 9-cm tumor with skin invasion? a. Tis b. T1 c. T2 d. T3 e. T4
answer
ANS: E Skin invasion depicts a T-stage that is extensive, T4. REF: Chapter 38, Breast Cancer, p. 877, Box 38-7
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8. What T stage is a breast cancer that is a 3.5-cm tumor near the nipple? a. Tis b. T1 c. T2 d. T3 e. T4
answer
ANS: C As defined by the AJCC Staging System for Breast Cancer, a tumor more than 2 cm but less than 5 cm is denoted as a T2.
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9. What T stage is a breast cancer that is a 1-cm tumor in the upper outer quadrant? a. Tis b. T1 c. T2 d. T3 e. T4
answer
ANS: B As defined by the AJCC Staging System for Breast Cancer, a tumor 2 cm or less in any dimension is denoted as a T1. REF: Chapter 38, Breast Cancer, p. 877, Box 38-7
question
10. What T stage is a breast cancer that is a 7-cm tumor in the upper outer quadrant with extension to the skin? a. Tis b. T1 c. T2 d. T3 e. T4
answer
ANS: D As defined by the AJCC Staging System for Breast Cancer, a tumor of any size with direct extension to the chest wall or skin is denoted as a T4.
question
11. What T stage is a breast cancer that is a 1.5-cm tumor near the nipple? a. Tis b. T1 c. T2 d. T3 e. T4
answer
ANS: B As defined by the AJCC Staging System for Breast Cancer, a tumor 2 cm or less in any dimension is denoted as a T1. REF: Chapter 38, Breast Cancer, p. 877, Box 38-7
question
12. What T stage is a breast cancer that is a 3-cm tumor invading the chest wall? a. Tis b. T1 c. T2 d. T3 e. T4
answer
ANS: E As defined by the AJCC Staging System for Breast Cancer, a tumor of any size with direct extension to the chest wall or skin is denoted as a T4. REF: Chapter 38, Breast Cancer, p. 877, Box 38-7
question
13. What is the ligament holding the breast in place? a. Cooper b. Montgomery c. Stoop d. Paget
answer
ANS: A The superficial pectoral fascia encompasses the breast tissue and is attached to the deep fascia by bands of connective tissue called Cooper suspensory ligaments, which support the breast.
question
14. What is the standard dose delivered to the tumor bed following tangential treatments? a. 4500 to 5000 cGy b. 5000 to 5600 cGy c. 6000 to 6600 cGy d. 7000 to 7600 cGy
answer
ANS: A Fields are treated daily with standard fractionation (180 to 200 cGy per fraction) to a total dose of 4500 to 5000 cGy. A boost dose may be delivered with a reduced photon field electron beam or interstitial technique, increasing the total dose to the primary tumor site to 6000 to 6600 cGy. REF: Chapter 38, Breast Cancer, p. 882
question
15. What is the medial treatment border when the internal mammary lymph nodes are to be included in the tangential field? a. midline b. 1 cm beyond midline to the contralateral side c. 3 cm beyond midline to the contralateral side d. 3 cm beyond midline to the ispalateral side
answer
ANS: C Rather than placing the edge of the medial tangential field at the patient's midline, the field is extended beyond the midline to the contralateral side by approximately 3 cm. REF: Chapter 38, Breast Cancer, p. 889
question
16. What is the standard dose delivered to the SCV field? a. 4000 to 4600 cGy b. 4500 to 5000 cGy c. 5000 to 5600 cGy d. 6000 to 6600 cGy
answer
ANS: B Peripheral (supraclavicular and/or axillary) lymphatic irradiation may also be required. Fields are treated daily with standard fractionation (180 to 200 cGy per fraction) to a total dose of 4500 to 5000 cGy
question
17. What is the stage of a breast cancer that is 3 cm in greatest diameter with three positive axillary lymph nodes? a. IIA b. IIB c. IIIA d. IIIB
answer
ANS: B Stage IIB is defined as a T2N1M0 or T3N0M0. In this case, the tumor is greater than 2 cm but less than 5 cm making it a T2, and it is N1 because there are 1-3 lymph nodes involved.
question
18. What is the stage of a breast cancer that has grown into the chest wall and has eight positive axillary lymph nodes? a. IIA b. IIB c. IIIA d. IIIB
answer
ANS: D Stage IIIB is defined as a T4N0M0, T4N1M0, or T4N2M0. In this case, the tumor extends to the chest wall, making it a T4, and it is N2 because there are 4-9 lymph nodes involved.
question
19. What stage is a inflammatory breast cancer that has not spread to distant organs but has distant lymph node involvement? a. stage I b. stage IIA c. stage IIIA d. stage IV
answer
ANS: D Stage IV is defined as any T, any N, and metastatic node involvement distantly.
question
20. What stage is a 6-cm breast cancer in the upper inner quadrant? a. Tis b. T1 c. T2 d. T3
answer
ANS: D T3 is defined by AJCC as a tumor more than 5 cm in greatest dimension.
question
21. Which of the following techniques may be used to adequately irradiate the internal mammary lymph nodes while limiting the exposure to other organs? a. AP 6 MV only b. AP photon/electron combination c. AP 6 MeV only d. extended medial tangent
answer
ANS: B An alternative method of irradiating the IM nodes involves the use of an en face (perpendicular to the skin surface with a slight angle toward the patient) IM field with a combination of electrons and photons. REF: Chapter 38, Breast Cancer, p. 889
question
1. A woman's risk of developing breast cancer is 1 in 8.
answer
ANS: T Current data indicate that every woman has approximately a 1-in-8 chance of developing breast cancer over her lifetime.
question
2. Breast implants at an early age increase a woman's risk of developing breast cancer.
answer
ANS: F Breast implants do not increase a woman's risk of breast cancer.
question
3. Breast cancer risk is influenced by hormonal variables; early menarche and late menopause increase the risk while oophorectomy before age 50 decreases the risk
answer
ANS: T The assumption that the overall length of ovarian function is related to breast cancer risk is supported by the increased activity associated with early menarche and late menopause as well as early cessation associated with removal of one or both ovaries before the age of 50.
question
4. Breast cancer is the most common cancer in women.
answer
ANS: T Breast cancers affect an estimated 178,480 new patients each year in the United States.
question
5. External beam radiotherapy for breast cancer irradiates the entire breast regardless of the tumor size.
answer
ANS: F Accelerated partial breast irradiation (APBI) has been investigated as a possible alternative treatment option for women undergoing breast-conserving therapy. Instead of treating the whole breast, partial breast irradiation targets the tumor bed with a margin.
question
6. Inverted nipples are always an indication of breast cancer.
answer
ANS: F Inverted nipples are not necessarily an indication of breast cancer.
question
7. Most breast lumps feel hard and have irregular edges.
answer
ANS: T The assessment of a breast mass must address the size, shape, consistency, mobility, pain or tenderness, location in the breast, and relation to skin and surrounding tissues. REF: Chapter 38, Breast Cancer, p. 873
question
8. Most breast cancers are infiltrating ductal carcinoma.
answer
ANS: T More than 70% of invasive breast cancers are infiltrating ductal carcinoma. REF: Chapter 38, Breast Cancer, p. 875
question
9. Radiation therapy is the only treatment necessary for T1 and T2 breast cancers.
answer
ANS: F All breast cancers will be removed either via mastectomy or lumpectomy.
question
10. The posterior axillary boost (PAB) field delivers 180 cGy to the axillary lymph
answer
ANS: F A PAB field is sometimes used to increase the midaxillary dose to the prescribed level in a subset of patients whose axillary fossa requires radiation. REF: Chapter 38, Breast Cancer, pp. 887-888
question
what is the most common malignancy in women?
answer
breast cancer
question
how many women will be diagnosed with breast cancer?
answer
1 in 8 women
question
How many cases will be men?
answer
1%
question
Breast cancer is second to what cancer in mortality?
answer
lung cancer is first in mortality for both men and women
question
What makes up the breast tissue?
answer
fat, glands, and ducts
question
What are the four quadrants of the breast?
answer
upper outer quadrant (UOQ) upper inner quadrant (UIQ) lower outer quadrant (LOQ) lower inner quadrant (LIQ)
question
Where is the most common location?
answer
upper outer quadrant
question
What is a rare location?
answer
central
question
What is the minimum size for a palpable lump?
answer
1 cm
question
What is the overall prognosis?
answer
good overall even with positive nodes
question
What are high risk factors associated with breast cancer?
answer
female gender family history history of benign breast disease early menarche late menopause nulliparity children at late age oral contraceptives
question
What are low risk factors associated with breast?
answer
asian ancestry early pregnancy (by age 18) early menopause late menarche oophorectomy by age 37
question
What other factors have a strong influence on breast cancer?
answer
genetics exposure to estrogen
question
What are the Invasive/Infiltrating histologies of breast cancer?
answer
ductal lobular tubular medullary (usually well circumscribed) papillary mucinous inflammatory
question
What are the noninvasive histologies of breast cancer?
answer
lobular or ductal carcinoma in situ (LCIS or DCIS) Paget disease (from underlying in situ or invasive disease)
question
What is the most common breast cancer?
answer
Infiltrating ductal carcinoma - 70% 0f invasive beast cancers
question
What is Paget disease?
answer
Paget's disease of the nipple is an uncommon type of cancer that forms in or around the nipple and accounts for about 1% of all breast cancers.
question
What is the lymphatic drainage of the breast?
answer
contiguous pattern through axillary, internal mammary, and supraclavicular
question
How does cancer of the breast metastasize?
answer
through the blood and Batson plexus to skin, bone, (especially thoracic spine) liver, and brain
question
What is the Batson plexus?
answer
A network of valveless veins in the human body that connect the deep pelvic veins and thoracic veins(draining the inferior end of the urinary bladder, breast and prostate) to the internal vertebral venous plexuses. Because of their location and lack of valves, they are believed to provide a route for the spread of cancer metastases.
question
What % of cases will have positive axillary nodes?
answer
55 to 70%
question
What node dissections are common for staging?
answer
axillary nodes
question
Internal mammary nodes are positive depending on location of the mass-where?
answer
central or inner quadrants
question
What is the workup done for breast cancer?
answer
physical exam history needle-guided biopsy with mammogram, ultrasound, or CT open biopsy (lumpectomy and node dissection) Sentinel node biopsy (removal of nodes first containing mets using radioactive tracer and blue colored dye) CT chest and abdomen bone scan and liver scan for suspected mets
question
What does tissue need evaluation for?
answer
estrogen and progesterone receptors (ER, PR)
question
How is breast cancer staged?
answer
TNM; clinical staging in office, pathologic staging required. positive supraclavicular nodes classified as M1
question
What M will positive supraclavicular nodes be classified as?
answer
M1
question
What is the primary treatment of breast cancer?
answer
removal of tumor by surgery is preferred with lumpectomy
question
What is a radical mastectomy?
answer
removal of breast, pectoralis muscles and regional lymph nodes-three levels of axillary)
question
What is partial excision?
answer
also known as wide excision (removal of lump and axillary nodes dissected through separate incision)
question
What is total mastectomy?
answer
removes breast and axillary tail, leaving the pectoralis muscles behind
question
What is a modified radical mastectomy?
answer
a total mastectomy with axillary nodes dissected and pectoralis minor
question
What happens when too many lymph nodes are removed?
answer
chronic lymphadema
question
What is the recurrence rate for radical vs total mastectomies?
answer
slightly lower for radical
question
What is the advantage of partial mastectomy/lumpectomy?
answer
psychological
question
How can surgery be used for reconstruction?
answer
silicone implants, grafts using autologous tissue from abdomen and upper thigh for areola
question
When would surgery be used prophylactically?
answer
for patients with high risk for developing cancer in opposite breast
question
Who would be at risk of developing cancer in opposite breast?
answer
family history, HER2neu, BRCA1 and 2 genes
question
Radiation is used definitively to irradiate the entire breast following?
answer
a lumpectomy
question
Radiation is used definitively to irradiate the chest wall following?
answer
mastectomy
question
What RT is done for those who had large tumors, positive surgical margins, or at least four positive lymph nodes?
answer
chest wall RT en face electron fields or photon tangential fields
question
What RT is done following lumpectomy for low risk patients? (older age, small tumors, negative nodes)
answer
local radiation, accelerated breast therapy with brachytherapy
question
When will chemotherapy have a role?
answer
following surgery
question
What type of chemotherapy?
answer
cytotoxic and hormonal therapy
question
What is used if ER and/or PR positive?
answer
hormonal therapy to maintain remission
question
What are common cytotoxic combinations?
answer
CMF or CAF- cyclophosphamide, methotrexate, 5-FU, adriamycin (doxorubicin)
question
What chemo drug has cardiac toxicity?
answer
Adriamycin (doxorubicin) so cardiac gating procedures may be employed for patients receiving radiation to the left breast especially
question
When is concomitant cytotoxic chemotherapy and RT used?
answer
is the standard following surgery for candidates not suited for accelerated brachytherapy
question
What is the common order of treatment?
answer
surgery, chemotherapy then radiation
question
What are radiation treatment fields for an intact breast?
answer
medial border at midline, lateral border beyond breast tissue, upper border above the superior tail of the breast (about the second intercostal space), lower border about 2 cm inferior to breast fold
question
What nodes at minimum are included in the tangential fields?
answer
first level axillary nodes
question
What fields are used if third level axillary nodes (apical nodes) found positive or if no axillary dissection, or if tumor was extracapsular?
answer
another field may be added and treated AP/PA or posterior only with a posterior axillary boost (PAB)
question
What is the field for the supraclavicular nodes if positive?
answer
medial border at midline, lateral border about two thirds of the clavicle and upper border about 2 to 3 cm above the clavicle; lower border carefully matched to tangential fields
question
What would a combination supraclavicular and apical nodes field show?
answer
an extended field down to the second rib
question
If treating internal mammary nodes what would the field look like?
answer
a wider tangential field or separate anterior field if tumor was located near midline
question
Where are the internal mammary nodes located?
answer
lateral of sternum about 2 cm on each side and from the level of the 3rd to 8th rib; border should be carefully matched to medial tangent and/or supraclavicular field
question
What is total dose for intact breast?
answer
50 Gy in 5 to 6 weeks
question
What fields are used for intact lung?
answer
tangents to avoid underlying lung
question
What is used for uniform dose distribution within the breast?
answer
wedge or compensators
question
what will the lumpectomy site be boosted to?
answer
10 to 20 Gy depending on tumor size and margins at surgery time electron energy depending on depth of tumor bed
question
What can be used for accelerated breast irradiation?
answer
Iridium for 1 week using hyperfractionated twice daily
question
When is brachytherapy used?
answer
for low recurrence risk patients instead of entire breast radiation
question
What will the chest wall be dosed to following lumpectomy?
answer
45 to 60 Gy with photons; bolus scar or entire chest wall
question
Can the chest wall radiation be delivered with electrons?
answer
yes
question
How is the supraclavicular field treated?
answer
AP only to depth of 3.0 cm to 45 Gy at 2Gy per day
question
When treating the supraclav field what needs to be protected?
answer
Cerrobend or MLC beam shaping to protect the head of the humerus and larynx; gantry angle may facilitate sparing of larynx
question
How are apical axillary fields treated?
answer
AP/PA or PAB treated to midline to 45 Gy
question
How will matching the tangential and supraclav fields be done?
answer
likely a half-beam technique and/or couch angles to prevent overlap at junction
question
How are internal mammary fields treated?
answer
with single anterior photon field or en face electrons or a combination; IM nodes at depth of 3 cm; careful planning to avoid overdose at junction
question
How is patient positioned?
answer
supine, with affected arm or both up, chin turned away from the affected side
question
How might large breasted patients be positioned?
answer
prone to pull breast away from the chest wall
question
What is a breast board used for?
answer
decrease the slope of the chest
question
What organ must be watched dose wise?
answer
the lung, so make sure match lines between tangents and supraclavicular are on
question
What reactions will occur with breast RT?
answer
skin reactions so educate on skin care.
question
The posterior Axillary Boost (PAB) field is intended to irradiate a. level 1 axillary nodes b. level 2 axillary nodes c. level 3 axillary nodes d. supraclavcular nodes
answer
c. level 3
question
lymphatic drainage of the breast is primarily to the a. axillary b. supraclavicular c. internal mammary
answer
all of them
question
For estrogen receptor positive cases, an antiestrogen may be used to maintain remission known as a. taxol b. tamoxifen c. megace d. prednisone
answer
b. tamoxifen
question
What are the two common cytotoxic drug combinations for management of breast carcinoma?
answer
CMF and CAF
question
What is the CAF combination?
answer
C: cyclophosphamide alkylating agent myelosupression, alopecia, nausea, vomiting, diarrhea A: Adriamycin (doxorubicin) anti-tumor antibiotic myelosupression, cardiotoxicity, alopecia, nausea/vomiting F: 5-fluourocail anti-metabolite oral and intestinal ulcers, nausea/vomiting, mild alopecia, radiation recall
question
What is the CMF combination?
answer
C: cyclophosphamide alkylating agent myelosupression, alopecia, nausea, vomiting, diarrhea M: methotrexate anti-metabolite mucositis, myelosuppression, mild alopecia F: 5-fluourocail anti-metabolite oral and intestinal ulcers, nausea/vomiting, mild alopecia, radiation recall
question
What is myelosuppression?
answer
the bone marrow making too few blood cells to replace the blood cells that have worn out. It doesn't hurt—a person with myelosuppression does not feel any specific pain from this condition. However, myelosuppression can lead to fatigue, excessive bleeding, or an increased vulnerability to certain infections. Fatigue: This results from a shortage of red blood cells. It is also known as Anemia. -- Bleeding: This results from a shortage of platelets. It is also known as Thrombocytopenia. -- Infection risk: This results from a shortage of white blood cells, notably neutrophils. It is also known as Neutropenia.
question
Special care must be taken to limit dose to the heart when treating left breast patients who have undergone CAF chemotherapy. Why?
answer
a unique toxicity associated with adriamycin is cardiac toxicity. radiation dose should be limited so as not to compound the potential latent injury to the heart
question
What is the difference between clinical staging and pathological staging?
answer
Clinical staging: includes physical exam taking survey of the skin of the breast and the status of palpable lymph nodes. imaging studies may also be used for clinical staging Pathological staging: includes everything necessary for clinical staging but adds surgical exploration and resection with pathological evaluation of tissue sample
question
If the lumpectomy bed is located in the right upper outer quadrant of the right breast what possible patient table and gantry positions would adequately deliver uniform dose distribution to the site?
answer
the objective is to have the horizontal plane of the beam be parallel to the patients tumor bed area 1. The patient may be positioned in left lateral oblique position and slightly inclined to flatten the area 2. The patient may continue in the same arm up position and the couch and gantry could be rotated to bring the horizontal axis parallel to the skin
question
look at question 10 in Mosbys for couch angles look at questions 11 and 12 calculations questions 20 and 24
answer
question
The most common symptom of breast cancer is a. painless lump b. clear nipple discharge c. dimpling of the skin d. inverted nipple
answer
a. painless lump
question
What is a radical mastectomy?
answer
resection of the breast, pectoralis muscles and regional lymph nodes
question
What is the HER2neu?
answer
an oncogene expression seen in certain breast cancer patients; an epidermal growth factor
question
What is the BRCA1?
answer
a tumor suppressor gene whose failed type is associated with elevated risk for breast cancer
question
What is Peau d-orange?
answer
an orange coloring of the skin of the breast indicating infiltration of cancerous cells into the dermal layers of the breast; skin feels thick and leathery
question
When using a breast board for positioning the optimal incline angle is influenced by a. the angle of the elbow when it is raised b. the ability of patient to raise arms c. the slope of the patients chest d. the gantry angle on the medial tangent
answer
c. slope of the patients chest
question
When the supraclavicular fossa is treated along with opposing tangents, the supraclavicular field is best treated using? a. AP/PA ports b. wedged pairs c. rotational beam d. half beam technique
answer
d. half beam technique
question
The total radiation dose received by the lumpectomy bed in standard whole breast irradiation followed by lumpectomy site boost is a. 40 to 50 Gy b. 50 to 60 Gy c. 60 to 70 Gy d. 70 to 80 Gy
answer
c. 60 to 70 Gy entire breast treated to 50 Gy and scar boosted 10 to 20 Gy
question
The most common histologic type of breast cancer is a. infiltrating ductal b. lobular insity c. paget disease d. medullary
answer
a. infiltrating ductal
question
The acceptable amount of lung tissue included in tangential breast fields is 2 cm in order to decrease the chance of latent a. pneumonia b. lung fibrosis c. pleural effusion d. atelectasis
answer
b. lung fibrosis
question
an en face electron boost to the lumpectomy bed is accidentally treated at 105cm instead of 100 cm SSD. the error in dose delivered is about a. 5% overdose b. 5% underdose c. 10% overdose d. 10% underdose
answer
d. 10% under dose
question
ductal carcinoma in situ (DCIS) is classified as a.stage 0 b. stage I c. Stage II d. stage II
answer
a. stage 0
question
A breast cancer classified as T3 N1 M1with the metastasis to the supraclavicular nodes only would be grouped as? a. stage I b. Stage II c. Stage III d. Stage IV
answer
d. Stage IV
question
a sentinel lymph node biopsy involves the injection of a blue dye and radioactive: a. iridium 92 b. technetium 99m c. strontium 89 d. samarium 137
answer
b. technetium 99m
question
The hinge angle between two half-beam tangential ports is 180 degrees. The medial tangent gantry angle is 310 degrees. What is the gantry angle for the lateral tangent? a. 230 b. 140 c. 130 d. 50
answer
c. 130
question
The pathologic staging system for breast cancer incorporates a. lymph node status b. tumor extent c. distant mets
answer
all of them
question
The most common presenting symptom of early stage breast cancer is a. nipple discharge b. pain c. palpable mass d. ulceration
answer
c. palpable mass
question
Which of the following is proper advice for a patient receiving RT to the breast? a. do not wear restrictive clothing b. avoid using commercial deodorant c. avoid sun exposure to the skin of the treated area
answer
All of them
question
TD 5/5 refers to a. minimal tolerance dose b. maximum tolerance dose c. tumor dose of 5 Gy in 5 days d. tumor dose of 5cGy in 5 days
answer
a. minimal tolerance dose the TD 50/5 would be maximal dose
question
The TD 5/5 for the spinal cord delivered through standard fractionation is a. 1500 cGy b. 3000 cGy c. 4500 cGy d. 6000 cGy
answer
c. 4500
question
Which of the following is not currently a standard technique for breast surgery? a. radical mastectomy b. modified radical mastectomy c. lumpectomy d. tylectomy
answer
a. radical mastectomy (tylectomy is aka lumpectomy)
question
Chemotherapy for breast cancer may consist of a. drug therapy b. endocrine therapy c. immunotherapy
answer
a and b
question
In treating a breast cancer patient via tangential fields plus an electron field boost, the usual total dose to the tumor bed delivered through standard fractionation is a.4000-4600 cGy b. 5000 to 5600 cGy c. 6000 to 6600 cGy d. 7000 to 7600 cGy
answer
c. 6000 to 6600
question
The technique that may be used to adequately irradiate the internal mammary nodes with left breast cancer and simultaneously deliver the least cardiac dose is a. anterior photon field 50 Gy in 5 weeks b. anterior photon-electron fields, equally weighted 50 Gy in5 weeks c. wide tangential fields, extending 5 cm across the midline 50 Gy in 5 weeks d. anterior electron field 50 Gy in 5 weeks
answer
b. anterior photon-electron fields, equally weighted 50 Gy in 5 weeks
question
The skin usually reacts in a pattern that is dose dependent. which of the following would you expect to see first for radiation administered using standard fractionation a. dry desquamation b. erythema c. moist desquamation d. radiation pneumontis
answer
b. erythema