question

What are the types of breast radiation for local disease?

answer

-WBI w/ boost -WBI w/o boost -Partial breast radiation w/ XRT -Partial breast radiation w/ intracavitary device -Partial breast radiation w/ interstitial needles

question

Types of Breast Radiation for boosts?

answer

-Lumpectomy/cavity boost -Post-mastectomy scar boost -Entire chestwall boost -Nodal Breast

question

What are the early stage breast cancer surgical options?

answer

Breast conservation vs. mastectomy

question

Lumpectomy + Sentinel node bx + XRT vs. total mastectomy + sentinel bx + reconstruction. (If + axillary LN disection.) Outcomes?

answer

Data shows similar outcomes; there is no real reason to remove breast.

question

Surgery: Breast conservation

answer

-Breast/tumor ratio -unicentric -negative margins -no contraindications for RT -smaller operation -better cosmesis -faster recovery

question

What are some contraindications for BCS?

answer

-Prior radiation, -pregnancy -history of autoimmune illness -scleraderma (tissues rock hard) -lupis, -RA (tend to not tolerate RT as well: skin rns stronger and less predictable)

question

What are some options for reconstructive surgery?

answer

1. Implants 2. Autologous tissue

question

For autologous tissue reconstruction, what are the options offered?

answer

1. Latissimus flap (back) 2. DIEP (abdominal fat) 3. TRAM (abdominal muscle & fat)

question

Is it okay to receive breast reconstruction prior to receiving XRT?

answer

NO!

question

Who needs XRT?

answer

-BCS: breast conservation surgery pts -Mastectomy patients @ high risk (large tumors with nodal involvement) -Pts with LN involvement -Locally advanced breast cancer pts

question

Name the two types of radiation that exist for breast cancer pts.

answer

1. XRT 2. Accelerated partial breast irradiation (APBI)

question

What does the acronym ALND stand for? What is it

answer

Axillary lymph node dissection; removal of LNs in axilla region

question

What is the long term morbidity associated with ALND?

answer

-lymphedema, arm dysfunction, sensory disturbances

question

In doing a sentinel lymph node bx, _____% are positive for mets and therefore go on to receive an ______ & _____% are negative for mets and go on to receive no ALND and ____________.

answer

33% positive receive ALND; 66% negative no ALND and observation.

question

Breast surgery for the management of DCIS consists of a ______________ with radiation. Or the other option is a ___________ alone.

answer

lumpectomy; mastectomy

question

Systemic therapy for DCIS is considered if ER-positive. Tamoxifen is used. True or False?

answer

True

question

There is no axillary staging with DCIS. True or false?

answer

True

question

Breast surgery for invasive cancer consists of ____________ with ___ margins. Or BCS (lumpectomy + RT) or total _____________.

answer

Excision w/ - margins; mastectomy

question

Axillary staging for invasive breast cancer consists of what two methods?

answer

1. SLNB 2. ALND

question

For invasive breast cancer, radiation therapy can be used ______-lumpectomy or post-__________.

answer

post-lumpectomy; post-mastectomy

question

Systemic therapy for the management of invasive breast cancer consists of what three options?

answer

1. Hormonal therapy 2. Chemotherapy 3. Herceptin therapy

question

Neoadjuvant therapy consists of chemotherapy/antihormonal therapy before or after surgery?

answer

Before

question

Indications for neoad. therapy include: 1. Patients with larger tumors who desire BCS 2. Locally advanced dz 3. Inflammatory breast cancer. True or False?

answer

True

question

Adjuvant systemic therapy consists of chrmotherapy/antihormonal therapy before or after surgery?

answer

After

question

What are the goals of adjuvant chemo/antihormonal therapy?

answer

1. Cure 2. Prevent recurrences 3. Eradicate micrometastases

question

Appropriate therapies for the adjuvent approach include: -Tamoxifen/Aromatase inhibitors -Ovarian oblation -Systemic therapy also called what?

answer

Chemotherapy

question

The following are considered to be determinants of what type of therapy? 1. Tumor size 2. LN status 3. Estrogen receptor/progesterone receptor (ER/PR) status 4. Her-2/Neu (H2N) status

answer

Systemic therapy

question

The following are mechanisms of action of which type of therapy? 1. Block estrogen action 2. Block estrogen synthesis 3. Downregulation of estrogen receptor

answer

Hormonal therapies

question

The following are some risks/benefits associated with which chemo drug? Benefits: -Decrease relapse and increase survival -Decrease incidence of contralateral disease Risks: -Irregular menses -Menopausal sx -Ovarian cysts -Uterine sarcomas

answer

Tamoxifen

question

For XRT treatment, what is the margin around the lumpectomy cavity?

answer

1.5cm

question

On scans, what is contoured?

answer

Heart, breast, lumpectomy bed

question

If you had a diagnosis of Grade 3 DCIS, which behaves more like an invasive disease, what is the margin here?

answer

2cm or larger

question

When treating the breast: The total dose is____Gy With an additional dose of ____ or____Gy Giving the cavity a total dose of ___-____Gy. Why do we tend to not treat the cavity to a higher dose?

answer

50 Gy 10-16Gy 60-66Gy -Fibrosis rates are higher and provide lower cosmetic results

question

Why would we sometimes treat patients with breast cancer on their left side prone?

answer

To avoid treating through their heart

question

How is the chestwall treated?

answer

Treat all of pec muscle to back of rib cage. If LN involvement --> treat LN (not at armpit b.c already removed) but those at level 2, 3 by the pec muscle, superclav and internal mammary.

question

What is a radical mastectomy?

answer

Removal of the breast with its overlying skin, all the axillary LNs, and the pectoral muscles

question

What is a modified radical mastectomy?

answer

Removal of the breast with ots overlying skin, some or all of the axillary LNs. Pectoralis muscle may be removed, leaving pectoralis major intact.

question

Excisional biopsy of a breast mass is sometimes referred to as ____________.

answer

Lumpectomy *involves removal of the tumor with a margin of normal appearing tissue. Overlying & underlying tissue kept intact

question

Breast construction is an option for women who have undergone a _________________.

answer

Mastectomy

question

What are some of the common chemo drugs used in the treatment of breast cancer?

answer

Cyclophosphamide (C), doxorubicin (Adriamycin) (A), and paclitaxel

question

This type of therapy consists of a variety of drugs used to deprive cancer cells of the hormones needed for growth. The most common agents are Tamoxifen and aromitase inhibitors.

answer

Endocrine therapy

question

Treatment options: Stage I (low incidence of relapse): Stages II & III: Stage IV:

answer

I. Chemotherapy II & III. Systemic therapy: multiagent chemotherapy (premenopausal women) & Tamoxifen and aromitase inhibitors alone or with chemo (postmenopausal women) IV. Combination of systemic & local treatment

question

Side effects of chemo and endocrine therapies include:

answer

N/V, loss of appetite, fatigue, change in menstruation, mouth ulcers and hair loss

question

Lower energy beams (4-8MV) used to achieve dose homogeneity. Tangentials used to encompass entire breast and chest wall. True or False?

answer

True

question

Fields are treated daily w/ standard fractionation (___-___cGy/fraction) to a total dose of _______-______cGy.

answer

180-200cGy daily; total @ 4500-5000cGy

question

A _____ dose may be delivered with a reduced photon field electron beam, which would increase the dose to the primary tumor site to ______-______cGy.

answer

6000-6600cGy

question

Women who require only breast or chest wall irradiation are treated with _________ fields. What is this purpose?

answer

Tangential *maximize coverage of the tissues at risk and minimize the radiation dose to underlying structures such as the heart and lungs

question

Borders for tangential treatment technique: Sup: at the most cephalad of the following points: 1st intercostal space, as far sup w/o including the arm, sup extent of palpable breast tissue, cephalad >2cm to original location of mass

answer

Inferior: caudad (1-2cm) to inframammary fold Medial:SSN & Xiphoid process Lateral: includes drain sites or incisions considered at risk, tumor bed, lung margin, midaxillary line

question

Isocentric method

answer

isocenter placed at some depth in pts breast or chestwall

question

If overlap occurs in the sclv and tangential fields these spots are _____, but it there are underdosed areas or _____, there is a higher chance of recurrence.

answer

Hot; cold

question

When used, the supraclavicular field is planned before or after the tangential field?

answer

Before

question

Border for SCLV field: Sup: 5cm above SSN Medial: Mid SSN

answer

Lateral: ~2-3cm of the humeral head Inf: Angle of Louis, just above sup extent of of the palpable breast tissue

question

The central ray of the ______ field is to be placed at the _______ margin of the volume to be treated.

answer

SCLV, inferior. *Inf half of the beam is blocked by MLCs creating a straight edge to avoid overdosing. Gantry can then be angled to avoid overdoing the spinal cord.

question

Accelerated partial breast irradiation (APBI)is an alternative for women undergoing breast conserving therapy. Describe it.

answer

Instead of treating the whole breast, partial breast irradiation targets the tumor bed with a margin. Trt can be completed in 5 days with bid trt. Treated to 3650cGy, PTV is drawn larger. Early stage considered candidates only. Total of ten fractions, not all XRT.

question

Whole breast radiation: standard two dimensional technique

answer

Supine-> wire medial & lateral-> wire sup & inf-> measure separation of field at central axis-> treatment depth = 1/2 the separation

question

For whole breast irradiation, the gantry is rotated. Why? What other device can be used to help reduce dose to the lung?

answer

To reduce the dose to the lung. This allows for the edge of the beam to be parallel to the chest wall. *custom blocks also reduce lung dose

question

We want ___cm flash anterior to the breast with the 2D technique.

answer

1cm

question

Standard Three Dimensional Technique

answer

Simulation similar to 2D. pt is supine-> immobilize arms above head to expose breast tissue-> wire on the scar and marking the edges of the breast tissue *Think of what volumes/structures are being treated: breast, lumpectomy bed, lumpectomy PTV for boost, lung, heart, patient contour

question

Chest wall radiation

answer

With the planning, it is important to get as much room as you can between the neck, axilla, and the breast tissue. Pts arms must be hyperextended and pulled open or out as much as possible while still being able to fit through the CT bore.

question

Why does the chin need to be hyperextended in some cases?

answer

To avoid it dropping into the sclv field

question

Match line: the two general regions of a chest wall

answer

Nodal plan are the: Sclv fields and chest wall fields *It is NOT possible to treat both areas with the same beams due to the issues with the organs at risk. The sclv is an AP/PA technique, if you used this for the chest wall, you would treat the whole lung and possibly the whole heart. If you used the tangents of the chest to treat the sclv, you would treat the entire neck and cord unnecessarily.

question

What are the two techniques used for planning chest wall regional nodal plans?

answer

Mono-isocenter tecnique and double isocenter technique

question

With the mono-isocenter technique you do not have to worry about divergence ____________ since it is a _______ ________ _________ techniqe.

answer

Superiorly; half beam block

question

What are two ways to help address the divergence of the beam into the lung?

answer

1. Rotation of the collimator 2. Use of MLC leaves to shape the field and reduce the exposure to the lung

question

The sclv field will typically have a ___-___ degree angle to avoid dose to what structure?

answer

15-20; spinal cord

question

What is a limitation to the mono-isocenter technique?

answer

Limitation of field size. -have 20cm of area to work with, which is not a huge issue for the sclv, but can become an issue for the chest well in women that have more surface area that needs to be covered.

question

Multiple isocenter for chest wall treatment.

answer

Not limited by the field length -can adjust by dropping matchline inferiorly to give more room to tangent fields -w/ a lower matchline, larger volume of the lung can be exposed in the sclv fields

question

One of the issues with the multiple center technique is the issue of divergence ___________. We address this issue by using a __________ block. Or you can kick the ________ approx. 5 degrees away from the head of the machine to make the beam more parallel.

answer

Superiorly; cheater block; kick the couch

question

In addition to wedge, field in _______ techniques are another way to control for hot spots within a plan.

answer

field in field; can get dinky field sizes in real life--> recreating positioning is difficult and not practical.

question

What is done to avoid divergence from the sclv field into the tangents/chest wall field?

answer

Half beam blocking

question

What position is ideal when you do not have to worry about treating the lymph nodes?

answer

Prone

question

What is a PAB?

answer

Posterior Axillary Boost: designed to boost Level/II axilla -Dose is usually 40-60cGy

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