|Year : 2020 | Volume
| Issue : 4 | Page : 435-436
MCQs on “Study of pathological complete response rate with neoadjuvant concurrent chemoradiation with paclitaxel in locally advanced breast cancer”
HS Darling1, Pradeep Jaiswal2, Nishant Lohia3, Nishant Tiwari4
1 Department of Medical Oncology and Hemato-oncology, Command Hospital Air Force, Bangalore, Karnataka, India
2 Department of Surgical Oncology, Command Hospital Air Force, Bangalore, Karnataka, India
3 Department of Radiation Oncology, Command Hospital, Lucknow, Uttar Pradesh, India
4 Department of Internal Medicine, B.J. Govt. Medical College, Pune, Maharashtra, India
|Date of Submission||19-Sep-2020|
|Date of Decision||19-Sep-2020|
|Date of Acceptance||19-Sep-2020|
|Date of Web Publication||18-Oct-2020|
H S Darling
Department of Medical Oncology and Hemato-oncology, Command Hospital Air Force, Bangalore, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Darling H S, Jaiswal P, Lohia N, Tiwari N. MCQs on “Study of pathological complete response rate with neoadjuvant concurrent chemoradiation with paclitaxel in locally advanced breast cancer”. Indian J Cancer 2020;57:435-6
|How to cite this URL:|
Darling H S, Jaiswal P, Lohia N, Tiwari N. MCQs on “Study of pathological complete response rate with neoadjuvant concurrent chemoradiation with paclitaxel in locally advanced breast cancer”. Indian J Cancer [serial online] 2020 [cited 2020 Oct 31];57:435-6. Available from: https://www.indianjcancer.com/text.asp?2020/57/4/435/298508
Q1. According to the United States Food and Drug Administration (USFDA), the definition of pathologic complete response (pCR) following neoadjuvant therapy is?
- No residual tumor in the primary or only in-situ tumor in primary and no tumor in nodes (YpT0N0/YpTisN0)
- No residual tumor in primary and nodes (YpT0N0)
- No tumor in the primary or microscopic invasive tumor in primary and nodes
- Any of the above.
Q2. Which of the following subset of patients had the highest pCR rates following neoadjuvant chemotherapy (NACT) + neoadjuvant concurrent chemoradiation (NACCRT) in the study?
- Her2/neu positive (HER2-positive)
- Hormone positive (ER/PR +ve and HER2-negative)
- Triple-negative (ER/PR −ve, HER2-negative)
- Triple positive (ER/PR −ve and HER2-positive).
Q3. The most common toxicity of neoadjuvant CCRT followed by surgery in the present study is?
- Febrile neutropenia
- Grade 3 skin toxicity
- Post-operative wound infection
- Delayed postoperative wound healing.
Q4. Which sequencing yielded highest pCR rate as per current study?
- CCRT (paclitaxel + RT) followed by Adriamycin/cyclophosphamide
- Adriamycin/cyclophosphamide followed by CCRT (paclitaxel + RT)
- Paclitaxel followed by RT followed by Adriamycin/cyclophosphamide
- Adriamycin/cyclophosphamide followed by RT followed by Paclitaxel.
Q5. Absolute indication for supraclavicular lymph node irradiation is all, except
- >4 positive LN after axillary dissection
- 1 positive LN with high-risk features
- 2 positive LN with no high-risk features
- Clinically N2 disease.
Q6. The axillary lymph node region is divided into three levels, each defined in relation to the pectoralis minor muscle. Level-I lymph nodes in relation to pectoralis minor are situated
- Beneath the muscle
- Superolateral to the muscle
- Superomedial to the muscle
- Inferolateral to the muscle.
Q7. Which of the following is incorrect with regard to inflammatory breast cancer (IBC)?
- It accounts for 1–5% of all breast cancers in the United States
- IBC is characterized by diffuse erythema, edema, and peau d'orange of the skin of the breast
- IBCs are more likely to be triple positive, or HER2 negative
- It has the worst prognosis among female breast cancers.
Q8. Which of the following best describes the dose of radiotherapy used in this study?
- 46 Gy/20 fractions
- 40 Gy/23 fractions
- 46 Gy/23 fractions
- 40 Gy/20 fractions.
Q9. According to the American Joint Committee on Cancer staging (AJCC), in addition to the TNM, the prognostic staging of breast cancer does not include?
- Grading of the tumor (G1, G2, G3)
- ER/PR/HER2-status (positive, negative)
- Any of the above
Q10. In this study, what percentage of patients undergoing modified radical mastectomy (MRM) following neoadjuvant CCRT had a pCR?
Answers and explanations:
1 (a) No residual tumor in the primary or only in-situ tumor in primary and no tumor in nodes (YpT0N0/YpTisN0)
There has not yet been a uniform definition of pCR, which has made reporting and interpretation of data from neoadjuvant trials challenging. The FDA of USA defines pCR as the absence of residual invasive cancer on hematoxylin and eosin evaluation of the complete resected breast specimen and all sampled regional lymph nodes following completion of neoadjuvant systemic therapy (i.e., ypT0/Tis ypN0) and this recommendation was based on the Chemotherapy Neoadjuvant in Breast Cancer (CTNeoBC) pooled analysis study. The FDA definition of pCR was used in this study.
2 (c) Triple-negative (ER/PR negative, HER2-negative)
Patients with triple-negative disease had the highest pCR (54.5%) followed by HER2/neu positive (34.2%) and hormone receptor-positive disease (29.4%). These results are consistent with the observation of higher pCR rates in patients with triple-negative breast cancer receiving NACT.
3 (d) Delayed postoperative wound healing
Grade 3 skin toxicity (moist desquamation) was observed in 24/100 (24%) patients, all of who had a delay in their planned duration of radiation by more than a week. The median delay in radiation due to grade 3 skin morbidity was 10 days (range 7–14 days). None of the patients had grade-4 skin toxicity. Grade 3 febrile neutropenia was observed in four patients (4%) with paclitaxel, none of which were during CCRT. During RT, 26/100 (26%) patients required filgrastim for the management of neutropenia. None of the patients developed symptomatic pneumonitis or any cardiac morbidity. Delayed wound healing (>4 weeks) was observed in 24/91 (26.3%) patients after MRM. Postoperative wound infection was observed in 13/91 (14%) patients and all the infections were superficial and were managed conservatively. Secondary suturing was required in 3/91 (3.2%) patients.
4 (a) CCRT (Paclitaxel + RT) followed by Adriamycin/cyclophosphamide
It was observed in this study that patients who received neoadjuvant CCRT followed by NACT had a higher pCR rate as compared to patients who received initial NACT followed by neoadjuvant CCRT (48.7% vs 38%, P = 0.3).
5 (c) 2 positive LN with no high-risk features
Supraclavicular lymph node irradiation can be avoided in clinically N1 disease with 1–2 node-positive and no high-risk features.
(Swanick CW, Smith BD. Indications for adjuvant radiation therapy in breast cancer: A review of the evidence and recommendations for clinical practice. Chin Clin Oncol 2016;5 (3):38. doi: 10.21037/cco. 2016.03.15)
6 (d). Inferolateral to the muscle
(Shiloh YR, Mahal BA, Wong S, Khan AJ, Bellon JR. Chapter 60: Breast Cancer: Locally Advanced, Part 1. In: Halperin EC, Brady LW, Wazer DE, Perez CA, eds. Perez and Brady's principles and practice of radiation oncology. 7th ed.. Philadelphia: Wolters Kluwer, 2018.)
7 (c). IBCs are more likely to be triple positive or HER2 negative.
IBCs are more likely to be high grade, triple-negative, or HER2 overexpressing and lack hormone receptor expression compared with other presentations of breast cancer.
(Jagsi R, King TA, Lehman C, Morrow M, Harris JR, Burstein HJ. Chapter 79: Malignant Tumors of the Breast. In: DeVita VT, Lawrence TS, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg's Cancer: Principles and Practice of Oncology. 11th ed.. Philadelphia, Pa: Lippincott Williams & Wilkins; 2019.)
8 (c). The dose of radiotherapy used in this study was 46 Gy/23 cycles. Careful consideration was given to the side effect profile of higher-dose radiation.
9 (b). The AJCC prognostic staging for breast cancer includes all of the enlisted characteristics of the tumor. The summary of the clinical staging is beyond the scope of this article. However, for a specific TNM stage, positivity for HER-2, ER/PR, and a lower grade tumor is associated with a lower prognostic stage (Better prognosis).
Lurie RH, Anderson BO, Abraham J, et al. NCCN Guidelines Version 6.2020 Breast Cancer; 2020.
10. (a). In this study, 37.7% of the patients who underwent MRM following neoadjuvant CCRT showed pCR.