Breast

Question 1

Name 8 risk factors breast cancer

Answer 1

• Female!
• increasing age!
• direct family member history
• brca 1 and 2 mutations (also ovarian, colon, gastric, prostate cancer )
• smoking
• alcohol
• early age menarche, later age menopause
• hormonal use, unproven
• obesity, first child after 30 or no children, history chest radiation
(Breast feeding = protective)

Question 2

What type of biopsy should be done for suspected benign breast lump?

Answer 2

Fine needle aspiration

Question 3

What type of biopsy should be done for suspected malignant breast lump?

Answer 3

Core needle biopsy
Excision biopsy only indicated if imaging guided core needle biopsy failed

Question 4

What does presence of progesterone receptor on breast biopsy pathology indicate?

Answer 4

Positive predictor that anti-oestrogen treatment should be effective if > 30% positive

Question 5

What is HER and Cerb and what does it indicate?

Answer 5

Human epidermal growth factor
Positive = much higher recurrence rates of breast cancer

Question 6

What is ki-67 and what does it indicate?

Answer 6

Assess proliferation: which percentage of cells are in mitotic process (breast cancer)

Question 7

Main areas metastasis of breast cancer? (5)

Answer 7

• Lung
Lymph
Brain
• pelvis
• Liver
• ovaries
• bone

Question 8

Indication radiotherapy for breast cancer? (5)

Answer 8

. After mastectomy if >4 nodes involved after axillary dissection (high risk chest wall recurrence)
• metastatic disease with spinal cord compromise or vertebral involvement
. Brain metastasis to decrease pressure (chemo ineffective)
• inoperable lesion
• after breast conserving surgery

Question 9

Indications adjuvant chemo and hormonal therapy in breast cancer? (3)

Answer 9

• Any nodal involvement
• lympho-vascular involvement
. Biologically aggressive tumours

Start ASAP after surgery, no later than 3-4 weeks

Question 10

Standard chemo regimen for breast cancer? (3)

Answer 10

• 5-fluorouracil
• cyclophosphamide
• adriamycin (cardiotoxic. If poor cardiac function, give methotrexate )
For 6 months

Question 11

New chemo regimen for breast cancer in healthy young patients? (3)

Answer 11

Cyclophosphamide and adriamycin monthly for 4 months
Weekly taxane for 12 weeks

Question 12

Which hormonal therapy for breast cancer are used in pre-menopausal women?

Answer 12

Selective estrogen receptor modulators (serms) eg tamoxifen daily 5-10 years

Question 13

Which hormonal therapy for breast cancer are used in post -menopausal women?

Answer 13

Aromatase inhibitors eg anastrasole, letrosole daily 5-10 years

Question 14

Clinical features early stage breast cancer?

Answer 14

Single, nontender, firm palpable mass
Usually in upper outer quadrant

Question 15

Clinical features locally advanced breast cancer? (5)

Answer 15

• Changes in size/shape breast (assymetry)
• skin retractions/ dimpling (fixation to pectoralis muscle, coopers lig/overlying skin)
• peau d’orange: blockage lymphatic drainage
• nipple inversion
• blood tinged discharge

Question 16

Diagnosis breast cancer? (3)

Answer 16

3 stage assessment

• clinical features

• radiological
- <30 y → ultra sound (dense breast tissue difficult to see on mammogram ) (benign = wide > tall, malignant = tall > wide)
-> 30 y → mammogram mediolateral oblique and craniocaudal view (stellate solid mass)

• Biopsy

Question 17

TNM Staging breast cancer?

Answer 17

Tumour
• T1: <2cm
- mi:microinvasion ≤ 0,1 cm
- a: 0,1-≤0,5
- b: 0,5- ≤1
-c: 1-≤2
• t2: 2-5 cm
• T3:>5 cm
• T4:local invasion
- a: infiltrate chest wall
- b: ulcerations, skin oedema , peau d’orange, and ipsilateral satellite skin lesions, nodules
- c: a and b
-d: inflammatory carcinoma (advanced invasive cancer - erythematous, oedema, skin plaques over rapidly growing mass)

Nodes
• n1: mobile ipsilateral (1-3 nodes)
• N2: ipsilateral fixed (4-9 nodes)
- A: axillary lymph nodes
-B: internal mammary lymph nodes
• n3: (more than 10 nodes)
-A: infra-clavicular lymph nodes
-B: axillary and ipsilateral internal mammary
-C: supra-clavicular

Metastasis
Mo
M1 distant

Question 18

Histological Classification breast cancer? (4)

Answer 18

• non-invasive carcinoma in situ: ductal/lobular

• invasive
- ductal: subtypes = medullary (brca), tubular/cribiform, mucinous/ colloid, papillary
-Lobular
-Paget’s disease: ductal carcinoma that invades nipple with scaling and eczematoid lesion

• progressive disease: ulcerations, arm oedema, Paget’s disease of nipple

• Metastatic disease: lymph, bone, lungs, liver, brain

Question 19

Bi-rads findings on mammography?

Answer 19

0: need additional imaging or prior examinations
1: negative, do routine screening
2: benign, do routine screening
3: probably benign (≤2% chance malignancy), short interval follow up in 6 months
4: suspicious,biopsy
5: highly suggestive of malignancy, biopsy
6: biopsy proven cancer, excise

Question 20

Molecular subclassification of breast cancer? (5)

Answer 20

• Luminal A: er and /or Pr positive, her negative, ki-67 low <14%. Most common, lower grade, good prognosis
• luminal B: er and /or Pr positive, her negative, ki-67 high > 14%. Recur more than luminal A
• her-2 enriched: er negative, Pr negative, her 2 positive (respond to herceptin, trastuzumab..)
• Triple negative (basal like): er negative, Pr negative, her negative ( ck 5/6 positive and or egfr positive) (aggnessive, always need chemo. High grade, usually young black female)
• normal breast-like breast cancer: er and or Pr positive, her 2 positive, low ki-67 < 14% (similar to luminal A but worse prognosis)

Question 21

Staging (o-4) of breast cancer?

Answer 21

• Stage 0: tis No Mo

• Stage 1
A- t1 No Mo
b- T 0/1 N 1mi ( micro metastasis > 0,2 mm and or > 200 cells but none >2mm) Mo

• stage 2
A- t1 n1 Mo or t2 No Mo
B- t2 N1 Mo or t3 No Mo

• stage 3
-A: t1-3 n2 Mo
-b : T4 No-2 Mo
-C: N3 Mo

• stage 4: m1

Question 22

Treatment stage o breast cancer? (3)

Answer 22

• Surgery: Breast conserving surgery lumpectomy (remove cancerous tissue with clear margins) or modified radical mastectomy (breast, axillary tail, axillary nodes level one (below pec minor) and 2 (under/post to pec minor), skin and nipple/areolar complex) if BCS contraindicated ; with sentinel lymph node biopsy SNLB
• adjuvant radiotherapy after BCS
• hormone treatment if positive

Question 23

Treatment stage 1 breast cancer? (5)

Answer 23

• Surgery: bcs/ mastectomy with snlb/ axillary dissection (alnd)
• adjuvant radiotherapy after bcs
• hormone therapy if positive
• chemo if tumour >1 cm and or hormone negative
• targeted If her positive

Question 24

Treatment stage 2 breast cancer? (6)

Answer 24

• Surgery: bcs/ mastectomy with snlb/ axillary dissection (alnd)
• adjuvant radiotherapy after bcs or mastectomy if lymph nodes involved or unclear margins
• hormone therapy if positive
• chemo if hormone negative
• targeted If her positive
• can use neo-adjuvant chemo/hormone/targeted to reduce tumour size before surgery

Question 25

Treatment stage 3 breast cancer? (6)

Answer 25

• Neo - adjuvant chemo with or without targeted therapy to shrink tumour
• Surgery: mastectomy with axillary dissection (alnd)
• adjuvant radiotherapy
• adjuvant hormone therapy if positive
• adjuvant chemo if hormone negative
• adjuvant targeted If her positive

Question 26

Treatment stage 4 breast cancer?

Answer 26

• Palliation: systemic chemo/hormone/ targeted/immune treatment with or without radiotherapy
• relieve symptoms eg analgesia, radiation for back pain
• consider mastectomy surgery to control local symptoms

Question 27

Name 3 contraindications breast conserving surgery

Answer 27

• Large tumour-to-breast ratio
• involvement skin or chest wall
• clear margins not guaranteed

Question 28

What is modifed radical mastectomy?

Answer 28

Remove whole breast, axillary tail, axillary lymph nodes levels 1 and 2, skin and nipple/areolar complex
Spare pectoralis minor and level 3 nodes

Question 29

Indication for SNLB breast cancer?

Answer 29

All patients with no clinical LN

Question 30

What is ALND breast cancer? How do?

Answer 30

Removal > 10 lymph nodes and histopathology

Question 31

What is targeted therapy in breast cancer? What use?

Answer 31

Target her 2 tyrosine kinase receptor if positive
Monoclonal antibody: trastozumab (cardiotoxic and contraindicated pregnancy)

Question 32

Name 4 complications breast cancer that pts may present with

Answer 32

• Malignant pleural effusion
• paraneoplastic syndrome
• secondary lymphoedema of arm
• endometrial cancer (high risk due to tamoxifen)

Question 33

Lymph drainage of breast? (4)

Answer 33

• axillary nodes 75% (including skin) to subclavian then L thoracic duct/R lymphatic trunk
• parasternal nodes (20%)
• posterior intercostal nodes (5%)
(Skin also to inferior deep cervical, infraclavicular)
(Nipple and aerola to subareolar lymph plexus)

Question 34

Name 6 indications for BRCA genetic testing in patients with breast cancer

Answer 34

• Strong direct family history
• Breast cancer diagnosed age 50 or younger
. Bilateral breast cancer
. Personal or family history ovarian cancer
• Ashkenazi Jew
• male breast cancer in direct family

Question 35

Name 3 indications modified radical mastectomy

Answer 35

• Unsuitable for breast conserving surgery eg unclear margins, patient unwilling to receive post-op radiation
•axillary lymph nodes positive
• clinical evaluation suitable for R0 resection where no macro or micro scopic tumour remains

Question 36

Name the 3 levels of axillary lymph nodes

Answer 36

• Level 1: lateral to pectoralis minor
• 2: between lower and upper edge, beneath pec minor
• 3: above/medial to pec minor.

Question 37

Name 3 peri-operative complications of modified radical mastectomy

Answer 37

• Thoracodorsal nerve (and artery) injury → latissimus dorsi atrophy → unable to fully extend, rotate and adduct arm.
• intercostal - brachial nerve injury → numbness, hypoesthesia, loss sensation to Axilla, lateral chest wall, medial arm.
. Long thoracic nerve injury → serratus anterior atrophy → scapular winging

Question 38

Name 9 post- op complications modified radical mastectomy

Answer 38

• Dehisced wound
• Seroma ( fluid build up )
• surgical site infection
• haematoma
• altered sensation and pain
• haemorrhage
• subcutaneous hydrops (oedema)
• skin paraesthesia
• lymphoedema affected upper limb: complication of node dissection and radiotherapy to Axilla

Question 39

Most common causes breast pain? (3)

Answer 39

1. Fibroadenoma.
2. Costochondritis
3. Mastitis
4. Cyst
5. Abscess
6. Fat necrosis

Question 40

Name and describe the 2 types of mastitis

Answer 40

• Lactational ( more common) - usually during first 3 months breastfeeding or during weaning. Associated with cracked nipples and milk stasis (poor feeding technique,) more common with first child .→ infection mostly S aureus or other skin and mouth commensals
• non-lactational: women with other conditions eg duct ectasia, as a peri-ductal mastitis. Rf tobacco smoking → damage to subareolar duct walls and predispose to bac infection

Question 41

Clinical presentation mammary duct ectasia? (3)

Answer 41

• Coloured green/yellow nipple discharge
• palpable mass
.Nipple retraction

Question 42

Causes fat necrosis of the breast? (2)

Answer 42

• Trauma 40%
•60% previous surgical or radiological intervention

Question 43

Define mammary duct ectasia

Answer 43

Dilatation and shortening of major lactiferous ducts. Common presentation peni-menopausal women

Question 44

Name 5 benign breast tumours

Answer 44

• Fibroadenoma (most common,low malignant potential)
• adenoma (glandular tumour in older women)
• papilloma (subareolar. Nipple discharge clear /bloody)
• lipoma
• phyllodes tumour ( fibroepithetial tumour, rare, malignant potential)

Question 45

Define fibroademona

Answer 45

Benign proliferation of stromal and epithelial tissue of duct lobules. Proliferation due to progesterone.
Simple terms-proliferating glandular tissue caught up in connective tissue