Breast

Question 1

Which breast cancer patient is more likely to have a heritable mutation?
A) patient with bilateral breast cancer
B) deep invasion
C) 38 years of age
D) positive lymph nodes

Answer 1

patient with bilateral breast cancer

Question 2

What is the appropriate treatment of patients with node-positive breast cancer s/p resection?

Answer 2

multiagent chemotherapy, followed by RT ( JD per NCCN), with or without tamoxifen

Question 3

Which breast cancer patients should receive adjuvant chemotherapy?

Answer 3

1. any patient with ER/PR NEGATIVE
2. any patient with positive axillary nodes
3. tumor >0.5cm AND Oncotype recurrence score >=26

Question 4

When is Tamoxifen given in breast cancer?

Answer 4

If tumor is ER/PR POSITIVE

Question 5

What does not increase lifetime risk of breast cancer?
a) Ataxia telangiectasia
b) MEN2
c) Cowden
d) Li Fraumeni

Answer 5

MEN2

PTEN (~40-60%)
BRCA1/2, TP53 (>60%)
STK11 (30-50%)
ATM (20-30%)

Question 6

What factors are considered in the GAIL model for breast cancer risk?

Answer 6

• age
• age at menarche
• age at first live birth
• number of first-degree relatives with breast cancer
• number of previous breast biopsies
• breast biopsy with atypical hyperplasia
• Race/ethnicity

Question 7

Which patients should receive annual breast MRI in addition to mammography?

Answer 7

• BRCA1/2, PALB2 mutation carrier status
• untested but with first degree relative with BRCA mutation status
• estimated risk of disease >20 %
• patients with chest wall RT between age 10 and 30
• patients with Li-Fraumeni (TP53), Cowden/Bannayan-Riley (PTEN), PJS (STK11)

Question 8

Tumor marker most likely elevated in metastatic breast CA?

Answer 8

CA27.29

AW: Not all breast ca express CA27-29. Can use CA15-3 instead. CA27-29 more sensitive

Question 9

What has the highest survival benefit for BRCA ppx?

Answer 9

BSO

Question 10

Which patients do NOT need MRI for screening along with mammogram?

Answer 10

• LCIS (lobular carcinoma in situ)
• ALH (atypical lobular hyperplasia)
• ADH (atypical ductal hyperplasia)
• dense breasts
• personal hx of breast cancer including DCIS (ductal carcinoa in situ)
• Lifetime risk < 15-20%

Question 11

Tx of LCIS

Answer 11

If needle bx, need to excise
If excisional bx, no addtl surgery

Traditionally, ppl got ppx mastectomies but now use chemoprevention (i.e., tam or AI)

Question 12

Lowest breast cancer risk
A) Chest radiation exposure at age 17
B) Cowden
C) Li-Fraumeni
D) 1st degree relative with BRCA2

Answer 12

A) Chest radiation exposure at age 17

Per UTD search appears up to ~30% risk JD

PTEN (~40-60%)
TP53 (>60%)

Question 13

Breast biopsy - atypical ductal cells - what is mgmt?

Answer 13

Lumpectomy to r/o DCIS or cancer, occurs in up to 10-30%

Question 14

% breast cancer risk reduction with oophorectomy in BRCA pos women

Answer 14

50%

** this is in Justin’s however on UTD the newest evidence is actually conflicting.**

Per NCCN, “To summarize, studies suggest a benefit of RRSO on breast cancer risk, but the magnitude of the effect based on age remains uncertain.”

Question 15

What is the association with in-utero DES exposure and breast cancer risk?

Answer 15

DES daughters may have slightly increased risk of breast cancer after age 40. US study suggested risk is not increased overall but that after age 40, DES daughters have 2x risk as unexposed women. Possible that risk is increased for a limited time at middle age. European study found no difference in breast cancer risk between exposed and unexposed.

Conflicting evidence

Question 16

What is the sensitivity of mammogram?

Answer 16

80-90%

Sensitivity refers to a test’s ability to designate an individual with disease as positive.
A highly sensitive test means that there are few false negative results, and thus fewer cases of disease are missed.

Dependent on age, breast characteristics

Question 17

What is the specificity of mammogram?

Answer 17

94%

The specificity of a test is its ability to designate an individual who does not have a disease as negative.

A highly specific test means that there are few false positive results.

———————————

SnNout: A test with a high sensitivity value (Sn) that, when negative (N), helps to rule out a disease (out).

SpPin: A test with a high specificity value (Sp) that, when positive (P) helps to rule in a disease (in).

Question 18

What % breast cancers are Her2+?

Answer 18

20%

Question 19

What % breast cancers are triple negative?

Answer 19

15%

Question 20

What to do with cluster of microcalcifications seen on mammogram

Answer 20

Core needle biopsy

Question 21

who cannot have breast conserving therapy? (BCT: is breast conserving surgery ie lumpectomy plus RT)

Answer 21

●Multicentric disease
●Large tumor size in relation to breast
●Presence of diffuse malignant-appearing calcifications on imaging (ie, mammogram or magnetic resonance imaging [MRI])
●Prior history of chest RT (eg, mantle radiation for Hodgkin disease)
●Pregnancy
●Persistently positive margins despite attempts at re-excision

Added question from up to date. Seems like its fair game to ask.
*would also avoid BCT in LFS as RT —> sarcoma)

Question 22

When would you use 21-gene RT-PCR for oncotype diagnosis of breast cancer?
A) ER- / HER2- / Node +
B) ER+ / HER2+
C) ER- / HER2+
D) ER+ / HER2- / Node +
E) ER+ / HER2- / Node -

Answer 22

E) ER+ / HER2- / Node -

It is used to identify patients with early stage invasive breast cancer who may benefit from adjuvant chemotherapy (as opposed to just hormonal therapy). MUST be ER+, HER2-, and non-metastatic.

Technically also for ER+/HER2- T1-3 and N1 tumors per NCCN