Breast cancer Flashcards
What tissue accounts for the majority of the breast contour and bulk?
1 - muscle
2 - adipose tissue
3 - fibrous tissue
4 - collagen
2 - adipose tissue
What is the large muscle that the mammary gland covers 2/3rds of on the chest?
1 - teres minor
2 - subscapularis
3 - pectoralis major
4 - pectoralis minor
3 - pectoralis major
What is the muscle that the mammary gland covers 1/3rd of on the lateral aspect of the chest?
1 - teres minor
2 - subscapularis
3 - pectoralis major
4 - serratus major
4 - serratus major
The mammary gland overlies which abdominal muscle and layer?
- recuts abdominas
- rectus sheath
The mammary gland sits infront of the pectoralis major, but between the pectoralis major and mammary gland lies a space. What is this space called?
1 - retromammary space
2 - quadrangular space
3 - pectoral space
4 - loose space
1 - retromammary space
- allows movement of the breast
- space that is filled with loose areolar tissue that can be used in reconstructive plastic surgery
The axilla is an anatomical region under the shoulder joint where the arm connects to the shoulder. It contains a variety of neurovascular structures, including the axillary artery, axillary vein, brachial plexus, and lymph nodes. What is the axillary tail of the breast?
1 - nerve supply to breast from axilla
2 - tail of axillary nerve supplying breast
3 - extension of axilla that includes the breast
4 - expansion of breast tissue ending in axilla
4 - expansion of breast tissue ending in axilla
- enters axilla through an opening in the deep fascia called foramen of Langer
The axilla is an anatomical region under the shoulder joint where the arm connects to the shoulder. It contains a variety of neurovascular structures, including the axillary artery, axillary vein, brachial plexus, and lymph nodes. The axillary tail of the breast, an extension of the tissue of the breast that extends into the axilla is able to enter the axilla through an opening in the deep fascia called foramen of Langer. What is the foramen of Langer?
1 - opening of the axilla
2 - opening in deep pectoralis fascia
3 - opening in superficial fascia
4 - opening at sternal notch
2 - opening in deep pectoralis fascia
- present at the level of the third intercostal space
The axilla is an anatomical region under the shoulder joint where the arm connects to the shoulder. The axillary tail of the breast, an extension of the tissue of the breast that extends into the axilla is able to enter the axilla through an opening in the deep fascia called foramen of Langer, an opening in the deep pectoralis fascia, present at the level of the third intercostal space. What is the importance of this site?
1 - breast attachment site
2 - site where breast reconstruction occurs
3 - 70% of lymph vessels drain breast into axilla
4 - nerves for breast pass through
3 - 70% of lymph vessels drain breast into axilla
- contains neurovascular structures, axillary artery, axillary vein, brachial plexus, and lymph nodes
The skin of the mammary gland has 2 main parts that can be visually seen and are important for breast feeding. What are these 2 areas called?
1 - nipple and areola
2 - nipple and labia majora
3 - labia minora and areola
4 - areloa and labia major
1 - nipple and areola
The areola is the pigmented area on the breast around the nipple. What is the function of the areola?
1 - holds nipple in place
2 - secretes oil around the nipple to reduce friction
3 - supplies innervation to the nipple
4 - supplied blood vessels to the nipple
2 - secretes oil around the nipple to reduce friction
What is the difference between stroma and parenchyma?
- parenchyma = functional tissue of an organ
- stroma = structural/supportive tissue of an organ
The stroma of the breast is composed of 2 main components, what are they?
1 - adipose tissue
2 - fibrous connective tissue
The stroma of the breast is composed of 2 main components, adipose tissue and fibrous connective tissue. The fibrous connective tissue of the breast separates the fatty lobules and ensures firm attachment of the adipose tissue to the dermis and deep fascia. What are these fibrous connective tissue organisations called?
1 - ligaments of cooper
2 - ligaments bouchard
3 - ligamentous longus
4 - trigeminal ligaments
1 - ligaments of cooper
What are mammary glands composed of?
- each breast contains aprox 12-20 lobes embedded in fat
- each lobe contains smaller structures called lobules or globules
- globules contain alveoli (hollow sacs)
The mammary glands are composed of aprox 12-20 lobes embedded in fat, where each lobe contains smaller structures called lobules or globules that contain alveoli (hollow sacs). What is the importance of these hollow sacs and what cells are they composed of?
1 - cuboidal cells secreting prolactin
2 - epithelial cells secreting oxytocin
3 - epithelial cells producing milk
4 - epithelial cells producing prolactin
3 - epithelial cells producing milk
- secrete milk that collects in the alveoli
The mammary glands are composed of aprox 12-20 lobes embedded in fat, where each lobe contains smaller structures called lobules or globules that contain alveoli (hollow sacs). The alveoli are lined by mammary secretary epithelial cells which secrete milk that collects in the alveoli. Select the correct path that the milk produced takes to the nipple:
1 - alveoli - lactiferous ducts - lactiferous sinus - nipple
2 - alveoli - lactiferous sinus - lactiferous ducts - nipple
3 - alveoli - lactiferous ducts - nipple
4 - alveoli - lactiferous sinus - nipple
1 - alveoli - lactiferous ducts - lactiferous sinus - nipple
Label the image of the breast using the labels below:
- lobe
- lactiferous duct
- lactiferous sinus
- areola
- lobules
Label the image of the breast using the labels below:
- lobe
- areola
- lactiferous sinus
- lactiferous duct
- lobules
The stroma of the breast is composed of 2 main components, adipose tissue and fibrous connective tissue. The fibrous connective tissue of the breast separates the fatty lobules and ensures firm attachment of the adipose tissue to the dermis and deep fascia. These fibrous connective tissue organisations are called ligaments of cooper. What is the importance of the ligaments of cooper clinically?
1 - breast become saggy if they are pathological
2 - breast become very tight if pathological
3 - shrivel up with dimples resembling an orange peel
4 - shrivel up and change their colour to orange
3 - shrivel up with dimples resembling an orange peel
- if ligaments of cooper are affected by pathology such as cancer they can contract and shrivel up
- can present as early marker of pathology with dimples on skin and retracted nipple
- looks like an orange and is therefore called peau d’orange
Which lymph does aprox 70% of the lymph from the breast tissue drain into?
- via axilla tail of the breast into the axillary lymph node
Sentinel Lymph Node is the 1st lymph node where cancer is likely to spread from primary tumour. What is a Sentinel Lymph Node Biopsy?
- a biopsy of the sentinel lymph nodes (first lymph node a cancer is likely to spread to)
- sit between the breast tissue and the axillary lymph node
What is a Sentinel Lymph Node?
1 - first lymph node discovered near the breast tissue
2 - site unaffected by cancers
3 - location where axilla tail drains into from the breast
4 - 1st lymph node where cancer is likely to spread from primary tumour
4 - 1st lymph node where cancer is likely to spread from primary tumour
A Sentinel Lymph Node Biopsy (SLNB) is a biopsy of the sentinel lymph nodes (first lymph node a cancer is likely to spread to) that sits from the cancer and the axillary lymph node. Why would the SLNB be performed?
- identifies if the tumour has metastasised into the lymphatics tissue
What is nipple retraction?
1 - nipples that have not formed
2 - nipples that point inward or are flat
3 - nipples that have discharge
4 - nipples that invert
2 - nipples that point inward or are flat
What is amastia?
1 - a rare, congenital condition in which a child’s breast tissue doesn’t develop
2 - breast surgery following cancer
3 - breast reconstruction
4 - breast over develop due to congenital abnormality
1 - a rare, congenital condition in which a child’s breast tissue doesn’t develop
What is polymastia?
1 - congenital condition causing only 1 breast to develop more than the other
2 - congenital condition causing a third breast to develop
3 - congenital condition causing an absence of nipples
4 - congenital condition causing inverted nipples
2 - congenital condition causing a third breast to develop
- may not present until puberty
What is gynaecomastia?
- development of breast tissue in males
What is athelia?
1 - congenital condition causing only 1 breast to develop more than the other
2 - congenital condition causing a third breast to develop
3 - congenital condition causing an absence of nipples
4 - congenital condition causing inverted nipples
3 - congenital condition causing an absence of nipples
- can occur on one (unilateral) or both (bilateral) breasts.
When a patient requires breast reconstruction, which muscle from the back can be used?
1 - teres major
2 - trapezius
3 - latissimus dorsi
4 - deltoid
3 - latissimus dorsi
When a patient requires breast reconstruction, which muscle from the thigh can be used?
1 - vastus medialis
2 - gracilis muscle
3 - sartorius muscle
4 - soleus muscle
2 - gracilis muscle
- muscle of inner thigh
What is often the site used in the breast for a breast implant?
- retromammary space
- space filled with loose areolar tissue between breast and pectoralis muscle
Nipple discharge can be caused by breast cancer. What happens to breast discharge in patients with breast cancer?
1 - decreases with age
2 - increases with age
3 - no change with age
2 - increases with age
- 3% in patients <40 y/o
- 10% in patients 40-60 y/o
- 32% in patients >60 y/o
In nipple discharge this can be single or multiple ducts affected. Which is more worrying from a diagnosis perspective?
- single
- more likely to be malignant
Is an intermittent coloured opaque discharge from multiple ducts physiological or pathophysiological?
- physiological
Is persistent discharge (>2/week) more likely to be physiological or pathophysiological?
- pathophysiological
- likely due to malignancy such as papilloma or cancer
What is a papilloma?
1 - blocked duct of breast
2 - benign growth in a milk duct
3 - cancerous growth in the milk duct
2 - benign growth in a milk duct
- can cause discharge in lactating women
Galactorrhoea should be ruled out in patients with nipple discharge. Which of the following is NOT true about galactorrhoea?
1 - pale milky in colour
2 - multiple ducts involved
3 - copious amounts
4 - unilateral
4 - unilateral
- normally bilateral
Prolactin is secreted by the anterior pituitary gland and is involved in milk production and breast growth in pregnancy. What can the levels reach that may account for nipple discharge?
1 - >10mlIU/L
2 - >100mlIU/L
3 - >1000mlIU/L
4 - >100,000mlIU/L
3 - >1000mlIU/L
- check for pituitary tumour
What is thick yellow discharge from nipples most commonly associated with?
1 - duct papillomas
2 - duct ectasia
3 - epithelial hyperplasia
4 - ductal carcinoma in situ or invasive carcinoma
2 - duct ectasia
- all others can cause blood
- benign (non-cancerous) breast condition that occurs when a milk duct in the breast widens and its walls thicken.
Serosanguineous (relates to blood and serum) or bloody discharge from a single duct can be caused by epithelial hyperplasia of the ducts in the breast. Does this always become malignant?
- no
- but can increase the risk of cancer
Serosanguineous (relates to blood and serum) or bloody discharge from a single duct can be caused by carcinoma in-situ or invasive carcinoma. What does carcinoma in-situ mean in relation to the ducts of the breast?
1 - cancer has spread inside the breast
2 - cancer has spread to nearby organs
3 - localised in duct and not beyond the basement membrane
3 - localised in duct and not beyond the basement membrane
- invasive just means it has passed the basement membrane
In a patient with nipple discharge they may undergo all of the following EXCEPT which one?
1 - sample of discharge sent to cytology
2 - mammogram for all patients
3 - ultrasound to identify papilloma or malignant lesions
4 - conservative management as most resolve spontaneously
2 - mammogram for all patients
- only performed in >40 y/o
When patients attend the specialist 2 week wait breast clinic they have CRP triple assessment:
- C = Clinical examination and given a ’P’ or ‘E’ code (palpation/examination, respectively)
- R = Radiographic Imaging assessment and given a ‘M’ code (mammogram) and ‘U’ code (ultrasound)
- P = Pathophysiological biopsy if appropriate ‘B’ code (biopsy)
- if a lump is identified following a mammogram then patient has an ultrasound
- ultrasound guided biopsy would then be done on the same day
Breast cancer is the most common cancer in women. What is the aprox number of invasive breast cancers in the UK each year?
1 - 60
2 - 600
3 - 6000
4 - 60,000
4 - 60,000
Breast cancer is the most common cancer in women. What is the aprox number of non-invasive breast cancers in the UK each year?
1 - 80-90
2 - 800-900
3 - 8000-9000
4 - 80,000-90,000
3 - 8000-9000
What % of women diagnosed with breast cancer will survive beyond 10 years?
1 - 7.6%
2 - 27.6%
3 - 57.6%
4 - 76%
4 - 76%
Which of the following is NOT a risk factor for breast cancer?
1 - age (>70)
2 - oestrogen exposure
3 - obesity
4 - alcohol
5 - hypertension
6 - ethnicity (highest in black women)
7 - higher socioeconomic group
8 - previous hodgkin lymphoma
5 - hypertension
The following are risk factors for breast cancer, but which is the largest risk factor?
1 - age (>70)
2 - oestrogen exposure
3 - obesity
4 - alcohol
5 - ethnicity (highest in black women)
6 - higher socioeconomic group
7 - previous hodgkin lymphoma
1 - age (>70)
Why is it important to know when a woman has menarche (1st period)?
1 - before this women are not at risk of breast cancer
2 - oestrogen exposure is a risk factor for breast cancer
3 - women who have delayed menarche will not develop breast cancer
2 - oestrogen exposure is a risk factor for breast cancer
- late menopause is also a risk as the patient will continue to have more exposure to estrogen
Breast cancer has a genetic risk associated with it. Which group of patients are at highest risk?
1 - asians
2 - ashkenazi jews
3 - caucasians
4 - muslims
2 - ashkenazi jews
What is neoplasis?
1 - rapid increase in cell number
2 - cells grow in size but not number
3 - cells grow in number, but abnormally and die like other cells
4 - cells grow in number, but abnormally and do not die like other cells
4 - cells grow in number, but abnormally and do not die like other cells
Are all neoplasias malignant?
- no
- can be benign and not invade other tissues
The range of neoplastic disease ranges from cellular atypia through carcinoma in situ to invasive disease. What is cellular atypia?
1 - cells with abnormal morphology growing rapidly
2 - normal cells growing rapidly
3 - cells growing in size and number
4 - too many cells present
1 - cells with abnormal morphology growing rapidly
What is the most common 2 week referral pathway from GPs?
1 - colon cancer
2 - breast cancer
3 - lung cancer
4 - pancreatic cancer
2 - breast cancer
There are a number of genetic risk factors for developing breast cancer. Which of the following is NOT a genetic risk factor for breast cancer?
1 - BRCA1
2 - BRCA2
3 - TP53
4 - HER2
5 - CA19-9
5 - CA19-9
- BRCA1 and BRCA2 can also cause endometrial, ovarian and pancreatic cancer
The breast cancer type 1 and 2 genes are tumour suppressor genes. Mutations in these mean tumours will continue to grow unchecked. Are these autosomal dominant or recessive?
- dominant
- meaning only 1 mutated gene is required to increase risk of cancer
The breast cancer type 1 and 2 genes are tumour suppressor genes. Mutations in these mean tumours will continue to grow unchecked. Is BRCA 1 or 2 more common?
- BRCA 1
The breast cancer type 1 and 2 genes are tumour suppressor genes. Mutations in these mean tumours will continue to grow unchecked. How much does the risk of breast and ovarian cancer increase if you have a mutation in either the BRCA1 or 2?
B = breast and O = ovarian
1 - B = x2 and O = x5
2 - B = x5 and O = x5
3 - B = x10 and O = x10
4 - B = x5 and O = x10-30
4 - B = x5 and O = x10-30
- also at increased risk of prostate, pancreatic and colon cancer
BRCA1 and BRCA2 genes are contained on the long arms of chromosomes 17 and 13 respectively. What type of inheritance are these genes?
1 - autosomal recessive
2 - autosomal dominant
3 - X-linked dominant
4 - X-linked recessive
2 - autosomal dominant
- only need 1 faulty gene from 1 parent to get mutated gene
Patients of a certain age will require a mammogram screening every 3 years at what age?
1 - >40
2 - >50
3 - >60
4 - >70
2 - >50
- typically get invited between 50-53 years of age
- stops at age 71
What % of breast lumps in women between 20-50 y/o are benign?
1 - 0.9%
2 - 9%
3 - 49%
4 - >90%
4 - >90%
- patients always think malignancy
- if lump is present we do triple therapy (CRP)
In patients with a BRCA1 or 2 mutation they will be screening annually. If they are aged >40 they will receive mammogram. if they are aged 30-49 they will receive what?
1 - ultrasound
2 - X-ray
3 - MRI
4 - PET
3 - MRI (most sensitive)
- ultrasound if MRI not possible
- mammogram not as sensitive on dense tissue (young breasts contain a lot of lobules that appear white on mammogram)
Are all suspected malignancies screened with mammogram detected?
- no
- of 10,000 screenings 500-700 women are recalled for reassessment
What is the most common presentation of breast cancer?
1 - pain
2 - discharge
3 - weight loss
4 - lump
4 - lump
Which of the following is NOT typically true in relation to a breast lump that is cancerous?
1 - soft
2 - immoveable
3 - single dominant lesion
4 - irregular borders
1 - soft
- normally hard
In women with breast cancer we might see pagets disease of the nipple. What is this?
1 - suspensory ligaments become tight affecting skin
2 - bloody discharge from nipple
3 - eczema-like changes of nipple
4 - nipple inversion
3 - eczema-like changes of nipple
In addition to the breast tissue, there are skin changes in breast cancer. What is peau d’orange?
1 - suspensory ligaments stretch affecting skin
2 - bloody discharge from nipple
3 - eczema-like changes of nipple
4 - nipple inversion
1 - suspensory ligaments stretch affecting skin
Triple negative breast cancer is by far the most common cause of death from breast cancer. What is triple negative breast cancer?
1 - 3 types of treatment have failed to cure breast cancer
2 - 3 methods have failed to diagnose the breast cancer
3 - negative for 3 most common receptors in breast cancer (HER-2, estrogen and progesterone)
3 - negative for 3 most common receptors in breast cancer (HER-2, estrogen and progesterone)
- it is really hard to treat this type of breast cancer
Breast cancer is typically divided into 2 types affecting either ductal epithelium or lobular epithelium. Which is more common?
- ductal epithelium
- accounts for 85-90%
In surgery for breast cancer the aim is always to achieve local control. What surgery is generally given for ductal carcinoma in-situ (DCIS)?
1 - mastectomy, axially node biopsy and radiotherapy
2 - wide local excision
3 - wide local excision + radiotherapy
4 - wide local incision + radiotherapy and axillary node biopsy
3 - wide local excision + radiotherapy
In surgery for breast cancer the aim is always to achieve local control. What surgery is generally given for invasive disease?
1 - mastectomy, axially node biopsy and radiotherapy
2 - wide local excision
3 - wide local excision + radiotherapy
4 - wide local incision + radiotherapy and axillary node biopsy
1 - mastectomy, axially node biopsy and radiotherapy
or
4 - wide local incision + radiotherapy and axillary node biopsy
A sentinel biopsy can be performed if we are concerned a patients breast cancer has spread. What is the sentinel lymph node?
1 - closest lymph node to tumour
2 - lymph node metastasis have to pass to mov e to different area
3 - lymph node metastasis are stopped at
2 - lymph node metastasis have to pass to mov e to different area
- if sentinel has metastasis then distal lymph nodes need removing
In addition to analysing if the biopsy is carcinoma in situ or invasive, we can also look at molecular markers. Which of the following is NOT a common marker looked for in breast biopsy?
1 - human epidermal growth factor receptor 2 (HER-2) receptors
2 - cancer antigen 19-9 (CA19-9) receptors
3 - estrogen receptors
4 - progesterone receptors
2 - Cancer antigen 19-9 (CA19-9) receptors
- if these come back positive then this is good as we can treat with immunotherapy
- Herceptin is given for HER-2 positive cancers
Is the recurrence of breast cancer predictable?
- no
- can be long term (>5 years)
Disease severity and staging determines the 5 year prognosis of a patient with breast cancer.The 5 year survival in stage 1 breast cancer is 98%. What is the 5 year survival for metastatic disease?
1 - 0.25%
2 - 2.5%
3 - 25%
4 - 50%
3 - 25%
- patients normally treated pallatively
Which if the following is NOT commonly associated with a poor prognosis in breast cancer?
ER = estrogen receptor
PR = progesterone receptor
1 - high grade cancer/metastatic disease
2 - young age at diagnosis (normally aggressive)
3 - triple positive (HER-2, ER and PR)
4 - axillary lymph node involvement
3 - triple positive (HER-2, ER and PR)
- this is good it means we can treat
- negative would be bad
When we talk about staging we refer to staging, which used the TNM staging. But we also use grading. The first part of the is the nuclear grade, what is this?
1 - what nucleus look like under a microscope
2 - how the tumour looks on FDG-PET-scan
3 - how patient responds to radiotherapy
1 - what nucleus look like under a microscope
- scored on a 1-3 basis
- grade 1 cells have a normal looking nucleus
- grade 3 cells have abnormal looking nucleus
When we talk about staging we refer to staging, which used the TNM staging. But we also use grading. The second part of grading is the mitotic rate, what is this?
1 - what nucleus look like under a microscope
2 - how the tumour looks on FDG-PET-scan
3 - how patient responds to radiotherapy
4 - speed at which cells are dividing
4 - speed at which cells are dividing
- scale: 1 being the slowest, 3 the quickest.
When we talk about staging we refer to staging, which used the TNM staging. But we also use grading. The third part of grading is the tubular formation, what is this?
1 - what nucleus look like under a microscope
2 - how the tumour looks on FDG-PET-scan
3 - number of cancer cells formed in tubules
4 - speed at which cells are dividing
3 - number of cancer cells formed in tubules
- 1 = >75% of cells are in tubule formation.
- 2 = 10 - 75% of cells are affected
- 3 = <10% of cells are in tubule formation
When we talk about staging we refer to staging, which used the TNM staging. But we also use grading, which included nucleus, mitotic rate and tubular formation. What is the lowest possible score (best outcomes)?
1 - 0
2 - 1
3 - 3
4 - 9
3 - 3
- each section has a minimum score of 1
When we talk about staging we refer to staging, which used the TNM staging. But we also use grading, which included nucleus, mitotic rate and tubular formation. What is the highest possible score (worst outcomes)?
1 - 0
2 - 1
3 - 3
4 - 9
4 - 9
- each section has a maximum score of 3
- scores 3-5 = well differentiated or low grade (Grade 1).
- scores 6 or 7 = moderately differentiated or intermediate grade (Grade 2).
- scores of 8 or 9 = poorly differentiated or high grade (Grade 3).
When we talk about staging we refer to staging, which used the TNM staging. But we also use grading, which included nucleus, mitotic rate and tubular formation, with the lowest score of 3 and the highest score being 9. The following are the 3 grades that can be generated. Which is most common?
1 - scores 3-5 = well differentiated or low grade (Grade 1).
2 - scores 6 or 7 = moderately differentiated or intermediate grade (Grade 2).
3 - scores of 8 or 9 = poorly differentiated or high grade (Grade 3).
2 - scores 6 or 7 = moderately differentiated or intermediate grade (Grade 2).
Cancer can metastasise through lymphatic channels to regional axillary lymph nodes. The size of the metastasis determines if the axillary lymph nodes are removed.
The range of neoplastic disease ranges from cellular atypia through carcinoma in situ to invasive disease. What is cellular atypia?
1 - normal cells present in a tumour
2 - presence of >1 cellular or architectural features deviating from normal appearing cells
3 - increase in cell size
4 - too many cells present
2 - presence of >1 cellular or architectural features deviating from normal appearing cells
- aytipia also means aytipical
When we look at breast on imaging we look for 4 things. Which of the following is not part of this:
1 - mass
2 - microcalcification (small speckles in breast)
3 - distortion (being pulled in)
4 - asymmetry
5 - age of breast tissue
5 - age of breast tissue
- can see on the image that the breast has a clear mass which is asymmetrical with the other breast, and the breast is being distorted (pulled in)
