Breast cancer management

Question 1

Treatment options

• LCIS
• DCIS

Answer 1

• LCIS
  
  • Observation
  • Chemoprevention (TMX)
  • Prophylactic bilateral total mastectomy
• DCIS
  
  • Low grade
    
    • Lumpectomy alone
  • Intermediate grade
    
    • Lumpectomy + RT
  • High grade
    
    • TM

Question 2

Management for stage I, IIa, IIb invasive breast cancer

Answer 2

• BCS +/- adjuvant chemo/RT
  
  • Lumpectomy
  • SLNB
  • RT

Question 3

Absolute contraindications to BCS

Answer 3

• Prior RT
• Pregnant (1st and 2nd trimester)
• Persistently positive margins
• Multicentric lesions
• Diffuse microcalcifications
• Connective tissue disorders (scleroderma)

Question 4

Most common type of mastectomy to treat breast cancer

Answer 4

Simple or total mastectomy

Question 5

The entire breast, including the nipple, is removed with the exception of the lymph nodes and muscle tissues

Answer 5

Simple or total mastectomy

Question 6

The nipple, areola, and breast tissue are removed while the skin on top the breast is left untouched

• Procedure
• Suitable for
• Not suitable for

Answer 6

• Procedure
  
  • Skin sparing mastectomy
• Suitable for
  
  • • Not suitable for

Question 7

Removes the entire breast, including the lymph nodes under the arm, and the pectoral muscles under the breast

• Procedure
• Other name

Answer 7

• Procedure
  
  • Radical mastectomy
• Other name
  
  • Halsted mastectomy

Question 8

Removes the entire breast including the lymph nodes under the arm and preserves the pectoralis major

Answer 8

MRM

Question 9

Levels of axillary lymph node

Answer 9

• Level I axillary lymph nodes
  
  • Nodes located lateral to pectoralis minor muscle
• Level II axillary lymph nodes
  
  • Nodes located beneath or over the pectoralis minor muscle
• Level III axillary lymph nodes
  
  • Nodes located medial to Pectoralis minor muscle

Question 10

1. Pectoralis minor removed to allow complete dissectiong of ALN I, II and III
2. Pectoralis minor muscle is divided but not removed to remove all ALN followed by repair
3. Pectoralis minor is retracted but not divided with dissection of axillary lymph nodes I and II

Answer 10

1. Patey’s
2. Scanlon’s
3. Auchincloss’

Memory aid:

• Patey pectoralis minor e tanggal
• Scan, slice and suture

Question 11

Management of advanced locoregional breast cancer

• Stages
• Treatment

Answer 11

• Stages
  
  • IIIa and IIIb
• Treatment
  
  • Neoadjuvant chemotherapy (Adriamycin containing) then either:
    
    • BCS or MRM + adjuvant chemotherapy/RT
    • Antiestrogen treatment

Question 12

Management of distant metastasis

Answer 12

• Palliative antiestrogen
• Chemotherapy
• RT
• BSC

Question 13

Hormonal therapy indication

Answer 13

ER/PR ⊕ without adverse prognostic features

Question 14

Management for locoregional recurrence

Answer 14

• S/P MRM
  
  • Excision + chemo and hormone therapy
• S/P BCS
  
  • MRM + chemo and hormone therapy

Question 15

Breast cancer treatment during pregnancy

Answer 15

• 1st and 2nd trimester
  
  • MRM
• 3rd trimester
  
  • BCS

Question 16

An 18-week pregnant, 35-year-old woman presents after undergoing a modified radical mastectomy for a 2-cm ductal cancer with one out of fifteen positive axillary lymph nodes. What should she be informed of regardingbreast cancer during pregnancy?

1. She cannot undergo chemotherapy until after she delivers
2. She should have a therapeutic abortion in order to proceed with radiotherapy
3. Breast cancer is the most common cancer during pregnancy
4. Radiotherapy is indicated
5. Most of these cancers are ER+

Answer 16

Answer: 3

• Breast cancer is the most common cancer during pregnancy

Rationale:

• Breast cancer is the most common cancer during pregnancy
• 5 – It is usually ER–/PR–
• 1 – Patients can undergo chemotherapy (nonmethotrexate regimens) starting after the first trimester and continue on with the pregnancy
• 2 and 4 – Radiotherapy cannot be given during pregnancy, so mastectomy is often indicated unless the patient is toward the end of the pregnancy, and the radiotherpy can be given postpartum