Breast Tis

Question 1

Considered a marker of increased risk for the subsequent development of invasive (usually ductal) carcinomas

Answer 1

LCIS

Question 2

In LCIS

If associated with another malignancy?

If sole histologic diagnosis?

Answer 2

If associated with another malignancy
manage the breast according to the dominant malignant histology and disregard the LCIS

If sole histologic diagnosis
close observation with regular physical examination and mammographic surveillance

Question 3

Bilateral prophylactic mastectomy indicated for “high risk”?

What are the high risk features?

Answer 3

Bilateral prophylactic mastectomy indicated for “high risk”:
young age
diffuse high-grade lesion
significant family history

Question 4

Clinical presentation
Itching and burning of the nipple and areola
Slow progression toward a crusting eczematoid appearance that can extend to the periareolar skin.
If neglected, bleeding, pain, and ulceration can occur.
Can be asymptomatic and present as a pathologic finding after incidental surgical removal of the nipple–areolar complex
Palpable mass: 50% of patients at diagnosis
No palpable mass: 66% to 86% will have an underlying DCIS

Answer 4

Pagets disease of the nipple

Question 5

In >____% of cases of Pagets disease, this will be an invasive carcinoma

Answer 5

90

Question 6

large and have hyperchromatic cells with:
round to oval nuclei
abundant amphophilic to clear cytoplasm
Location: Epidermis
MITOSES
Basal layer (Clusters)

Answer 6

Pagets cells

Question 7

Motility factor

Chemotaxis of Paget’s cells that migrate to the overlying nipple epidermis

Answer 7

Heregulin alpha

Question 8

Most practical management for Pagets?

Answer 8

Most practical breast-conserving approach:

combination of limited surgical resection and postoperative radiotherapy

Question 9

lacks the ability to metastasize and is confined to the breast
axillary node involvement is rare (0% to 5%) and most likely is associated with an undetected focus of invasive carcinoma

Typical presentations (Pre-mammography era): 
palpable mass 
nipple discharge

Answer 9

DCIS

Question 10

Most typical abnormality in mammography in DCIS

Answer 10

Microcalcifications
MOST TYPICAL abnormalities
linear and segmental calcifications associated with DCIS in up to 80% of cases

Question 11

What are the diff Growth patterns of DCIS?

Describe each

Answer 11

Unicentric – one area only
Multicentric – 2 distinct areas separated by >4cm
Continuous – extension along ductal system without gaps
Discontinuous/multifocal – 2 or more areas separated by

Question 12

Favery et al.
_____ cm margin of normal tissue around the lesion would lead to complete surgical clearance of histologically evident DCIS in 90% of cases

Answer 12

1 cm

Question 13

Precursor lesion to invasive ductal carcinoma (10 fold risk)

Answer 13

DCIS

Question 14

In DCIS:
This modality has
Locoregional control rate of 96% - 100%  
Cancer-specific mortality rates of ≤4%
Local or regional recurrence rates 

No significant differences in overall survival
Death-related within 10 years after diagnosis
Occurs 1-2% of all patients (irrespective whether mastectomy or BCT done)

Answer 14

Mastectomy

Question 15

Chest wall failure rate was sufficiently low that a routine recommendation of postmastectomy radiation DCIS with high-risk features was not warranted

True or False?

Answer 15

True

Question 16

Factors associated with an increased risk of local recurrence in DCIS that necessitates RT

Answer 16

In EORTC 10853 trial

Factors associated with an increased risk of local recurrence:
≤40 years of age
Clinically symptomatic presentation (nipple discharge or palpable mass)
Intermediate or poorly differentiated DCIS
Solid/comedo and cribriform histologic growth pattern
Involved or uncertain margins
Treatment by local excision alone

Question 17

Radiotherapy was not adequate to compensate for involved margins because even with the application of irradiation, the recurrence rate was 20% in this group.

True or False?

Answer 17

True

Question 18

Addition of _______:
NO benefit toward overall ipsilateral local control when administered in addition to radiotherapy
however, ______did appear to reduce the ipsilateral recurrence rate of DCIS (but not invasive carcinoma) in the absence of radiotherapy

What is the drug?

Answer 18

Tamoxifen

Question 19

In EBCTG:

Demonstrated that the absolute greater benefits of radiotherapy in women at increased risk for tumor recurrence:

Answer 19

Demonstrated that the absolute greater benefits of radiotherapy in women at increased risk for tumor recurrence:
Involved surgical margins (identified on retrospective pathologic review)
younger women
Tumors: high-grade or comedonecrotic features

Question 20

In DCIS

Local recurrences after breast-conserving surgery and radiotherapy are generally treated with ______

Answer 20

Local recurrences after breast-conserving surgery and radiotherapy are generally treated with mastectomy

Question 21

Mastectomy is prefered than BCS in what features?

Answer 21

“Multicentric
(2 or more quadrants)”

Extensive/Diffuse DCIS
Suspicious Microcalcif.

Negative Margins but
Acceptable cosmesis cannot be achived w/ BCS”

Question 22

Is there a role of RT in post BCS DCIS patients?

Answer 22

Yes

After breast-conserving surgery, radiotherapy is administered using tangential fields to the whole breast
standard dose of 45 to 50 Gy delivered in daily fractions of 180 to 200cGy
a radiation boost to the tumor bed may be added to whole-breast treatment
CLOSE SURGICAL MARGINS
Benefit: NOT established

Question 23

Characterized by
loose discohesive epithelial cells
variable in shape
Normal C:N ratio.

Multicentric distribution up to 90%
Bilateral involvement in 35-59%
Commonly estrogen receptor positive
C-erbB-2 and p53 uncommon
Loss of e-cadherin often observed

Answer 23

LCIS