Chapter 55 Breast Cancer Tis

Question 1

Non invasive carcinoma of breast(Stage Tis) includes

Answer 1

Paget’s disease of nipple Lobular carcinoma in situ Ductal carcinoma in situ

Question 2

Characteristics of LCIS

Answer 2

Multicentric breast involvement Loose, discohesive epithelial cells large in size, variable in shape, normal cytoplasm to nucleus ratio Overlap of histologic morphology

Question 3

LCIS Percentage of multicentric distribution in mastectomy specimens? Bilateral involvement of breast? Percentage representation of noninvasive cancer?

Answer 3

90% 35-59% <15%

Question 4

LCIS usually which harmone positive?

Answer 4

ER+

Question 5

LCIS Average age of diagnosis?

Answer 5

45 years Premenopausal at diagnosis

Question 6

What are clinical or mammographic characteristics of LCIS?

Answer 6

No clinical or mammographic indicators It is often detected as an incidental biopsy findings

Question 7

LCIS is considered a marker of increased risk for subsequent development of

Answer 7

Ductal carcinoma Bilateral breast Direct precursor lesion to invasive lobular carcinoma is unresolved (NSABP B-17 trial for reference)

Question 8

Role of MRI as a useful screening tool to detect development of invasive disease in LCIS

Answer 8

3.8-4.5% breast cancer detection rate (NCCN 2009 reference)

Question 9

What is the widely accepted management of breast with mixed LCIS,DCIS or Invasive carcinoma?

Answer 9

Manage breast according to dominant malignant histology

Question 10

LCIS as a sole histologic diagnosis, what is most widely accepted clinical practice?

Answer 10

Close observation and mammographic surveillance

Question 11

Role of RT in management of LCIS?

Answer 11

NO ROLE

Question 12

High risk patient for bilateral prophylactic mastectomy?

Answer 12

Young age Diffuse high grade lesion Significant family history

Question 13

Less radical prophylactic approach in high risk LCIS patients?

Answer 13

Tamoxifen has shown reduction of invasive carcinoma by 56%

Question 14

Presentation/ characteristics of Paget’s disease of nipple

Answer 14

Crusting and eczematous changes of nipple-areola complex Itching and burning of nipple and areole Presence of Paget’s cells located throughout epidermis

Question 15

Describe Paget’s cells

Answer 15

Large Hyperchromatic Round to oval nuclei with abundant amphophilic to clear cytoplasm Mitosis commonly seen Cells found in cluster or individually in basal layers

Question 16

Percentage of underlying malignancy in Paget’s disease

Answer 16

>95?

Question 17

Motility factor released by epidermal keratinocytes that results in chemotaxis of Paget’s cells that migrate to overlying nipple epidermis.

Answer 17

Heregulin-alpha

Question 18

Differential diagnosis of Paget’s disease

Answer 18

Superficial spreading melanoma Pagetoid SCC in situ Clear cells of toker

Question 19

Percentage of palpable mass at diagnosis in Paget’s disease

Answer 19

50% Of which >90% cases invasive carcinoma

Question 20

What percentage and histology in presentation of non palpable mass in Paget’s disease

Answer 20

66-86% DCIS

Question 21

Mammographic findings in Paget’s disease of nipple

Answer 21

Palpable mass Normal mammograms reported in as many as 50%

Question 22

Management of Paget’s disease

Answer 22

Local treatment, systemic and regional node disease should be based on associated disease

Question 23

EORTC 10873 study for Paget’s disease of nipple

Answer 23

Complete excision with tumor free surgical margin and whole breast RT Median follow up 6.4 years Majority are DCIS without palpable mass 5 years local recurrence rate 5.2%

Question 24

Risk factor for DCIS

Answer 24

Family history Delayed age of first live birth and nulliparity History of benign breast biopsy Alcohol

Question 25

Percentage of new cases of DCIS present with mammogram

Answer 25

95%

Question 26

Findings of mammographic abnormalities in DCIS

Answer 26

Microcalcifications most typical

Question 27

DCIS Linear and segmental calcifications? Linear and branching calcifications? Fine and granular calcifications?

Answer 27

DCIS in 80% of cases High grade DCIS and necrosis Low grade DCIS

Question 28

Role of MRI in DCIS

Answer 28

Highest sensitivity particularly High-grade DCIS Extent of DCIS involvement aiding treatment planning

Question 29

Nipple discharge and negative mammogram. How to distinguish underlying DCIS vs Papilloma?

Answer 29

Galactography

Question 30

5 subtypes of DCIS

Answer 30

Comedo Solid Cribiform Micropapillary Papillary Less common Apocrine Neuroendocrine Signet ring cystic hypersecretory carcinoma Clinging DCIS

Question 31

DCIS Working Party of the EORTC Features that convey prognostic significance

Answer 31

Nuclear grade Presence of necrosis Polarization Architectural patterns Margin status Lesion size Extent of microcalcification Correlation between specimen x-ray and mammographic findings

Question 32

Faverly et al DCIS growth pattern within ductal free and lmplication for surgical excision

Answer 32

Unicentric Multicentric(2 distinct areas separated by \>4cm) Continuous Discontinuous or Multifocal(2 or more areas separated by \<4cm)

Question 33

What genetic abnormality in DCIS demonstrate synchronous invasive breast cancer

Answer 33

Loss of heterozygosity

Question 34

Which subtype of DCIS share loss of heterozygosity with synchronous invasive lesion

Answer 34

77% nocomedo 80% comedo

Question 35

Molecular markers in DCIS All High grade Low grade

Answer 35

ER 70% high grade 25% low grade 90% HER 50% P53 25%

Question 36

Occult micro invasive breast cancer are most common in

Answer 36

DCIS \>2.5cm in diameter Present with palpable masses or nipple discharge High grade DCIS or Comedonecrosis

Question 37

DCIS is not a single disease

Answer 37

DCIS encompass diverse group of lesion that differ in regards to clinical presentation, mammographic features, extent and distribution with breast, histologic characteristics, biologic markers

Question 38

Factors identified in local failure risks in DCIS

Answer 38

Symptomatic presentation Lesion size Histopathologic subtype Nuclear/cytologic grade Central necrosis Margin status Patient age

Question 39

LRR and CSMR in mastectomy for DCIS

Answer 39

LRR 96-100% CSMR \<=4%

Question 40

What could be cause of local treatment failure after mastectomy for DCIS

Answer 40

Unrecognized invasive carcinoma Incomplete removal of breast tissue with subsequent formation of new primary

Question 41

Role of PORT following mastectomy or skin sparing mastectomy in DCIS

Answer 41

High grade with pathologic margin \<1mm

Question 42

Name trials in DCIS Lumpectomy vs Lumpectomy+RT

Answer 42

NSABP B-17 EORTC 10853 UK/ANZ SweDCIS

Question 43

Answer 43

A

Question 44

Answer 44

A