Chapter 56 Breast Cancer : Early Stage

Question 1

Boundary of Breast

Answer 1

Superficial to Pectoralis major
Midline to mid axillary line
Cranially 2nd anterior rib
Caudally 6th anterior rib
Upper outer quadrant may extend to axillary tail of Spence

Question 2

Contents of chest wall

Answer 2

Ribs
Intercostal muscles
Serratus anterior muscle(not pectoral muscle)

Question 3

Where does most breast cancer develop anatomically?

Answer 3

Interface between ductal system and lobules, region called terminal ductal lobular unit

Question 4

Lymphatic drainage of breast

Answer 4

Predominant axillary lymph nodes
Supraclavicular lymph nodes
Internal mammary lymph nodes

Question 5

Describe division of axillary nodes

Answer 5

In relation to pectoral minor muscle
Level 1 caudal and lateral to muscle
Level 2 beneath the muscle
Level 3(Infraclavicular region) cranial and medial to muscle

Question 6

Describe IMC lymph nodes

Answer 6

IMC lie along internal mammary vessels
3-4cm lateral to midline
First 3 intercostal space nodes are usually involved

Question 7

Drainage of IMC lymph nodes

Answer 7

Medial, central and lower breast

Question 8

Describe process of sentinel lymph node imaging

Answer 8

Use of lymphoscintigraphy by injecting technicium-99 radiocolloid into peritumoral region followed by scintillation scanning.

Question 9

Causes of breast cancer

Answer 9

Older age (>50 years)
Age of menarche(early) and menopause(late)
Late age of first child birth, Nulliparity
Family history
Geographic and ethnic variability
Life style(Obesity)
Personal(dense breast)
Radiation induced
Hormonal therapy induced
Dietary factors(alcohol)

Question 10

What percentage of postmenopausal hormonal replacement therapy increased annual relative risk of developing breast cancer?

Answer 10

2.3%

Question 11

Randomized trial of postmenopausal hormonal therapy from Women’s health initiative group E+P vs Placebo
What percentage had breast cancer

Answer 11

24% increase in breast cancer, coronary heart disease, stroke, pulmonary emboli

Question 12

What percentage of women would have increased relative risk of breast cancer
Use of E+P vs non-user

Answer 12

8%

Question 13

What percentage of women would have increased relative risk of breast cancer
Use of Estrogen only vs non-user

Answer 13

1%

Question 14

Use of hormonal replacement therapy in women who have undergone hysterectomy

Answer 14

Estrogen only has minimal effect on breast cancer risk

Question 15

Use of hormonal replacement therapy in women who have not undergone hysterectomy

Answer 15

Estrogen and Progesterone remains standard to avoid risk of endometrial cancer associated with unopposed estrogen replacement

Question 16

How many years of oral contraceptives use prior to first pregnancy increases the risk of breast cancer

Answer 16

Some evidence shows 4 years

Question 17

Risk of breast cancer in family history
1st degree
2nd degree

Answer 17

1. 5

1. 7-2.5

Question 18

Describe genetic predisposition in breast cancer

Answer 18

1. Actual risk depends on number of relatives affected and their at diagnosis
2. Women with strong family history, multiple first and second degree relatives, diagnosed in premenopausal age are at risk of carrying mutation(BRCA1/BRAC2)

Question 19

Factors for radiation induced breast cancer

Answer 19

Increasing Dose

Young Age

Question 20

Relation of BMI and Breast cancer

Answer 20

Predominately in postmenopausal women
Higher estradiol levels associated with increased adipose tissue and increased aromatase involved in conversion of androgen to estradiol.

Question 21

Gail et al model for predicting annual and lifetime risk of breast cancer,is based on

Answer 21

Present age
Number of first degree relatives
Age at first birth
Age at menarche
Number of breast biopsies
History of atypical ductal hyperplasia

Question 22

Table 56.2

Answer 22

Table 56.3

Question 23

Which tumor suppressor gene is called ‘Guardian of the genome’

Answer 23

P53 because of its critical role in cellular pathway that recognize and direct the response to DNA injury

Question 24

What percentage of patients with Li-Fraumeni syndrome have life time risk of breast cancer

Answer 24

90%

Question 25

BRCA1 types of cancer and incidence

Answer 25

Breast cancer 65-85% life time risk
Ovarian cancer 50% life time risk
Colon and prostate cancer

Question 26

BRAC2 types of cancer and incidence

Answer 26

Breast cancer 65-85% life time risk
Ovarian cancer much less risk than BRAC1
Male breast cancer
Pancreas cancer

Question 27

What percentage of breast cancer patient carry germline mutation in BRAC1 and BRAC2

Answer 27

7%

Question 28

Table 56.4

Answer 28

A

Question 29

Most common site of origin of breast cancer

Answer 29

Upper outer quadrant 38.5%
Central area 29%
Upper inner quadrant 5%
Lower outer quadrant 8.8%
Lower inner quadrant 5%
Rates correlates with amount of breast tissue in various quadrants

Question 30

Breast cancer is more common in which side?

Answer 30

Left

Question 31

What percentage of women with history of breast cancer have risk of developing new primary in contralateral breast

Answer 31

10-15%

Question 32

Voogd et al invasive ductal cancinoma, 5125 patients, clinically negative nodes underwent axillary dissection. Describe findings

Answer 32

34% had positive nodes in pathologic examination
Univariate analysis showed nodal metastasis associated with following
Tumor > 1cm
Moderately or poorly differentiated nuclear grade
High fraction of cells in growth phase (S phase)
LVSI
Age younger than 60 years

Question 33

Veronesi et al. Internal mammary node spread

Answer 33

Tumor larger than 2 cm, younger than 40 years and positive axillary nodes had 41% risk of having positive IMNs.