BREAST

Question 1

What are the predisposing factors for breast cancer?

Answer 1

Increased oestrogen exposure, high number of total menstrual cycles, early menarche, late menopause, nulliparity, first full-term pregnancy after age 35, exogenous oestrogen intake, personal history of breast cancer, positive family history, previous radiation treatment in childhood, lifestyle factors (low-fiber and high-fat diet, smoking, alcohol consumption, obesity in post-menopausal women, disrupted sleep cycle).

Question 2

What is the genetic predisposition for breast cancer?

Answer 2

Approximately 5-10% of women with breast cancer have an underlying genetic predisposition, commonly due to BRCA1 or BRCA2 gene mutations.

Question 3

What is the lifetime risk associated with BRCA1 and BRCA2 mutations?

Answer 3

BRCA1 and BRCA2 mutations are associated with a significant increase in breast cancer risk, up to 50-70% lifetime risk, and an increased risk of ovarian cancer.

Question 4

What are other high penetrance genes associated with breast cancer?

Answer 4

SMAK2, RAD51C, PALB2, ATM, PTEN, CDH1, among others.

Question 5

What is Li-Fraumeni syndrome?

Answer 5

An autosomal dominant inherited mutation of the p53 tumour suppressor gene (TP53) associated with multiple malignancies at an early age.

Question 6

What is Peutz-Jeghers syndrome?

Answer 6

An autosomal dominant inherited STK11 mutation associated with gastrointestinal tract polyps and increased risk for multiple malignancies.

Question 7

What is Cowden Syndrome?

Answer 7

An autosomal dominant inherited PTEN or WWP1 genetic mutation associated with multiple non-cancerous tumour-like growths and increased risk for several cancers.

Question 8

What is the approach to suspected breast cancer?

Answer 8

In countries with mammographic screening, abnormalities are detected on mammography. In other cases, patients may present with a self-palpated mass. The diagnostic approach involves clinical assessment, radiographic imaging, and biopsy.

Question 9

What should a clinical assessment for breast cancer include?

Answer 9

A thorough history and physical examination, including age, symptoms and duration, personal and family history of cancers, age of menarche, age at first live birth, breastfeeding history, menopause, use of oral contraception, hormone replacement therapy, smoking and alcohol use, and lifestyle factors.

Question 10

How can a patient’s risk for breast cancer be calculated?

Answer 10

Using online calculators like IBIS (The Tyer-Cuzick Model).

Question 11

What should be looked for during a breast examination?

Answer 11

Obvious asymmetry, skin changes, visible lumps, etc.

Question 12

What characterizes non-invasive carcinomas?

Answer 12

The absence of stromal invasion.

Question 13

What is localized DCIS?

Answer 13

DCIS is contained to the milk duct.

Question 14

What is the most common type of invasive breast carcinoma?

Answer 14

Invasive ductal carcinoma, accounting for 70-80% of all invasive breast carcinomas.

Question 15

What are the characteristics of invasive ductal carcinoma?

Answer 15

Unilateral localization, mostly unifocal tumors, and more aggressive compared to lobular carcinoma.

Question 16

What percentage of invasive breast carcinomas is invasive lobular carcinoma?

Answer 16

10-15% of all invasive breast carcinomas.

Question 17

What are the characteristics of invasive lobular carcinoma?

Answer 17

Can be unilateral or bilateral, frequently multifocal, less aggressive than ductal carcinoma, and has slower metastasis.

Question 18

What are some less common subtypes of invasive breast carcinoma?

Answer 18

Mucinous (< 5%), medullary (5%), tubular (1-2%).

Question 19

What is inflammatory breast cancer?

Answer 19

A type of breast cancer that is characterized by swelling and redness of the breast.

Question 20

What does biological classification refer to?

Answer 20

The expression of hormone receptors, such as estrogen and progesterone.

Question 21

What are the three major molecular subtypes of breast cancer?

Answer 21

Luminal-type (subtype A and B), HER2 amplified, and basal-like (triple negative).

Question 22

What is the purpose of molecular tests in breast cancer?

Answer 22

To provide more information on tumor biology and improve the accuracy of prognosis.

Question 23

What is the significance of receptor testing of biopsy samples?

Answer 23

Determines biological classification and is used as a surrogate for molecular classification.

Question 24

What is the positive rate for estrogen receptor (ER) and progesterone receptor (PR) status?

Answer 24

Positive in 70% of cases.

Question 25

What does HER2/neu testing indicate?

Answer 25

Positive (overexpression) in approximately 20% of cases.

Question 26

What is triple-negative breast cancer?

Answer 26

Cancer that is ER negative, PR negative, and HER2 negative, occurring in approximately 10% of cases.

Question 27

What does axillary lymph node status indicate?

Answer 27

Suggests that hematogenic spread has potentially occurred.

Question 28

What staging tests are needed for Stage 1 breast cancer patients?

Answer 28

No expensive staging tests are needed as the incidence of metastasis at presentation is low (~1-4%).

Question 29

What imaging is used for suspected bone metastasis?

Answer 29

Bone scan if localized bone pain, raised ALP, or advanced disease (Stage 3).

Question 30

What imaging is used for suspected liver metastasis?

Answer 30

Abdominal CT or Abdominal Ultrasound, usually requested if nodal spread.

Question 31

What imaging is used for suspected lung metastasis?

Answer 31

CXR or Chest CT, usually requested if nodal spread has occurred.

Question 32

What is the purpose of thoracocentesis in lung metastasis?

Answer 32

To detect malignant cells in pleural effusion fluid.

Question 33

When is a CT brain scan performed?

Answer 33

For detection of brain metastasis in symptomatic patients only.

Question 34

What is the essential step in diagnosing skin lesions in the breast?

Answer 34

Exclusion of an underlying invasive tumour is essential. ## Footnote MRI is often used in addition to mammography and ultrasound in these instances.

Question 35

What is the treatment approach for large skin lesions in the breast?

Answer 35

Surgical treatment, if possible, using a breast-conserving procedure.

Question 36

What defines inflammatory breast cancer?

Answer 36

A rare form of advanced, invasive carcinoma characterized by dermal lymphatic invasion of tumor cells, most commonly a ductal carcinoma.

Question 37

What are the clinical features of inflammatory breast cancer?

Answer 37

Erythematous and edematous skin plaques over a rapidly growing breast mass, tenderness, burning sensation, blood-tinged nipple discharge, and axillary lymphadenopathy.

Question 38

What percentage of patients with inflammatory breast cancer have metastatic disease at presentation?

Answer 38

25% of patients have metastatic disease at the time of presentation.

Question 39

What is the diagnostic method for inflammatory breast cancer?

Answer 39

Skin punch biopsy.

Question 40

What are the differential diagnoses for inflammatory breast cancer?

Answer 40

Mastitis and breast abscess.

Question 41

What is the treatment for inflammatory breast cancer?

Answer 41

Chemotherapy + radiotherapy + radical mastectomy.

Question 42

What is the prognosis for inflammatory breast cancer?

Answer 42

5-year survival with treatment: ~50%, without treatment: < 5%.

Question 43

What is the case study of a 35-year-old woman with breast cancer?

Answer 43

A 35-year-old woman presents with a new area of nodularity in her upper right breast, confirmed as invasive ductal carcinoma.

Question 44

What is the traditional management for the case study patient?

Answer 44

Surgery to remove a portion of breast tissue or mastectomy, followed by adjuvant chemotherapy and radiotherapy.

Question 45

What is the current management approach for the case study patient?

Answer 45

Advocate a switch in the order of treatment to deliver chemotherapy first.

Question 46

What are the advantages of neoadjuvant chemotherapy?

Answer 46

It is likely to shrink the tumour mass, allowing a smaller breast volume to be removed after chemotherapy.

Question 47

What happens if the patient tests positive for BRCA1 or BRCA2 genes?

Answer 47

Surgical discussion would center on the benefits of bilateral mastectomy surgery, with or without immediate reconstruction.

Question 48

What happens if the patient tests negative for breast cancer genes?

Answer 48

Breast-conserving surgery is made much easier by a reduction in the volume of breast tissue removed.

Question 49

What techniques do breast surgeons use to minimize cosmetic impact?

Answer 49

Breast surgeons can adopt several oncoplastic techniques to move residual breast tissue to fill in defects.

Question 50

What is the typical duration of radiotherapy after chemotherapy and surgery?

Answer 50

Usually for a period of three weeks to the breast itself.

Question 51

What is the recommended adjuvant treatment if the tumour is ER positive?

Answer 51

Adjuvant tamoxifen at a dose of 20mg per day.

Question 52

What are common side effects of tamoxifen?

Answer 52

Hot flushes, which are difficult to control.

Question 53

What is the follow-up protocol for the patient?

Answer 53

Clinical follow-up at one year.

Question 54

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Interdisciplinary Team

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Pain & Symptom Management

Question 60

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Endocrine & Soft Tissue Surgery

Question 62

PROGNOSIS

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Specialized Case

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Management

Question 65

Physical Health

Question 66

PATIENT &

Question 67

LOVED ONES

Question 68

Community Support

Question 69

Psycho-social Support

Question 70

Prognostic factors

Question 71

• Biological subtype and grade (most important prog-

Question 72

nostic factor)

Question 73

• Axillary lymph node status

Question 74

• Tumor size

Question 75

• Patients age

Question 76

HER2-positive cancers demonstrate a more aggressive tu-

Question 77

mor growth and higher recurrence rates and therefore are

Question 78

associated with a poor prognosis. Since the development

Question 79

of targeted therapy with trastuzumab

Answer 79

the prognosis for

Question 80

patients with HER2-positive cancers has improved.

Question 81

SURVIVAL

Question 82

• Early-stage disease without lymph node involvement

Question 83

• 10-year survival rate: 70%

Question 84

radiotherapy

Question 85

• Metastatic disease: 3-year survival rate of 48-71%

Question 86

SPECIAL SUBTYPES AND VARIANTS

Question 87

PAGET DISEASE OF THE BREAST

Question 88

COMPLICATIONS

Question 89

• Metastatic disease: bone metastasis (most common)

Question 90

> liver metastasis > lung metastasis > brain metastasis

Question 91

• Recurrence: up to 30% are local (chest wall

Answer 91

lymph

Question 92

nodes)

Question 93

• Paraneoplastic syndrome: hypercalcemia of malig-

Question 94

nancy

Question 95

• Treatment-associated complications:

Question 96

• Lymphedema of the arm: results in immobility

Question 97

of the limb

Answer 97

increased risk of infection

Question 98

wound healing

Answer 98

and cosmetic disfigurement. This

Question 99

should be managed by a lymphoedema specialist

Question 100

(trained physiotherapist or occupational therapist)

Question 101

with specialist massage

Answer 101

compression stockings

Question 102

and exercise

Question 103

• Angiosarcoma of the breast

Question 104

• Sometimes referred to as lymphangiosarcoma or

Question 105

hemangiosarcoma

Answer 105

depending on whether it arises

Question 106

from lymphatic or capillary endothelial cells

Question 107

• Rare

Question 108

secondary malignancy that results from

Question 109

chronic lymphedema in patients who underwent

Question 110

radiation therapy and/or ANC after mastectomy

Question 111

• Presents with multiple blue/purple

Answer 111

macular

Question 112

papular lesions in the area of the breast

Answer 112

chest wall

Question 113

or upper extremity

Question 114

• Endometrial cancer is promoted by tamoxifen ther-

Question 115

apy

Question 116

• Certain chemotherapy agents are cardiotoxic

Question 117

• Certain chemotherapy agents may elicit an anaphylac

Question 118

tic reaction

Question 119

Sate mary side lens thin shod chem managed.

Question 120

pro-actively

Question 121

• Posteradiain mascaus on stress and demate to

Question 122

the underlying lung tissue.

Question 123

Relapse typically occurs within the first five years after

Question 124

completion of treatment.

Question 125

192 | www.uctgeneralsurgery.co.za

Question 126

Figure 7. Paget disease of the breast

Question 127

Definition

Question 128

a lucas as that a teas he nola and are either insitu

Question 129

Clinical features

Question 130

• Erythematous

Answer 130

scaly

Question 131

nipple and areola

Question 132

• Pruritu

Answer 132

burning sensation

Question 133

• The lesion eventually ulcerates → blood-tinged nipple

Question 134

discharge

Question 135

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Question 136

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