Breast

Question 1

Miller Payne classification

Answer 1

1 - No response
2 - <30%
3 - 30-90%
4 - >90% response
5 - No residual cancer

Question 2

What is the BiRADs and what to do with each of the scores

Answer 2

0 - incomplete exam
1 - negative
2- Benign
3- Likely benign (<2% chance of malignancy) - short interval follow up 6 months
4- Suspicious - biopsy recommended
5- Highly suspicious of malignancy >95% chance
6 - biopsy proven malignancy

Question 3

Stages of lymphoedema

Answer 3

Assess the softness vs firmness of the limb to gauge - increased fibroadipose tissue with worsening lymphoedma.
Severe has >40% increased limb volume
Mod - 20-40%

0 - not apparently clinically - subclinical latent phase
1 - clinically apparent, resolves with 24 hours of elevation, accumulation of protein rich fluid. Pitting oedema no fibrosis
2 - Some deposition of fibrofatty tissue, evolving dermal fibrosis. “spontaneously irreversible lymphoedema”
3 - lymphostatic elephantitis

Question 4

Van Nuys prognostic index

Answer 4

Age <40, 40-60, >60
Size >40, 16-40, <15mm
Margin <1 mm, 1-9 mm, >10 mm
Histology - non high, +comedo necrosis, High + necrosis

<7 - excise
7-9 = medium risk - recommend excision + RTx
>9 - mastectomy

Question 5

How do you class implant capsular contracture

Answer 5

Baker classification

1 - breast feels and looks normal
2 - feels a bit firm but looks normal
3- firm and looks abnormal
4- painful and hard
3 and 4 are usually removed

Question 6

Advantages and disadvantages of immediate recon

Answer 6

No time without breast
Enables skin sparing mastectomy - superior cosmesis
- retain inferior mammary fold

One op

Risk of complications which could potentially delay adjuvant treatment
Long procedure
Need to find the time with two teams available
Inferior cosmesis if has adjuvant radiation -
Limited time to think over options

Question 7

Advantages and disadvantages of delayed recon

Answer 7

Allows all adjuvant Treatment to be completed
Allows time for woman to adjust to mastectomy and diagnosis. More time for decisions to be made

Cannot preserve skin
Tissue expander or flap based

Question 8

Contraindications for recon

Answer 8

Avoid if Severe obesity (>30-35)- high rates of complications from prolonged procedure- but not absolute contraindication

Severe comobrid unresectable cancer

Advise smoking cessation

Question 9

What features to assess in phyllodes to determine if benign, borderline or malignant

Answer 9

Stromal cellular atypia
Mitotic activity
Margins
Stromal overgrowth

Question 10

Types of phyllodes

Answer 10

50% benign
25% borderline
25% malignant

Question 11

Grading dcis

Answer 11

According to nuclear size (large = higher grade), pleiomorphism

Low
Intermediate
High grade +/- comedo necrosis

Question 12

Definition of dcis and difference with adh

Answer 12

Clinal proliferation of neoplastic luminal cells that fill the terminal duct lobular units but do not breach the basement membrane
ADH doesn’t completeLy fill ducts and is less than 2mm

Question 13

USS features benign and malignant breast mass

Answer 13

Malignant =
Taller than wide
Irregular margins
Multilobulated 
Micro Calcifications
Hypoechoic/heterogenous 
Acoustic shadow 
Thick hyperechoic shadow

Benign=
Wider than tall
Minimal shadow
Smooth lobulations
Well circumscribed
Hyperechoic
Compressible

Question 14

Mammogram malignant

Answer 14

Spiculation
Mass
Architectural distortion
Skin changes 
Asymmetric 
Calcification

Question 15

Grading of DCIS

Answer 15

nuclear pleiomorphism

nuclear size

Question 16

What are the 6 principals of level 1 oncoplastic breast surgery

Answer 16

1. Skin incision - wide enough to allow access for excision and reshaping. Always think of tension lines.
2. Undermine skin
3. Undermine nipple areolar complex
4. Full thickness excision
5. Reapproximation (mobilise breast)
6. Deepitheliasation and reposition nipple

Question 17

natural history of fibroadenoma

Answer 17

55% stay the same
35% smaller
10% get bigger

Question 18

grading of DCIS

Answer 18

nuclear size and pleiomorphism

+ necrosis

Question 19

bloomfield richardson grading breast cancer

Answer 19

1-3 tubular formation
1-3 mitoses
1-3 nuclear pleiomorphism

Question 20

NPI + %10 year survival

Answer 20

<2.41 = 96%
5.41-6.4 = 50%
>6.4 = 38%

Question 21

TNM breast cancer

Answer 21

T1 <2cm
T2 2-5cm
T 3 >5cm
T4 invasion/IBC

N1 - 1-3 nodes
N2 - 4-9 nodes b - clinically positive internal mammary node
N3 - 10+ or supraclavicular nodes

Question 22

Indications for breast MRI

Answer 22

Surveillance of high risk patients (BRCA, Li Fraumini, prior chest wall Rtx)
Breast cancer in women with very dense breast tissue
Occult malignancy in Paget’s or axillary mets
Pre reconstruction
locally advanced breast cancer

Question 23

indications for frozen section

Answer 23

Immediate reconstruction
Neoadjuvant therapy
Negative FNA with an abnormal node radiologically/clinically

Question 24

Considerations for SNLB after NAC

Answer 24

excise 2-3 nodes due to otherwise high false negative rates -
ok to do SNLB if clinically negative pre NAC otherwise should be doing a dissection
Gray area - low burdern of lymph node disease pre NAC which completely responds radiologically - could do a SLNB ensuring clipped node is taken and do a frozen section