Breast Cancer FRCR C02A Flashcards
(419 cards)
1
Q
How is each breast divided?
A
5 regions
1. Central and
2. UOQ
3. UIQ
4. LOQ
5. LIQ
2
Q
What’s the Lymphatic Drainage of Breast?
A
Axillary LNs
IMNs
3
Q
What are the types of cancer affecting Breast?
A
Invasive ductal carcinoma
Invasive lobular carcinoma
4
Q
what’s the status of E-cadherin in IDC and ILC?
A
+ in IDC
- in ILC
5
Q
What are the reasons for improvement in 5 yr OS for Breast Cancer?
A
- screening
- improved treatment (sugical techniques, adjuvant Hormone Rx and better ChT)
6
Q
what are the RFs for Breast Cancer?
A
- Age
- Reproductive factors
- History of Benign disease
- Previous Radiation exposure
- Dietary factors
- Genetic Factors
7
Q
How does age affect Breast cancer risk?
A
Incidence increases with age, X2 every 10 yrs until menopause, then rate slows
8
Q
What Reproductive Factors are a/w BC?
A
- Early menarche
- Late natural menopause
- Late age at 1st birth
- nulliparity
B/L Oophorectomy b4 age of 35: reduced risk of BC
9
Q
How are exogenous hormones a/w BC?
A
Estrogen and Progesterone in combination Increases risk more than taking Estrogen alone,
increases with increasing length of HRT use
10
Q
Does HRT in BC pts affect risk of recurrence?
A
Yes,
HABITS trial has shown that
11
Q
What Dietary FActors are a/w BC?
A
- Obesity
- Alcohol intake
12
Q
Does obesity in premenopausal women increase risk of BC?
A
No in fact studies have shown it reduces
But it increases risk in Post menopausal women by about 50 %
13
Q
How does family Hx affect risk of BC?
A
1st degree relative with BC: doubled
if >1, 1st degree relative, higher risk or has BC at young age
14
Q
Mutations in which genes are a/w Familial BC?
A
BRCA 1 and 2, TP53
15
Q
where is BRCA 1 located, how much does it Increase risk of BC?
A
chromosome 17q21
35 to 85 %
16
Q
what are features of BRCA 1 associated BC?
A
young age
increased risk of ovarian cancer
more malignant pathological features
Typically TNBC
17
Q
Where is BRCA2 gene located?
A
Chromosome arm 13q
18
Q
By what % BC risk is increased with BRCA 2 +?
A
20 to 60 %
19
Q
what are other cancers BRCA 2 associated?
A
Male: PRostate
pancreas and bladder cancer
NHL,
20
Q
What’s peculiar about BRCA 2 associated BC?
A
ER and PR +, higher grade with less tubule formation
21
Q
What is TP53, % of increased BC risk, location?
A
17p13
Li Fraumeni Syndrome
50% risk of developing BC
22
Q
what other genetic syndromes are a/w BC?
A
Ataxia Telengiectasia (AR )
Cowden’s Syndrome (AD) (PTEN)
Muir Torre Syndrome
Peutz Jeghers Syndrome
23
Q
what’s the histology of BC?
A
almost all Adenocarcinoma
24
Q
Location wise incidence of BC?
A
UOQ 50%
Central 20 %
UIQ 10%
LIQ 10 %
LOQ 10%
25
How is BC graded ?
Bloom Richardson system modification
Grade is based on
1. degree of tubule formation
2. nuclear pleomorphism
3. mitotic inded
Grade 1 (3 to 5)
Grade 2 (6 to 7)
Grade 3 (8 to 9)
26
How does Hormonal Status of Tumor differ in pre and post menopausal women?
ER 2/3 of post menopausal
< 1/2 of pre menopausal
27
What are molecular subtypes of BC?
1. Luminal A
2. Luminal B
3. Her 2 +
4. Basal like
28
what is Lumina A BC?
ER and PR +
Her 2 -
Ki67 low
29
what is luminal B BC?
two types
1. luminal B Like (her 2 -): ER +, HER 2 - and atleast one of : Ki 67 high, PR - or low
2. luminal B like (Her 2 +)
ER +, Her 2 + any Ki 67 and any PR
30
what is Her 2 +?
Her 2 +
ER and PR -
31
what is Basal like BC?
TNBC
32
what % of symptomatic BC pts have ALN +?
50 %
33
what % of screen detected BC pts have ALN+?
10 to 20 %
34
what are RFs for IMN involvment?
1. > 4 ALN +
2. Inner quadrant tumors
35
what are regional LNs for BC?
Axillary (I to III)
Infraclavicular
IMN
supraclavicular
36
Which age group should undergo BC screening?
50 to 70 yrs
37
what are 2 views of Mammogram?
Mediolateral oblique
craniocaudal
38
why is mammogram less effective in young age?
Radiodense breast
39
when is MRI surveillance recommended?
Age 30 to 49 yrs at moderate and high risk of BC, BRCA 1 and 2 mutation and TP53
40
what are preventive options for high risk individual of BC?
chemoprevention
prophylactic mastectomy
41
what drugs are used for chemoprevention of High risk BC?
tamoxifen or Raloxifen
42
How does BC present?
1. Breast Lump
2. skin changes
3. Nipple changes
4. Regional disease
5. metastatic disease
43
what are features of BC lump?
u/l, solitary, hard, irregular, non mobile and non tender
44
what are skin changes in BC?
thickening, redness, dimpling and/or inflammation
45
what is peau d'orange and why does it happen?
infiltration of tumor into the subcutaneous lymphatic channels
46
what are nipple changes in BC?
1. loss of elasticity
2. flattening or inversion of nipple
3. scaly or eczema like lesion
4. spontaneous discharge in pts > 50 yrs of age
47
what is triple assessment in BC diagnosis?
1. Physical Examination
2. Radiological Investigations
3. Needle Biopsy
48
What's advantage of core biopsy over FNAC?
provides tissue for histological examination and can differentiate between invasive and in situ carcinoma
49
when should metastatic work up be carried out in BC pts?
T3 and T4 disease
50
what is DCIS?
1. True premalignant condition, 30 to 50 % of untreated DCIS will develop invasive cancer in I/L breast within 10 yr of Dxw
51
what's the mammographic finding of DCIS?
Branching macrocalcifications localized to a small region of breast
52
what genes are often a/w DCIS
TP 53 and Her 2 amplification
53
what are factors a/w prognosis in DCIS?
Grade, size and distance to resection margin
Age
54
What's the preferred Rx for DCIS?
WLE followed by Adjuvant RT
55
what margin should be achieved for WLE of DCIS?
atleast 1 mm
56
when is mastectomy done for DCIS?
widespread disease (>2 quadrants) or where surgical margins can not be achieved
57
IS LND necessary in DCIS?
No
not even SNB
58
what's the role of RT in DCIS?
given after WLE, results show reduced local recurrence across all subgroups of women with DCIS
59
what is LCIS?
not a true premalignant condition but increased risk of BC (30 % ) lifetime risk
60
How does LCIS usually present?
premenopausal women; always multicentric and B/L in 1/3
61
WHat's the hormonal status of LCIS?
usually ER +, HER2 - and TP53 negative
62
How is LCIS usually detected?
usually not palpable or detectable by mammogram
incidentally in 1% of benign breast biopsies
63
what's the Rx of LCIS
observation bcoz low risk of malignant transformation (21 % over 15 years)
64
what type of LCIS behave like DCIS?
Pleomorphic LCIS
65
if at all, LCIS is to be treated Like family Hx, what surgery is done?
B/L mastectomy with/without reconstruction
risk of cancer is equal in both breasts
66
What's the Rx of Early BC?
1. MRM and axillary dissection
2. BCS f/b RT
67
what structures are removed in MRM?
1. entire breast
2. Nipple and areola
3. Axillary node dissection
68
What is BCT?
BCS + Adj. RT
69
what has NSABP-06 trial shown?
Lumpectomy + RT Vs Lumpectomy only
significant difference in Local Recurrence (14 % Vs 39%)
70
what's the most important factor a/w local rec post WLE ?
margin status, should be at least 1 mm
71
what should be done in case of + margin post WLE?
Re-excision, if feasible, if not mastectomy
somecases RT with boost to margin
72
what are absolute C/Is for BCS and RT?
1. Previous RT to breast / CW
2. during pregnancy
3. diffuse malignancies
4. positive pathological margin
73
what are relative C/I for BCT?
1. connective tissue disease
2. tumor > 5 cm
3. focally + margin
74
How many LNs should be at least resected in ALND?
10
75
what are S/Es of ALND?
1. axillary pain and numbness
2. decreased range of arm movement
3. chronic lymphedema
76
What are different axillary LNs levels?
level I: lateral to p minor
level II: beneath p minor
level III: superomedial to p minor
77
when is SLNB an option instead of ALND?
Node negative BC patients
78
what is SLN?
1st node in regional lymphatic basin to which tumor drains
79
How is localization of SLN done?
injecting blue dye and radioactive colloid tracer around the tumor, into the dermis, or under the nipple
SLN are detectable as blue nodes or as radioactive nodes by hand probe
80
what things should be considered b4 SLNB?
1. experienced surgical team
2. node clinical negative
3. no prev ChT or HT
81
What's the current recommendation for a women with SLNB?
Axillary node clearance
82
What to do for T1 and T2 pts with 1 to 2 SLN + BC patients?
Z0011 study, no difference in Rx arms in terms of OS or DFS, morbidity lower in observation VS Axillary Dissection
all pts had received post op RT to preserved breast and formal nodal irradiatiion was not included
83
what has AMAROS trial shown?
T1-2 disease, SLN + disease
Further dissection Vs Axillary RT
No diff in OS or DFS, less lymphedema in RT arm
84
what's the role of adj. RT to whole breast post BCS?
SOC, halve the risk of local rec among all subgroups of women (EBCTG, 2011)
reduced BC death at 15 years
85
when can omitting Adj RT be considered post BCS?
elderly women > 70 years, low risk cancers and clear margins
86
when is RT usually given?
post ChT
87
Should Anthracycline be combined with RT?
No
88
What are indications of SCF RT?
> 4 positive ALNs
89
is Axillary RT given post Axillary clearance?
N0
90
what are indications of Axillary RT post BCS?
AMAROS , 1 - 2 SLNs +
incomplete macroscopic excision
extensive extra nodal spread
91
what has MA 20 trial tested?
N+ (1 to 3) or high risk N- BC to either whole breast RT or to WBRT and nodal irradiation
Nodal RT (Axilla I to III, IMN and SCF)
Result: at 10 yr, no diff in OS, DFS improved in nodal RT 82 % vs 77 %, balanced against increased pneumonitis and lymphedema
92
when should IMN RT be considered? c
involved LNs
93
when is prone breast board used for RT ?
Large Breast
94
what are conventional RT field borders for BReast RT?
Medial: MIDLINE
LateraL: mid axillary line
Supr: suprasternal notch
infr: 1 cm below the breast tissue
Deep: incorporating max of 2 to 3 cm of lung
95
What are conventional RT field borders for SCF and axillary field?
Medial: 1 cm lateral to the midline
Lat: (SCF only): 1 cm lateral to the outer border of the 1st rib if no clips are used
Lat (SCF + axilla): to cover axillary region laterally
Supr: 3 cm above the clavicle
Infr: matched to tangential field
96
How are field arrangement done for SCF and Axilla?
single antr field for SCF, when axilla is added, a postr beam may be required
97
What are different RT dose regimens in BC?
START trial: 40 Gy/ 15#
others: 50 Gy/ 25#, 45 Gy/ 20#
FAST trial
28.5 Gy/ 5#
30 Gy/ 5#
FAST FORWARD Trial
27 Gy/ 5 #
26 Gy/ 5#
98
what's the palliative RT dose for fungating tumors of Breast?
36 Gy/ 6#, once a week with weekly review
99
How can hotspots be reduced while planning for BC?
adding mini fields
100
what are OARs constraints for BC RT ?
START and FAST FORWARD trial
I/L Lung, max depth of 2 cm or V30% <17 %
Heart: max depth of 1.0 cm or
V25%<5% and V5%<30%
101
what things can be done if dose constraints for OAR not achieved?
MLC shielding
Breath hold technique
102
What is APBI?
2 fractions per day over 1 week, with RT given only to breast tissue closest to site of excised tumor
RAPID trial: increased rate of poor cosmesis with APBIo
103
How is Intra op RT delivered?
Single dose during surgery with electrons (6-9 MeV) or via an intrabeam device with 50 kV photons
104
when is ONCOtype Dx recommended by NICE ?
for ER +, LN - and Her 2 - BC
105
what's the advantage of Oncotype Dx?
ChT can be avoided in low risk of recurrence pts, who previously received Chemo
106
what are different chemo regimens for adj BC?
1st Gen: CMF
2nd GEN: Epi-CMF
TAC
FEC f/b Taxel
AC f/b Paclitaxel
Dose Dense regimens
107
what's the role of Tamoxifen in BC adjuvant setting?
useful in both pre and post menopausal women
EBCTCG : ER+ pts for 5 years, reduced annual rec by 41 % and annual mortality by 34%
108
which trials have compared 5 yrs vs 10 yr of tamoxifen?
ATLAST and a TTOM , further benefits
109
when should tamoxifen be started in adjuvant setting?
after completion of Chemo
110
tamoxifen is c/i, what can be done?
OFS with gosrelin
111
who gets most benefit from OFS?
women at greater risk of recurrence
112
what should be used as HT for post menopausal ladies with ER + BC?
AIs
113
what are s/es of tamoxifen and AI?
Tamoxifen: higher rate of gynecological and vascular symptoms
AI: arthralgia and bone #
114
for how long should AI be used
5 yrs
should monitor bone health
no advantage found with further extension
115
For how long is Trastuzumab given in adjuvant setting for Her 2 + BC ?
1 year
116
what's the main S/E of Trastuzumab?
Cardiac Toxicity
117
when should cardiac function be monitored for Trastuzumab?
B4 starting and then every 4 months during Rx
118
should Anthracycline and Trastuzumab combine?
NO
Docetaxel CArboplatin and Trastuzumab is less cardiotoxic than Doxorubicin cyclophosphamide and Trastuzumab
119
What are LABC?
Stage IIIA (T0-3, N2, M0)
Stage IIIB (T4, N0-2, M0)
Stage IIIC (any T, N3)
120
How are LABC managed?
NACT or NAHT, or Her2 targeted therapy f/b BCS or mastectomy
mastectomy can be prevented in 80% of pts
121
When is BCT not possible?
Central Tumors
Multifocal tumors or with
Inflammatory BC
122
what's other advantage of NACT except downstaging?
to assess the sensittivity of tumors to systemic therapy
pathological CR: good prognosis
pts with radiological CR: Sx can be avoided, increased local rec
123
what's the usual Rx of LABC?
NACT f/b BCT and ALND + RT with /without HT (except inflammatory BC)
Mastectomy + ALND with/without RT , hormones or delayed breast reconstruction
Definitive RT to breast axilla and SCF with/without Hormones
124
what are features of BC during Pregnancy?
diagnosed late and often involved ALNs, larger tumors and poorly differentiated, ER/PR - and Her 2 + (30 %)
125
Investigations during pregnancy for BC
Mammogram (appropriate shielding of fetus)
USG breast
CxR with shielding
USG Liver
126
How to treat BC in 1st trimester?
Continue pregnancy and Rx with mastectomy and ALND
begin adj chemo in 2nd trimester
Taxane, trastuzumab, Adj Rt and adj HT can only be given post partum
127
what S/E trastuzumab cause during pregnancy?
Oligohydramnios
128
What's paget disease?
1 - 4 % of BC, > 90 % are a/w underlying BC, 50% are palpable, palpable tumors are invasive cancers and 66 and 68 % have DCIS
129
How is pagets's diz treated?
mastectomy and axillary staging
excision of NAC with whole breast RT
adjuvant systemic Rx as with other Breast cancers
130
what is inflammatory BC?
3 % of all BCs, rare but poor prognosis, rapid (< 3 months) hx of diffue, brawny indurations of skin with an erysipeloid edge
131
whats the receptors status in IBC?
ER/PR -
HER2 +
132
How is IBC managed?
NACT f/b mastectomy and ALND with ADj RT and /or HT with/without Trastuzumab
133
what are prognostic factors in BC?
1. regional LN status: most important
2. Tumor size
3. Tumor grade
4. Age (< 35) poor prognosis
5. Hormone Receptor status
6. histological type
7. LVSI
8. her2 status
134
how is histology related with prognosis?
special types of invasive BC (tubular, cribriform, mucinous, papillary, microinvasive, adenoid cystic and medullary) better prognosis then of no special type`
135
1st L for ER/PR +, Her 2 - post menopausal or premenopausal with OFS
| Metastatic Disease
Aromatase inhibitor + ribociclib (category 1)
Aromatase inhibitor + abemaciclib
Aromatase inhibitor + palbociclib
136
If disease progression on adjuvant endocrine therapy or relapse within 12
months of adjuvant endocrine therapy completion consider:
Fulvestrantd + CDK4/6 inhibitorb
Fulvestrant + ribociclib (category 1)
Fulvestrant + abemaciclib (category 1)
Fulvestrant + palbociclib
137
1st L for ER/PR +, Her 2 + post menopausal or premenopausal with OFS
## Footnote
metastatic disease
* Aromatase inhibitor ± trastuzumab
* Aromatase inhibitor ± lapatinib
* Aromatase inhibitor ± lapatinib + trastuzumab
* Fulvestrant ± trastuzumab
* Tamoxifen ± trastuzumab
138
1st L for HR-Negative and HER2-Negative (Triple-Negative Breast Cancer; TNBC) NCCN 2025
## Footnote
metastatic
PD-L1 CPS ≥10g regardless of germline BRCA
mutation status: Pembrolizumab + chemotherapy (albumin-bound paclitaxel,
paclitaxel, or gemcitabine and carboplatin)i (category 1, preferred)
PD-L1 CPS <10g and no germline BRCA1/2
mutation: systemic therapy
PD-L1 CPS <10g and germline BRCA1/2 mutation: * PARPi (olaparib, talazoparib) (category 1, preferred)
* Platinum (cisplatin or carboplatin) (category 1, preferred)
139
2nd L for HR-Negative and HER2-Negative metastatic (Triple-Negative Breast Cancer; TNBC) NCCN 2025
## Footnote
metastatic disease
BRCA1/2: olaparib, niraparib
any: Sacituzumab govitecan
140
1st L for metastatic HR-Positive or -Negative and HER2-Positive
Pertuzumab + trastuzumab + docetaxel (category 1, preferred)
or Pertuzumab + trastuzumab + paclitaxel (preferred)
140
2nd L for metastatic HR-Positive or -Negative and HER2-Positive
Fam-trastuzumab deruxtecan
141
3rd for metastatic HR-Positive or -Negative and HER2-Positive
Tucatinib + trastuzumab + capecitabine
142
targeted therapies in BC
HR +, her2 -: PIK3CA: inavolisib + palbociclib + fulvestrant
alpelisib + fulvestrant
143
ESR 1 mutations
Elacestrant
144
RET fusion
selpercatinib
145
NTRK fusion
larotrectinib
entractenib
146
chemo for visceral crisis
anthracyclines
taxanes
anti metabolites
147
What is the most common female malignancy in the UK and USA?
Breast cancer
## Footnote
Breast cancer accounts for a significant number of new cases and deaths annually in both countries.
148
How many new cases of breast cancer occur each year in the UK?
30,000
## Footnote
This statistic highlights the prevalence of breast cancer in the UK.
149
What is the annual number of breast cancer deaths in the USA?
43,300
## Footnote
This number reflects the mortality rate associated with breast cancer in the USA.
150
What is the life-time risk of developing breast cancer for a woman in the UK?
1 in 12
## Footnote
This statistic indicates the likelihood of breast cancer development among women in the UK.
151
What is the life-time risk of developing breast cancer for a woman in the USA?
1 in 8
## Footnote
This shows a higher risk compared to the UK.
152
What are the reported risk factors for breast cancer?
* Hormonal
* Genetic
* Dietetic
* Radiation
## Footnote
These factors contribute to the aetiology of breast cancer.
153
Which hormone is considered the most significant aetiological factor in breast cancer?
Oestrogen
## Footnote
The role of hormones, particularly oestrogen, is crucial in the development of breast cancer.
154
What is the association of BRCA1 mutation with breast cancer?
Cancers tend to occur at an early age, are highly aggressive, and typically negative for ER, PgR, and HER2/neu
## Footnote
This mutation is linked to 'Triple negative' breast cancers.
155
What percentage of breast cancers are accounted for by BRCA2 mutations?
1%
## Footnote
These cancers are often ER and PgR positive.
156
How does previous breast cancer affect the risk of contralateral breast cancer?
Increases the risk by 0.5–1% per year
## Footnote
This statistic emphasizes the ongoing risk after a prior diagnosis.
157
What is the relative risk increase associated with prior radiation to the breast?
RR 3
## Footnote
This indicates a threefold increase in risk.
158
What are some benign conditions of the breast that can increase cancer risk?
* Atypical hyperplasia
## Footnote
These conditions are important to monitor for potential progression to cancer.
159
From which cells does breast cancer arise?
Epithelial cells lining the terminal duct lobular unit
## Footnote
This highlights the origin of breast cancer at the cellular level.
160
What is lobular carcinoma-in-situ considered in relation to invasive lobular cancer?
A precursor
## Footnote
However, it usually does not progress to the invasive stage.
161
What does atypical ductal hyperplasia increase the risk of?
Invasive cancer by 4–5 times
## Footnote
This condition is characterized by intraductal epithelial proliferation.
162
What characterizes ductal carcinoma-in-situ (DCIS)?
Malignant epithelial proliferation confined to a duct with no stromal invasion
## Footnote
It accounts for a significant percentage of both palpable and screen-detected breast cancers.
163
What percentage of palpable breast cancer does DCIS account for?
3–5%
## Footnote
This statistic underscores the importance of DCIS in breast cancer detection.
164
How is DCIS graded?
According to the appearance of cell nuclei
## Footnote
This grading helps in assessing the severity and potential progression of the condition.
165
What is microinvasive carcinoma?
Focus of invasive cancer of <1 mm in maximum extent
## Footnote
This type represents a very early stage of invasive breast cancer.
166
What percentage of all invasive carcinomas are classified as invasive ductal carcinomas?
70–80%
## Footnote
Invasive ductal carcinoma is thought to arise from DCIS.
167
What is the most common subtype of invasive ductal carcinoma?
'Ductal no special type' (ductal NST)
## Footnote
Ductal NST is a diagnosis of exclusion.
168
What are the percentages of tubular carcinoma in breast cancer?
1–2%
## Footnote
Tubular carcinoma is one of the special subtypes of ductal carcinomas.
169
What is the percentage range for medullary carcinoma in breast cancer?
4–9%
## Footnote
Medullary carcinoma is a special subtype of ductal carcinoma.
170
What percentage of breast cancer is mucinous carcinoma?
2%
## Footnote
Mucinous carcinoma is another subtype of ductal carcinoma.
171
What is the prevalence of papillary carcinoma in breast cancer?
1–2%
## Footnote
Papillary carcinoma is classified as a subtype of ductal carcinoma.
172
What percentage of invasive cancers does invasive lobular carcinoma constitute?
10–15%
## Footnote
Invasive lobular carcinoma infiltrates diffusely, affecting imaging and histologic findings.
173
What types of cancers can be included under other cancers in malignant breast lesions?
* Lymphoma
* Sarcoma
* Melanoma
* Metastasis
## Footnote
These are additional cancers that can be associated with breast lesions.
174
What should the postoperative pathology report include?
* Number of tumours
* Maximum diameter of largest tumour
* Histologic type and grade
* Circumferential excision margin
* Minimal margin
* Vascular invasion
* Number of nodes retrieved
* Number of nodes involved
* Extent of involvement
* Presence of DCIS
* Immunohistochemical status of ER and PgR and HER2
## Footnote
Details in the report are crucial for understanding the pathology of the tumours.
175
What is required for patients with an ambiguous HER2 (2+) status on immunohistochemistry?
Fluorescent in situ hybridization (FISH)
## Footnote
FISH is used to look for gene amplification.
176
How many subtypes of breast cancer have been identified through molecular profiling?
Five
## Footnote
The subtypes are luminal A, luminal B, HER2+, normal breast-like, and basal-like.
177
Which breast cancer subtypes are ER+?
* Luminal A
* Luminal B
## Footnote
Other subtypes are ER−.
178
What is the current status of molecular profiling in clinical practice?
Evolving
## Footnote
Future treatments may vary based on these subtypes.
179
What is the Nottingham grading system used for?
It is used for grading breast cancer.
180
What score indicates >75% degree of tubule formation in the Nottingham grading system?
Score 1
181
What score is assigned for <10% degree of tubule formation in the Nottingham grading system?
Score 3
182
What are the grades in the Nottingham grading system based on mitotic frequency?
Grade I: score 3–5, Grade II: score 6–7, Grade III: score 8–9
183
What is the scoring range for nuclear pleomorphism in the Nottingham grading system?
Mild, Moderate, Severe
184
What does McCarty’s Semi quantitative H scoring system measure?
It measures ER and PgR levels in breast cancer.
185
What is the maximum score in McCarty’s H scoring system?
300
186
What score is considered negative in McCarty’s H scoring system?
≤50 (−)
187
What score indicates a weakly positive result in McCarty’s H scoring system?
51–100 (+)
188
What score indicates a strongly positive result in McCarty’s H scoring system?
201–300 (+++)
189
What does the Her-2/neu scoring system assess?
It assesses the presence of Her-2/neu in breast cancer.
190
What is the score range for Her-2/neu immunohistochemical scoring?
0–3+
191
What does a score of 0–1+ indicate in Her-2/neu scoring?
Negative
192
What does a score of 2+ indicate in Her-2/neu scoring?
Borderline – needs further testing
193
What does a score of 3+ indicate in Her-2/neu scoring?
Positive
194
What does a FISH score of <2.0 indicate?
Not amplified: Negative
195
What does a FISH score of >2.0 indicate?
Amplified: Positive
196
What is the superior boundary of the adult breast?
Second rib
## Footnote
The adult breast extends from the second rib superiorly to the sixth rib inferiorly.
197
What is the inferior boundary of the adult breast?
Sixth rib
## Footnote
The adult breast extends from the second rib to the sixth rib.
198
What are the lateral and medial boundaries of the adult breast?
Medial: lateral edge of the body of the sternum; Lateral: mid-axillary line
## Footnote
The adult breast extends from the lateral edge of the sternum medially to the mid-axillary line laterally.
199
List the relative risk factors for breast cancer associated with early menarche.
3
## Footnote
Early menarche (before 11 years) has a relative risk of 3 for breast cancer.
200
What is the relative risk of breast cancer for nulliparity?
3
## Footnote
Nulliparity is a significant risk factor for breast cancer with a relative risk of 3.
201
What is the risk factor associated with having one maternal first-degree relative diagnosed with breast cancer?
1.5–2
## Footnote
The risk increases to 1.5–2 if there is one maternal first-degree relative.
202
What are the protective factors for breast cancer?
Artificial menopause before 35 years, Increased parity, Age at first pregnancy less than 30 years, Breast feeding
## Footnote
These factors can reduce the risk of developing breast cancer.
203
What is the modified WHO classification of breast cancer?
Precursor lesions, Malignant lesions
## Footnote
The classification includes precursor lesions such as lobular carcinoma-in-situ and malignant lesions like invasive ductal carcinoma.
204
What are the three levels of axillary lymph nodes?
Level I: inferior to pectoralis minor, Level II: posterior to pectoralis minor, Level III: superior to pectoralis minor
## Footnote
The axillary lymph nodes are categorized into three levels based on their location relative to the pectoralis minor.
205
How many internal mammary nodes are typically present?
3–5 nodes
## Footnote
Internal mammary nodes lie 2–3 cm from the sternal edge.
206
What percentage of lymphatic drainage passes through the axillary nodes?
More than 75%
## Footnote
Most lymphatic drainage from the breast passes through the axillary nodes.
207
What is a common presentation of early breast cancer?
Painless lump
## Footnote
The most common presentation is a painless lump in 65–75% of cases.
208
What is the 'triple' assessment for suspected breast cancer?
Clinical examination, Breast imaging, Pathologic evaluation
## Footnote
This approach allows for a definitive diagnosis in 99% of cases.
209
What is the most common mammographic abnormality of ductal carcinoma in situ (DCIS)?
Micro-calcification
## Footnote
Micro-calcification is seen in 50% of DCIS cases.
210
What does a hypoechoic lesion indicate in ultrasound examination?
Malignancy
## Footnote
Malignancy appears as a hypoechoic lesion with distortion of surrounding tissues.
211
Fill in the blank: The Nottingham grading system includes degree of tubule formation, nuclear pleomorphism, and _______.
Mitoses/10 HPF
## Footnote
The grading system evaluates these characteristics to classify breast cancer.
212
True or False: Ultrasound is more sensitive than mammography for early detection of breast cancer.
False
## Footnote
Ultrasound is less sensitive than mammography for early detection.
213
What is the sensitivity of MRI in detecting cancers?
Almost 100%
## Footnote
MRI has a lower sensitivity in detecting DCIS at 80%, but it has a higher false positivity rate.
214
In which group of patients is MRI particularly useful?
Young women with dense breast tissue
## Footnote
MRI is useful for screening women at high risk for breast cancer.
215
List the key points to consider for all patients in breast cancer case presentations.
* Age
* Menopausal status
* Performance status
* Previous breast disease
* Co-morbidities
* Family history
* Other medications and allergies
216
What are the important factors to assess for a new patient with local disease?
* Size and location of tumour
* Nodal status
* Receptor status
* Patient anxieties about body image
* Planned surgery
217
What information is crucial for a new patient with metastatic disease?
* Location and extent of metastatic disease
* Receptor status
* Signs of impending emergencies
* Signs of life-threatening visceral involvement
218
For a patient with local relapse, what historical information is needed?
* Previous stage and date of original diagnosis
* Details of previous treatments
* Receptor status
* Duration of current symptoms
* Staging at time of local relapse
219
What details are necessary for a patient with metastatic relapse?
* Previous stage and date of original diagnosis
* Details of previous treatments
* Current staging
* Signs of impending emergencies
* Signs of life-threatening visceral involvement
220
What imaging techniques can be used for pathological diagnosis?
* Core biopsy
* Open surgical biopsy
* Vacuum assisted biopsy
## Footnote
Vacuum assisted core biopsy yields a larger sample.
221
What is the purpose of staging investigations in breast cancer?
To assess the need for neoadjuvant systemic treatment prior to surgery.
222
Define Stage 0 breast cancer.
* Tx – primary tumour cannot be assessed
* T0 – no evidence of primary tumour
* Tis – carcinoma-in-situ and Paget’s disease with no tumour
223
What characterizes Stage I breast cancer?
* T1 – tumour 2 cm or less
* N0 – no regional lymph node metastasis
* M0 – no distant metastases
224
What defines Stage II breast cancer?
* IIA: T2 (tumour >2 cm but ≤5 cm), N1 (ipsilateral non-fixed lymph node metastasis)
* IIB: T3 (tumour >5 cm)
225
What are the characteristics of Stage III breast cancer?
* IIIA: N2 (ipsilateral fixed axillary node)
* IIIB: T4 (tumour of any size with direct extension)
* IIIC: N3 (metastasis to supraclavicular lymph nodes)
226
What is the classification for Stage IV breast cancer?
Any T, any N, M1
## Footnote
M1 indicates distant metastasis.
227
What are the necessary investigations after the triple assessment for early-stage breast cancer?
* Full blood count
* Liver function tests
* Renal function tests
* Serum alkaline phosphatase
* Chest X-ray and CT scan
* Bone scan
228
When is routine staging not advised for patients with fewer than four positive lymph nodes?
When biochemistry is normal and there are no symptoms suggestive of metastasis.
229
Fill in the blank: MRI is better than mammography in delineating _______.
[intraductal disease and multifocal disease]
230
What is the TNM staging system for breast cancer?
A system used to classify the extent of cancer based on Tumor size (T), Node involvement (N), and Metastasis (M)
## Footnote
TNM staging helps guide treatment decisions and predict outcomes.
231
What characterizes Type 1a enhancement in breast cancer imaging?
Continuous straight enhancement
## Footnote
This type is mostly benign (83%) and has a 9% malignant rate.
232
What are the characteristics of Type 3 enhancement?
Curve washes out, decrease intensity after peak
## Footnote
This type is typical malignant with 57% malignant and 5% benign.
233
What is the aim of treatment for Ductal carcinoma-in-situ (DCIS)?
Prevent local recurrence, particularly of invasive cancer
## Footnote
After biopsy alone, 40% will progress to invasive cancer.
234
What surgical options are available for unicentric DCIS?
Conservative surgery and simple mastectomy
## Footnote
These choices should be discussed with patients.
235
What is the recommended margin for DCIS?
>10 mm is adequate, <1 mm is inadequate (NICE recommends 2 mm)
## Footnote
Patients with a persistent positive margin may require mastectomy.
236
What is the incidence of axillary node metastasis in DCIS?
Up to 2% due to unrecognized invasive cancer
## Footnote
Axillary staging and dissection are unnecessary for pure DCIS.
237
What effect does postoperative radiotherapy have on breast cancer recurrence?
Reduces breast recurrence (both in situ and invasive)
## Footnote
No effect on survival, irrespective of prognostic factors.
238
In what cases can radiotherapy be safely omitted for DCIS?
In <10 mm, low/intermediate grade DCIS with adequate margin
## Footnote
Local recurrence rate is <10% at 10 years.
239
What were the findings of the NSABP B-24 trial regarding tamoxifen in DCIS?
Tamoxifen reduced local recurrence of DCIS and invasive cancer (11% vs. 7.7%, p = 0.02)
## Footnote
This indicates tamoxifen's potential benefits in DCIS management.
240
What percentage of women with DCIS may develop a contralateral tumor per annum?
0.5–1%
## Footnote
This highlights the ongoing risk of breast cancer in these patients.
241
What is the management approach for isolated Lobular carcinoma-in-situ (LCIS)?
Close observation
## Footnote
The progression rate to cancer after biopsy alone is approximately 1% per annum.
242
What is the risk of invasive cancer development in patients with LCIS over 20 years?
One-third of patients may develop invasive cancer
## Footnote
LCIS is associated with invasive cancer in 10% of cases.
243
What is the role of tamoxifen in LCIS management?
Prophylactic treatment to reduce invasive recurrence by 56%
## Footnote
It is increasingly used among patients with LCIS.
244
What are the initial treatment options for early stage invasive cancer?
Conservative surgery with axillary surgery, mastectomy with axillary surgery, neoadjuvant chemotherapy followed by conservative surgery
## Footnote
These options depend on tumor characteristics and patient preferences.
245
What is the goal of surgery in breast cancer management?
Removal of the primary breast tumor and staging/treatment of the axilla
## Footnote
Surgery is a key component in breast cancer treatment.
246
What factors increase the risk of local recurrence after wide local excision (WLE)?
* Positive margin (<1 mm)
* Age ≤35 years
* Extensive intraductal component
* Lymphovascular invasion
* Tumor grade
## Footnote
These factors necessitate careful surgical planning.
247
What is the definition of a positive margin in breast cancer surgery?
Margin <1 mm
## Footnote
A positive margin significantly increases the risk of recurrence.
248
What are the options for breast reconstruction after mastectomy?
* Immediate reconstruction
* Delayed reconstruction
* Tissue expanders
* Autologous tissue
## Footnote
The choice depends on tumor characteristics and planned radiotherapy.
249
What is the primary goal of axillary surgery?
To assess and manage axillary lymph nodes
## Footnote
Options include sentinel node biopsy and axillary dissection.
250
What are contraindications to breast conservation surgery?
* Prior radiotherapy to the breast
* Diffuse suspicious microcalcification
* Widespread disease
* Persistent positive margins
* Active connective tissue disease
* Tumors >5 cm
* Women ≤35 years with BRCA1/2 mutation
## Footnote
These factors may preclude successful breast conservation.
251
What are the indications for radiotherapy in breast cancer?
* After breast conservation for invasive cancer
* After breast conservation for DCIS (except low risk)
* Postmastectomy chest wall in high-risk cases
## Footnote
Radiotherapy plays a critical role in reducing recurrence.
252
What is the typical dose for whole breast radiotherapy?
50 Gy in 25 fractions / 40 Gy in 15 fractions
## Footnote
This regimen is commonly used for breast cancer treatment.
253
What is the detection rate of sentinel node biopsy?
>95%
## Footnote
This high detection rate makes it a preferred method for axillary staging.
254
What happens if a patient is sentinel node positive?
They will undergo axillary clearance
## Footnote
This is to ensure comprehensive management of potential metastasis.
255
What is the TNM staging system for breast cancer?
A system used to classify the extent of cancer based on Tumor size (T), Node involvement (N), and Metastasis (M)
## Footnote
TNM staging helps guide treatment decisions and predict outcomes.
256
What characterizes Type 1a enhancement in breast cancer imaging?
Continuous straight enhancement
## Footnote
This type is mostly benign (83%) and has a 9% malignant rate.
257
What are the characteristics of Type 3 enhancement?
Curve washes out, decrease intensity after peak
## Footnote
This type is typical malignant with 57% malignant and 5% benign.
258
What is the aim of treatment for Ductal carcinoma-in-situ (DCIS)?
Prevent local recurrence, particularly of invasive cancer
## Footnote
After biopsy alone, 40% will progress to invasive cancer.
259
What surgical options are available for unicentric DCIS?
Conservative surgery and simple mastectomy
## Footnote
These choices should be discussed with patients.
260
What is the recommended margin for DCIS?
>10 mm is adequate, <1 mm is inadequate (NICE recommends 2 mm)
## Footnote
Patients with a persistent positive margin may require mastectomy.
261
What is the incidence of axillary node metastasis in DCIS?
Up to 2% due to unrecognized invasive cancer
## Footnote
Axillary staging and dissection are unnecessary for pure DCIS.
262
What effect does postoperative radiotherapy have on breast cancer recurrence?
Reduces breast recurrence (both in situ and invasive)
## Footnote
No effect on survival, irrespective of prognostic factors.
263
In what cases can radiotherapy be safely omitted for DCIS?
In <10 mm, low/intermediate grade DCIS with adequate margin
## Footnote
Local recurrence rate is <10% at 10 years.
264
What were the findings of the NSABP B-24 trial regarding tamoxifen in DCIS?
Tamoxifen reduced local recurrence of DCIS and invasive cancer (11% vs. 7.7%, p = 0.02)
## Footnote
This indicates tamoxifen's potential benefits in DCIS management.
265
What percentage of women with DCIS may develop a contralateral tumor per annum?
0.5–1%
## Footnote
This highlights the ongoing risk of breast cancer in these patients.
266
What is the management approach for isolated Lobular carcinoma-in-situ (LCIS)?
Close observation
## Footnote
The progression rate to cancer after biopsy alone is approximately 1% per annum.
267
What is the risk of invasive cancer development in patients with LCIS over 20 years?
One-third of patients may develop invasive cancer
## Footnote
LCIS is associated with invasive cancer in 10% of cases.
268
What is the role of tamoxifen in LCIS management?
Prophylactic treatment to reduce invasive recurrence by 56%
## Footnote
It is increasingly used among patients with LCIS.
269
What are the initial treatment options for early stage invasive cancer?
Conservative surgery with axillary surgery, mastectomy with axillary surgery, neoadjuvant chemotherapy followed by conservative surgery
## Footnote
These options depend on tumor characteristics and patient preferences.
270
What is the goal of surgery in breast cancer management?
Removal of the primary breast tumor and staging/treatment of the axilla
## Footnote
Surgery is a key component in breast cancer treatment.
271
What factors increase the risk of local recurrence after wide local excision (WLE)?
* Positive margin (<1 mm)
* Age ≤35 years
* Extensive intraductal component
* Lymphovascular invasion
* Tumor grade
## Footnote
These factors necessitate careful surgical planning.
272
What is the definition of a positive margin in breast cancer surgery?
Margin <1 mm
## Footnote
A positive margin significantly increases the risk of recurrence.
273
What are the options for breast reconstruction after mastectomy?
* Immediate reconstruction
* Delayed reconstruction
* Tissue expanders
* Autologous tissue
## Footnote
The choice depends on tumor characteristics and planned radiotherapy.
274
What is the primary goal of axillary surgery?
To assess and manage axillary lymph nodes
## Footnote
Options include sentinel node biopsy and axillary dissection.
275
What are contraindications to breast conservation surgery?
* Prior radiotherapy to the breast
* Diffuse suspicious microcalcification
* Widespread disease
* Persistent positive margins
* Active connective tissue disease
* Tumors >5 cm
* Women ≤35 years with BRCA1/2 mutation
## Footnote
These factors may preclude successful breast conservation.
276
What are the indications for radiotherapy in breast cancer?
* After breast conservation for invasive cancer
* After breast conservation for DCIS (except low risk)
* Postmastectomy chest wall in high-risk cases
## Footnote
Radiotherapy plays a critical role in reducing recurrence.
277
What is the typical dose for whole breast radiotherapy?
50 Gy in 25 fractions / 40 Gy in 15 fractions
## Footnote
This regimen is commonly used for breast cancer treatment.
278
What is the detection rate of sentinel node biopsy?
>95%
## Footnote
This high detection rate makes it a preferred method for axillary staging.
279
What happens if a patient is sentinel node positive?
They will undergo axillary clearance
## Footnote
This is to ensure comprehensive management of potential metastasis.
280
What does adjuvant radiotherapy reduce?
Local recurrence by two-thirds and improves 15-year survival by 5%
## Footnote
It is indicated that for every four local recurrences prevented, one breast cancer death is avoided at 15 years.
281
What is the 5-year local recurrence rate with radiotherapy after breast conservation?
7%
## Footnote
Without radiotherapy, the rate is 26%.
282
In patients over 70 years with good prognostic factors, what might be omitted without compromising survival?
Radiotherapy
## Footnote
Good prognostic factors include less than 2 cm tumor, grade 1 or 2, ER positive, node negative, and no lymphovascular invasion.
283
What is the 10-year local recurrence rate with boost radiotherapy compared to without boost?
6.2% with boost and 10.2% without boost
## Footnote
The p-value for this difference is < 0.001.
284
What is the only significant predictor of local recurrence in multivariate analysis?
Age
## Footnote
The greatest benefit from boost radiotherapy was seen in those aged less than 40 years.
285
What is the risk of chest wall recurrence for patients with a tumor of ≥5 cm size and ≥4 positive lymph nodes?
20–30%
## Footnote
Routine postoperative chest wall radiotherapy is advised for these patients.
286
What is the local recurrence rate with postoperative chest wall radiotherapy compared to without?
6% vs. 23%
## Footnote
This also improves 15-year survival by 5%.
287
In what cases might postmastectomy radiotherapy be considered?
T1 tumors with 1–3 positive nodes or T2 tumors with biological aggressiveness
## Footnote
Features of biological aggressiveness include ER−, HER2+, grade 3, and high proliferative index.
288
What is the risk of supraclavicular recurrence for patients with ≥4 involved nodes after axillary dissection?
>15%
## Footnote
Hence, supraclavicular radiotherapy is advised.
289
What is the risk of significant lymphoedema after axillary dissection without radiotherapy?
30–40%
## Footnote
Axillary radiotherapy is not recommended unless there is residual macroscopic disease.
290
What is the aim of adjuvant systemic treatment?
Preventing recurrences by eradicating micro metastatic disease
## Footnote
This is presumed to be present at the time of diagnosis.
291
What are the most important determinants in the choice of systemic treatment?
Hormone receptor status and HER2 status
292
What treatment may patients with ER+ tumors receive?
Hormones alone or a combination of endocrine treatment and chemotherapy
293
What is generally recommended for intermediate and high-risk patients according to the 2007 St. Gallen Consensus?
Adjuvant chemotherapy
294
What does a meta-analysis suggest about 6 months of anthracycline-based chemotherapy?
Reduces yearly death from breast cancer by about 38% in women younger than 50 years and by 20% for women aged 50–69 years
295
What is the absolute risk reduction at 5 years for DFS and OS with addition of a taxane to anthracycline-based chemotherapy?
5% for DFS and 3% for OS
296
What is the practical approach for using chemotherapy in patients without high-risk early breast cancer?
Use anthracycline-based chemotherapy (e.g. FEC or Epi-CMF)
297
What chemotherapy combination is licensed for use in patients with node positive breast cancer in the UK?
Anthracyclines-taxane combination
298
What is the effect of tamoxifen for 5 years in oestrogen receptor positive breast cancer patients?
41% proportional reduction in recurrence and 34% proportional reduction in mortality
## Footnote
Irrespective of age, menopausal status, and administration of chemotherapy.
299
What are the acute side effects of radiotherapy?
* Fatigue
* Skin erythema (100%)
* Inframammary fold desquamation (10%)
## Footnote
Acute side effects occur during or shortly after treatment.
300
List the late side effects of radiotherapy.
* Swelling and induration of breast (30%)
* Telangiectasia (1% severe)
* Asymptomatic lung changes (1%)
* Sarcoma (<1% risk at 30 years)
* Lymphoedema (3–40% depending on axillary surgery extent)
* Brachial plexopathy (1%)
## Footnote
Late side effects may develop months to years after treatment.
301
What is the CMF chemotherapy regime?
* Cyclophosphamide 100 mg/m2 po days 1–14
* Methotrexate 40 mg/m2 IV days 1 and 8
* 5 FU 600 mg/m2 IV days 1 and 8
* Folinic Acid Rescue 15 mg 6-hourly × 6 doses po days 2 and 9
* 28-day cycle × 4–6 cycles
## Footnote
CMF stands for Cyclophosphamide, Methotrexate, and Fluorouracil.
302
What is the recommended adjuvant hormone therapy for premenopausal women?
* Tamoxifen (20 mg daily for 5 years)
* Tamoxifen with ovarian function ablation for at least 2 years
* Goserelin (GnRH agonist)
## Footnote
Goserelin showed a reduction in cancer-related events and deaths when used with tamoxifen.
303
What are the adjuvant hormone options for postmenopausal women?
* Tamoxifen for 5 years
* Tamoxifen for 2–3 years with early switch to AIs
* AI for 5 years (letrozole or anastrazole)
* Tamoxifen for 5 years followed by AI for another 2–3 years
## Footnote
AI stands for Aromatase Inhibitors.
304
What is the mechanism of action of tamoxifen?
Tamoxifen causes competitive inhibition with oestrogen for oestrogen receptors, resulting in a G1 block leading to decreased tumour growth
## Footnote
It also induces apoptosis and increases NK cell activity.
305
What are common side effects of tamoxifen?
* Hot flushes (50%)
* Vaginal discharge
* Irregular menses
* Increased risk of endometrial cancer
* Thromboembolism (1–2%)
## Footnote
Tamoxifen also increases bone mineral density and decreases LDL.
306
What do aromatase inhibitors do?
Reduce oestrogen levels in postmenopausal women by inhibiting the aromatase enzyme
## Footnote
They are ineffective in premenopausal women due to increased gonadotropin secretion.
307
What are the two types of aromatase inhibitors?
* Type 1: Steroidal analogue (e.g., exemestane)
* Type 2: Non-steroidal analogue (e.g., anastrazole, letrozole)
## Footnote
Type 1 inhibitors irreversibly bind to aromatase.
308
What is the recommended duration of treatment for HER2+ breast cancer with Trastuzumab in Adjuvant setting?
One year of adjuvant trastuzumab is recommended
## Footnote
Trastuzumab is a humanized monoclonal antibody against HER2.
309
What are the common side effects of trastuzumab?
* Hypersensitivity
* Flu-like symptoms
* Cardiotoxicity (<4% symptomatic or severe cardiac failure)
## Footnote
Cardiac monitoring during treatment is mandatory.
310
What is the loading dose and maintenance dose schedule for trastuzumab?
Loading dose: 8 mg/kg
Maintenance dose: 6 mg/kg every three weeks
## Footnote
Treatment should restart with a loading dose if there is a delay of more than 7 days.
311
What is the classification for locally advanced disease in breast cancer?
T3 N1, T1–3 N2–3, T4 N0–3
312
What is the aim of neoadjuvant systemic therapy in locally advanced breast cancer?
Down staging the primary tumour
313
What type of treatment can be used initially in older women with receptor positive tumours?
Hormonal treatment
314
Which aromatase inhibitor is the only licensed drug for neoadjuvant use?
Letrozole
315
What was the response rate of letrozole compared to tamoxifen in a comparative study?
Letrozole: 55%, Tamoxifen: 36%
316
In patients with HER-1 or HER-2+ tumours, what was the response rate to letrozole?
88% vs. 21%
317
What is the standard treatment for patients with large primary tumours?
Neoadjuvant chemotherapy
318
What percentage of pathological complete response can be expected from chemotherapy?
20%
319
What did NSABP B-27 study find regarding initial anthracycline regime followed by docetaxel?
Better response rate (90.7% vs. 85.5%) and pathological complete response (64% vs. 40%)
320
What is advisable to incorporate with neoadjuvant non-anthracycline chemotherapy in HER2 positive tumours?
Trastuzumab
321
What is the treatment approach for inflammatory breast cancer patients after neoadjuvant chemotherapy?
Total mastectomy
322
What is required for all patients post-surgery?
Postoperative radiotherapy to chest wall or breast
323
What percentage of patients present with distant metastasis at diagnosis?
Approximately 6%
324
What are the common sites of metastasis in breast cancer?
* Bone
* Lung
* Liver
* Brain
325
What is the primary aim of treatment for metastatic disease?
Symptom control, improving quality of life and survival
326
Which treatment is given to patients with hormone receptor positive disease without life-threatening visceral involvement?
Hormonal treatment
327
What is the standard option for premenopausal women who have not previously had tamoxifen?
Tamoxifen and ovarian ablation/suppression
328
What is the drug of choice for postmenopausal women in breast cancer treatment?
Aromatase inhibitors
329
What was the response rate of letrozole compared to tamoxifen in advanced breast cancer?
Letrozole: 30%, Tamoxifen: 20%
330
What is the first-line treatment for patients who have not previously received an anthracycline?
Anthracyclines
331
What agents are considered after anthracycline failure?
* Docetaxel
* Paclitaxel
332
What is the treatment option for patients with HER2 positive disease who progress on trastuzumab?
Change of chemotherapy with continuation of trastuzumab
333
What is lapatinib and when is it considered?
An inhibitor of HER2 and EGFR, considered after trastuzumab failure
334
What response rate should be evaluated after 3 months of endocrine treatment?
Response to treatment
335
What percentage of patients may present with loco-regional recurrence after conservative surgery?
2–20%
336
What is required before potentially curative treatment for isolated loco-regional recurrence?
Complete staging
337
What is the purpose of palliative care in bone metastases?
Pain management as per WHO analgesic ladder and local radiotherapy
## Footnote
Studies show that 8–10 Gy as a single fraction has similar efficacy to prolonged treatment.
338
What should women with bone metastases be given to control pain?
Bisphosphonates
## Footnote
Examples include pamidronate, ibandronate, clodronate, and zoledronic acid.
339
What is a significant risk factor for brain metastasis in breast cancer patients?
HER2+ disease
## Footnote
Particularly at risk for metastasis to the posterior fossa.
340
How are tumor-related symptoms such as fungation, discharge, and bleeding treated?
Palliative mastectomy or radiotherapy
341
What is the most important prognostic factor in breast cancer?
Lymph node metastasis
342
What factors affect the prognosis of breast cancer?
Factors include:
* Tumor size
* Grade
* Age
* Hormone receptor status
* Lymphatic invasion
* HER2 positivity
343
What is the 5-year survival rate for stage II breast cancer?
70%
344
Which age group is targeted for breast cancer screening in the UK?
Women aged 50–69 years
345
What is the breast cancer prevalence among women undergoing screening?
About 0.5% (1 in 200 women)
346
What is Paget’s disease?
A pre-malignant condition of the nipple and areola
347
What are the clinical features of Paget’s disease?
Erythema, dryness, and fissuring of the nipple
348
What is the treatment of choice for Paget's disease?
Conservative surgery followed by radiotherapy
349
What is inflammatory breast cancer and its prevalence?
Accounts for 2% of all breast cancers
350
What are the clinical features of inflammatory breast cancer?
Ill-defined erythema, tenderness, induration, eczema-like skin changes
351
What is the typical treatment for patients without distant metastasis diagnosed with inflammatory breast cancer?
Neoadjuvant chemotherapy followed by mastectomy and adjuvant radiotherapy
352
What characterizes triple negative breast cancer?
Lacks the expression of estrogen, progesterone, and HER2 receptors
353
What is the association of triple negative breast cancer with BRCA-1?
Similar to BRCA-1 associated breast cancer
354
What is the incidence of bilateral breast cancer in patients with a strong family history?
Less than 1% for synchronous and 1-2% per year for metachronous
355
What is the average age at diagnosis for male breast cancer?
10 years later than women
356
What is the most common type of male breast cancer?
Infiltrating ductal carcinoma (80%)
357
What is the primary treatment for male breast cancer?
Total mastectomy with an axillary procedure
358
What hormonal manipulation methods are available for male breast cancer?
Tamoxifen, orchidectomy, anti-androgens, aminoglutethimide
359
What is the significance of recent studies involving bevacizumab?
Showed better response rate and progression-free survival compared to paclitaxel alone
360
What are some agents currently under investigation for breast cancer treatment?
Sunitinib, PARP inhibitors, cetuximab, ixabepilone
361
What key patient information should be collected for all patients with breast cancer?
Age, menopausal status, performance status, previous breast disease, co-morbidities, history of blood clots, other medications, allergies, family history of breast cancer, ovary, prostate, sarcoma.
## Footnote
Co-morbidities include conditions such as cardiac issues, diabetes, and systemic sclerosis.
362
What factors are important for a new patient with local disease?
Size and location of tumour, nodal status, receptor status, patient anxieties about body image, thoughts about reconstruction, planned surgery.
## Footnote
Patient concerns about body image and reconstruction may influence treatment decisions.
363
What should be assessed for a new patient with metastatic disease?
Location and extent of metastatic disease, receptor status, signs of impending emergencies, signs of life-threatening visceral involvement.
## Footnote
Impending emergencies may include conditions like superior vena cava obstruction (SVCO) or spinal cord compression (SCC).
364
What information is crucial for a patient with local relapse?
Previous stage and date of original diagnosis, details of previous treatments, treatment-related complications, time since completion of original treatment, receptor status, duration of current symptoms/signs, hormone status, current staging.
## Footnote
Understanding the patient's treatment history is essential for planning further care.
365
What should be considered for a patient with metastatic relapse?
Previous stage and date of original diagnosis, details of previous treatments, treatment-related complications, time since completion of original treatment, receptor status, duration of current symptoms/signs, hormone status, current staging, signs of impending emergencies, signs of life-threatening visceral involvement.
## Footnote
Similar to local relapse, a comprehensive history helps in managing the patient's condition effectively.
366
Mammogram.
Mediolateral oblique
(MLO) view (A) shows an
irregular lesion in the
breast with specks of
calcification (arrows).
Craniocaudal
(superioinferior) view (B)
conventionally represents
the outer or lateral aspect
of breast at the top of the
film and medial aspect at
the bottom of the film
and hence the mass is in
the medial aspect of
breast.
367
368
What does Tx represent in Stage 0 of breast cancer?
Primary tumour cannot be assessed.
369
What does T0 signify in the context of breast cancer staging?
No evidence of primary tumour.
370
What is Tis in breast cancer staging?
Carcinoma-in-situ and Paget’s disease with no tumour.
371
What defines Stage I breast cancer?
T1N0M0 where T1 is tumour 2 cm or less, N0 is no regional lymph node metastasis, M0 is no distant metastases.
372
What does T1 indicate?
Tumour 2 cm or less in its greatest dimension.
373
What is the meaning of N0 in breast cancer staging?
No regional lymph node metastasis.
374
What does M0 represent?
No distant metastases.
375
What are the classifications for Stage II breast cancer?
IIA (TxN1M0, T1N1M0, T2N0M0) and IIB (T2N1M0, T3N0M0).
376
What is defined as T2 in breast cancer staging?
Tumour larger than 2 cm but not larger than 5 cm.
377
What does N1 indicate?
Ipsilateral non-fixed lymph node metastasis.
378
What is T3 in the context of breast cancer?
Tumour more than 5 cm.
379
What classifications are included in Stage III breast cancer?
IIIA (Tx-2N2M0, T2-3N1-2M0), IIIB (T4N0-2M0), IIIC (any T, N3 M0).
380
What does N2 signify in breast cancer staging?
Ipsilateral fixed axillary node or ipsilateral internal mammary lymph nodes.
381
What does T4 represent?
Tumour of any size with direct extension.
382
What are the subcategories of T4?
* T4a – Extension to chest wall
* T4b – Oedema or ulceration of the breast skin
* T4c – Both T4a and T4b
* T4d – Inflammatory breast cancer.
383
What does N3 indicate in Stage IIIC breast cancer?
Metastasis to ipsilateral supraclavicular lymph nodes or infraclavicular lymph nodes.
384
What defines Stage IV breast cancer?
Any T, any N, M1.
385
What does M1 signify in breast cancer staging?
Distant metastasis.
386
What tests are included in the evaluation of breast cancer?
* Full blood count
* Liver function tests
* Renal function tests
* Serum alkaline phosphatase
* Chest X-ray
* CT scan of chest and abdomen
* Bone scan.
387
What is a contraindication to breast conservation surgery related to previous treatment?
Prior radiotherapy to the breast or chest wall
## Footnote
Cannot give more radiotherapy.
388
What is a contraindication to breast conservation surgery during pregnancy?
Radiotherapy during pregnancy
## Footnote
Risk of radiation to the foetus.
389
What type of microcalcification presents a contraindication to breast conservation surgery?
Diffuse suspicious or malignant appearing microcalcification
## Footnote
Difficult to obtain clear margin.
390
What condition related to the extent of disease affects eligibility for breast conservation surgery?
Widespread disease that cannot be completely excised with satisfactory cosmesis
## Footnote
May result in negative margin and/or poor cosmesis.
391
What does a persistent positive pathological margin indicate?
Cannot obtain clear margin of >1 mm
## Footnote
This is a contraindication for surgery.
392
Which active disease involving the skin is a contraindication to breast conservation surgery?
Active connective tissue disease (scleroderma and lupus)
## Footnote
Due to increased risk of radiation toxicity.
393
What size of tumors may lead to poor cosmesis in breast conservation surgery?
Tumours of >5 cm
## Footnote
Conservation can be attempted after neoadjuvant chemotherapy.
394
What type of disease with intraductal components may affect breast conservation surgery eligibility?
Focally positive disease with extensive intraductal component
## Footnote
Focally positive disease without extensive intraductal component can be treated with higher dose of radiotherapy.
395
What is the contraindication for women ≤35 years or premenopausal with BRCA1/2 mutation?
Higher risk of recurrence
## Footnote
This group is advised against breast conservation surgery.
396
What is the indication for whole breast radiotherapy after breast conservation?
After breast conservation for invasive cancer and DCIS (except low risk of recurrence)
## Footnote
DCIS stands for Ductal Carcinoma In Situ, which is a non-invasive form of breast cancer.
397
Who are the patients recommended for a tumour bed boost in radiotherapy?
All patients <40 years, 40–50 years with high risk features, patients with <1 mm margin and further surgery is not contemplated
## Footnote
High risk features may include factors like grade of the tumor and lymph node involvement.
398
What are the indications for postmastectomy chest wall radiotherapy?
T3/T4 tumour and ≥4 positive nodes after dissection
## Footnote
T3/T4 classification indicates larger tumor size or local invasion.
399
When is supraclavicular fossa radiotherapy indicated?
≥4 positive nodes after dissection
## Footnote
This indicates a higher risk of regional recurrence.
400
What is the recommended position for a patient during CT planning for radiotherapy?
Supine with arm abducted
## Footnote
This position allows for better access and visualization of the breast area.
401
What is the clinical target volume (CTV) for whole breast radiotherapy?
Entire breast tissue and subcutaneous tissue excluding muscles, rib cage and skin
## Footnote
The CTV ensures that the entire affected area receives adequate treatment.
402
What does the planning target volume (PTV) include?
1 cm margin around CTV
## Footnote
This margin accounts for uncertainties in patient positioning and internal organ motion.
403
What is the prescribed dose for whole breast radiotherapy?
50 Gy in 25 fractions or 40 Gy in 15 fractions
## Footnote
Gy stands for Gray, a unit of radiation dose.
404
What is the dose for a tumour bed boost in radiotherapy?
16 Gy in 8 fractions, 9 Gy in 3, 10 Gy in 5, 12.5 Gy in 5, etc.
## Footnote
The EORTC study provides evidence for these dosing regimens.
405
What is included in the clinical target volume (CTV) for the chest wall?
Skin including scar extending up to deep fascia excluding muscles and rib cage
## Footnote
This helps to ensure that any residual cancer cells in the chest wall are treated.
406
What does the clinical target volume (CTV) for the tumour bed encompass?
1.5–2 cm around surgical cavity or haematoma
## Footnote
This distance helps to encompass potential residual disease.
407
What is the purpose of localization in radiotherapy?
To use simulator or CT planning to accurately define target volumes
## Footnote
Accurate localization is critical for effective treatment delivery.
408
What is the recommended position for conventional radiotherapy planning?
Supine with angled breast boards
## Footnote
This positioning improves treatment accuracy and comfort for the patient.
409
What are the acute side effects of radiotherapy?
* Fatigue
* Skin erythema (100%)
* Inframammary fold desquamation (10%)
## Footnote
Acute side effects occur shortly after treatment and can significantly impact patient comfort.
410
What is the percentage of patients experiencing skin erythema as an acute side effect?
100%
## Footnote
Skin erythema is a common and expected reaction to radiotherapy.
411
What is the percentage of patients experiencing inframammary fold desquamation as an acute side effect?
10%
## Footnote
This side effect indicates skin breakdown in the inframammary region.
412
What are the late side effects of radiotherapy?
* Swelling and induration of breast (30%)
* Telangiectasia (1% severe)
* Asymptomatic lung changes (1%)
* Sarcoma (<1% risk at 30 years)
* Lymphoedema (3–40% depends on the extent of axillary surgery)
* Brachial plexopathy (1%)
## Footnote
Late side effects can develop months or years after treatment and may require long-term management.
413
What is the risk percentage of developing sarcoma 30 years after radiotherapy?
<1%
## Footnote
Sarcoma is a rare but serious potential late effect of radiotherapy.
414
What is the incidence range of lymphoedema after radiotherapy?
3–40% (depends on the extent of axillary surgery)
## Footnote
Lymphoedema can vary significantly based on surgical intervention.
415
What percentage of patients may experience brachial plexopathy as a late side effect?
1%
## Footnote
Brachial plexopathy can lead to nerve damage and functional impairment.
416
True or False: Telangiectasia occurs in 1% of patients as a late side effect of radiotherapy.
True
## Footnote
Telangiectasia refers to small dilated blood vessels that can appear on the skin.
417
Fill in the blank: The late side effect characterized by swelling and induration of the breast occurs in _______ of patients.
30%
## Footnote
This side effect may present as firmness or swelling in the breast tissue.
418
What serious late effect has a risk of less than 1% at 30 years post-radiotherapy?
Sarcoma
## Footnote
This indicates a long-term risk associated with radiation exposure.
