Breast Surgery JC076: Breast Mass: Breast Cancer, Benign Breast Diseases, Mammography, Breast Cancer Screening

Question 1

Management of Breast disease

Answer 1

Triple assessment:
1. Clinical
- History + P/E
- S/S

2. Radiological
   - Mammography
   - USG
   - MRI
3. Pathological
   - FNAC
   - Core biopsy
   - Incisional biopsy
   - Excisional biopsy

—> Combined: sensitivity 99.6% + specificity 93%

• Triple assessment is positive if ***ANY of above is positive
• negative if ***ALL 3 negative
• if findings not correlate —> further investigations / monitoring necessary

Question 2

History taking of Breast disease

Answer 2

1. HPI / Breast symptoms
   - **Lump
   - **Pain (Mastalgia)
   - ***Discharge from nipple (Unilateral / Bilateral, Single / Multiple ducts, Nature)
2. Symptoms characterisation
   - **Duration
   - **Changes of symptoms (e.g. change with menstrual cycle, analgesia)
   - Unilateral / Bilateral
   - Characteristics (SSSTCM: Site, Size, Shape, Tenderness, Consistency, Mobility)
3. Family history
   - 1st / 2nd degree
   - ***Age of onset (correlate with familial risks)
4. ***Hormonal risk (esp. Steroid receptor +ve breast cancer)
   - Early menarche / Late menopause
   - Gestational history (Nulliparity)
   - Breast feeding history (↓ risk)
   - OC pills (exogenous estrogen)
   - Hormonal replacement therapy (exogenous estrogen)
5. Previous breast disease / screening

Question 3

P/E of Breast disease

Answer 3

Position + Exposure (at least clavicle to abdomen)

1. Inspection (end of bed)
   - Asymmetry
   - Scar (esp. inframammary fold)
   - Mass
   - Skin changes
2. Palpation (along clock face)
   - Breast mass
   - Nipple discharge
   - Axillary LN

Question 4

Nipple discharge

Answer 4

Types:
1. Blood stained
- mostly pathological

2. Serous
   - pathological / physiological
3. Milky
   - lactation

Question 5

Skin changes

Answer 5

1. Eczematous change
   - scaling of skin + areola
   - if scaling / involvement of **nipple —> **Paget’s disease of nipple —> need incisional biopsy for Paget’s cells
2. Peau d’orange
   - **skin tethering + **SC lymphedema changes —> associated with underlying cancer
   (from wiki: hair follicles become buried in edema)
3. Inverted nipple
   - ask how long its been there
   - underlying tumour causing retraction of nipple

Question 6

***DDx of Breast mass

Answer 6

Benign (Mobile, Round, Smooth):
1. Fibroadenoma
2. Breast cyst
3. Fat necrosis
4. Skin / SC lesions (Sebaceous cyst, Lipoma)

Other DDx of Benign breast lump
1. Galactocele (if lactating)
2. **Lipoma
3. **Fat necrosis
4. Diabetic mastopathy
5. Infective causes: Mastitis, ***Breast abscess, Chronic recurrent subareolar infections e.g. from ductal ectasia
(6. Skin lesions: Sebaceous cysts
7. Postpartum engorgement)

Malignant (Irregular shape, Diffuse / Poorly defined border, Rapidly growing, Harder):
1. In-situ cancer
- DCIS
- LCIS
2. Invasive cancer
- Invasive Ductal
- Invasive Lobular
- Special types
3. Malignant phyllodes tumour (indeterminate)

Question 7

***Histological types of Breast cancer

Answer 7

In-situ carcinoma:
1. **DCIS (Low / Intermediate / High grade)
(2. **LCIS (Lobular carcinoma-in-situ): a premalignant condition / risk factor rather than cancer, commonly bilateral —> only surveillance needed)

Invasive carcinoma:
1. **Invasive Ductal (80%) (now called **Invasive carcinoma of no special type (NST))
2. **Invasive Lobular (3%)
3. **Special types (unimportant, better prognosis)
- Tubular / Cribriform
- Papillary (Malignant form of Intraductal papilloma)
- Mucinous
- Medullary
- Paget’s (Nipple areolar complex involvement)
- Inflammatory (Skin infiltration)

Question 8

***5 Steps in treating ANY cancer

Answer 8

1. Confirm diagnosis (by biopsy / triple assessment)
2. Metastatic workup (know extent of disease)
3. Assessment of co-morbidities
4. Nutritional assessment
5. Definitive treatment

Question 9

***Treatment options of Breast cancer

Answer 9

Curative treatment:
1. Surgery
- Mastectomy (Simple / Skin sparing / Nipple-Areolar sparing)
- Breast conserving surgery (BCS) (Wide local excision) (Need RT)

Adjuvant treatment (↓ recurrence risk + improve survival):
1. Chemotherapy
2. RT
3. Hormonal therapy
4. Targeted therapy

Question 10

***Choice of treatment in Breast cancer

Answer 10

Patient factor:
1. Age / Menopause status

Tumour factor:
1. Tumour size
2. Tumour grade
3. No. of involved LN
4. ER / PR status
5. HER2 gene amplification (gene signatures)

Question 11

***Surgical treatment option of Breast cancer

Answer 11

Aim:
- Oncological outcome vs Cosmetic outcome
1. Loco-regional control
2. Cosmesis

1. Breast surgery
   - **Mastectomy
   - **BCS
2. Axillary surgery
   - **Sentinel LN biopsy (SLNB) (+ Frozen section)
   - **Axillary dissection (AD)
3. Reconstruction (additional option)
   - Autologous (Flap reconstruction)
   - Implant

Question 12

CI to BCS

Answer 12

Absolute CI:
1. Tumor size **too large (Large Tumour to Breast size ratio)
- BCS will not result in a good cosmetic result
2. **Multicentric cancer (across quadrants)
3. Where ***RT is contraindicated (e.g. Pregnancy, SLE, previous radiation, ipsilateral breast recurrence)

Relative CI:
1. Multifocal (within same quadrant)
2. Cancer underneath nipple or nipple involvement (can perform lumpectomy if large breasts)

Question 13

1. Mastectomy

Answer 13

1. Simple mastectomy
   - removal of whole breast + some skin
   - most of the cases
2. Skin sparing mastectomy
   - leave a lot more skin behind for future ***reconstruction
3. Nipple / Areolar sparing mastectomy
   - reserved for selective low risk patients with **no nipple involvement of cancer
   - **prophylactic mastectomy

Question 14

2. Axillary surgery (SLNB / AD)

Answer 14

Landmark of LN: Pectoralis ***minor muscle (NOT major!!!)
- Level 1: Lateral
- Level 2: Posterior
- Level 3: Medial

Axillary dissection (AD):
- Clear ***Level 1 + 2 LN
- 20% lymphedema rate

NOT remove everything ∵ avoid lymphedema

Sentinel LN biopsy (SLNB):
- **First LN which drains the tumour
- **Dye / Radioisotope (Dual tracer: injection of **methylene blue dye + **99Tc colloid in the sub-areolar area —> identify dyed or radioactive LN using gamma probe (“hot and blue”)
—> travel along lymphatics to Sentinel LN
—> biopsy for **frozen section (done **intra-operatively)
—> -ve: no need AD, +ve: need AD

Aim of SLNB:
- Suitable for **early stage cancers to avoid unnecessary AD
- Avoid **complications related to AD
- Do less surgery without compromising **oncological outcome (e.g. early breast cancer often not involve LN)
- AD may not be necessary in patients with **minimal tumor load in axillary LN + receiving BCS and RT

Question 15

***Complications of AD

Answer 15

Early complication:
1. Nerve damage
- **Thoracodorsal bundle (i.e. artery + vein + nerve) —> **Latissimus dorsi —> Unable to raise trunk with upper limb e.g. climbing
- **Long thoracic nerve —> **Serratus anterior —> Pain, weakness, limitation of shoulder elevation, scapular winging
- **Intercostobrachial nerve —> **Sensory nerve to Triceps area
- Brachial plexus (uncommon ∵ more upward (area around level 3 LN))

2. Vessel damage
   - **Thoracodorsal bundle
   - **Axillary vein

Late complication:
3. ***Lymphedema

Question 16

***Surgical strategy for Breast cancer

Answer 16

4 combinations (2 Breast surgery + 2 Axillary surgery):
1. Mastectomy + SLNB
2. Mastectomy + AD (i.e. ***MRM: Modified radical mastectomy)
3. Breast conserving + SLNB
4. Breast conserving + AD

Choice of breast surgery (Mastectomy vs BCS?):
1. **Tumour response / size
2. **Breast size
3. Tumour **location + **Multiplicity
4. Patient’s preference

(Modified Radical vs Radical mastectomy:
- Modified Radical: Mastectomy + Level 1+2 LN
- Radical: Remove pectoralis as well)

Question 17

3. Reconstruction

Answer 17

Types:
1. Implant based
- saline / silicon gel
- temporary / permanent
- one stage / two stage
- placed behind pectoralis muscle
- advantages: simpler procedure, **no donor site morbidity (i.e. no additional scar)
- disadvantages: **↑ risk of infection, questionable ***durability, asymmetry more common

2. Autologous tissue based
   - **Latissimus dorsi (LD)
   - **Transverse rectus abdominis myocutaneous (TRAM) —> Pedicle flap / Free flap / Deep inferior epigastric perforator flap (DIEP flap) (only skin + vessel, no muscle —> avoid herniation in future)
   - advantages: better cosmetic result
   - disadvantages: need ***additional scar / wound, may cause complications e.g. hernia in abdomen, ↑ chance of wound infection, longer surgery, more complex procedures
3. Mixture of both types

Question 18

Nipple-Areola reconstruction

Answer 18

• Final touch up procedure (i.e. 2nd stage procedure)
• Usually performed >=6 months after initial operation
• Under local anaesthesia as day case
• Use of ***local flaps to recreate nipple projection
• Expect 50% reduction in height
• Nipple sharing nearly obsolete
• ***Tattoo to restore natural colour

Question 19

Adjuvant therapy: RT

Answer 19

Indications:
1. >=4 LNs involved
2. Large tumours
3. Multifocal tumours
4. High grade
5. Lymphovascular permeation
6. ***BCS

Method:
- Whole breast RT / Partial breast RT / Intraop RT

Complications from radiation:
Early:
1. **Skin burn (preventable with radiogel)
2. **Infection

Late:
3. **Lung fibrosis
4. **Cardiomyopathy
5. **Lymphedema —> **Lymphangiosarcoma (Stewart-Treves syndrome) (Resection + RT / CT)
6. Skin discolouration
7. ***Sternal necrosis (in bilateral breast cancer)

Question 20

Adjuvant therapy: Chemotherapy

Answer 20

Types:
1. Adjuvant: Kill of microscopic disease
2. Neoadjuvant: Pre-surgery control
3. Palliative / Salvage: At recurrence

Indications:
1. LN involvement
2. High risk (e.g. young age)
3. High grade
4. Large tumour

SE:
- N+V
- Injection site reaction, extravasation
- Hair loss
- **Bone marrow suppression (infection risk: Neutropenic fever)
- Allergic reaction
- Cardiotoxicity
- **Neuropathy —> Numbness
- Nephrotoxicity
- Hepatotoxicity
- Amenorrhoea —> Infertility
- Hepatitis B flare up

Question 21

Adjuvant therapy: Hormonal therapy

Answer 21

1. SERM (Selective estrogen receptor modulator) (e.g. Tamoxifen)
   - Suitable in **Pre + Postmenopausal patients
   - Increase **endometrial cancer risk, ***clotting disorders
   - Beneficial effect in blood lipids (lower LDL)
2. Aromatase inhibitor (e.g. Letrozole)
   - Only in **Postmenopausal patients
   - Type I: Enzyme inactivator (steroidal)
   —> Exemestane
   - Type II: Competitive antagonist (non-steroidal)
   —> Anastrozole
   —> **Letrozole
   - **Decrease bone density
   - **Dyslipidaemia
   - ***Multiple joint pain
3. Estrogen receptor antagonist (e.g. Fulvestrant)

Others:
4. Oophorectomy
5. Ovarian irradiation
6. Endocrine therapy (GnRH analogue) (Zoladex)

Question 22

Adjuvant therapy: Targeted therapy

Answer 22

Based on HER2 overexpression:
- Trastuzumab
- Pertuzumab
- Lapatinib

SE:
- Cardiotoxicity (Trastuzumab)
- Skin rash (Lapatinib)

Other new emerging drugs:
- CDK4/6 inhibitors
- Parp inhibitors
- Everolimus

Question 23

Neoadjuvant therapy

Answer 23

1. Reduce size of tumour —> increase ***BCS rate
2. Improve **local control + **long term outcome

Question 24

Benign breast disease

Answer 24

• A spectrum of diseases
• 90% of clinical presentation
• ANDI (Aberrations of Normal Development and Involution of the breast) (—> now known as **Fibrocystic disease???)
  —> all encompassing term to describe a wide spectrum of benign breast diseases: **Cysts to ***Fibroadenoma
  —> allow better description of benign disease vs normal breast

S/S:
- Nodularity
- Tenderness
- Mobile

Question 25

***Fibrocystic disease: Physiological cyclical swelling + tenderness

Answer 25

**Fibrocystic disease (aka **Fibroadenosis)
- ***NOT a disease but general term that refers to a group of anomalies / symptoms
- main benign diagnosis in 30-40 yo

S/S:
1. **Cyclical mastalgia, **Lumpiness, **Nodularity
- areas of pronounced nodularity can mimic a lump
- **premenstrual breast tenderness with mild swelling (engorgement of breast during menstrual period) —> result from variation in plasma concentration of gonadotrophic + ovarian hormones

2. Breast can be nodular with ***no definitive mass —> Not considered abnormal breast

Question 26

***Fibroadenoma

Answer 26

• A disease entity
• most common benign breast tumour

Onset:
- any time after puberty
- most frequently 20-30 yo

S/S:
- **Painless (記住!)
- **Well-circumscribed
- ***Freely movable tumours with rounded lobulated / discoid configuration —> “Breast mouse”
- Multiple in 10-15%
- Can become quite large

Prognosis:
- **NOT regress with time but tends to grow slowly
- Estimated incidence of malignancy: 0.12-0.3%
- **Giant Fibroadenoma (>5 cm): may rapid growth
—> require excision (usually in young girls)
—> ∵ triple assessment not 100% accurate
—> have to rule out ***Phyllodes tumour

Treatment options:
1. Surveillance (USG)
2. Surgery (Excision)
3. HIFU
- can be used to treat various solid tumours (e.g. Fibroadenoma, Thyroid adenoma)

Question 27

Cyst

Answer 27

• A disease entity
• Commonest breast lump in 30-50 yo

Types:
1. **Simple cysts: Accumulation of fluid
2. **Complex cysts: contain debris (solid components) —> need to rule out ***cystic tumour by Triple assessment

Treatment:
1. Aspiration to confirm nature (to rule out cystic tumour), also therapeutic to relieve symptom
2. **Fluid for cytology
3. **Excision for suspicious lesions (e.g. complex cysts with solid components)

Question 28

Mastalgia

Answer 28

1. ***Cyclical
2. ***Non-cyclical
   - Muscular pain
   - Costochondritis
   - Non-specific

Question 29

Nipple discharge

Answer 29

1. Unilateral vs Bilateral
   - ***Unilateral: pathological likely (involving single site)
   - Bilateral: physiological likely (e.g. lactation (but can be prolactinoma))
2. Single ductal vs Multiductal
   - ***Single duct: pathological likely (involving single site)
   - Multiductal: physiological likely
3. Nature of discharge
   - Milk (Galactorrhoea): Lactation, Prolactinoma
   - ***Blood / Brown (Suspicious): Intraduct papilloma, Malignancy
   - Yellowish / Green: Infection, Ductal ectasia
   - Serous / Colourless: Physiological, Ductal ectasia

Investigations:
Triple assessment
- +/- **Ductogram (inject contrast into diseased duct to look for filling defect —> identify cause of nipple discharge + location of lesion)
- +/- **Ductoscopy (allow direct visualisation of lining of lactiferous ducts via a small fibreoptic scope)

Question 30

Other benign breast disease

Answer 30

1. ***Sclerosing adenosis
2. Radial scars and complex sclerosing lesions
3. ***Papillomas
   - Intraductal papilloma (usually only involves single duct)
4. **Atypical lesions
   - **Atypical ductal hyperplasia
   - Atypical lobular hyperplasia
   - Atypical columnar cell hyperplasia
   - etc.
   —> Atypia ↑ risk of breast cancer —> whenever see this in biopsy —> **excise (*surveillance NOT an option)

Question 31

Investigations: Imaging

Answer 31

1. Mammography
   - used for screening
   - for older female
2. USG
   - for younger female (denser breast: USG better penetration)
3. MRI breast

Question 32

1. Mammography

Answer 32

Malignant features on mammogram
1. **Clustered + **Pleomorphic microcalcifications
- apoptosis of dead cells (a normal phenomenon, but if ↑ cell turnover —> clustered instead of scattered)
- different size and shape (∵ some cells die quickly / slowly)
- Coarse calcifications: likely ***benign

2. ***Spiculated border, High density mass
3. Architectural distortion
   - ***tethering of skin
   - involvement of muscles etc.
4. ***Asymmetrical density
   - compare both breasts + both views

Question 33

2. USG

Answer 33

Benign features:
1. **Regular border
2. **Oval in shape (grow along anatomical plane) (Width > Height)
3. Lobulated (sometimes)
4. **Posterior enhancement (indicate fluid in lesion) (Solid tumour: posterior shadowing)
5. **Homogeneous

Malignant features:
1. **Irregular outline
2. **Height > Width (i.e. grow across anatomical planes: invading up / down)
3. ***Posterior shadowing (Acoustic shadowing)
4. Echogenic halo

Question 34

3. MRI breast

Answer 34

Not routinely done
- very sensitive but not specific

Indications:
1. Screening women at high risk of breast cancer (e.g. BRCA carriers)
2. Patients with **breast implants / augmentation (obscure view on USG)
3. Evaluate questionable suspicious lesions seen on mammography / USG (conflicting between imaging and histology)
4. Identify patients with clinical **occult tumour presenting with positive axillary LN
5. Monitor result of neoadjuvant therapy
6. Identify extent of residual disease after excision which show positive margins

Question 35

Pathological exam (Biopsy)

Answer 35

Indication:
1. Evaluation of a palpable breast mass
2. Evaluation of a non-palpable breast mass
3. Evaluation of nipple discharge

4 techniques:
1. FNAC
2. Core biopsy
3. Incisional biopsy
4. Excisional biopsy

Question 36

FNAC vs Core biopsy

Answer 36

FNAC:
Advantages:
- safe, simple, inexpensive
- immediately distinguishes ***cysts from solid masses (tumour)

Disadvantages:
- cannot reliably distinguish **DCIS from invasive cancer
- cannot perform **immunohistochemical staining

Core biopsy:
Advantages:
- distinguishes DCIS from invasive cancer
- allow **immunohistochemical staining for **ER / PR / C-erbB2 (HER2) status

Disadvantages:
- relatively ***more invasive, require local anaesthesia
- small stab incision

Question 37

Evaluation of a non-palpable breast mass

Answer 37

1. Imaging
   - USG
   - Mammogram
   - MRI
2. Biopsy (depends on which imaging picked up the lesion)
   - USG picked up —> USG guided FNAC / Core biopsy
   - Mammogram picked up —> Mammogram-guided biopsy (aka **Stereotactic guided biopsy —> for **microcalcifications)
   - MRI picked up —> MRI guided biopsy

Biopsy techniques:
1. FNAC / Core biopsy (when clinical suspicion)
2. Vacuum assisted core biopsy (***larger bore, more traumatic, vacuum to suck lesion, can achieve complete removal of small lesion)
3. Hookwire guided excisional biopsy (can do specimen mammogram / radiology / USG)
4. Radio-guided occult lesion localisation (ROLL)

Excisional vs Incisional biopsy:
Incisional:
- **Fungating / **Ulcerative tumour
- take out a strip of tissue directly from skin surface from **fungating edge (because **rapidly-growing area)
- cannot be done on a breast lump ***without ulceration

Excisional:
- when conflict between radiological vs core biopsy —> to be **100% sure
- cannot be done on a breast lump **without ulceration

Question 38

Breast cancer screening

Answer 38

• Aim to detect cancer as an asymptomatic + curable stage
• Already proven decrease mortality rate in international studies
• Problems: Psychological impact / over-diagnosis, Cost effectiveness

Why suitable for screening?
- Common disease / high prevalence
- Significant impact to population
- Detectable in early phase
- Low cost
- Accurate
- Specific
- Critical point before clinical diagnosis
- Short lag phase
- Tool is acceptable / tolerable to population
- Treatment available after diagnosis
- Treatment acceptable to population

“Standard” screening guidelines:
30s:
- ***Yearly breast examination
- Monthly self-breast examination

40s:
- Mammogram every ***2 years
- Yearly breast examination
- Monthly self-breast examination

50s:
- Mammogram every ***1 year
- Yearly breast examination
- Monthly self-breast examination

Question 39

Interactive tutorial: Management of breast cancer
Breast cancer screening

Answer 39

Pros:
- Decreased breast cancer mortality + total mortality
- Decreased morbidity from breast cancer (Reduction of late-stage breast cancer)

Cons:
- Radiation exposure
- False-positive and false-negative mammography results, additional imaging + biopsies
- Anxiety, distress, psychological responses

World:
- Variation in different countries depending on resources
- Voluntary: Not population screening
- Privately / Charity funded
- Means of screening: Mammography
- USG as part of screening (but lack evidence)
- Age 40: every 1-2 years
- Age 50: every 2 years
- Can consider screening earlier if family history

HK:
Past: Voluntary breast screening
Last year (2021):
***Risk based breast screening:
- Starting at age 44 based on risk calculation model
- Screening every 2 years

Question 40

Signs of Breast cancer on Mammogram

Answer 40

1. **Microcalcifications
   - **Clustered / Segmental
   - **Pleomorphic (有大有細)
   - **Stellate patterns (星狀)
2. ***Spiculated, high density mass
3. ***Architectural distortion
4. ***Asymmetrical density

**BiRADS score: Mammogram reporting (now for USG + MRI as well)
Category 0: Need further investigations (without any clinical examinations)
Category 1: Normal
Category 2: **Benign
Category 3: Probably benign (<2% malignant)
Category 4: Suspicious of malignancy
Category 5: Highly suggestive of malignancy >=95%
Category 6: Malignancy proven with biopsy

Question 41

Limitations of mammography

Answer 41

1. Breast implant
2. Dense breast
3. Paraffin calcification

Question 42

USG

Answer 42

• Mammography still most sensitive test for breast cancer detection
• USG used in conjunction with mammography
• USG is commonly used in our locality to add diagnosis of breast lesion

Cons:
- USG not as sensitive for macrocalcification detection
- Less useful in fatty breast

Pros:
- Good at: mass lesions, cysts
- Easy to use, fast, cheap
- Useful in breasts with dense parenchyma

Reading USG:
- R93N: Right, 9 o’clock , 3 cm from nipple

Question 43

MRI breast indications

Answer 43

• Screening women at ***high risk of breast cancer e.g. strong family history, hereditary cause
• Evaluate ***questionable suspicious lesions seen on mammography / USG
• Identify patients with **clinically occult (i.e. **non-palpable) tumour presenting with positive axillary nodes
• Monitor result of ***neoadjuvant therapy
• Exclude ***multifocal lesions when planning breast conservation surgery

MRI breast kinetic curve:
- leaky neovascularisation —> type 3 kinetic curve —> contrast concentration drops rapidly (vs benign disease will hold contrast)

Question 44

Staging of Breast cancer

Answer 44

Purpose (ALWAYS answer in exam):
1. Stage to plan treatment
2. Prognostication

Methods:
1. PET-CT / PET-MR

Alternative ways:
2. Bone scan
3. CT thorax / abdomen
4. USG

(AJCC TNM staging:
T stage:
T0: no evidence of primary tumour
Tis: Carcinoma in Situ
T1: Tumour **<2cm
- T1a: 0.1-0.5cm
- T1b: 0.5-1.0cm
- T1c: 1.0-2.0cm
T2: Tumour **>2cm but <5cm
T3: Tumour **>5cm
**T4: Tumour with **direct extension to
- T4a: chest wall (ribs, IC, serratus)
- T4b: skin (Peau d’orange, ulceration, satellite skin nodule)
- T4c: T4a + T4b
- T4d: inflammatory breast cancer

N stage (**Clinical / **Pathological):
N0: no lymph node involvement
N1: mets to movable ipsilateral level I, II axillary LN
N2: mets to ipsilateral level I,II axillary LN – clinically fixed or matted or mets to ipsilateral mammary LN in absence of axillary LN
N3: mets to ipsilateral infraclavicular (level III) lymph nodes, ipsilateral mammary LN, ipsilateral supraclavicular LN (with or w/o level I & II axillary LN)

M stage:
M0: no distant mets
M1: distant detectable metastasis (histologically proven > 0.2mm))

Question 45

Biopsy of Breast lumps

Answer 45

1. FNAC
2. Core biopsy (e.g. Vacuum assisted core biopsy)
3. Excisional biopsy

If **palpable —> **Direct / Free hand
If **non-palpable —> **Image-guided
- USG guided
- Mammogram (Stereotactic) guided
- MRI guided
(others: Wire guided, Radio-guided occult lesion localisation (ROLL))

Question 46

Cytology Reporting Categories

Answer 46

C1: Inadequate
C2: Benign
C3: Atypia, probably benign
C4: Suspicious of malignancy
C5: Malignant

Question 47

***Risk factors of Breast cancer

Answer 47

Hormonal factors:
1. Early menarche <12
2. Late menopause >55
3. Pregnancy after age 30
4. Nulliparity
5. Use of OC pills / HRT
6. Obesity

Non-hormonal factors:
7. Family history of breast cancer (BRCA1, 2)
8. History of breast biopsy showing a premalignant condition, atypical ductal hyperplasia, proliferative fibrocystic changes, LCIS, DCIS
9. Smoking, Alcohol
10. Diet
11. Lack of exercise
12. Advanced age

Question 48

BRCA1, BRCA2

Answer 48

BRCA1:
- Breast cancer
- Ovarian cancer
- Prostate cancer
- Colon cancer

BRCA2:
- Breast cancer
- Male breast cancer
- Ovarian cancer
- Prostate cancer
- Laryngeal cancer
- Bile duct cancer
- Stomach cancer
- Colon (minimal) melanoma
- Pancreatic cancer

Question 49

Infertility issues

Answer 49

Pre-surgery / Pre-chemotherapy egg harvesting + storage can be offered