Early stage Breast Cancer Part 1

Question 1

The _______ of the breast extends into the region of the low axilla and is frequently referred to as the axillary tail of Spence. This anatomical feature results in the _________ of the breast containing a greater percentage of total breast tissue compared with the other quadrants, and, therefore, a greater percentage of breast cancers occur in this anatomical location

Answer 1

upper-outer quadrant (38.5%)

Question 2

The surface of the breast has deep attachments of fibrous septa, called _______, which run between the superficial fascia (attached to the skin) and the deep fascia (covering the pectoralis major and other muscles of the chest wall). Skin dimpling may be caused by tumors affecting these supporting structures.

Answer 2

Cooper’s ligament

Question 3

The function of the ____ is to produce milk

The function of the _____ is to transport lactation products to the nipple

Answer 3

lobules

Ducts

Question 4

Most breast cancers develop at the interface between the ductal system and the lobules, a region called the ______.

Answer 4

terminal ductal lobular unit

Question 5

The predominant lymphatic drainage of the breast is to axillary lymph nodes, which is commonly described in three levels, based on the relation of the lymph node regions to the _______.

Answer 5

pectoralis minor muscle

Question 6

Describe the axillary lymph node levels with respect to pectoralis minor muscle

Answer 6

The level I axilla is caudal and lateral to the muscle,
level II is beneath the muscle, and
level III (also known as the infraclavicular region) is cranial and medial to the muscle.

Question 7

A standard axillary lymph node dissection resects the tissue and lymph nodes within what axillary levels?

Answer 7

levels I and II

Question 8

Located in parasternal space
Anatomical region: internal mammary vessels
Usually lie 3 to 4 cm lateral to midline

Majority of involvement is limited to lymph nodes in the first three interspaces
Breast CA that develop in the medial, central, or lower breast more commonly drain to the IMC

Answer 8

Internal mammary nodes

Question 9

Axillary drainage is more common than internal mammary drainage, even in inner quadrant lesions
However, internal mammary drainage was present in over __% of lower inner quadrant lesions.

Answer 9

50%

Question 10

most frequently diagnosed cancer in women
2nd among cancer deaths in women (after lung cancer)
incidence is lower in African American women
age of onset is younger and African American women are more likely to be diagnosed at a more advanced stage

Answer 10

Breast cancer

Question 11

The risk of breast cancer decreases exponentially up to the age of menopause, at which time the rate of increase in the risk slows significantly

True or false?

Answer 11

False

The risk of breast cancer increases exponentially up to the age of menopause, at which time the rate of increase in the risk slows significantly

Question 12

Worldwide case control study, MacMahon et al:

Demonstrated a nearly linear relation between relative risk of breast cancer and age at first birth, with women aged 20 to 25 having nearly a _______ in the relative risk of breast cancer compared with nulliparous women. Interestingly, for women whose first childbirth occurred over age 35, the risk appears greater than nulliparous women. Data on the effect of breastfeeding are not as strong as the data on age at first childbirth, but they do suggest a protective effect.

Answer 12

50% reduction

Question 13

The Oxford Collaborative Group:

Analysis of 47 studies evaluating breastfeeding and breast cancer risk and reported a decrease in relative risk of breast cancer by ____ for each 12 months of breastfeeding

Answer 13

4.3%

Question 14

early menarche and late menopause contributing significantly to breast cancer risk

T or F?

Answer 14

True

Question 15

Randomized trial of postmenopausal hormone therapy from the Women’s Health Initiative Study:

compared estrogen and progestin with placebo was closed prematurely, demonstrating a ____% increase in breast cancer, coronary heart disease, stroke, and pulmonary emboli.

Answer 15

24%

Question 16

National Comprehensive Cancer Network (NCCN) published guidelines for genetic testing. In the context of pre- and posttest counseling, the NCCN recommends that genetic testing be offered when?

Answer 16

National Comprehensive Cancer Network (NCCN) published guidelines for genetic testing. In the context of pre- and posttest counseling, the NCCN recommends that genetic testing be offered when:

1. The individual has a family history of a known BRCA1/BRCA2 mutation,
2. Personal history of breast cancer plus one of the following:
	a. Diagnosed age 45 years or younger
	b. Diagnosed age ≤50 years with one or more close blood relatives with breast cancer ≤50 years
	c. Two breast primaries when first breast primary occurred before age 50
	d. Diagnosed at any age, with two or more close blood relatives with breast and/or epithelial ovarian/fallopian tube/primary peritoneal cancer at any age
	e. Close male relative with breast cancer
	f. An individual of ethnicity associated with higher mutation frequency (e.g., Ashkenazi Jewish).
3. Personal history of epithelial ovarian/fallopian tube/primary peritoneal cancer, or
4. Personal history of male breast cancer.

Question 17

Land et al. reviewed reports on three populations of patients exposed to ionizing radiation by atomic bombings, multiple fluoroscopic examinations for tuberculosis, and multiple examinations for mastitis. They concluded that the risk of radiation-induced cancer of the breast increased approximately linearly with increasing dose and was heavily dependent on age at exposure.

True or False?

Answer 17

True

Question 18

Alcohol Consumption

In an analysis by the Oxford Group of 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without breast cancer, women with daily consumption of _____ drinks a day had a 50% higher breast cancer risk
Mammographic Density

Answer 18

four or more

Question 19

Mammographic Density
Boyd et al. and Byrne et al. noted that women with 75% or greater breast density parenchymal patterns on the mammogram had a ____fold greater risk of breast cancer

Answer 19

Five

Question 20

Approximately ___% of breast CA pxs have familial breast cancer

Answer 20

10%

Question 21

increased risk for a variety of cancers, including childhood sarcomas, gynecologic tumors, and breast cancer. Breast cancer is the most common malignancy in patients with Li-Fraumeni syndrome; the lifetime risk is estimated to be 90%.

Answer 21

Mutations in p53

Question 22

“guardian of the genome”

Answer 22

p53

Question 23

Li-Fraumeni syndrome

Lifetime risk of breast CA: estimated to be ____%

Answer 23

90%

Question 24

Lifetime risk
Breast cancer of 65-85%
Ovarian cancer up to 50%
May develop more frequently: colon and prostate CA

Answer 24

BRCA1

Question 25

Lifetime risk Breast cancer: mirrors that of BRCA1 Ovarian cancer: much less than that of BRCA1 Associated with male breast CA and pancreatic CA

Answer 25

BRCA2

Question 26

Study to test efficacy of 5yrs of tamoxifen in the prevention of breast CA Results: tamoxifen reduced the rates Invasive breast CA – 49% Noninvasive breast CA - 50% 86% risk reduction - with a history of atypical ductal hyperplasia 56% risk reduction – with a history of LCIS

Answer 26

NSABP P-1 trial

Question 27

most breast cancer is a consequence of a series of _____ mutations

Answer 27

somatic

Question 28

Using estimates of tumor doubling time, average of approximately __ years for a tumor to reach palpable size

Answer 28

5

Question 29

Involvement of the superficial and deep lymphatics

Answer 29

Edema of the skin (peau d’orange)

Question 30

Caused by involvement of Cooper’s ligament

Answer 30

Skin dimpling

Question 31

common route of spread of breast carcinoma | 10-40% of newly diagnosed T1 and T2 breast CA have pathologic evidence of _______

Answer 31

axillary nodal metastases/spread

Question 32

In Voogd et al, lymph node metastases were associated with:

Answer 32

lymph node metastases were associated with: tumors larger than 1 cm (P = .001) moderate or poorly differentiated nuclear grade (P = .005) high fraction of cells in the growth phase (S phase) of the cell cycle (P = .041) presence of lymphatic vascular invasion (P

Question 33

``` Usually follows involvement in the high axillary lymph nodes or IMN’s depending on the location of the primary lesion Predictive factors: High histologic grade >4 positive nodes Axillary level II or III involved nodes ```

Answer 33

Supraclavicular spread

Question 34

Mammography | National Cancer Institute, American Cancer Society, and the American College of Radiology recommendation:

Answer 34

baseline mammogram at the age of 35 years (30 years in high-risk groups) Repeat examinations should be carried out every 2 years beginning at 40 years of age. In women older than 50 years, mammograms should be performed annually

Question 35

complementary tool to mammography for the diagnosis of breast cancer NCCN recommends ultrasound for those women presenting with a dominant mass or asymmetric thickening or nodularity

Answer 35

Ultrasound

Question 36

potential limitation of _____ is that it provides cytology and no tissue architecture. Therefore, while the presence of malignant cells can be detected, cytology from fine-needle aspiration cannot conclusively differentiate invasive from noninvasive disease. However, for lesions that are palpable or easily visualized on ultrasound, this method results in rapid and efficient diagnosis

Answer 36

fine-needle aspiration

Question 37

True or false? Clinically node-negative patients have pathologic involvement in 10% to 40% of cases (depending on primary tumor size), whereas no pathologic evidence of tumor is found in 25% to 30% of patients with clinically palpable axillary nodes.

Answer 37

True

Question 38

Small clusters of cells not greater than 0.2 millimeters Nonconfluent Nearly confluent clusters of cells not exceeding 200 cells in a single histologic lymph node cross section

Answer 38

Isolated tumor cells

Question 39

defined by presence of either: disseminated tumor cells detectable in bone marrow, circulating tumor cells, or found incidentally in other tissues (such as ovaries removed prophylactically) if not exceeding 0.2 millimeters.

Answer 39

new M0(i+) category

Question 40

Defined as the extension of cancer cells beyond the basement membrane into the adjacent tissues with no focus more than 0.1 cm in greatest dimension T1mic

Answer 40

Microinvasive

Question 41

most common type of breast cancer, comprising more than 50% of all cases Appears as solid cords or groups of ductal tumor cells varying in size and cytoplasmic content and degree of differentiation

Answer 41

Invasive or infiltrating

Question 42

nonaggressive growth pattern, with an excellent prognosis | frequency of nodal metastasis of 13.8%

Answer 42

Tubular carcinoma

Question 43

Prognosis, in general, is better than for other tumors | frequently seen in younger women and are commonly associated with patients with BRCA1 mutations

Answer 43

Medullary carcinoma

Question 44

tend to be aggressive and multicentric and are prone to development of distant metastases “mammographically silent,” meaning its detection or the full appreciation of extent of disease is often not visualized mammographically much more commonly ER-positive than invasive ductal carcinoma

Answer 44

Lobular invasive carcinoma

Question 45

observed in older women with relatively long duration of symptoms slowly growing with a pushing border and has a low frequency of axillary lymph node metastasis survival is appreciably better than with invasive ductal carcinoma

Answer 45

Mucinous carcinoma

Question 46

rarely found in the breast | features and clinical behavior are similar to its counterpart in the salivary gland and the upper respiratory tract

Answer 46

Adenocystic carcinoma

Question 47

characterized by growth of tumor cell clusters in prominent clear spaces resembling dilated angiolymphatic vessels

Answer 47

Invasive micropapillary carcinoma

Question 48

relatively rare | increased expression of EGFR (HER1) provides an opportunity for targeted tumor therapy in these tumors.

Answer 48

Metaplastic carcinoma

Question 49

cytokeratin markers but variable staining with neuroendocrine markers histologic type and prognosis are identical to those of lung cancer to distinguish these lesions from metastatic lung tumors or direct invasion of breast by Merkel cell carcinoma, lymphoma, or carcinoid tumor reasonable to treat these patients with aggressive multiagent chemotherapy, excision of the primary tumor, and breast irradiation, although no data are available on the outcome of this approach.

Answer 49

Primary neuroendocrine small cell carcinoma

Question 50

involvement of the nipple by tumor | Breast conserving surgery followed by radiation is effective in this disease

Answer 50

Paget’s disease

Question 51

usually a benign lesion tumors are large; usually they are encapsulated, without invasion of the adjacent breast have a long initial period of slow growth followed by a sudden, rapid increase in size grade (mitotic rate), surgical margins, and proliferative index have prognostic importance

Answer 51

Cystosarcoma phyllodes

Question 52

variant of metaplastic carcinoma, includes a wide spectrum of lesions with mildly atypical features that may resemble fasciitis, fibromatosis, or myofibroblastic tumors Unlike spindle cell carcinomas in general, they have no propensity for distant metastasis and should be termed tumors rather than carcinomas

Answer 52

Spindle cell carcinoma of the breast

Question 53

In a review of MRI in the management of breast cancer, Hylton summarized the poten- tial for the current use of MRI:

Answer 53

the current use of MRI: to complement mammography in screening; for differential diagnosis of questionable findings on physical examination, mammography, and ultrasound; assessment of response in the neoadjuvant treatment of breast cancers

Question 54

Bone scans are more commonly recommended:

Answer 54

``` in patients with stage II larger tumors (>3 cm) aggressive histopathologic features stage III or IV cancer. ```

Question 55

Category I prognostic factors?

Answer 55

``` tumor size lymph node status micrometastasis histologic grade mitotic count hormonal-receptor status ```

Question 56

Category II Prognostic factors?

Answer 56

HER2/neu expression p53 mutations lymphovascular invasion DNA ploidy

Question 57

Category III prognostic factors?

Answer 57

``` tumor angiogenesis EGFR transforming growth factor Bcl-2 cathepsin D overexpression ```

Question 58

strongest predictor of distant metastasis and disease-free and overall survival

Answer 58

Tumor size | Nodal status

Question 59

strongest predictor of disease-free and overall survival and is the primary factor that governs breast cancer staging

Answer 59

Axillary nodal status

Question 60

the number of axillary nodes involved and the risk of dis- tant metastasis, the most commonly employed schema is to group patients into four prognostic categories namely:

Answer 60

node negative 1 to 3 involved nodes 4 to 9 involved nodes more than 10 involved nodes

Question 61

tubular, mucinous, and medullary subtypes have been shown to have a more favorable prognosis, compared with invasive ductal invasive lobular tumors appear to have a prognosis similar to invasive ductal tumors Poor prognostic categories include metaplastic, undifferentiated, and other rarer subtypes

Answer 61

Tumor Type

Question 62

utilizes mitotic index, differentiation, and pleomorphism, each with scores of 1 to 3. Scores of 3 to 5 are well differentiated, 6 to 7 moderately differentiated, and 8 to 9 poorly differentiated Elston and Ellis244 of the Nottingham group refined this methodology

Answer 62

Scarff-Bloom-Richardson classification system

Question 63

True or false? Tumors that express both ER and PR have the greatest benefit from hormonal therapy, but those containing only ER or PR still have significant responses.

Answer 63

True

Question 64

Overexpression of the protein is associated with tumor aggressiveness and decreased disease-free survival in node-positive patients, with variable prognostic significance among node-negative patients

Answer 64

Her2/Neu

Question 65

breast can extend from the midline to near the midaxillary line and cranial caudally from the ________

Answer 65

second anterior rib to the sixth anterior rib