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Questions and Answers
What does the 'N' in the TNM staging system refer to?
What does the 'N' in the TNM staging system refer to?
T4a classification indicates involvement of skin with satellite nodules.
T4a classification indicates involvement of skin with satellite nodules.
False
What is the most common site of metastasis for breast cancer?
What is the most common site of metastasis for breast cancer?
Bones
The classification Tis indicates _____ cancer.
The classification Tis indicates _____ cancer.
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Match the TNM classifications with their descriptions:
Match the TNM classifications with their descriptions:
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Which of the following statements is true regarding LCIS?
Which of the following statements is true regarding LCIS?
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Pectoral muscle involvement is considered in T4a classification.
Pectoral muscle involvement is considered in T4a classification.
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What is the half-life (T1/2) of the dye used in PET-CT scans?
What is the half-life (T1/2) of the dye used in PET-CT scans?
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PET CT is not sensitive for __________, and MRI is used for brain metastases.
PET CT is not sensitive for __________, and MRI is used for brain metastases.
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Match the following classifications with their features:
Match the following classifications with their features:
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Which type of biopsy is considered the gold standard for breast tissue detection?
Which type of biopsy is considered the gold standard for breast tissue detection?
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Fine Needle Aspiration Cytology (FNAC) is routinely used for breast lesions.
Fine Needle Aspiration Cytology (FNAC) is routinely used for breast lesions.
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What is the gauge size range commonly used for Fine Needle Aspiration Cytology (FNAC)?
What is the gauge size range commonly used for Fine Needle Aspiration Cytology (FNAC)?
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The __________ biopsy uses a vacuum system and is designed for scarless fibroadenoma surgery.
The __________ biopsy uses a vacuum system and is designed for scarless fibroadenoma surgery.
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Match the following biopsy techniques with their uses:
Match the following biopsy techniques with their uses:
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Which of the following is NOT a risk factor for breast cancer?
Which of the following is NOT a risk factor for breast cancer?
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The relative risk of developing breast cancer is highest for individuals with atypical ductal hyperplasia.
The relative risk of developing breast cancer is highest for individuals with atypical ductal hyperplasia.
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At what maternal age at first live birth is associated with increased risk for breast cancer?
At what maternal age at first live birth is associated with increased risk for breast cancer?
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A relative risk of 1 indicates _____ compared to the general population.
A relative risk of 1 indicates _____ compared to the general population.
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Match the histologic category with its corresponding relative risk:
Match the histologic category with its corresponding relative risk:
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Which of the following conditions is associated with an increased risk of breast cancer in smokers?
Which of the following conditions is associated with an increased risk of breast cancer in smokers?
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Maternal age at first live birth less than 30 years is a protective factor against breast cancer.
Maternal age at first live birth less than 30 years is a protective factor against breast cancer.
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What gene is commonly mutated in familial breast cancer?
What gene is commonly mutated in familial breast cancer?
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Low dose oral contraceptives (OCPs) do not ______ the risk of breast cancer.
Low dose oral contraceptives (OCPs) do not ______ the risk of breast cancer.
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Match the following BRCA genes with their characteristics:
Match the following BRCA genes with their characteristics:
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What is a significant advantage of breast ultrasound compared to other imaging techniques?
What is a significant advantage of breast ultrasound compared to other imaging techniques?
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Breast ultrasound is the preferred imaging method during pregnancy.
Breast ultrasound is the preferred imaging method during pregnancy.
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What is the main reason breast ultrasound is considered advantageous?
What is the main reason breast ultrasound is considered advantageous?
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Breast ultrasound is better at differentiating ______ lesions.
Breast ultrasound is better at differentiating ______ lesions.
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Match the advantages of breast ultrasound with their descriptions:
Match the advantages of breast ultrasound with their descriptions:
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What is the likelihood of cancer for a BIRADS 3 classification?
What is the likelihood of cancer for a BIRADS 3 classification?
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A BIRADS 1 classification indicates a negative finding with a routine follow-up screening in one year.
A BIRADS 1 classification indicates a negative finding with a routine follow-up screening in one year.
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What is the recommended age for women at average risk to begin yearly screening mammography?
What is the recommended age for women at average risk to begin yearly screening mammography?
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BIRADS 5 classification suggests a likelihood of malignancy of at least _____%.
BIRADS 5 classification suggests a likelihood of malignancy of at least _____%.
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Match the following BIRADS categories with their management:
Match the following BIRADS categories with their management:
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What is the primary risk reduction percentage achieved through bilateral prophylactic mastectomy?
What is the primary risk reduction percentage achieved through bilateral prophylactic mastectomy?
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Ovarian cancer risk can be reduced by 90% through bilateral salpingo oophorectomy.
Ovarian cancer risk can be reduced by 90% through bilateral salpingo oophorectomy.
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What lifestyle modification can help reduce the risk of breast cancer?
What lifestyle modification can help reduce the risk of breast cancer?
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The _____ carcinoma is the most common type of breast cancer.
The _____ carcinoma is the most common type of breast cancer.
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Match the following histological types of breast cancer with their prognosis:
Match the following histological types of breast cancer with their prognosis:
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What is the purpose of mammography?
What is the purpose of mammography?
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Which breast cancer subtype has the best prognosis?
Which breast cancer subtype has the best prognosis?
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Benign lesions in breast imaging typically show spiculated margins.
Benign lesions in breast imaging typically show spiculated margins.
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The Claudin low type is associated with a low recurrence rate.
The Claudin low type is associated with a low recurrence rate.
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What type of mammographic view is crucial for visualizing the axilla?
What type of mammographic view is crucial for visualizing the axilla?
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_____ lesions often show macro calcifications but with additional features such as spiculated margins.
_____ lesions often show macro calcifications but with additional features such as spiculated margins.
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What does a Ki67 index indicate in breast cancer?
What does a Ki67 index indicate in breast cancer?
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The _____ subtype of breast cancer is characterized by positive expression of HER2.
The _____ subtype of breast cancer is characterized by positive expression of HER2.
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Match the following breast lesions with their descriptions:
Match the following breast lesions with their descriptions:
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Match the molecular subtype of breast cancer with its characteristics:
Match the molecular subtype of breast cancer with its characteristics:
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What is typically observed in normal lymphatic nodes?
What is typically observed in normal lymphatic nodes?
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3D Full Field Digital Tomosynthesis is used for better image quality in dense breasts.
3D Full Field Digital Tomosynthesis is used for better image quality in dense breasts.
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What classification system is used for describing breast imaging findings?
What classification system is used for describing breast imaging findings?
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Study Notes
TNM Staging
- T: Tumor size (e.g., Tis: cancer in situ, T1: ≤2cm )
- N: Lymph node status (e.g., No: No regional node metastasis, N1: Palpable mobile ipsilateral axillary nodes)
- M: Distant mets (e.g., M0: No distant mets, M1: Distant mets)
- Most common site of mets: Bones (Lumbar vertebrae d/t Batson plexus of valveless veins - osteolytic > osteoblastic)
Breast Cancer staging: Important notes
- LCIS: benign disease, but with increased risk of cancer (no longer in situ cancer)
- Pectoral muscle involvement: Not considered in T4a.
- Dimpling & retraction: Not considered in T4b.
- Contralateral (C/L) LN: Considered metastatic if the other breast does not have cancer.
PET-CT
- Used for staging breast cancer.
- Radiotracer: 18 FDG (Fluorodeoxyglucose)
- Half-life: 110 mins.
- Not sensitive for brain mets (MRI used for brain mets)
- PSMA PET is used in prostate cancer.
Breast Investigation Instruments
- Fine Needle Aspiration Cytology (FNAC): No longer used routinely for breast lesions (has high false negative rate)
- Core Needle Biopsy/Tru-cut Biopsy: Used for breast lumps. Commonly uses 14 gauge needles.
- Punch Biopsy: Used for skin lesions and Paget's disease.
- Vacuum Assisted Breast Biopsy (VABB): Designed for scarless fibroadenoma surgery; An 8-11 gauge probe is attached to a vacuum system.
- Excisional Biopsy: Considered the gold standard (100% chance of detection).
Risk Factors for Breast Cancer
- Increased age, early menarche, late menopause, nulliparity, obesity (peripheral conversion of fat → aromatase → estrogen), alcohol consumption, smoking, family history (maternal & paternal), hormone replacement therapy, maternal age at first live birth (≥ 30 yrs)
Dupont & Page Classification
- Classify breast cancer risk based on existing lesions
- Nonproliferative lesions (e.g., Cysts, mild hyperplasia): No increased risk (relative risk 1).
- Proliferative lesions without atypia (e.g., Sclerosing adenosis, moderate or florid ductal hyperplasia): Increased risk (relative risk 1.3-1.9).
- Fibroadenoma with complex features: Increased risk (relative risk 4-5).
- Atypical hyperplasia (e.g., Atypical ductal hyperplasia, Atypical lobular hyperplasia): Further increased risk.
- Carcinoma in-situ: Highest increased risk (relative risk 9).
Breast Cancer: Additional Information
- Smokers: Increased risk of breast cancer, duct ectasia, and Mondor’s disease.
- Protective factors: Maternal age at first live birth ≥ 30 years, breastfeeding ≥ 1 year.
- Low dose oral contraceptives (OCPs): Do not increase the risk of breast cancer.
Breast Cancer Genes
- Familial: 10%
- Sporadic: 90%
- Genes associated with breast cancer:
- p53: Breast cancer
- BRCA1: Familial breast cancer
- PIK3CA: ER, PR+ve breast cancer
- p53: Triple-negative breast cancer (TNBC)/HER2-positive breast cancer
BRCA Genes
- Give rise to HBOC syndrome (Hereditary breast & ovarian cancer syndrome)
-
BRCA1:
- Location: 17q
- Higher aggression
- Subtype: Basal (TNBC)
- Histology: Basal (TNBC), medullary
- Cancer Risk: Breast & ovarian cancer (BRCA1 > BRCA2), Pancreatic, prostate, male breast cancer (BRCA2 > BRCA1), Colorectal & peritoneal cancer (BRCA1 = BRCA2).
-
BRCA2:
- Location: 13q
- Lower aggression
- Subtype: Luminal
- Histology: Medullary
Indications for BRCA Testing:
- Patients with deleterious BRCA1/2 gene mutation in a blood relative.
- Personal history of ovarian, fallopian tube, and/or primary peritoneal cancer.
Breast Ultrasound advantages:
- No radiation exposure.
- Differentiates solid and cystic lesions.
- Preferred in pregnancy.
- Better imaging of dense breast tissue.
Mammography
- X-ray of the breast.
- Radiation exposure: 0.1 to 0.2 cGy (low radiation dosage).
- Views: Craniocaudal (CC), Mediolateral oblique (MLO) - crucial to visualize the axilla.
- Technique: 3D Full Field Digital Tomosynthesis is a more modern technique for denser breasts, providing better picture quality.
Mammography: Findings
- Benign lesions: Often show macro calcifications (popcorn calcifications).
- Malignant lesions: Show macro calcifications but also have features like spiculated margins.
- Fibroadenoma: Well-defined, round mass on mammogram, often with a smooth border
- Calcified Fibroadenoma: Similar to fibroadenoma, but with calcium deposits.
- Phyllodes Tumor: Distinctive round shape, loss of fatty hilum, high likelihood of malignant features
- Normal Lymphatic Nodes: Kidney shape, retaining fatty hilum.
- Malignant Lymphatic Nodes: Rounded with loss of fatty hilum.
BIRADS: Breast Imaging Reporting and Data Systems
- BIRADS 0: Needs additional imaging.
- BIRADS 1: Negative (essentially 0% likelihood of cancer).
- BIRADS 2: Benign (essentially 0% likelihood of cancer).
- BIRADS 3: Probably benign (2% likelihood of cancer).
- BIRADS 4: Suspicious (likelihood of cancer: 4a: 2-10%; 4b: 10-50%; 4c: 50-95%).
- BIRADS 5: Highly suspicious of malignancy (95% likelihood of cancer).
- BIRADS 6: Known biopsy proven.
ASBRS Breast Cancer Screening Guidelines
-
25 years: Formal risk assessment for breast cancer (e.g., Gail Index)
- Average risk: Yearly mammograms starting at 40 years old
- Life expectancy ≥20 years with strong family history:
- Begin 3D mammogram from 35 years old
- Consider MRI if mammogram does not show relevant features
Risk Factors and Strategies for Breast Cancer
-
High risk patients:
- ≥ 21 blood relatives diagnosed with breast cancer at age 45.
- Personal history of breast cancer at age 50.
- Personal history of triple-negative breast cancer at age 60.
- Personal history of male breast cancer.
-
Lifestyle Modifications:
- Weight reduction, regular exercise, cessation of smoking and alcohol consumption.
- MRI breast screening from age 25.
-
Risk Reduction Strategies:
- Bilateral Prophylactic Mastectomy: 95% risk reduction (skin and nipple spared).
-
Bilateral Salpingo-Oophorectomy:
- Time: After completion of childbearing (within 40 years of age).
- Ovarian cancer risk reduction: 90% (10% risk of fallopian tube/peritoneal cancer).
- Breast cancer risk reduction: 50%.
- Tamoxifen (SERM): 47% reduction in breast cancer risk.
Breast Cancer Biopsy & Histological Types
- Invasive ductal carcinoma (m/c type)
- Lobular carcinoma
- Ductal carcinoma: NOS (Not otherwise specified)
- Special Types:
- Tubular (good prognosis)
- Mucinous
- Medullary (associated with BRCA1)
IHC: Immunohistochemistry and Molecular Classification of Breast Cancer
- ER & PR (nuclear receptors): Allred score (0-8) is used for grading.
-
Her2 neu (membranous marker): Grades:
- -ve
- 1+
- 2+: Equivocal
-
Processing and Staining:
- FISH (Fluorescent in situ hybridization) can indicate gene amplification (positive) or non-amplification (negative).
- Ki67: Proliferation index marker.
Molecular Subtypes of Breast Cancer (Based on Gene Expression Profiling):
Molecular Subtypes | ER | PR | HER2 | Ki-67 | Cytokeratin 5 and 6 | Prognosis |
---|---|---|---|---|---|---|
Luminal A (m/c) | + | + | - | ↓ | - | Best prognosis |
Luminal B | + | + | + | ↑ | - | |
HER2 enriched | + | - | + | Any | - | |
Basal like | - | - | - | Any (usually ↑) | + | Worst prognosis |
Claudin low type | - | - | - | Any | - | Most aggressive; High recurrence rate; Young age; High rate of mets; TNBC paradox: Respond best to chemo |
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Test your knowledge on the TNM staging system for breast cancer, including tumor size, lymph node status, and distant metastasis. Explore important notes regarding LCIS and the investigation tools used in breast cancer diagnostics, such as PET-CT and FNAC. This quiz will help deepen your understanding of breast cancer staging and diagnostics.