Surgery Marrow Pg 51-60 (Breast)
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What does the 'N' in the TNM staging system refer to?

  • Distant metastasis
  • Lymph node status (correct)
  • Clinical staging
  • Tumor size
  • T4a classification indicates involvement of skin with satellite nodules.

    False

    What is the most common site of metastasis for breast cancer?

    Bones

    The classification Tis indicates _____ cancer.

    <p>cancer in situ</p> Signup and view all the answers

    Match the TNM classifications with their descriptions:

    <p>No = No regional node metastasis N₃a = Ipsilateral infraclavicular lymph node M₁ = Distant metastasis T₄d = Inflammatory cancer</p> Signup and view all the answers

    Which of the following statements is true regarding LCIS?

    <p>LCIS is a benign disease with a risk of cancer.</p> Signup and view all the answers

    Pectoral muscle involvement is considered in T4a classification.

    <p>False</p> Signup and view all the answers

    What is the half-life (T1/2) of the dye used in PET-CT scans?

    <p>110 minutes</p> Signup and view all the answers

    PET CT is not sensitive for __________, and MRI is used for brain metastases.

    <p>brain</p> Signup and view all the answers

    Match the following classifications with their features:

    <p>T4a = Pectoral muscle involvement not considered T4b = Dimpling and retraction not considered PET-CT = Uses 18 FDG dye Brain mets = Diagnosed using MRI</p> Signup and view all the answers

    Which type of biopsy is considered the gold standard for breast tissue detection?

    <p>Excisional Biopsy</p> Signup and view all the answers

    Fine Needle Aspiration Cytology (FNAC) is routinely used for breast lesions.

    <p>False</p> Signup and view all the answers

    What is the gauge size range commonly used for Fine Needle Aspiration Cytology (FNAC)?

    <p>23-30 gauge</p> Signup and view all the answers

    The __________ biopsy uses a vacuum system and is designed for scarless fibroadenoma surgery.

    <p>Vacuum Assisted Breast Biopsy (VABB)</p> Signup and view all the answers

    Match the following biopsy techniques with their uses:

    <p>Core Needle Biopsy = Used for breast lumps Punch Biopsy = Used for skin lesions and Paget's disease Vacuum Assisted Breast Biopsy (VABB) = Designed for scarless fibroadenoma surgery Excisional Biopsy = Considered the gold standard</p> Signup and view all the answers

    Which of the following is NOT a risk factor for breast cancer?

    <p>Increased physical activity</p> Signup and view all the answers

    The relative risk of developing breast cancer is highest for individuals with atypical ductal hyperplasia.

    <p>True</p> Signup and view all the answers

    At what maternal age at first live birth is associated with increased risk for breast cancer?

    <p>30 years</p> Signup and view all the answers

    A relative risk of 1 indicates _____ compared to the general population.

    <p>no risk</p> Signup and view all the answers

    Match the histologic category with its corresponding relative risk:

    <p>Nonproliferative lesions = 1 Proliferative lesions without atypia = 1.3-1.9 Fibroadenoma with complex features = 4-5 Carcinoma in-situ = 9</p> Signup and view all the answers

    Which of the following conditions is associated with an increased risk of breast cancer in smokers?

    <p>Duct ectasia</p> Signup and view all the answers

    Maternal age at first live birth less than 30 years is a protective factor against breast cancer.

    <p>False</p> Signup and view all the answers

    What gene is commonly mutated in familial breast cancer?

    <p>BRCA1</p> Signup and view all the answers

    Low dose oral contraceptives (OCPs) do not ______ the risk of breast cancer.

    <p>increase</p> Signup and view all the answers

    Match the following BRCA genes with their characteristics:

    <p>BRCA1 = Associated with basal subtype of breast cancer (TNBC) BRCA2 = Risk of pancreatic and prostate cancer is higher than BRCA1</p> Signup and view all the answers

    What is a significant advantage of breast ultrasound compared to other imaging techniques?

    <p>Best at differentiating solid and cystic lesions</p> Signup and view all the answers

    Breast ultrasound is the preferred imaging method during pregnancy.

    <p>True</p> Signup and view all the answers

    What is the main reason breast ultrasound is considered advantageous?

    <p>No radiation exposure</p> Signup and view all the answers

    Breast ultrasound is better at differentiating ______ lesions.

    <p>solid and cystic</p> Signup and view all the answers

    Match the advantages of breast ultrasound with their descriptions:

    <p>No radiation exposure = Makes it safer for patients, especially during pregnancy Best investigation to differentiate lesions = Allows clear identification of solid versus cystic Preferred in pregnancy = Minimizes risks associated with radiation Better in specific situations = Often used in complex cases requiring detailed imaging</p> Signup and view all the answers

    What is the likelihood of cancer for a BIRADS 3 classification?

    <p>2%</p> Signup and view all the answers

    A BIRADS 1 classification indicates a negative finding with a routine follow-up screening in one year.

    <p>True</p> Signup and view all the answers

    What is the recommended age for women at average risk to begin yearly screening mammography?

    <p>40 years</p> Signup and view all the answers

    BIRADS 5 classification suggests a likelihood of malignancy of at least _____%.

    <p>95</p> Signup and view all the answers

    Match the following BIRADS categories with their management:

    <p>BIRADS 0 = Recall for additional imaging BIRADS 4 = Tissue Diagnosis (Biopsy) BIRADS 1 = Routine screening in 1 year BIRADS 6 = Surgical excision</p> Signup and view all the answers

    What is the primary risk reduction percentage achieved through bilateral prophylactic mastectomy?

    <p>95%</p> Signup and view all the answers

    Ovarian cancer risk can be reduced by 90% through bilateral salpingo oophorectomy.

    <p>True</p> Signup and view all the answers

    What lifestyle modification can help reduce the risk of breast cancer?

    <p>Regular exercise</p> Signup and view all the answers

    The _____ carcinoma is the most common type of breast cancer.

    <p>invasive ductal</p> Signup and view all the answers

    Match the following histological types of breast cancer with their prognosis:

    <p>Tubular = Good prognosis Mucinous = Varied prognosis Medullary = Associated with BRCA 1</p> Signup and view all the answers

    What is the purpose of mammography?

    <p>To assess breast tissue through x-ray imaging</p> Signup and view all the answers

    Which breast cancer subtype has the best prognosis?

    <p>Luminal A</p> Signup and view all the answers

    Benign lesions in breast imaging typically show spiculated margins.

    <p>False</p> Signup and view all the answers

    The Claudin low type is associated with a low recurrence rate.

    <p>False</p> Signup and view all the answers

    What type of mammographic view is crucial for visualizing the axilla?

    <p>Mediolateral oblique (MLO)</p> Signup and view all the answers

    _____ lesions often show macro calcifications but with additional features such as spiculated margins.

    <p>Malignant</p> Signup and view all the answers

    What does a Ki67 index indicate in breast cancer?

    <p>Proliferation rate</p> Signup and view all the answers

    The _____ subtype of breast cancer is characterized by positive expression of HER2.

    <p>HER2 enriched</p> Signup and view all the answers

    Match the following breast lesions with their descriptions:

    <p>Fibroadenoma = A benign breast tumor with a smooth border Phyllodes Tumor = May exhibit a rounded shape and malignant features Calcified Fibroadenoma = Shows deposits of calcium in a benign tumor Malignant Lesion = Characterized by irregular shapes and spiculated margins</p> Signup and view all the answers

    Match the molecular subtype of breast cancer with its characteristics:

    <p>Luminal A = Best prognosis, ER +, PR +, HER2 - Basal like = Aggressive, ER -, PR -, HER2 - HER2 enriched = HER2 +, ER +, PR - Claudin low = Triple negative, high recurrence rate</p> Signup and view all the answers

    What is typically observed in normal lymphatic nodes?

    <p>Kidney shape retaining fatty hilum</p> Signup and view all the answers

    3D Full Field Digital Tomosynthesis is used for better image quality in dense breasts.

    <p>True</p> Signup and view all the answers

    What classification system is used for describing breast imaging findings?

    <p>BIRADS</p> Signup and view all the answers

    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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    Description

    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.

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