1.

What is the preferred imaging modality for

a 29 yr patient with a palpable breast

mass?
a. Mammography
b. Ultrasound
c. CT scan
d. MRI

Answer : B- Ultrasound

Mammography not ideal for women less

than 30 years old
because of breast density.
CT scan generally not used for evaluation of
breast lesions.
MRI - false positive rate is 6% leading to
unnecessary mastectomy or additional
biopsies.

Breast Cancer Screening and

Diagnosis
Ultrasound
(preferred)
or

Lump/
mass
Age <30 yr

Needle Sampling
or

Observe for 1- 2
menstrual cycles (option
for low clinical
suspicion)

2. What is the preferred imaging modality for

a 49y/o female patient with a palpable

breast mass?
a. Mammography
b. Ultrasound
c. CT scan
d. MRI

Answer : A-Mammography

Mammography - can detect palpable and

nonpalpable masses
including microcalcifications in
this age group.
Ultrasound- is not capable of detecting
microcalcifications

Breast Cancer Screening and

Diagnosis
Final
Assessment
category 1- 3

Lump/
mass
Age >30 yr

Mammogram

Final
Assessment
category 4- 5

3. A 28y/o female with a palpable breast

mass had an US result of a solid breast

mass suspicious for malignancy. What kind
of biopsy is preferred in this case?
a. FNAB
b. Core Bx
c. Incisional Bx
d. Excisional Bx

Answer : B-Core Bx

FNAB - sensitivity- 95%

- Needs an experienced cytopathologist
- False [+]- 0- 0.4% False [-] 0 4%
- Can not distinguish between in situ
carcinoma and invasive carcinoma
accurately
Core needle bx - biopsy technique of choice
specially in the absence of
an experiencecytopathologist.
- sensitivity 98.7%
- has the ability to distinguish
between in situ carcinoma
and invasive carcinoma.

Incisional bx - when open biopsy is indicated

for large lesions
Excisional bx - indicated when needle biopsy
is nondiagnostic and is
discordant with physical exam
and imaging findings.
- difficult to do BCS after this
type of biopsy.

Breast Cancer Screening and

Diagnosis

Core
needle
biopsy
(preferred)

Solid:
Indeter
minate
or
suspicious

Mam
mogram

Tissue
biopsy

or

Excision

4. A 45y/o female underwent mammogram

for breast screening. Mammograms final

assessment was BIRADS Cat. 3. What
would you do?
a. do nothing
b. do biopsy
c. surveillance/follow up

Answer : C- surveillance/follow up

BIRADS Breast Imaging Reporting And

Data System
BIRADS Cat 3 Probable benign findings<2% risks of malignancy
Follow up PE every 6 mos.,
mammogram every 6-12
mos. until long term stability
is demonstrated (2 yrs or
longer)

5. A 25y/o female underwent FNA for a breast

mass. Aspirate was non bloody fluid and

the mass completely disappeared . Next
step would be:
a. cytology of aspirate
b. excision biopsy
c. follow up after 6 weeks

Answer : C- follow up after 6 weeks

Simple cyst are almost never malignant

Aspirated cyst fluid should not be routinely
sent for cytologic examination.

The clinical validity of atypia identified in

a cyst aspirate fluid is questionable and
of low yield.

Hindle et.al. routine cytologic exam of

cyst aspirate fluid often results in
unnecessary surgical biopsy and is not
cost effective.

6. A 30y/o female underwent FNA for a breast

mass. Aspirated fluid was greenish brown in

color. After aspiration the mass did not
completely resolve. Next step would be:
a. cytology of aspirated fluid
b. excision biopsy
c. follow up after 6 weeks

Answer : B- excision biopsy

Indications for excision biopsy of a cyst

after FNA:

bloody or serosanguineous aspirate

residual mass
recurrent cyst after 2 aspirations

Breast Cyst - Algorithm

Breast mass
FNA

Ultrasound

Cyst
Bloody

Non-bloody
Follow up after 6 wks.
Recur
Reaspirate
Recur
Excisional Bx

Excisional Bx

Does not recur

Follow up in 1 yr.

Residual mass
Excisional Bx

7. A 24y/o female consulted at your clinic

because of a breast mass of 2mos. duration.

On PE mass was found to be 2cms. in size,
well circumscribed, movable, and non
tender. There were no palpable axillary
masses. Needle biopsy was done and
histopath
result
was
fibroadenoma.
Management would be:
a. surgical excision
b. observe
c. total mastectomy
d. quadrantectomy

Answer : A & B - Surgical excision or

observe

Surgical excision if patient desires removal

of the mass
Breast mass can be observed if:
- characteristic (clinically benign),2 3cms.
in size
- < 25y/o, acceptable for those 25 30y/o
but probably not there after
Observation is at 3 6mos. interval for 1
2yrs.
FA usually cease to grow at 2 3cms and
may regress in postmenopausal women

8. A 45y/o female with a 5cms. breast mass

underwent core biopsy of said mass. Final

histopath showed malignant cystosarcoma
phylloides. Appropriate treatment would
include:
a. wide excision
b. adjuvant chemotherapy
c. adjuvant hormonal therapy
d. MRM
e. adjuvant RT

Answer : A- wide excision

Wide excision with clear margins [ 1cms. ]

appropriate surgical treatment of phyllodes
tumors whether benign or malignant.
Adjuvant chemotherapy- at present has no role
for CSP
role of chemotherapy [ Ifosfamide ] for
metastatic CSP currently under
investigation.
Adjuvant hormonal therapy no role in CSP
ER & PR [+] in 43% - 84% in epithelial
component
[+] in 5% in stromal component

ALND 20% with palpable axillary nodes

<1% to 5% with [+] axillary nodes
minimally invasive nodal sampling done for
clinically suspicious axillary nodes.
Adjuvant RT role is unclear
indicated in recurrent tumors after
mastectomy
anecdotal cases support the use of
combined chemo RT following CSP
recurrences.

9. A 42y/o female with a 5cms. breast mass

underwent FNAB and was diagnosed to have

fibroadenoma. However, after excision, final
histopath turned out to be CSP. Further
management would be:
a. Immediate reexcision
b. Observe
c. RT to involved breast

Answer : B-Observe

Authors opinion differ on whether

immediate reexcision is necessary.
Chua, Thomas & Ng [ Singapore ] 16%
recurrence rate
Zurrida et al [ Milan ] 8% recurrence
rate
These authors suggest that a wait and
watch policy for benign CSP may be
considered in place of mandatory surgical
reexcision.
Specially
in
cases
where
reexcision would be difficult and deforming.

10.A 35y/o female consulted because of

breast pain and tenderness. 3 days PTC,

ultrasound was done which showed a
complex mass at the UIQ of the left
breast. Appropriate treatment would be:
a. I&D + antibiotics
b. Repeated aspiration + antibiotics
c. Surgical excision
d. Core bx

Answer : B- Repeated aspiration +

antibiotics

The combination of repeated aspiration and

oral antibiotics is usually effective at resolving
local abscess formation and is the current
treatment of choice for most breast
abscesses.
Aspiration should be repeated
every 2 3 days until no further puss is
obtained.

Immediate I&D is done if the skin overlying

the abscess in thinned and puss is visible on
ultrasound.

11.Risk

of subsequent breast CA among

patients with this benign breast lesion is
not increased.
a. fibroadenoma
b. sclerosing adenosis
c. apocrine change
d. atypical ductal hyperplasia

Answer : C- apocrine change

Categorization of Benign Breast Lesions

according to the Criteria of Dupont,
Page, and Rogers
Nonprolifetative - NO Risk
Cyst
Papillary apocrine change
Epithelial-related calcifications
Mild hyperplasia of the usual type
Proliferative lesions w/o atypia - 1.5-2x Risk
Moderate or florid ductal hyperplasia of the usual type
Intraductal papilloma
Sclerosing adenosis
Fibroadenoma
Profilerative lesions w/ atypia - 4 -5x Risk
Atypical ductal hyperplasia
Atypical lobular hyperplasia

12.32 y/o female diagnosed with LCIS with

negative family history of breast or ovarian

CA. Most appropriate management would be:
a. Observation/ Surveillance
b. Chemoprevention with Tamoxifen
c. Prophylactic mastectomy
d. Breast conservation surgery

Answer : A- Observation and

Surveillance

LCIS 5% incidence
marker of increased breast cancer risk
but not a disease by itself
App. risk of developing invasive BCA is
1%/ yr.
If with [ + ] family history risk is
increased to 2% / yr.
Observation - strategy selected by most
patients
16.4% developed invasive BCA
disease related mortality 2.8% vs.
0.9% (patients treated with
prophylactic mastectomy).

Tamoxifen reduce incidence of BCA by 49%

- effect not known in women
<35y/o
Prophylactic mastectomy indications:
New LCIS lesions 16x risk
Strong family history of breast and
ovarian CA
BRCA1 & BRCA2 genetic mutations
Patient preference

13.A 39y/o female consulted with a

mammogram finding of suspicious calcifications on the right breast. Stereotactic core

bx was done and histopath revealed LCIS.
However, not all calcifications were removed
during the core bx procedure. You would:
a. Observation / surveillance
b. Mammography guided needle

localization bx of remaining calcifications

c. Do RT of right breast
Answer : B-Mammography guided needle
localization bx of remaining
calcifications

LCIS is an incidental finding on biopsies. It

does not account for any physical findings or
mammographic/ultrasonographic
abnormalities. Primary concern should focus
on whether some additional pathologic
process is present that would explain the
clinical/ imaging feature that prompted the
biopsy. Although very low rates of significant
disease is found on follow up excision bx ,
the preponderance of the data reveals that
the completely benign cases can not be
reliably predicted, and therefore follow up
excision bx is the definitive management

14.A 50y/o female consulted because of a

mammographic result of BIRADS-4. Needle

localization excision bx was done and
histopath result was DCIS 0.5cms. in size
with negative margins. Possible surgical
management would include:
a. Excision alone
b. Excision + RT
c. Total mastectomy
d. Total mastectomy + RT
e. MRM

Answers: A, B & C -Excision alone;

Excision + RT; Total
mastectomy

Adjuvant RT after total mastectomy is not

indicated
in DC IS because total
mastectomy alone has a local recurrence rate
of only about 1%.
Axillary dissection is not indicated in DCIS
because the incidence of ALN mets is only
about 0.5%.
For many patients with DCIS total
mastectomy is over treatment.

Indications for Mastectomy:

Large diffuse lesions [>3cms. in size]
Documented multicentric disease
Patient unwilling to take even the
slightest increased risk of death
Patient with no interest for BCT or
medically unsuited for BCT
Patient unwilling or unable to undergo
careful long term clinical follow up.
Persistent [+] margins

Ductal Carcinoma In Situ

Margins
negative

Excision + RT
or
Total mastectomy
w/o lymph node
dissection +
reconstruction

Small (<0.5cm),
unicentric, low
grade

Excision + RT
or
Total mastectomy
w/o lymph node
dissection +
reconstruction or
Excision alone

15.A 52y/o female was diagnosed with DCIS.

After excision histopath result was; tumor

size was 1.6cms., margins were >1cms.,
tumor was non- high grade with comedo
necrosis. Based on the Van Nuys Prognostic
Index, treatment of choice would be:
a. Excision alone
b. Excision + RT
c. Total mastectomy

Answer: B-Excision + RT [VNPI score7]

Van Nuys Prognostic Index:

Size score- 15mm or less- 1 ; 16mm
to 40mm-2; 41mm or more- 3

Margin score- 10mm or more- 1 ;

1mm to 9mm- 2 ; 1mm or less- 3

Pathological Classification score- non-high

grade w/o comedo necrosis- 1 ; non- high
grade w/ comedo necrosis- 2 ; high grade
lesion- 3

Age score- >60y/o- 1 ; 40y/o to 60y/o- 2

;<40y/o- 3

Treatment Recommendations:
Old
New
Recommendation
3 to 4
4 to 5 to 6
Excision alone
5 to 6 to 7 7 to 8 to 9
Excision + RT
8 to 9
10 to 11 to 12 Total mastectomy

16.A 45y/o patient consulted in your clinic

because of a 4cms. breast mass fixed to

the pectoralis muscles. There were
palpable movable axillary nodes in the
ipsilateral axilla. Biopsy was done and
histopath result was IDCA. There were no
clinical evidence of metastases. What is
the clinical stage?
a. Stage
b. Stage
c. Stage
d. Stage

III-B
IV
III-A
II-B

Answer: D-Stage II-B [T2 N1]

T4a - Extension to chest wall , not including

pectoralis muscle
T2 - Tumor >2cms. but not >5cms. in
greatest dimension
N1- Metastasis to movable ipsilateral axillary
lymph
node[s]
Stage II-B T2 N1 M0
T3 N0 M0

17.A 57y/o patient has a 2cms. breast mass

diagnosed as IDCA. Nipple retraction and

skin dimpling was noted on the ipsilateral
breast. There were no palpable ipsilateral
axillary nodes and there were no clinical
evidence of metastasis. What is the clinical
stage?
a. Stage
b. Stage
c. Stage
d. Stage

IV
III-C
I
III-B

Answer: C- Stage I [T1 N0

T4b - Edema [including peau dorange] or

ulceration of the skin of the breast,
or satellite nodules confined to the
same breast.

T1c -tumor >1cm. but not >2cms. in

greatest dimension
Skin of breast - Dimpling of the skin, nipple
retraction, or any other skin
change except those described
under T4b and T4d may occur
in T1,T2,orT3 without changing
the classification

18.A 61y/o patient has a 1.5cms. breast mass

diagnosed as IDCA. A palpable

supraclavicular node was also noted. What is
the clinical stage?
a. Stage
b. Stage
c. Stage
d. Stage

IV
III-A
III-B
III-C

Answer: D- Stage III-C [T1 N3c M0]

N3a - Metastasis in ipsilateral infraclavicular

lymph node [s]
N3b - Metastasis in ipsilateral internal
mammary lymph node[s] and axillary lymph
node [s]
N3c - Metastasis in ipsilateral supraclavicular
lymph node [s]

Invasive Breast Cancer PreOp

Work up
H&P
CBC, platelets
Liver function tests
Chest x-ray
Diagnostic billateral mammogram,
ultrasound as necessary
Pathology review
Determination of tumor
estrogen/progesterone receptor (ER/PR)
status and HER-2 status
Breast MRI w/ dedicated breast coil may
be considered for breast conserving therapy
for preoperative evaluation of extent of
disease and detection of mammographically
occult disease in the breast (optional).
Bone scan (optional)
Abdominal CT or US or MRI (optional)

Stage I
Stage IIA
Stage IIB
T3, N1, M0

19.A 55y/o female consulted in your clinic

because of a 2cms. breast mass which was

subsequently diagnosed as IDCA. There were
no palpable axillary nodes. Possible surgical
treatment would include:
a. Lumpectomy + ALND
b. Lumpectomy alone
c. Total mastectomy
d. MRM

Answer: A & D -Lumpectomy +

ALND; MRM

BCS- Lumpectomy + ALND

BCT- Lumpectomy + ALND + RT
Incidence of [+] ALN mets in IDCA measuring
2cms.-> 25%

20.A 62y/o patient with a 2.5cms. breast

mass at the UOQ of the right breast

underwent bx which showed IDCA.
Mammography showed clustered
calcifications in the IUQ & LOQ of the right
breast. Bx of said lesions showed DCIS.
Surgical treatment of choice would be:
a. BCS
b. MRM
c. Radical mastectomy
d. Extended radical mastectomy

Answer: B-MRM

Absolute Contraindications to BCT:

Women with 2 or more primary tumors in
separate quadrants of the breast or with
diffuse, malignant appearing
microcalcifications are not considered
candidates for BCT.

A history of previous therapeutic

irradiation to the breast region that,
combined with the proposed treatment,
would result in an excessively high total
radiation dosage to asignificant
volume.

Pregnancy is an absolute contraindication

to the use of breast irradiation. However,
in many cases, it may be possible to
perform BCS in the 2nd & 3rd trimester and
treat the patient with irradiation
after
delivery.

Persistent [+] margins after reasonable

surgical attempts absolutely contraindicate
BCT. The importance of a single, focally [+]
microscopic margin needs further study and
may not be an absolute contraindication.

Relative Contraindications to BCT:

A history of collagen vascular disease is

a relative contraindication to BCT, because
published reports indicate that such
patients poorly tolerate irradiation. Most
radiation oncologists will not treat patients
with scleroderma or active lupus
erythematosus, considering either an
absolute contraindication. In contrast,
rheumatoid arthritis is neither a relative
nor an absolute contraindication.

Patients with multiple gross tumors in the

same quadrant and indeterminate
calcifications must be carefully assessed for
suitability because studies in this area are not
definitive.

Tumor size is not an absolute

contraindication to BCT, although few reports
have been published about treating patients
with tumors larger that 4 to 5cms. However a
relative contraindication is the presence of a
large tumor in a small breast, in which an
adequate resection would result in significant
cosmetic alteration. In this circumstance,
preoperative chemotherapy or endocrine
therapy or the use of partial breast
reconstruction should be considered if the
patient desires BCT.

Breast
size
can
be
a
relative
contraindication.
Women with large or
pendulous breasts can be treated with
irradiation if reproducibility of patient
setup can be ensured and if it is
technically possible to obtain adequate
dose homogeneity.

Women

35 y or younger.

Premenopausal

women
BRCA mutation.

with

known

Non Mitigating Factors:

The presence of clinical or pathologic

involvement in axillary nodes.Tumor
location is not a factor in the choice of
treatment. Tumors in a superficial
subareolar location occasionally may
require resection of the nipple areolar
complex so that [-] margins can be
achieved, but this does not affect outcome.
The patient and her physicians need to
assess whether such a resection is
preferable to mastectomy.

A high risk of systemic relapse is not a

contraindication for BCT but it is a
determinant of the need for adjuvant
therapy.

21.A 52y/o female underwent screening

mammography which showed

microcalcifications on her left breast. It
was read as a BIRADS Cat 5 lesion.
Management would include:
a. US guided core bx
b. Mammography guided needle

localization excision bx
c. Stereotactic core bx
d. If dx as malignant- determination of
hormone receptor status
e. Frozen section

Answer: C, B, D - Stereotactic core

bx;Mammography
guided needle
localization bx ;
If dx
as
malignantdetermination of
hormone receptor
status
US core bx- ultrasound can not detect
mammographic calcifications
Stereotactic core bx- preferred bx technique
for mammographic calcifications
because its accuracy is the same as
that of MGNLB and is less invasive.

Frozen sections should not be performed on

non palpable lesions because of the loss of
tissue caused by the FS process. In addition,
because most of the specimen is fat [which
does not freeze well], they are technically
difficult to perform, often inaccurate, and may
be extremely difficult to interpret. Most impt.,
definitive treatment should not be decided on
until permanent sections have been
thoroughly evaluated.

With
Tamoxifen
NSABP B14 -10 yr. rate of
recurrence in ipsilateral
breast
Stockholm grp

4.3%
-3.0%
W/ RT

NSABP B21 - 8 yr. rate of

ipsilateral recurrence

9.3%

W/o
Tamoxifen

14.7%
-12.0%
RT +
Tamoxifen
2.8%

22.A 52y/o female who was diagnosed with

IDCA is undergoing MRM. During axillary

dissection the surgeon was able to palpate
enlarged nodes posterior to the pectoralis
minor muscle. Appropriate axillary dissection
would be:
a. Axillary sampling
b. Level I dissection only
c. Level 1&2 dissection
d. Total axillary lymphadenectomy

[level1,2,3]

Answer: D- Total axillary

lymphadenectomy

Types of ALND:
Axillary sampling- provides 4 to 7 nodes,
includes axillary tail of Spence and level 1
nodes
Low level 1, dissection stops superiorly
at the level of the major intercostobrachial
nerve

Level 1, up to axillary vein superiorly;

mean # of nodes is 10; lateral border is
the latissimus dorsi and medial border is
the pectoralis minor muscle

Level 1&2, includes nodes posterior to

the pectoralis minor muscle and Rotters
nodes.

Level 1,2,3 [Total axillary

lymphadenectomy] medial border is the
subclavius muscle[Halsteds ligament]

Surgical Extent:
ALND is therapeutic by reducing the
risk of
axillary recurrence to <5% and
prognostic,
by allowing even more
accurate determination of nodal
metastasis.
Clearly 80% - 90% of ALN are found
in levels 1&2
A level 1&2 dissection is adequate in
the absence of gross disease.

Incidence of skip mets to level 3 - 1% to 3%

[+] level 1 nodes - 28% risk of mets to level
2&3
Skip mets to level 2- 1.2% - 5%
Level 1&2 [+]- 33% of level 3 nodes are [+]
Incidence
Axillary sampling
Level 1&2
Level 1,2,3
Axillary RT
Axillary RT + Total ALND

of lymphedema:
0 2.8%
2.7% - 7.4%
3.1% - 8%
2.1% - 8.3%
3 7 fold increase in incidence

Werner [MSKCC]
The level of node dissection was not
statistically related to the development of arm
edema, the only factor that was significantly
associated was obesity.

Armando Giuliano [John Wayne Cancer

Inst.]
When surgery is the treatment selected,
level 1&2 dissection is sufficient for staging
and local control, with dissection of level 3
reserved for extensive gross disease to
improve local control.

23.A 55y/o female with a 4.5cms mass at the

left breast was diagnosed by core bx to

have IDCA. Patient underwent MRM.
Margins were >1mm and ALN were [-] for
mets. Would you give adjuvant RT?
a. Yes
b. No

Answer: B-No

Indications for PMRT:

Patients with 4 or more [+] ALN
Patients with 1 to 3 [+] ALN- there is
insufficient evidence to make
recommendations or suggestions for the
routine use of PMRT in these patients.

Patients with T3 or Stage III tumors- PMRT is

suggested for patients with T3 tumors with
[+] ALN and patients with operable Stage III
tumors

Patients undergoing preop systemic therapythere is insufficient evidence to make

recommendations or suggestions on whether
all patients initially treated with preop
systemic therapy should be given PMRT
following surgery.

Invasive Breast Cancer LocoRegional

Treatment of Clinical Stage I,II or T3,N1, M0

Total
mastectomy
w/ surgical
axillary staging
(category 1) +
reconstruction

> 4 positive
axillary nodes

1- 3 positive
axillary nodes

Negative axillary
nodes and tumor
>5cm T3,No or
margins positive

RT to chest wall +
supraclavicular
area(category1). Consider
RT to IMN (category 3)

Consider RT to chest wall +

supraclavicular area
(category1) if RT is given,
consider internal mammary
RT (category 3)
RT to chest wall. Consider
RT to supraclavicular area
(category 2B) Consider RT
to internal mammary
nodes (category 3).

Invasive Breast Cancer LocoRegional

Treatment of Clinical Stage I,II or
T3,N1, M0
Total
mastectomy
w/ surgical
axillary
staging
(category 1)
+
reconstruction

Negative
axillary nodes
and tumor
<5cm and
margins close
(<1mm)
Negative
axillary nodes
and tumor
<5cm and
margins
>1mm

Consider RT to chest
wall

No RT

24.A 70y/o female with a 9mm. right breast

mass was diagnosed b y core bx to have

IDCA. Lumpectomy + ALND was done.
Axilla was [-] for mets. Tumor was
ER+/PR+. Adjuvant treatment must include:
a. Adjuvant RT
b. Adjuvant chemotherapy
c. Adjuvant hormonal therapy

Answer: C- Adjuvant hormonal

therapy

Adjuvant RT should always accompany

BCS. However, in those 70 yrs. of age or
older with ER+, node[-], T1 tumors breast
RT may be omitted.
There is no indication for chemotherapy
in this case. There is insufficient data to
make chemotherapy recommendation for
those 70y/o and over. Always consider
comorbid recommendations.
Adjuvant hormonal therapy is indicated
in all patients with ER+/PR+ tumors.

25.A 50y/o female has an 8mm breast mass

diagnosed as IDCA. She underwent BCS.

Axilla had 2[+] nodes out of 10. Tumor was
ER-/PR-. Adjuvant treatment would include:
a. Adjuvant RT
b. Adjuvant chemotherapy
c. Adjuvant hormonal therapy

Answers: A,B - Adjuvant RT &

Adjuvant chemotherapy
For node [+] patients chemotherapy is given
regardless of age and hormone receptor
status.

26.A 42y/o female with a 1.5cms. breast

mass was diagnosed to have IDCA. She

underwent MRM. Axillary nodes were [-]
for mets. Tumor was ER-/PR-, HER 2 +.
Appropiate adjuvant treatment would be:
a. Adjuvant RT
b. Adjuvant chemotherapy
c. Adjuvant hormonal therapy
d. No adjuvant therapy
e. Adjuvant chemotherapy +

trastuzumab

Answer: E-Adjuvant chemotherapy

+ trastuzumab

Invasive Breast Cancer Systemic

Adjuvant Treatment Hormone NonResponsive Disease

ERnegative
and PRnegative
and
HER2
positive

Histology
Ductal,
NOS
Lobular
Mixed
Metaplastic

pT1,pT2, or
pT3 and
pN0 or
pN1mi (<
2mm
axillary
node
metastasis)

Invasive Breast Cancer Systemic

Adjuvant Treatment Hormone NonResponsive Disease
pN0
pT1,pT2,
or pT3
and pN0
or pN1mi
(< 2mm
axillary
node
metastasis)

Tumor<0.5
cm or
Micro
invasice

Tumor 0.61.0cm
Tumor >1cm

pN1mi

No adjuvant
therapy
Consider
chemotherapy
Consider
chemotherapy
(category1)
Adjuvant
chemotherapy +
trastuzumab

27.A 39y/o female, premenopausal, with a

2cms. breast mass was diagnosed with IDCA.

BCT was done. Tumor was ER+/PR+. What is
the most appropriate adjuvant hormonal
treatment?
a. Ovarian ablation
b. Tamoxifen 20mgs. X 10yrs.
c. Tamoxifen 20mgs. X 5yrs.
d. Aromatase inhibitors
e. Megestrol acetate [Megace]

Answer: C-Tamoxifen 20mgs. X 5yrs.

Level II, grade A evidence supports no added

benefit of ovarian ablation in women with
node negative or node positive BCA who are
treated with chemotherapy. Whether there is
benefit for women who do not become
amenorrheic following chemotherapy is not
known.

Tamoxifen given for more than 5yrs.

does not improve LRR and DFS compared
to Tamoxifen given for a maximum of 5yrs.
Aromatase inhibitors at present are
given only to postmenopausal patients.
Megestrol acetate [Progerstin], is
generally not used because of the
availability of better agents for hormonal
treatment.

28.A 46y/o premenopausal patient undergoes

BCS for a 2cms. tumor diagnosed as IDCA

of the left breast. The margins are clear
and 5 out of 15 ALN are [+] for mets.
Tumor was ER-/PR+. Recommended
adjuvant treatment should be:
a. RT + Chemotherapy
b. RT + Hormonal therapy
c. Chemotherapy + Hormonal therapy
d. RT alone
e. Chemotherapy + RT + Hormonal

therapy

Answer: E- Chemotherapy + RT +
Hormonal therapy
Chemotherapy- tumor size is >1cm.
RT- as part of BCT; >4 [+] ALN for mets
Hormonal Tx- tumor is PR+

29.What is the most appropriate sequence in

giving adjuvant therapy?

a. RT then Chemotherapy then Hormonal

Tx
b. Hormonal Tx then Chemotherapy then
RT
c. [RT + Chemotherapy] then Hormonal
d. Chemotherapy then RT then Hormonal
Tx
e. Chemotherapy then Hormonal Tx then
RT
Answer: D-Chemotherapy then RT
then Hormonal Tx

Chemotherapy is given initially because its

effect are both on locoregional and systemic
control.
RT is given next for locoregional control.
Chemotherapy and RT are usually not
combined because of higher morbidity rates.
Hormonal treatment is given last and is
given for 5yrs. It is usually not combined with
chemotherapy because theoretically it inhibits
cell proliferation.

Chemotherapy is more effective on

proliferating cells.

American Society of Clinical Oncology For

Breast Cancer Follow-Up Care
Test

Frequency

Recommended
History (eliciting of symptoms) and physical
examination
Breast self-examination
Mammography
Pelvic examination
Patient educate regarding symptoms of
recurrence
Coordination of care
Not recommended
Complete blood cell count
Automated chemistry studies
Chest roentgenography
Bone scan
Ultrasound of the liver
Computed tomography of chest, abdomen,
and pelvis
Tumor marker CA-15-3
Tumor marker carcinoembryonic antigen

Every 3-6 mo for 3 years;

every 6-12 mo for 2 years;
then annually
Monthly
Annually
Annually
NA
NA

30.A 61y/o female consulted in your clinic

because of a 7cms. ulcerating, fixed mass of

the left breast. There were palpable movable
ALN in the left axilla. Biopsy of the mass
revealed IDCA. What would be the
appropriate initial management?
a. MRM
b. RT
c. Radical mastectomy
d. Extended radical mastectomy
e. Neoadjuvant chemotherapy

Answer: E-Neoadjuvant chemotherapy

The historical experience of surgically

treated patients with LABC was poor.
Although surgical resection was technically
possible, 10yrs. after diagnosis >80% of
patients had succumbed to the disease.
After giving neoadjuvant chemotherapy
a major reduction in tumor volume occurred
in most [60% to 80%] patients. Clinical
complete remissions were reported in 10% to
20% of patients so treated in most clinical
trials. In one multicenter trial, the increase in
clinical and pathologic complete response
rate was associated with improved diseasefree and overall survival rates.

Invasive Breast Cancer Treatment for

LABC
Response
Doxorubicin-or
epirubicinbased or
paclitaxel-or
docetaxelbased
preoperative
chemotherapy
preferred

No
response

MRM +
RT or BCT
or High
dose RT
alone
(category
3)

Additional
chemothera
py +
hormonal
therapy if
estrogen
receptor
postive or
unknown

Consider additional
systematic
chemotherapy
and/or preoperative
radiation

31.A 62y/o female underwent BCT of the left

breast because of a 2cms. mass diagnosed

as IDCA. 5yrs. later, a 2.5cms. mass was
noted again on the left breast. Core bx was
done and histopath result was IDCA. What is
the preferred surgical management?
a. MRM
b. BCS
c. Total mastectomy
d. Radical mastectomy

Answer: C-Total mastectomy

Management of LRBC after BCT:

Radiologic evaluation
Bilateral mammography
Other imaging studies as indicated [US
and MRI]
Establish diagnosis
Core biopsy or surgical biopsy
[preferred]
FNA cytology

Metastatic workup for patients with invasive

carcinoma Treatment
Mastectomy [preferred]
Less than mastectomy [ local excision,
reirradiation] for highly selected patients
Consider systemic therapy [ chemotherapy
and/or hormonal therapy] for high risk patients
[short disease free interval, high grade
tumor,[+] ALN].

32.A 49y/o patient underwent MRM for a

4cms. right breast mass diagnosed as IDCA.

There were no nodes [+] for mets. 2yr.
later, patient noted a 3cms. fixed mass on
the chest wall. Biopsy of the mass showed
IDCA. Tumor was hormone receptor [+].
Appropriate management would include:
a. Excision of chest wall mass
b. RT
c. Chemotherapy
d. Hormonal therapy
e. All of the above

Answer: E-All of the above

Management of LRBC after

mastectomy:
Establish diagnosis
Metastatic work up
Treatment
Local excision if operable
RT, generally to minimum volumes
of chest wall and supraclavicular fossa
Consider chemotherapy and/or
hormonal therapy
For inoperable local recurrence,
consider radiation [or reirradiation],
systemic therapy, other modalities
[hyperthermia, photodynamic
therapy].

Invasive Breast Cancer Treatment of

LRBC

Local
recurrence

Initial
treatment w/
mastectomy
Initial
treatment w/
lumpectomy
+ RT

Surgical
resection (if
possible) +
RT (if
possible)
Mastectomy

Consider
systemic
therapy

Consider
systemic
therapy

33.A 30y/o patient, pregnant AOG-10-11wks.,

consulted because of a 1.5cms. mass on the

left breast. Core bx result was IDCA.
Appropriate surgical treatment would be:
a. Lumpectomy + ALND
b. Lumpectomy alone
c. Total mastectomy
d. MRM

Answer: D-MRM

BCT is contraindicated in pregnancy during

the 1st trimester.
ALND should always be a part of definitive
surgical procedures for the treatment of
invasive BCA.

34.Recommended adjuvant treatment for the

above case would be:

a. Adjuvant RT
b. Adjuvant chemotherapy
c. Adjuvant hormonal therapy
d. None of the above
e. All of the above

Answer: D - None of the above

Management of PABC:
MRM is the standard management of a
patient with BCA during pregnancy.

RT should be avoided during any trimester

because of the dose, due mainly to
internal
scatter, absorbed by the fetus.

Chemotherapy during pregnancy must be

considered on a case by case basis
because of the risk of fetal damage,
including the effort to avoid chemotherapy
in the 1st trimester. There is an 11.5% to
12.7% incidence of teratogenicity during
the 1st trimester. Although chemotherapy
may be started during the 2nd trimester,
there are reports of impaired CNS
development and delayed cognitive
damage during this period.
Hormonal therapy is not indicated during
pregnancy because there is positive
evidence of human fetal risk [teratogenic
or embryocidal etc.].

35.A 50y/o woman consulted because of a

6cms. mass at the right breast. Core biopsy

showed IDCA. Mammography was done
which showed a 0.8cms. mass at the left
breast. Biopsy result of the left breast mass
was DCIS. Both tumors were hormone
receptor [+]. Management would include:
a. MRM right, Lumpectomy left
b. Bilateral MRM
c. MRM right, Lumpectomy + ALND left
d. Adjuvant RT both sides
e. Adjuvant chemotherapy + hormonal

therapy

Answer: A,D, E - MRM right,

Lumpectomy left;
Adjuvant RT both sides ;
Adjuvant chemotherapy
+ hormonal therapy

Manage each lesion individually.

ALND is not necessary for DCIS lesions

Adjuvant RT is indicated for lesions 5cms. or
more in size and as part of management for
DCIS lesions.

Adjuvant chemotherapy is indicated for

invasive lesions 1cm. or more in size.
Adjuvant hormonal therapy is indicated for all
hormone receptor [+] breast cancer.

Criteria for the diagnosis of a second

primary breast cancer
1.The demonstration of a situ change in the
contralateral tumor is considered absolute
proof that the contralateral lesion is
primary tumor.
2.The tumor in the second breast is
considered to be a new primary if it is
histologically different from the cancer in
the first breast.

Criteria for the diagnosis of a second

primary breast cancer
3.The carcinoma in the second breast is
considered to be a new primary if its degree
of histologic differentiation is distinctly
greater that that of the lesion in the first
breast.

4.In the absence of definite histologic

difference, a contralateral carcinoma is
considered to be compatible with an
independent lesion provided there is no
evidence of local, regional, or distant
metastases from the cancer in the ipsilateral
breast.

36.A 25y pregnant woman consulted in your

clinic because of a firm 2.5cms. left breast

mass which is tender and sometimes
painful. Core bx showed granulomatous
lobular mastitis. Management would be:
a. Excision Biopsy
b. Antibiotics
c. I & D
d. Observation
e. Steroids

Answer: Observation

Excision of the mass in granulomatous

lobular mastitis should be avoided because it
is often followed by persistent wound
discharge and failure of the wound to heal.

Antibiotics- the role of organisms in the

etiology of this condition is unclear and until
this is confirmed antibiotics is not clearly
indicated in this condition.

I&D- indicated only in the presence of an

abscess.

Current tx involves establishing the dx and

observation because the condition usually
resolves w/o specific tx.

Steroids have been tried w/o consistent

success.

37.The only group of patients w/ benign non

proliferative breast lesions with an

increased risk for development of BCA are
those patients with:

a. Papillary apocrine change

b. Mild hyperplasia w/ + family history of

BCA
c. Epithelial related calcifications
d. Cyst w/ + family history of BCA

Answer: D Cysts w/ + family

history of BCA

According to Dupont and Page, the risk of

subsequent BCA in px w/ non proliferative
breast lesions even with + family history of
BCA compared to women who have had no
breast bx is not increased. The only group of
px in the non proliferative category w/ an
increased risk for development of BCA was
that of gross cysts + a family history of BCA.
The relative risk was increased to 3.0.

38.60y woman underwent MGNLB. Histopath

showed DCIS w/ close surgical margins

(<1mm) at the fibroglandular boundary of
the breast. The appropriate subsequent tx
is:
a. Surgical re-excision is a must
b. Higher boost dose radiation is

indicated to the lumpectomy site.

c. Chemotherapy
d. Total mastectomy

Answer: B- Higher boost dose

radiation to lumpectomy site

With respect to pathologic margins between

110mm, wider margins are generally
associated w/ lower recurrence rates.
However, close surgical margins (<1mm) at
the fibroglandular boundary of the breast
(chest wall and skin) do not mandate surgical
re-excision but is an indication for higher
boost dose radiation to the involved
lumpectomy site. (Cat.2B)

Chemotherapy- not indicated

Total

mastectomy- not indicated

39.The following are relative contraindications

to BCT except:

a. Active connective tissue disease

involving the skin.

b. Tumors > 5cms.
c. Diffuse suspicious or malignant
appearing calcifications involving more
than 1 quadrant of the breast.
d. Women 35y and younger
e. Premenopausal women w/ a known
BRCA mutation.
Answer: C- (Absolute
contraindication)

40.53y female was dx w/ DCIS after core

needle bx. She underwent lumpectomy of

the remaining lesion. Histopath of the
lesion showed a concomitant invasive
disease w/ adequate negative margins.
Further surgical management would be:
a. Total mastectomy
b. Total mastectomy w/ ALND
c. Axillary staging
d. No further surgical mx

Answer: C- Axillary staging

Total mastectomy- not necessary because

excision of the lesion
revealed adequate
negative margins.

Axillary staging- necessary for all invasive

lesions. ( ALND & SLNB )

41.48y woman underwent MRM for a 2cms.

Left breast mass w/c turned out to be ILCA.

ALND revealed 16 axillary nodes w/ 11 (+)
for micrometastases. There was no
evidence of distant metastases. Px
pathologic stage is:
a. Stage
b. Stage
c. Stage
d. Stage

III-C
II-A
III-A
II-B

Answer: B- Stage II-A (T1N1M0)

Micrometastases are defined as tumor

deposits > 0.2mm but not > 2.0mm in
largest dimension. Cases in w/c only
micromets are detected are classified as
pN1mi.

pN3a- Metastases in 10 or more ALN w/ at

least 1 tumor deposit > 2.0mm, or mets to
the infraclavicular lymph nodes.

42.57y female w/ a right breast mass

measuring 3cms. in size. Core bx done

showed IDCA. MRM was done. Tumor was
ER+/PR+, HER2+ w/ negative ALN. All of
the foll. are indicated adjuvant tx except:
a. Chemotx
b. Radiotx
c. Hormonal Tx
d. trastuzumab

Answer: B- Radiotx

Adj. chemotx- indicated for tumor size

>1cm.

Adj. hormonal tx- ER+/PR+

Adj.
Adj

trastuzumab- HER2 +

postmastectomy RT- indicated in px w/

T3N1 tumors and in
px w/ 4 or more +
for mets ALN.

43.42 y female dx w/ BCA is on adjuvant

tamoxifen. She became amenorrheic after

3yrs of tamoxifen and was later shifted to
Letrozole (AI). After 4 mos. on Letrozole
she begun to menstruate again. You would:
a. Continue Letrozole
b. Shift to other AI (Anastrozole or

Exesmestane)
c. D/C Letrozole & resume tamoxifen
d. D/C hormonal tx

Answer: C- D/C Letrozole & resume

tamoxifen

NCCN- Some women who appear to

become postmenopausal on tamoxifen tx
have resumption of ovarian function after d/c
tamoxifen and initiation of an AI. Therefore,
serial monitoring of plasma estradiol and FSH
levels is encouraged in this clinical setting .
Should ovarian function resume, the AI
should be discontinued and tamoxifen
resumed.

44.65y woman w/ a 5cms. Left breast mass

underwent core bx. Histopath showes IDCA

and the tumor was ER+/PR+ and HER2 +.
She desires BCT. All are accepted tx prior to
BCT except:
a. Neoadjuvant chemotx
b. Neoadjuvant hormonal tx
c. Neoadjuvant chemotx + trastuzumab
d. None of the above

Answer: D- None of the above

Neoadjuvant chemotx- Anthracycline based

regimens or taxanes are usually used for 3 to
4 cycles.

Neoadjuvant

hormonal tx- Hormonal tx

alone may be considered for receptor +
disease in postmenopausal px. Aromatase
inhibitor is preferred.
Neoadjuvant

chemotx + trastuzumab- Px w/
HER2 + tumors should be considered for
preoperative
chemotx
incorporating
trastuzumab.

45.A 60y female w/ a 6cms. ulcerating mass

of the left breast w/ palpable axillary nodes

was dx w/ IDCA. Neoadj chemotx was done
x 3cycles. The ulceration and palpable ALN
disappeared and the mass decreased to
2cms. in size. Px underwent MRM. Is
adjuvant RT still indicated in this case?
a. Yes
b. No

Answer: A- Yes

Adjuvant RT postmastectomy is based on

prechemotx tumor characteristics.

46.Criteria for determining menopause include

any of the following except:

a. Prior bilateral oophorectomy

b. Age 60y and above
c. Age <60y but amenorrheic for 12

mos. or more.
d. Age <60y, amenorrheic for 12mos and
on chemotx.
e. None of the above
Answer: D- Age <60y, amenorrheic
for 12mos. and on chemotx

For women <60y and amenorrheic for 12 or

more mos. in the absence of chemotx,
tamoxifen,
toremifene,
or
ovarian
suppression and FSH and estradiol are in the
postmenopausal range, they are considered
as menopausal.

47.A 45y woman underwent MRM for a

hormone receptor + BCA. She was given

adj. chemotx for 6 cycles after w/c she
became amenorrheic. What would you do
to ensure postmenopausal status if you
want to use aromatase inhibitors?
a. Surgical oophorectomy
b. TAH-BSO
c. Serial measurement of FSH &/or

estradiol
d. RT oophorectomy
Answer: A,C,D

In women premenopausal at the beginning

of adjuvant chemotx, amenorrhea is not a
reliable indicator of menopausal status as
ovarian function may still be intact or resume
despite
anovulation/amenorrhea
after
chemotx. For these women w/ chemotx
induced amenorrhea, oophorectomy or serial
measurement of FSH and/or estradiol are
needed to ensure postmenopausal status if
the use of AI is considered as a component of
endocrine tx.

48.45y female consulted because of a non-

healing eczema of the NAC. Mammography

done showed a breast lesion w/c turned out
to be DCIS after core bx.Bx of the NAC
showed Pagets disease. Surgical mx would
include:
a. MRM
b. Mastectomy + SLNB
c. Wide excision of breast lesion and NAC
d. Wide excision of breast lesion and NAC

+ RT of ipsilateral breast

Answer: B&D- Mastectomy + SLNB;

Wide excision of breast lesion and
NAC + RT of ipsilateral breast

Pagets Disease Treatment

Breast and
NAC biopsy
negative

Clinical follow up
Re-biopsy if not healing

Breast DCIS
and NAC
Pagets

Mastectomy + axillary staging or Excision of

breast tumor and excision NAC with whole
breast radiation, consider boost to breast
and NAC sites

Breast
invasive
cancer and
NAC Pagets

Mastectomy + axillary staging or Excision of

breast tumor and excision NAC with whole
breast radiation, consider boost to breast
and NAC sites

Breast
negative for
cancer and
positive NAC
Pagets

Mastectomy + axillary staging or Excision of

NAC with whole breast radiation, consider
boost to breast and NAC sites

49.The following surgical procedures can be

done during the late 2nd trimester of

pregnancy except:

a. MRM- Total mastectomy + ALND

b. BCS- Lumpectomy + ALND
c. Total mastectomy + SLNB
d. Lumpectomy + SLNB
e. None of the above

Answer: E- None of the above

MRM- can be done in all trimester of PABC

BCS- can be done during the 2nd trimester

w/ RT being done in the postpartum period.

SLNB- w/ radioactive tracer(eg, technetium

99m sulfur colloid) should be safe. Isosulfan
blue dye for SLNB is not recommended
during pregnancy

50.The following adjuvant tx can be given

during the 2nd trimester of pregnancy:

a. FAC
b. Taxanes
c. trastuzumab
d. Hormonal tx
e. Adjuvant RT

Answer: A- FAC

The greatest experience in pregnancy has

been with anthracycline and alkylating agent
chemotherapy. Fetal malformation risks in
the 2nd & 3rd trimester are approx. 1.3%, not
different than that of fetuses not exposed to
chemotx during pregnancy.

There are limited data on the use of

taxanes during pregnancy. As a consequence
they are not recommended for use during
pregnancy.

There are only 2 case reports of

trastuzumab use during pregnancy. Both case
reports
indicated
oligohydramnios
w/
administration of trastuzumab. Trastuzumab
should be used in the post delivery setting.

Endocrine tx and RT are contraindicated

during pregnancy.

51.A 45y px consulted because of a palpable

irregular mass at the UOQ of the left

breast. Mammography was requested w/c
showed a BIRADS 4 lesion at the UIQ of the
same breast. What would be your next
step:
a. Bx of palpable lesion
b. Bx of mammographic lesion
c. Ultrasound of the breast
d. Bx of both lesions

Answer: C- Ultrasound of the breast

It is important to assess the geographic

correlation between clinical and imaging
findings. If there is a lack of correlation do
other imaging studies for further workup of
the palpable lesion.

52.A 45y female has a right breast mass w/c

is 2cms. In size, irregular in shape, firm

and slightly movable. Mammogram showed
a Birads 3 category lesion. US was
requested and the result was that of a solid
lesion suspicious for malignancy. Core bx
result was benign. Next step would be:
a. Observe
b. Repeat mammogram
c. Repeat ultrasound
d. Surgical excision

Answer: D- Surgical Excision

Breast Cancer Screening and Diagnosis

Indeterminate
or suspicious
Solid
BI-RADS
Category 1-3
Lump/mass
Age > 30 y

Mammogram

Probably
benign
finding

Ultrasound

Breast Cancer Screening and Diagnosis

Core needle
biopsy
(preferred)
Solid:
Indeterminate
or suspicious

Tissue
biopsy

Benign
and image
discordant

Surgical
excision

53.A 50y female w/ a left breast mass,

2.5cms. In size, smooth, movable and nontender underwent mammogram. Result was
a BIRADS 2 lesion. US done showed a
probably benign finding. Next step would
be:
a. MRI
b. Observe (PE+US+mammogram every

6-12mos.)
c. Tissue dx (Core bx or Open bx)
d. BCS
Answer: C- Tissue Dx

Breast Cancer Screening and Diagnosis

Indeterminate
or suspicious
Solid
BI-RADS
Category 1-3
Lump/mass
Age > 30 y

Mammogram

Probably
benign
finding

Ultrasound

Breast Cancer Screening and Diagnosis

Observation
(if<2cm with low
clinical suspicion)

Solid:
Probably
benign
finding

Tissue
diagnosis

Core needle
biopsy
(preferred)
Excision (if
core needle
biopsy not
possible)