Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/225

Click to flip

225 Cards in this Set

  • Front
  • Back
Where do most cancers initially form?
In the terminal duct lobular units of the breast.
Why do half of all breast cancers occur in the upper outer quadrants?
Glandular tissue is more abundant in those areas.
What comprises the chest wall?
1
2
3
1 Ribs
2 Intercostal muscles
3 Serratus anterior muscle

NOT the pectoral muscles
Breast lymphatics drain by which three major routes?
1
2
3
1 Axillary
- Interpectoral (Rotter's) nodes
- Nodes along the axillary vein and its tributaries
2 Supraclavicular
3 Internal mammary
- Nodes in the intercostal spaces along the edge of the sternum in the endothoracic fascia
What defines the supraclaviular fossa?
1 Lateral and superior border
2 Medial border
3 Inferior border
1 Omohyoid muscle and tendon
2 Internal jugular vein
3 Clavicle and subclavian vein

Adjacent nodes outside the triangle are lower cervical nodes (M1).
What are the four major sites of breast metastases?
1 Bone
2 Lung
3 Brain
4 Liver
If there is tumor in the margin of resection by macroscopic examination, how is the cancer coded?
pTX because the total extent of the primary tumor cannot be assessed.
What certain histologic tumor types and sizes have very low incidence of axillary lymph node metastasis and do not usually require an axillary lymph node dissection?
Pure tubular carcinoma < 1cm
Pure mucinous carcinoma < 1cm
Microinvasive carcinoma
If there is a 4.0-cm intraductal component and a 0.3-cm invasive component, what would be the pathologic tumor classification?
T1a since the pathologic tumor size for the T component is a measurement of only the invasive component.
What is microvasion of breast carcinoma?
Microinvasion is the extension of cancer cells beyond the basement membrane into the adjacent tissues with no focus more than 0.1cm in greatest dimension.

When there are multiple foci of microinvasion, the size of only the largest focus is used to classify the microinvasion.
What is inflammatory carcinoma of the breast?
Inflammatory carcinoma is a clinicopathologic entity characterized by diffuse erythema and edema (peau d'orange) of the breast, often without underlying palpable mass.
Should involve the majority of the skin of the breast.
Should NOT be applied to the patient with neglected locally advanced cancer presenting late in the course of her disease.
Staged at T4d.
What are micrometastases?
Tumor deposits greater than 0.2mm but not greater than 2.0 mm in largest dimension that may have histologic evidence of malignant activity, eg, proliferation or stromal reaction.
T stages of breast cancer
T1 2cm or less
T1mic Microinvasion 0.1cm or less
T1a 0.1 < x < 0.5 cm
T1b 0.5 < x < 1.0 cm
T1c 1 < x < 2 cm
T2 2 < x < 5 cm
T3 > 5 cm
T4a Extension to chest wall but not pec muscle
T4b Edema or ulceration of the skin or satellite skin nodules in the same breast
T4c Both T4a and T4b
T4d Inflammatory carcinoma
Clinical N stages of breast cancer
N1 Met to movable ipsi axillary LN
N2a - Mets in ipsi axillary LN fixed or matted
N2b - Mets only in CA ipsi IMN in the absence of CA axillary LNs
N3a - Mets in ipsi infraclav LNs
N3b - Mets ipsi IMN in the presence of CA axillary LN
N3c - Mets in ipsi supraclav LNs
Pathologic N stages of breast cancer
pN1mi Micromets 0.2 < x < 2.0mm
pN1a Mets in 1-3 ax LNs
pN1b Mets in IMN with microscopic disease detected by SLND but not CA
pN1c Mets to 1-3 ax LNs with in IMN with microscopic disease detected by SLND but not CA
pN2a Mets in 4-9 ax LNs (at least one > 2.0 mm)
pN2b Mets in CA IMN without ax LNs
pN3a - Mets in >= 10 ax LNs
- Mets to infraclav LNs
pN3b - Mets in CA ipsi IMN with 1 or more positive axillary LNs
- Mets in more than 3 ax LNs and in IMN with microscopic disease detected by SLND but not CA
pN3c Mets in ipsi supraclav LNs
Stage groupings for breast cancer
0
I
IIA
IIB
IIIA
IIIB
IIIC
IV
0 TisN0M0
I T1N0M0
IIA T2N0M0, T0-1N1M0
IIB T3N0M0, T2N1M0
IIIA T3N1M0, T0-3N2M0
IIIB T4N0-2M0
IIIC Any T N3M0
IV Any T Any N M1
Five-year Survival by Stage Grouping for Breast Cancer
0 100%
I 98%
IIA 88%
IIB 76%
IIIA 56%
IIIB 49%
IV 16%
In what situations in adj chemotherapy recommended?
Tumors > 1cm
Positive lymph nodes
What are the indications for SCV RT?
Patients with 4+ involved ax LNs
What is removed with total (simple) mastectomy?
Breast tissue without axillary dissection
What are the indications for post-mastectomy RT?
T3/4 disease
Positive margins
Gross ECE
>= 4 positive LNs
NSABP B-04
NEJM 2002
1079 clinically negative LN randomized to 1 of 3 arms
1: Radical mastectomy
2: Total mastectomy without axillary dissection but with post-op RT
3: Total mastectomy plus axillary dissection if LN pathologically positive
Also 586 patients
Clinically positive axillary LN randomized to 1 of 2 arms
1: Radical mastectomy
2: Total mastectomy without axillary dissection but with post-op RT
None received adj systmic therapy
At 25 years follow-up
- No significant differences in LF, DFS, or OS
- True for both patient groups
NSABP B-06
NEJM 2002
1851 patients with stage I/II breast ca (<4 cm, neg margins)
Randomized
1: Total mastectomy
2: Lumpectomy alone
3: Lumpectomy + 50 Gy RT
At 20 years follow-up
- No significant differences among the three groups for
-- DFS, OS, or DM-free survival
- Addition of RT to lumpectomy reduced LF from 39% to 14%
EORTC 10801
J Natl Cancer Inst 2000
902 patients stage I/II breast cancer
Randomized
1: Modified rdical mastectomy
2: Lumpectomy + 50 Gy RT + boost
At 10 years follow-up
- No difference in OS
- LF 12% vs 20% (significnant)
- But 48% lumpectomy patients had positive margins
Milan I
NEJM 2002
701 patients with T1No breast cancer
Randomized
1: Radical mastectomy
2: Quadrantectomy + 60 Gy
At medial follow-up 20 years
- No difference in OS
- No difference in breast cancer-specific survival
- Local failure 2.3 vx 8.8% (p < 0.001)
Milan III
Ann Oncol 2001
570 patients with tumors < 2.5cm
Randomized
1: Surgery alone (quadrantectomy + axillary dissection)
2: Surgery + 60 Gy
At 10 years follow-up
- Addition of RT reduced LF (23.5 --> 5.8%)
- No difference in OS
- Patients < 45 yoa had highest LF but also derived most benefit from RT
EORTC Boost Trial
NEJM 2001
5569 patients with stage I/II breast cancer s/p lumpectomy with negative margins
Randomized
1: 50 Gy
2: 50 Gy + 16 Gy boost
Boost decreased LF 7.3 --> 4.5%
Largest benfit in patients <= 40 years
Lyon Boost Trial
JCO 1997
1024 patients with early-stage breast cancer s/p lumpectomy (tumor < 3cm), axillary LN dissection, and 50 Gy
Randomized
1: Boost of 10 Gy
2: No boost
At median follow-up 3 years
- Boost reduced LF 3.6 00> 4.5%
- No difference in self-assessed cosmetic response
NSABP B-21
JCO 2002
1009 patients s/p lumpectomy for tumors <= 1cm (both ER/PR -/+)
Randomized
1: Tamoxifen
2: RT + placebo
3: RT + Tamoxifen
At 8 years follow-up
- Tamoxifen and RT independently reduced LF
- OS and DM-free survival did not differ between the 3 groups
CALGB C9343/INT trial
NEJM 2004
636 patients > 70 yoa T1N0 ER+ s/p lumpectomy
Randomized
1: Tamoxifen + RT
2: Tamoxifen alone
Addition of RT to Tamoxifen
- Improved 5yr LF (1 vs 4%, p < 0.001)
- No difference in breast cancer-specific survival or OS
NSABP B18
J Natl Cancer Inst Mongr 2001
1523 patients
Randomized
1: AC x 4 preop
2: AC x 4 postop
At 9 years follow-up
- No significant difference in DFS, DM-free survival, OS
NSABP B-20
J Natl Cancer Inst 1997
2306 patients s/p survery with pathologically LN-/ER+ brast cancer
Randomized
1: Tanoxifen alone
2: Tamoxifen + MF
3: Tamoxifen + CMF
At 5 years follow-up
- Addition of CT to tamoxifen resulted in better DFS (85% vs 90%)
NSABP B-14
NEJM 1989
2644 patients s/p surgery with pathologically LN-/ER-
Randomized
1: Tamoxifen x 5 yrs
2: Placebo
At 4 years follow-up
- Adj tamoxifen reduced LF (3 --> 1%)
- Improved DFS (77 --> 83%)
- No difference in OS
Vicini
J Natl Cancer Inst 2003
Phase II trial with 199 patients with early-stage breast cancer treated with limited field RT to region of tumor bed only (LDR 60%, HDR 40%)
At median follow-up 65 months
- LF was 1% and comparable to matched-pair controls with whole breast RT
Goss
NEJM 2003
5187 postmenopausal patients (98% ER+) s/p definitive therapy and adj tamoxifen x 5 years
Randomized x 5 years
1: Letrozole (2.5 mg)
2: Placebo
Addition of letrozole improved 4-yr DFS (87 --> 93%)
JCRT Sequencing
JCO 2005
244 patients with stage I/II s/p lumpectomy
Randomized
1: Adj doxorubicin-based chemo followed by RT
2: Adj RT followed by 4 cycles of same chemo
At 11 years follow-up
- No differences in OS, DM, time to any event, or site of first failure
- For close margins, crude LR was 32% (chemo first) vs 4% (RT first)
- For positive margins, crude LR was 20-23% in both arms.
Breast: Noninvasive breast entities

1
2
3
Breast: Noninvasive breast entities

1 LCIS
2 Paget's disease
3 DCIS
Breast: LCIS

% Multicentric

% Bilateral involvement
Breast: LCIS

90% Multicentric

35-59% Bilateral involvement
Breast: LCIS
Breast: LCIS
Breast:
Breast:
Breast:
Breast:
Criteria for conservation
Criteria for conservation
1 Patient desire
2 Unifocal disease
3 Clear margins
4 No extensive DCIS
5 No collagen vascular disease
6 No prior RT
7 Access to RT facility
What study showed the equivalence of conversation therapy and mastectomy?
What study showed the equivalence of conversation therapy and mastectomy?

NSABP B06
What number of nodes is indicative of adequate axillary dissection?
What number of nodes is indicative of adequate axillary dissection?

At least 10 lymph nodes
What are prognostic factors for systemic recurrence?
What are prognostic factors for systemic recurrence?

1 Age
2 Tumor size
3 Tumor grade
4 Number of axillary nodes
5 ER/PR and Her2/neu status
What is Her2/neu and in what percent of cancers is it overexpressed?
What is Her2/neu and in what percent of cancers is it overexpressed?

20-40%
Indications for chemotherapy
Indication for chemotherapy

1 Tumor > 1 cm

2 Positive lymph nodes
Indications for post-mastectomy RT
Indications for post-mastectomy RT

1 T3/4 disease
2 Positive margins
3 Gross ECE
4 More than three positive nodes
What is PBI?
What is PBI?

Adjuvant RT of less than whole breast with focus on tumor bed
Criteria for PBI
Criteria for PBI
1 Age > 45
2 Tumor < 3 cm
3 2mm negative margins
In the Danish Breast Cancer Cooperative Group 82B Trial (DBCG 82B), 1708 women who underwent mastectomy for pathologic stage II or III breast cancer were randomly assigned to one of the following two arms:
1) 8 cycles of chemotherapy plus chest wall radiation therapy
2) 9 cycles of chemotherapy
Median follow up for the study was approximately 10 years. The end points studied were locoregional recurrence, distant metastases, disease free survival, and overall survival.
Axillary dissection included removal of the level I and part of the level II nodes.

What was the median number of lymph nodes removed?
4
7
10
13
7
In the Danish Breast Cancer Cooperative Group 82B Trial (DBCG 82B), 1708 women who underwent mastectomy for pathologic stage II or III breast cancer were randomly assigned to one of the following two arms:
1) 8 cycles of chemotherapy plus chest wall radiation therapy
2) 9 cycles of chemotherapy
Median follow up for the study was approximately 10 years. The end points studied were locoregional recurrence, distant metastases, disease free survival, and overall survival.
From the following list, select the eligibilty criteria for enrollment on the DBCG 82B Trial.
Premenopausal Women
Postmenopausal Women
Tumor Size > 3 cm
Tumor Size > 5 cm
Involvement of the Skin
Involvement of the Pectoral Fascia
1 or more positive axillary nodes
4 or more positive axillary nodes
Premenopausal Women
Tumor Size > 5 cm
Involvement of the Skin
Involvement of the Pectoral Fascia
1 or more positive axillary nodes
4 or more positive axillary nodes
The Early Breast Cancer Trialists Collaborative Group meta-analysis included approximately 40 randomized trials that evaluated the efficacy of post-mastectomy radiation therapy.

########

This meta-analysis found an absolute reduction of 6% for breast cancer-specific mortality with post-mastectomy radiation therapy, but no difference in overall survival. True or False
True
The Early Breast Cancer Trialists Collaborative Group meta-analysis included approximately 40 randomized trials that evaluated the efficacy of post-mastectomy radiation therapy.

What was the relative reduction in the locoregional recurrence rate with the addition of post-mastectomy radiation therapy?
10%
33%
50%
67%
90%
67%
In which level of the axilla is a breast cancer patient most likely to recur following a modified radical mastectomy and an axillary lymph node dissection?
Level I
Level II
Level III
Level III
A breast cancer patient is treated with mastectomy and adjuvant chemotherapy. If she develops an isolated locoregional recurrence, where is she most likely to fail?

Rank the following sites from most likely to least likely (i.e. type 1 by the most likely site of failure, type 2 by the next most likely site of failure and so on).

Axilla
Supraclavicular Nodes
Chest Wall
1 Chest Wall
2 Supraclavicular Nodes
3 Axilla
A 58 year old woman presents with a mass in the upper outer quadrant of the left breast. The mass is biopsied and pathology returns infiltrating ductal carcinoma.

She elects to have a mastectomy and axillary lymph node dissection. Margins are negative, however 3 out of 12 nodes were positive for metastatic disease. Extracapsular extension was noted at 1 axillary node.

You have recommended post-mastectomy radiation therapy. Which regions will you treat?
Chest Wall
Axillary Nodes
Surgical Scar
Cervical Nodes
Supraclavicular Nodes
All listed except cervical.
What is the risk for locoregional recurrence following mastecomy for a patient with T2N1 infiltrating ductal carcinoma? 2 out of 10 lymph nodes were positive. (MD Anderson retrospective review)
<5%
15%
25%
35%
15%
According to the 2001 NCI Consensus Conference, post-mastectomy radiation therapy should be recommended for ... all patients.
patients with 1 or more positive lymph nodes.
patients with 2 or more positive lymph nodes.
patients with 3 or more positive lymph nodes.
patients with 4 or more positive lymph nodes.
Patients with 4 or more positive lymph nodes.
Let's assume that a new chemotherapy is found to reduce mortality from 5% to 4%. The absolute reduction in mortality is 1%. What is the relative reduction in mortality? 10%
20%
40%
60%
80%
90%
20%
In the Danish Breast Cancer Cooperative Group 82B Trial (DBCG 82B), 1708 women who underwent mastectomy for pathologic stage II or III breast cancer were randomly assigned to one of the following two arms:
1) 8 cycles of chemotherapy plus chest wall radiation therapy
2) 9 cycles of chemotherapy
Median follow up for the study was approximately 10 years. The end points studied were locoregional recurrence, distant metastases, disease free survival, and overall survival.

Which of the following regions were treated with radiation therapy?
Chest Wall
Surgical Scar
Supraclavicular Nodes
Infraclavicular Nodes
Axillary Nodes
Internal Mammary Nodes
All listed regions
In the Danish Breast Cancer Cooperative Group 82B Trial (DBCG 82B), 1708 women who underwent mastectomy for pathologic stage II or III breast cancer were randomly assigned to one of the following two arms:
1) 8 cycles of chemotherapy plus chest wall radiation therapy
2) 9 cycles of chemotherapy
Median follow up for the study was approximately 10 years. The end points studied were locoregional recurrence, distant metastases, disease free survival, and overall survival.
A higher mortality rate was found in patients with left sided cancers compared to right sided cancer. True or False
False
In the Danish Breast Cancer Cooperative Group 82B Trial (DBCG 82B), 1708 women who underwent mastectomy for pathologic stage II or III breast cancer were randomly assigned to one of the following two arms:
1) 8 cycles of chemotherapy plus chest wall radiation therapy
2) 9 cycles of chemotherapy
Median follow up for the study was approximately 10 years. The end points studied were locoregional recurrence, distant metastases, disease free survival, and overall survival.
Which of the following statements is correct regarding the outcome of this study?
There was no statistically significant improvement in either locoregional control or overall survival.
There was a statistically significant improvement in locoregional control, but no difference in overall survival.
There was a statistically significant improvement in locoregional control and overall survival.
There was a statistically significant improvement in locoregional control and overall survival.
In the Danish Breast Cancer Cooperative Group 82B Trial (DBCG 82B), 1708 women who underwent mastectomy for pathologic stage II or III breast cancer were randomly assigned to one of the following two arms:
1) 8 cycles of chemotherapy plus chest wall radiation therapy
2) 9 cycles of chemotherapy
Median follow up for the study was approximately 10 years. The end points studied were locoregional recurrence, distant metastases, disease free survival, and overall survival.
The following were found to be independent prognostic factors for locoregional recurrence and overall survival:
Tumor Size
Number of Positive Nodes
Presence of Extracapsular Extension
Size of the Largest Involved Lymph Node
Tumor Grade
Age
Treatment with Radiation Therapy.
True or False
False
In the Danish Breast Cancer Cooperative Group 82C Trial (DBCCG 82C), 1375 women, who underwent mastectomy for pathologic stage II or III breast cancer, were randomly assigned to one of the following two arms:
1) 30 mg Tamoxifen
2) 30 mg Tamoxifen plus radiation therapy
Median follow up for the study was approximately 10 years. The end points studied were locoregional recurrence, distant metastases, disease free survival, and overall survival.
From the following list, select the eligibilty criteria for enrollment on the DBCG 82C Trial:
Premenopausal Women
Postmenopausal Women
Tumor Size > 3 cm
Tumor Size > 5 cm
Involovement of the Skin
Involvement of the Pectoral Muscle
1 or more positive axillary nodes
4 or more positive axillary nodes
Postmenopausal Women
Tumor Size > 5 cm
Involovement of the Skin
Involvement of the Pectoral Muscle
1 or more positive axillary nodes
In the Danish Breast Cancer Cooperative Group 82C Trial (DBCCG 82C), 1375 women, who underwent mastectomy for pathologic stage II or III breast cancer, were randomly assigned to one of the following two arms:
1) 30 mg Tamoxifen
2) 30 mg Tamoxifen plus radiation therapy
Median follow up for the study was approximately 10 years. The end points studied were locoregional recurrence, distant metastases, disease free survival, and overall survival.
Which of the following regions were treated with radiation therapy on this trial?
Chest Wall
Surgical Scar
Supraclavicular Nodes
Infraclavicular Nodes
Axillary Nodes
Internal Mammary Nodes
Chest Wall
Surgical Scar
Supraclavicular Nodes
Infraclavicular Nodes
Axillary Nodes
Internal Mammary Nodes
In the Danish Breast Cancer Cooperative Group 82C Trial (DBCCG 82C), 1375 women, who underwent mastectomy for pathologic stage II or III breast cancer, were randomly assigned to one of the following two arms:
1) 30 mg Tamoxifen daily for one year
2) 30 mg Tamoxifen daily for one year plus radiation therapy
Median follow up for the study was approximately 10 years. The end points studied were locoregional recurrence, distant metastases, disease free survival, and overall survival.
All patients on this trial had estrogen receptor positive tumors.
True or False
False
In the Danish Breast Cancer Cooperative Group 82C Trial (DBCCG 82C), 1375 women, who underwent mastectomy for pathologic stage II or III breast cancer, were randomly assigned to one of the following two arms:
1) 30 mg Tamoxifen daily for one year
2) 30 mg Tamoxifen daily for one year plus radiation therapy
Median follow up for the study was approximately 10 years. The end points studied were locoregional recurrence, distant metastases, disease free survival, and overall survival.
Which of the following statements is correct regarding the outcome of this study?
There was a statistically significant improvement in locoregional control and overall survival.
There was a statistically significant improvement in locoregional control, but no difference in overall survival.
There was no statistically significant improvement in either locoregional control or overall survival.
There was a statistically significant improvement in locoregional control and overall survival.
On which of the following trials did some patients with estrogen-receptor positive tumors receive ovarian ablation therapy (20 Gy / 5 fractions plus prednisone)? Danish Breast Cancer Collaborative Group 82A
Danish Breast Cancer Collaborative Group 82B
Danish Breast Cancer Collaborative Group 82C
British Columbia Trial
British Columbia Trial
In the British Columbia Trial, 318 patients were enrolled in the study after undergoing modified radical mastectomy and axillary lymph node dissection. Patients were then randomized to one of the following arms:

1) Chemotherapy alone
2) Chemotherapy plus radiation therapy

Median follow up was 15 years.

~~~~~~~~

From the following list, select the eligibilty criteria for enrollment on the British Columbia Trial.

Premenopausal Women
Postmenopausal Women
1 or more positive axillary nodes
4 or more positive axillary nodes
Premenopausal Women
1 or more positive axillary nodes
In the British Columbia Trial, 318 patients were enrolled in the study after undergoing modified radical mastectomy and axillary lymph node dissection. Patients were then randomized to one of the following arms:

1) Chemotherapy alone
2) Chemotherapy plus radiation therapy

Median follow up was 15 years.

~~~~~~~

What dose of radiation therapy was prescribed to the chest wall?
37.5 Gy / 16 fxs
59.4 Gy / 33 fxs
45 Gy / 25 fxs
50.4 Gy / 28 fxs
50 Gy / 25 fxs
37.5 Gy / 16 fxs
In the British Columbia Trial, 318 patients were enrolled in the study after undergoing modified radical mastectomy and axillary lymph node dissection. Patients were then randomized to one of the following arms:

1) Chemotherapy alone
2) Chemotherapy plus radiation therapy

Median follow up was 15 years.

~~~~~~~~

Select all regions treated with radiation therapy on this trial.
Chest Wall
Surgical Scar
Supraclavicular Nodes
Infraclavicular Nodes
Axillary Nodes
Internal Mammary Nodes
Chest Wall
Surgical Scar
Supraclavicular Nodes
Infraclavicular Nodes
Axillary Nodes
Internal Mammary Nodes
In the British Columbia Trial, 318 patients were enrolled in the study after undergoing modified radical mastectomy and axillary lymph node dissection. Patients were then randomized to one of the following arms:
1) Chemotherapy alone
2) Chemotherapy plus radiation therapy
Median follow up was 15 years.
Which statement below best describes the results of this study?
There was no stat sig improvement in DFS, CSS, and OS.
There was a stat sig improvement in DFS, but no stat sig improvement in breast CSS and OS.
There was a stat sig improvement in DFS and breast CSS, but no stat sig improvement in OS.
There was a stat sig improvement in DFS, breast CSS, and OS.
There was a stat sig improvement in DFS and breast CSS, but no stat sig improvement in OS.
Which chemotherapy agents were used in the DBCCG 82B and British Columbia Trials?
Adriamycin and cyclophosphamide
Adriamycin, cyclophosphamide, and taxotere
Cyclophosphamide and 5FU
Cyclophosphamide, methotrexate, and 5FU
Cyclophosphamide, methotrexate, and 5FU
A 35 year old female presents with a diffusely edematous and erythematous left breast. The skin is warm, but there are no palpable nodules. The breast has the classic "peau d'orange" appearance.

What finding establishes the diagnosis of inflammatory carcinoma of the breast?
Tumor emboli are seen surrounding dermal nerves.
Tumor emboli are seen in the dermal lymphatics.
Tumor emboli are seen in the dermal capillaries
Tumor emboli are seen in the dermal lymphatics.
A patient is diagnosed with inflammatory carcinoma of the breast. What treatment do you recommend first?
Radiation Therapy
Mastectomy
Systemic Chemotherapy
Hormonal Therapy
Systemic Chemotherapy
According to the current American Cancer Society screening guidelines, at what age should women begin screening mammography?
30
35
40
45
50
55
60
40
What is a woman's lifetime risk for developing breast cancer?
17% (1 in 6)
12% (1 in 8)
10% (1 in 10)
8%(1 in 12)
12% (1 in 8)
Approximately what percent of all women diagnosed with breast cancer will die from breast cancer?
10%
30%
50%
70%
90%
30%
Using the Gail Model, you determine that your patient has a 15% lifetime risk for the develoment of breast cancer.

According to the NCI recommendations for MRI screening, this patient should have annual screening mammography and breast MRIs.
True or False
False
What percent of all breast cancers have a major inherited component (i.e. BRCA-1 or 2, p53, PTEN, or ATM mutations)?
10%
33%
50%
67%
90%
10%
What percent of heritable breast cancers have a BRCA-1 mutation present?

Choose the closest answer. 10%
33%
50%
67%
90%
50%
What percent of women with a BRCA-1 mutation will develop breast cancer over the course of their lifetime (i.e. what is the penetrance of the BRCA-1 mutation for the development of breast cancer)?
10%
33%
50%
67%
90%
90%
Development of what cancer other than breast cancer is associated with the presence of a BRCA-1 germ line mutation?
Pancreatic Cancer
Glioma
Sarcoma
Leukemia
Ovarian Cancer
Ovarian
Which of the following is considered a risk factor for the development of breast cancer?
Multiparity
Early menopause
Breastfeeding
Early menarche
Exercise
Early menarche
The level I axillary lymph nodes are located ... ?
Lateral to the Pectoralis Minor
Beneath the Pectoralis Minor
Medial to the Pectoralis Minor
Lateral to the Pectoralis Minor
If the level I and II axillary lymph nodes are negative, what percent of the time are the level III axillary lymph nodes positive?
< 5%
10%
20%
30%
< 5%
Which of the following is the most common histologic subtype of invasive breast cancer?
Medullary Carcinoma
Tubular Carcinoma
Mucinous Carcinoma
Lobular Carcinoma
Ductal Carcinoma
Ductal Carcinoma
Which histology is associated with an increased risk for multifocal and bilateral disease?
Medullary Carcinoma
Tubular Carcinoma
Lobular Carcinoma
Ductal Carcinoma
Mucinous Carcinoma
Lobular Carcinoma
In which region of the breast do breast cancers most frequently arise?
Upper Outer Quadrant
Lower Outer Quadrant
Central Region
Lower Inner Quadrant
Upper Inner Quadrant
Upper Outer Quadrant
What percent of the time do breast cancers arise within the upper outer quadrant of the breast?
10%
25%
33%
50%
66%
75%
90%
50%
What percent of patients with T1 tumors have a positive axilla?
5%
20%
40%
60%
80%
20%
What percent of patients with T2 tumors have a positive axilla?
10%
20%
40%
60%
80%
40%
What percent of patients with a clinically negative axilla will be found to have a postive axilla after a lymph node dissection?
10%
33%
50%
67%
90%
33%
You are told that a patient treated at the University of Iowa had a lumpectomy and an axillary lymph node dissection.

Most likely this patient's level III axillary lymph nodes were dissected.
True or False
False
If the axilla is positive, what percent of the time are the internal mammary nodes also positive?

Choose the best answer.
10%
33%
50%
67%
90%
33%
During sentinal lymph node mapping, a blue dye and a radiocolloid are injected into the tumor bed in order to locate the sentinel node. The sentinel node is removed and assessed by the pathologist.

How accurate is this procedure at determining whether the axilla is truely positive or negative?
>95%
90%
80%
70%
>95%
To which site does breast cancer most frequently metastasize?
Liver
Lung
Brain
Bone
Bone
If a patient is found to have a 4.5 cm breast cancer with no chest wall or skin involvement, what is her T stage? T1
T2
T3
T4
T2
Node positive patients are candidates for breast conservation therapy.
True or False
True
A 28 year old woman with cT2N0M0 infiltrating ductal carcinoma (LVI present, ER/PR negative, Her-2-Neu positive) is a candidate for breast conservation therapy.
True or False
True
A patient is diagnosed with breast cancer. Which of the following is the most important prognostic factor for this patient's overall survival?
Histologic Subtype
Hormone Receptor Status
Margin Status
Lymph Node Status
Age
Tumor Grade
Tumor Size
Lymph Node Status
Margin status is a major criterion for breast conservation therapy. Negative margins should be the goal for all patients.

The definition of an acceptable negative margin is somewhat controvertial.

According to Dr. Jacobson and most literature, what is an acceptable negative margin?
< 1 mm
1 mm
2 mm
3 mm
5 mm
2 mm
In order for a breast cancer to be considered EIC+ (EIC: extensive intraductal component), DCIS must comprise at least what percent of the tumor?
10%
25%
50%
75%
90%
25%
EIC (extensive intraductal component) positive breast cancers are associated with an increased risk for postive margins and an increased risk for local recurrence following breast conservation therapy.
True or False
True
Radiation oncologists should be familiar with these randomized trials comparing mastectomy alone and breast conservation therapy:

1. Milan [NCI - Italy]
2. Gustave - Rousy [NCI - France]
3. NSABP B-06
4. NCI - United States
5. EORTC 10801
6. Danish Trial

These trials show that there is a statistically significant improvement in disease free survival and overall survival for node positive breast cancer patients treated with mastectomy.
True or False
False
Radiation oncologists should be familiar with these randomized trials comparing lumpectomy alone to lumpectomy followed by radiation therapy:

1. Uppsala-Orebro Breast Cancer Study Group
2. Milan [NCI - Italy]
3. NSABP B-06
4. Ontario Clinical Oncology Group
5. Scottish Trial

All of these trials show an improvement in local control and overall survival for patients treated with lumpectomy followed by radiation therapy.
True or False
False
Radiation oncologists should be familiar with these randomized trials comparing lumpectomy alone to lumpectomy followed by radiation therapy:

1. Uppsala-Orebro Breast Cancer Study Group
2. Milan [NCI - Italy]
3. NSABP B-06
4. Ontario Clinical Oncology Group
5. Scottish Trial

What is the relative reduction in the local recurrence rate with the addition of radiation therapy?
10%
25%
50%
75%
90%
75%
The results of NSABP B-21 show that for well-selected patients (tumors < 1 cm, node negative), tamoxifen alone can replace external beam radiation therapy following lumpectomy.
True or False
False
The EORTC and Lyon trials support the use of a boost following whole breast radiation therapy.

Both trials report what absolute reduction in the local recurrence rate with a boost?
<3%
5%
10%
25%
33%
<3%
Regarding treatment planning for whole breast radiotherapy:

An isocentric technique is typically used. The collimators are rotated to define the deep edge of the radiation field.

The deep edges of the medial and lateral tangent fields should be ...
Coplanar
Divergent
None of the above
Coplanar
A patient with T1 N0 infiltrating ductal carcinoma comes to you for whole breast radiotherapy as part of her breast conservation therapy.

A calc point is placed near the chest wall. What dose will you most likely prescribe to that calc point?
40 Gy / 20 fxs
45 Gy / 25 fxs
50.4 Gy / 28 fxs
59.4 Gy / 33 fxs
60 Gy / 30 fxs
50.4 Gy / 28 fxs
What is the most common late effect following breast conservation therapy?
Brachial Plexopathy
Lymphedema
Radiation Pneumonitis
Carcinogenesis
Rib fractures
Cardiac Toxicity
Lymphedema
Which of the following is the most common radiation-induced malignancy in patients who received whole breast radiation therapy?
Lung Cancer
Leukemia
Contralateral Breast Cancer
Lymphangiosarcoma
Lung Cancer
What number of axillary lymph nodes removed for sampling during a level I/II node dissection for breast cancer most likely would require postoperative radiation therapy to the axilla?
A) 2
B) 6
C) 8
D) 10
A) 2
Which of the following factors is the most important predictor of disease-free survival and overall survival in patients with breast cancer?
A) Tumor size
B) Mitotic index
C) Axillary lymph node status
D) Hisopathologic tumor grade
C) Axillary lymph node status
For the following trials, what is the correct isolated locoregional failure rate over a 10-year period for a premenopausal patient with one to three positive lymph nodes who receives postmastectomy chemotherapy and tamoxifen with no radiation therapy? NSABP (5-study analysis), 24%
Danish trial (82b), 30%
IBCSG, 35%
Vancouver, BC trial, 38%
Danish trial (82b), 30%
Which of the following treatment outcomes is associated with patients who have DCIS, according to prospective randomized trials?
A) IN NSABP B-17, the actuarial rate of breast cancer recurrence after 12 years in patients who received surgery only was 24%
B) In NSABP B-17, the actuarial rate of breast cancer recurrence after 12 years in patients who received surgery plus breast irradiation was 16%.
C) In NSABP B-24, breast irradiation reduced the risk of breast cancer recurrence in all subgroups except for the patients with positive surgical margins.
D) In EORTC 10853, the subtype of DCIS histology had no effect on patients' risk for breast cancer recurrence.
B) In NSABP B-17, the actuarial rate of breast cancer recurrence after 12 years in patients who received surgery plus breast irradiation was 16%.
Which of the following pathological stages of breast cancer is associated with a patient who has a 5.0-cm primary tumor and 12/15 positive, non-fixed lymph nodes?
A) pT3N2
B) pT3N3
C) PT2N1
D) pT2N3
D) pT2N3
Which of the following statements associated with the postmastectomy Danish trials investigating the use of radiation therapy is true?
A) The trials studied the use of anthracycline chemotherapy for all premenopausal patients.
B) The trials studied the use of tamoxifen over a 5-year period for all postmenopausal patients.
C) The trials found that the favorable association of radiation therapy with improved 10-year overall survival was lost after 15 years of follow-up.
D) The trials found an association between the use of radiation therapy and reduced rates of subsequent development of metastatic disease.
D) The trials found an association between the use of radiation therapy and reduced rates of subsequent development of metastatic disease.
Which of the following statements about breast cancer in men is true?
A) The tumor is most commonly ER-positive.
B) The disease should be treated with cisplatin-based chemotherapy.
C) The majority of patients who undergo genetic screening will be found to have a BRCA1 germline mutation.
D) Approximately 25% of patients will have noninvasive disease at diagnosis.
A) The tumor is most commonly ER-positive.
Which of the following adjuvant systemic therapies would be most appropriate to recommend for an otherwise healthy patient who has HER-2/neu-positive (FISH) ER/PR_negative breast cancer with positive axillary lymph nodes?
A) Four cycles of dose-dense doxorubicin and cyclophosphamide (AC) in conjunction with four cycles of paclitaxel
B) Four cycles of AC, four cycles of paclitaxel with concurrent trastuzumab, and continuation of trastuzumab for 1 year
C) Four cycles of paclitaxel, four cycles of AC with concurrent trastuzumab, and continuation of trastuzumab for 1 year
D) Six cycles of docetaxel, doxorubicin, and cyclophosphamide
B) Four cycles of AC, four cycles of paclitaxel with concurrent trastuzumab, and continuation of trastuzumab for 1 year
The basal molecular phenotype of breast cancer most commonly is:
A) ER-positive, PR-positive, HER-2/neu-negative.
B) ER-positive, PR-positive, HER-2/neu-positive.
C) ER-negative, PR-negative, HER-2/neu-negative.
D) ER-negative, PR-negative, HER-2/neu-positive.
C) ER-negative, PR-negative, HER-2/neu-negative.
Which of the following statements about patients who are diagnosed with breast cancer and have supraclavicular lymph node involvement is true?
A) The diagnosis should be classified as stage M1 breast cancer.
B) Approximately 30% of patients will have clinically detectable internal mammary lymp nodes on CT scan of the chest.
C) Over 20% of patients will have lymphedema and brachial plexopathy.
D) Over 20% of patients will survive 10 years with aggressive trimodality therapy.
D) Over 20% of patients will survive 10 years with aggressive trimodality therapy.
Which of the following statements about level III involvement of the axillary lymph nodes in a patient with breast cancer is true?
A) This region is immediately lateral to the infraclavicular fossa.
B) The region is superomedial to the pectoralis minor muscle and lateral to the clavicular bone.
C) The lymph nodes are commonly removed by standard axillary lymph node dissection.
D) Metastases to this region would be classified as stage N3b disease.
B) The region is superomedial to the pectoralis minor muscle and lateral to the clavicular bone.
Which of the following statements about the diagnosis of inflammatory breast cancer is true?
A) There may not be a discrete palpable mass at presentation.
B) At presentation, a patient may report having a longstanding breast mass that developed skin changes over time.
C) A biopsy is not required, since the diagnosis is clinically established.
D) Dermal lymph node involvement must be demonstrated.
A) There may not be a discrete palpable mass at presentation.
Which of the following statements about metastasis of breast cancer to the bone is true?
A) Metastasis to the epidural spine is most commonly associated wtih worsening back pain in the supine positionn or with the Valsalva maneuver.
B) Compression of the epidural spinal cord associated with breast cancer most commonly has a single site of vertebral metastasis.
C) Radicular pain in the thoracic spine is typically unilateral.
D) Pain from T12, L1 vertebral lesions is not associated with a referred pain pattern to the bilateral iliac crests or to the bilateral sacroiliac joints.
A) Metastasis to the epidural spine is most commonly associated wtih worsening back pain in the supine positionn or with the Valsalva maneuver.
Which of the following radiation treatment sites would be most appropriate for a patient with breast cancer who undergoes postoperative irradiation after successful wide excision for a localized chest wall recurrence 2 years after mastectomy and chemotherapy? A) Chest wall only
B) Chest wall and draining lymph nodes
C) Excision scar and a 5-cm margin
D) No radiation is required if the excision reveals negative margins.
B) Chest wall and draining lymph nodes
Which of the following findings is associated with a better outcome for patients who have a local recurrence of breast cancer after breast-conserving surgery?
A) Metaplastic histology
B) A disease-free interval of <2 years
C) Recurrent DCIS in a different quadrant of the breast
D) Concurrent involvement of the supraclavicular lymph nodes
C) Recurrent DCIS in a different quadrant of the breast
Which of the following statements about the treatment of bone metastases secondary to breast cancer is true?
A) Radiation therapy will achieve partial or complete pain relief within 4 weeks.
B) Single-fraction irradiation provides equivalent results to protracted radiation treatment schedules for pain control durability and reduced risk of subsequent fracture.
C) Metastatic sites with extraosseous bone involvement should be treated with 153Sm only, because localized external-beam irradiation is not beneficial.
D) An 8-Gy dose of hemibody irradiation should be administered in a single fraction to the upper, middle, or lower hemibody regions for treatment of painful bony metastases.
A) Radiation therapy will achieve partial or complete pain relief within 4 weeks.
Microinvasion of DCIS is most likely to be found in patients with:
A) micropapillary histology.
B) DCIS and LCIS mixed histology.
C) a unilateral clear nipple discharge.
D) a clinically palpable mass >2.5 cm.
B) DCIS and LCIS mixed histology.
The NSABP and EORTC completed randomized trials that compared neoadjuvant chemotherapy against adjuvant chemotherapy. In these trials, what percentage of patients who initially were not candidates for breast conservation therapy underwent this procedure after neoadjuvant chemotherapy?
A) 0-10%
B) 11-20%
C) 21-30%
D) 31-40%
E) 41-50%
C) 21-30%
A 30-year-old non-Ashkenazi woman is diagnosed with breast cancer. Her family history is significant for a mother with breast cancer at age 50. There is no history of ovarian cancer in her family. Her estimated probability of having a BRCA1 or BRCA2 mutation would be which one of the following?
A) <5%
B) 10%-25%
C) 26%-50%
D) 51%-75%
E) 76%-90%
B) 10%-25%
The probability of an isolated supraclavicular lymph node recurrence in a patient with a 2.5 cm lateral breast tumor and 2/18 positive axillary lymph nodes is which one of the following?
A) 3-5%
B) 6-10%
C) 11-15%
D) 16-20%
E) 20-25%
A) 3-5%
For the following type of breast cancer, select the one lettered feature that is MOST closely associated with it:

Invasive lobular carcinoma
A) Can contain cartilage and other connective tissue elements
B) Is associated with contralateral breast cancer in 1/3 of the cases
C) Is estrogen receptor-positive over 80% of the time
D) Occurs predominantly in African-Americans
E) Is more common in breast cancers occurring in patients with a germline mutation in BRCA1
C) Is estrogen receptor-positive over 80% of the time
For the following type of breast cancer, select the one lettered feature that is MOST closely associated with it:

Metaplastic carcinoma
A) Can contain cartilage and other connective tissue elements
B) Is associated with contralateral breast cancer in 1/3 of the cases
C) Is estrogen receptor-positive over 80% of the time
D) Occurs predominantly in African-Americans
E) Is more common in breast cancers occurring in patients with a germline mutation in BRCA1
A) Can contain cartilage and other connective tissue elements
NSABP B-06 trial
A) Twenty-year results demonstrated an improvement in overall survival when radiation was given after lumpectomy and axillary dissection.
B) Found the tamoxifen after radiation decreased ipsilateral breast events for women with DCIS
C) Suggested that axillary recurrences after no primary axillary treatment are not associated with poorer overall survival
D) Demonstrated the radiation reduces ipsilateral breast recurrences in patients with tumors less than 1cm with negative lymph nodes treated with surgery and tamoxifen
E) Found the 20-year ipsilateral breast recurrence rate for patients treated with lumpectomy, axillary dissection and radiation +/- chemotherapy to be 14%
E) Found the 20-year ipsilateral breast recurrence rate for patients treated with lumpectomy, axillary dissection and radiation +/- chemotherapy to be 14%
NSABP B-04 trial
A) Twenty-year results demonstrated an improvement in overall survival when radiation was given after lumpectomy and axillary dissection.
B) Found the tamoxifen after radiation decreased ipsilateral breast events for women with DCIS
C) Suggested that axillary recurrences after no primary axillary treatment are not associated with poorer overall survival
D) Demonstrated the radiation reduces ipsilateral breast recurrences in patients with tumors less than 1cm with negative lymph nodes treated with surgery and tamoxifen
E) Found the 20-year ipsilateral breast recurrence rate for patients treated with lumpectomy, axillary dissection and radiation +/- chemotherapy to be 14%
C) Suggested that axillary recurrences after no primary axillary treatment are not associated with poorer overall survival
NSABP B-21 trial
A) Twenty-year results demonstrated an improvement in overall survival when radiation was given after lumpectomy and axillary dissection.
B) Found the tamoxifen after radiation decreased ipsilateral breast events for women with DCIS
C) Suggested that axillary recurrences after no primary axillary treatment are not associated with poorer overall survival
D) Demonstrated that radiation reduces ipsilateral breast recurrences in patients with tumors less than 1cm with negative lymph nodes treated with surgery and tamoxifen
E) Found the 20-year ipsilateral breast recurrence rate for patients treated with lumpectomy, axillary dissection and radiation +/- chemotherapy to be 14%
D) Demonstrated that radiation reduces ipsilateral breast recurrences in patients with tumors less than 1cm with negative lymph nodes treated with surgery and tamoxifen
Concerning HER2/Neu: It is a tumor suppressor gene located on chromosome 18.
True or False
False - it's on long arm of 17
Concerning HER2/Neu: It is amplified in 20 - 30% of all breast cancers.
True or False
True
Concerning HER2/Neu: Is associated with resistance to particular systemic treatments
True or False
True
Concerning HER2/Neu: Is a member of the Epidermal Growth Factor Receptor family
True or False
True
Concerning HER2/Neu: Amplification predicts response to trastuzumab. True or False
True
Concerning the Danish 82b and 82c clinical trials evaluating postmastectomy radiation: Both demonstrated radiation improved overall survival only in the patients with 4 or more positive lymph nodes.
True or False
False
Concerning the Danish 82b and 82c clinical trials evaluating postmastectomy radiation: For the patients randomized to irradiation, the internal mammary lymph nodes were included in the treatment fields.
True or False
True
Concerning the Danish 82b and 82c clinical trials evaluating postmastectomy radiation: After 10 years, there was no difference in cardiac-related mortality or morbidity. True or False
True
Concerning the Danish 82b and 82c clinical trials evaluating postmastectomy radiation: The median number of axillary lymph nodes dissected was 12.
True or False
False - it was 7.
Concerning the Danish 82b and 82c clinical trials evaluating postmastectomy radiation: The Danish 82b study demonstrated that those treated with radiation had a statistically significant improvement in both local-regional control and overall survival.
True or False
True
The single most important risk factor for the development of female breast cancer is which one of the following?
A) Parity
B) Cyclical estrogen exposure (age at menarche/menopause)
C) Postmenopausal estrogen replacement therapy
D) Family history
E) Age
E) Age
Bloody nipple discharge with a palpable mass
A) Invasive ductal carcinoma
B) Invasive lobular carcinoma
C) Papilloma
D) LCIS
E) Invasive papillary carcinoma
A) Invasive ductal carcinoma
Clear nipple discharge
A) Invasive ductal carcinoma
B) Invasive lobular carcinoma
C) Papilloma
D) LCIS
E) Invasive papillary carcinoma
C) Papilloma
Pagetoid changes involving the nipple with a palpable underlying mass
A) Invasive ductal carcinoma
B) Invasive lobular carcinoma
C) Papilloma
D) LCIS
E) Invasive papillary carcinoma
A) Invasive ductal carcinoma
Ipsilateral supraclavicular node involvement
A) pN2a
B) pN2b
C) pN3a
D) pN3b
E) pN3c
E) pN3c
Ipsilateral, clinically apparent, internal mammary node in absence of any axillary or other nodes
A) pN2a
B) pN2b
C) pN3a
D) pN3b
E) pN3c
B) pN2b
Seven positive lymph nodes with largest node measuring 3 cm, positive gross extracapsular extension
A) pN2a
B) pN2b
C) pN3a
D) pN3b
E) pN3c
A) pN2a
3 cm invasive ductal carcinoma with direct extension of tumor into the dermis
A) T1
B) T2
C) T4a
D) T4b
E) T4d
B) T2

T4a - chest wall not pec
T4b - edema (peau)
- ulceration
- satellite skin nodules
4.5 cm invasive lobular carcinoma with peau d'orange over 2/3 of the breast, no skin erythema
A) T1
B) T2
C) T4a
D) T4b
E) T4d
D) T4b
2 cm invasive ductal carcinoma with invasion into the pectoralis muscle
A) T1
B) T2
C) T4a
D) T4b
E) T4d
A) T1
According to the Oxford Overview of Randomized Adjuvant Chemotherapy Trials: The optimal duration of adjuvant chemotherapy is 3 - 6 months.
True or False
True
According to the Oxford Overview of Randomized Adjuvant Chemotherapy Trials: The absolute reduction in the risk for recurrence with polychemotherapy in women under the age of 50 years was 10% in node-negative and 15% in node-positive patients.
True or False
True
According to the Oxford Overview of Randomized Adjuvant Chemotherapy Trials: The absolute reduction in mortality in women under the age of 50 years with the use of adjuvant chemotherapy was 6% in axillary node-negative and 12% in axillary node-positive patients.
True or False
True
According to the Oxford Overview of Randomized Adjuvant Chemotherapy Trials: In women aged 50 - 69 years, the absolute reduction in mortality was 15% in axillary node-positive patients.
True or False
False
According to the Oxford Overview of Randomized Adjuvant Chemotherapy Trials: The absolute benefit offered by use of an anthracycline-based chemotherapy regimen over CMF was approximately a 2% improvement in outcome measures.
True or False
True
Regarding the application in treatment and/or prevention of bone metastases secondary to breast carcinoma: Both samarium and strontium are most effective in patients with diffuse osteoblastic disease.
True or False
True
Regarding the application in treatment and/or prevention of bone metastases secondary to breast carcinoma: Strontium has less myelosuppression than samarium.
True or False
False
Regarding the application in treatment and/or prevention of bone metastases secondary to breast carcinoma: There is little additional benefit derived from use of external beam irradiation to regions of significant tumor burden irrespective of correlative symptoms in these areas.
True or False
False
Regarding the application in treatment and/or prevention of bone metastases secondary to breast carcinoma: Bisphosphonates inhibit osteoblastic activity regardless of the activating factors involved.
True or False
True
Regarding the application in treatment and/or prevention of bone metastases secondary to breast carcinoma: The rationale for use of adjuvant bisphosphonates in patients with operable breast carcinoma is based on studies, which show a significant reduction in the incidence of bone metastases at 5 years, as well as a reduction in breast cancer mortality.
True or False
True
According to data from the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-21 trial, the estimated annual risk of a breast recurrence for a postmenopausal woman with a T1 N0 breast cancer treated with lumpectomy, breast radiation, and tamoxifen is approximately:
A) 0.5% per year
B) 1.0% per year
C) 1.5% per year
D) 0% per year
A) 0.5% per year
According to data from the Harvard Nurses' Study, which one of the following lifestyle variables was associated with the greatest relative risk for developing breast cancer?
A) High-saturated-fat diet vs. low-fat diet
B) Smoking 1 pack of cigarettes per day or greater vs no smoking history
C) Moderate/high alcohol use vs no alcohol use
D) Lack of soy intake vs high-soy diet
C) Moderate/high alcohol use vs no alcohol use
Benefits of neoadjuvant chemotherapy compared with adjuvant chemotherapy include all of the following, EXCEPT:
A) Permits breast conservation for selected patients who initially would be required to have mastectomy
B) Reduces the rates of distant metastases by delivering chemotherapy earlier in the treatment course
C) Provides a short-term outcome parameter (rate of pathologic complete response) that has been shown to correlate with favorable survival and therefore can be used to compare 2 chemotherapy regimens.
D) Provides an opportunity to assess response to a particular chemotherapy regimen
B) Reduces the rates of distant metastases by delivering chemotherapy earlier in the treatment course
Which one of the following is the respective incidence of local regional recurrence after breast conservation therapy vs mastectomy at 20-year follow-up according to NSABP B-06?
A) 8% vs 6%
B) 13% vs 6%
C) 13% vs 15%
D) 8 % vs 15%
D) 8 % vs 15%
Which one of the following is the median time to local recurrence at the primary site after breast conservation therapy?
A) 1.5-2 years
B) 3-4 years
C) 5-6 years
D) 7 or more years
B) 3-4 years
Which one of the following is the time interval when MOST "elsewhere" failures (outside the quadrant of the primary lesion) occur?
A) 1.5-2 years
B) 3-4 years
C) 5-6 years
D) 7 or more years
D) 7 or more years
For the following clinical trial, select the one lettered answer that describes the observed rate of axillary failure in the clinically negative axilla with no axillary lymph node dissection that is MOST closely associated with it:

NSABP B-04
A) 25%
B) 20%
C) 10%
D) 5%
A) 20%
For the following clinical trial, select the one lettered answer that describes the observed rate of axillary failure in the clinically negative axilla with no axillary lymph node dissection that is MOST closely associated with it:

Danish Breast Cancer Group
A) 25%
B) 20%
C) 10%
D) 5%
B) 20%
For the following clinical trial, select the one lettered answer that describes the observed rate of axillary failure in the clinically negative axilla with no axillary lymph node dissection that is MOST closely associated with it:

Manchester (1976-1988)
A) 25%
B) 20%
C) 10%
D) 5%
B) 20%
Selective estrogen receptor down-regulator (SERD) (preclinical studies demonstrate loss of the estrogen receptor)
A) Fulvestrant (Faslodex)
B) Raloxifene (Evista)
C) Tamoxifen (Nolvadex)
D) Anastrazole (Arimidex)
E) Exemestane (Aromasin)
A) Fulvestrant (Faslodex)
Nonsteroidal aromatase inhibitor (reversible inactivation of aromatase enzyme)
A) Fulvestrant (Faslodex)
B) Raloxifene (Evista)
C) Tamoxifen (Nolvadex)
D) Anastrazole (Arimidex)
E) Exemestane (Aromasin)
D) Anastrazole (Arimidex)
Steroidal aromatase inhibitor (irreversible inactivation of aromatase enzyme)
A) Fulvestrant (Faslodex)
B) Raloxifene (Evista)
C) Tamoxifen (Nolvadex)
D) Anastrazole (Arimidex)
E) Exemestane (Aromasin)
E) Exemestane (Aromasin)
Selective estrogen receptor modulator (SERM) (potent antiestrogenic effects in breast and uterus while retaining an agonist effect on bone)
A) Fulvestrant (Faslodex)
B) Raloxifene (Evista)
C) Tamoxifen (Nolvadex)
D) Anastrazole (Arimidex)
E) Exemestane (Aromasin)
B) Raloxifene (Evista)
Implicated in the increased cardiac toxicity seen in the Stockholm postmastectomy trial
A) INternal mammary field
B) Deep tangents
C) Supraclavicular field
D) Axillary boost field
B) Deep tangents
Field that includes level III of the axilla
A) INternal mammary field
B) Deep tangents
C) Supraclavicular field
D) Axillary boost field
C) Supraclavicular field
Field that contributes most to the risk of arm edema
A) INternal mammary field
B) Deep tangents
C) Supraclavicular field
D) Axillary boost field
D) Axillary boost field
With respect to the phase 3 clinical trials that compared adjuvant aromatase inhibitors with tamoxifen for patients with non-metastatic breast cancer: Adjuvant Arimidex (anastrazole) improved relapse-free survival compared with tamoxifen
True or False
True
With respect to the phase 3 clinical trials that compared adjuvant aromatase inhibitors with tamoxifen for patients with non-metastatic breast cancer: Adjuvant Arimidex (anastrazole) increased the risk of thrombo-embolic events compared with tamoxifen
True or False
False
With respect to the phase 3 clinical trials that compared adjuvant aromatase inhibitors with tamoxifen for patients with non-metastatic breast cancer: Adjuvant Arimidex (anastrazole) increased the risk of osteoporosis relative to tamoxifen
True or False
True
With respect to the phase 3 clinical trials that compared adjuvant aromatase inhibitors with tamoxifen for patients with non-metastatic breast cancer: After completion of 2 to 3 years of tamoxifen, switching therapy to exemestane improved relapse-free survival compared with continuing tamoxifen
True or False
True
With respect to the phase 3 clinical trials that compared adjuvant aromatase inhibitors with tamoxifen for patients with non-metastatic breast cancer: After 5 years of adjuvant tamoxifen, additional treatment with Femara (letrozole) improved relapse-free survival compared with placebo therapy
True or False
True
With respect to the Danish 82b postmastectomy radiation trial: All patients were treated with doxorubicin chemotherapy
True or False
False
With respect to the Danish 82b postmastectomy radiation trial: Radiation led to an absolute survival advantage of 9% at 10 years
True or False
True
With respect to the Danish 82b postmastectomy radiation trial: The improvement in locoregional recurrence associated with radiation was limited to patients with 4 or more positive lymph nodes
True or False
False
With respect to the Danish 82b postmastectomy radiation trial: Radiation use was associated with an increased risk for a cardiovascular event
True or False
False
With respect to the Danish 82b postmastectomy radiation trial: The median number of lymph nodes recovered from the axillary surgery was 7
True or False
True
Regarding bilateral breast cancer: Prognosis is primarily attributable to the highest stage of disease
True or False
True
Regarding bilateral breast cancer: For patients with breast cancer having a BRCA2 mutation, the risk of developing a contralateral breast cancer is 1.8% per year
True or False
True
Regarding bilateral breast cancer: For patients with breast cancer testing negative for BRCA1 and BRCA2 mutations, the risk of developing a contralateral breast cancer is 0.7% per year
True or False
True
Regarding bilateral breast cancer: Invasive lobular carcinoma is associated with a higher risk of synchronous rather than metachronous bilateral breast cancer
True or False
False
Regarding bilateral breast cancer: In the Oxford overview meta-analysis, there was a 47% reduction in the observed rate of contralateral breast cancer among women treated with 5 years of adjuvant tamoxifen therapy
True or False
True
Concerning the finding of occult axillary micrometastases: Ludwig Breast Cancer Study Group, Trial V found a 9% incidence of occult metastases by serial sectioning in clincially node-negative, H & E node negative-patients
True or False
True
Concerning the finding of occult axillary micrometastases: The 5-year disease-free survival and overall survivals were significantly worse for Ludwig V patients who had positive occult lymph node metastases
True or False
True
Concerning the finding of occult axillary micrometastases: The yield of IHC (immunohistochemical)-detected micrometastases is greater for ductal than lobular cancers
True or False
False
Concerning the finding of occult axillary micrometastases: IHC detection, with or without the use of serial sectioning, is not superior to H & E/serial sectioning alone for the detection of micrometastases
True or False
False
Which of the following recommendations about current clinical management of lobular carcinoma in situ (LCIS) is true?
A) Negative surgical margins are necessary when LCIS alone is detected.
B) The presence of LCIS with a coexisting invasive cancer or ductal carcinoma in situ (DCIS) is a contraindication for breast-conserving therapy.
C) LCIS alone detected by a core-needle biopsy in a region of mammographic architectural distortion warrants additional surgical sampling.
D) Patients with LCIS who received tamoxifen in the NSABP P-01 trial were found to have no reduction in the incidence of breast cancer when compared to LCIS patients who received a placebo.
C) LCIS alone detected by a core-needle biopsy in a region of mammographic architectural distortion warrants additional surgical sampling.
The NSABP B-17 and EORTC trials for ductal carcinoma in situ (DCIS) have NOT demonstrated which of the following outcomes for patients receiving excisional biopsy with or without whole-breast irradiation? A) The annual rate of invasive recurrence is 0.5% to 1% per year after irradiation.
B) Irradiation reduces the risk of both invasive and DCIS recurrences by 50% to 60%.
C) Irradiation reduces overall ipsilateral breast tumor recurrence by 50% to 60%.
D) More than 60% of recurrences are invasive after excision alone.
D) More than 60% of recurrences are invasive after excision alone.
Which of the following statements about the use of boost therapy after whole-breast irradiation as part of conservation therapy for early-stage breast cancer is FALSE?
A) The EORTC-60 trial demonstrated a 5-year ipsilateral breast recurrence rate of 6.8% in patients without boost therapy versus a rate of 4.3% in patients with boost therapy.
B) The EORTC-60 trial demonstrated a greater local control benefit associated with the use of boost therapy for premenopausal patients than for postmenopausal patients.
C) The EORTC0-60 trial demonstrated a significant reduction in the proportion of patients who had an excellent or good cosmetic outcome due to the use of boost therapy.
D) Boost dose escalation can improve long-term control rates when surgical margins are less than 1 mm.
D) Boost dose escalation can improve long-term control rates when surgical margins are less than 1 mm.
Which of the following factors is most important in determining an acceptable cosmetic outcome for patients who have undergone breast-conserving therapy for breast cancer?
A) Volume of resection
B) Quadrant of the primary tumor
C) Concurrent systemic chemotherapy and irradiation
D) Total dose of radiation therapy to the whole breast as well as to the boost site
A) Volume of resection
Which of the following factors is not associated with an increased risk of locoregional recurrence after a patient undergoes breast-conserving therapy or mastectomy without radiation therapy?
A) Tumor size
B) Number of involved axillary lymph nodes
C) High histologic tumor grade
D) Young patient age
B) Number of involved axillary lymph nodes
Which of the following findings is not an absolute contraindication to irradiation of the breast as part of conservation therapy? A) Pregnancy
B) Collagen vascular disease
C) Prior irradiation to the ipsilateral breast
D) Multicentric disease
B) Collagen vascular disease
The International Breast Cancer Study Group (IBCSG) evaluated risk factors for locoregional recurrence after mastectomy and chemotheraopy without irradiation in over 5,000 patients treated in seven prospective trials. Which of the following situations is NOT associated with a higher risk of locoregional failure?
A) Higher tumor grade in patients with lymph node involvement
B) Presence of LVI (lymph-vascular space invasion) in premenopausal patients with positive lymph node involvement and in premenopausal or postmenopausal patients with negative lymph node involvement
C) Tumor size greater than 2 cm in premenopausal patients with negative lymph nodes
D) Tumor size greater than 2 cm in postmenopausal patients with negative lymph nodes
D) Tumor size greater than 2 cm in postmenopausal patients with negative lymph nodes
What percentage of patients with locally advanced breast cancer would be expected to have no residual disease in either the breast or lymph nodes after four cycles of neoadjuvant anthracycline-based chemotherapy?
A) <5%
B) 10%
C) 15% to 20%
D) 30% to 40%
C) 15% to 20%
Which of the following statements about the NSABP B-18 trial, which compared neoadjuvant to adjuvant chemotherapy, is true?
A) Patients receiving neoadjuvant chemotherapy had improved relapse-free survival.
B) Patients receiving adjuvant chemotherapy had improved relapse-free survival.
C) Over 50% of the patients were initially considered candidates for mastectomy, but underwent breast-conserving therapy after responding favorably to neoadjuvant chemotherapy.
D) Over 50% of the patients were candidates for breast-conserving therapy at the time they enrolled in the trial.
D) Over 50% of the patients were candidates for breast-conserving therapy at the time they enrolled in the trial.
Which of the following statements about pathological complete response (pCR) after neoadjuvant chemotherapy administered for breast cancer is true?
A) The estimated long-term survival of patients who achieve pCR is improved compared to the estimated survival predicted at diagnosis.
B) All patients who achieve pCR are at low risk for local recurrence after undergoing a mastectomy, and they do not benefit from radiation therapy.
C) Patients who achieve pCR after undergoing breast-conserving therapy do not require radiation therapy.
D) There is no difference in the pCR rate of patients receiving combined anthracycline/taxane-based chemotherapy comnpared with those receiving anthracycline-based chemotherapy alone.
A) The estimated long-term survival of patients who achieve pCR is improved compared to the estimated survival predicted at diagnosis.
Which of the following statements about the epidemiology of advanced breast cancer is true? A) While rates of ductal carcinoma in situ (DCIS) have increased, rates of advanced breast cancers have remained constant
B) In the year 2000, approximately 25% of all breast cancers were 5 cm or greater at diagnosis.
C) Delayed age at first chilbirth is associated with a greater probability of having a tumor diagnosed an an advanced versus an early stage.
D) Compared to Caucasian patients, African-American patients with breast cancer are more commonly diagnosed with locally advanced disease.
D) Compared to Caucasian patients, African-American patients with breast cancer are more commonly diagnosed with locally advanced disease.
Which of the following statements about the meta-analysis of radiation therapy performed by the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) is true?
A) Radiation therapy was associated with an increased risk for cardiovascular death.
B) Radiation therapy was associated with an absolute overall survival rate in approximately 10% of women at 10 years.
C) Patients with T4-stage tumors were included in the analysis.
D) The survival rate of patients in trials conducted in the 1960s was better than that of patients treated in the 1980s.
A) Radiation therapy was associated with an increased risk for cardiovascular death.
A 42-year-old patient has inoperable, 5-cm axillary lymph node recurrence of breast cancer 2 years after undergoing mastectomy and adjuvant doxorubicin-based chemotherapy for stage II breast cancer. Which of the following statements about htis patient scenario is true? A) Chemotherapy is not indicated.
B) Randomized trials have shown improved survival rates for patients who receive taxane-based chemotherapy.
C) The treatment of choice is radiation therapy to 60 Gy over 6 weeks.
D) The treatment of choice is neoadjuvant taxane-based chemotherapy, reassessment for operability, and irradiation of the subsequent chest wall and regional lymphatics.
D) The treatment of choice is neoadjuvant taxane-based chemotherapy, reassessment for operability, and irradiation of the subsequent chest wall and regional lymphatics.
Which of the following statements about the HER2/neu gene expression is true?
A) It is a tumor suppressor gene.
B) It encodes for a cellular receptor with a tyrosine kinase domain.
C) It can be identified by cytokeratin immunostaining.
D) Germline mutations are associated with an increased risk of breast cancer.
B) It encodes for a cellular receptor with a tyrosine kinase domain.
Which of the following scenarios is most appropriate for a diagnosis of inflammatory breast cancer?
A) A patient has erythema and edema that have developed over a large area of the breast during a 1 week period, but no palpable mass. Fine-needle aspiration and biopsy reveal inflammatory cells.
B) A patient notices a mass in the breast that has grown to 6 cm over the past year before examination. Over the last 2 weeks, erythema and swelling have developed in a small area overlying the mass. Biopsy reveals ductal carcinoma and cancer cells in the skin.
C) A patient feels a mass in the breast. Over the next 2 weeks, the skin over half of the breast becomes erythematous and edematous. Biopsy reveals ductal carcinoma.
D) A patient has a large mass in the breast that broke throught the skin with surrounding erythema and edema. Biopsy reveals invasive ductal carcinoma.
C) A patient feels a mass in the breast. Over the next 2 weeks, the skin over half of the breast becomes erythematous and edematous. Biopsy reveals ductal carcinoma.
Which of the following statements about the diagnosis of inflammatory breast cancer is true?
A) Pathologic disease confirmation is unnecessary since inflammatory breast cancer is a clinical diagnosis.
B) The dermal lymphatic system needs to be involved to confirm the diagnosis.
C) Approximately 50% of patients do not have a palpable mass at the time of diagnosis.
D) Antiobiotic therapy must be proven to be ineffective for patients before the diagnosis can be made.
C) Approximately 50% of patients do not have a palpable mass at the time of diagnosis.
Which of the following treatments is most appropriate for patients who have a poor Karnofsky performance status, chemorefractory metastatic breast cancer, and multiple brain recurrences after undergoing whole-brain radiation therapy?
A) Gamma knife stereotactic therapy
B) Hospice care for comfort measures
C) Admission to a tertiary care center
D) Enrollment in a phase II trial using a tyrosine kinase inhibitor
B) Hospice care for comfort measures
Which of the following statements about the use of FDG PET scans in the detection of bone metastases secondary to breast cancer is FALSE?
A) PET scans demonstrate more sites of metastatic bone lesions than do positive bone scans.
B) PET scans are more sensitive than radionuclide scans in detecting lytic and mixed lytic and blastic lesions.
C) PET scan findings can document the response of bone metastases to endocrine therapy.
D) PET scans can be used routinely as the sole diagnostic modality for the detection of both osseous and nonosseous metastases.
D) PET scans can be used routinely as the sole diagnostic modality for the detection of both osseous and nonosseous metastases.
Which of the following statements about the treatment of bone metastases secondary to breast cancer is FALSE? A) Patients treated with Samarium-153 can experience pain relief within 1 week, and a subjective response can persist for 16 weeks after administration.
B) Eighty to ninety percent of patients will experience at least a partial subjective response after external-beam irradiation.
C) Thirty percent of patients will have recurrent pain at the initial site of treatment after palliative irradiation.
D) RTOG 97-14 (patients with prostate and breast cancer randomized to 8-Gy single dose fraction versus 30 Gy per 10 fractions) demonstrated higher subjective partial and complete response rates with single dose per fraction therapy.
D) RTOG 97-14 (patients with prostate and breast cancer randomized to 8-Gy single dose fraction versus 30 Gy per 10 fractions) demonstrated higher subjective partial and complete response rates with single dose per fraction therapy.
Which of the following findings does NOT support a diagnosis of brachial plexus syndrome due to recurrent or metastatic breast cancer rather than a late complication of radiation therapy?
A) Motor weakness typically involves the muscles innervated by the upper plexus alone or by both the upper and lower plexus.
B) Moderate to severe paing precedes neurologic signs for up to 9 months.
C) Pain is located in the sensory distribution involving the lower brachial plexus.
D) Lymphedema is rarely a presenting symptom.
A) Motor weakness typically involves the muscles innervated by the upper plexus alone or by both the upper and lower plexus.
A patient has a single, mobile, and suspicious axillary lymph node. Which of the following pathologic classification stages of breast cancer is most appropriate after the patient undergoes initial mastectomy and has pathologic findings of disease in nine axillary lymph nodes?
A) pN1
B) pN2
C) pN3
D) pNX
B) pN2