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SU25.1-5 | Breast Surgery — Graded Quiz
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A 48-year-old woman has a hard, irregular, fixed breast lump. Clinical examination and mammography both suggest malignancy. Which third component completes triple assessment and provides the definitive diagnosis?
Correct. Tissue diagnosis is the third arm of triple assessment, and core needle biopsy is preferred because it provides histology (architecture, invasion, receptor status) rather than just cytology. It completes the clinical-imaging-pathology triad.
Core biopsy provides the histological (pathology) arm of triple assessment, including receptor status.
The pathological arm of triple assessment is tissue biopsy, and core biopsy (histology) is the modern standard because it characterises invasion and receptors. Tumour markers and repeat imaging do not provide a tissue diagnosis.
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A 45-year-old woman reports bilateral, lumpy, tender breasts that fluctuate with her menstrual cycle, worse premenstrually. Triple assessment shows no discrete mass and no malignancy. What is the most likely diagnosis?
Correct. Bilateral, cyclical, lumpy and tender breasts that worsen premenstrually with no discrete mass on triple assessment describe fibrocystic change, a common benign hormonally-driven condition managed with reassurance and symptomatic measures.
Fibrocystic change: bilateral, cyclical, tender lumpiness, no discrete mass; benign and hormonally driven.
Bilateral cyclical lumpiness and tenderness without a discrete mass is fibrocystic change — a benign, hormone-responsive condition, not a malignancy or abscess.
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A breast core biopsy shows malignant cells confined within the ducts without breaching the basement membrane. Which diagnosis does this describe?
Correct. Malignant cells confined within the duct lumen without invasion through the basement membrane define ductal carcinoma in situ (DCIS), a non-invasive (pre-invasive) lesion. Once cells breach the basement membrane the lesion becomes invasive ductal carcinoma.
DCIS = malignant cells confined within ducts, basement membrane intact (non-invasive); invasion makes it invasive ductal carcinoma.
Malignant cells contained within the ducts and NOT breaching the basement membrane is the definition of DCIS (in situ). Invasion through the basement membrane defines invasive carcinoma.
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Which is the most common histological type of invasive breast cancer?
Correct. Invasive ductal carcinoma (now often termed invasive carcinoma of no special type) is by far the most common type of invasive breast cancer. Invasive lobular carcinoma is the second most common and tends to grow diffusely.
Invasive ductal carcinoma (no special type) is the commonest invasive breast cancer; lobular is second.
The most common invasive breast cancer is invasive ductal carcinoma (no special type). Lobular carcinoma is the second most common.
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A breast tumour is ER-negative, PR-negative, and HER2-negative. How is this subtype described, and what is the key therapeutic implication?
Correct. ER-negative, PR-negative and HER2-negative defines triple-negative breast cancer. Because it lacks all three targets, it does not benefit from endocrine therapy or anti-HER2 agents, so cytotoxic chemotherapy is the mainstay of systemic treatment.
Triple-negative (ER-/PR-/HER2-): no endocrine or anti-HER2 target; chemotherapy is the systemic mainstay.
Loss of all three receptors (ER-, PR-, HER2-) is triple-negative breast cancer. Without targets, endocrine therapy and trastuzumab are ineffective, leaving chemotherapy as the main systemic option.
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A patient with a clinically node-negative early breast cancer is planned for surgery. Which axillary procedure is preferred to stage the axilla while minimising morbidity such as lymphoedema?
Correct. In a clinically node-negative axilla, sentinel lymph node biopsy accurately stages the axilla while avoiding the higher morbidity (lymphoedema, nerve injury) of routine complete axillary clearance, which is reserved for proven significant nodal disease.
SLNB stages the clinically node-negative axilla with less morbidity than routine axillary clearance.
For a clinically node-negative early breast cancer, sentinel lymph node biopsy is preferred to stage the axilla with less morbidity than routine clearance.
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A breast cancer over-expresses HER2. Which targeted systemic agent specifically addresses this receptor status?
Correct. Trastuzumab is the monoclonal antibody that targets the HER2 receptor and is used in HER2-positive breast cancer. Tamoxifen and aromatase inhibitors target the hormone-receptor pathway, not HER2.
Trastuzumab targets HER2-positive breast cancer; endocrine agents (tamoxifen, AIs) target hormone receptors.
HER2-positive disease is treated with anti-HER2 therapy — trastuzumab. Tamoxifen and aromatase inhibitors target hormone receptors instead.
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When performing a clinical breast examination, why should inspection be carried out with the patient in three positions — arms by the side, arms raised, and hands pressed on the hips?
Correct. Inspecting in the three positions — particularly hands pressed on the hips and arms raised — tenses pectoralis major and stretches the overlying skin, which can unmask subtle skin dimpling, tethering, or nipple changes caused by an underlying tumour that are not apparent at rest.
Three-position inspection tenses pectoralis major / stretches skin to unmask dimpling or tethering not seen at rest.
The three-position inspection is diagnostic: tensing pectoralis major and stretching the skin reveals dimpling or tethering from an underlying lesion that may be invisible at rest. It complements, not replaces, palpation.
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