Breast Cancer — Viva

Q1: Triple assessment (2 min)

"A woman presents with a breast lump. Describe your assessment."

• Triple assessment (98% accurate):
  1. Clinical examination (inspect + palpate all quadrants + axilla)
  2. Imaging (mammography >35y, ultrasound <35y)
  3. Core needle biopsy (histology + ER/PR/HER2)
• Examine BOTH breasts and BOTH axillae + supraclavicular nodes

Q2: Molecular subtypes (2 min)

"Classify breast cancer by molecular subtype and how each is treated."

• Luminal A (ER+/PR+, low Ki-67): endocrine therapy. Best prognosis.
• Luminal B (ER+/PR+, high Ki-67): endocrine + chemotherapy.
• HER2-enriched (HER2+): chemotherapy + trastuzumab.
• Triple-negative (ER-/PR-/HER2-): chemotherapy only. Worst prognosis. BRCA1-associated.

Q3: Surgery (3 min)

"Describe the surgical options for early breast cancer."

• Breast: Wide local excision (WLE) + radiotherapy = breast-conserving therapy (BCT) — equal survival to mastectomy (NSABP B-06). OR mastectomy ± reconstruction.
• Axilla: Sentinel lymph node biopsy (blue dye + radioisotope). If negative: no clearance. If 1-2 positive: debatable (Z0011). If 3+ positive: axillary clearance.
• WLE requires clear margins (>1mm).

Q4: Special situations (2 min)

"What is inflammatory breast cancer and Paget disease?"

• Inflammatory (T4d): peau d'orange, erythema, dermal lymphatic invasion. Neoadjuvant chemo → mastectomy → radiotherapy. Poor prognosis.
• Paget disease: eczematous nipple (crusting, scaling), underlying DCIS/invasive carcinoma. Paget cells on biopsy. Treat underlying cancer.