Management of Ductal Carcinoma In Situ — MCQs

10 questions

A 55-year-old female patient presented with a $4 \times 3 \mathrm{~cm}$ lump in the right upper outer quadrant, with no axillary lymph node involvement. Mammography revealed BIRADS 4b staging. She underwent breast conservation surgery, and the final HPE report showed high nuclear-grade DCIS with necrosis and 10 mm margin clearance. What is the further management?

Sentinel lymph node biopsy in carcinoma breast is done if -

CHOP is used in the treatment of?

Which of the following is the most sensitive investigation for ductal carcinoma in situ (DCIS) of the breast?

Which condition typically presents with irregular, hard palpable masses in the breast?

Which type of breast cancer is most commonly bilateral?

Which of the following factors is NOT a component of the Van Nuys prognostic index?

In which of the following situations is breast conservation surgery not indicated?

Which of the following is not true about breast cancer?

Q10

Which of the following breast lesions characteristically shows central necrosis with calcification?

Management of Ductal Carcinoma In Situ Indian Medical PG Practice Questions and MCQs

Question 1: A 55-year-old female patient presented with a $4 \times 3 \mathrm{~cm}$ lump in the right upper outer quadrant, with no axillary lymph node involvement. Mammography revealed BIRADS 4b staging. She underwent breast conservation surgery, and the final HPE report showed high nuclear-grade DCIS with necrosis and 10 mm margin clearance. What is the further management?

A. Follow up 6 monthly for 2 years and then yearly follow up
B. Trastuzumab therapy
C. Adjuvant chemotherapy
D. Adjuvant radiotherapy (Correct Answer)

Explanation: ***Adjuvant radiotherapy*** - For **high-grade DCIS** with necrosis after breast conservation surgery, adjuvant radiotherapy significantly reduces the risk of **local recurrence** (by approximately 50%). - Even with adequate margin clearance (10 mm), radiotherapy is recommended to treat **potential residual microscopic disease** elsewhere in the breast tissue. - This is the **standard of care** for high-grade DCIS post-BCS, particularly when necrosis is present. *Follow up 6 monthly for 2 years and then yearly follow up* - While regular follow-up is essential for all breast cancer patients, it is **not sufficient alone** for high-grade DCIS treated with breast conservation. - **Adjuvant radiotherapy** is necessary to reduce recurrence risk before initiating the follow-up schedule. *Trastuzumab therapy* - **Trastuzumab** is specifically indicated for **HER2-positive invasive breast cancer**. - The patient has **DCIS**, which is **non-invasive (in situ)**, making trastuzumab inappropriate. - There is no role for targeted therapy in DCIS management. *Adjuvant chemotherapy* - **Adjuvant chemotherapy** is generally reserved for **invasive breast cancers**, especially those with high-risk features like lymph node involvement or aggressive tumor biology. - For **DCIS**, even high-grade with necrosis, chemotherapy is **not indicated** as it provides no proven benefit for non-invasive disease.

Question 2: Sentinel lymph node biopsy in carcinoma breast is done if -

A. LN palpable
B. Breast lump with palpable axillary node
C. Metastatic CA breast
D. Breast mass but no lymph node palpable (Correct Answer)

Explanation: ***Breast mass but no lymph node palpable*** - Sentinel lymph node biopsy is primarily performed in patients with **clinically negative axillae** (no palpable lymph nodes) to assess for microscopic metastatic disease. - The goal is to avoid full axillary lymph node dissection if the sentinel nodes are negative, thus reducing the risk of **lymphedema** and other complications. *LN palpable* - If a lymph node is palpable, it is often considered **clinically suspicious** and may warrant a direct fine-needle aspiration (FNA) or core biopsy rather than a sentinel node biopsy. - A positive biopsy from a palpable node would typically lead directly to an **axillary lymph node dissection** or neoadjuvant therapy, as the sentinel node procedure offers less benefit in this scenario. *Breast lump with palpable axillary node* - Similar to a palpable LN, a **palpable axillary node** in the presence of a breast lump suggests established nodal involvement. - In such cases, **sentinel lymph node biopsy** is often not the initial step; rather, direct biopsy of the palpable node or upfront axillary dissection (sometimes after neoadjuvant treatment) is considered. *Metastatic CA breast* - In **metastatic breast cancer** (stage IV disease), the focus shifts to systemic treatment, and axillary lymph node dissection, including sentinel node biopsy, is generally not indicated for staging purposes. - The primary goal is palliative care or controlling systemic disease, not regional lymph node staging.

Question 3: CHOP is used in the treatment of?

A. NHL (Correct Answer)
B. Head and neck cancer
C. Ca Stomach
D. Ca Lung

Explanation: ***NHL*** - **CHOP** is the **gold standard first-line chemotherapy regimen** for most types of **Non-Hodgkin Lymphoma**, particularly **diffuse large B-cell lymphoma (DLBCL)** [1]. - The regimen combines **cyclophosphamide** (alkylating agent), **hydroxydaunorubicin/doxorubicin** (anthracycline), **oncovin/vincristine** (vinca alkaloid), and **prednisone** (corticosteroid) for optimal efficacy [1]. *Head and neck cancer* - Treatment primarily involves **platinum-based regimens** such as **cisplatin or carboplatin** combined with **5-fluorouracil** or **taxanes**. - **CHOP is not a standard chemotherapy regimen** for head and neck malignancies, which are solid tumors requiring different therapeutic approaches. *Ca Stomach* - Gastric cancer chemotherapy typically uses regimens like **FOLFOX** (fluorouracil, leucovorin, oxaliplatin) or **FLOT** (fluorouracil, leucovorin, oxaliplatin, docetaxel). - **CHOP is not used for gastric cancer** treatment, as it requires **platinum-based or fluoropyrimidine-based combinations**. *Ca Lung* - Lung cancer treatment involves **platinum-based doublets** such as **cisplatin/carboplatin** combined with **pemetrexed, paclitaxel, or gemcitabine** [2]. - **CHOP is not used for lung cancer** as it is specifically designed for **hematological malignancies**, not solid tumors like lung cancer.

Question 4: Which of the following is the most sensitive investigation for ductal carcinoma in situ (DCIS) of the breast?

A. PET Scan
B. Ultrasound
C. Mammography (Correct Answer)
D. MRI

Explanation: ***Mammography*** - **Mammography** is the **gold standard** and **primary imaging modality** for detecting **ductal carcinoma in situ (DCIS)**, primarily because it excels at visualizing **microcalcifications**, which are the hallmark of DCIS. - Approximately **80-90% of DCIS cases** present as **microcalcifications** on mammograms, making it the most important screening and diagnostic tool. - Mammography has **high sensitivity (85-95%)** for detecting DCIS, especially calcified forms, and is widely available and cost-effective. *MRI* - While **MRI** has high sensitivity for invasive breast cancer and can detect non-calcified DCIS, it is **not the primary screening tool** for DCIS detection. - MRI is typically used for **staging known DCIS**, evaluating **extent of disease**, detecting **additional foci**, and screening **high-risk patients**. - However, MRI has lower specificity and higher false-positive rates compared to mammography, limiting its use as a primary diagnostic tool. *PET Scan* - **PET scans** are generally **not sensitive** for detecting **DCIS** because DCIS lesions typically have a **low metabolic rate** and do not avidly take up the **FDG tracer**. - PET scans are primarily used for detecting **invasive cancers** and assessing **metastatic disease**, not for non-invasive lesions like DCIS. *Ultrasound* - **Ultrasound** has **limited sensitivity** for detecting **DCIS** because DCIS often does not present as a palpable mass or a distinct sonographic abnormality. - While ultrasound can be useful for evaluating palpable masses or guiding biopsies, it frequently **misses microcalcifications** that are characteristic of DCIS. - Ultrasound is mainly used as a **complementary tool** to mammography, not as a primary diagnostic modality for DCIS.

Question 5: Which condition typically presents with irregular, hard palpable masses in the breast?

A. Non comedo DCIS
B. Fibroadenoma
C. Invasive ductal carcinoma (Correct Answer)
D. Comedocarcinoma

Explanation: ***Paget's disease*** - Paget's disease of the breast leads to **palpable abnormalities** such as skin changes and underlying mass formation [1]. - Often presents with **nipple discharge** and alterations in the areola, indicating an underlying malignancy [2]. *Non comedo DCIS* - Non comedo ductal carcinoma in situ (DCIS) typically presents with **microscopic changes** and lacks palpable masses. - Frequently asymptomatic and may not cause any **significant clinical findings** or changes in the breast. *None* - This option suggests the absence of a related condition, which does not address the query about a type of DCIS causing a **palpable abnormality**. - In the context of DCIS, there are sure conditions (like Paget's) that **do cause palpable changes**. *Comedocarcinoma* - This type of DCIS is characterized by **necrosis and calcifications**, rather than a palpable mass. - While potentially aggressive, it usually does not present with noticeable **palpable abnormalities** like Paget's disease. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1061-1062. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 456-457.

Question 6: Which type of breast cancer is most commonly bilateral?

A. Lobular (Correct Answer)
B. Medullary
C. None of the options
D. Paget's disease

Explanation: ***Lobular*** - **Invasive lobular carcinoma (ILC)** is the breast cancer type most frequently associated with **bilateral disease**, occurring in about 5-28% of cases. - This tendency is attributed to its infiltrative growth pattern and potential for multifocal involvement, making bilateral involvement more likely. *Paget's disease* - **Paget's disease of the breast** is a rare form of breast cancer that primarily affects the skin of the **nipple and areola**. - It is almost exclusively **unilateral**, and its presentation with eczematous changes is distinct from bilateral parenchymal involvement. *Medullary* - **Medullary carcinoma** is a rare subtype of invasive ductal carcinoma known for its often **well-circumscribed appearance** and better prognosis. - While it can be multifocal, it does not have a strong propensity for **bilateral occurrence** like lobular carcinoma. *None of the options* - This option is incorrect because **lobular carcinoma** is well-established in medical literature as having the highest incidence of bilateral presentation among breast cancer types.

Question 7: Which of the following factors is NOT a component of the Van Nuys prognostic index?

A. Age
B. Tumor size
C. Estrogen receptor (ER) status (Correct Answer)
D. Margin width

Explanation: ***Estrogen receptor (ER) status*** - The **Van Nuys prognostic index** (VNPI) for **ductal carcinoma in situ (DCIS)** assesses factors related to local recurrence risk after breast-conserving therapy. - The VNPI includes: **tumor size, margin width, pathologic classification (nuclear grade and necrosis), and age**. - While ER status is an important prognostic factor in **invasive breast cancer**, it is **not included** in the VNPI scoring system for DCIS. *Age* - **Age** is a key component of the VNPI, with younger patients having higher risk of local recurrence. - Patients **under 40 years** receive score 3, **40-60 years** receive score 2, and **over 60 years** receive score 1. *Tumor size* - The **size of the DCIS lesion** is a critical component of the VNPI. - Lesions **≥41 mm** receive score 3, **16-40 mm** receive score 2, and **≤15 mm** receive score 1. *Margin width* - **Surgical margin width** is an essential component of the VNPI. - Margins **<1 mm** receive score 3, **1-9 mm** receive score 2, and **≥10 mm** receive score 1.

Question 8: In which of the following situations is breast conservation surgery not indicated?

A. SLE
B. Large pendular breast
C. Diffuse microcalcification
D. All of the options (Correct Answer)

Explanation: ***All of the options*** - All listed scenarios—**large pendular breast**, **SLE**, and **diffuse microcalcification**—represent situations where breast conservation surgery is generally contraindicated or challenging. - Their presence often necessitates alternative treatment approaches, such as mastectomy, to achieve optimal oncologic and cosmetic outcomes. *Large pendular breast* - While not an absolute contraindication, a **very large or pendulous breast** can make it difficult to achieve a satisfactory cosmetic outcome after breast conservation surgery. - The disproportionate breast size post-lumpectomy may lead to significant **asymmetry**, requiring further reconstructive procedures. *SLE* - Patients with **Systemic Lupus Erythematosus (SLE)** are at an increased risk of complications from radiation therapy, a mandatory component of breast conservation surgery. - They tend to experience more severe and prolonged **acute and chronic skin reactions** to radiation, which can significantly impair healing and quality of life. *Diffuse microcalcification* - **Diffuse microcalcification** within the breast can indicate widespread in situ carcinoma (e.g., DCIS) or an invasive carcinoma with extensive intraductal component. - In such cases, achieving **clear surgical margins** with breast conservation surgery can be challenging and often leads to multiple re-excisions or an increased risk of local recurrence.

Question 9: Which of the following is not true about breast cancer?

A. Family history is a risk factor
B. Paget’s disease affects the nipple
C. Lobular carcinoma is most common (Correct Answer)
D. Estrogen exposure increases risk

Explanation: ***Lobular carcinoma is most common*** - This statement is **incorrect** because **invasive ductal carcinoma (IDC)** accounts for the majority (**70-80%**) of all breast cancers. - While **invasive lobular carcinoma (ILC)** is the second most common type, it only represents about **5-15%** of cases. *Family history is a risk factor* - A **positive family history**, especially in a first-degree relative, significantly increases the risk of breast cancer due to inherited genetic mutations like **BRCA1** and **BRCA2**. - These mutations impair DNA repair, leading to uncontrolled cell growth. *Paget’s disease affects the nipple* - **Paget's disease of the nipple** is a rare form of breast cancer that presents as an eczematous lesion of the nipple and areola. - It is often associated with an **underlying invasive or in-situ ductal carcinoma**. *Estrogen exposure increases risk* - Prolonged or higher levels of **estrogen exposure** are known risk factors for breast cancer, as estrogen stimulates the growth of hormone-receptor-positive breast cancer cells. - Factors increasing estrogen exposure include **early menarche, late menopause, obesity**, and **hormone replacement therapy**.

Question 10: Which of the following breast lesions characteristically shows central necrosis with calcification?

A. Cribriform sub type of DCIS
B. Lobular carcinoma in situ
C. Colloid carcinoma
D. Comedo sub type of DCIS (Correct Answer)

Explanation: ***Comedo sub type of DCIS*** - This subtype is characterized by high-grade pleomorphic tumor cells with **central necrosis** within the ducts [1]. - The necrotic debris often calcifies, leading to characteristic **microcalcifications** visible on mammograms [2]. *Cribriform sub type of DCIS* - This subtype features uniform cells forming gland-like spaces within the ducts, but **typically lacks significant central necrosis** and extensive calcification [1]. - It usually presents with a **low nuclear grade** and less aggressive features compared to comedo DCIS [1]. *Lobular carcinoma in situ* - Characterized by small, discohesive cells filling and expanding the acini of the lobules, but it **does not involve ductal necrosis or calcification**. - It is often an **incidental finding** and represents a marker for increased risk of invasive carcinoma in either breast, rather than an obligate precursor lesion visible with calcifications. *Colloid carcinoma* - This is a type of **invasive ductal carcinoma** where tumor cells float in abundant extracellular mucin. - While it is an invasive cancer, it does not typically present with the extensive **ductal necrosis and calcification** seen in comedo DCIS. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1062-1064. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 452-453.

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