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MEDICALFACTSANDMCQ'S
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AIPPGSOLVEDPAPERS
(9) BreastMCQ
ANATOMY(8) 1.Afterintraductalpapilloma,unilateralbloodynippledischargefromoneductorificeis
COMMUNITYMEDICIINE mostcommonlycausedbywhichofthefollowingpathologicconditions?
(2) A.Paget'sdiseaseofthenipple.
DERMATOLOGY(5) B.Intraductalcarcinoma.
C.Inflammatorycarcinoma.
ENT(2)
D.Subareolarmastitis.
FORENSICMEDICINE(3)
Answer:B
GENERALMEDICINE(17)

GYNAECOLOGY(2)
DISCUSSION:Nippledischargeissurgicallysignificantwhenitisgrosslybloodyand
IMPORTANTFACTS(39)
whenitappearsatasingleductorificeononenipple.Bloodydischargeisusuallyduetoa
INTERESTINGFACTS(7) benignintraductalpapillomahowever,intraductalcarcinomainthelargeductsunder
MCQ's(40) thenipplecanbethecauseofbloodydischarge,andpathologicallythelesionisfrequently
alargepapillarytumorthathasbecomemalignant.Paget'sdiseaseofthenippleisalso
MEDICINE(8)
duetointraductalcarcinomaarisinginsubareolarducts,butitrarelyisassociatedwith
MICROBIOOLOGY(1)
nippledischarge.Subareolarmastitismayproducenippledischarge,butitispurulent
OBSTETRICS(3) andnotbloody.Inflammatorycarcinomaisnotassociatedwithnippledischarge.
OPHTHALMOLOGY(65)

ORTHOPEDICS(12)

PATHOLOGY(4) 2.Whichofthefollowingconditionsisassociatedwithincreasedriskofbreastcancer?
PEDIATRICS(9) A.Fibrocysticmastopathy.
B.Severehyperplasia.
PHARMACOLOGY(15)
C.Atypicalhyperplasia.
PHYSIOLOGY(3)
D.Papillomatosis.
PREVIOUSPAPERS(19) Answer:C
RADIOLOGY(8)
DISCUSSION:Fibrocysticmastopathy,orfibrocysticdisease,wasoncethoughtto
SURGERY(102)
increasetheriskofbreastcancerhowever,laterstudiesofthepathologicfindingsin
fibrocysticcomplexfoundanincreasedcancerriskonlyforpatientswhosebiopsies
showedatypicalhyperplasia.Severehyperplasiaisapathologictermthatreferstothe
amountofhyperplasiaandisfrequentlyseeninthebiopsyspecimensofyoungwomenit
isamisleadingtermandisnotassociatedwithadiseaserisk.Papillomatosisisalsopart
ofthefibrocysticcomplexandisafrequentfindinginbenignbreastbiopsiesitdoesnot
conferanincreasedriskofcancer.

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 Followers(49)
3.Whichofthefollowingbreastlesionsarenoninvasivemalignancies?
A.Intraductalcarcinomaofthecomedotype.
B.Tubularcarcinomaandmucinouscarcinoma.
C.Infiltratingductalcarcinomaandlobularcarcinoma.
D.Medullarycarcinoma,includingatypicalmedullarylesions.
Answer:A

DISCUSSION:Tubular,mucinous,andmedullarycarcinomasarehistologicvariantsof
infiltratingductalcancerandareallinvasivemalignancies.Infiltratinglobularcanceris
aparticularhistologicvariantofinvasivebreastcancercharacterizedbypermeationof
thestromawithsmallcellsthatresemblethosefoundinthebreastlobuleoracinus.
Followers
Followthisblog Intraductalcarcinomareferstoamalignancyofductaloriginthatremainsenclosed
Mgasumusubaybay(19)
Susunod withinductstructures.Thisnoninvasiveproliferationcanundergocentralnecrosis,
whichfrequentlycalcifiestoformthemicrocalcificationsseenonmammography.The
centralnecrosiswithinenlargedandbacktobackductalstructuresresemblescomedoes
andgivesrisetothetermcomedocarcinoma,nowreservedforthishistologicvarietyof
intraductalcarcinoma.

Sundin
4.Whichofthefollowingarethemostimportantandclinicallyusefulriskfactorsfor
breastcancer?
Therewasanerrorinthis
gadget A.Fibrocysticdisease,age,andgender.
B.Cysts,familyhistoryinimmediaterelatives,andgender.
C.Age,gender,andfamilyhistoryinimmediaterelatives.
SubscribeTo
D.Obesity,nulliparity,andalcoholuse.
Posts Answer:C
Comments
DISCUSSION:Themostimportantriskfactorsforbreastcancerarethepatient'sage,
gender,andafamilyhistoryofbreastcancerinimmediaterelatives(sisters,mother,
Bloggers.com daughter).Theageadjustedincidenceofbreastcancerincreaseswithage.Breastcancer
Reviewthisblogon doesoccurinmales,butthediseaseisfarmorecommoninwomen.Familyhistoryis
Bloggers.com importantwhenbreastcanceroccurswithintheimmediatefamilyhistoryofbreast
cancerinmoredistantrelatives(grandmothers,cousins,aunts)islessimportant.In
addition,agefactorsintotheriskassociatedwithfamilyhistory.Anaffectedyoung
primaryrelativeisfarmoresignificantasariskfactorthananolderrelativewithbreast
cancer.Theotherimportantriskfactornotlistedhereisahistoryofbreastcancer,either
withintheconservedipsilateralbreastorinthecontralateralbreast.Again,ageplaysan
importantmodifyingroleastheageatwhichbreastcancerwasfirstdiagnosedincreases,
theriskofasubsequentsecondcancerdecreases.Althoughpatientswithfibrocystic
diseaseareatincreasedriskforbreastcancer,riskconcentratesinthosepatientswith
fibrocysticdiseasewhoshowatypicalepithelialhyperplasiawithinbreastducts.Obesity,
nulliparity,andalcoholallappeartoincreaseriskslightlyandareimportanttothe
epidemiologicstudyofbreastcancerhowever,theeffectofthesefactorsisnotsufficient
towarranttheiruseincommonclinicalpractice.

5.Whichofthefollowingpathologicfindingsisthestrongestcontraindicationtobreast
preservation(lumpectomywithbreastradiation)asprimarytreatmentforanewly
diagnosedbreastcancer?
A.Grade3,poorlydifferentiated,infiltratingductalcarcinoma.
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B.Extensiveintraductalcanceraroundtheinvasivelesion.
C.Tumorsizegreaterthan3cm.
D.Positivesurgicalmarginforinvasivecancer.
Answer:D

DISCUSSION:Theonlyfirmcontraindicationtowideexcisionandradiation(breast
preservation,lumpectomy)astheprimarysurgicaltreatmentforanewlydiscovered
breastcanceristheinabilitytoachieveanuninvolvedsurgicalmarginafterexcisionof
thetumor.Apositivesurgicalmarginrequires,atleast,reoperationwithanattemptatre
excisionofthecancer.Ifthemarginofremovalispositiveafterattemptsatreexcision,
thisisastrongreasontorecommendmastectomyinpreferencetobreastconservation.
Tumorsizeisarelativecontraindicationwhenthecancerissolargeinrelationtothe
breastthatexcisiontoacleansurgicalmarginseemsunreasonable.Otherhistologic
findings,suchastumorgradeorvascularinvasion,arenotstrongreasonstorecommend
mastectomyifthepatientwouldpreferbreastconservation.

6.Axillarylymphnodedissectionisroutinelyusedforallofthefollowingconditions
except:
A.2cm.purecomedotypeintraductalcarcinoma.
B.1cm.infiltratinglobularcarcinoma.
C.8mm.infiltratingductalcarcinoma.
D.Apuremedullarycancerintheupperinnerquadrant.
Answer:A

DISCUSSION:Intraductalcarcinomaiscarcinomainsituanddoesnotmetastasizeto
regionalordistantsites.Lymphnodedissectionisnotroutinelyrequiredforapureinsitu
cancerofthebreast.Incontrast,alloftheothercancerslistedabove(infiltratinglobular,
infiltratingductal,andmedullarycarcinoma)areinvasivemalignanciesthatarecapable
ofnodalanddistantmetastasis.Lymphnodedissectioniscommonlyrecommendedfor
theseinvasivemalignancies.Intraductallesionsthathavegrownlargerthan5cm.are
moreapttohavebecomefocallyinvasive.Sincethisinvasivecomponentmightbemissed
histologically,manysurgeonsadvocateselectiveuseofaxillarynodedissectionforlarge
intraductallesions,particularlyhighgradetumorssuchasthecomedovariant.However,
apurelyintraductal2cm.cancerwouldmostlikelybetreatedwithoutperformingnode
dissection.

7.Failuretoperformradiationafterwideexcisionofaninvasivecancerriskswhichof
thefollowingoutcomes?
A.Recurrenceofcancerintheipsilateralbreast.
B.Shortersurvivaltime.
C.Regionalnodalrecurrence.
D.Greaterchanceofbreastcancermortality.
Answer:A

DISCUSSION:Retrospectivereviewsandprospectivesurgicaltrialsagreethatomission
ofbreastradiationafterwideexcisionleadstoahigherrateofipsilateralbreast
recurrence.However,survivalandtheriskofdistantdiseasearenotalteredinpatients
treatedbyexcisionalone,withinthefollowuptimeofthestudiesandgiventheirinherent
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powertodetectdifferencesinoutcome.Regionalnodemetastasisisnotaffectedbythe
choiceofmastectomyversuswideexcisionandradiation.

8.Whichofthefollowingtreatmentsshouldneverberecommendedtoapatientwith
purelyintraductalcarcinoma?
A.Modifiedradicalmastectomy.
B.Lumpectomytoclearsurgicalmargins,followedbyobservation.
C.Incisionalbiopsywithaninvolvedmargin,followedbyradiation.
D.Excisionalbiopsytoclearmargins,followedbyradiation.
Answer:C

DISCUSSION:Thetreatmentapproachtointraductalcarcinomadependsontheextent
ofthedisease,itsmultifocality,andtheinvolvementofthesurgicalmargin.Forextensive
disease,modifiedradicalmastectomyisappropriate,particularlyifthereisagreat
likelihoodofoccultinvasivedisease,makingaxillarydissectionlogical.Forsmallfociof
diseaseexcisedtoclearsurgicalmargins,observationisanacceptablerecommendationto
awellinformedpatient.SeveralnoncontrolledreviewsandtheNationalSurgical
AdjuvantBreastandBowelProject(NSABP)trialforintraductaldiseasewouldindicate
agreaterchanceofipsilateralbreastrecurrenceforlumpectomyonlyhowever,the
magnitudeoftheriskissmall,andsurvivalisexcellentandunaffected.Theonlymodeof
treatmentthatcannotberecommendedforroutinemanagementisleavingresidual
diseaseinthebreastandtreatingonlywithradiation.

9.Thepropertreatmentforlobularcarcinomainsitu(LCIS)includeswhichofthe
followingcomponents?
A.Closefollowup.
B.Radiationafterexcision.
C.Mirrorimagebiopsyoftheoppositebreast.
D.Mastectomyandregionalnodedissection.
Answer:A

DISCUSSION:LCISisbestthoughtofasaprecursorlesionthatconfersincreasedrisk
foreventualcancer.Themagnitudeofthisriskappearstobeintherangeofsevento
ninefoldoverbaselinerisk.Thechanceofbreastcancerisequalinbothbreasts,notjust
inthebiopsiedbreast,andthetypeofcancerisnotconfinedtoalobularhistology.Aftera
diagnosisofLCIS,patientsareatincreasedriskforinvasiveandnoninvasiveductal
carcinomainbothbreasts.Therefore,mirrorimagebiopsyaspracticedinthepasthas
littletooffer.SinceLCISispurelynoninvasive,nodaldissectionisnotrequiredif
mastectomyischosen.TherearenodataontheuseofbreastradiationtherapyforLCIS.
MostsurgicaloncologistsrecommendclosefollowupforpatientswhohaveLCISonly
thealternativesurgicaltreatmentthatmakesmostsenseisbilateralsimplemastectomies,
withorwithoutreconstruction.

10.Whichofthefollowingstatementsmostaccuratelyreflectsthefindingsoflarge
overviewanalysesofclinicaltrialsinwhichadjuvantchemotherapyforearlystagebreast
cancerwascomparedtoacontrolgrouptreatedonlywithsurgery?
A.Thebenefitofadjuvanttherapyisconfinedtoyoungpatients.
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B.Adjuvanttherapybenefitsallpatientsandisindependentofageornodestatus.
C.Adjuvanttherapydoesnotworkinestrogenpositivepatients.
D.Themagnitudeofbenefitisverylarge.
Answer:B

DISCUSSION:Anoverviewanalysis(metaanalysis)examinednearlyallrandomized
clinicaltrialsinwhichchemotherapyaftersurgerywascomparedtosurgeryalonefor
treatmentofearlystagebreastcancer.Thisexaminationoftheworld'spublished
literaturerevealedthatthemagnitudeofbenefit(thereductionintheoddsofrecurrence)
fromchemotherapywasrelativelysmallandintherangeofa20%reductioninthe
chanceofrecurrenceordeathhowever,thisbenefitextendedtopatientsofallages
(youngandolder)andtobothnodepositiveandnodenegativepatients.Thevalueof
adjuvantchemotherapydoesnotdependonthehormonereceptorcontentofthecancer.
Itisusefultorememberthataconstantreductionintheoddsofrecurrenceresultsina
higherabsolutebenefitastheprognosisworsens.Ifthechanceofrecurrenceis50%(for
nodepositivegroups)theabsolutereductionwillbeintherangeof10%or15%.In
contrast,iftherecurrencerateis10%,theabsolutedifferencebetweentreatedand
controlgroupswillbelessthan5%.Thismeansthatmanypatientsneedtobeexposedto
therisksandsideeffectsofchemotherapytobenefitaverysmallnumber.Thiskindof
thinkingiscurrentlyusedtodecidewhoshouldreceiveadjuvantchemotherapyafter
primarytreatment(mastectomyorlumpectomy).

11.Whichofthefollowingstatementsaretrueaboutreconstructionofthebreast
followingmastectomy?
A.Apermanentprosthesisortissueexpandermaybeinsertedatthetimeoftheablative
surgery.
B.Ifthepatientrequiresadjuvantchemotherapyorradiationtherapy,reconstructionof
thebreastisdelayeduntilcompletionofthetreatment.
C.Extensivepostmastectomydefectsrequiretheuseofaflap.
Answer:ABC

DISCUSSION:Reconstructioncanbeinitiatedatthetimeoftheablativesurgery,usinga
6cm.slightlycurvedincisionatthelevelofthesixthribthroughtheserratusmuscle.A
pocketiscreatedbeneaththeserratusandpectoralismajormuscles,extendingmedially
totheperforatinginternalmammaryvesselsandinferiorlybeneaththefascialinsertion
oftherectusabdominismuscle.Atissueexpanderprosthesisisinsertedintothepocket.If
thepatientrequiresadjuvantchemotherapyorradiationtherapy,reconstructionofthe
breastisdelayeduntiltreatmentiscompletedandanadequaterecoveryperiodhas
passed.Ifthequantityorqualityofthechestskinorthepectoralismajormuscleis
insufficient,tissuemustbebroughtinfromadjacentareas.Alatissimusdorsi
musculocutaneousflapmaybetransferredonitsbloodsupplyviathethoracodorsal
arteryandvein.Extensivepostmastectomydefectsnecessitatetheuseofthelargerrectus
abdominismusculocutaneousflap,whichisbasedonthesuperiorepigastricvessels.A
freemicrovascularrectusabdominisorothermyocutaneousflapsmaybeused.The
thoracodorsaloranteriorserratusvesselscanusuallybeanastomosedtotheinferior
epigastricvesselsoftherectusabdominisflap.

12.Whichofthefollowingstatementsaretrueaboutthemanagementofmammary
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hyperplasia?
A.Reductionmammaplastycanbeperformedonlyonwomenyoungerthan40years.
B.Removalofbreasttissuetoreducesizeofthebreastisusuallypredicatedontheuseof
anipple,areola,anddermalpedicleflap.
C.Ifremovalof2000gm.ofbreasttissueisneeded,breastamputationwithimmediate
freenippleareolagraftingisperformed.
Answer:BC

DISCUSSION:Reductionmammaplastycanbeperformedatanyage.Becauseofthe
increasedweightofthebreastconsiderableshoulderandbackpain,accompaniedby
excoriationoftheskinintheinframammaryareaandtheshoulders,canoccur.Older
womenfrequentlyseekrelieffromtheseproblems,whichcanberesolvedbyareduction
mammaplasty.Thereductioninbreastvolumeisusuallyaccomplishedbymovingthe
nippleandareolaonadermalpedicleflap.Theflapcanbebasedinferiorly,medially,
superiorly,laterally,vertically,orhorizontally.Itispossibletoremoveupto3000gm.of
breasttissueutilizingapyramidalbasedbreastflapwithaninferiordermalnippleareola
pediclesincethebloodsupplytothetissuesispreservedbythistechnique.Breast
reductioninvolvingremovalofmorethan3000gm.requiresabreastamputation
techniquewithimmediatefreenipplegrafting.

13.Whichofthefollowingstatement(s)is/aretrueconcerningtheanatomyofthebreast?

a.About25%ofthelymphaticdrainageofthebreastcoursestotheinternalmammary
nodes
b.Nerveswithintheaxillaryfatpadincludetheintercostalbrachialnerve,thelong
thoracicnerve,andthoracodorsalnerve
c.Fascialbandsprojectingthroughthebreasttotheskinformasupportingframework
knownasCoopersligaments
d.Theductalsystemofthebreastfromthealveolitotheskinarelinedwithcolumnar
epithelium
Answer:b,c

Thebreastabutsagainstthefasciaofthepectoralismajorandserratusanteriormuscles.
Projectionsofthefasciacoursethroughthebreasttotheskin,formingasupporting
frameworkofthebreastparenchyma.Thesefascialbands,calledsuspensoryligamentsof
Cooper,arebetterdevelopedintheupperbreast.Thestructureofthebreastcanbe
dividedintolobularandductalelements.Thelobuleisthefunctionalunitofthebreast.
Withinalobule,theterminalelongatedtubularductsarereferredtoasalveoli.Tentoone
hundredalveolicoalescetoformalargerductwhichdefinesalobularunit.Thelobular
ductsjointoformprogressivelylargerductsandultimatelyanexcretoryduct.The
alveolarducts,lobularducts,andexcretoryductsarealllinedwitheithercuboidalor
columnarepithelium.Eventually,1020excretoryducts,eachdilateintoashortexcretory
sinus(linedwithsquamousepithelium)justbeneaththeareola.Excretoryductsthen
courseperpendiculartoexitthroughthenipple.
Thelymphaticanatomyofthebreastisofinteresttothesurgeonbecauseofthetendency
ofbreastcancertoinvolvetheregionallymphnodes.Studiesusingradioactivetracers
demonstrateatleast97%oflymphaticflowfromthebreastisintotheaxillathe
remaindercoursesintotheinternalmammarynodes.Thesestudiesalsoshowthatlymph
flowingintotheinternalmammaryglandchainisnotrestrictedinorigintothemedial
halfandsubareolarregionofthebreast,aswasthought,butcanoriginateinany
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quadrantofthebreast.Intheaxilla,lymphaticvesselsterminateinthelymphnodes
embeddedwithintheaxillaryfatpad.Alsowithintheaxillaryfatpadaretheintercostal
brachialnerves(asensorynervesupplyintheunderarm),thelongthoracicnerve(a
motornervetotheserratusanteriorandsubscapularismuscles)andthethoracodorsal
nerve(amotornervetothelatissimusdorsiadjacenttoitsaccompanyingarteriesand
veins).

14.Whichofthefollowingstatement(s)is/aretrueconcerningtherecurrenceofbreast
cancer?

a.Themajorityofpatientsrecurwithinfiveyearsofdiagnosis
b.Morethan70%ofbreastcancerrecurrenceinvolvedistantmetastases
c.Pulmonarymetastasesarethemostcommoninitialsiteofdistantrecurrence
d.Thelocalrecurrenceratefollowingbreastconservingproceduresvariesfrom10%to
40%whetherornotradiationwasused
e.Recurrentdiseasewillbeseeninatleast35%ofnodenegativepatientsundergoing
appropriateprimarybreasttherapy
Answer:a,b,d

Metastaticdiseasefollowingprimarytherapyforbreastcancercanrecuratanytime.
However,ofthosewhorelapse,50%to70%dowithintwoyearsandover85%relapse
withinfiveyears.Morethan70%ofrecurrencesaredistant,butanywherefrom10%to
30%ofrecurrencesarelocal.Boneandlungarethemostcommoninitialsitesofdistant
relapse(50%and25%),respectively.Abreastconservingprocedurecanbeassociated
withalocaltumorrecurrencerate.Therateoflocalrecurrencefallsfrom40%to10%if
postoperativeradiationtherapyisgiventotheentirebreast.Despitepotentiallycurative
resection,atleast20%ofnodenegativeand60%ofnodepositivebreastcancerpatients
haverecurrenceoftheirdiseaseatsometimeaftersurgery.

15.Whichofthefollowingstatement(s)is/aretrueconcerningmammography?

a.Upto50%ofcancersdetectedmammographicallyarenotpalpable
b.Onethirdofpalpablebreastcancersarenotdetectedbymammography
c.Thesensitivityofmammographyincreaseswithage
d.TheAmericanCancerSocietycurrentlyrecommendsroutinescreeningmammography
beginningatage40
e.Onlyabout10%ofnonpalpablelesionsdetectionmammographicallyarefoundtobe
malignantatbiopsy
Answer:a,c,d

Althoughmammographyhasbeenavailableforyears,itdidnotbecomewidelyuseduntil
thefindingsoftheHealthInsurancePlanofNewYorkandtheBreastCancerDetection
Demonstrationprojectstudiesofscreeningmammographyweredisseminated.Theseand
otherinvestigatorsdemonstratedthat10%50%ofcancersdetectedmammographically
arenotpalpable.Conversely,palpationrecognizes10%20%oftumorsnotdetectable
mammographically.Theincidenceofbreastcancerbeginstorisesharplyatage40,and
thesensitivityofmammogramsincreaseswithageasthedenseparenchymaltissueof
youngwomenisprogressivelyreplacedbyfattytissue.Routinescreeningmammography
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hasbeenshowntodecreasebreastcancerrelatedmortalityinasymptomaticwomenover
theageof50.Controversyexistsconcerningtheroleofscreeninginyoungerwoman.
However,currentlytheAmericanCancerSocietyrecommendsthatmammographic
screeningbeginatage40.Althoughsensitive,mammographyisnotspecific.Onlyabout
25%ofnonpalpablelesionsdetectedmammographicallyarefoundtobemalignantat
biopsy.Aspiculateddensitywithilldefinedmarginsonmammogramisalmostcertainly
malignant.Mostcommonly,featuresareseenthataresuggestivebutnotdiagnosticof
cancer.Theseincludeclusteredmicrocalcifications,asymmetricdensity,ductal
asymmetry,anddistortionofnormalbreastarchitectureand/orskinornippledistortion.

16.Whichofthefollowingstatement(s)is/aretrueconcerningradiationtherapyafter
lumpectomy?

a.Thetotaldosegiventothebreastisusuallyintherangeof2500to3000cGy
b.Radiationtotheaxillarynodalbedisnormallypartoftheprocedureinmostpatients
c.Longtermcomplicationsofradiationtherapyincluderibfracturesandarmedema
d.Breastedemaandskinerythemausuallyresolveswithinafewweeks
e.Noneoftheabove
Answer:c

Breastconservationusuallyinvolvestheuseoflumpectomyandradiationtherapyto
achievelocalcontrolofbreastcancer.Anytechniqueusedforpostlumpectomyradiation
ofthebreastmustadequatelycoverthevolumeatrisk,deliverahomogenousdose
throughoutthetargettissues,avoidoverlappingorinadequateappositionoffields,and
minimizethedosereachingtheheartandlung.Theentirebreastshouldbetreatedwitha
totaldoseof4500to5000cGy.Thereisnogoodevidencetosupportaradiationboostto
thesiteoftheprimarytumor.Complicationsfrombreastradiationareuncommonif
performedcorrectly.Acutecomplicationsofradiotherapyincludefatigue,breastedema,
andskinerythemathesearealmostalwaysselflimitedandresolveoverweeks(fatigue)2
months(erythema)oryears(edema).Themostcommonlongtermproblemsarerib
fracturesandminorarmedema,eachofwhichoccurabout5%ofthetime.

17.A35yearoldwoman,whoiscurrentlybreastfeedingherfirstbornchild,developsan
erythematousandinflamedfluctuantareaonbreastexamination.Whichofthefollowing
statement(s)is/aretrueconcerningherdiagnosisandmanagement?

a.ThemostcommonorganismwhichwouldexpecttobeculturedisStaphylococcus
aureus
b.Opensurgicaldrainageislikelyindicated
c.Breastfeedingabsolutelyshouldbediscontinued
d.Iftheinflammatoryprocessdoesnotcompletelyrespond,abiopsymaybeindicated
Answer:a,b,d

Infectioncomplicatesbreastfeedinginfewerthan1:100women,buttheselactational
infectionsstillaccountfor80%ofallbreastinfections.Presumably,gainingaccessviathe
skinoftheirritatednippleofthenursingwoman,Staphylococcusaureusisbyfarthe
mostcommonpathogeninthissetting.Manybreastinfectionsbeginascellulitis,without
abscessformation.Whenanactualabscessissuspected,percutaneousaspirationcan
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establishthediagnosisandallowforbacterialcultureandsensitivitytesting.Open
surgicaldrainageisthemostprudentandeffectivetreatment.Althoughwomenmay
choosetoceasebreastfeeding,thereisnoabsoluteindicationforthis.Whenmastitisor
breastinfectionissuspectedclinically,thepossibilityofaninflammatorycarcinomamust
alsobeentertained.Anyinflammatoryprocessthatdoesnotrespondcompletelyand
promptlytoantibioticsordrainageshouldbesubjectedtobiopsytoruleoutcancer.

18.Whichofthefollowingstatement(s)is/aretrueconcerningthesurgicalstagingof
breastcancer?

a.Allbiopsyspecimensshouldbetransportedtopathologyinformalinwithin24hoursof
theprocedure
b.RemovalofonlylevelIaxillarylymphnodesmayunderstagebreastcancerinupto
onefourthofpatients
c.LevelIIIaxillarylymphnodesshouldberemovedinallaxillarylymphnodedissections
d.Aclinicallynegativeaxillawillbefoundtohavehistologicallypositivemetastasisin
approximatelyonethirdofpatients
Answer:b,d

Pathologicstagingbeginswiththeinitialbiopsy.Unlesspreviouslysecured,freshtumor
needstobeobtainedforhormonereceptoranalysispriortoplacementintoformalin
solution.Aperiodofwarmischemiaasshortas30minutesmaycauseunderestimationof
estrogenreceptorlevels.Theneedtoremoveaxillarynodesmustbedetermined
preoperatively.Axillarylymphnodemetastasiswillbefoundinapproximatelyonethird
ofclinicallynegativeaxillae,butonlyifproperaxillarydissectionisperformed.Removal
ofonlylevelInodesorsamplingofaxillarylymphnodesinahaphazardfashion
increasestheriskofinjurytomajoraxillaryneurovascularstructuresandmay
understageupto25%ofwomen.Properstagingofaxillarylymphnodesshouldinclude
enblocremovalandexaminationoflevelIandlevelIInodes.Whenconductedfor
staging,axillarylymphnodedissectionshouldnotincluderemovaloflevelIIIaxillary
nodesinfewerthan2%aremetastasespresentinlevelIIInodeswhenlevelIandlevelII
nodesarenegative.RemovaloflevelIIInodes,however,doesincreasetheincidenceof
postoperativearmlymphedemaalmostfivefold.Therapeuticaxillarylymphnode
dissectionperformedforpalpablediseaseintheaxillashouldincluderemovalofalllevels
tocleargrossdisease.

19.Whichofthefollowingstatement(s)is/aretrueconcerningtheeffectofvarious
hormonesonbreastphysiology?

a.Estrogenreceptorsarepresentonlyinbreastcancercells
b.Mammaryductaldilatationanddifferentiationofalveolarepithelialcellsandsecretory
cellsaretheresultofrisingprogesteronelevels
c.Theearlyfirsttrimesterbreastchangesareprimarilyduetotheincreasedprogesterone
effectsofpregnancy
d.Milkproductionandsecretionafterchildbirtharemaintainedbyongoingsecretionof
prolactinbytheanteriorpituitarygland
Answer:b,d
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Breastgrowth,development,andfunctionareorchestratedbyavarietyofhormonesand
growthfactors.Estrogenplaysacentralroleinbreastdevelopment,growth,and
differentiation.Lipidsolubleestrogensgainentrytothenormalandmalignantbreastcell
bydiffusingtothecellmembrane.Oncewithinthecell,estrogensbindwiththeestrogen
receptor.Bothnormalandmalignantbreastcellscontainestrogenreceptors,butthelow
levelsofreceptorsinnormalbreasttissueandinsomebreastcancersresultintheir
testingnegativeinclinicalassays.Cyclicchangesassociatedwiththemenstrualcyclehave
aprofoundinfluenceonbreastmorphologyandphysiology.Duringtheperiodofrelative
quiescence,increasingGraafianfolliclesecretionofestrogenstimulatesbreastepithelial
proliferation.Asthelutealphaseofthecycleisentered,progesteronelevelsrise.
Mammaryductaldilatationanddifferentiationofalveolusepithelialcellsintosecretory
cellsresult.Attheonsetofmenstruation,therapiddeclineofcirculatingsexhormone
levelsleadstobreastinvolutionandthecyclebeginsanew.Duringpregnancy,marked
ductular,lobular,andalveolargrowthoccurundertheinfluenceofestrogen,
progesterone,placentallactogen,prolactin,andchorionicgonadotropin.Thesechanges
preparethebreastsformilkproductionatparturition.Earlyinthefirsttrimester,ductal
sproutingandlobularformationproceedunderestrogenicinfluence.Duringthesecond
trimester,lobulareventspredominateundertheinfluenceofprogestins.Abrupt
withdrawalofplacentallactogenandsexhormonesthatoccurswithdelivery,leavesthe
breastpredominatelyundertheinfluenceofpituitaryderivedprolactin.Milkproduction
andsecretionaremaintainedduringlactationbyongoingsecretionofprolactinbythe
anteriorpituitary.

20.Apremenopausalwomanthreeyearsaftermastectomyforbreastcancerpresents
withpulmonarymetastases.Whichofthefollowingstatement(s)is/aretrueconcerning
hermanagement?

a.Ifthepatienthasreceivedadjuvanttherapy,herresponseislikelytobebetter
b.IfthepatientisERpositive,hormonaltherapyshouldbethefirstlineoftreatment
c.Theresponsetochemotherapywilllikelybedosedependent
d.Combinationchemotherapywilllikelyworkbetterinthispatientthanawomanwhois
postmenopausal
Answer:b,c,d

Chemotherapyformetastaticbreastcancerismorelikelytobeemployedforyoung
women,thosewithERnegativetumors,thosewithvisceralorganinvolvementandthose
withrapidlyadvancingorlifethreateningdisease.Generally,combinationsofagentsare
usedintreatingmetastaticbreastcancerwiththeresponserateusuallydosedependent.
Allregimensareslightlylessactiveinpostmenopausalwomen.Responseratesare
highestinwomenwhohavenotreceivedpriortreatmentformetastaticdisease.Prior
adjuvanttherapyisnotconsistentlyassociatedwithapoorerresponsetotherapy,
particularlyifalongintervalhaslapsedbetweenadjuvanttherapyandthedevelopment
ofmetastases.Endocrinetherapyisappropriateasthefirstlinetreatmentfornearlyall
womenwithERpositivemetastaticbreastdisease.Tamoxifenistheagentofchoicefor
firstlinehormonaltherapyformetastaticbreastcancer.Bothpremenopausalandpost
menopausalpatientscanreceivethisagentandsideeffectsareminimal.

21.Whichofthefollowingstatement(s)is/aretrueconcerningintraductalpapilloma?
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a.Thislesionisthemostcommoncauseofbloodynippledischarge
b.Serousnonbloodydischargeisunlikelytobeduetoanintraductalpapilloma
c.Anonpalpablelesioncanoftenbediagnosedwithductography
d.Anisolatedlesionisconsideredpremalignant
Answer:a,c

Intraductalpapillomarepresentsthemostcommoncauseofbloodynippledischarge,
althoughinhalfofthecases,thedischargeisserous.Sincetheaveragesizeofan
intraductalpapillomais34mm.,theyarerarelypalpable.Ductographymay
demonstratethelesion,oritmaybefoundaftersubareolarductexcisionperformedto
treatthedischarge.Anisolatedintraductalpapillomaisnotconsideredpremalignantnor
doesitplacethepatientatincreasedriskforbreastcancer.Unlikeisolatedpapillomas,
diffusepapillomatosisisassociatedwithanincreasedriskofbreastcancer,perhapsas
highasin40%ofwomen.

22.A21yearoldwomanpresentswithanasymptomaticbreastmass.Whichofthe
followingstatement(s)is/aretrueconcerningherdiagnosisandtreatment?

a.Mammographywillplayanimportantroleindiagnosingthelesion
b.Ultrasonographyisoftenusefulinthedifferentialdiagnosisofthislesion
c.Themassshouldalwaysbeexcised
d.Thelesionshouldbeconsideredpremalignant
Answer:b

Fibroadenomarepresentsthemostcommontumorinadolescentsandyoungwoman,but
ifalsofrequentlyencounteredinolderwomen.Itgenerallypresentsasapalpablebreast
massandmustbedifferentiatedfromcancer.Typically,fibroadenomapresentsasa
painless,slowgrowingmassfoundincidentallyonbreastselfexamination.Palpationofa
massusuallyrevealsawellcircumscribed,ovalorround,mobilemasswithafirm,
rubberytexture.Becausethemammographicappearanceofafibroadenomaisrarely
characteristic,mammographyplayslittleroleindiagnosingthislesion.Ultrasonography
candifferentiateasolidmassfromacyst.Additionally,theultrasonicappearanceofa
wellmarginated,homogenousmassmaybesufficientlycharacteristictopermitdiagnosis
offibroadenoma.Excisionalbiopsyisnotnecessaryforeveryfibroadenoma.Women
under30yearsofagewithcharacteristicphysicalexaminationandsonographic
appearanceofthefibroadenomamaybegiventheoptionofobservation.Generally,
fibroadenomasarenotfelttobepremalignantlesions,nortoindicateanyincreasedrisk
forthedevelopmentofbreastcancer.

23.Whichofthefollowingarefactorsassociatedwithanincreasedriskfordeveloping
breastcancer?

a.Nulliparity
b.Oophorectomybeforeage35
c.Useoforalcontraceptives
d.Highfat,highcaloricdiet
e.Postmenopausaluseofconjugatedestrogens
Answer:a,d2 Tweet
Womenwhoundergooophorectomybeforeage35anddonottakereplacementestrogens
haveatwothirdsreductionintheirbreastcancerrisk.Replacementestrogentherapy
eliminatesthebeneficialeffectofoophorectomy.Mostinvestigationsoforalcontraceptive
usedonotdemonstrateanassociatedincreasedriskofbreastcancerdevelopment.
Studiesofestrogenreplacementtherapyforpostmenopausalwomenhaveyielded
equivocalresults.Mostcontemporarystudiesfailtodemonstrateanassociationbetween
breastcancerriskandpostmenopausaluseofconjugatedestrogens.
BREASTCANCERRISKFACTORS

DEMOGRAPHICFACTORS
Agemorethan30y
Femalegender(130:1female/maleratio)

GREATLYINCREASEDRISK
Knowncarrierofbreastcancersusceptibilitygene
Strongfamilyhistorytwoormorefirstdegreerelativeswith
bilateralorpremenopausalbreastcancer
Atypicalductalorlobularhyperplasiaorlobularcarcinomainsitu
Ductalcarcinomainsitu,risklimitedtoipsilateralbreast

MODERATELYINCREASEDRISK
Familyhistoryoneormorerelativeswithbreastcancer,not
bilateralorpremenopausal
Menstrualhistorymenarchebeforeage12y,menopauseafter
age55y
Paritynulliparityorfirstlivebirthafterage30y
Radiationexposuretolowdoseionizingradiationinchildhoodor
adolescence
Previousbreastcancerlowgrade,nodenegative,orreceptor
positivelobularhistology
Othercancerscolonorendometrialcancer
Diethighfatorhighcaloriediet

24.Whichofthefollowingchromosomaland/orgeneticabnormalitiesis/areassociated
withthedevelopmentofbreastcancer?

a.Mutationsinthep53tumorsuppressorgene
b.Amutationintheshortarmofchromosome2
c.ThepresenceofaBRCA1geneonchromosome17
d.ThepresenceoftheBRCA2geneonchromosome13
Answer:a,b,c,d

Therearefourinheritedsyndromesassociatedwiththedevelopmentofbreastcancer.
TheLiFraumenisyndromehasanautosomaldominantmodeofinheritance.The
syndromeisattributedtomutationsinthep53tumorsuppressorgene,agenethatcodes
foraproteinthatservesasaG1Scheckpointregulatorofthecellcycle.Morerecently,a
mutationhasbeencharacterizedontheshortarmofchromosome2inageneassociated
withDNArepair.Predispositiontoawiderangeofmalignancies,includingbreastand
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coloncancerisassociatedwithabnormalitiesatthislocus.Themostexcitingdevelopment
ininheritedsusceptibilitytobreastcancerrelatetotheidentificationandcloningofthe
BRCA1gene,whichwasinitiallylocalizedonthelongarmofchromosome17bylinkage
analysis.GermlineabnormalitiesinBRCAamayberesponsibleforasmanyas5%ofall
breastcancersintheUnitedStates.Thegeneischaracterizedbyautosomaldominant
inheritancewithahighdegreeofpenetrance.Almost60%ofwomeninheritingthegene
willdevelopbreastcancerbyage50,andalifelongriskapproaches85%.Anotherbreast
cancersusceptibilitygene,dubbedBRCA2,hasbeenlocalizedbylinkageanalysistoa
smallregionofchromosome13q1213.BRCA2apparentlyconfersthehighriskofearly
onsetfemalebreastcancer.SimilartoBRCA1,thelifetimebreastcancerriskapproaches
90%incarriersofthisgene.

25.A45yearoldwomanpresentswithaweepingeczematoidlesionofhernipple.Which
ofthefollowingstatement(s)is/aretrueconcerningherdiagnosisandmanagement?

a.Treatmentiswithwarmcompressesandoralantibiotics
b.Biopsyofthenipplerevealingmalignantcellswithinthemilkductsisinvariably
associatedwithanunderlyinginvasivecarcinoma
c.Theappropriatetreatmentismastectomy
d.Thelesionalwaysrepresentsahighriskdiseasewithasignificantriskofsubsequent
metastaticdisease
Answer:c

Pagetsdiseaseischaracterizedbyweeping,eczematoidlesionofthenipple.Thereisoften
accompanyingedemaandinflammation.Biopsyofthenipplerevealsmalignantcells
withinthemilkducts.Thelesionisinvariablyassociatedwithanunderlyinginvasiveor
insituductalcarcinoma.TheprognosisofPagetsdiseaseisthatoftheunderlyingcancer.
Standardtreatmentismastectomywithaxillarylymphnodedissectiononlyifinvasive
cancerispresent.

26.Whichofthefollowingtreatment(s)is/areofprovenbenefitinthetreatmentof
mastodyniaassociatedwithfibrocysticbreastdisease?

a.Avoidanceofmethylxanthinecompounds,particularlycaffeine
b.Cessationofsmoking
c.VitaminE
d.Danazol
Answer:a,b,d

Therelationshipofmethylxanthines,particularlycaffeine,tomastodyniaandbreast
nodularityremainscontroversial.Mostwomendo,however,experiencediminutionof
theirsymptomsandaresubjecttoimprovementinbreastnodularitybylimitingor
eliminatingcaffeineintake.Mastodyniapatientsshouldbeadvisedtoeliminatecaffeine
beveragesforaperiodof2to3monthstodetermineiftherehasbeenimprovementin
theirsymptoms.Inadditiontocaffeineabstention,patientsshouldbeurgedtostop
smokingbecausenicotineispurportedtoworsenmastodynia.Anumberofmedications
havebeenadvocatedforthetreatmentofmastodynia.Unfortunately,becauseofthe
subjectivenatureofthediseaseanditspropensitytobebettertoleratedbypatientswith
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reassurance,theexactmethodofmostoftheseinterventionsisunclear.VitaminEhas
beentoutedasbeneficial,however,clinicaldatadonotsupporttheuseofthisorother
vitaminsforthiscondition.Theuseofhormonalagentstotreatmastodyniahasbeen
moreextensivelytreated.Danazol,aweakantigen,isthemosteffectivedrugavailablefor
treatmentofmastodyniarelatedtofibrocysticdisease.Unfortunately,Danazols
androgenicsideeffectsaretroublesomeenoughtorestrictitsusetothemostproblematic
casesofmastodynia.Otherhormonalagentshavebeeninvestigatedforthemanagement
ofmastodynia.Inyoungwomen,oralcontraceptiveshaveavariableeffecton
mastodynia.Atrialanderrorsearchforoptimalpreparationsmaybenecessaryasthe
effectoforalcontraceptivesisdependentontheformulationofthepill.

27.Whichofthefollowingstatement(s)is/aretrueconcerningbreastreconstruction?

a.Thetimingofbreastreconstructionisofnooncologicsignificance
b.Breastreconstructionmayinterferewithdetectionoflocalrecurrenceofbreastcancer
c.Maintenanceofaneffectivesubpectoralpocketforabreastimplantrequires
preservationofthepectoralisfascia
d.Becauseofitscomplexity,theTRAMflapisseldomusedforprimarybreast
reconstruction
Answer:a,c

Breastreconstructionissuitableforanywomanwhohasundergonemastectomywho
desiresreconstruction.Breastreconstructionmaybeperformedatthetimeof
mastectomy(immediate)orsometimesubsequently(delayed)Becausethepresenceof
reconstructionmayinterferewiththeaccurateplanningandadministrationofradiation
therapy,reconstructionisgenerallydelayediftheuseoflocalorregionalradiation
therapyisanticipated.Otherwise,timingofbreastreconstructionisofnooncologic
significance.Becausemostlocalrecurrencesoccurintheskinssubcutaneoustissues,the
presenceofareconstructionwillnotinterferewithdetection.Similarly,areconstruction
doesnotcomplicatetheadministrationofchemotherapy.
Breastreconstructiontechniquesutilizeeitherautogenoustissueorsyntheticprostheses
torecreateabreastmound.Prostheticreconstructionisusuallyaccomplishedbysub
pectoralplacementofasalineorsiliconegelfilledimplant.Maintenanceofaneffective
subpectoralpocketforanimplantrequirespreservationofthepectoralisfasciaandthe
medialpectoralnerveduringmastectomy.Thetransferaserectusabdominous
myocutaneous(TRAM)flapistheautogenousreconstructionofchoice.TheTRAM
operationiscomplexandtimeconsuming.Despitethemagnitudeoftheprocedure,itis
stillcommonlyusedforimmediatereconstruction.

28.Whichofthefollowingstatement(s)is/aretrueconcerningthehistologicvariantsof
invasivebreastcarcinoma?

a.Thepresenceofaninsitucomponentwithinvasiveductalcarcinomaadverselyaffects
prognosis
b.Medullarycarcinomas,althoughoftenoflargesize,areassociatedwithabetteroverall
prognosisthancommoninvasiveductalcancers
c.Mucinousorcolloidcarcinomaisoneofthemorecommonvariantsofinvasiveductal
cancer 2 Tweet
d.Invasivelobularcarcinomaisassociatedwithahigherincidenceofbilateralbreast
cancer
Answer:b,d

Althoughthebreastiscomposedofbothlobularandductalelements,mostbreastcancer
arisesintheductalelements.Invasiveductalcarcinomaaccountsfor70%to80%ofall
casesofbreastcancer.Althoughthereisnosinglemicroscopicfeaturespecificfor
infiltratingductalcarcinoma,itcanberecognizedhistologicallyasaninvasive
adenocarcinomainvolvingductalelements.Themalignantductalcellsareoftendispersed
withinthefibrousstroma,leadingtotheappellationofscirrhouscarcinoma.Anumberof
lesscommontypesofbreastcancerarisefromtheductalepitheliumandarehence
classifiedasvariantsofinvasiveductalcarcinoma.Therearedistincthistologiccriteria
forclassifyingtheselesionsthesecriteriamustbemetthroughouttheentiretumor.
Prognostically,histologicallypureexamplesofthesevarianttumorsareassociatedwitha
betterlongtermsurvivalthanordinarytypeinvasiveductalcarcinoma.Whenmixed
histologiesareencountered,theclinicalbehaviorparallelsthatoftheinvasiveductal
element,nottheothersubtype.Hence,thesemixedtumorsareconsideredtogetherwith
pureinvasiveductalcarcinomaforprognosticpurposes.Inmanycases,whenareasofin
situductalcarcinomaareseen,thepresenceofaninsitucomponentdoesnotadversely
affectprognosis,althoughitjeopardizestheattemptsatbreastconservation.Medullary
carcinomaisoneofthemorecommonvariants,accountingforapproximately6%ofall
invasivebreastcancers.Thesetumorsmaygrowtobearatherlargesizewithinthe
breast(5to10cm)andarecharacteristicallywellcircumscribed.Mucinouscarcinoma,
alsoreferredascolloidcarcinoma,isencounteredin1%to2%ofbreastcancercases.
Invasivelobularcarcinomaarisesfromthelobularcomponentofthebreastandinmost
seriesaccountsforapproximately10%ofbreastcancers.Almosteveryserieshasstressed
thehigherincidenceofbilateralcancerinpatientswithinvasivelobularcarcinoma.The
contralateralbreastisinvolvedeithersynchronously(3%ofpatients)ormetachronously
inupto30%ofpatients.

29.Whichofthefollowingstatement(s)is/arecorrectconcerningcystosarcomaphyllodes?

a.Thetumorismostcommonlyseeninpostmenopausalwomen
b.Totalmastectomyisnecessaryforallpatientswiththisdiagnosis
c.Axillarylymphnodedissectionisnotnecessaryformalignantcystosarcomaphyllodes
d.Mostpatientswiththemalignantvariantofcystosarcomaphyllodesdieofmetastatic
disease
Answer:c

Cystosarcomaphyllodesisatumorarisinginthemesenchymaltissueofthebreast.The
tumorsusuallypresentasapainlessbreastmass.Phyllodestumorismostcommonly
encounteredinwomenage3040yearsofagebutcanoccuratanyage,evenbefore
puberty.Thedifferentiationofabenignfromamalignantphyllodestumormaybe
difficult.Aboutonefourthofallphyllodestumorsarehistologicallymalignant,butonlya
fractionofthesepatientsactuallydevelopmetastaticdisease.Theoptimumtreatmentfor
benignormalignantphyllodestumoriswideexcisionwithamarginofnormalbreast
tissue.Themarginmustbehistologicallyfreeofinvolvementbecauseevenbenignlesions
canrecurafterincompleteexcision.Ifthiscanbedoneleavinganadequatecosmetic
appearance,mastectomyisnotnecessary.Totalmastectomyisreservedforlargelesions
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insmallbreastedwomenorrecurrencesafterpreviouslocalexcisionthatisnotamenable
torepeatlocalexcision.Axillarylymphnodedissectionisnotperformedintheabsenceof
biopsyprovennodalinvolvement,evenformalignantphyllodestumors,becauseaxillary
metastasesareuncommon.

30.Whichofthefollowingstatement(s)is/aretrueconcerninglocalrecurrenceofbreast
cancer?

a.Thepercentageofpatientswithchestwallrecurrenceastheirinitialsiteoffailure
followingmastectomyissimilarfornodenegativeandnodepositivepatients
b.Mostpatientswithlocalregionalrecurrenceoftheirdiseasewilleventuallydieof
metastaticdisease
c.Thetreatmentoflocalrecurrencefollowingmastectomyincludeslocalradiation
therapyandsystemicchemotherapy
d.Inbreastrecurrencefollowingbreastconservingsurgeryisnotanegativeprognostic
factor
e.Regionallymphnoderecurrencefollowingaxillarynodedissectionisrare
Answer:a,b,c,e

Recurrenceinthechestwallaftermastectomyisominous.Inalargeseriesofpatients
treatedwithmastectomy,6.5%ofnodenegativeand8.8%ofnodepositivewomenhad
chestwallrecurrenceastheirinitialsiteoffailure.Bytenyearsafterlocalregional
recurrence,about60%ofinitiallynodenegativeandalmostall(>90%)ofinitiallynode
positivepatientshadevidenceofmetastaticdisease.Patientswithlocalrecurrence,who
havenothadpriorchestwallradiation,shouldreceiveradiationtherapy.Afullcourseof
atleast4500to5000cGyshouldbedeliveredtotheentirechestwall,withconsideration
giventoaboostdoseatanysitesofgrosstumor.Becausepostmastectomyrecurrenceis
oftenrapidlyfollowedbymetastaticdisease,itislogicaltopostulatearoleforadjuvant
systemictherapyoncelocalmeasureshaveachievedcontrolofchestwalldisease.
Recentdatasuggeststhatinbreastrecurrencefollowingbreastconservationisa
prognosticfactor.Womenwhodevelopaninbreastrecurrencehaveahigherlikelihood
ofdevelopingsystemicdiseasethandowomenwhoremaindiseasefreeintheirbreast.
Fewerthan3%ofpatientsdeveloprecurrenceofdiseaseintheaxillaafteraxillarynode
dissection.

31.Whichofthefollowingstatement(s)is/arecorrectconcerningprognosticfactorsfor
breastcarcinoma?

a.Prognosisisimprovedwithestrogenorprogesteronereceptorpositivity
b.Increasedthymidinelabelingindex,ameasureoftheproportionofcellsintheDNA
syntheticphase(Sphase),isassociatedwithimprovedsurvival
c.HightumorlevelsofcathepsinDareassociatedwithanimprovedprognosis
d.Immunohistochemicaldemonstrationofactiveangiogenesiscorrelateswithincreased
metastaticpotentialandpoorprognosis
Answer:a,d

32.Whichofthefollowingstatement(s)is/aretrueconcerningadjuvantsystemictherapy?
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a.Adjuvanttamoxifeninpostmenopausal,nodepositive,ERpositivewomenis
equivalenttocytotoxicchemotherapy
b.Tamoxifenclearlyimprovessurvivalinallhormonalreceptorpositivepatients
c.CMFisassociatedwithimprovedoverallsurvivalinbothpremenopausalandpost
menopausalnodepositivepatients
d.Thereisnoevidencetosuggestaroleforchemotherapyinnodenegativepatients
Answer:a

AdjuvanttamoxifenleadstoaprolongeddiseasefreeintervalinpostmenopausalER
positivewomenwithhistologicallypositivenodesandinpremenopausalandpost
menopausalERpositivewomenwithnegativenodes.Becauseofsimilarresultsand,
becausetamoxifenisgenerallylesstoxicthanchemotherapy,thistreatmentisthe
treatmentofchoiceforpostmenopausal,nodepositive,ERpositivewomen.CMF
(cyclophosphamide,methotrexate,and5fluorouracil)isassociatedwithbothalonger
diseasefreesurvivalandoverallsurvivaltimeinpremenopausalpatientswithpositive
lymphnodes.Inpostmenopausalwomenwithpositivenodes,thereisanimproved
diseasefreesurvival,butthereisnosignificantdifferenceinoverallsurvival.Several
trialsofadjuvantchemotherapywithCMForrelatedregimenshavebeenconductedin
nodenegativepatients.Theearlyresultsofallofthesetrialshavebeensimilar:disease
freesurvivalisdefinitelyimprovedwithadjuvantchemotherapy.Thesestudiesare
definitelynotmatureenoughtodrawdefinitiveconclusionsregardingoverallsurvival.
Therefore,theNationalCancerInstitutehasrecommendedtheuseofadjuvant
chemotherapyforallpatientswithtumorslargeenoughtohavehormonalreceptorlevels
measured.

33.Whichofthefollowingstatement(s)is/aretrueconcerningtissuesamplingtechniques
forbreastmasses?

a.Thesensitivityoffineneedleaspirationbiopsyissuchthatmastectomycanbe
performedinthecaseofmalignantdiagnosis
b.Theaccuracyofmammographicdirectedfineneedleaspirationbiopsyiscomparable
tothatachievedforthatofpalpablelesions
c.Coreneedlebiopsyshowingnormalbreasttissueisanacceptablediagnosis
d.Thetechniqueofcoreneedlebiopsyisnotapplicabletoradiographicallydetected
lesions
Answer:b

Whatevertissuesamplingmethodischosen,onlybiopsy(examinationofcellsortissue)
andnotphysicalexaminationormammographycanestablishadefinitivediagnosisand
avoiddelayintreatment.Fineneedleaspirationbiopsy(FNAB)permitsrapid,minimally
invasivediagnosisofmanypalpableandsomenonpalpable,radiologicallydetected
breastmasses.Thetechniqueisbothreliableandaccurate.Theincidenceoffalsepositive
findingsisgenerallylessthan0.5%.FNABisnot,however,sohighlyspecificthat
definitivesurgery(particularlymastectomy)shouldbeperformedwithoutprior
intraoperativefrozensectionconfirmationofthepresenceofcancer.Reportedsensitivity
ofFNABrangesfrom7%to99%with85%agoodestimateofthetruesensitivityin
clinicallyrelevantsettings.Recently,xrayguidedFNABhasbeenusedtoofferminimally
invasivediagnosisinnonpalpablebreastlesionsdetectedmammographically.The
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techniqueisquiteeffective,especiallyformasslesions.Accuracyiscomparabletothat
achievedwithFNABofpalpablelesions.Coreneedlebiopsyisahelpfultissuesampling
methodforpalpablemasses.Thetissueobtainedisusefulforhistologicanalysisalthough
inadequateforcytosolhormonereceptordetermination.Thetechniqueisalsoapplicable
byusingmammographicguidancefornonpalpablelesions.

34.A42yearoldwomanundergoesherfirstmammogram.Clusteredmicrocalcifications
areseenbutthereisnomasspalpable.Whichofthefollowingstatement(s)is/aretrue
concerningthispatientsdiagnosisandmanagement?

a.Aneedlelocalizationandexcisionofthemassisnecessarytoestablishthediagnosis
b.Frozensectionexaminationisparticularlyusefulinthediagnosisofthislesion
c.Intenseinterlobularfibrosisandproliferationofsmallductuleswithlossoforientation
oflobulesandepithelialcellsmaysuggestcarcinoma
d.Thisfindingisassociatedwithanincreasedriskofcancer
Answer:a,c

Sclerosingadenosisisahistologicsubtypeoffibrocysticchangethatisnotassociatedwith
anincreasedriskofcancerdevelopment.Itis,however,oneofthebenignbreastprocesses
mostlikelytobeconfusedradiologicallyandhistologicallywithcancer.Mostcommonly,
itisdetectedonroutinemammographyasclustermicrocalcificationswithoutan
associatedpalpablemass.Inthesecases,needlelocalizationandexcisionarerequiredto
establishadiagnosis.Sclerosingadenosismicroscopicallyischaracterizedbyinterlobular
fibrosisandproliferationofsmallductules.Ifthefibrouscomponentisparticularly
intense,theorientationoflobulesandepithelialcellsmaybelost,mimickingcarcinoma.
Differentiatingsclerosingadenosisfromcanceronfrozensectionexaminationcanbe
particularlydifficultandshouldnotbeattempted.

35.Whichofthefollowingconclusion(s)canbedrawnfromtheresultsoftheNSABP
prospectiverandomizedtrialscompletedinthe1970sand1980s?

a.Delayofaxillarynodedissectionuntilthereisclinicalevidenceofdiseasedoesnot
influenceoverallsurvival
b.Removalofclinicallynegativenodeshasnotherapeuticbenefit
c.Breastirradiationreducesbothlocalrecurrenceandoverallsurvival
d.Modifiedradicalmastectomyoffersnoadvantageoflumpectomywithaxillarynode
dissection
Answer:a,b,d

ThescientificbasisoflocalregionaltreatmentstrategiesforstageIandstageIIbreast
cancerwasestablishedbyaseriesofstudiesconductedduringthe1970sand1980sby
theNSABP.Inthefirstoftheseprotocols,totalmastectomywithdelayednodedissection
onlyfornodesthatsubsequentlyturnedpositive,totalmastectomywithlocalregional
radiationtherapy,andradicalmastectomywereclinicallyequivalent.Furthermore,the
findingthatdelayofaxillarynodedissectionuntilthereisclinicalevidenceofdiseasedoes
notinfluencesurvivalemphasizesthattheroleofaxillarydissectioninclinicallynode
negativepatientsissolelyforstaging.Theremovalofclinicallynegativenodeshasno
therapeuticbenefitifregionalrecurrencesaredetectedandtreatedpromptly.Inthe
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secondoftheseprotocols,modifiedradicalmastectomy,lumpectomywithaxillarynode
dissection,andlumpectomy,axillarynodedissection,andbreastorirradiationwere
comparedinsmallbreastcancers.Modifiedradicalmastectomyofferednoadvantage
overothertreatmentswhenanalyzedbydiseasefreeoroverallsurvivalineithernode
negativeornodepositivepatients.Breastirradiationafterlumpectomyreducedthe
likelihoodofinbreasttumorrecurrencefrom39%to10%butdidnotaffectoverall
survivalwhencomparedwithlumpectomyalone.

36.Whichofthefollowingstatement(s)is/aretrueconcerningnoninvasivebreast
carcinoma?

a.Ductalcarcinomainsitu(DCIS)isassociatedwithasignificantriskofdevelopmentof
invasiveductalcarcinomainthesamequadrantofthesamebreastastheinitiallesion
b.DCISshouldnotbetreatedwithbreastconservationtherapy
c.Lobularcarcinomainsitu(LCIS)isthemostcommonformofnoninvasivebreast
cancer
d.WhenLCISisfound,thereisanupto50%chanceoflobularcarcinomainsituofthe
contralateralbreast
e.AboutonethirdofpatientswithbiopsyprovenLCISdevelopinvasivecancer,always
ofthesamebreast
Answer:a,d

Noninvasive(insitu)cancerisdefinedasaneoplasticentitywithintheepitheliumof
originandwithoutinvasiontothebasementmembrane.Ductalcarcinomainsitu(DCIS)
arisesfromtheductularelements.TheagedistributionofDCISdoesnotdiffer
significantlyfromthatofinvasiveductalcarcinoma.Noteverywomanwhoundergoes
completeexcisionofafocusDCISdevelopsinvasiveductalcancer.Variousstudiessuggest
halformorepatientsdevelopinvasivebreastcancerafterexcisionalbiopsyalone.Whena
subsequentinvasivecancerdoesoccur,itisalmostalwaysoftheinvasiveductaltypeand
locatedinthesamequadrantofthebreastastheinitialDCIS.Thelatentperiodbefore
thedevelopmentofinvasivecancerusuallyexceedsfiveyears.Totalmastectomyisusually
associatedwithanearly100%curerateforthiscondition.Althoughtotalmastectomy
remainsthegoldstandardfortreatmentofDCIS,thereisincreasingexperiencewith
breastconservingtherapy.BreastconservationmaybeofferedtoDCISpatientsinwhom
theentiretumorcanbesurgicallyremovedwithnegativehistologicmarginsandinwhom
theremainingbreasttissuecanbereliablyassessedclinicallyandradiographically.It
wouldappearthatthediseasefreesurvivalfollowinglumpectomyandradiationtherapy
isworsethanthatachievablewithsimplemastectomy.Therefore,breastconservationfor
DCIScommitspatientstomorecarefullongtermfollowupandwilllikelysubjectthem
toadditionalsubsequenttreatmenttodealwiththerecurrences.Lobularcarcinomain
situ(LCIS)accountsforonethirdofthenoninvasivebreastcancers.LCISpatientsare
significantlyyoungerthanpatientswithinvasivebreastcancer.Threefourthsofaffected
womenarepremenopausal.LCISisaninfrequentfindinginwomenover75.Whenthe
oppositebreastissampledatthetimeofdiagnosis,contralateralLCISisfoundin30
50%ofcases.TheprognosisofLCISissolelyrelatedtothesubsequentdevelopmentof
invasivecarcinoma.AboutonethirdofpatientswithbiopsydemonstratedLCISdevelop
invasivecancerhalfoccurintheindexbreastandhalfinthecontralateralbreast.The
subsequentbreastcancerscanbeeitherlobularorductalinhistology.
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37.A33yearoldwomanisreferredwithnippledischarge.Whichofthefollowing
statement(s)is/aretrueconcerningherdiagnosisandmanagement?

a.Bilateralgalactorrheaissuggestiveofanunderlyingendocrinopathy
b.Brownishdischargeisusuallysuggestiveofoldbloodandisworrisomeforan
underlyingbreastcancer
c.Expressiblebloodynippledischargeshouldbeevaluatedwithaductogram
d.Milkybreastdischargewouldnotbeexpectedoneyearafterdiscontinuationofbreast
feeding
Answer:a,c

Atonetimeoranother,manywomennoticeanippledischarge.Themostcommon
physiologicbasisfornippledischargeislactation.Milkmaycontinuetobesecreted
intermittentlyforaslongastwoyearsafterbreastfeedinghasstopped,particularlywith
breaststimulation.Amilkywhitishdischarge,usuallybilateral,thatisnotrelatedto
lactationorbreaststimulationistermedgalactorrhea.Thepresenceofbilateral
galactorrheashouldpromptanevaluationforunderlyingendocrinopathycausing
increasedprolactinsecretionbythepituitary.Classically,thisisassociatedwith
amenorrhea,butgalactorrheamaybetheonlysignofhypoprolactinemia.Nipple
dischargesassociatedwithfibrocysticdiseasearegenerally,green,yellow,orbrown,
Intraductalpapillomasandcancerleadtoabloodyorbloodtingedserousdischarge.The
brownishdischargeoffibrocysticdiseasecaneasilybeconfusedwitholdblood.Aguaiac
testorsimplydabbingthedischargewithagauzepadandexaminingthestaincan
usuallydifferentiatethetwo.Abloodyorbloodtingeddischargemustbepromptly
evaluatedtoexcludecarcinoma.Ifthedischargeisexpressibleatthetimethepatientis
seen,acontrastductogrammaybeobtained.

38.Clinicalfeaturesofbreastcancerwhichareassociatedwithaparticularlypoor
prognosisinclude:

a.Edemaoftheskinofthebreast
b.Skinulceration
c.Lateralarmedema
d.Dermallymphaticinvasion
Answer:a,b,c,d

Thehistologichallmarkofinflammatorybreastcancerisdermallymphaticinvasion
demonstrableonskinbiopsy.Thestigmataofthisclinicalsyndromeincludebreast
warmth,tenderness,erythema,andedema.

39.Whichofthefollowingstatement(s)is/areassociatedwithgynecomastia?

a.Ifthediseaseisunilateral,itisunlikelydrugrelated
b.Thestandardsurgicaltreatmentissubcutaneousmastectomy
c.Thepresenceofgynecomastiaisoftenassociatedwiththesubsequentdevelopmentof
breastcancer
d.Aformalendocrineevaluationisindicatedinmostpatientswithgynecomastia
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Answer:b

Gynecomastiaisdefinedaspalpableenlargementofthemalebreast.Pathologiccausesof
estrogenexcessortestosteronedeficiencyareassociatedwithgynecomastia.Inmany
cases,nocauseisfound.Clinicallysignificantgynecomastiahasbeenassociatedwiththe
useofanumberordrugsincludingcimetidine,digoxin,spironolactoneandtricyclic
antidepressants.Theuseofmarijuanahasalsobeenassociatedwithgynecomastia.Drug
relatedgynecomastiaisoftenunilateralorunequalbetweenthetwobreasts,and
discontinuationoftheoffendingdrugdoesnotalwaysleadtoresolutionofthecondition.
Aformalendocrineevaluationisnotindicatedforgynecomastiaunlesssomeothersignof
hormonalimbalanceisfoundonroutineevaluation.Thestandardsurgicaltreatmentof
gynecomastiaconsistsofsubcutaneousmastectomyperformedunderlocalanesthesia.
Thepresenceofgynecomastiaisnotassociatedwiththesubsequentdevelopmentof
cancer,yetprotractedhyperestrogenemicstates,whichareassociatedwithgynecomastia
arelinkedtobreastcancerdevelopment

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