A 52-year-old woman has felt a lump in her breast for the past 2 months.

On physical examination a firm

2 to 3 cm mass is palpable in the upper outer quadrant of her right breast. There are no palpable axillary
nodes. A lumpectomy with axillary node dissection is performed. The breast lesion is found to have
positive immunohistochemical staining for HER2/neu (c-erb B2). Staining for estrogen and progesterone
receptors is negative. Which of the following treatment options is most likely to be efficacious in this
woman?
A Letrozole
B Tamoxifen
C Trastuzumab
D Prednisone
E Doxorubicin
(A) Incorrect. Letrozole is an aromatase inhibitor that may be useful when the estrogen receptor assay is
positive.
(B) Incorrect. Tamoxifen is most useful with estrogen receptor positive carcinomas of the breast.
(C) CORRECT. This is an infiltrating ductal carcinoma. The lack of ER staining suggests a poor response
to hormonal therapy with tamoxifen or letrozole. The positive C-erb B2 (HER2/neu) staining suggests that
the monoclonal antibody traztuzumab may be effective. Radical mastectomies are rarely performed.
(D) Incorrect. Prednisone is a corticosteroid that may make the patient feel better for a short time, but has
no significant anti-cancer effect.
(E) Incorrect. Doxorubicin is a chemotherapy agent that may be part of regimens used to treat
carcinomas, but its efficacy is not predicted by HER2 status. Some ER+ carcinomas may do worse with
doxorubicin.

Question 2
A 47-year-old woman undergoes routine mammographic screening and there are multiple small areas of
increased density, though a single distinctive mass lesion is not detectable either by palpation or by
mammography. A fine needle aspiration biopsy of an abnormal density reveals cells suspicious for a
malignancy. An excisional breast biopsy yields a diagnosis of lobular carcinoma in situ of the breast.
Which of the following is the most likely finding associated with this woman's carcinoma?
A No residual carcinoma
B Opposite breast involvement
C Absent family history of breast cancer
D Concomitant Paget disease of the nipple
E Negative estrogen receptor assay
(A) Incorrect. With multiple densities, a simple excision of one of them is likely not curative. Lobular
carcinoma in situ (LCIS) may not be localized to a single focus, and the opposite breast may also be
involved.
(B) CORRECT. Bilaterality is a frequent characteristic of lobular carcinoma in situ (LCIS). The prognosis
is still good, but more surgery may be needed.
(C) Incorrect. Breast cancer, including LCIS, is more likely to occur with a family history.
(D) Incorrect. Paget disease of the nipple is most often associated with an underlying ductal carcinoma.
(E) Incorrect. Most breast cancers are estrogen receptor positive, particularly the better differentiated and
in situ carcinomas.

A 15-year-old healthy girl of normal height and weight for age is concerned because her right breast has
developed to twice the size of her left breast since the onset of puberty at age 12. On physical
examination both breasts have a similar consistency on palpation, with no lumps, and there is no
tenderness. The nipples and areolae appear normally formed. Which of the following is the most likely
cause for these findings?
A Cystosarcoma phyllodes
B Adrenogenital syndrome
C Virginal hypertrophy
D Fibrocystic changes
E Ductal carcinoma in situ
(A) Incorrect. Phyllodes tumors are large bulky tumors that typically does not appear in persons this
young.
(B) Incorrect. Any syndrome of hormone excess from any source would affect both breasts.
(C) CORRECT. Virginal hypertrophy, or rapid enlargement of one or both breasts following puberty, is a
problem that can be easily remedied with plastic surgery, and tamoxifen therapy may reduce recurrence.
As breasts are enlarging following puberty, there is often some unequal growth, but eventually an equal
size is reached by the end of puberty.
(D) Incorrect. Fibrocystic changes are usually seen later and produce palpable breast 'lumps' but not
significant breast enlargement.
(E) Incorrect. Breast carcinomas are uncommon below age 25 and do not typically produce significant
breast enlargement.

A 20-year-old woman notes a mass in her left breast after following the directions for breast self-
examination provided by her health clinic. Her physician palpates a firm, 1 to 2 cm mass. There is no
nipple discharge and no pain. No axillary adenopathy is present. The overlying skin of the breast appears
normal. Her left breast is slightly larger than the right, a condition she says has been present since
puberty. Her urine pregnancy test is negative. Mammography confirms the presence of a rounded
density, which has no microcalcifications, and reveals no lesions of the opposite breast. Which of the
following is the most likely diagnosis?
A Focus of fat necrosis
B Fibroadenoma
C Intraductal papilloma
D Infiltrating ductal carcinoma
E Phyllodes tumor
(A) Incorrect. Fat necrosis follows trauma to the breast, and though producing a mass lesion, it is not
discrete, and may mimic carcinoma.
(B) CORRECT. At her age, such a firm small movable mass is most likely to be a benign lesion, and a
fibroadenoma is the most likely cause for this small 'lump' in the breast. Cancers are not common at this
age.
(C) Incorrect. Large duct papillomas are not common. They tend to be subareolar, and they tend to be
associated with bloody nipple discharge.
(D) Incorrect. A carcinoma would not be expected to be discrete, and age 25 is quite young for
carcinoma.
(E) Incorrect. A phyllodes tumor is typically a large mass. It is far less common than fibroadenoma.

A 19-year-old woman gave birth to a healthy male infant at term following an uncomplicated pregnancy.
She has now been breast feeding the baby for a month, but notes that her left breast has gradually
become swollen and painful to touch over the past week. On physical examination her temperature is
38.2C. Which of the following is the most likely diagnosis?
A Acute mastitis
B Fibrocystic disease
C Fat necrosis
D Intraductal papilloma
E Galactocele
(A) CORRECT. The causative organism is most often Staphylococcus aureus or Streptococcus. Antibiotic
therapy is usually successful.
(B) Incorrect. Fibrocystic changes lead to breast lumps but not to acute inflammation.
(C) Incorrect. Fat necrosis is typically the result of trauma and may produce a palpable mass lesion, but
not acute inflammatory changes.
(D) Incorrect. An intraductal papilloma may produce a bloody nipple discharge, but not acute
inflammation.
(E) Incorrect. A galactocele could arise with lactation, but acute inflammation is not part of the picture.

A 35-year-old woman has noted a palpably firm, irregular mass in her right breast for the past 3 months.
On physical examination there is no tenderness or swelling. By mammography there is an irregular 2 cm
density that contains scattered microcalcifications. Biopsy of this mass reveals extensive fat necrosis.
Which of the following is the most likely cause for this breast lesion?
A Pregnancy
B Prolactinoma
C Trauma
D Fibrocystic changes
E Lobular carcinoma in situ
F Mastitis
(A) Incorrect. Pregnancy is associated with lactational changes, but fat necrosis is not part of this
process.
(B) Incorrect. Galactorrhea may complicate a pituitary adenoma secreting prolactin.
(C) CORRECT. Trauma leads to fat necrosis. This lesion can sometimes mimic a carcinoma on physical
examination and on the grossly excised breast tissue.
(D) Incorrect. Fibrocystic changes may include cysts, duct enlargement, and fibrous thickening, but
necrosis is not part of this process.
(E) Incorrect. LCIS may not be palpable, or produce subtle irregular densities, because the foci are small,
and necrosis is typically not part of the process.
(F) Incorrect. Mastitis is more likely to present as a more diffuse process, associated with pain and
tenderness. Often mastitis is associated with breast feeding.

A study of postpartum women is performed. Some of them developed a palpable 'lump' in one or both
breasts postpartum. The lump appeared following cessation of breast feeding and persisted for more than
one month, Many of these lumps regressed following fine needle aspiration. Which of the following breast
lesions is most likely to fulfill these criteria?
A Papilloma
B Fat necrosis
C Galactocele
D Ductal epithelial hyperplasia
E Sclerosing adenosis
(A) Incorrect. Papillomas are solid masses, not related to pregnancy. They may be associated with a
nipple discharge, but the fluid may be bloody and not resemble milk.
(B) Incorrect. Fat necrosis is typically produced by trauma to the breast. The lesion is solid.
(C) CORRECT. Galactocele occurs secondary to obstruction of lactiferous ducts. It is a non-neoplastic
process. Following cessation of lactation milk may be retained and produce a cystic lesion. Aspiration of
the cyst removes the fluid and the cyst collapses. The cyst is lined by cuboidal to flat epithelium. The cyst
contents often appear milky, but microscopically contain inflammatory cells and/or necrotic debris.
Extravasation of the milk may produce chronic inflammation and even fat necrosis.
(D) Incorrect. There is lobular hyperplasia post-partum, but the epithelium of ducts does not proliferate to
a great degree. Any physiologic hyperplasia will be uniform throughout the breast, not producing a local
mass.
(E) Incorrect. Sclerosing adenosis is part of fibrocystic changes of the breast. Any cystic changes are
microscopic, and the process is often found on examination or by radiologic imaging as irregular
densities.

A 49-year-old woman notes increasing size to her right breast over the past year. This breast is not
painful, but the heaviness causes some discomfort. On physical examination the overlying skin and nipple
appear normal. There is no nipple discharge. There is no axillary lymphadenopathy. Mammography
reveals a solid 12-cm circumscribed mass. The mass is biopsied, and on microscopic examination shows
a cellular stromal component along with an epithelial component. Which of the following is the most likely
diagnosis?
A Fibroadenoma
B Phyllodes tumor
C Sclerosing adenosis
D Hamartoma
E Medullary carcinoma
(A) Incorrect. Fibroadenomas have a stromal and epithelial component, but are not highly cellular, and
they are usually small.
(B) CORRECT. Phyllodes tumors are much less common than fibroadenomas, but they can be quite
large. The stromal component of a phyllodes tumor is more cellular than a fibroadenoma, and it may
show atypia or frank malignancy.
(C) Incorrect. Sclerosing adenosis is part of fibrocystic changes and does not form a large mass, though it
may produce a palpable lump or a radiologic imaging density.
(D) Incorrect. A hamartoma is a solid mass lesion that is quite rare in the breast.
(E) Incorrect. Medullary carcinomas can be bulky tumors, but there is no stromal component.

A 46-year-old woman has a silicone breast implant placed following a left mastectomy for treatment of an
infiltrating ductal carcinoma. She is advised of potential complications, including leakage of the silicone
breast implant. Which of the following is most likely to be caused by breast implant leakage?
A Phyllodes tumor
B Scleroderma
C Breast abscess
D Infiltrating ductal carcinoma
E Contracture
(A) Incorrect. This is a rare tumor and is not associated with breast implants.
(B) Incorrect. There is no convincing evidence that immunologic disease results from breast implants.
(C) Incorrect. The implant within the breast is unlikely to become infected, ruptured or not.
(D) Incorrect. Women with breast implants actually have a lower rate of carcinoma of the breast. In
women who have had breast cancer, the risk of recurrence is not increased.
(E) CORRECT. Pain and contracture with cosmetic deformity are the major complications of leaking
breast implants.

A 52-year-old woman feels a lump in her right breast on self-examination and goes to her physician. On
physical examination the 4 cm mass is not freely movable and feels quite hard. A fine needle aspirate is
performed and cytologic examination shows cells are present consistent with carcinoma. Which of the
following features of this carcinoma is most likely to suggest a worse prognosis?
A Estrogen receptor positivity
B Family history of breast carcinoma
C Presence of an in-situ component
D Axillary lymph node metastases
E Lack of aneuploidy
(A) Incorrect. An ER postitive tumor has a better prognosis because it will respond to certain hormonal
therapies.
(B) Incorrect. A family history makes breast cancer more likely, but does not predict prognosis.
(C) Incorrect. In situ lesions are the lowest stage possible for a carcinoma.
(D) CORRECT. Invasion of lymphatics is a poor prognostic sign, because it suggests that the carcinoma
is spreading.
(E) Incorrect. Aneuploidy diagnosed with flow cytometry suggests a worse prognosis.

A 45-year-old woman feels a 'lump' in her left breast. Her physician palpates a 2 cm irregular area in the
upper outer quadrant. A biopsy is performed and microscopic examination shows no evidence for
carcinoma. Which of the following microscopic findings in this biopsy is most likely to suggest an
increased risk for subsequent development of breast carcinoma?
A Atypical hyperplasia
B Sclerosing adenosis
C Apocrine metaplasia
D Galactocele
E Multiple cysts
(A) CORRECT. Particularly when atypical microscopic features are present, lobular or ductal hyperplasia
is the component of fibrocystic disease that is associated with subsequent increased risk for development
of carcinoma, probably about a 5 fold risk.
(B) Incorrect. This component of fibrocystic disease has about a 2 fold increased risk for breast cancer.
(C) Incorrect. This lesion may be part of fibrocystic changes, but it does not predispose to carcinoma.
(D) Incorrect. This is a complication of obstruction to lactiferous sinuses during lactation. It may rarely
occur with oral contraceptive use. It is not premalignant.
(E) Incorrect. Simple cysts with fibrocystic disease are not associated with an increased risk for
carcinoma.

A 20-year-old woman gives birth to a term girl infant following an uncomplicated pregnancy. She breast
feeds the infant. Six weeks later, her left breast becomes painful and slightly swollen. On physical
examination there is a tender 3 cm mass in the left breast beneath a nipple that shows several painful
fissures. Which of the following pathologic findings is most likely to be present in this breast?
A Infiltrating ductal carcinoma
B Plasma cell infiltrate
C Sclerosing adenosis
D Staphylococcus aureus infection
E Fat necrosis
(A) Incorrect. Ductal carcinomas are ill-defined masses that are usually not tender. They are extremely
rare before age 25.
(B) Incorrect. A 'plasma cell mastitis' is the result of inspissated duct secretions and is most often seen in
women in their 40's and 50's.
(C) Incorrect. This is a part of fibrocystic disease, which may have a cystic mass that may be tender, but
not nipple fissuring.
(D) CORRECT. A breast abscess is present. These are most common in the postpartum period when the
nipple becomes cracked or fissured with nursing.
(E) Incorrect. Fat necrosis is usually due to trauma and leads to an ill-defined mass.

Question 13
A 25-year-old woman palpates a left breast 'lump' on self-examination. Her nurse practitioner palpates an
ill-defined mass. There is no pain or tenderness. No axillary lymphadenopathy is noted. Fine needle
aspiration is performed and cytologic examination shows cells that appear benign. The lesion persists,
and 6 months later another biopsy is taken and shows ductal epithelial proliferation with ductal apocrine
metaplasia, stromal fibrosis, and sclerosing adenosis. Which of the following is the most likely diagnosis?
A Infiltrating ductal carcinoma
B Ductal carcinoma in situ
C Lobular carcinoma in situ
D Fibrocystic changes
E Intraductal papilloma
(A) Incorrect. Carcinomas have abnormal cells, not just proliferation of cells.
(B) Incorrect. Ductal carcinoma in situ is marked by highly atypical, disorganized cells within ductal
lumens.
(C) Incorrect. Lobular carcinoma in situ is marked by highly atypical cells filling and expanding lobules.
(D) CORRECT. Fibrocystic changes are very common and benign, but can produce a mass effect and
must be distinguished from breast cancer.
(E) Incorrect. An intraductal papilloma is a focal lesion with both epithelial and stromal proliferation in a
papillary pattern.

Question 14
A 39-year-old woman has noted red, scaling area on her breast for 3 months. On physical examination
there is an eczematous 1 cm diameter area on the skin of the right breast areola. There is no palpable
lump in this breast. Biopsy of the skin lesion is performed and on microscopic examination shows large
cells at the dermal-epidermal junction that stain positively for mucin. Which of the following is the most
likely diagnosis?
A Nipple discharge
B Paget disease of breast
C Intraductal carcinoma
D Dermatophyte infection
E Inflammatory carcinoma
F Eczematous dermatitis
(A) Incorrect. Discharges are more likely with intraductal papillomas, and they do not lead to the
appearance of malignant cells at the dermal-epidermal junction.
(B) CORRECT. Paget disease of the breast is a skin lesion that appears grossly eczematous, but
microscopically shows the presence of malignant cells. There is typically an underlying carcinoma that
may be hard to locate.
(C) Incorrect. Such a lesion should be within the breast and not involve overlying skin.
(D) Incorrect. Skin infections may produce erythematous lesions, but without malignant cells present.
(E) Incorrect. An 'inflammatory carcinoma' is not a histologic type of breast cancer, but a term that
describes dermal lymphatic involvement by breast cancer. In this case, the malignant cells are not in
lymphatics.
(F) Incorrect. A rough, red, scaling patch of skin can be termed eczema, but should not contain malignant
cells staining for mucin.

Question 15
A 39-year-old woman has noted a bloody nipple discharge from the right breast for the past 5 weeks. On
physical examination there is no palpable mass or tenderness. The skin of this breast shows no lesions.
A small amount of bloody fluid can be expressed from the right nipple. Which of the following is the most
likely diagnosis?
A Mastitis
B Intraductal papilloma
C Trauma
D Infiltrating ductal carcinoma
E Tuberculosis
F Fibrocystic changes
(A) Incorrect. The inflammation with mastitis does not usually erode breast tissue and cause bleeding.
(B) CORRECT. This solitary lesion of a lactiferous sinus is not common, but you should suspect it when
there is a bloody discharge. This lesion is not premalignant.
(C) Incorrect. Fat necrosis leads to scarring and hemorrhage is not common (at least, hemorrhage into
the lactiferous sinuses is not common).
(D) Incorrect. The slowly infiltrative growth of ductal cancers leads to scarring, not hemorrhage.
(E) Incorrect. Mycobacterial infections involving the breast are quite rare.
(F) Incorrect. Fibrocystic changes are not likely to be accompanied by hemorrhage.

Question 16
A 61-year-old woman has noted a rough, reddened appearance increasing in size over the skin of her
right breast for the past 5 months. This persists despite application of a corticosteroid cream. On physical
examination the skin over the right breast is indurated, roughened, and reddish-orange. There is nipple
retraction. A firm, irregular 5 cm mass is palpable in this breast. Which of the following is the most likely
risk factor for this woman's condition?
A Cigarette smoking
B Prior fibrocystic disease
C Multiparity
D Family history
E Human papillomavirus infection
(A) Incorrect. Smoking increases the risk for lung cancers, urinary tract cancers, and pancreatic
carcinomas. However, there is no link to breast cancers.
(B) Incorrect. Fibrocystic changes in the breast are not a significant risk factor for subsequent
development of breast cancer, unless there is some epithelial atypia present.
(C) Incorrect. Multiparity tends to reduce the overall risk for breast cancer.
(D) CORRECT. A The findings point to breast carcinoma with invasion of the overlying skin ('inflammatory
carcinoma'). A family history of breast cancer increases the risk for breast cancer the most.
(E) Incorrect. HPV infections increase the risk for squamous epithelial dysplasias and carcinomas in the
female genital tract, not the breast.

Question 17
A 41-year-old woman has felt a large breast lump that has increased slowly in size for the past 3 years.
On physical examination there is a 9 cm firm, movable mass present in her left breast. The overlying skin
appears normal; there is no axillary lymphadenopathy. The mass is excised and grossly appears soft and
fleshy. On microscopic examination this mass has a lymphoid stroma with little fibrosis surrounding
sheets of large vesicular cells with frequent mitoses. Which of the following is the most likely diagnosis?
A Infiltrating ductal carcinoma
B Colloid carcinoma
C Medullary carcinoma
D Lobular carcinoma
E Phyllodes tumor
F Diffuse large B cell lymphoma

(A) Incorrect. A ductal carcinoma is unlikely to reach this size, is irregular in shape, and it does not have a
lymphoid stroma. It often has pronounced desmoplasia.
(B) Incorrect. Colloid carcinomas produce abundant mucin. They are often well circumscribed.
(C) CORRECT. Medullary carcinoma is often bulky, with pushing margins. It lacks the desmoplasia typical
of ductal carcinomas. It accounts for only about 1% of breast cancers.
(D) Incorrect. Lobular carcinomas do not form a large mass and are poorly circumscribed. They are
bilateral about 20% of the time. They make up only 5 to 10% of breast cancers.
(E) Incorrect. This tumor can become quite large, but is composed of both epithelial and stromal
components, either or both of which may be malignant.
(F) Incorrect. Non-Hodgkin lymphoma involving the breast is not common. Lymphomas do not have a
malignant epithelial component.

Question 18
A clinical study is performed involving subjects who are women ranging in age from 15 to 45 years who
palpated breast 'lumps' on self-examination. The presence of breast mass lesions in these subjects was
subsequently confirmed by physical examination and by mammography. All subjects had a needle biopsy
or excision of their lesion performed, with a definitive pathologic diagnosis made. Which of the following
diagnoses is likely to be the most frequently made in these subjects?
A Abscess
B Fibroadenoma
C Fibrocystic changes
D Lobular carcinoma in situ
E Infiltrating ductal carcinoma
(A) Incorrect. Abscesses are uncommon, though some may arise as complications in women who nurse
their babies and develop fissures in the nipple.
(B) Incorrect. These represent about 1 in 13 lumps, but they are more prominent in younger women of
reproductive years.
(C) CORRECT. About 40% of breast lumps turn out to be caused by fibrocystic changes.
(D) Incorrect. Lobular CIS is uncommon.
(E) Incorrect. Overall, carcinomas represent about 10% of breast lumps, but it is very important to find
them.
Question 19
A 61-year-old woman has increasing dyspnea with chest pain for the past 4 months. On physical
examination there is dullness to percussion over both lungs. A chest x-ray shows bilateral pleural
effusions. A thoracentesis yields bloody fluid that cytologically contains small malignant cells forming long
rows or rings. A mammogram shows an irregular area of architectural disortion in her left breast. Which of
the following histologic types of breast cancer is most likely to be present in this woman?
A Lobular
B Ductal
C Medullary
D Tubular
E Papillary
(A) CORRECT. Invasive lobular carcinomas are most likely to metastasize widely to surfaces: pleural,
peritoneal, meningeal. They also may metastasize to femal genital tract and gastrointestinal tract. The
cells have minimal associated desmoplasia, so a palpable mass may not be present.
(B) Incorrect. Ductal carcinomas are more likely to produce a palpable mass and to metastasize first to
axillary nodes.
(C) Incorrect. Medullary carcinomas tend to form a bulky mass; there is often an accompanying
lymphoplasmacytic component.
(D) Incorrect. Tubular carcinomas form - well - tubules, and tend to be well-differentiated and less
aggressive.
(E) Incorrect. Papillary carcinomas are rare; they form papillations; overall they are less aggressive breast
cancers.

Question 20
A 30-year-old woman has felt a mass in her right breast for 6 months. On physical examination there is a
5 cm right breast mass and firm, non-tender lymphadenopathy. A fine needle aspiration is performed and
cytologic examination shows carcinoma cells. A right mastectomy with axillary lymph node dissection is
performed. Microscopic examination shows a poorly differentiated carcinoma that is negative for estrogen
and progesterone receptors and negative for HER2/neu. One axillary lymph node demonstrates
micrometastases. Her 32 year old sister is found to have a similar lesion. Which of the following is the
most likely risk factor for this woman's breast cancer?
A BRCA1 mutation
B Late menarche
C Positive antinuclear antibody test
D Exposure to hydrocarbon compounds
E Prior fibrocystic changes
(A) CORRECT. A small number of breast cancers are the result of an inherited BRCA1 mutation (or
BRCA-2), but the family history of breast cancer at a young age makes this more likely. The 'triple
negative' breast cancers (ER, PR, HER2 negative) are harder to treat.
(B) Incorrect. Early menarche and late menopause and nulliparity are risks for breast cancer.
(C) Incorrect. Autoimmune diseases do not appreciably increase the risk for breast cancer.
(D) Incorrect. Breast cancers are not typically thought to be related to environmental exposures.
(E) Incorrect. Fibrocystic changes do not substantially increase the risk for breast cancer. Atypical
epithelial hyperplasia would increase the risk.

Question 21
A 45-year-old woman has noted a mass in her right breast for 7 months. On physical examination there is
a 5 cm diameter right breast mass. A biopsy of the mass is performed and on microscopic examination a
carcinoma is present. Which of the following pathologic findings involving this lesion suggests a better
prognosis for this woman?
A Estrogen receptor negative
B Axillary lymph node metastasis
C Age at diagnosis
D Aneuploidy by flow cytometry
E Intraductal histologic pattern
(A) Incorrect. The presence of estrogen receptors suggests better differentiation and better response to
hormonal manipulation.
(B) Incorrect. Axillary lymph node metastasis is the single most important prognostic factor for patients
with early breast carcinoma. Metastases imply a worse prognosis.
(C) Incorrect. Breast cancers occur over a wide age range, and prognosis depends more upon the type of
cancer, stage, and molecular markers.
(D) Incorrect. Aneuploidy suggests a more aggressive neoplasm and a worse prognosis.
(E) CORRECT. The best overall survival is with intraductal carcinomas (those that have not invaded out
from the ducts); this is the lowest stage possible.

Question 22
A 51-year-old healthy man has noted bilaterally enlarged breasts for the past 35 years. On physical
examination his breasts are 3 times normal size, with no masses present, no tenderness, and no axillary
lymphadenopathy. Which of the following conditions is most likely to be associated with his breast
enlargement?
A Antidepressant drug therapy
B 47, XXY karyotype
C Family history
D Seminoma of the testis
E Increased testosterone levels
(A) Incorrect. Chronic alcoholism may lead to gynecomastia. Digoxin therapy may have this complication.
(B) CORRECT. Gynecomastia is common with Klinefelter syndrome. It is a benign condition with no risk
for cancer.
(C) Incorrect. He has a benign process. Male breast carcinomas can be associated with BRCA mutations.
Male breast cancers are not common, and they more often associated with advanced age.
(D) Incorrect. There is an association between gynecomastia and some functioning testicular tumors such
as Leydig cell tumors (or rarely, Sertoli cell tumors).
(E) Incorrect. Gynecomastia is related to hyperestrinism, and one of the most common causes for this is
cirrhosis of the liver in chronic alcoholics.

Question 23
A study of breast carcinomas is conducted. Some of these carcinomas are found to be 'triple negative' for
estrogen receptor, progesterone receptor, and HER2. Which of the following microscopic findings is most
characteristic for these triple negative breast carcinomas?
A Inflammatory component
B Multifocality
C High grade
D Tubular growth pattern
E Desmoplasia
(A) Incorrect. A reactive inflammatory process around the cancer does not predict prognosis. A lymphoid
stroma may be a characteristic of medullary carcinomas, but does not correlate with marker status.
Multiple breast cancer types may spread via lymphatics including dermal lymphatics as an 'inflammatory'
carcinoma.
(B) Incorrect. Some cancers, such as lobular carcinomas, may be more often multifocal, but that does not
correlate with marker status.
(C) CORRECT. Triple negative breast cancers are typically high-grade, agressive cancers that tend to
recur quickly and spread to visceral sites. Treatment is a challenge, because targeted hormonal therapies
or biotherapies do not work well.
(D) Incorrect. Some breast cancers have a tubular pattern, and they tend to act in a less aggressive
manner.
(E) Incorrect. Desmoplasia, or production of a prominent collagenous stroma, is found in many invasive
breast cancers, and imparts their firm and fixed features palpable on examination. Desmoplasia does not
correlate with marker status.

Question 24
A 49-year-old woman goes to her physician for a routine health maintenance examination. A screening
mammogram is performed and shows a 3 cm irregular density in her left breast that has
microcalcifications. A needle biopsy of this area shows ducts containing solid sheets of malignant cells,
with central necrosis and calcification. There is no invasion. A lumpectomy with wide excision to clear
margins is performed along with axillary lymph node sampling that shows no metastases. Malignant cells
are positive for HER2 but negative for estrogen receptor. Which of the following is the most likely
outcome for this woman?
A Recurrence in the opposite breast
B Cure with no further therapy
C Response to therapy with tamoxifen
D Development of inflammatory carcinoma
E Her children will inherit a BRCA1 mutation
(A) Incorrect. Appearance in the opposite breast is a feature of lobular carcinomas.
(B) CORRECT. She has a ductal carcinoma in situ (DCIS). Since it is non-invasive at the time of
diagnosis, it has a good prognosis. Some will recur locally. If left alone, DCIS will often progress to
become an invasive carcinoma.
(C) Incorrect. The lack of estrogen receptor positivity in the tumor cells predicts a poor response to
hormonal therapy with tamoxifen or letrozole.
(D) Incorrect. Spread via lymphatics to the skin overlying the breast is not likely, since this is an in situ
carcinoma.
(E) Incorrect. At her age, this is less likely to be a cancer associated with BRCA1 or BRCA-2 than in a
younger woman. Only a small number of all breast cancers are associated with known mutations.

Question 25
A 69-year-old woman has a screening mammogram that shows an irregular 1 to 2 cm density in her right
breast. She has no axillary lymphadenopathy. A needle biopsy is performed and on microscopic
examination shows malignant cells floating in mucinous lakes. The nuclei show minimal pleomorphism
and no mitoses are seen. The cells are positive for estrogen receptor and negative for HER2 (c-erb B2).
A chest x-ray shows no abnormal findings. A bone scan is negative. What is the most likely designation
for grade and stage of this neoplasm?
A Grade I, Stage T1 M0 N0
B Grade I, Stage T2 M1 N1
C Grade II, Stage T3 M0 N0
D Grade II, Stage T2 M0 N1
E Grade III, Stage T3 M0 N1
(A) CORRECT. The histologic features are those of a low grade colloid carcinoma, a histologic type that
typically is ER positive, without metastases, and with a good prognosis. The stage is low because there is
a small tumor without evidence of either nodal or distant metastases.
(B) Incorrect. No evidence for nodal metastases is present; the tumor size is small.
(C) Incorrect. The tumor is a low grade, and the size is small.
(D) Incorrect. The tumor is a low grade, and the size is small; no evidence for nodal metastases is
present.
(E) Incorrect. The tumor is a low grade, and the size is small; no evidence for nodal metastases is
present.