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MedCosmos Surgery
Surgery Lecture Notes, Books, MCQ and Good Articles
FR IDA Y , S EPT EMB ER 5, 2008 MedCosmos Medical Blogs

Breast MCQ .All MedCosmos Series
1. After intraductal papilloma, unilateral bloody nipple discharge from

one duct orifice is most commonly caused by which of the following
pathologic conditions?
A. Paget's disease of the nipple.
B. Intraductal carcinoma.
C. Inflammatory carcinoma.
D. Subareolar mastitis.
Answer: B
DISCUSSION: Nipple discharge is surgically significant when it is

grossly bloody and when it appears at a single duct orifice on one
nipple. Bloody discharge is usually due to a benign intraductal
papilloma; however, intraductal carcinoma in the large ducts under Labels
the nipple can be the cause of bloody discharge, and pathologically the
History Taking (6)
lesion is frequently a large papillary tumor that has become
malignant. Paget's disease of the nipple is also due to intraductal Important Eponyms (1)
carcinoma arising in subareolar ducts, but it rarely is associated with MCQ : Breast (1)
nipple discharge. Subareolar mastitis may produce nipple discharge,
MCQ : Cardiac Surgery (1)
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MCQ : Cardiac Surgery (1)
but it is purulent and not bloody. Inflammatory carcinoma is not
associated with nipple discharge. MCQ : Endocrine (1)
MCQ : General Surgery (1)
MCQ : Hernia-Acute Abdomen (1)
2. Which of the following conditions is associated with increased risk
of breast cancer? MCQ : Large Intenstine (1)
A. Fibrocystic mastopathy. MCQ : Liver-Pancreas (1)
B. Severe hyperplasia.
MCQ : NeuroSurgery (1)
C. Atypical hyperplasia.
D. Papillomatosis. MCQ : Oncology (1)
Answer: C MCQ : Pediatric Surgery (1)
MCQ : Small Intenstine (1)
DISCUSSION: Fibrocystic mastopathy, or fibrocystic disease, was once
thought to increase the risk of breast cancer; however, later studies MCQ : Spleen (1)
of the pathologic findings in fibrocystic complex found an increased MCQ : Stomach-Esophagus (1)
cancer risk only for patients whose biopsies showed atypical
MCQ : Thoracic Surgery (1)
hyperplasia. “Severe hyperplasia” is a pathologic term that refers to
the amount of hyperplasia and is frequently seen in the biopsy MCQ : Thyroid Gland (1)
specimens of young women; it is a misleading term and is not MCQ : Transplantation (1)
associated with a disease risk. Papillomatosis is also part of the
MCQ : Trauma and Burns (1)
fibrocystic complex and is a frequent finding in benign breast
biopsies; it does not confer an increased risk of cancer. MCQ : Urology (1)
MCQ : Vascular Surgery (1)
Surgery Books (7)
3. Which of the following breast lesions are noninvasive
malignancies? Surgery Lectures (1)
A. Intraductal carcinoma of the comedo type. Surgery Must Read (1)
B. Tubular carcinoma and mucinous carcinoma.
Surgery Pamphlets (2)
C. Infiltrating ductal carcinoma and lobular carcinoma.
D. Medullary carcinoma, including atypical medullary lesions.
Blog Archive
Answer: A
▼ 2008 (48)
▼ 2008 (48)
DISCUSSION: Tubular, mucinous, and medullary carcinomas are ▼ September (48)
histologic variants of infiltrating ductal cancer and are all invasive Paradoxical Aciduria
malignancies. Infiltrating lobular cancer is a particular histologic
Thoracic Surgery MCQ
variant of invasive breast cancer characterized by permeation of the
stroma with small cells that resemble those found in the breast lobule Cardiac Surgery MCQ
or acinus. Intraductal carcinoma refers to a malignancy of ductal NeuroSurgery MCQ
origin that remains enclosed within duct structures. This noninvasive Urology MCQ
proliferation can undergo central necrosis, which frequently calcifies
Pediatric Surgery MCQ
to form the microcalcifications seen on mammography. The central
necrosis within enlarged and back-to-back ductal structures resembles Vascular Surgery MCQ
comedoes and gives rise to the term “comedocarcinoma,” now Liver and Pancreas MCQ
reserved for this histologic variety of intraductal carcinoma. Large Intenstine MCQ
Stomach and Esophagus MCQ
4. Which of the following are the most important and clinically useful Hernia and Acute Abdomen
risk factors for breast cancer? MCQ
A. Fibrocystic disease, age, and gender. Trauma and Burns MCQ
B. Cysts, family history in immediate relatives, and gender.
General Surgery MCQ
C. Age, gender, and family history in immediate relatives.
D. Obesity, nulliparity, and alcohol use. Thyroid Gland MCQ
Answer: C Small Intenstine MCQ
Oncology MCQ
DISCUSSION: The most important risk factors for breast cancer are
Transplantation MCQ
the patient's age, gender, and a family history of breast cancer in
immediate relatives (sisters, mother, daughter). The age-adjusted Enocrine Surgery MCQ
incidence of breast cancer increases with age. Breast cancer does Breast MCQ
occur in males, but the disease is far more common in women. Family Spleen MCQ
history is important when breast cancer occurs within the immediate
Technical Basis Of Radiation
family; history of breast cancer in more distant relatives
Therapy
(grandmothers, cousins, aunts) is less important. In addition, age
Metastasis of Prostate Cancer
factors into the risk associated with family history. An affected young Metastasis of Prostate Cancer
primary relative is far more significant as a risk factor than an older Schwartz Manual Surgery 8th
relative with breast cancer. The other important risk factor not listed Edition
here is a history of breast cancer, either within the conserved Bailey & Love's Short Practice
ipsilateral breast or in the contralateral breast. Again, age plays an of Surgery
important modifying role; as the age at which breast cancer was first
Sabiston Textbook of Surgery
diagnosed increases, the risk of a subsequent second cancer
decreases. Although patients with fibrocystic disease are at increased A History of Plastic Surgery
risk for breast cancer, risk concentrates in those patients with Endoscopic Surgery of
fibrocystic disease who show atypical epithelial hyperplasia within Potential anatomical spaces
breast ducts. Obesity, nulliparity, and alcohol all appear to increase 1000 Eponyms in Surgery
risk slightly and are important to the epidemiologic study of breast
Sentinel Lymph Node
cancer; however, the effect of these factors is not sufficient to
warrant their use in common clinical practice. History & Examination in
Rheumatoid Arthritis
Varicose veins examination
5. Which of the following pathologic findings is the strongest
Examination for a diabetic
contraindication to breast preservation (lumpectomy with breast foot
radiation) as primary treatment for a newly diagnosed breast cancer?
Thyroid Examination
A. Grade 3, poorly differentiated, infiltrating ductal carcinoma.
B. Extensive intraductal cancer around the invasive lesion. Lump History & Examination
C. Tumor size greater than 3 cm. Named Hernia
D. Positive surgical margin for invasive cancer.
Deep Vein Thrombosis
Answer: D
Post Operative Fever
DISCUSSION: The only firm contraindication to wide excision and Staging of breast cancer
radiation (breast preservation, lumpectomy) as the primary surgical PERIPHERAL VASCULAR
treatment for a newly discovered breast cancer is the inability to DISEASE History
achieve an uninvolved surgical margin after excision of the tumor. A
Q-A Scrotal Swelling
positive surgical margin requires, at least, reoperation with an
attempt at re-excision of the cancer. If the margin of removal is Management of Differentiated
Thyroid Carcinoma
positive after attempts at re-excision, this is a strong reason to Thyroid Carcinoma
recommend mastectomy in preference to breast conservation. Tumor Top 100 Secrets in Surgery
size is a relative contraindication when the cancer is so large in Burns
relation to the breast that excision to a clean surgical margin seems
Sister Mary Joseph Nodule
unreasonable. Other histologic findings, such as tumor grade or
vascular invasion, are not strong reasons to recommend mastectomy DD of rectal bleeding
if the patient would prefer breast conservation. DD of scrotal swelling
DD of breast lumps
6. Axillary lymph node dissection is routinely used for all of the Lots of Surgery Pamphlets
following conditions except:
A. 2-cm. pure comedo-type intraductal carcinoma.
B. 1-cm. infiltrating lobular carcinoma.
C. 8-mm. infiltrating ductal carcinoma.
D. A pure medullary cancer in the upper inner quadrant.
Answer: A
DISCUSSION: Intraductal carcinoma is carcinoma in situ and does not

metastasize to regional or distant sites. Lymph node dissection is not
routinely required for a pure in situ cancer of the breast. In contrast,
all of the other cancers listed above (infiltrating lobular, infiltrating
ductal, and medullary carcinoma) are invasive malignancies that are
capable of nodal and distant metastasis. Lymph node dissection is
commonly recommended for these invasive malignancies. Intraductal
lesions that have grown larger than 5 cm. are more apt to have
become focally invasive. Since this invasive component might be
missed histologically, many surgeons advocate selective use of
axillary node dissection for large intraductal lesions, particularly high-
grade tumors such as the comedo variant. However, a purely
intraductal 2-cm. cancer would most likely be treated without
performing node dissection.
7. Failure to perform radiation after wide excision of an invasive
cancer risks which of the following outcomes?
A. Recurrence of cancer in the ipsilateral breast.
B. Shorter survival time.
C. Regional nodal recurrence.
D. Greater chance of breast cancer mortality.
Answer: A
DISCUSSION: Retrospective reviews and prospective surgical trials

agree that omission of breast radiation after wide excision leads to a
higher rate of ipsilateral breast recurrence. However, survival and the
risk of distant disease are not altered in patients treated by excision
alone, within the follow-up time of the studies and given their
inherent power to detect differences in outcome. Regional node
metastasis is not affected by the choice of mastectomy versus wide
excision and radiation.
8. Which of the following treatments should never be recommended

to a patient with purely intraductal carcinoma?
A. Modified radical mastectomy.
B. Lumpectomy to clear surgical margins, followed by observation.
C. Incisional biopsy with an involved margin, followed by radiation.
D. Excisional biopsy to clear margins, followed by radiation.
Answer: C
DISCUSSION: The treatment approach to intraductal carcinoma

depends on the extent of the disease, its multifocality, and the
involvement of the surgical margin. For extensive disease, modified
radical mastectomy is appropriate, particularly if there is a great
likelihood of occult invasive disease, making axillary dissection
logical. For small foci of disease excised to clear surgical margins,
observation is an acceptable recommendation to a well-informed
patient. Several noncontrolled reviews and the National Surgical
Adjuvant Breast and Bowel Project (NSABP) trial for intraductal
disease would indicate a greater chance of ipsilateral breast
recurrence for lumpectomy only; however, the magnitude of the risk
is small, and survival is excellent and unaffected. The only mode of
treatment that cannot be recommended for routine management is
leaving residual disease in the breast and treating only with radiation.
9. The proper treatment for lobular carcinoma in situ (LCIS) includes

which of the following components?
A. Close follow-up.
B. Radiation after excision.
C. Mirror-image biopsy of the opposite breast.
D. Mastectomy and regional node dissection.
Answer: A
DISCUSSION: LCIS is best thought of as a precursor lesion that confers

increased risk for eventual cancer. The magnitude of this risk
appears to be in the range of seven- to ninefold over baseline risk.
The chance of breast cancer is equal in both breasts, not just in the
biopsied breast, and the type of cancer is not confined to a lobular
histology. After a diagnosis of LCIS, patients are at increased risk for
invasive and noninvasive ductal carcinoma in both breasts.
Therefore, mirror-image biopsy as practiced in the past has little to
offer. Since LCIS is purely noninvasive, nodal dissection is not
required if mastectomy is chosen. There are no data on the use of
breast radiation therapy for LCIS. Most surgical oncologists
recommend close follow-up for patients who have LCIS only; the
alternative surgical treatment that makes most sense is bilateral
simple mastectomies, with or without reconstruction.
10. Which of the following statements most accurately reflects the

findings of large overview analyses of clinical trials in which adjuvant
chemotherapy for early-stage breast cancer was compared to a control
group treated only with surgery?
A. The benefit of adjuvant therapy is confined to young patients.
B. Adjuvant therapy benefits all patients and is independent of age or
node status.
C. Adjuvant therapy does not work in estrogen-positive patients.
D. The magnitude of benefit is very large.
Answer: B
DISCUSSION: An overview analysis (meta-analysis) examined nearly all

randomized clinical trials in which chemotherapy after surgery was
compared to surgery alone for treatment of early-stage breast cancer.
This examination of the world's published literature revealed that the
magnitude of benefit (the reduction in the odds of recurrence) from
chemotherapy was relatively small and in the range of a 20% reduction
in the chance of recurrence or death; however, this benefit extended
to patients of all ages (young and older) and to both node-positive
and node-negative patients. The value of adjuvant chemotherapy
does not depend on the hormone receptor content of the cancer. It is
useful to remember that a constant reduction in the odds of
recurrence results in a higher absolute benefit as the prognosis
worsens. If the chance of recurrence is 50% (for node-positive groups)
the absolute reduction will be in the range of 10% or 15%. In contrast,
if the recurrence rate is 10%, the absolute difference between treated
and control groups will be less than 5%. This means that many
patients need to be exposed to the risks and side effects of
chemotherapy to benefit a very small number. This kind of thinking is
currently used to decide who should receive adjuvant chemotherapy
after primary treatment (mastectomy or lumpectomy).
11. Which of the following statements are true about reconstruction

of the breast following mastectomy?
A. A permanent prosthesis or tissue expander may be inserted at the
time of the ablative surgery.
B. If the patient requires adjuvant chemotherapy or radiation
therapy, reconstruction of the breast is delayed until completion of
the treatment.
C. Extensive postmastectomy defects require the use of a flap.
Answer: ABC
DISCUSSION: Reconstruction can be initiated at the time of the

ablative surgery, using a 6-cm. slightly curved incision at the level of
the sixth rib through the serratus muscle. A pocket is created beneath
the serratus and pectoralis major muscles, extending medially to the
perforating internal mammary vessels and inferiorly beneath the
fascial insertion of the rectus abdominis muscle. A tissue expander
prosthesis is inserted into the pocket. If the patient requires
adjuvant chemotherapy or radiation therapy, reconstruction of the
breast is delayed until treatment is completed and an adequate
recovery period has passed. If the quantity or quality of the chest skin
or the pectoralis major muscle is insufficient, tissue must be brought
in from adjacent areas. A latissimus dorsi musculocutaneous flap may
be transferred on its blood supply via the thoracodorsal artery and
vein. Extensive postmastectomy defects necessitate the use of the
larger rectus abdominis musculocutaneous flap, which is based on the
superior epigastric vessels. A “free” microvascular rectus abdominis
or other myocutaneous flaps may be used. The thoracodorsal or
anterior serratus vessels can usually be anastomosed to the inferior
epigastric vessels of the rectus abdominis flap.
12. Which of the following statements are true about the

management of mammary hyperplasia?
A. Reduction mammaplasty can be performed only on women younger
than 40 years.
B. Removal of breast tissue to reduce size of the breast is usually
predicated on the use of a nipple, areola, and dermal pedicle flap.
C. If removal of 2000 gm. of breast tissue is needed, breast
amputation with immediate free nipple-areola grafting is performed.
Answer: BC
DISCUSSION: Reduction mammaplasty can be performed at any age.

Because of the increased weight of the breast considerable shoulder
and back pain, accompanied by excoriation of the skin in the
inframammary area and the shoulders, can occur. Older women
frequently seek relief from these problems, which can be resolved by
a reduction mammaplasty. The reduction in breast volume is usually
accomplished by moving the nipple and areola on a dermal pedicle
flap. The flap can be based inferiorly, medially, superiorly, laterally,
vertically, or horizontally. It is possible to remove up to 3000 gm. of
breast tissue utilizing a pyramidal-based breast flap with an inferior
dermal nipple-areola pedicle since the blood supply to the tissues is
preserved by this technique. Breast reduction involving removal of
more than 3000 gm. requires a breast amputation technique with
immediate free nipple grafting.
13. Which of the following statement(s) is/are true concerning the

anatomy of the breast?
a. About 25% of the lymphatic drainage of the breast courses to the

internal mammary nodes
b. Nerves within the axillary fat pad include the intercostal brachial
nerve, the long thoracic nerve, and thoracodorsal nerve
c. Fascial bands projecting through the breast to the skin form a
supporting framework known as Cooper’s ligaments
d. The ductal system of the breast from the alveoli to the skin are
lined with columnar epithelium
Answer: b, c
The breast abuts against the fascia of the pectoralis major and
serratus anterior muscles. Projections of the fascia course through
the breast to the skin, forming a supporting framework of the breast
parenchyma. These fascial bands, called suspensory ligaments of
Cooper, are better developed in the upper breast. The structure of
the breast can be divided into lobular and ductal elements. The lobule
is the functional unit of the breast. Within a lobule, the terminal
elongated tubular ducts are referred to as alveoli. Ten to one hundred
alveoli coalesce to form a larger duct which defines a lobular unit. The
lobular ducts join to form progressively larger ducts and ultimately an
excretory duct. The alveolar ducts, lobular ducts, and excretory ducts
are all lined with either cuboidal or columnar epithelium. Eventually,
10-20 excretory ducts, each dilate into a short excretory sinus (lined
with squamous epithelium) just beneath the areola. Excretory ducts
then course perpendicular to exit through the nipple.
The lymphatic anatomy of the breast is of interest to the surgeon
because of the tendency of breast cancer to involve the regional
lymph nodes. Studies using radioactive tracers demonstrate at least
97% of lymphatic flow from the breast is into the axilla; the remainder
courses into the internal mammary nodes. These studies also show
that lymph flowing into the internal mammary gland chain is not
restricted in origin to the medial half and sub-areolar region of the
breast, as was thought, but can originate in any quadrant of the
breast. In the axilla, lymphatic vessels terminate in the lymph nodes
embedded within the axillary fat pad. Also within the axillary fat pad
are the intercostal brachial nerves (a sensory nerve supply in the
under arm), the long thoracic nerve (a motor nerve to the serratus
anterior and subscapularis muscles) and the thoracodorsal nerve (a
motor nerve to the latissimus dorsi adjacent to its accompanying
arteries and veins).
14. Which of the following statement (s) is/are true concerning the
recurrence of breast cancer?
a. The majority of patients recur within five years of diagnosis

b. More than 70% of breast cancer recurrence involve distant
metastases
c. Pulmonary metastases are the most common initial site of distant
recurrence
d. The local recurrence rate following breast-conserving procedures
varies from 10% to 40% whether or not radiation was used
e. Recurrent disease will be seen in at least 35% of node-negative
patients undergoing appropriate primary breast therapy
Answer: a, b, d
Metastatic disease following primary therapy for breast cancer can
recur at any time. However, of those who relapse, 50% to 70% do
within two years and over 85% relapse within five years. More than
70% of recurrences are distant, but anywhere from 10% to 30% of
recurrences are local. Bone and lung are the most common initial sites
of distant relapse (50% and 25%), respectively. A breast-conserving
procedure can be associated with a local tumor recurrence rate. The
rate of local recurrence falls from 40% to 10% if postoperative
radiation therapy is given to the entire breast. Despite potentially
curative resection, at least 20% of node-negative and 60% of node-
positive breast cancer patients have recurrence of their disease at
some time after surgery.
15. Which of the following statement(s) is/are true concerning

mammography?
a. Up to 50% of cancers detected mammographically are not palpable

b. One third of palpable breast cancers are not detected by
mammography
c. The sensitivity of mammography increases with age
d. The American Cancer Society currently recommends routine
screening mammography beginning at age 40
e. Only about 10% of nonpalpable lesions detection mammographically
are found to be malignant at biopsy
Answer: a, c, d
Although mammography has been available for years, it did not

become widely used until the findings of the Health Insurance Plan of
New York and the Breast Cancer Detection Demonstration project
studies of screening mammography were disseminated. These and
other investigators demonstrated that 10%–50% of cancers detected
mammographically are not palpable. Conversely, palpation recognizes
10%–20% of tumors not detectable mammographically. The incidence
of breast cancer begins to rise sharply at age 40, and the sensitivity
of mammograms increases with age as the dense parenchymal tissue
of young women is progressively replaced by fatty tissue. Routine
screening mammography has been shown to decrease breast cancer-
related mortality in asymptomatic women over the age of 50.
Controversy exists concerning the role of screening in younger
woman. However, currently the American Cancer Society recommends
that mammographic screening begin at age 40. Although sensitive,
mammography is not specific. Only about 25% of nonpalpable lesions
detected mammographically are found to be malignant at biopsy. A
spiculated density with ill-defined margins on mammogram is almost
certainly malignant. Most commonly, features are seen that are
suggestive but not diagnostic of cancer. These include clustered
microcalcifications, asymmetric density, ductal asymmetry, and
distortion of normal breast architecture and/or skin or nipple
distortion.

radiation therapy after lumpectomy?
a. The total dose given to the breast is usually in the range of 2500 to
3000 cGy
b. Radiation to the axillary nodal bed is normally part of the procedure
in most patients
c. Long-term complications of radiation therapy include rib fractures
and arm edema
d. Breast edema and skin erythema usually resolves within a few
weeks
e. None of the above
Answer: c
Breast conservation usually involves the use of lumpectomy and

radiation therapy to achieve local control of breast cancer. Any
technique used for post-lumpectomy radiation of the breast must
adequately cover the volume at risk, deliver a homogenous dose
throughout the target tissues, avoid overlapping or inadequate
apposition of fields, and minimize the dose reaching the heart and
lung. The entire breast should be treated with a total dose of 4500 to
5000 cGy. There is no good evidence to support a radiation boost to
the site of the primary tumor. Complications from breast radiation
are uncommon if performed correctly. Acute complications of
radiotherapy include fatigue, breast edema, and skin erythema; these
are almost always self-limited and resolve over weeks (fatigue) 2
months (erythema) or years (edema). The most common long-term
problems are rib fractures and minor arm edema, each of which occur
about 5% of the time.
17. A 35-year-old woman, who is currently breast-feeding her

firstborn child, develops an erythematous and inflamed fluctuant area
on breast examination. Which of the following statement(s) is/are
true concerning her diagnosis and management?
a. The most common organism which would expect to be cultured is

Staphylococcus aureus
b. Open surgical drainage is likely indicated
c. Breast-feeding absolutely should be discontinued
d. If the inflammatory process does not completely respond, a biopsy
may be indicated
Answer: a, b, d
Infection complicates breast-feeding in fewer than 1:100 women, but

these lactational infections still account for 80% of all breast
infections. Presumably, gaining access via the skin of the irritated
nipple of the nursing woman, Staphylococcus aureus is by far the most
common pathogen in this setting. Many breast infections begin as
cellulitis, without abscess formation. When an actual abscess is
suspected, percutaneous aspiration can establish the diagnosis and
allow for bacterial culture and sensitivity testing. Open surgical
drainage is the most prudent and effective treatment. Although
women may choose to cease breast feeding, there is no absolute
indication for this. When mastitis or breast infection is suspected
clinically, the possibility of an inflammatory carcinoma must also be
entertained. Any inflammatory process that does not respond
completely and promptly to antibiotics or drainage should be
subjected to biopsy to rule out cancer.

surgical staging of breast cancer?
a. All biopsy specimens should be transported to pathology in formalin

within 24 hours of the procedure
b. Removal of only level I axillary lymph nodes may understage breast
cancer in up to one-fourth of patients
c. Level III axillary lymph nodes should be removed in all axillary
lymph node dissections
d. A clinically negative axilla will be found to have histologically
positive metastasis in approximately one-third of patients
Answer: b, d
Pathologic staging begins with the initial biopsy. Unless previously
secured, fresh tumor needs to be obtained for hormone receptor
analysis prior to placement into formalin solution. A period of warm
ischemia as short as 30 minutes may cause underestimation of
estrogen receptor levels. The need to remove axillary nodes must be
determined preoperatively. Axillary lymph node metastasis will be
found in approximately one-third of clinically negative axillae, but
only if proper axillary dissection is performed. Removal of only level I
nodes or “sampling” of axillary lymph nodes in a haphazard fashion
increases the risk of injury to major axillary neurovascular structures
and may understage up to 25% of women. Proper staging of axillary
lymph nodes should include en bloc removal and examination of level I
and level II nodes. When conducted for staging, axillary lymph node
dissection should not include removal of level III axillary nodes; in
fewer than 2% are metastases present in level III nodes when level I
and level II nodes are negative. Removal of level III nodes, however,
does increase the incidence of postoperative arm lymph edema
almost fivefold. Therapeutic axillary lymph node dissection performed
for palpable disease in the axilla should include removal of all levels to
clear gross disease.

effect of various hormones on breast physiology?
a. Estrogen receptors are present only in breast cancer cells

b. Mammary ductal dilatation and differentiation of alveolar epithelial
cells and secretory cells are the result of rising progesterone levels
c. The early first trimester breast changes are primarily due to the
increased progesterone effects of pregnancy
d. Milk production and secretion after childbirth are maintained by
ongoing secretion of prolactin by the anterior pituitary gland
Answer: b, d
Breast growth, development, and function are orchestrated by a

variety of hormones and growth factors. Estrogen plays a central role
in breast development, growth, and differentiation. Lipid-soluble
estrogens gain entry to the normal and malignant breast cell by
diffusing to the cell membrane. Once within the cell, estrogens bind
with the estrogen receptor. Both normal and malignant breast cells
contain estrogen receptors, but the low levels of receptors in normal
breast tissue and in some breast cancers result in their testing
negative in clinical assays. Cyclic changes associated with the
menstrual cycle have a profound influence on breast morphology and
physiology. During the period of relative quiescence, increasing
Graafian follicle secretion of estrogen stimulates breast epithelial
proliferation. As the luteal phase of the cycle is entered, progesterone
levels rise. Mammary ductal dilatation and differentiation of alveolus
epithelial cells into secretory cells result. At the onset of
menstruation, the rapid decline of circulating sex-hormone levels
leads to breast involution and the cycle begins anew. During
pregnancy, marked ductular, lobular, and alveolar growth occur under
the influence of estrogen, progesterone, placental lactogen, prolactin,
and chorionic gonadotropin. These changes prepare the breasts for
milk production at parturition. Early in the first trimester, ductal
sprouting and lobular formation proceed under estrogenic influence.
During the second trimester, lobular events predominate under the
influence of progestins. Abrupt withdrawal of placental lactogen and
sex-hormones that occurs with delivery, leaves the breast
predominately under the influence of pituitary-derived prolactin. Milk
production and secretion are maintained during lactation by ongoing
secretion of prolactin by the anterior pituitary.
20. A pre-menopausal woman three years after mastectomy for breast

cancer presents with pulmonary metastases. Which of the following
statement(s) is/are true concerning her management?
a. If the patient has received adjuvant therapy, her response is likely

to be better
b. If the patient is ER-positive, hormonal therapy should be the first
line of treatment
c. The response to chemotherapy will likely be dose-dependent
d. Combination chemotherapy will likely work better in this patient
than a woman who is post-menopausal
Answer: b, c, d
Chemotherapy for metastatic breast cancer is more likely to be

employed for young women, those with ER-negative tumors, those
with visceral organ involvement and those with rapidly advancing or
life-threatening disease. Generally, combinations of agents are used
in treating metastatic breast cancer with the response rate usually
dose-dependent. All regimens are slightly less active in post-
menopausal women. Response rates are highest in women who have
not received prior treatment for metastatic disease. Prior adjuvant
therapy is not consistently associated with a poorer response to
therapy, particularly if a long interval has lapsed between adjuvant
therapy and the development of metastases. Endocrine therapy is
appropriate as the first-line treatment for nearly all women with ER-
positive metastatic breast disease. Tamoxifen is the agent of choice
for first-line hormonal therapy for metastatic breast cancer. Both pre-
menopausal and post-menopausal patients can receive this agent and
side effects are minimal.
intraductal papilloma?
a. This lesion is the most common cause of bloody nipple discharge

b. Serous non-bloody discharge is unlikely to be due to an intraductal
papilloma
c. A nonpalpable lesion can often be diagnosed with ductography
d. An isolated lesion is considered premalignant
Answer: a, c
Intraductal papilloma represents the most common cause of bloody

nipple discharge, although in half of the cases, the discharge is
serous. Since the average size of an intraductal papilloma is 3–4 mm.,
they are rarely palpable. Ductography may demonstrate the lesion, or
it may be found after subareolar duct excision performed to treat the
discharge. An isolated intraductal papilloma is not considered
premalignant nor does it place the patient at increased risk for breast
cancer. Unlike isolated papillomas, diffuse papillomatosis is
associated with an increased risk of breast cancer, perhaps as high as
in 40% of women.
22. A 21-year-old woman presents with an asymptomatic breast mass.

Which of the following statement(s) is/are true concerning her
diagnosis and treatment?
a. Mammography will play an important role in diagnosing the lesion

b. Ultrasonography is often useful in the differential diagnosis of this
lesion
c. The mass should always be excised
d. The lesion should be considered pre-malignant
Answer: b
Fibroadenoma represents the most common tumor in adolescents and

young woman, but if also frequently encountered in older women. It
generally presents as a palpable breast mass and must be
differentiated from cancer. Typically, fibroadenoma presents as a
painless, slow-growing mass found incidentally on breast self
examination. Palpation of a mass usually reveals a well-
circumscribed, oval or round, mobile mass with a firm, rubbery
texture. Because the mammographic appearance of a fibroadenoma is
rarely characteristic, mammography plays little role in diagnosing this
lesion. Ultrasonography can differentiate a solid mass from a cyst.
Additionally, the ultrasonic appearance of a well-marginated,
homogenous mass may be sufficiently characteristic to permit
diagnosis of fibroadenoma. Excisional biopsy is not necessary for
every fibroadenoma. Women under 30 years of age with
characteristic physical examination and sonographic appearance of
the fibroadenoma may be given the option of observation. Generally,
fibroadenomas are not felt to be pre-malignant lesions, nor to
indicate any increased risk for the development of breast cancer.
23. Which of the following are factors associated with an increased

risk for developing breast cancer?
a. Nulliparity
b. Oophorectomy before age 35
c. Use of oral contraceptives
d. High-fat, high-caloric diet
e. Post-menopausal use of conjugated estrogens
Answer: a, d
Women who undergo oophorectomy before age 35 and do not take

replacement estrogens have a two-thirds reduction in their breast
cancer risk. Replacement estrogen therapy eliminates the beneficial
effect of oophorectomy. Most investigations of oral contraceptive use
do not demonstrate an associated increased risk of breast cancer
development. Studies of estrogen replacement therapy for post-
menopausal women have yielded equivocal results. Most
contemporary studies fail to demonstrate an association between
breast cancer risk and post-menopausal use of conjugated estrogens.
BREAST CANCER RISK FACTORS
DEMOGRAPHIC FACTORS
Age more than 30 y
Female gender (130:1 female/male ratio)
GREATLY INCREASED RISK

Known carrier of breast cancer susceptibility gene
Strong family history—two or more first-degree relatives with
bilateral or premenopausal breast cancer
Atypical ductal or lobular hyperplasia or lobular carcinoma in situ
Ductal carcinoma in situ, risk limited to ipsilateral breast
MODERATELY INCREASED RISK

Family history—one or more relatives with breast cancer, not
bilateral or premenopausal
Menstrual history—menarche before age 12 y, menopause after
age 55 y
Parity—nulliparity or first live birth after age 30 y
Radiation—exposure to low-dose ionizing radiation in childhood or
adolescence
Previous breast cancer—low-grade, node-negative, or receptor-
positive; lobular histology
Other cancers—colon or endometrial cancer
Diet—high-fat or high-calorie diet
24. Which of the following chromosomal and/or genetic abnormalities

is/are associated with the development of breast cancer?
a. Mutations in the p53 tumor suppressor gene

b. A mutation in the short arm of chromosome 2
c. The presence of a BRCA 1 gene on chromosome 17
d. The presence of the BRCA 2 gene on chromosome 13
Answer: a, b, c, d
There are four inherited syndromes associated with the development

of breast cancer. The Li-Fraumeni syndrome has an autosomal
dominant mode of inheritance. The syndrome is attributed to
mutations in the p53 tumor suppressor gene, a gene that codes for a
protein that serves as a G1-S checkpoint regulator of the cell cycle.
More recently, a mutation has been characterized on the short arm of
chromosome 2 in a gene associated with DNA repair. Predisposition to
a wide range of malignancies, including breast and colon cancer is
associated with abnormalities at this locus. The most exciting
development in inherited susceptibility to breast cancer relate to the
identification and cloning of the BRCA 1 gene, which was initially
localized on the long arm of chromosome 17 by linkage analysis.
Germline abnormalities in BRCA a may be responsible for as many as
5% of all breast cancers in the United States. The gene is
characterized by autosomal dominant inheritance with a high degree
of penetrance. Almost 60% of women inheriting the gene will develop
breast cancer by age 50, and a lifelong risk approaches 85%. Another
breast cancer susceptibility gene, dubbed BRCA 2, has been localized
by linkage analysis to a small region of chromosome 13q12-13. BRCA
2 apparently confers the high-risk of early onset female breast
cancer. Similar to BRCA 1, the lifetime breast cancer risk approaches
90% in carriers of this gene.
25. A 45-year-old woman presents with a weeping eczematoid lesion

of her nipple. Which of the following statement(s) is/are true
concerning her diagnosis and management?
a. Treatment is with warm compresses and oral antibiotics

b. Biopsy of the nipple revealing malignant cells within the milk ducts
is invariably associated with an underlying invasive carcinoma
c. The appropriate treatment is mastectomy
d. The lesion always represents a high-risk disease with a significant
risk of subsequent metastatic disease
Answer: c
Paget’s disease is characterized by weeping, eczematoid lesion of the

nipple. There is often accompanying edema and inflammation. Biopsy
of the nipple reveals malignant cells within the milk ducts. The lesion
is invariably associated with an underlying invasive or in situ ductal
carcinoma. The prognosis of Paget’s disease is that of the underlying
cancer. Standard treatment is mastectomy with axillary lymph node
dissection only if invasive cancer is present.
26. Which of the following treatment(s) is/are of proven benefit in
the treatment of mastodynia associated with fibrocystic breast
disease?
a. Avoidance of methylxanthine compounds, particularly caffeine

b. Cessation of smoking
c. Vitamin E
d. Danazol
Answer: a, b, d
The relationship of methylxanthines, particularly caffeine, to

mastodynia and breast nodularity remains controversial. Most women
do, however, experience diminution of their symptoms and are
subject to improvement in breast nodularity by limiting or eliminating
caffeine intake. Mastodynia patients should be advised to eliminate
caffeine beverages for a period of 2 to 3 months to determine if
there has been improvement in their symptoms. In addition to
caffeine abstention, patients should be urged to stop smoking
because nicotine is purported to worsen mastodynia. A number of
medications have been advocated for the treatment of mastodynia.
Unfortunately, because of the subjective nature of the disease and its
propensity to be better tolerated by patients with reassurance, the
exact method of most of these interventions is unclear. Vitamin E has
been touted as beneficial, however, clinical data do not support the
use of this or other vitamins for this condition. The use of hormonal
agents to treat mastodynia has been more extensively treated.
Danazol, a weak antigen, is the most effective drug available for
treatment of mastodynia related to fibrocystic disease. Unfortunately,
Danazol’s androgenic side effects are troublesome enough to restrict
its use to the most problematic cases of mastodynia. Other hormonal
agents have been investigated for the management of mastodynia. In
young women, oral contraceptives have a variable effect on
mastodynia. A trial and error search for optimal preparations may be
necessary as the effect of oral contraceptives is dependent on the
formulation of the pill.
27. Which of the following statement(s) is/are true concerning breast

reconstruction?
a. The timing of breast reconstruction is of no oncologic significance

b. Breast reconstruction may interfere with detection of local
recurrence of breast cancer
c. Maintenance of an effective subpectoral pocket for a breast
implant requires preservation of the pectoralis fascia
d. Because of its complexity, the TRAM flap is seldom used for
primary breast reconstruction
Answer: a, c
Breast reconstruction is suitable for any woman who has undergone

mastectomy who desires reconstruction. Breast reconstruction may be
performed at the time of mastectomy (immediate) or sometime
subsequently (delayed) Because the presence of reconstruction may
interfere with the accurate planning and administration of radiation
therapy, reconstruction is generally delayed if the use of local or
regional radiation therapy is anticipated. Otherwise, timing of breast
reconstruction is of no oncologic significance. Because most local
recurrences occur in the skin’s subcutaneous tissues, the presence of
a reconstruction will not interfere with detection. Similarly, a
reconstruction does not complicate the administration of
chemotherapy.
Breast reconstruction techniques utilize either autogenous tissue or
synthetic prostheses to recreate a breast mound. Prosthetic
reconstruction is usually accomplished by sub-pectoral placement of a
saline-or silicone gel-filled implant. Maintenance of an effective sub-
pectoral pocket for an implant requires preservation of the pectoralis
fascia and the medial pectoral nerve during mastectomy. The
transferase rectus abdominous myocutaneous (TRAM) flap is the
autogenous reconstruction of choice. The TRAM operation is complex
and time consuming. Despite the magnitude of the procedure, it is
still commonly used for immediate reconstruction.

histologic variants of invasive breast carcinoma?
a. The presence of an in situ component with invasive ductal

carcinoma adversely affects prognosis
b. Medullary carcinomas, although often of large size, are associated
with a better overall prognosis than common invasive ductal cancers
c. Mucinous or colloid carcinoma is one of the more common variants
of invasive ductal cancer
d. Invasive lobular carcinoma is associated with a higher incidence of
bilateral breast cancer
Answer: b, d
Although the breast is composed of both lobular and ductal elements,

most breast cancer arises in the ductal elements. Invasive ductal
carcinoma accounts for 70% to 80% of all cases of breast cancer.
Although there is no single microscopic feature specific for infiltrating
ductal carcinoma, it can be recognized histologically as an invasive
adenocarcinoma involving ductal elements. The malignant ductal cells
are often dispersed within the fibrous stroma, leading to the
appellation of scirrhous carcinoma. A number of less common types of
breast cancer arise from the ductal epithelium and are hence
classified as variants of invasive ductal carcinoma. There are distinct
histologic criteria for classifying these lesions; these criteria must be
met throughout the entire tumor. Prognostically, histologically pure
examples of these variant tumors are associated with a better long-
term survival than ordinary type invasive ductal carcinoma. When
mixed histologies are encountered, the clinical behavior parallels that
of the invasive ductal element, not the other sub-type. Hence, these
mixed tumors are considered together with pure invasive ductal
carcinoma for prognostic purposes. In many cases, when areas of in
situ ductal carcinoma are seen, the presence of an in situ component
does not adversely affect prognosis, although it jeopardizes the
attempts at breast conservation. Medullary carcinoma is one of the
more common variants, accounting for approximately 6% of all
invasive breast cancers. These tumors may grow to be a rather large
size within the breast (5 to 10 cm) and are characteristically well-
circumscribed. Mucinous carcinoma, also referred as colloid
carcinoma, is encountered in 1% to 2% of breast cancer cases.
Invasive lobular carcinoma arises from the lobular component of the
breast and in most series accounts for approximately 10% of breast
cancers. Almost every series has stressed the higher incidence of
bilateral cancer in patients with invasive lobular carcinoma. The
contralateral breast is involved either synchronously (3% of patients)
or metachronously in up to 30% of patients.
29. Which of the following statement(s) is/are correct concerning

cystosarcoma phyllodes?
a. The tumor is most commonly seen in post-menopausal women
b. Total mastectomy is necessary for all patients with this diagnosis
c. Axillary lymph node dissection is not necessary for malignant
cystosarcoma phyllodes
d. Most patients with the malignant variant of cystosarcoma phyllodes
die of metastatic disease
Answer: c
Cystosarcoma phyllodes is a tumor arising in the mesenchymal tissue

of the breast. The tumors usually present as a painless breast mass.
Phyllodes tumor is most commonly encountered in women age 30–40
years of age but can occur at any age, even before puberty. The
differentiation of a benign from a malignant phyllodes tumor may be
difficult. About one-fourth of all phyllodes tumors are histologically
malignant, but only a fraction of these patients actually develop
metastatic disease. The optimum treatment for benign or malignant
phyllodes tumor is wide excision with a margin of normal breast
tissue. The margin must be histologically free of involvement because
even benign lesions can recur after incomplete excision. If this can be
done leaving an adequate cosmetic appearance, mastectomy is not
necessary. Total mastectomy is reserved for large lesions in small-
breasted women or recurrences after previous local excision that is
not amenable to repeat local excision. Axillary lymph node dissection
is not performed in the absence of biopsy-proven nodal involvement,
even for malignant phyllodes tumors, because axillary metastases are
uncommon.
30. Which of the following statement(s) is/are true concerning local

recurrence of breast cancer?
a. The percentage of patients with chest wall recurrence as their
initial site of failure following mastectomy is similar for node-
negative and node-positive patients
b. Most patients with local-regional recurrence of their disease will
eventually die of metastatic disease
c. The treatment of local recurrence following mastectomy includes
local radiation therapy and systemic chemotherapy
d. In-breast recurrence following breast conserving surgery is not a
negative prognostic factor
e. Regional lymph node recurrence following axillary node dissection is
rare
Answer: a, b, c, e
Recurrence in the chest wall after mastectomy is ominous. In a large

series of patients treated with mastectomy, 6.5% of node-negative
and 8.8% of node-positive women had chest wall recurrence as their
initial site of failure. By ten years after local-regional recurrence,
about 60% of initially node-negative and almost all (> 90%) of initially
node-positive patients had evidence of metastatic disease. Patients
with local recurrence, who have not had prior chest wall radiation,
should receive radiation therapy. A full course of at least 4500 to
5000 cGy should be delivered to the entire chest wall, with
consideration given to a boost dose at any sites of gross tumor.
Because post-mastectomy recurrence is often rapidly followed by
metastatic disease, it is logical to postulate a role for adjuvant
systemic therapy once local measures have achieved control of chest
wall disease.
Recent data suggests that in-breast recurrence following breast
conservation is a prognostic factor. Women who develop an in-breast
recurrence have a higher likelihood of developing systemic disease
than do women who remain disease-free in their breast. Fewer than
3% of patients develop recurrence of disease in the axilla after
axillary node dissection.
31. Which of the following statement(s) is/are correct concerning

prognostic factors for breast carcinoma?
a. Prognosis is improved with estrogen or progesterone receptor

positivity
b. Increased thymidine labeling index, a measure of the proportion of
cells in the DNA synthetic phase (S-phase), is associated with
improved survival
c. High tumor levels of cathepsin D are associated with an improved
prognosis
d. Immunohistochemical demonstration of active angiogenesis
correlates with increased metastatic potential and poor prognosis
Answer: a, d

adjuvant systemic therapy?
a. Adjuvant tamoxifen in post-menopausal, node-positive, ER-

positive women is equivalent to cytotoxic chemotherapy
b. Tamoxifen clearly improves survival in all hormonal receptor-
positive patients
c. CMF is associated with improved overall survival in both pre-
menopausal and post-menopausal node-positive patients
d. There is no evidence to suggest a role for chemotherapy in node-
negative patients
Answer: a
Adjuvant tamoxifen leads to a prolonged disease-free interval in
post-menopausal ER-positive women with histologically positive nodes
and in pre-menopausal and post-menopausal ER-positive women with
negative nodes. Because of similar results and, because tamoxifen is
generally less toxic than chemotherapy, this treatment is the
treatment of choice for post-menopausal, node-positive, ER-positive
women. CMF (cyclophosphamide, methotrexate, and 5-fluorouracil) is
associated with both a longer disease-free survival and overall
survival time in pre-menopausal patients with positive lymph nodes.
In post-menopausal women with positive nodes, there is an improved
disease-free survival, but there is no significant difference in overall
survival. Several trials of adjuvant chemotherapy with CMF or related
regimens have been conducted in node-negative patients. The early
results of all of these trials have been similar: disease-free survival is
definitely improved with adjuvant chemotherapy. These studies are
definitely not mature enough to draw definitive conclusions regarding
overall survival. Therefore, the National Cancer Institute has
recommended the use of adjuvant chemotherapy for all patients with
tumors large enough to have hormonal receptor levels measured.
33. Which of the following statement(s) is/are true concerning tissue

sampling techniques for breast masses?
a. The sensitivity of fine needle aspiration biopsy is such that

mastectomy can be performed in the case of malignant diagnosis
b. The accuracy of mammographic-directed fine needle aspiration
biopsy is comparable to that achieved for that of palpable lesions
c. Core-needle biopsy showing normal breast tissue is an acceptable
diagnosis
d. The technique of core-needle biopsy is not applicable to
radiographically detected lesions
Answer: b
Whatever tissue sampling method is chosen, only biopsy (examination

of cells or tissue) and not physical examination or mammography can
establish a definitive diagnosis and avoid delay in treatment. Fine
needle aspiration biopsy (FNAB) permits rapid, minimally invasive
diagnosis of many palpable and some non-palpable, radiologically
detected breast masses. The technique is both reliable and accurate.
The incidence of false-positive findings is generally less than 0.5%.
FNAB is not, however, so highly specific that definitive surgery
(particularly mastectomy) should be performed without prior
intraoperative frozen-section confirmation of the presence of cancer.
Reported sensitivity of FNAB ranges from 7% to 99%; with 85% a good
estimate of the true sensitivity in clinically relevant settings.
Recently, x-ray-guided FNAB has been used to offer minimally
invasive diagnosis in nonpalpable breast lesions detected
mammographically. The technique is quite effective, especially for
mass lesions. Accuracy is comparable to that achieved with FNAB of
palpable lesions. Core-needle biopsy is a helpful tissue sampling
method for palpable masses. The tissue obtained is useful for
histologic analysis although inadequate for cytosol hormone receptor
determination. The technique is also applicable by using
mammographic guidance for nonpalpable lesions.
34. A 42-year-old woman undergoes her first mammogram. Clustered

microcalcifications are seen but there is no mass palpable. Which of
the following statement(s) is/are true concerning this patient’s
diagnosis and management?
a. A needle localization and excision of the mass is necessary to
establish the diagnosis
b. Frozen-section examination is particularly useful in the diagnosis
of this lesion
c. Intense interlobular fibrosis and proliferation of small ductules with
loss of orientation of lobules and epithelial cells may suggest
carcinoma
d. This finding is associated with an increased risk of cancer
Answer: a, c
Sclerosing adenosis is a histologic subtype of fibrocystic change that

is not associated with an increased risk of cancer development. It is,
however, one of the benign breast processes most likely to be
confused radiologically and histologically with cancer. Most commonly,
it is detected on routine mammography as cluster microcalcifications
without an associated palpable mass. In these cases, needle
localization and excision are required to establish a diagnosis.
Sclerosing adenosis microscopically is characterized by interlobular
fibrosis and proliferation of small ductules. If the fibrous component
is particularly intense, the orientation of lobules and epithelial cells
may be lost, mimicking carcinoma. Differentiating sclerosing
adenosis from cancer on frozen-section examination can be
particularly difficult and should not be attempted.
35. Which of the following conclusion(s) can be drawn from the results
of the NSABP prospective randomized trials completed in the 1970’s
and 1980’s?
a. Delay of axillary node dissection until there is clinical evidence of

disease does not influence overall survival
b. Removal of clinically negative nodes has no therapeutic benefit
c. Breast irradiation reduces both local recurrence and overall survival
d. Modified radical mastectomy offers no advantage of lumpectomy
with axillary node dissection
Answer: a, b, d
The scientific basis of local-regional treatment strategies for stage I

and stage II breast cancer was established by a series of studies
conducted during the 1970’s and 1980’s by the NSABP. In the first of
these protocols, total mastectomy with delayed node dissection only
for nodes that subsequently turned positive, total mastectomy with
local-regional radiation therapy, and radical mastectomy were
clinically equivalent. Furthermore, the finding that delay of axillary
node dissection until there is clinical evidence of disease does not
influence survival emphasizes that the role of axillary dissection in
clinically node negative patients is solely for staging. The removal of
clinically negative nodes has no therapeutic benefit if regional
recurrences are detected and treated promptly. In the second of these
protocols, modified radical mastectomy, lumpectomy with axillary
node dissection, and lumpectomy, axillary node dissection, and breast
or irradiation were compared in small breast cancers. Modified radical
mastectomy offered no advantage over other treatments when
analyzed by disease-free or overall survival in either node-negative or
node-positive patients. Breast irradiation after lumpectomy reduced
the likelihood of in-breast tumor recurrence from 39% to 10% but did
not affect overall survival when compared with lumpectomy alone.
36. Which of the following statement(s) is/are true concerning non-

invasive breast carcinoma?
a. Ductal carcinoma in situ (DCIS) is associated with a significant risk
of development of invasive ductal carcinoma in the same quadrant of
the same breast as the initial lesion
b. DCIS should not be treated with breast conservation therapy
c. Lobular carcinoma in situ (LCIS) is the most common form of non-
invasive breast cancer
d. When LCIS is found, there is an up to 50% chance of lobular
carcinoma in situ of the contralateral breast
e. About one-third of patients with biopsy-proven LCIS develop
invasive cancer, always of the same breast
Answer: a, d
Non-invasive (in situ) cancer is defined as a neoplastic entity within

the epithelium of origin and without invasion to the basement
membrane. Ductal carcinoma in situ (DCIS) arises from the ductular
elements. The age distribution of DCIS does not differ significantly
from that of invasive ductal carcinoma. Not every woman who
undergoes complete excision of a focus DCIS develops invasive ductal
cancer. Various studies suggest half or more patients develop
invasive breast cancer after excisional biopsy alone. When a
subsequent invasive cancer does occur, it is almost always of the
invasive ductal type and located in the same quadrant of the breast
as the initial DCIS. The latent period before the development of
invasive cancer usually exceeds five years. Total mastectomy is
usually associated with a nearly 100% cure rate for this condition.
Although total mastectomy remains the gold-standard for treatment
of DCIS, there is increasing experience with breast-conserving
therapy. Breast conservation may be offered to DCIS patients in
whom the entire tumor can be surgically removed with negative
histologic margins and in whom the remaining breast tissue can be
reliably assessed clinically and radiographically. It would appear that
the disease-free survival following lumpectomy and radiation therapy
is worse than that achievable with simple mastectomy. Therefore,
breast conservation for DCIS commits patients to more careful long-
term follow-up and will likely subject them to additional subsequent
treatment to deal with the recurrences. Lobular carcinoma in situ
(LCIS) accounts for one-third of the non-invasive breast cancers. LCIS
patients are significantly younger than patients with invasive breast
cancer. Three-fourths of affected women are pre-menopausal. LCIS is
an infrequent finding in women over 75. When the opposite breast is
sampled at the time of diagnosis, contralateral LCIS is found in 30–
50% of cases. The prognosis of LCIS is solely related to the
subsequent development of invasive carcinoma. About one-third of
patients with biopsy-demonstrated LCIS develop invasive cancer; half
occur in the index breast and half in the contralateral breast. The
subsequent breast cancers can be either lobular or ductal in histology.
37. A 33-year-old woman is referred with nipple discharge. Which of

the following statement(s) is/are true concerning her diagnosis and
management?
a. Bilateral galactorrhea is suggestive of an underlying endocrinopathy

b. Brownish discharge is usually suggestive of old blood and is
worrisome for an underlying breast cancer
c. Expressible bloody nipple discharge should be evaluated with a
ductogram
d. Milky breast discharge would not be expected one year after
discontinuation of breast feeding
Answer: a, c
At one time or another, many women notice a nipple discharge. The
most common physiologic basis for nipple discharge is lactation. Milk
may continue to be secreted intermittently for as long as two years
after breast feeding has stopped, particularly with breast stimulation.
A milky whitish discharge, usually bilateral, that is not related to
lactation or breast stimulation is termed “galactorrhea.” The
presence of bilateral galactorrhea should prompt an evaluation for
underlying endocrinopathy causing increased prolactin secretion by
the pituitary. Classically, this is associated with amenorrhea, but
galactorrhea may be the only sign of hypoprolactinemia. Nipple
discharges associated with fibrocystic disease are generally, green,
yellow, or brown, Intraductal papillomas and cancer lead to a bloody or
blood-tinged serous discharge. The brownish discharge of fibrocystic
disease can easily be confused with old blood. A guaiac test or simply
dabbing the discharge with a gauze pad and examining the stain can
usually differentiate the two. A bloody or blood-tinged discharge must
be promptly evaluated to exclude carcinoma. If the discharge is
expressible at the time the patient is seen, a contrast ductogram may
be obtained.
38. Clinical features of breast cancer which are associated with a

particularly poor prognosis include:
a. Edema of the skin of the breast

b. Skin ulceration
c. Lateral arm edema
d. Dermal lymphatic invasion
Answer: a, b, c, d
The histologic hallmark of inflammatory breast cancer is dermal

lymphatic invasion demonstrable on skin biopsy. The stigmata of this
clinical syndrome include breast warmth, tenderness, erythema, and
edema.
39. Which of the following statement(s) is/are associated with

gynecomastia?
a. If the disease is unilateral, it is unlikely drug-related

b. The standard surgical treatment is subcutaneous mastectomy
c. The presence of gynecomastia is often associated with the
subsequent development of breast cancer
d. A formal endocrine evaluation is indicated in most patients with
gynecomastia
Answer: b
Gynecomastia is defined as palpable enlargement of the male breast.

Pathologic causes of estrogen excess or testosterone deficiency are
associated with gynecomastia. In many cases, no cause is found.
Clinically significant gynecomastia has been associated with the use
of a number or drugs including cimetidine, digoxin, spironolactone
and tricyclic antidepressants. The use of marijuana has also been
associated with gynecomastia. Drug-related gynecomastia is often
unilateral or unequal between the two breasts, and discontinuation of
the offending drug does not always lead to resolution of the condition.
A formal endocrine evaluation is not indicated for gynecomastia
unless some other sign of hormonal imbalance is found on routine
evaluation. The standard surgical treatment of gynecomastia consists
of subcutaneous mastectomy performed under local anesthesia. The
presence of gynecomastia is not associated with the subsequent
development of cancer, yet protracted hyperestrogenemic states,
which are associated with gynecomastia are linked to breast cancer
development.
Posted by MedCosmos at 5:32 PM

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FR IDA Y , S EPT EMB ER 5, 2008 MedCosmos Medical Blogs

1. After intraductal papilloma, unilateral bloody nipple discharge from

DISCUSSION: Nipple discharge is surgically significant when it is

DISCUSSION: Intraductal carcinoma is carcinoma in situ and does not

DISCUSSION: Retrospective reviews and prospective surgical trials

8. Which of the following treatments should never be recommended

DISCUSSION: The treatment approach to intraductal carcinoma

9. The proper treatment for lobular carcinoma in situ (LCIS) includes

DISCUSSION: LCIS is best thought of as a precursor lesion that confers

10. Which of the following statements most accurately reflects the

DISCUSSION: An overview analysis (meta-analysis) examined nearly all

11. Which of the following statements are true about reconstruction

DISCUSSION: Reconstruction can be initiated at the time of the

12. Which of the following statements are true about the

DISCUSSION: Reduction mammaplasty can be performed at any age.

13. Which of the following statement(s) is/are true concerning the

a. About 25% of the lymphatic drainage of the breast courses to the

a. The majority of patients recur within five years of diagnosis

Metastatic disease following primary therapy for breast cancer can

15. Which of the following statement(s) is/are true concerning

a. Up to 50% of cancers detected mammographically are not palpable

Although mammography has been available for years, it did not

16. Which of the following statement(s) is/are true concerning

Breast conservation usually involves the use of lumpectomy and

17. A 35-year-old woman, who is currently breast-feeding her

a. The most common organism which would expect to be cultured is

Infection complicates breast-feeding in fewer than 1:100 women, but

18. Which of the following statement(s) is/are true concerning the

a. All biopsy specimens should be transported to pathology in formalin

19. Which of the following statement(s) is/are true concerning the

a. Estrogen receptors are present only in breast cancer cells

Breast growth, development, and function are orchestrated by a

20. A pre-menopausal woman three years after mastectomy for breast

a. If the patient has received adjuvant therapy, her response is likely

Chemotherapy for metastatic breast cancer is more likely to be

a. This lesion is the most common cause of bloody nipple discharge

Intraductal papilloma represents the most common cause of bloody

22. A 21-year-old woman presents with an asymptomatic breast mass.

a. Mammography will play an important role in diagnosing the lesion

Fibroadenoma represents the most common tumor in adolescents and

23. Which of the following are factors associated with an increased

Women who undergo oophorectomy before age 35 and do not take

GREATLY INCREASED RISK

MODERATELY INCREASED RISK

24. Which of the following chromosomal and/or genetic abnormalities

a. Mutations in the p53 tumor suppressor gene

There are four inherited syndromes associated with the development

25. A 45-year-old woman presents with a weeping eczematoid lesion

a. Treatment is with warm compresses and oral antibiotics

Paget’s disease is characterized by weeping, eczematoid lesion of the

a. Avoidance of methylxanthine compounds, particularly caffeine

The relationship of methylxanthines, particularly caffeine, to

27. Which of the following statement(s) is/are true concerning breast

a. The timing of breast reconstruction is of no oncologic significance

Breast reconstruction is suitable for any woman who has undergone

28. Which of the following statement(s) is/are true concerning the

a. The presence of an in situ component with invasive ductal