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A 41-year-old woman comes to the physician 3 weeks after a vaginal delivery,

complaining of a lump in her right breast. She states that over


the past few days, she has noticed increasing redness in the area and that the
site is painful and feels somewhat firm to her. She also
complains of fever and chills. She is concerned because she is currently breastfeeding her child. She has no medical or surgical history. She
uses acetaminophen occasionally for headaches and is allergic to sulfa drugs.
Her temperature is 37.8 C (100.1 F), blood pressure is
110/70 mm Hg, pulse is 98/minute, and respirations are 12/minute. The right
breast has an area of erythema and edema that is tender with
no fluctuance.
Question 1 of 4

Which of the following is the most likely diagnosis?


/A. Breast carcinoma
/B. Eczema
/C. Fibroadenoma
/D. Mastitis
/E. Trauma
Explanation - Q: 1.1

Close

The correct answer is D. Mastitis represents a parenchymatous infection of


the mammary glands. It is most often seen in postpartum women who are
breast-feeding, and the symptoms typically appear 3-4 weeks postpartum.
Most women with mastitis complain of pain in the breast with an area of
redness and "hardness." Women also often have fever and chills, myalgias
and arthralgias, and tachycardia. Examination shows erythema, edema, and
tenderness.
Patients with breast carcinoma (choice A) often present with an
asymptomatic mass. While it is possible for patients with breast cancer to
have erythema and edema of the breast and tenderness on exam, this
presentation in a postpartum, breast-feeding woman is most consistent with
mastitis.
Eczema (choice B) does not present with a lump, as this patient has. It is a
superficial disorder involving the top part (epidermis and upper dermis) of the
skin only. It is also characterized by scale with erythema and not associated
with fever, chills, and systemic symptoms like this patient has.
Fibroadenoma (choice C) represents a proliferation of fibrous tissue in the
breast. It is the most common tumor in young women. Patients with
fibroadenoma typically present with complaints of a breast lump. The mass is
usually small, unilateral, firm, and freely mobile. Patients with fibroadenoma
do not usually present with erythema, edema, pain in the breast, and systemic

signs of infection.
Trauma (choice E) to the breast can lead to a condition called fat necrosis.
Patients with breast trauma usually complain of a firm area of the breast,
sometimes mobile, and occasionally with induration. However, patients with
fat necrosis from breast trauma usually recall a prior incident of trauma.
Question 2 of 4

Histological examination of diagnostic tissue from this patient would reveal which
of the following?
/A. A Iocalized area of acute inflammation
/B. Cellular, fibroblastic stroma enclosing cystic spaces lined by epithelium
/C. Edema fluid within the intercellular spaces of the epidermis
/D. Hemorrhage enclosed within the tissue
/E. Strands of infiltrating tumor cells
Explanation - Q: 1.2

Close

The correct answer is A. This patient has a presentation that is most


consistent with mastitis, which represents an acute localized infection.
Histologic evaluation would, therefore, reveal a localized area of acute
inflammation with edema and neutrophil emigration.
Cellular, fibroblastic stroma enclosing cystic spaces lined by epithelium
(choice B) would be the histology of a fibroadenoma and not mastitis.
Edema fluid within the intercellular spaces of the epidermis (choice C) is the
histologic finding in eczema.
Hemorrhage enclosed within a tissue (choice D) describes a hematoma and
would be the expected histologic finding in a patient with trauma to the breast
with a resultant hematoma. This patient's presentation is more consistent with
mastitis than trauma.
Strands of infiltrating tumor cells (choice E) would be the expected finding in
a patient with certain types of carcinoma of the breast. This is not the
histologic finding in mastitis.
Question 3 of 4

Which of the following is most likely responsible for this pathologic process?

Explanation - Q: 1.3

Close

The correct answer is E. Staphylococcus aureus is a catalase-positive,


coagulase-positive, and beta-hemolytic organism that is the most common
cause of mastitis. The source of the organism is almost always from the
nursing infant's oropharynx. Enterotoxin F, or Toxic Shock Syndrome Toxin,
has been reported to cause toxic shock syndrome in some patients with
mastitis caused by Staphylococcus aureus.
Blunt force injury (choice A) to the breast might be expected to cause a
hematoma or fat necrosis. This patient has a presentation that is consistent
with mastitis, and not traumatic injury to the breast.
Chlamydia trachomatis(choice B) is an obligate intracellular organism. It is
most commonly found in the genital tract and is associated with cervicitis and
pelvic inflammatory disease in women, urethritis in men, and pneumonia and
conjunctivitis in newborns. It is not normally associated with mastitis.
Hormonal exposure (choice C) is not considered causative of mastitis. There
is some evidence that hormonal exposure may contribute to the development
of breast cancer. This patient, however, has a presentation more consistent
with mastitis than breast cancer.
Neisseria gonorrhoeae(choice D) is a gram-negative coccus that can cause
cervicitis, pelvic inflammatory disease, arthritis, pharyngitis, and urethritis. It
can also cause neonatal conjunctivitis. It is not commonly associated with
mastitis.
Question 4 of 4

The patient is started on dicloxacillin. This medication works via which of the
following mechanisms?
/A. BIocking cell wall synthesis
/B. Inhibition of bacterial dihydrofolate reductase
/C. Inhibition of bacteriaI DNA gyrase
/D. Inhibition of protein synthesis
/E. Inhibition of resorption of sodium and chloride
Explanation - Q: 1.4

Close

The correct answer is A. Dicloxacillin belongs to the general class of


penicillin antibiotics. Penicillins interfere with bacterial cell wall synthesis by
binding to bacterial penicillin binding proteins, resulting in eventual bacterial
cell lysis. Bacterial resistance to penicillins results when bacterial betalactamases disrupt the beta-lactam ring contained within these antibiotics.
Dicloxacillin (like methicillin and nafcillin) is synthesized to be resistant to
beta-lactamases. However, resistance to these antibiotics is increasing as
well. If a patient with mastitis does not respond to dicloxacillin, bacterial
resistance should be suspected and vancomycin should be used.
Inhibition of bacterial dihydrofolate reductase (choice B) is the mechanism of
action of trimethoprim and pyrimethamine.
Inhibition of bacterial DNA gyrase (choice C) is the mechanism of action of
the fluoroquinolones and quinolones.
Inhibition of protein synthesis (choice D) is the mechanism of action of the
lincosamines (clindamycin, lincomycin). These drugs bind the 50S subunit of
ribosomes to inhibit the bacterial protein synthesis.
Inhibition of resorption of sodium and chloride (choice E) is the mechanism of
furosemide (a loop diuretic).
A 37-year-old woman undergoes a routine breast examination. During the breast
examination, the physician is aware that the skin of the
breast moves together with the underlying breast tissue, rather than being
obviously separate from it.
Question 1 of 6

The breast tissue is normally attached to the overlying skin via which of the
following?
/A. Cooper's ligaments
/B. Cruciate ligaments
/C. Falciform ligament
/D. Poupart's ligaments
/E. Rhomboid ligaments
Explanation - Q: 2.1

Close

The correct answer is A. The suspensory ligaments of Cooper are fibrous


condensations of connective tissue stroma that attach the mammary gland to
the dermis of the overlying skin. These are particularly prominent in the
superior aspect of the breast, and help to support the breast tissue.
The cruciate ligaments(choice B) are in the knee.

The falciform ligament (choice C) attaches the peritoneum to the liver.


Poupart's ligament (choice D) is an alternative name for the inguinal
ligament.
The rhomboid ligament (choice E) is another name for the costoclavicular
ligament.
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Question 2 of 6

Careful examination of the central depressed area of the nipple demonstrates


multiple small openings. These openings are from which of the
following?
/A. Areola
/B. Lactiferous ducts
/C. Montgomery's glands
/D. Sweat glands
/E. Terminal ductules
Explanation - Q: 2.2

Close

The correct answer is B. The lactiferous ducts open into the nipples. The
area of each of these ducts immediately below the nipple is usually dilated,
forming a lactiferous sinus, which can store a droplet of milk that helps to
initiate the baby's sucking reflex during nursing.
The areola (choice A) is the ring of darkly pigmented skin around the nipple.
Montgomery's glands (choice C) are modified eccrine glands (described
incorrectly by some authors as sebaceous glands) that provide oil and
moisture for the skin of the nipple and areola. They open into the areola in
small tubercles rather than the nipple.
Sweat glands (choice D) are common in the skin of the breast generally, but
are too small to be able to seen by the unaided eye.
The terminal ductules (choice E) of the breast system are at the deep end of
the duct system of the breasts, and receive milk from the lobular tissue.
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Question 3 of 6

The physician identifies a palpable mass in one breast, and the patient is
scheduled for a "Iumpectomy." The reason that "Iumpectomies" for
breast lumps can be safely performed in some patients is that the breast is
divided into multiple lobes, each of which contains a separate
duct system with connecting lobules. The normal breast usually contains how
many lobes?

/A. 2 to 3
/B. 5 to 7
/C. 10 to 12
/D. 15 to 25
/E. 30 to 50

Explanation - Q: 2.3

Close

The correct answer is D. The normal breast contains 15 to 25 lobes. Each


lobe can be thought of as having an "inverted tree" composed of a "trunk"
made of the lactiferous duct, "branches" made of smaller ducts that feed into
the lactiferous duct, and "leaves" made of lobular tissue. Depending on the
clinical setting, surgeons will also sometimes excise the duct system under
the nipple along with the lump in the breast.
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Question 4 of 6

The surgical specimen is sent fresh from the surgical suite to the laboratory for
frozen section examination. Before cutting into the specimen,
the pathologist makes a careful gross examination, which demonstrates that
most of the specimen has replacement of the normally fatty
breast tissue with strands of dense, white, firm tissue. In a few areas, roughly
spherical lesions up to 3-cm diameter with a bluish hue to them
are seen. Palpation of these areas produces a fluctuant sensation. Which of the
following is the most likely diagnosis based on the gross
evaluation?
/A. Breast cancer
/B. Changes of pregnancy
/C. Fibroadenoma
/D. Fibrocystic disease
/E. Mastitis
Explanation - Q: 2.4

Close

The correct answer is D. While a careful pathologist will wait for appropriate
frozen or permanent tissue histologic examination, the description given in the
question stem is most suggestive of fibrocystic disease. The fibrous part of
the lesion forms the dense, white tissue strands, while the blue lesions are
what are called "blue-domed cysts. The blue color comes from the presence
of darkly colored fluid (which usually means old hemorrhage) within the cyst.
The interior cyst wall is usually smooth. These blue-domed cysts are a
favorite of examiners because they produce a distinctive gross picture and
should be specifically associated with fibrocystic disease, but you should be
aware that in real life they do not occur with anything near the frequency of
fibrocystic disease without obvious large cysts grossly (but many smaller

cysts on microscopic examination). Fibrocystic disease of the breast is a very


common lesion, and a frequent source of palpable lumps in the breast, which
may require further evaluation through either excisional biopsy (as in this
case), Tru-cut needle biopsy (producing a thin core about 1 cm long), or
needle aspiration (producing fluid or cells for cytology).
While a diagnosis of breast cancer should obviously be confirmed
microscopically before telling the clinician, invasive breast cancer (choice A)
can be suspected when there is a hard, white, nodular area of the breast that
has irregular (but often reasonably well-defined - in contrast to the fibrotic
areas of fibrocystic disease) boundaries.
The changes of pregnancy (choice B) cannot be reliably picked up on gross
examination of the breast.
Fibroadenoma (choice C), like breast cancer, tends to produce a well-defined
mass lesion, but it typically has smooth borders and may have a slightly gray
and slightly mucoid (e.g., shiny or oily appearing) surface on cross-section.
Long-standing mastitis (choice E) can cause breast fibrosis, but will not
cause blue-domed cyst formation. More acutely, mastitis can produce
abscesses (which appear white rather than blue).
Question 5 of 6

Frozen section examination demonstrates fibrosis and cystic spaces. AIso seen
are areas of compressed glands with a lobular orientation.
The glands are lined by a single layer of epithelial cells with oval nuclei and
regular arrangement. No true invasion of glands into the adjacent
stroma is seen. This patient probably has which of the following?
/A. Atypical ductal hyperplasia
/B. Ductal carcinoma in situ
/C. Lobular carcinoma in situ
/D. Sclerosing adenosis
/E. Usual ductal hyperplasia
Explanation - Q: 2.5

Close

The correct answer is D. The lesion described is sclerosing adenosis. The


tip-offs in the description are the references to compressed glands and lobular
orientation. Sclerosing adenosis is a common component of fibrocystic
disease, and occurs when fibrosis distorts the normal lobular architecture.
The result can be some fairly bizarre, but completely benign, compressed
glands that may mimic carcinoma on both frozen and permanent sections.
Low power examination is often helpful, as this emphasizes the lobular
character of the lesion.
Lesions actually involving the epithelium of the duct system typically have

multiple layers of cells and range from usual ductal hyperplasia (choice E,
with low risk of invasive carcinoma and characterized by the presence of both
myoepithelial cells and epithelial cells within the duct) through atypical ductal
hyperplasia (choice A, with medium risk of invasive carcinoma and
characterized by ductal carcinoma in situ-like features only involving portions
of a duct) to ductal carcinoma in situ (choice B, with relatively high risk of
invasive carcinoma and characterized by clearly abnormal features such as
loss of myoepithelial cells and formation of cribriform patterns involving
complete cross-sections of ducts).
Lobular carcinoma in situ (choice C) typically produces lobular units whose
lumina are completely filled with epithelial cells.
In practice, while you may be asked to distinguish classic examples of the
different lesions mentioned in the choices on examinations, you should be
aware that this whole area can be very problematic in real-life microscopic
examinations of breast tissue, and one piece of breast tissue sent to different
experts in breast pathology may be returned with a variety of diagnoses.
Question 6 of 6

Which of the following breast lesions is considered to have the greatest potential
for eventual progression to a malignant lesion?
/A. Apocrine metaplasia
/B. BIue dome cyst
/C. Epithelial hyperplasia
/D. Fat necrosis
/E. Fibrosis
Explanation - Q: 2.6

Close

The correct answer is C. While fibrocystic disease may have many


components, including cyst formation (choice B), apocrine metaplasia
(choice A, a benign alteration of cyst epithelium to resemble that of apocrine
sweat glands), sclerosing adenosis, and fibrosis (choice E), only the epithelial
hyperplasia (usual, atypical, or carcinoma in situ) is thought to indicate
significant premalignant (or malignant, for carcinoma in situ) potential. For this
reason, most pathologists pay particular attention to the epithelial lining of the
ducts and lobules when evaluating breast biopsy specimens with fibrocystic
disease. Fibrocystic breasts without any evidence of epithelial changes do not
appear to have any significant increased risk of progression to breast cancer.
(You should, however, be aware that a fibrocystic breast may make both
breast palpation and mammography more difficult and make it more likely to

miss a small lesion.)


Fat necrosis (choice D) is seen after breast trauma, and has no significant
malignant potential.
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A 47-year-old man presents to his physician because he has noticed that his right
breast is noticeably larger than his left breast. Breast
examination demonstrates that the right breast is diffusely enlarged. The breast
tissue is freely mobile and without distinct masses. The
patient reports that the breast has been slowly enlarging over a period of several
years.
Question 1 of 7

Which of the following is the most likely diagnosis?


/A. Ductal carcinoma in situ
/B. Fibroadenoma
/C. Gynecomastia
/D. Invasive ductal carcinoma
/E. Lobular carcinoma in situ
Explanation - Q: 3.1

Close

The correct answer is C. The most common cause for male breast
evaluation in the United States is gynecomastia, or benign breast
enlargement. Gynecomastia may involve one or both breasts. Male breasts
can also develop ductal carcinoma in situ (choice A), invasive ductal
carcinoma (choice D), and fibroadenoma (choice B), but these lesions are
much less common than gynecomastia.
The glands in male breasts do not have lobular tissue, so lobular carcinoma in
situ (choice E) does not occur.
Question 2 of 7

AIso noted on physical examination is the presence of multiple spider angiomata.


These are most closely associated with disease of which
of the following organs?
/A. Liver
/B. Prostate
/C. Stomach
/D. Testes
/E. Thyroid
Explanation - Q: 3.2

Close

The correct answer is A. Spider angiomas are small vascular lesions with
small blood vessels radiating from a central point. They are specifically
associated with liver disease, particularly due to alcohol abuse. They are not
specifically associated with diseases of the other organs listed in the choices.
Question 3 of 7

The presence of the spider angiomas should specifically trigger a question to the
patient about his history of use of which of the following?
/A. AIcohol
/B. Caffeine
/C. Cigarettes
/D. Heroin
/E. Marijuana
Explanation - Q: 3.3

Close

The correct answer is A. Spider angiomas are most often associated with
liver disease related to alcohol abuse. Abuse of the other items listed in the
choices does not predispose for spider angioma formation.
Question 4 of 7

Which of the following is the most likely mechanism causing a relative excess of
hormone leading to the breast enlargement in this patient?
/A. Decreased production of testosterone secondary to primary hypogonadism
/B. Drug that inhibits testosterone synthesis
/C. Drug with estrogen-Iike activity
/D. Increased peripheral conversion of androgens to estrogens
/E. Increased production of estrogen by a cancer
Explanation - Q: 3.4

Close

The correct answer is D. Peripheral conversion of androgens (testosterone


and androstenedione) to estrogens occurs mainly in adipose tissue, muscle,
and skin. In patients with chronic liver disease, malnutrition, and
hyperthyroidism, this peripheral conversion is increased, and may be
associated with feminization (seen as changes in hair distribution, body fat
distribution, and breast size).
Conditions that cause primary or secondary hypogonadism (choice A) can
cause gynecomastia by the mechanisms of decreased production and/or
action of testosterone. These conditions can include Klinefelter syndrome,
congenital anorchia, testicular trauma or torsion, viral orchitis (e.g., mumps),
pituitary tumors, and renal failure.

Drugs that can cause gynecomastia by inhibiting testosterone synthesis


(choice B) or action include ketoconazole, metronidazole, cisplatin,
spironolactone, and cimetidine.
Drugs that can cause gynecomastia because of their estrogen-like activity
(choice C) include diethylstilbestrol, digitalis, and estrogen-containing foods
and cosmetics.
Gynecomastia can also be seen as a consequence of increased estrogen
production by some tumors (choice E), including testicular tumors and
cancers secreting ectopic hCG (from lung, kidney, GI tract, and extragonadal
germ cell tumors). Gynecomastia can also occur as a normal physiologic
variant, particularly during puberty and in older men.
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Question 5 of 7

Which of the following enzymes converts androgens to estrogens?


/A. ALA synthase
/B. Aromatase
/C. Branching enzyme
/D. MethylmalonyI CoA mutase
/E. PRPP synthetase
Explanation - Q: 3.5

Close

The correct answer is B. The enzyme aromatase is found in adipose tissue


(and hence is increased in fat people), muscle, and skin. It acts on androgens
to form estrogens by adding double bonds to make a benzene-like ring. It is
this enzyme whose activity is relatively increased in liver disease.
ALA synthase (choice A) is an important early enzyme in heme synthesis.
Branching enzyme (choice C) is used in glycogen formation.
Methylmalonyl CoA mutase (choice D) is involved in the propionic acid
pathway leading to synthesis of succinyl CoA.
PRPP synthetase (choice E) occurs in purine synthesis.

Question 6 of 7

Which of the following is a genetic syndrome associated with this patient's


condition and a 10- to 20-fold increased incidence of breast
cancer?
/A. Cushing syndrome
/B. Down syndrome
/C. Hashimoto disease
/D. KIinefelter syndrome
/E. Turner syndrome
Explanation - Q: 3.6

Close

The correct answer is D. The genetic condition Klinefelter syndrome


(47,XXY) is fairly unique among the causes of gynecomastia in that it is
accompanied by an increased incidence of male breast cancer. In most types
of patients with gynecomastia, the incidence of breast cancer is not
increased, and there are no adverse medical complications of the
gynecomastia (although social and psychological problems may occur).
Gynecomastia is usually only treated (with surgery) in patients in whom the
breast either continues to enlarge or is personally troubling to the patient.
Gynecomastia may occur in Cushing syndrome (choice A) and
hyperthyroidism related to Hashimoto disease (choice C), but these are not
genetic diseases.
Gynecomastia is not usually a feature of Down syndrome (choice B), or
Turner syndrome (choice E).
Question 7 of 7

The normal male breast differs from the normal female breast in which of the
following ways?
/A. Adipose tissue is absent
/B. Dermis is absent
/C. Ductal tissue is absent
/D. Lobular tissue is absent
/E. Muscle is absent
Explanation - Q: 3.7

Close

The correct answer is D. The normal male breast (and the male breast with
gynecomastia), unlike the normal female breast, lacks lobular tissue. Both
male and female breasts contain ductal tissue (choice C), adipose tissue
(choice A), dermis (choice B), and small amounts of smooth muscle tissue
(choice E).

A 53-year-old woman consults a physician after discovering a mass in her breast.


Physical examination demonstrates a 1.5-cm diameter,
firm mass lesion in the upper, outer quadrant of her right breast. The mass is
surgically removed and pathologic examination of tissue
obtained at surgery reveals invasive breast cancer.
Question 1 of 5

What percentage of breast masses are discovered by the patient, rather than by
mammography or physician examination of the breasts?
/A. 5%
/B. 20%
/C. 50%
/D. 80%
/E. 95%
Explanation - Q: 1.1

Close

The correct answer is D. Breast cancer accounts for the greatest number of
new cancer cases in women each year. Mammography is the screening
method used to detect subclinical breast cancer-the stage at which breast
cancer is least likely to have spread, but about 80% of breast masses are
discovered initially by the patient, which it is why it is important to continue to
stress breast self-examination.
Question 2 of 5

While about 75% of the lymphatic fluid from the breast drains first to the axilla,
most of the remaining lymphatic fluid drains first to which of the
following groups of lymph nodes?
/A. Anterior internal thoracic nodes
/B. Internal inferior thoracic nodes
/C. Lateral intercostal nodes
/D. Superior mediastinal nodes
/E. Tracheobronchial nodes
Explanation - Q: 1.2

Close

The correct answer is A. The anterior internal thoracic nodes, also known as
the internal mammary nodes, are a pair of chained lymph nodes running
superiorly to inferiorly along the chest wall near both sides of the sternum.
They are inaccessible for surgical removal during mastectomy, but may
contain metastatic breast cancer. Rarely, the lateral intercostal nodes (choice
C) may contain metastatic breast cancer.

The inferior internal thoracic nodes (choice B) drain the liver and diaphragm.
The superior mediastinal nodes (choice D) drain the trachea, esophagus, and
heart.
The tracheobronchial nodes (choice E) drain the lung.
Question 3 of 5

Which of the following will most likely be identified at pathologic examination of


this woman's breast mass?
/A. Ductal carcinoma
/B. Lobular carcinoma
/C. Medullary carcinoma
/D. Paget disease
/E. Tubular carcinoma
Explanation - Q: 1.2

Close

The correct answer is A. The anterior internal thoracic nodes, also known as
the internal mammary nodes, are a pair of chained lymph nodes running
superiorly to inferiorly along the chest wall near both sides of the sternum.
They are inaccessible for surgical removal during mastectomy, but may
contain metastatic breast cancer. Rarely, the lateral intercostal nodes (choice
C) may contain metastatic breast cancer.
The inferior internal thoracic nodes (choice B) drain the liver and diaphragm.
The superior mediastinal nodes (choice D) drain the trachea, esophagus, and
heart.
The tracheobronchial nodes (choice E) drain the lung.
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Question 3 of 5

Which of the following will most likely be identified at pathologic examination of


this woman's breast mass?
/A. Ductal carcinoma
/B. Lobular carcinoma
/C. Medullary carcinoma
/D. Paget disease
/E. Tubular carcinoma
Explanation - Q: 1.3

Close

The correct answer is A. There is a cumulative risk in women of developing


breast cancer of 1 in 8 by age 95; 1/3 to 1/2 of the patients die of the disease.
Breast cancer may occur in a ductal or a lobular pattern. Invasive ductal

carcinoma, not otherwise specified, is the most common histological type of


invasive breast cancer. Risk factors for breast cancer include positive family
history, early menarche, late menopause, late first pregnancy, and history of in
situ or invasive breast cancer. Women who develop breast cancer before age
35 tend to have more aggressive disease. Two breast cancer genes, BRCA1
and BRCA2, have been identified; 5% of women with breast cancer carry one
or the other of these genes. Male breast cancer is much less common than
female, but has a high mortality rate
Lobular carcinoma (choice B) is the second most common type of breast
cancer. It may occur bilaterally in some patients.
Medullary carcinoma (choice C) and tubular carcinoma (choice E) are
histological variants of ductal carcinoma with statistically better prognoses
than ductal carcinoma, not otherwise specified.
Paget disease (choice D) is the presence of individual adenocarcinoma cells
within the skin overlying a breast cancer.
Question 4 of 5

Immunohistochemical examination of paraffin-embedded sections through the


tumor demonstrates that it stains for estrogen receptors (ER)
and progesterone receptors (PR). This finding specifically suggests that the
tumor may respond to which of the following drugs?
/A. 5-FIuorouracil
/B. Cyclophosphamide
/C. Doxorubicin
/D. Methotrexate
/E. Tamoxifen
Explanation - Q: 1.4

Close

The correct answer is E. Treatment with adjuvant tamoxifen for 5 years in


ER positive tumors can reduce the risk of death by 25% in both pre- and
postmenopausal women with or without axial lymph node involvement. Breast
cancers that express the Her-2/neu receptor may respond to a new drug,
trastuzumab, which is a monoclonal antibody directed against the receptor.
The other drugs listed are all used for breast cancer chemotherapy, but work
because they are cytotoxic rather than because they affect the hormonal
response of the cancer.
Question 5 of 5

The patient's physician suggests that she immediately begin chemotherapy


treatment. The patient dismisses his suggestion and says, "I do

not need any medicine, all l need is bedrest." This statement is most consistent
with which of the following responses to illness?
/A. Acceptance
/B. Anger
/C. Bargaining
/D. Denial
/E. Grieving
Explanation - Q: 1.5

Close

The correct answer is D. Denial is a coping mechanism to defend against


overwhelming anxiety. Pathologic and extreme denial can interfere with
accurate diagnosis, impede treatment, and consequently perpetuate the
disease state. Denial is common in the early stages of dealing with a terminal
illness and is not necessarily pathologic. Less extreme forms of denial may
even serve the patient in positive ways. "I'm as strong now as I was when I
was 20 and I'm gonna make it." Notably, the stages of grieving over the loss
of a loved one (bereavement) are very similar to grieving over the loss of
one's health (stages of dying).
Acceptance (choice A) is a realistic perspective concerning the
consequences of illness. "Coming to terms" with the illness restores emotional
equilibrium and patients appear to return to their baseline personality and
emotional functioning.
Anger (choice B) is often directed at fate, God, themselves, their caretakers,
and their families and, if taken to the extreme, may result in isolation from
much needed support.
Bargaining (choice C) entails promises to buy additional time.
Grieving (choice E) is a process of changing affective states over time and
includes five stages as described by Elisabeth Kubler-Ross (denial, anger,
bargaining, depression, and acceptance). Denial, anger, anxiety, depression,
and dependence can all be abnormal responses to illness (when extreme).
A 23-year-old woman comes to the physician because of a lump in her right
breast. She states that she first noted the lump about a year ago
and that it has seemed to enlarge over the past year. She notes some occasional
tenderness in the area, usually at the same time during her
menstrual cycle. She has no medical problems. She had an appendectomy at the
age of 18. She takes no medications and is allergic to
penicillin. Examination of the breast demonstrates a freely mobile, smoothly
contoured, discrete mass in the upper outer quadrant of the

breast. UItrasonography demonstrates a smooth mass with circumscribed


margins and homogeneous echo pattern, consistent with a solid
Iesion.
Question 1 of 4

Which of the following is the most likely diagnosis?


/A. Breast abscess
/B. Fibroadenoma
/C. Fibrocystic breast changes
/D. Mastitis
/E. Pregnancy
Explanation - Q: 2.1

Close

The correct answer is B. Fibroadenomas are the most common breast


lesions found in women under 25 years of age. Fibroadenomas are the
second most common cause of benign breast lesions (second only to
fibrocystic changes) in women of all ages. Patients with a fibroadenoma
typically present complaining of a palpable lump, often with some gradual
growth. There may be some occasional cyclic tenderness. Management is
with biopsy or close observation. If the lesion is palpable, increasing in size,
or psychologically disturbing, biopsy should be performed. If the woman is
less than 25 years of age with small fibroadenomas that appear "classic" by
imaging, then expectant management with careful continued observation can
be considered.
A breast abscess (choice A) can also present as a lump in the breast.
However, an abscess represents a localized collection of pus resulting from
an infection. Therefore, patients with a breast abscess will often have
erythema, edema, pain, and tenderness around the area of the mass. Such
patients may also have systemic signs of infection, including fever and
tachycardia. This patient has no evidence of infection.
Fibrocystic breast changes (choice C) are the most common, benign
condition of the breast. They can be present in young women, become more
common as a woman approaches the menopause, and often regress during
and after the menopause. The most common symptoms are pain and
tenderness, and the masses are usually bilateral. Mammography and
ultrasound of the breast often reveal the fibrocystic changes.
Mastitis (choice D) is an infection of the breast. It can occur in any woman,
but most often occurs in lactating women during the postpartum period.
Patients with mastitis will often present with tenderness and erythema of the
breast along with fever. Treatment is with antibiotics.

Pregnancy (choice E) is associated with a number of changes in the breast,


especially as the breast prepares for lactation. Fibroadenomas may grow
rapidly during pregnancy, but the primary diagnosis, and hence the best
answer, is still fibroadenoma
Question 2 of 4

Histological examination of diagnostic tissue from this patient would reveal which
of the following?
/A. A classic cribriform pattern with neoplastic epithelial cells
/B. Cystically dilated ducts plus stromal fibrosis
/C. Irregular steatocytes and intervening necrotic material and inflammatory
cells
/D. Lobular hypertrophy
/E. Proliferating ducts and stromal cells
Explanation - Q: 2.2

Close

The correct answer is E. Fibroadenomas have a typical microscopic


appearance. The predominant feature is the fibroblastic stroma. This is a
delicate, cellular, fibroblastic stroma resembling intralobular stroma. Within
this fibroblastic stroma are seen proliferating ducts. These ducts are usually
compressed and are lined by benign-appearing epithelium. If the margin
includes surrounding tissue beyond the fibroadenoma, compressed breast
connective tissue forming a "capsule" to the mass may be seen as well.
A classic cribriform pattern with neoplastic epithelial cells (choice A) is what
would be revealed by histological examination of an intraductal carcinoma of
the breast. The epithelium in a fibroadenoma is benign-appearing.
Histologic examination of a biopsy specimen from a patient with fibrocystic
breast changes would demonstrate cystically dilated ducts plus stromal
fibrosis (choice B).
Irregular steatocytes and intervening necrotic material and inflammatory cells
(choice C) describes the findings on pathologic evaluation of a biopsy
specimen from a patient with fat necrosis. Fat necrosis is most commonly
caused by trauma, but can also occur after surgery or radiation therapy.
Lobular hypertrophy (choice D) is seen in pregnant women. This lobular
hypertrophy occurs during the pregnancy to allow for lactation in the
postpartum period.
Question 3 of 4

If the histologic examination revealed similar findings as in this patient, but


demonstrated increased cellularity, an elevated mitotic rate,
stromal overgrowth, and infiltrative borders, then which of the following is the
most likely diagnosis?
/A. Fat necrosis
/B. Fibrocystic changes
/C. Mastitis
/D. Normal breast tissue
/E. Phyllodes tumor
Explanation - Q: 2.2

Close

The correct answer is E. Fibroadenomas have a typical microscopic


appearance. The predominant feature is the fibroblastic stroma. This is a
delicate, cellular, fibroblastic stroma resembling intralobular stroma. Within
this fibroblastic stroma are seen proliferating ducts. These ducts are usually
compressed and are lined by benign-appearing epithelium. If the margin
includes surrounding tissue beyond the fibroadenoma, compressed breast
connective tissue forming a "capsule" to the mass may be seen as well.
A classic cribriform pattern with neoplastic epithelial cells (choice A) is what
would be revealed by histological examination of an intraductal carcinoma of
the breast. The epithelium in a fibroadenoma is benign-appearing.
Histologic examination of a biopsy specimen from a patient with fibrocystic
breast changes would demonstrate cystically dilated ducts plus stromal
fibrosis (choice B).
Irregular steatocytes and intervening necrotic material and inflammatory cells
(choice C) describes the findings on pathologic evaluation of a biopsy
specimen from a patient with fat necrosis. Fat necrosis is most commonly
caused by trauma, but can also occur after surgery or radiation therapy.
Lobular hypertrophy (choice D) is seen in pregnant women. This lobular
hypertrophy occurs during the pregnancy to allow for lactation in the
postpartum period.
Question 3 of 4

If the histologic examination revealed similar findings as in this patient, but


demonstrated increased cellularity, an elevated mitotic rate,
stromal overgrowth, and infiltrative borders, then which of the following is the
most likely diagnosis?
/A. Fat necrosis
/B. Fibrocystic changes
/C. Mastitis
/D. Normal breast tissue

/E.

Phyllodes tumor
Explanation - Q: 2.3

Close

The correct answer is E. Phyllodes tumors are similar to fibroadenomas in


that they arise from intralobular stroma. Furthermore, on pathologic
evaluation, low-grade phyllodes tumors can resemble fibroadenomas.
However, there are important differences. First, most phyllodes tumors
present in the sixth decade, whereas fibroadenomas most commonly present
in young women. Also, while most phyllodes tumors are low-grade tumors that
only rarely metastasize, some are aggressive high-grade lesions that
commonly recur locally and do metastasize hematogenously. These
aggressive lesions are often called cystosarcoma phyllodes. Some phyllodes
tumors are small, while others may be large enough to involve virtually the
entire breast. Grossly, these tumors often have leaf-like projections off of
them. On histologic evaluation, the keys to distinguishing between
fibroadenoma and phyllodes tumor are the increased cellularity, enhanced
mitotic rate, stromal overgrowth, nuclear pleomorphism, and infiltrative
borders that are seen in phyllodes tumors and are absent in fibroadenomas.
Fat necrosis (choice A) demonstrates necrotic fat cells that are surrounded
by lipid-filled macrophages and an infiltration of neutrophils. It does not
resemble a fibroadenoma.
Fibrocystic changes (choice B) are characterized by cysts, and do not closely
resemble fibroadenomas, as low-grade phyllodes tumors do.
Mastitis (choice C) is an infection of the breast, usually by Staphylococcus
aureus. It is characterized by acute inflammation and does not resemble
fibroadenoma.
Normal breast tissue (choice D) is not characterized by a pattern similar to
fibroadenoma, except with increased cellularity, elevated mitotic rate, stromal
overgrowth, and infiltrative borders. These are characteristics of phyllodes
tumors.
Question 4 of 4

If the patient were instead found to have an aggressive breast carcinoma with a
poor prognosis, the Kubler-Ross model predicts that she will
go through which of the following stages?
/A. Acceptance, anger, ambivalence, deniaI, depression
/B. BIues, depression, psychosis, treatment, resolution
/C. DeniaI, anger, bargaining, depression, acceptance
/D. DeniaI, anger, psychosis, homicide, suicide
/E. Realization, infantilization, socialization, condemnation

Explanation - Q: 2.4

Close

The correct answer is C. Elisabeth Kubler-Ross is the psychiatrist who


authored the groundbreaking "On Death and Dying" in 1969. She was born in
Switzerland, but moved to the United States in the 1950s, where she worked
with dying patients. Her model identified five stages that occur when
individuals are confronted with death: 1) Denial, 2) Anger, 3) Bargaining, 4)
Depression, and 5) Acceptance. While she originally described this process
as it relates to facing death, others have used these 5 steps to describe
reaction to grief or loss. While these stages are useful to understand and
contemplate the experience of grief or dying, it is important to recognize that
not all people will go through these steps. Those who do go through each of
these steps may also not go through them in the "order" described by the
Kubler-Ross model. No model is perfect for explaining the intricacies of every
different human being's response to grief or death. The Kubler-Ross model
does provide a nice framework and starting point for understanding these
difficult issues.
None of the other choices correctly describes the stages proposed by KublerRoss.