breast surgery

Breast1. After intraductal papilloma, unilateral bloody nipple discharge from one duct orifice is most commonly caused bywhich 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 ductorifice on one nipple. Bloody discharge is usually due to a benign intraductal papilloma; however, intraductalcarcinoma in the large ducts under the nipple can be the cause of bloody discharge, and pathologically the lesion isfrequently a large papillary tumor that has become malignant. Paget's disease of the nipple is also due to intraductalcarcinoma arising in subareolar ducts, but it rarely is associated with nipple discharge. Subareolar mastitis may producenipple discharge, but it is purulent and not bloody. Inflammatory carcinoma is not associated with nipple discharge.

2. Which of the following conditions is associated with increased risk of breast cancer?A. Fibrocystic mastopathy.B. Severe hyperplasia.C. Atypical hyperplasia.D. Papillomatosis.Answer: C

DISCUSSION: Fibrocystic mastopathy, or fibrocystic disease, was once thought to increase the risk of breast cancer;however, later studies of the pathologic findings in fibrocystic complex found an increased cancer risk only for patientswhose biopsies showed atypical hyperplasia. “Severe hyperplasia” is a pathologic term that refers to the amount ofhyperplasia and is frequently seen in the biopsy specimens of young women; it is a misleading term and is notassociated with a disease risk. Papillomatosis is also part of the fibrocystic complex and is a frequent finding in benignbreast biopsies; it does not confer an increased risk of cancer.

3. Which of the following breast lesions are noninvasive malignancies?A. Intraductal carcinoma of the comedo type.B. Tubular carcinoma and mucinous carcinoma.C. Infiltrating ductal carcinoma and lobular carcinoma.D. Medullary carcinoma, including atypical medullary lesions.Answer: A

DISCUSSION: Tubular, mucinous, and medullary carcinomas are histologic variants of infiltrating ductal cancer andare all invasive malignancies. Infiltrating lobular cancer is a particular histologic variant of invasive breast cancercharacterized by permeation of the stroma with small cells that resemble those found in the breast lobule or acinus.Intraductal carcinoma refers to a malignancy of ductal origin that remains enclosed within duct structures. Thisnoninvasive proliferation can undergo central necrosis, which frequently calcifies to form the microcalcifications seenon mammography. The central necrosis within enlarged and back-to-back ductal structures resembles comedoes andgives rise to the term “comedocarcinoma,” now reserved for this histologic variety of intraductal carcinoma.

4. Which of the following are the most important and clinically useful risk factors for breast cancer?A. Fibrocystic disease, age, and gender.B. Cysts, family history in immediate relatives, and gender.C. Age, gender, and family history in immediate relatives.D. Obesity, nulliparity, and alcohol use.Answer: C

DISCUSSION: The most important risk factors for breast cancer are the patient's age, gender, and a family history ofbreast cancer in immediate relatives (sisters, mother, daughter). The age-adjusted incidence of breast cancer increaseswith age. Breast cancer does occur in males, but the disease is far more common in women. Family history is importantwhen breast cancer occurs within the immediate family; history of breast cancer in more distant relatives(grandmothers, cousins, aunts) is less important. In addition, age factors into the risk associated with family history. Anaffected young primary relative is far more significant as a risk factor than an older relative with breast cancer. Theother important risk factor not listed here is a history of breast cancer, either within the conserved ipsilateral breast or in

the contralateral breast. Again, age plays an important modifying role; as the age at which breast cancer was firstdiagnosed increases, the risk of a subsequent second cancer decreases. Although patients with fibrocystic disease are atAsir Surgery MCQs Bank. © 1422H-2002- first impression ©

This project was raised after an idia by Dr. Gharama Al-Shehri (consultant surgeon). Developed and typed by Dr. Ghazi Al-Shumrani (intern).

Breastincreased risk for breast cancer, risk concentrates in those patients with fibrocystic disease who show atypical epithelialhyperplasia within breast ducts. Obesity, nulliparity, and alcohol all appear to increase risk slightly and are important tothe epidemiologic study of breast cancer; however, the effect of these factors is not sufficient to warrant their use incommon clinical practice.

5. Which of the following pathologic findings is the strongest contraindication to breast preservation (lumpectomy withbreast radiation) as primary treatment for a newly diagnosed breast cancer?A. Grade 3, poorly differentiated, infiltrating ductal carcinoma.B. Extensive intraductal cancer around the invasive lesion.C. Tumor size greater than 3 cm.D. Positive surgical margin for invasive cancer.Answer: D

DISCUSSION: The only firm contraindication to wide excision and radiation (breast preservation, lumpectomy) as theprimary surgical treatment for a newly discovered breast cancer is the inability to achieve an uninvolved surgicalmargin after excision of the tumor. A positive surgical margin requires, at least, reoperation with an attempt at re-excision of the cancer. If the margin of removal is positive after attempts at re-excision, this is a strong reason torecommend mastectomy in preference to breast conservation. Tumor size is a relative contraindication when the canceris so large in relation to the breast that excision to a clean surgical margin seems unreasonable. Other histologicfindings, such as tumor grade or vascular invasion, are not strong reasons to recommend mastectomy if the patientwould prefer breast conservation.

6. Axillary lymph node dissection is routinely used for all of the 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. Lymphnode dissection is not routinely required for a pure in situ cancer of the breast. In contrast, all of the other cancers listedabove (infiltrating lobular, infiltrating ductal, and medullary carcinoma) are invasive malignancies that are capable ofnodal 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 invasivecomponent might be missed histologically, many surgeons advocate selective use of axillary node dissection for largeintraductal 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 wideexcision leads to a higher rate of ipsilateral breast recurrence. However, survival and the risk of distant disease are notaltered in patients treated by excision alone, within the follow-up time of the studies and given their inherent power todetect differences in outcome. Regional node metastasis is not affected by the choice of mastectomy versus wideexcision 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

Asir Surgery MCQs Bank. © 1422H-2002- first impression ©


BreastDISCUSSION: 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 ofdisease 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 forintraductal disease would indicate a greater chance of ipsilateral breast recurrence for lumpectomy only; however, themagnitude of the risk is small, and survival is excellent and unaffected. The only mode of treatment that cannot berecommended 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. Themagnitude of this risk appears to be in the range of seven- to ninefold over baseline risk. The chance of breast cancer isequal in both breasts, not just in the biopsied breast, and the type of cancer is not confined to a lobular histology. After adiagnosis 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, nodaldissection 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 surgicaltreatment 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 trialsin which adjuvant chemotherapy for early-stage breast cancer was compared to a control group treated only withsurgery?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 whichchemotherapy after surgery was compared to surgery alone for treatment of early-stage breast cancer. This examinationof the world's published literature revealed that the magnitude of benefit (the reduction in the odds of recurrence) fromchemotherapy 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. Thevalue of adjuvant chemotherapy does not depend on the hormone receptor content of the cancer. It is useful toremember that a constant reduction in the odds of recurrence results in a higher absolute benefit as the prognosisworsens. If the chance of recurrence is 50% (for node-positive groups) the absolute reduction will be in the range of10% or 15%. In contrast, if the recurrence rate is 10%, the absolute difference between treated and control groups willbe less than 5%. This means that many patients need to be exposed to the risks and side effects of chemotherapy tobenefit a very small number. This kind of thinking is currently used to decide who should receive adjuvantchemotherapy 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 untilcompletion 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 incisionat the level of the sixth rib through the serratus muscle. A pocket is created beneath the serratus and pectoralis majormuscles, extending medially to the perforating internal mammary vessels and inferiorly beneath the fascial insertion ofthe 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 adequaterecovery period has passed. If the quantity or quality of the chest skin or the pectoralis major muscle is insufficient,Asir Surgery MCQs Bank. © 1422H-2002- first impression ©


Breasttissue must be brought in from adjacent areas. A latissimus dorsi musculocutaneous flap may be transferred on its bloodsupply via the thoracodorsal artery and vein. Extensive postmastectomy defects necessitate the use of the larger rectusabdominis musculocutaneous flap, which is based on the superior epigastric vessels. A “free” microvascular rectusabdominis or other myocutaneous flaps may be used. The thoracodorsal or anterior serratus vessels can usually beanastomosed 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 dermalpedicle flap.C. If removal of 2000 gm. of breast tissue is needed, breast amputation with immediate free nipple-areola grafting isperformed.Answer: BC

DISCUSSION: Reduction mammaplasty can be performed at any age. Because of the increased weight of the breastconsiderable shoulder and back pain, accompanied by excoriation of the skin in the inframammary area and theshoulders, can occur. Older women frequently seek relief from these problems, which can be resolved by a reductionmammaplasty. The reduction in breast volume is usually accomplished by moving the nipple and areola on a dermalpedicle flap. The flap can be based inferiorly, medially, superiorly, laterally, vertically, or horizontally. It is possible toremove up to 3000 gm. of breast tissue utilizing a pyramidal-based breast flap with an inferior dermal nipple-areolapedicle since the blood supply to the tissues is preserved by this technique. Breast reduction involving removal of morethan 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 nodesb. Nerves within the axillary fat pad include the intercostal brachial nerve, the long thoracic nerve, and

thoracodorsal nervec. Fascial bands projecting through the breast to the skin form a supporting framework known as Cooper’s

ligamentsd. 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 coursethrough the breast to the skin, forming a supporting framework of the breast parenchyma. These fascial bands, calledsuspensory ligaments of Cooper, are better developed in the upper breast. The structure of the breast can be divided intolobular and ductal elements. The lobule is the functional unit of the breast. Within a lobule, the terminal elongatedtubular ducts are referred to as alveoli. Ten to one hundred alveoli coalesce to form a larger duct which defines a lobularunit. 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 excretoryducts, each dilate into a short excretory sinus (lined with squamous epithelium) just beneath the areola. Excretory ductsthen 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 theregional lymph nodes. Studies using radioactive tracers demonstrate at least 97% of lymphatic flow from the breast isinto the axilla; the remainder courses into the internal mammary nodes. These studies also show that lymph flowing intothe internal mammary gland chain is not restricted in origin to the medial half and sub-areolar region of the breast, aswas thought, but can originate in any quadrant of the breast. In the axilla, lymphatic vessels terminate in the lymphnodes embedded within the axillary fat pad. Also within the axillary fat pad are the intercostal brachial nerves (asensory nerve supply in the under arm), the long thoracic nerve (a motor nerve to the serratus anterior and subscapularismuscles) and the thoracodorsal nerve (a motor nerve to the latissimus dorsi adjacent to its accompanying arteries andveins).

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 diagnosisb. More than 70% of breast cancer recurrence involve distant metastasesc. Pulmonary metastases are the most common initial site of distant recurrenced. 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 breasttherapy



Answer: a, b, dBreast

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, butanywhere 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. Therate of local recurrence falls from 40% to 10% if postoperative radiation therapy is given to the entire breast. Despitepotentially curative resection, at least 20% of node-negative and 60% of node-positive breast cancer patients haverecurrence 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 palpableb. One third of palpable breast cancers are not detected by mammographyc. The sensitivity of mammography increases with aged. The American Cancer Society currently recommends routine screening mammography beginning at age 40e. 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 HealthInsurance Plan of New York and the Breast Cancer Detection Demonstration project studies of screeningmammography were disseminated. These and other investigators demonstrated that 10%–50% of cancers detectedmammographically are not palpable. Conversely, palpation recognizes 10%–20% of tumors not detectablemammographically. The incidence of breast cancer begins to rise sharply at age 40, and the sensitivity of mammogramsincreases with age as the dense parenchymal tissue of young women is progressively replaced by fatty tissue. Routinescreening mammography has been shown to decrease breast cancer-related mortality in asymptomatic women over theage of 50. Controversy exists concerning the role of screening in younger woman. However, currently the AmericanCancer Society recommends that mammographic screening begin at age 40. Although sensitive, mammography is notspecific. Only about 25% of nonpalpable lesions detected mammographically are found to be malignant at biopsy. Aspiculated density with ill-defined margins on mammogram is almost certainly malignant. Most commonly, features areseen 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.

16. Which of the following statement(s) is/are true concerning radiation therapy after lumpectomy?

a. The total dose given to the breast is usually in the range of 2500 to 3000 cGyb. Radiation to the axillary nodal bed is normally part of the procedure in most patientsc. Long-term complications of radiation therapy include rib fractures and arm edemad. Breast edema and skin erythema usually resolves within a few weekse. None of the above

Answer: c

Breast conservation usually involves the use of lumpectomy and radiation therapy to achieve local control of breastcancer. 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, andminimize the dose reaching the heart and lung. The entire breast should be treated with a total dose of 4500 to 5000cGy. There is no good evidence to support a radiation boost to the site of the primary tumor. Complications from breastradiation are uncommon if performed correctly. Acute complications of radiotherapy include fatigue, breast edema, andskin 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 inflamedfluctuant area on breast examination. Which of the following statement(s) is/are true concerning her diagnosis andmanagement?

a. The most common organism which would expect to be cultured is Staphylococcus aureusb. Open surgical drainage is likely indicated

c. Breast-feeding absolutely should be discontinuedd. If the inflammatory process does not completely respond, a biopsy may be indicated



Answer: a, b, dBreast

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 andallow 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 breastinfection is suspected clinically, the possibility of an inflammatory carcinoma must also be entertained. Anyinflammatory process that does not respond completely and promptly to antibiotics or drainage should be subjected tobiopsy to rule out cancer.

18. Which of the following statement(s) is/are true concerning the surgical staging of breast cancer?

a. All biopsy specimens should be transported to pathology in formalin within 24 hours of the procedureb. Removal of only level I axillary lymph nodes may understage breast cancer in up to one-fourth of patientsc. Level III axillary lymph nodes should be removed in all axillary lymph node dissectionsd. A clinically negative axilla will be found to have histologically positive metastasis in approximately one-third

of patientsAnswer: b, d

Pathologic staging begins with the initial biopsy. Unless previously secured, fresh tumor needs to be obtained forhormone receptor analysis prior to placement into formalin solution. A period of warm ischemia as short as 30 minutesmay cause underestimation of estrogen receptor levels. The need to remove axillary nodes must be determinedpreoperatively. 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 nodesin a haphazard fashion increases the risk of injury to major axillary neurovascular structures and may understage up to25% of women. Proper staging of axillary lymph nodes should include en bloc removal and examination of level I andlevel II nodes. When conducted for staging, axillary lymph node dissection should not include removal of level IIIaxillary 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 alllevels to clear gross disease.

19. Which of the following statement(s) is/are true concerning the effect of various hormones on breast physiology?

a. Estrogen receptors are present only in breast cancer cellsb. Mammary ductal dilatation and differentiation of alveolar epithelial cells and secretory cells are the result of

rising progesterone levelsc. The early first trimester breast changes are primarily due to the increased progesterone effects of pregnancyd. Milk production and secretion after childbirth are maintained by ongoing secretion of prolactin by the anterior

pituitary glandAnswer: b, d

Breast growth, development, and function are orchestrated by a variety of hormones and growth factors. Estrogen playsa central role in breast development, growth, and differentiation. Lipid-soluble estrogens gain entry to the normal andmalignant 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 breasttissue and in some breast cancers result in their testing negative in clinical assays. Cyclic changes associated with themenstrual cycle have a profound influence on breast morphology and physiology. During the period of relativequiescence, increasing Graafian follicle secretion of estrogen stimulates breast epithelial proliferation. As the lutealphase of the cycle is entered, progesterone levels rise. Mammary ductal dilatation and differentiation of alveolusepithelial cells into secretory cells result. At the onset of menstruation, the rapid decline of circulating sex-hormonelevels leads to breast involution and the cycle begins anew. During pregnancy, marked ductular, lobular, and alveolargrowth 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 andlobular formation proceed under estrogenic influence. During the second trimester, lobular events predominate underthe influence of progestins. Abrupt withdrawal of placental lactogen and sex-hormones that occurs with delivery, leavesthe 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.



Breast20. 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 betterb. If the patient is ER-positive, hormonal therapy should be the first line of treatmentc. The response to chemotherapy will likely be dose-dependentd. 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-negativetumors, 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. Allregimens are slightly less active in post-menopausal women. Response rates are highest in women who have notreceived prior treatment for metastatic disease. Prior adjuvant therapy is not consistently associated with a poorerresponse to therapy, particularly if a long interval has lapsed between adjuvant therapy and the development ofmetastases. Endocrine therapy is appropriate as the first-line treatment for nearly all women with ER-positive metastaticbreast 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.

21. Which of the following statement(s) is/are true concerning intraductal papilloma?

a. This lesion is the most common cause of bloody nipple dischargeb. Serous non-bloody discharge is unlikely to be due to an intraductal papillomac. A nonpalpable lesion can often be diagnosed with ductographyd. 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, thedischarge 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 thedischarge. An isolated intraductal papilloma is not considered premalignant nor does it place the patient at increasedrisk for breast cancer. Unlike isolated papillomas, diffuse papillomatosis is associated with an increased risk of breastcancer, 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 trueconcerning her diagnosis and treatment?

a. Mammography will play an important role in diagnosing the lesionb. Ultrasonography is often useful in the differential diagnosis of this lesionc. The mass should always be excisedd. The lesion should be considered pre-malignant

Answer: b

Fibroadenoma represents the most common tumor in adolescents and young woman, but if also frequently encounteredin 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 amass usually reveals a well-circumscribed, oval or round, mobile mass with a firm, rubbery texture. Because themammographic appearance of a fibroadenoma is rarely characteristic, mammography plays little role in diagnosing thislesion. 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. Excisionalbiopsy is not necessary for every fibroadenoma. Women under 30 years of age with characteristic physical examinationand sonographic appearance of the fibroadenoma may be given the option of observation. Generally, fibroadenomas arenot 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 35c. Use of oral contraceptives



d. High-fat, high-caloric diete. Post-menopausal use of conjugated estrogens

Answer: a, d

Breast

Women who undergo oophorectomy before age 35 and do not take replacement estrogens have a two-thirds reduction intheir breast cancer risk. Replacement estrogen therapy eliminates the beneficial effect of oophorectomy. Mostinvestigations 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. Mostcontemporary studies fail to demonstrate an association between breast cancer risk and post-menopausal use ofconjugated estrogens.BREAST CANCER RISK FACTORS

DEMOGRAPHIC FACTORSAge more than 30 yFemale gender (130:1 female/male ratio)

GREATLY INCREASED RISKKnown carrier of breast cancer susceptibility geneStrong family history—two or more first-degree relatives withbilateral or premenopausal breast cancerAtypical ductal or lobular hyperplasia or lobular carcinoma in situDuctal carcinoma in situ, risk limited to ipsilateral breast

MODERATELY INCREASED RISKFamily history—one or more relatives with breast cancer, notbilateral or premenopausalMenstrual history—menarche before age 12 y, menopause afterage 55 yParity—nulliparity or first live birth after age 30 yRadiation—exposure to low-dose ionizing radiation in childhood oradolescencePrevious breast cancer—low-grade, node-negative, or receptor-positive; lobular histologyOther cancers—colon or endometrial cancerDiet—high-fat or high-calorie diet

24. Which of the following chromosomal and/or genetic abnormalities is/are associated with the development of breastcancer?

a. Mutations in the p53 tumor suppressor geneb. A mutation in the short arm of chromosome 2c. The presence of a BRCA 1 gene on chromosome 17d. 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 hasan 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 mutationhas been characterized on the short arm of chromosome 2 in a gene associated with DNA repair. Predisposition to awide range of malignancies, including breast and colon cancer is associated with abnormalities at this locus. The mostexciting development in inherited susceptibility to breast cancer relate to the identification and cloning of the BRCA 1gene, which was initially localized on the long arm of chromosome 17 by linkage analysis. Germline abnormalities inBRCA a may be responsible for as many as 5% of all breast cancers in the United States. The gene is characterized byautosomal dominant inheritance with a high degree of penetrance. Almost 60% of women inheriting the gene willdevelop breast cancer by age 50, and a lifelong risk approaches 85%. Another breast cancer susceptibility gene, dubbedBRCA 2, has been localized by linkage analysis to a small region of chromosome 13q12-13. BRCA 2 apparentlyconfers the high-risk of early onset female breast cancer. Similar to BRCA 1, the lifetime breast cancer risk approaches90% in carriers of this gene.

25. A 45-year-old woman presents with a weeping eczematoid lesion of her nipple. Which of the followingstatement(s) is/are true concerning her diagnosis and management?



a. Treatment is with warm compresses and oral antibiotics

Breast

b. Biopsy of the nipple revealing malignant cells within the milk ducts is invariably associated with an underlyinginvasive carcinoma

c. The appropriate treatment is mastectomyd. 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 andinflammation. Biopsy of the nipple reveals malignant cells within the milk ducts. The lesion is invariably associatedwith an underlying invasive or in situ ductal carcinoma. The prognosis of Paget’s disease is that of the underlyingcancer. 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 associatedwithfibrocystic breast disease?

a. Avoidance of methylxanthine compounds, particularly caffeineb. Cessation of smokingc. Vitamin Ed. 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 breastnodularity by limiting or eliminating caffeine intake. Mastodynia patients should be advised to eliminate caffeinebeverages for a period of 2 to 3 months to determine if there has been improvement in their symptoms. In addition tocaffeine abstention, patients should be urged to stop smoking because nicotine is purported to worsen mastodynia. Anumber of medications have been advocated for the treatment of mastodynia. Unfortunately, because of the subjectivenature of the disease and its propensity to be better tolerated by patients with reassurance, the exact method of most ofthese interventions is unclear. Vitamin E has been touted as beneficial, however, clinical data do not support the use ofthis or other vitamins for this condition. The use of hormonal agents to treat mastodynia has been more extensivelytreated. Danazol, a weak antigen, is the most effective drug available for treatment of mastodynia related to fibrocysticdisease. Unfortunately, Danazol’s androgenic side effects are troublesome enough to restrict its use to the mostproblematic cases of mastodynia. Other hormonal agents have been investigated for the management of mastodynia. Inyoung women, oral contraceptives have a variable effect on mastodynia. A trial and error search for optimalpreparations 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 significanceb. Breast reconstruction may interfere with detection of local recurrence of breast cancerc. Maintenance of an effective subpectoral pocket for a breast implant requires preservation of the pectoralis

fasciad. 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. Breastreconstruction may be performed at the time of mastectomy (immediate) or sometime subsequently (delayed) Becausethe 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 ofbreast reconstruction is of no oncologic significance. Because most local recurrences occur in the skin’s subcutaneoustissues, the presence of a reconstruction will not interfere with detection. Similarly, a reconstruction does not complicatethe 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 themedial pectoral nerve during mastectomy. The transferase rectus abdominous myocutaneous (TRAM) flap is theautogenous 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.



Breast28. Which of the following statement(s) is/are true concerning the histologic variants of invasive breast carcinoma?

a. The presence of an in situ component with invasive ductal carcinoma adversely affects prognosisb. Medullary carcinomas, although often of large size, are associated with a better overall prognosis than

common invasive ductal cancersc. Mucinous or colloid carcinoma is one of the more common variants of invasive ductal cancerd. 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 singlemicroscopic feature specific for infiltrating ductal carcinoma, it can be recognized histologically as an invasiveadenocarcinoma 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 ductalepithelium and are hence classified as variants of invasive ductal carcinoma. There are distinct histologic criteria forclassifying these lesions; these criteria must be met throughout the entire tumor. Prognostically, histologically pureexamples of these variant tumors are associated with a better long-term survival than ordinary type invasive ductalcarcinoma. 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 forprognostic purposes. In many cases, when areas of in situ ductal carcinoma are seen, the presence of an in situcomponent does not adversely affect prognosis, although it jeopardizes the attempts at breast conservation. Medullarycarcinoma is one of the more common variants, accounting for approximately 6% of all invasive breast cancers. Thesetumors 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. Invasivelobular 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 invasivelobular carcinoma. The contralateral breast is involved either synchronously (3% of patients) or metachronously in up to30% 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 womenb. Total mastectomy is necessary for all patients with this diagnosisc. Axillary lymph node dissection is not necessary for malignant cystosarcoma phyllodesd. 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 apainless breast mass. Phyllodes tumor is most commonly encountered in women age 30–40 years of age but can occurat 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 actuallydevelop metastatic disease. The optimum treatment for benign or malignant phyllodes tumor is wide excision with amargin of normal breast tissue. The margin must be histologically free of involvement because even benign lesions canrecur after incomplete excision. If this can be done leaving an adequate cosmetic appearance, mastectomy is notnecessary. Total mastectomy is reserved for large lesions in small-breasted women or recurrences after previous localexcision that is not amenable to repeat local excision. Axillary lymph node dissection is not performed in the absence ofbiopsy-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 issimilar for node-negative and node-positive patients

b. Most patients with local-regional recurrence of their disease will eventually die of metastatic diseasec. The treatment of local recurrence following mastectomy includes local radiation therapy and systemic

chemotherapyd. In-breast recurrence following breast conserving surgery is not a negative prognostic factore. 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% ofnode-negative and 8.8% of node-positive women had chest wall recurrence as their initial site of failure. By ten yearsAsir Surgery MCQs Bank. © 1422H-2002- first impression ©


Breastafter local-regional recurrence, about 60% of initially node-negative and almost all (> 90%) of initially node-positivepatients 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 oftenrapidly followed by metastatic disease, it is logical to postulate a role for adjuvant systemic therapy once local measureshave achieved control of chest wall disease.Recent data suggests that in-breast recurrence following breast conservation is a prognostic factor. Women who developan 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 positivityb. Increased thymidine labeling index, a measure of the proportion of cells in the DNA synthetic phase (S-phase),

is associated with improved survivalc. High tumor levels of cathepsin D are associated with an improved prognosisd. Immunohistochemical demonstration of active angiogenesis correlates with increased metastatic potential and

poor prognosisAnswer: a, d

32. Which of the following statement(s) is/are true concerning adjuvant systemic therapy?

a. Adjuvant tamoxifen in post-menopausal, node-positive, ER-positive women is equivalent to cytotoxicchemotherapy

b. Tamoxifen clearly improves survival in all hormonal receptor-positive patientsc. CMF is associated with improved overall survival in both pre-menopausal and post-menopausal node-positive

patientsd. 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 withhistologically 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 thetreatment 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-menopausalpatients with positive lymph nodes. In post-menopausal women with positive nodes, there is an improved disease-freesurvival, but there is no significant difference in overall survival. Several trials of adjuvant chemotherapy with CMF orrelated regimens have been conducted in node-negative patients. The early results of all of these trials have beensimilar: disease-free survival is definitely improved with adjuvant chemotherapy. These studies are definitely notmature enough to draw definitive conclusions regarding overall survival. Therefore, the National Cancer Institute hasrecommended the use of adjuvant chemotherapy for all patients with tumors large enough to have hormonal receptorlevels 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 ofmalignant diagnosis

b. The accuracy of mammographic-directed fine needle aspiration biopsy is comparable to that achieved for thatof palpable lesions

c. Core-needle biopsy showing normal breast tissue is an acceptable diagnosisd. 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 examinationor 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 detectedbreast masses. The technique is both reliable and accurate. The incidence of false-positive findings is generally less than0.5%. 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 rangesfrom 7% to 99%; with 85% a good estimate of the true sensitivity in clinically relevant settings. Recently, x-ray-guidedAsir Surgery MCQs Bank. © 1422H-2002- first impression ©


BreastFNAB 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 ofpalpable lesions. Core-needle biopsy is a helpful tissue sampling method for palpable masses. The tissue obtained isuseful for histologic analysis although inadequate for cytosol hormone receptor determination. The technique is alsoapplicable 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 masspalpable. 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 diagnosisb. Frozen-section examination is particularly useful in the diagnosis of this lesionc. Intense interlobular fibrosis and proliferation of small ductules with loss of orientation of lobules and epithelial

cells may suggest carcinomad. 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 cancerdevelopment. It is, however, one of the benign breast processes most likely to be confused radiologically andhistologically with cancer. Most commonly, it is detected on routine mammography as cluster microcalcificationswithout an associated palpable mass. In these cases, needle localization and excision are required to establish adiagnosis. Sclerosing adenosis microscopically is characterized by interlobular fibrosis and proliferation of smallductules. 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 beparticularly difficult and should not be attempted.

35. Which of the following conclusion(s) can be drawn from the results of the NSABP prospective randomized trialscompleted in the 1970’s and 1980’s?

a. Delay of axillary node dissection until there is clinical evidence of disease does not influence overall survivalb. Removal of clinically negative nodes has no therapeutic benefitc. Breast irradiation reduces both local recurrence and overall survivald. 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 aseries of studies conducted during the 1970’s and 1980’s by the NSABP. In the first of these protocols, totalmastectomy 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 ofaxillary node dissection until there is clinical evidence of disease does not influence survival emphasizes that the role ofaxillary dissection in clinically node negative patients is solely for staging. The removal of clinically negative nodes hasno 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, andbreast or irradiation were compared in small breast cancers. Modified radical mastectomy offered no advantage overother 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 notaffect 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 ductalcarcinoma in the same quadrant of the same breast as the initial lesion

b. DCIS should not be treated with breast conservation therapyc. Lobular carcinoma in situ (LCIS) is the most common form of non-invasive breast cancerd. When LCIS is found, there is an up to 50% chance of lobular carcinoma in situ of the contralateral breaste. 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 DCISdoes not differ significantly from that of invasive ductal carcinoma. Not every woman who undergoes completeAsir Surgery MCQs Bank. © 1422H-2002- first impression ©


Breastexcision of a focus DCIS develops invasive ductal cancer. Various studies suggest half or more patientsdevelopinvasive breast cancer after excisional biopsy alone. When a subsequent invasive cancer does occur, it is almost alwaysof the invasive ductal type and located in the same quadrant of the breast as the initial DCIS. The latent period beforethe development of invasive cancer usually exceeds five years. Total mastectomy is usually associated with a nearly100% cure rate for this condition. Although total mastectomy remains the gold-standard for treatment of DCIS, there isincreasing experience with breast-conserving therapy. Breast conservation may be offered to DCIS patients in whomthe entire tumor can be surgically removed with negative histologic margins and in whom the remaining breast tissuecan be reliably assessed clinically and radiographically. It would appear that the disease-free survival followinglumpectomy and radiation therapy is worse than that achievable with simple mastectomy. Therefore, breastconservation for DCIS commits patients to more careful long-term follow-up and will likely subject them to additionalsubsequent 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-fourthsof affected women are pre-menopausal. LCIS is an infrequent finding in women over 75. When the opposite breast issampled at the time of diagnosis, contralateral LCIS is found in 30–50% of cases. The prognosis of LCIS is solelyrelated to the subsequent development of invasive carcinoma. About one-third of patients with biopsy-demonstratedLCIS develop invasive cancer; half occur in the index breast and half in the contralateral breast. The subsequent breastcancers 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 concerningher diagnosis and management?

a. Bilateral galactorrhea is suggestive of an underlying endocrinopathyb. Brownish discharge is usually suggestive of old blood and is worrisome for an underlying breast cancerc. Expressible bloody nipple discharge should be evaluated with a ductogramd. 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 nippledischarge is lactation. Milk may continue to be secreted intermittently for as long as two years after breast feeding hasstopped, particularly with breast stimulation. A milky whitish discharge, usually bilateral, that is not related to lactationor breast stimulation is termed “galactorrhea.” The presence of bilateral galactorrhea should prompt an evaluation forunderlying endocrinopathy causing increased prolactin secretion by the pituitary. Classically, this is associated withamenorrhea, but galactorrhea may be the only sign of hypoprolactinemia. Nipple discharges associated with fibrocysticdisease are generally, green, yellow, or brown, Intraductal papillomas and cancer lead to a bloody or blood-tingedserous discharge. The brownish discharge of fibrocystic disease can easily be confused with old blood. A guaiac test orsimply dabbing the discharge with a gauze pad and examining the stain can usually differentiate the two. A bloody orblood-tinged discharge must be promptly evaluated to exclude carcinoma. If the discharge is expressible at the time thepatient 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 breastb. Skin ulcerationc. Lateral arm edemad. Dermal lymphatic invasion

Answer: a, b, c, d

The histologic hallmark of inflammatory breast cancer is dermal lymphatic invasion demonstrable on skin biopsy. Thestigmata 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-relatedb. The standard surgical treatment is subcutaneous mastectomyc. The presence of gynecomastia is often associated with the subsequent development of breast cancerd. 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 ortestosterone deficiency are associated with gynecomastia. In many cases, no cause is found. Clinically significantAsir Surgery MCQs Bank. © 1422H-2002- first impression ©


Breastgynecomastia has been associated with the use of a number or drugs including cimetidine, digoxin, spironolactone andtricyclic antidepressants. The use of marijuana has also been associated with gynecomastia. Drug-related gynecomastiais often unilateral or unequal between the two breasts, and discontinuation of the offending drug does not always lead toresolution of the condition. A formal endocrine evaluation is not indicated for gynecomastia unless some other sign ofhormonal imbalance is found on routine evaluation. The standard surgical treatment of gynecomastia consists ofsubcutaneous mastectomy performed under local anesthesia. The presence of gynecomastia is not associated with thesubsequent development of cancer, yet protracted hyperestrogenemic states, which are associated with gynecomastia arelinked to breast cancer development.

breast surgery

Health & Medicine

tubular carcinoma

mucinous carcinoma

lobular carcinoma

inflammatory carcinoma

infiltrating ductal

increased cancer risk

increased risk of cancer

fibrocystic disease