20- Breast & Endocraniology MSQs Only Flashcards
1 of 67
A 38 year old lady has undergone a mastectomy and axillary node clearance for invasive ductal carcinoma. The histology report shows a completely excised 3.5cm lesion which is grade 3. Two of the axillary lymph nodes contain metastatic disease. The tumour is oestrogen receptor negative. What should be the next course of action?
Administration of cytotoxic chemotherapy
The combination of a grade 3 tumour and axillary nodal metastasis in a young female would attract a recommendation for chemotherapy. Some may also add herceptin (if they are HER 2 positive).
10 of 67
A 45 year old man is referred to the breast clinic with gynaecomastia. He takes the drugs listed below. Which is least likely to be the cause of his symptoms?
Spironolactone
Carbimazole(Right)
Chlorpromazine
Cimetidine
Methyldopa
…………………………………………
Mnemonic for drugs causing gynaecomastia: DISCO
D igitalis
I soniazid
S pironolactone
C imetidine
O estrogen
Mnemonic for causes of gynaecomastia: METOCLOPRAMIDE
M etoclopramide
E ctopic oestrogen
T rauma skull/tumour breast, testes
O rchitis
C imetidine, Cushings
L iver cirrhosis
O besity
P araplegia
R A
A cromegaly
M ethyldopa
I soniazid
D igoxin
E thionamide
Carbimazole is not associated with gynaecomastia. Note the question asks for the least likely cause.
11 of 67
A 55 year old woman presents with nipple discharge. On examination, she has a slit like retraction of the nipple in the centre of this area is a small amount of cheese like material. No discrete mass lesion is palpable in the underlying breast. Which of the factors listed below is most strongly associated with developing this condition?
Smoking
Smoking is a major risk factor for duct ectasia
12 of 67
A 27 year old lady presents with a breast lump. She has previously undergone a breast augmentation with an implant. Which of these imaging techniques is the most appropriate next step?
Ultrasound
Unless there are concerns about implant rupture, the imaging of a breast lump in a young patient with implants would be USS initially. If this is not conclusive then MRI should be performed.
13 of 67
A 45 year old lady presented with a 2cm mobile breast mass. A mammogram is indeterminate (M3), USS shows benign changes (U2), clinical examination is also indeterminate (P3). What is the next most appropriate course of action?
Image guided core biopsy
…………………………………………………….
Core biopsy Vs fine needle aspiration cytology
Core biopsy is preferred over FNAC by most surgeons. The reason for this is that FNAC often yielded inadequate tissue for assessment. When FNAC demonstrated benign changes, it had to be repeated at least once to confirm this. If it yielded cells that were indeterminate, then a core biopsy was needed. A core biopsy removes many of these stages and is thus more reliable.
All discrete breast lumps, including those that seem benign, should have a confirmed histological diagnosis. In this case, a core biopsy has not yet been performed. This may yield a diagnosis that is concordant with imaging findings. In which case, this concludes the investigative process (if benign). If it remains unclear, excision biopsy will be needed.
14 of 67
A 43 year old lady is diagnosed as having a malignant lesion in the inferior aspect of her left breast. There is palpable axillary lymphadenopathy. What is the most appropriate course of action?
Image guided fine needle aspiration of the axillary nodes
Where axillary nodal involvement is suspected from the outset it is important to establish whether this is the case prior to surgery. This is because, if axillary metastatic disease is present then the correct management would be an axillary node clearance and this is irrespective of the surgical plans for the breast primary.
In the case of breast cancer, image guided FNAC is acceptable as it is accurate and if carcinoma cells are identified at FNA then axillary node clearance can be performed. If FNAC is negative then a sentinel node biopsy should accompany excision of the primary tumour.
Where the axilla is clinically clear on palpation and imaging then a sentinel lymph node biopsy should accompany excision of the primary tumour.
15 of 67
A 35 year old woman has undergone a wide local excision. The histology shows an invasive lobular carcinoma present at 3 of the resection margins. Cavity shavings taken at the original operation are also involved. Sentinel node biopsy was negative. What is the most appropriate course of action?
Arrange for completion mastectomy alone
This patient has an extensive disease process and lobular cancers are notorious for being multifocal. In this case a mastectomy is the safest next step. Radiotherapy is not appropriate in this setting as the margins are not clear.
16 of 67
A 55 year old man is on the intensive care unit for many months after open aortic surgery. He is maintained on total parenteral nutrition. Clinically he is euthyroid, but his thyroid function tests reveal a low TSH and low T4. What is the most likely diagnosis?
Sick euthyroid syndrome
Sick euthyroid syndrome is most commonly seen in chronically ill patients or those with starvation. The thyroid function tests are often low and the patient clinically euthyroid.
17 of 67
Which of the following statements regarding papillary carcinoma of the thyroid is false?
They account for the majority of thyroid carcinomas
Spread predominantly via the lymphatics
May be diagnosed using fine needle aspiration cytology
When viewed microscopically may demonstrate ‘orphan Annie ‘nuclei
Have a five year survival of 65% if confined to the thyroid alone(Right)
……………………………………………………..
The prognosis for localised papillary carcinomas is excellent. Survival rates at 5 years approach 90%.
18 of 67
A 55 year old women presents with nipple discharge. On examination, she has a slit like retraction of the nipple in the centre of this area is a small amount of cheese like material. No discrete mass lesion is palpable in the underlying breast. What is the commonest underlying cause?
Duct ectasia
Duct ectasia is a common alteration in the breast that occurs with aging. As the ducts shorten and dilate a degree of symmetrical slit like retraction occurs. A small amount of cheese like discharge may occur.
19 of 67
A 48 year old lady with thyrotoxicosis is referred to the clinic, she was poorly controlled on carbimazole and has received orbital radiotherapy for severe proptosis. This has improved matters but she relapsed on stopping her carbimazole. What is the most appropriate course of action?
Total thyroidectomy
The recurrence of symptoms following medical therapy attracts a recommendation for definitive treatment. Since radio-iodine can worsen eye signs, this is not a wise choice. Surgery in the form of a total thyroidectomy would be curative.
2 of 67
Which of the blood tests listed below is most likely to be abnormal in a 33 year old lady presents with a recently diagnosed goitre and a diagnosis of Hashimotos thyroiditis is suspected?
Thyroid peroxidase antibodies
Antibodies to thyroid peroxidase are found in most patients with Graves disease or Hashimotos thyroiditis.
20 of 67
A 55 year old woman complains of nipple discharge. This was blood stained on one occasion. But not subsequently. Clinical examination shows clear fluid but no discrete lump. Imaging with ultrasound and mammography is normal. What is the best course of action?
Microdochectomy
Although this is likely to be benign disease, her age coupled with an episode of blood stained discharge would attract a recommendation for microdochectomy. She may have an intraductal papilloma. But the concern would be DCIS.
21 of 67
A 52 year old woman presents with a neck swelling. On examination she is noted to have single nodule on the thyroid gland. A CXR shows two mass lesions. What is the most likely cause?
Follicular thyroid cancer
A solitary nodule with signs of haematogenous spread indicates a follicular tumour. Note that papillary tumours tend to be multinodular and spread via the lymphatic system. Lymphatic spread from a papillary thyroid cancer is nearly always to neck nodes in the first instance and mediastinal lymphadenopathy is vanishingly rare. Lung lesions are typically synonymous with haematogenous metastasis of which a follicular lesion is the most likely culprit.
22 of 67
A 32 year old Indian lady presents with a diffuse swelling of the left breast. She has a 4 month old child. Clinically, she has jaundice and there is erythema of the left breast. Which of the following lesions is most likely?
Inflammatory carcinoma
Inflammatory breast cancers have an aggressive nature. Dissemination occurs early and is more resistant to adjuvant treatments than other types of breast cancer. Often occurs in pregnancy or lactation.
23 of 67
A 34 year old lady is admitted with recurrent episodes of non-specific abdominal pain. On each admission all blood investigations are normal, as are her observations. On this admission a CT scan was performed. This demonstrates a 1.5cm nodule in the right adrenal gland. This is associated with a lipid rich core. Urinary VMA is within normal limits. Other hormonal studies are normal. What is the most likely diagnosis?
Benign non functional adenoma
This is typical for a benign non functional adenoma. Benign adenomas often have a lipid rich core that is readily identifiable on CT scanning. In addition the nodules are often well circumscribed.
24 of 67
You are the specialist trainee in endocrinology clinic. The medical team have referred a man for a parathyroidectomy who has a corrected calcium of 2.82 (elevated) and a PTH of 11 (elevated). Which of the following is not an indication for parathyroidectomy in this case?
Nephrolithiasis
Reduction in bone mineral density of the femoral neck, lumbar spine, or distal radius of more than 2.5 standard deviations below peak bone mass
Age < 50 years
Episode of life threatening hypercalcaemia
None of the above(Right)
…………………………………….
All of the situations listed are indications for parathyroidectomy. See below for more information.
25 of 67
An 88 year old lady presents with a large mass in the upper inner quadrant of her right breast. Investigations confirm an oestrogen receptor positive, invasive ductal carcinoma. She has declined operative treatment. What is the best course of action?
Administration of letrozole
Elderly patients may be managed using endocrine therapy alone. Eventually most will escape hormonal control. In post menopausal women oestrogens are produced by the peripheral aromatization of androgens and aromatase inhibitors are therefore the most popular agent in this age group.
27 of 67
A 53 year old lady presents with a creamy nipple discharge. On examination, she has discharge originating from multiple ducts and associated nipple inversion. What is the most likely cause?
Duct ectasia
Duct ectasia is common during the period of breast involution that occurs during the menopausal period. As the ducts shorten they may contain insipiated material. The discharge will often discharge from several ducts.
26 of 67
A 56 year old lady undergoes a mastectomy as treatment for multifocal ductal carcinoma in situ. Two weeks post operatively she attends the clinic and complains of a diffuse swelling at the surgical site. On examination she has a large, fluctuant area underlying the mastectomy skin flaps. She is otherwise well. What is the most likely cause?
Seroma
Seromas are very common after breast surgery. The exposed raw surfaces created during the elevation of the skin flaps are a common cause. Treatment usually involves percutaneous drainage under aseptic conditions.
28 of 67
A 21 year old female notices a bloody discharge from the nipple. She is otherwise well. On examination, there are no discrete lesions to feel and mammography shows dense breast tissue but no mass lesion. What is the most likely cause?
Intraductal papilloma
Intraductal papillomata are the commonest cause of blood stained nipple discharge in younger women. There is seldom any palpable mass. An ultrasound is required and possibly a galactogram.
29 of 67
A 38 year old man is noted to have a blood pressure of 175/110 on routine screening. On examination there are no physical abnormalities of note. CT scanning shows a left sided adrenal mass. Plasma metanephrines are elevated. What is the most likely cause?
Phaeochromocytoma
Hypertension in a young patient without any obvious cause should be investigated.
Urinary VMA and plasma metanephrines are typically elevated.
3 of 67
A 23 year old lady has Graves disease that has relapsed on stopping anti thyroid drugs, radioiodine is offered as the next treatment by the endocrinologists. Which statement is false?
Close contact with children is not permitted for up to 4 weeks following treatment
15% of patients with opthalmopathy will see worsening of eye signs
Symptomatic improvement takes 6-8 weeks
Up to 80% of patients will become hypothyroid
It increases the risk of parathyroid carcinoma(Right)
…………………………………………………………..
Radio-iodine- may worsen opthalmopathy, contraindicated in pregnancy and those wishing to concieve within 6 months.
31 of 67
Administration of which of the following may facilitate the identification of parathyroid glands intra operatively?
Methylene blue intravenously
Methylene blue stains the parathyroid glands and can be useful in facilitating their identification.
30 of 67
A 59 year old lady undergoes a breast reconstruction following a mastectomy. A breast implant is placed anterior to pectoralis major. What is the most appropriate method of wound closure?
Use of a pedicled myocutaneous flap
The use of a pedicled latissimus dorsi flap is a common method of providing breast reconstruction over an implant. Free flaps do not heal are reliably as pedicled ones and these would therefore be used in preference in this particular setting.
33 of 67
A 44 year old lady presents with a mass in the upper outer quadrant of her right breast. Imaging, histology and clinical examination confirm a 1.5cm malignant mass lesion with no clinical evidence of axillary nodal disease. What is the most appropriate treatment?
Wide local excision and sentinel node biopsy
………………………………………………………….
Small peripheral breast cancers are well suited to breast conserving surgical techniques.
A small peripheral lesion such as this would usually be suitable for breast conserving surgery. Since imaging and clinical examination is not suspicious for axillary disease, a sentinel lymph node biopsy should be performed. Axillary node sampling is a procedure that become obsolete with the introduction of sentinel node biopsy.
32 of 67
Which of the following are not true of follicular thyroid cancer?
They often appear to be encapsulated.
Those with a Hurthle cell subtype have an excellent prognosis.(Right)
Haematogenous metastasis is more common than in Papillary carcinoma.
The overall mortality rate is 24%.
Vascular invasion is seen in up to 60% of cases.
…………………………………………………..
The Hurthle cell subtype have a worse prognosis.
34 of 67
A 72 year old female presents with a painless breast lump. Clinically, she has a 4cm diameter irregular breast mass, with no other palpable masses. What is the most likely lesion?
Invasive ductal carcinoma
A post menopausal woman is more likely to have a ductal carcinoma and they tend to occur at a single focus within the breast.
35 of 67
A 55 year old lady has undergone a wide local excision and sentinel lymph node biopsy for breast cancer. The histology report shows a completely excised 1.3cm grade 1 invasive ductal carcinoma. The sentinel node contained no evidence of metastatic disease. The tumour is oestrogen receptor negative. What is the next course of action?
Arrange radiotherapy
Radiotherapy is routine following breast conserving surgery. Without irradiation the local recurrence rates are approximately 40%. These rates are potentially lower in older patients who receive endocrine therapy and who have small low grade tumours.
36 of 67
A 52 year old woman presents with a neck swelling. Her GP reports that her TSH value is low at 0.01. A scintigraphy demonstrates a hot nodule. What is the most likely diagnosis?
Toxic adenoma
This lady has thyrotoxicosis (low TSH) and a hot solitary nodule indicating a toxic adenoma. Thyroid cancer rarely causes thyrotoxicosis or hot nodules.
