Breast

Question 1

Concerning breast cancer, which of the following is LEAST correct?

1. Only approx. 10% of breast cancers present as pain
2. Only 10% of palpable masses under 40 years of age are malignant
3. Galactorrhea is not associated with primary breast malignancy
4. Only 2 – 4% of breast malignancies are mammographically occult
5. The most common cause of a bloody discharge is ductal neoplasm (either in situ or invasive)

Answer 1

4. *Only 2 – 4% of breast malignancies are mammographically occult

Question 2

Concerning Breast Cancer mimics, which of the following is LEAST correct?

1. About 50% of women with fat necrosis have a history of recognised previous trauma or surgery
2. Lymphocytic mastopathy / sclerosing lymphocytic lobulitis is more common in diabetics or patients with autoimmune thyroid disorders
3. Granulomatous mastitis only occurs in parous women
4. While rare localised tuberculous infection can be seen in immunosuppressed patients or patients with piercings
5. Piercings/ Nickel allergy is a cause of deep granulomatous response due to ion concentration in ductal fluid

Answer 2

5. *Piercings/ Nickel allergy is a cause of deep granulomatous response due to ion concentration in ductal fluid

Question 3

Concerning Breast carcinomas, which of the following is most correct?

1. By the age of 90 the risk of breast carcinoma in our community is 5%
2. They are most commonly HER -ve
3. Average age of diagnosis is 70 – 80 years of age
4. Risk of death is approximately 40%
5. Approximately 45 -50% of patients have a sibling or 1 st generation relative with breast cancer

Answer 3

2. *They are most commonly HER -ve

Question 4

Concerning BRCA1 and 2 mutations, which of the following is most correct?

1. These account for 20% of breast carcinomas
2. The risk of breast cancer can be 30 - 90%
3. BRACA 2 has a higher risk of ovarian cancer than BRCA1 (and in the order of 50-60%)
4. BRCA 1 and 2 do not affect breast cancer risk in affected males
5. A mutation / polymorphism in the BRCA1 or 2 coding implies a risk of breast cancer

Answer 4

2. *The risk of breast cancer can be 30 - 90%

Question 5

Concerning BRCA 1 mutation associated breast carcinomas. Which of the following is most correct?

1. There is an increased risk (and increased likelihood) of medullary carcinomas - which are often circumscribed masses
2. There is an increased proportion of papillary carcinomas (which are most common small stellate lesions)
3. There is an increase in ductal but lobular carcinomas
4. There is no specific subtype increase in carcinomas
5. There is an increased risk for all breast neoplasms

Answer 5

1. • There is an increased risk (and increased likelihood) of medullary carcinomas - which are often circumscribed masses

Question 6

Which of the following conditions is LEAST associated with epithelial proliferative change?

1. Complex sclerosing lesions
2. Epithelial hyperplasia
3. Sclerosing adenosis
4. Fibrocystic change
5. Papilloma

Answer 6

4. *Fibrocystic change

Question 7

Concerning LCIS, which of the following is most correct?

1. Is classically associated with microcalcifications on mammography
2. Is most commonly detected as a palpable abnormality due to associated desmoplasia
3. LCIS is bilateral in 2-4% of cases
4. The risk of subsequent invasive carcinoma is similar to DCIS but is similar for both breasts
5. Confirms an increased risk of lobular carcinoma but not other subtypes

Answer 7

4. *The risk of subsequent invasive carcinoma is similar to DCIS but is similar for both breasts

Question 8

Concerning Breast carcinoma subtypes which of the following is LEAST correct?

1. Lobular carcinomas have a higher than average incidence of diffuse/ infiltrative margins
2. Mucinous carcinomas have a higher than average incidence of appearing as circumscribed masses
3. Tubular carcinomas have a higher than average incidence of appearing as small stellate lesions
4. Inflammatory carcinomas, while a clinical type, are predominately mucinous
5. Lobular carcinomas have a higher than average incidence of peritoneal, retroperitoneal and leptomeningeal metastasis

Answer 8

4. *Inflammatory carcinomas, while a clinical type, are predominately mucinous

Question 9

Concerning male breast cancer, which of the following is LEAST correct?

1. On average they occur at earlier age than females
2. Risk factors include Klinefelter’s syndrome BRAC-1 and BRAC-2 mutations
3. They are most common in the upper outer quadrant
4. Axillary nodal metastases are present in approx. 50% at presentation
5. Prognosis is similar to similar disease in women when matched for stage

Answer 9

1. *On average they occur at earlier age than females

Question 10

Which lesion is most likely a B2 lesion? (March 2016)

a. Atypical lobular hyperplasia
b. Atypical ductal hyperplasia

Answer 10

Lesions within BI-RADS category 2:
o	Calcified fibroadenomas
o	Multiple secretory calcifications
o	Fat containing lesions:
(- Oil cysts; Breast lipomas; Galactocoeles; Mixed density hamartomas)
o	Cutaneous neurofibromas
o	Inflammatory lymph nodes
o	Breast sebaceous cysts
o	Simple breast cysts

Borderline breast disease:
o Atypical ductal hyperplasia
- Excision biopsy. Often upgrades to DCIS
o Atypical lobular hyperplasia
- Incidental finding; Similar implication to LCIS
o Columnar alteration w prominent apical snouts & secretions (CAPSS)
o Lobular intra-epithelial neoplasia
o Radial scar: complex sclerosing lesion
- Associated underlying lesions: DCIS (30%); Tubular ca; Atypical ductal hyperplasia; Atypical lobular hyperplasia

ANSWER: Neither of the responses are benign lesions (BI-RADS 2), and are both considered borderline lesions

Question 11

Which is not important in the grading of breast cancer? (September 2013)

a. Nuclear grade
b. Histological microstructure
c. Internal necrosis
d. Mucin production

Answer 11

Histological grading of breast cancer:
o Tumour tubule formation - Lower percentage of tubule formation implies a higher grade
o Mitotic figures
o Nuclear pleomorphism - Greater variation in nuclear size and shape correlates with a higher grade

Nottingham Histologic Score (evaluates the above):
o Grade I:
- Well differentiated
- Tubular pattern w small, round nuclei & low proliferative rate
o Grade II:
- Moderately differentiated
- Some tubule formation but solid clusters or single infiltrating cells are also present
- More mitoses & greater cellular pleomorphism
o Grade III:
- Poorly differentiated
- Invade as ragged nests or solid sheets of cells w enlarged irregular nuclei
- High proliferative rate & areas of necrosis

ANSWER: Mucin production is not part of the Nottingham Criteria

Question 12

Regarding Paget disease of the breast, which is true? (August 2016)

a. DCIS of distal ducts invading the areola

Answer 12

Infiltration of the nipple epidermis by malignant cells
o Most cases have underlying DCIS or invasive ductal cancer, but occasionally no underlying lesion is found

Epidemiology
o 1-5% of breast cancer
o Women in the 6th decade

Clinical staging of Paget disease of the breast/nipple:
o Stage 0: Lesion confined to the epidermis, w/o underlying DCIS in the breast
o Stage 1: Associated w DCIS just below the nipple
o Stage 2: Associated w extensive DCIS
o Stage 3: Associated w IDC

Pathology:
o	Extension of malignant cells to the epidermis of the nipple through the terminal lactiferous ducts
o	Histological variants:
	- Adenocarcinoma-like cell type
	- Spindle cell type
	- Anaplastic cell type
	- Acantholytic cell type
	- Pigmented cell type

ANSWER: DCIS of the distal ducts invading the epidermis of the areola and nipple via the terminal lactiferous ducts

Question 13

Which is correct regarding Paget disease of the nipple? (March 2016)

a. More than 50% is associated with DCIS
b. More than 50% is associated with IDC
c. More than 50% have a nipple which appears macroscopically normal
d. More than 50% are associated with calcification of the lactiferous ducts of the nipple

Answer 13

Regarding Paget disease of the nipple:
o 50% are associated w DCIS
o 50-60% are associated w IDC (which may be palpable as a mass)
o Most cases have a morphologically abnormal nipple
o 50% have abnormal microcalcifications reflecting DCIS

ANSWER: More than 50% are associated with DCIS and IDC, and approximately 50% have microcalcifications

Question 14

Paget disease of the nipple often has a normal mammogram. Why? (September 2013)

a. It is confined to the nipple
b. There is an intact basement membrane
c. DCIS infiltrates the areolar and rarely extends to the lactiferous sinuses
d. Pagets is subareolar and DCIS is often occult
e. It is an eczematoid reaction

Answer 14

Paget disease of the nipple:
o Heralds an underlying ductal cancer
o Bright red nipple: Eczematous nipple-areolar changes; Ulceration
o Cancer location is often subareolar but may be anywhere in the breast
- 50% have a normal mammogram
- Nipple change and skin/areolar thickening in 30%
o Subareolar mass or calcifications are considered suspicious

ANSWER: The cancer associated with Paget disease is often subareolar and the DCIS component is occult on mammogram

Question 15

LCIS (March 2014)

Answer 15

•LCIS is almost always an incidental finding
o May be found when biopsying calcifications assoc w another pathology
o Discohesive cells which lack e-cadherin expression
o 27-30% chance of developing invasive ductal or lobular carcinoma w/in 10 years in the ipsilateral or contralateral breast

Question 16

Which is true regarding the management of Paget disease of the breast? (March 2014)

a. Referral to a breast surgeon
b. Referral to a dermatologist for management of the eczema

Answer 16

ANSWER: Referral to a breast surgeon

Question 17

Breast calcifications are biopsied. The pathology report described LCIS. What is the most likely explanation? (September 2013)

a. Calcification due to necrotic cells in the duct lumen
b. Sclerosis/fibrosis/inflammation around the duct
c. Calcification is an incidental finding in LCIS
d. Calcification implies invasion of the stroma

Answer 17

ANSWER: LCIS is often an incidental finding on biopsy. It is not typically associated with calcification.

Question 18

Regarding DCIS, which is true? (September 2013)

a. DCIS has branching calcifications with lucent centres

Answer 18

ANSWER: DCIS calcification is branching and pleomorphic, but do not have a lucent centre

Question 19

Which is least true of invasive lobular carcinoma? (August 2016)

a. It metastasizes to lung
b. It metastasizes to brain
c. It metastasizes to peritoneum

Answer 19

Metastases for ILC are most common to lung, liver & bone
o Also to unusual locations such as the retroperitoneum, adrenals, GI tract, ovary & leptomeninges

ANSWER: Of these options, brain would be least likely (meninges > brain parenchyma)

Question 20

Which is not a complication of breast cancer treatment? (March 2015)

a. Angiosarcoma
b. Aplastic anaemia
c. Myelodysplasia
d. Ovarian cancer
e. Endometrial cancer

Answer 20

• Angiosarcoma: 0.3% incidence in the breast skin secondary to radiotherapy (5-10 year latency)
• Aplastic anaemia: secondary to chemotherapy
• Myelodyplasia: secondary to chemotherapy or radiotherapy
• Endometrial cancer: Tamoxifen treatment gives an increased risk of endometrial proliferation (which can progress to atypia, which can progress to endometrial cancer)

ANSWER: Ovarian cancer

Question 21

Regarding the associations of DCIS, which is true? (September 2013)

a. Increased recurrence with wide margins

Answer 21

ANSWER: Unclear question. There is increased recurrence of DCIS with wide local excision compared to mastectomy. DCIS has a 1% rate of progression to invasive cancer per year

Question 22

What is the best way to diagnose inflammatory breast cancer? (March 2015)

a. Stereotactic core biopsy
b. Hookwire open biopsy
c. Vacuum assisted biopsy
d. FNA
e. Skin punch biopsy

Answer 22

Inflammatory breast cancer
o 1% of all breast cancers
o Aggressive cancer w a poor prognosis
o Most important differential of unilateral breast oedema - Often mistaken for mastitis

Clinical

- Enlarging erythematous breast w peau d’orange
- Should be distinguished from a focal invasive cancer, which is causing an erythematous skin reaction, or skin metastasis

Mammogram:
	- Skin thickening
	- Findings of cancer:
•	Breast mass
•	Asymmetric density
•	Microcalcifications
•	Nipple retraction
•	Axillary adenopathy

Ultrasound:
	- Oedema (almost all)
	- Breast mass in 80%
	- Dilated lymphatics in 70%
Biopsy:
	- Shows invasion of dermal lymphatics in 80%

ANSWER: Skin punch biopsy shows invasion of dermal lymphatics in 80%. If there is a mass on ultrasound or mammogram – biopsy this.

Question 23

What is a typical combination for invasive lobular cancer? (March 2015)

a. ER+ PR+ HER2+
b. ER- PR- HER2-
c. ER+ PR+ HER2-
d. ER- PR+ HER2-
e. ER- PR- HER2+

Answer 23

Major characteristics used to classify breast cancer are:
o	Histopathological type
o	Grade of the tumour
o	Stage of the tumour
o	Expression of proteins and genes

Receptor status/molecular subtype:
o Triple negative/basal-like
- ER- PR- HER2-
- Accounts for most BRCA1

o Luminal A (50-60% of breast cancer)

- ER+ PR+ HER2-
- Low grade, low Ki67
- Slow growing, best prognosis
- Metastases more common in bone - (Liver, lung and CNS metastases in <10%)
- Majority of lobular cancers are in this group

o Luminal B

- ER+ PR+ HER2+/-
- Higher grade, high Ki 67
- Grow faster, worse prognosis than Luminal A

o Her2-enriched

- ER- PR- HER2+
- Grow faster, have a worse prognosis than luminal cancers BUT are often treated w targeted therapies (e.g. Herceptin)

• Lobular breast carcinoma lacks e-cadherin on immunohistochemical staining

ANSWER: A typical combination for lobular breast cancer is ER+ PR+ HER2- (Luminal A)

Question 24

What is the most likely to present as a spiculated mass? (March 2015)

a. Tubular
b. Medullary
c. Mucinous
d. Fibroadenoma
e. Phylloides

Answer 24

Differential diagnosis of a spiculated breast lesion:
o	Summation shadow
o	Benign:
	- Sclerosing adenosis
	- Post-surgical scar
	- Radial scar/benign sclerosing ductal lesion
	- TB
	- Post-traumatic oil cyst / Fat Necrosis
o	Malignant:
	- IDC
	- DCIS (rarely)
	- ILC
	- Tubular carcinoma

ANSWER: Tubular carcinoma is more likely to present as a spiculated mass

Question 25

Which of the following is not a well-circumscribed mammographic mass? (September 2013, August 2014)

a. Tubular
b. Medullary
c. Mucinous
d. Fibroadenoma
e. Phylloides

Answer 25

• Not-well circumscribed implies that the mass is a spiculated lesion
• Well-defined breast lesions include:
o	Mucinous
o	Medullary
o	Phylloides
o	Papillary
o	Metaplastic

ANSWER: Tubular carcinoma is typically not a well defined mass

Question 26

Which of the following is the most likely to present as a stellate mammographic lesion? (September 2013, March 2014)

a. Complex adenosis
b. Medullary cancer
c. Mucinous cancer
d. Phylloides

Answer 26

Complex (sclerosing) adenosis:
o Mammary lobular hyperplasia
o Causes architectural distortion
o May be seen as a spiculated mass w microcalcifications on mammogram (Mimic of IDC)

ANSWER: Complex (sclerosing) adenosis

Question 27

Which of the following is most likely to have a non-spiculated appearance? (August 2016)

a. Medullary cancer
b. ILC

Answer 27

Differential of well defined breast cancers:
o High grade invasive ductal carcinoma – proliferating too quickly to develop a desmoplastic reaction
o Mucinous breast cancer – may be markedly hypoechoic on ultrasound & mimic a cyst
o Medullary breast cancer – similar appearance to mucinous
o Papillary breast cancer

ANSWER: Medullary cancer

Question 28

What is the mammographic appearance of tubular carcinoma? (March 2014)

a. Spiculated mass

Answer 28

ANSWER: Tubular cancer is most often a small, spiculated mass on mammogram

Question 29

Which of the following is most associated with BRCA1? (September 2013)

a. Medullary
b. Mucinous
c. Tubular

Answer 29

BRCA1:
o Tumour suppressor gene (17q21)
o Accounts for 5% of the breast cancers in young women (<40)
- 35-80% lifetime risk of breast cancer (65% as per Radiopaedia)
o Mutation assoc w development of medullary breast ca, which has a more favourable prognosis than other subtypes
- 60% of breast cancers in women with BRCA1 have medullary features
- 13% medullary type
o Other sites of increased malignancy risk:
- Colon – 4x increased risk of adenoca
- Ovary – 30-60% lifetime risk of ovarian ca. Most commonly serous cystadenoca. Often younger women w higher stage. Responsible for 90% of hereditary ovarian cancers. (10% of ovarian cancers are hereditary)
- Prostate – 3x increased risk of prostate ca (<30%). Male breast cancer – 1-2%. Pancreatic cancer – 2%

ANSWER: Medullary subtype is most common in patients w BRCA1

Question 30

Regarding medullary breast cancers, which is true? (September 2013)

a. Peak age is 40-50
b. Associated with BRCA 1
c. Poor prognosis
d. Associated with DCIS in 75%

Answer 30

ANSWER: Medullary breast cancer is assoc w BRCA 1; the peak age is 46-54years and the cancer can present in women under the age of 35

Question 31

A breast lesion is triple negative. What is the most likely lesion? (August 2014)

a. Invasive tubular
b. Lobular invasive
c. Mucinous
d. Medullary

Answer 31

Pathological features of triple negative breast cancer:
o	Higher histological grade
o	Elevated mitotic count
o	Central necrosis
o	Fibrosis
o	Pushing margins
o	Scant stromal reaction (less likely to be spiculated)
o	Stromal lymphocytic response
o	Ductal or mixed histology w over-representation of unusual histological types:
	- Metaplastic
	- Medullary
	- Adenoid cystic carcinoma

ANSWER: Medullary subtype carcinoma is most likely to be triple negative. This is associated w BRCA1. Other implicated histological subtypes are metaplastic & adenoid cystic.

Question 32

Regarding the risk factors for breast cancer, which is the least likely association? (March 2014)

a. Von Hippel Lindau
b. Cowden syndrome
c. Li fraumeni
d. Ataxia telangectasia
e. BRCA 2

Answer 32

ANSWER: VHL is not assoc w increased risk of breast cancer

Robbins Table p 1049
Li-Fraumeni - TP53, ER+ HER2+ (50-60%)
Cowden - PTEN (20-80%)
Peutz-Jeghers - STK11 (40-60%)
Hereditary Diffuse Gastric Ca - CDH1, 50%, majority are lobular Ca
Hereditary Breast Ca - PALPB2, 30-60%, Biallelic mutations cause a form of Fanconi anaemia
Ataxia-Telengiectasia - ATM 15-30%

Question 33

A woman with breast cancer has an axillary clearance. 3 out of 14 nodes are positive. Which is true regarding prognosis? (April 2013)

a. 2 year survival less than 10%
b. 5 year survival 10%
c. 5 year survival 20%
d. 5 year disease free survival 20-30%
e. 10 year disease free survival 30-40%

Answer 33

Prognosis of breast cancer:
o	Stage I (in breast): 85-95%
o	Stage II (N1 nodes): 75%
o	Stage III (N2/3 with large tumour size): 45%
o	Stage IV (metastases): 10-15%

ANSWER: There is approximately 30-40% 10 year disease free survival for patients with 1-3 axillary nodes

No nodal involvement: 70-80% 10 year survival
1-3 nodes: 35-40% 10 year survival
>10 nodes: 10-15%
Robbins p 1059

Question 34

Breast angiosarcoma – which is false? (March 2015)

a. Primary angiosarcoma has no risk factors
b. Secondary tends to affect older women (>60s)
c. Median latency of 2 years
d. Poor prognosis with widespread metastases

Answer 34

Angiosarcoma of the breast accounts for 0.05% of breast malignancies. Can be primary/sporadic or secondary

Sporadic
o Breast parenchyma of young women (mean age 35)
o High grade, poor prognosis

Secondary:
o Most tumours arise as a complication of radiation therapy (latency 5-10 years)
o Tumours arise in the breast skin
o 0.3% incidence following radiotherapy

• Stewart-Treves Syndrome: angiosarcoma arising in the setting of post-mastectomy lymphodema

ANSWER: Median latency of 2 years – latency following radiation therapy 5-10 years

Question 35

What can be diagnosed on FNA? (March 2015)

a. PASH
b. LCIS
c. Sclerosing adenitis
d. Diabetic mastopathy
e. Fat necrosis

Answer 35

PASH: Pseudoangiomatous stromal hyperplasia
o Benign, ill defined non-calcified ovoid mass
- Stromal & epithelial proliferation
o Premenopausal women or post menopausal women on hormone replacement
o Occasionally shows rapid growth & requires biopsy
on US: Mixed or hyperechoic mass with ill defined borders
o Biopsy:
- Fine needle biopsy can be inconclusive (as can core)
- Low grade angiosarcoma can mimic PASH on core biopsy (Excision is recommended if the mass grows)

LCIS:
o High-risk marker for developing breast cancer, rather than a cancer in itself
- 10x increased risk for developing cancer above background -> Contralateral or ipsilateral breast
- Invasive ductal or lobular carcinoma
o Requires core for biopsy – classification of in situ requires assessment of the basement membrane

Sclerosing adenosis:
o Proliferative benign lesion resulting in mammary lobular hyperplasia - Considered a borderline lesion
o Formation of fibrous tissue which distorts & envelops the glandular tissue
- Sclerosis of the surrounding tissue
- Small duct lumens contain microcalcs
- May have skin retraction
- Imaging findings difficult to distinguish from an invasive cancer given spiculated margins & microcalc
- Not palpable in 80%
o Women w sclerosing adenosis are 1.5-2x more likely to develop cancer -> Marker of higher risk
o Can be a component of other proliferative lesions:
- Intraductal and/or sclerosing papilloma, & complex sclerosing lesions
- Within fibroadenomas
- Coexisting w in situ or invasive carcinomas
o Core biopsy given the increased risk of co-existent cancers & additional lesions

Diabetic mastopathy:
o Hard irregular mobile mass in a patient w RFs (usually long history of IDDM)
o Autoimmune reaction to the accumulation of abnormal matrix proteins in the setting of hyperglycaemia
- Obliteration of normal glandular tissue causes fibrosis
o Risk factors:
- Long term insulin dependent diabetics
- Thyroid disease (rare)
o Core biopsy or excision biopsy may be needed to demonstrate architecture, however may exacerbate the condition
- Fibrosis & dense lymphatic infiltration around breast lobules & ducts
- High incidence of local recurrence post excisional biopsy
o Mammogram:
- Asymmetric density w ill defined margins
- No microcalcs or dense glandular tissue
o Ultrasound:
- Hypoechoic mass w dense shadowing
- Mimics scirrhous breast cancer

Fat necrosis:
o Benign inflammatory process, caused by saponification of fat w/in the breast
o Pathology:
- Necrotic fat cells
- Infiltration of lipid laden macrophages, multinucleated giant cells & acute inflammatory cells
- Fibrosis develops & encloses areas of necrotic fat & cellular debris
- Outcome – may be totally replaced by scar or scarring surrounding a persistent core of necrotic lipid & debris
o Can be diagnosed on FNA

ANSWER: Fat necrosis can be diagnosed on FNA

Question 36

Regarding PASH, which is correct? (March 2016)

a. It is an incidental finding, with no further treatment required
b. 50% will be associated with malignancy and an open surgical biopsy is recommended

Answer 36

ANSWER: PASH is an incidental finding w no further treatment required (unless enlarging or symptomatic); it is not assoc w malignancy

Question 37

Diabetic mastopathy is also known as? (August 2016)

a. Sclerosing lymphocytic lobulitis

Answer 37

Diabetic mastopathy
o Benign tumour like breast masses in women w longstanding type 1 or type 2 insulin dependent diabetes
	- Has been reported in men
	- Large, painless, hard breast lump
	- Often multicentric or bilateral
o Assoc w other autoimmune diseases

Pathology:

- Form of lymphocytic mastitis & stromal fibrosis
- Dense fibrosis & a predominantly B-cell infiltrate which surrounds the ducts, lobules & vessels
- Thought to be immune related but the pathogenesis is not well understood

ANSWER: Diabetic mastopathy is also known as sclerosing lymphocytic lobulitis, & is considered part of the group of lymphocytic mastitis

Question 38

What is the most likely breast lesion in diabetes? (March 2016)

a. Lymphocytic mastitis
b. Fibroadenoma
c. PASH

Answer 38

ANSWER: Diabetic mastopathy is a form of lymphocytic mastitis.

Question 39

Regarding fibroadenoma, which is false? (September 2013)

a. Contain foci of invasive cancer
b. Increase in size with pregnancy and infarction
c. Common in post-menopausal women
d. Associated with cyclosporine

Answer 39

ANSWER: Fibroadenomas do not contain foci of invasive cancer; fibroadenomas are more common in premenopausal women however persist in post-menopausal women

Question 40

Which is the least likely breast tumour to arise in the stroma? (March 2016)

a. Lipoma
b. Myofibroblastoma
c. Phylloides
d. Collagenous spherulosis
e. Angiosarcoma
f. Fibrolipoma

Answer 40

Collagenous spherulosis: benign breast lesion, uncommon
o May be seen incidentally on biopsy
o Can form calcifications
o Tubular/cribriform architecture w intratubular eosinophillic material, arranged like spokes of a wheel
o Composed of epithelial & myoepithelial cells

Lipomas:
o Benign breast lesions, usually soft and mobile
o Mesenchymal
o Can be seen anywhere in the breast but subcutaneous tissues is the most common location

ANSWER: Lipoma is the least likely tumour to arise in the stroma – it is more common in the subcutaneous tissues

Question 41

Which is least associated with Phylloides tumour? (March 2016)

a. Circumscribed but not encapsulated
b. Mastectomy and lymph node excision
c. Contains cystic spaces
d. Large rapidly enlarging lesions
e. Contain foci or chondroid, osteoid and lipoid metaplasia

Answer 41

Phyllodes tumour:
o Biphasic fibroepithelial neoplasm w a double layered epithelium surrounded by overgrowing stroma
- Clefts bw leaf-like projections form ‘cystic’ spaces

Mammogram:

- Large, rapidly growing circumscribed lesions
- Dense, oval or lobulated mass

Ultrasound:

- Hypoechoic mass w cystic spaces
- Posterior acoustic enhancement

MRI:

- Suspicious kinetics
- Non-enhancing internal septa

Pathology:
- Benign (75%), borderline (16%) & malignant (9%) subtypes
• Benign vs malignant determined by the number of mitoses per high powered field
- Solid, fleshy, leaf-like mass
- Cystic areas
- Circumscribed lesion
- Focal areas of necrosis & haemorrhage
- Metaplasia – lipoid, chondroid, osteoid – may occur

Clinical:
- Middle aged women
- DDx of fibroadenoma more common in younger women
- Complete excision is curative
• WLE or mastectomy in the case of large tumours
• LN dissections rarely indicated, even in malignant tumours
- 4-10% risk of local recurrence
• Usually w/in 2 years
• Recurrence decreased by ½ if >1cm clear margins are achieved

ANSWER: Phyllodes is not typically treated w mastectomy & lymph node excision.

Question 42

Regarding breast lymphoma, which is most likely? (August 2016)

a. Mass with axillary nodes

Answer 42

Breast lymphoma may be primary or secondary
o Both rare - <0.5% of breast malignancies
o Primary less common than secondary
- Usually B cell type NHL (both primary & secondary)

Clinical presentation:
o Palpable mass of diffuse thickening of the breast
o Axillary lymph nodes are often enlarged

Criteria for diagnosis of primary breast lymphoma:
o Disease should be in the breast or in close proximity to the breast tissue
o No evidence of widespread disease elsewhere
o No previous history of lymphoma
o Ipsilateral lymph nodes may be involved if developing simultaneously with the primary breast tumour
- Mimics the appearance of primary breast cancer & benign/borderline stromal tumours

ANSWER: Breast lymphoma is most likely to present as a mass with axillary nodes

Question 43

Which is not a risk factor for gynaecomastia? (August 2014)

a. Germ cell tumour
b. Chronic renal failure
c. Liver failure
d. Spironolactone

Answer 43

Gynaecomastia:
o Excess of male breast tissue, usually reversible

Clinical: palpable, firm, tender, disc-like mound of tissue

Pathology:

- Benign proliferation of benign ductal & stromal elements
- Central, symmetric location
- Deep to the nipple
- Related to an imbalance between oestrogens and androgens

Causes:
Hormonal
•	Neonatal: maternal oestrogen
•	Pubertal: high oestrodiol levels
•	Elderly: decline in testosterone
•	Syndromes: Kleinfelter syndrome; Anorchism; Testicular cancer

Drugs:
•	Diethylstilbestrol
•	Spironolactone
•	Thiazide diuretics
•	Digoxin
•	Anabolic steroids
•	Narcotics
•	HAART (antiretrovirals)
•       ETOH, Marijuana, heroin

Systemic disorders:
•	Advanced cirrhosis/liver failure
•	Advanced pulmonary disease e.g. emphysema or TB
•	CRF on haemodialysis
•	Hyperthyroidism
•	Malnutrition

Tumours
•	Adrenal carcinoma
•	Hepatoma
•	Lung cancer
•	Pituitary adenoma
•	Testicular cancer: sex-cord stromal and germ cell tumours (ie Leydig or Sertoli cell tumours)

Idiopathic

ANSWER: Chronic liver disease, renal failure, germ cell tumours & spironolactone are all assoc w gynaecomastia

Question 44

Which is the least likely cause of gynaecomastia? (March 2017)

a. Anti-retroviral drugs
b. Cirrhosis
c. Sertoli cell tumour
d. Leydig cell tumour

Answer 44

ANSWER: All are potential causes of gynaecomastia