breast diseases

Question 1

which of the following does not increase a woman’s risk of breast cancer?

a. late menopause
b. first full-term pregnancy before age 35
c. early menarche
d. hormone replacement therapy

Answer 1

b. first full-term pregnancy before age 35

increased oestrogen exposure increases risk of breast cancer

having children at a younger age is protective

Question 2

Which of the following is false regarding Paget’s disease of the nipple?

a. A biopsy will show halo cells
b. Arises from lobular carcinoma in situ
c. Occurs due to breakdown of the tight junctions of the squamous epithelial layer
d. Presents with eczematous change to the nipple and areola

Answer 2

b. Arises from lobular carcinoma in situ

Paget’s disease is a/w ductal carcinoma in situ –> cancer cells migrate along lactiferous ducts, through the pore into the skin, while not breaking the basement membrane

Question 3

Which of the following is false regarding imaging of the breast?

a. A height greater than width of a mass indicates it is a benign mass
b. Mammograms aren’t usually suitable for younger women as their breasts have a high density
c. Breast mammography is provided free for women aged 50 – 74, every 2 years
d. Breast ultrasounds can determine between a solid and cystic structure

Answer 3

a. A height greater than width of a mass indicates it is a benign mass

If the height of a mass is greater than the width, this indicates that it’s not obeying the planes of the tissue and thus, indicates an invasive or malignant growth.

Breast ultrasounds can determine between a solid and cystic structure: correct, the probe can be depressed over the mass and a cystic structure will be compressible

Question 4

Which of the following breast cancer molecular sub-typing is incorrect?

a. HER2 - ER/PR negative, HER2 positive
b. Triple negative, ER/PR negative, HER2 negative
c. Luminal B, ER/PR positive, HER2 positive or negative
d. Luminal A, ER/PR positive, HER2 positive

Answer 4

d. Luminal A, ER/PR positive, HER2 positive

Luminal A is HER2-negative

Question 5

Which of the following is an adverse effect of trastuzumab (HERceptin - anti-HER2 treatment)?

a. Osteoporosis
b. Dilated cardiomyopathy
c. Increased risk of DVT
d. Increased risk of uterine cancer

Answer 5

b. Dilated cardiomyopathy (monitor CVS health, baseline ECG, follow up)

osteoporosis: anastrozole (oestrogen synthesis inhibitor)
increased DVT risk/uterine cancer: tamoxifen (oestrogen receptor antagonist)

Question 6

A 56 year old woman has breast cancer, and one of her medications is trastuzumab. Which of the following is an indication for treating breast cancer with trastuzumab?

a. Only if her cancer is HER2 positive
b. ER positive
c. Radiotherapy is contraindicated
d. She is post-menopausal

Answer 6

a. Only if her cancer is HER2 positive

Question 7

A 35 year old woman presents with a breast lump with associated nipple inversion and puckering of the skin. She is diagnosed with luminal A invasive ductal carcinoma. Which of the following would be first-line in the medical management of her breast cancer?

a. Trastuzumab (anti-HER2 treatment)
b. Anastrozole (aromatase inhibitor –> block osetrogen synthesis)
c. Goserelin
d. Tamoxifen (oestrogen receptor antagonist)

Answer 7

d. Tamoxifen (oestrogen receptor antagonist)
- first-line in premenopausal women with luminal A cancer (hormone receptor positive / ER/PR positive)

anastrozole: in postmenopausal women
goserelin: GnRH agonist (secondary option to tamoxifen if CI present)
trastuzumab: luminal A cancers are HER2 negative

Question 8

Which of the following is not an indication for BRCA screening?

a. The patient was found to have a right breast cancer and simultaneous ovarian cancer
b. The patient was found to have breast cancers in both the right and left breast
c. The patient has been diagnosed with breast cancer at age 38
d. The patient’s mother was diagnosed with breast cancer at 64, and her aunt was diagnosed at age 52

Answer 8

d. The patient’s mother was diagnosed with breast cancer at 64, and her aunt was diagnosed at age 52

RACGP guidelines for BRCA screening
- diagnosed under age 40
- bilateral breast cancers
- breast cancer and ovarian cancer in same woman

Question 9

Which of the following pairings is correct regarding biopsy of breast tissue? Finding on biopsy ______; Diagnosis ______

a. Lack of E-cadherin; Ductal carcinoma
b. Staghorn cell arrangement; Phyllodes tumour
c. Leaf-like pattern; Fibroadenoma
d. Halo cells; Paget’s disease

Answer 9

d. Halo cells; Paget’s disease

lack of E-cadherin: lobular carcinoma
staghorn cell arrangement: fibroadenoma
leaf-like pattern: phyllodes tumour

Question 10

Peau d-orange is a sign associated with which type of breast cancer?

a. Tubular carcinoma
b. Medullary carcinoma
c. Mucinous carcinoma
d. Inflammatory carcinoma

Answer 10

d. Inflammatory carcinoma

Inflammatory carcinoma involves dermal lymphatic oedema that builds up in the interstitial space. This would normally cause swelling, but Cooper’s suspensory ligaments prevent the skin from stretching so the skin becomes thickened and dimpled.

Question 11

which biopsy finding will be seen in lobular carcinoma?

a. lack of E-cadherin
b. staghorn cell arrangement
c. leaf-like pattern
d. halo cells

Answer 11

a. lack of E-cadherin

Question 12

which biopsy finding will be seen in fibroadenoma?

a. lack of E-cadherin
b. staghorn cell arrangement
c. leaf-like pattern
d. halo cells

Answer 12

b. staghorn cell arrangement

Question 13

which biopsy finding will be seen in phyllodes tumour?

a. lack of E-cadherin
b. staghorn cell arrangement
c. leaf-like pattern
d. halo cells

Answer 13

c. leaf-like pattern

Question 13

which biopsy finding will be seen in Paget’s disease?

a. lack of E-cadherin
b. staghorn cell arrangement
c. leaf-like pattern
d. halo cells

Answer 13

d. halo cells

Question 14

name two types of intralobular stromal tumours

Answer 14

fibroadenoma and phyllodes tumour

Question 15

name some types of interlobular stromal tumours

Answer 15

myofibroblastoma, lipoma, fibromatosis, angiosarcoma

Question 16

lumpy bumpy breasts, pain, fluctuates with menstrual cycle
resolution of cyst after FNA

what diagnosis?

Answer 16

fibrocystic breasts

Question 17

most common pathogen in acute mastitis

a. Candida albicans
b. S. aureus
c. H. influenzae
d. E. coli
e. Lactobacillus acidophilus

Answer 17

b. S. aureus

Question 18

poorly-defined, palpable periareolar mass
thick dirty white/black/green secretions +/- skin retraction
usually in multiparous women

blockage of mammary duct –> chronic inflammation

what diagnosis?

Answer 18

mammary duct ectasia

Question 19

BRCA1 gene is usually associated with which subtype of intraductal carcinoma?

Answer 19

TNBC

Question 20

BRCA2 gene is usually associated with which subtype of intraductal carcinoma?

Answer 20

ER-positive breast carcinoma

Question 21

are lobular carcinomas often unilateral or bilateral?

Answer 21

bilateral!!

Question 22

60 year old woman presents with large breast mass that she first detected 3 months ago. Mammography reveals a well circumscribed mass measuring 8cm in diameter. A breast biopsy shows loose fibroconnective tissue with a sarcomatous stroma, abundant mitoses, and nodules and ridges lined by cuboidal epithelial cells. Which of the following is the appropriate diagnosis?

a. fibroadenoma
b. paget disease
c. phyllodes tumour
d. medullary carcinoma
e. tubular carcinoma

Answer 22

c. phyllodes tumour

• LARGE breast mass found 3 months ago –> rapid enlargement
  (in malignancy –> gradual enlargement)
• both epithelial and stromal components present

Question 23

35 year old woman consults her family physician because of painful swelling of her breasts, particularly as she approaches the end of her menstrual cycle. On self-examination, she recently felt a tender nodule in the right breast. Physical examination reveals an irregular nodularity of both breasts with diffuse tenderness. Examination of axilla is negative. A mammogram demonstrates irregular areas of density in the lower, outer quadrants of both breasts. Which of the following histopathologic features is considered to be a risk factor for the development of carcinoma in this patient?

a. apocrine metaplasia
b. cystic change
c. duct ectasia
d. papillomatosis
e. stromal fibrosis

Answer 23

d. papillomatosis

proliferative fibrocystic change increases the risk of cancer

Question 24

54F complains of bloody discharge from her left nipple. Physical examination reveals a 0.5cm nodule in the subareolar breast tissue, which is surgically excised. Histologic examination reveals cuboidal and myoepithelial cell-lined vascular connective tissue cores, which project into the lumen of a major lactiferous duct. Which of the following is the appropriate diagnosis?

a. ductal carcinoma in situ
b. intraductal papilloma
c. lobular carcinoma in situ
d. medullary carcinoma
e. paget disease

Answer 24

b. intraductal papilloma

• different from papillomatosis (which occurs in peripheral ducts as a component of proliferative fibrocystic change)

Question 25

58F is found to have a 4-cm circumscribed mass, without calcifications, in her left breast. An excisional biopsy shows solid nests and sheets of highly pleomorphic cells, with many mitotic figures, surrounded by dense infiltrate of lymphocytes. Which of the following is the most likely diagnosis?

a. invasive ductal carcinoma
b. invasive lobular carcinoma
c. medullary carcinoma
d. paget disease
e. phyllodes tumour

Answer 25

c. medullary carcinoma
- characterised by dense lymphoid infiltrate encompassing periphery of tumour

Question 26

which of the following would not be in keeping with a fibroadenoma?

a. normal axillary lymph nodes
b. mass size fluctuates with menstrual cycle
c. well-defined borders on mammogram
d. slow-growing
e. non-mobile mass

Answer 26

e. non-mobile mass

mobile mass indicates benign neoplasm (usually fibroadenoma)

Question 27

is receptor status a prognostic or predictive factor?

Answer 27

both prognostic and predictive