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Question 1: A 52-year-old woman has felt a lump in her of puberty at age 12.

On physical examination both breasts


breast for the past 2 months. On physical examination a firm have a similar consistency on palpation, with no lumps, and
2 to 3 cm mass is palpable in the upper outer quadrant of her there is no tenderness. The nipples and areolae appear
right breast. There are no palpable axillary nodes. A normally formed. Which of the following is the most likely
lumpectomy with axillary node dissection is performed. The cause for these findings?
breast lesion is found to have positive immunohistochemical
A Cystosarcoma phyllodes
staining for HER2/neu (c-erb B2). Staining for estrogen and
progesterone receptors is negative. Which of the following B Adrenogenital syndrome
treatment options is most likely to be efficacious in this
woman? C Virginal hypertrophy

A Letrozole D Fibrocystic changes

B Tamoxifen E Ductal carcinoma in situ

C Trastuzumab C) CORRECT. Virginal hypertrophy, or rapid enlargement of


one or both breasts following puberty, is a problem that can
D Prednisone
be easily remedied with plastic surgery, and tamoxifen
E Doxorubicin therapy may reduce recurrence. As breasts are enlarging
following puberty, there is often some unequal growth, but
(C) CORRECT. This is an infiltrating ductal carcinoma. The lack eventually an equal size is reached by the end of puberty.
of ER staining suggests a poor response to hormonal therapy
with tamoxifen or letrozole. The positive C-erb B2
(HER2/neu) staining suggests that the monoclonal antibody Question 4: A 20-year-old woman notes a mass in her left
traztuzumab may be effective. Radical mastectomies are breast after following the directions for breast self-
rarely performed. examination provided by her health clinic. Her physician
palpates a firm, 1 to 2 cm mass. There is no nipple discharge
Question 2: A 47-year-old woman undergoes routine and no pain. No axillary adenopathy is present. The overlying
mammographic screening and there are multiple small areas skin of the breast appears normal. Her left breast is slightly
of increased density, though a single distinctive mass lesion larger than the right, a condition she says has been present
is not detectable either by palpation or by mammography. A since puberty. Her urine pregnancy test is negative.
fine needle aspiration biopsy of an abnormal density reveals Mammography confirms the presence of a rounded density,
cells suspicious for a malignancy. An excisional breast biopsy which has no microcalcifications, and reveals no lesions of
yields a diagnosis of lobular carcinoma in situ of the breast. the opposite breast. Which of the following is the most likely
Which of the following is the most likely finding associated diagnosis?
with this woman's carcinoma?
A Focus of fat necrosis
A No residual carcinoma
B Fibroadenoma
B Opposite breast involvement
C Intraductal papilloma
C Absent family history of breast cancer
D Infiltrating ductal carcinoma
D Concomitant Paget disease of the nipple
E Phyllodes tumor
E Negative estrogen receptor assay
(B) CORRECT. At her age, such a firm small movable mass is
(B) CORRECT. Bilaterality is a frequent characteristic of most likely to be a benign lesion, and a fibroadenoma is the
lobular carcinoma in situ (LCIS). The prognosis is still good, most likely cause for this small 'lump' in the breast. Cancers
but more surgery may be needed. are not common at this age.

Question 3: A 15-year-old healthy girl of normal height and Question 5: A 19-year-old woman gave birth to a healthy
weight for age is concerned because her right breast has male infant at term following an uncomplicated pregnancy.
developed to twice the size of her left breast since the onset She has now been breast feeding the baby for a month, but
notes that her left breast has gradually become swollen and
E Sclerosing adenosis
painful to touch over the past week. On physical examination
her temperature is 38.2°C. Which of the following is the most
(C) CORRECT. Galactocele occurs secondary to obstruction of
likely diagnosis?
lactiferous ducts. It is a non-neoplastic process. Following
A Acute mastitis cessation of lactation milk may be retained and produce a
cystic lesion. Aspiration of the cyst removes the fluid and the
B Fibrocystic disease
cyst collapses. The cyst is lined by cuboidal to flat epithelium.
C Fat necrosis The cyst contents often appear milky, but microscopically
contain inflammatory cells and/or necrotic debris.
D Intraductal papilloma Extravasation of the milk may produce chronic inflammation
E Galactocele and even fat necrosis.

(A) CORRECT. The causative organism is most Question 8: A 49-year-old woman notes increasing size to her
often Staphylococcus aureus or Streptococcus. Antibiotic right breast over the past year. This breast is not painful, but
therapy is usually successful. the heaviness causes some discomfort. On physical
examination the overlying skin and nipple appear normal.
Question 6: A 35-year-old woman has noted a palpably firm, There is no nipple discharge. There is no axillary
irregular mass in her right breast for the past 3 months. On lymphadenopathy. Mammography reveals a solid 12-cm
physical examination there is no tenderness or swelling. By circumscribed mass. The mass is biopsied, and on
mammography there is an irregular 2 cm density that microscopic examination shows a cellular stromal
contains scattered microcalcifications. Biopsy of this mass component along with an epithelial component. Which of
reveals extensive fat necrosis. Which of the following is the the following is the most likely diagnosis?
most likely cause for this breast lesion? A Fibroadenoma
A Pregnancy B Phyllodes tumor
B Prolactinoma C Sclerosing adenosis
C Trauma D Hamartoma
D Fibrocystic changes E Medullary carcinoma
E Lobular carcinoma in situ (B) CORRECT. Phyllodes tumors are much less common
than fibroadenomas, but they can be quite large. The stromal
F Mastitis component of a phyllodes tumor is more cellular than a
fibroadenoma, and it may show atypia or frank malignancy.
(C) CORRECT. Trauma leads to fat necrosis. This lesion can
sometimes mimic a carcinoma on physical examination and Question 9: A 46-year-old woman has a silicone breast
on the grossly excised breast tissue. implant placed following a left mastectomy for treatment of
an infiltrating ductal carcinoma. She is advised of potential
Question 7: A study of postpartum women is performed. complications, including leakage of the silicone breast
Some of them developed a palpable 'lump' in one or both implant. Which of the following is most likely to be caused by
breasts postpartum. The lump appeared following cessation breast implant leakage?
of breast feeding and persisted for more than one month, A Phyllodes tumor
Many of these lumps regressed following fine needle
aspiration. Which of the following breast lesions is most likely B Scleroderma
to fulfill these criteria? C Breast abscess
A Papilloma D Infiltrating ductal carcinoma
B Fat necrosis E Contracture
C Galactocele
D Ductal epithelial hyperplasia
(E) CORRECT. Pain and contracture with cosmetic deformity
B Plasma cell infiltrate
are the major complications of leaking breast implants.
C Sclerosing adenosis
Question 10: A 52-year-old woman feels a lump in her right
breast on self-examination and goes to her physician. On D Staphylococcus aureus infection
physical examination the 4 cm mass is not freely movable and E Fat necrosis
feels quite hard. A fine needle aspirate is performed and (D) CORRECT. A breast abscess is present. These are most
cytologic examination shows cells are present consistent common in the postpartum period when the nipple becomes
with carcinoma. Which of the following features of this cracked or fissured with nursing.
carcinoma is most likely to suggest a worse prognosis?
A Estrogen receptor positivity Question 13: A 25-year-old woman palpates a left breast
'lump' on self-examination. Her nurse practitioner palpates
B Family history of breast carcinoma an ill-defined mass. There is no pain or tenderness. No
axillary lymphadenopathy is noted. Fine needle aspiration is
C Presence of an in-situ component
performed and cytologic examination shows cells that
D Axillary lymph node metastases appear benign. The lesion persists, and 6 months later
another biopsy is taken and shows ductal epithelial
E Lack of aneuploidy
proliferation with ductal apocrine metaplasia, stromal
(D) CORRECT. Invasion of lymphatics is a poor prognostic
fibrosis, and sclerosing adenosis. Which of the following is
sign, because it suggests that the carcinoma is spreading.
the most likely diagnosis?
Question 11: A 45-year-old woman feels a 'lump' in her left A Infiltrating ductal carcinoma
breast. Her physician palpates a 2 cm irregular area in the
B Ductal carcinoma in situ
upper outer quadrant. A biopsy is performed and
microscopic examination shows no evidence for carcinoma. C Lobular carcinoma in situ
Which of the following microscopic findings in this biopsy is
most likely to suggest an increased risk for subsequent D Fibrocystic changes
development of breast carcinoma? E Intraductal papilloma
A Atypical hyperplasia (D) CORRECT. Fibrocystic changes are very common and
benign, but can produce a mass effect and must be
B Sclerosing adenosis distinguished from breast cancer.
C Apocrine metaplasia
Question 14: A 39-year-old woman has noted red, scaling
D Galactocele area on her breast for 3 months. On physical examination
there is an eczematous 1 cm diameter area on the skin of the
E Multiple cysts
right breast areola. There is no palpable lump in this breast.
(A) CORRECT. Particularly when atypical microscopic features
Biopsy of the skin lesion is performed and on microscopic
are present, lobular or ductal hyperplasia is the component
examination shows large cells at the dermal-epidermal
of fibrocystic disease that is associated with subsequent
junction that stain positively for mucin. Which of the
increased risk for development of carcinoma, probably about
following is the most likely diagnosis?
a 5 fold risk.
A Nipple discharge
Question 12: A 20-year-old woman gives birth to a term girl
B Paget disease of breast
infant following an uncomplicated pregnancy. She breast
feeds the infant. Six weeks later, her left breast becomes C Intraductal carcinoma
painful and slightly swollen. On physical examination there is
a tender 3 cm mass in the left breast beneath a nipple that D Dermatophyte infection
shows several painful fissures. Which of the following E Inflammatory carcinoma
pathologic findings is most likely to be present in this breast?
F Eczematous dermatitis
A Infiltrating ductal carcinoma (B) CORRECT. Paget disease of the breast is a skin lesion that
appears grossly eczematous, but microscopically shows the
presence of malignant cells. There is typically an underlying examination this mass has a lymphoid stroma with little
carcinoma that may be hard to locate. fibrosis surrounding sheets of large vesicular cells with
frequent mitoses. Which of the following is the most likely
Question 15: A 39-year-old woman has noted a bloody nipple diagnosis?
discharge from the right breast for the past 5 weeks. On
A Infiltrating ductal carcinoma
physical examination there is no palpable mass or
tenderness. The skin of this breast shows no lesions. A small B Colloid carcinoma
amount of bloody fluid can be expressed from the right
nipple. Which of the following is the most likely diagnosis? C Medullary carcinoma

A Mastitis D Lobular carcinoma

B Intraductal papilloma E Phyllodes tumor

C Trauma F Diffuse large B cell lymphoma


(C) CORRECT. Medullary carcinoma is often bulky, with
D Infiltrating ductal carcinoma pushing margins. It lacks the desmoplasia typical of ductal
carcinomas. It accounts for only about 1% of breast cancers.
E Tuberculosis
F Fibrocystic changes Question 18: A clinical study is performed involving subjects
who are women ranging in age from 15 to 45 years who
(B) CORRECT. Papilloma, a solitary lesion of a lactiferous palpated breast 'lumps' on self-examination. The presence of
sinus, is not common, but you should suspect it when there breast mass lesions in these subjects was subsequently
is a bloody discharge. This lesion is not premalignant. confirmed by physical examination and by mammography.
All subjects had a needle biopsy or excision of their lesion
Question 16: A 61-year-old woman has noted a rough, performed, with a definitive pathologic diagnosis made.
reddened appearance increasing in size over the skin of her Which of the following diagnoses is likely to be the most
right breast for the past 5 months. This persists despite frequently made in these subjects?
application of a corticosteroid cream. On physical
A Abscess
examination the skin over the right breast is indurated,
roughened, and reddish-orange. There is nipple retraction. A B Fibroadenoma
firm, irregular 5 cm mass is palpable in this breast. Which of
the following is the most likely risk factor for this woman's C Fibrocystic changes
condition? D Lobular carcinoma in situ
A Cigarette smoking E Infiltrating ductal carcinoma
B Prior fibrocystic disease (C) CORRECT. About 40% of breast lumps turn out to be
caused by fibrocystic changes.
C Multiparity
Question 19: A 61-year-old woman has increasing dyspnea
D Family history
with chest pain for the past 4 months. On physical
E Human papillomavirus infection examination there is dullness to percussion over both lungs.
A chest x-ray shows bilateral pleural effusions. A
(D) CORRECT. A The findings point to breast carcinoma with thoracentesis yields bloody fluid that cytologically contains
invasion of the overlying skin ('inflammatory carcinoma'). A small malignant cells forming long rows or rings. A
family history of breast cancer increases the risk for breast mammogram shows an irregular area of architectural
cancer the most. disortion in her left breast. Which of the following histologic
Question 17: A 41-year-old woman has felt a large breast types of breast cancer is most likely to be present in this
lump that has increased slowly in size for the past 3 years. On woman?
physical examination there is a 9 cm firm, movable mass
A Lobular
present in her left breast. The overlying skin appears normal;
there is no axillary lymphadenopathy. The mass is excised B Ductal
and grossly appears soft and fleshy. On microscopic
C Medullary D Aneuploidy by flow cytometry
D Tubular E Intraductal histologic pattern
E Papillary
(E) CORRECT. The best overall survival is with intraductal
carcinomas (those that have not invaded out from the ducts);
(A) CORRECT. Invasive lobular carcinomas are most likely to
this is the lowest stage possible.
metastasize widely to surfaces: pleural, peritoneal,
meningeal. They also may metastasize to femal genital tract
Question 22: A 51-year-old healthy man has noted bilaterally
and gastrointestinal tract. The cells have minimal associated
enlarged breasts for the past 35 years. On physical
desmoplasia, so a palpable mass may not be present.
examination his breasts are 3 times normal size, with no
masses present, no tenderness, and no axillary
lymphadenopathy. Which of the following conditions is most
Question 20: A 30-year-old woman has felt a mass in her
likely to be associated with his breast enlargement?
right breast for 6 months. On physical examination there is a
5 cm right breast mass and firm, non-tender A Antidepressant drug therapy
lymphadenopathy. A fine needle aspiration is performed and
B 47, XXY karyotype
cytologic examination shows carcinoma cells. A right
mastectomy with axillary lymph node dissection is C Family history
performed. Microscopic examination shows a poorly
differentiated carcinoma that is negative for estrogen and D Seminoma of the testis
progesterone receptors and negative for HER2/neu. One E Increased testosterone levels
axillary lymph node demonstrates micrometastases. Her 32
year old sister is found to have a similar lesion. Which of the (B) CORRECT. Gynecomastia is common with Klinefelter
following is the most likely risk factor for this woman's breast syndrome. It is a benign condition with no risk for cancer.
cancer?
A BRCA1 mutation
B Late menarche
C Positive antinuclear antibody test
D Exposure to hydrocarbon compounds Question 23: A study of breast carcinomas is conducted.
Some of these carcinomas are found to be 'triple negative'
E Prior fibrocystic changes
for estrogen receptor, progesterone receptor, and HER2.
Which of the following microscopic findings is most
(A) CORRECT. A small number of breast cancers are the result
characteristic for these triple negative breast carcinomas?
of an inherited BRCA1 mutation (or BRCA-2), but the family
history of breast cancer at a young age makes this more A Inflammatory component
likely. The 'triple negative' breast cancers (ER, PR, HER2
negative) are harder to treat. B Multifocality
C High grade
Question 21: A 45-year-old woman has noted a mass in her
right breast for 7 months. On physical examination there is a D Tubular growth pattern
5 cm diameter right breast mass. A biopsy of the mass is E Desmoplasia
performed and on microscopic examination a carcinoma is
present. Which of the following pathologic findings involving (C) CORRECT. Triple negative breast cancers are typically
this lesion suggests a better prognosis for this woman? high-grade, agressive cancers that tend to recur quickly and
A Estrogen receptor negative spread to visceral sites. Treatment is a challenge, because
targeted hormonal therapies or biotherapies do not work
B Axillary lymph node metastasis well.
C Age at diagnosis
Question 24: A 49-year-old woman goes to her physician for Question 26: A 66-year-old man has observed an enlarging
a routine health maintenance examination. A screening lump near the right nipple for 5 months. On examination
mammogram is performed and shows a 3 cm irregular there is a firm, fixed 1.5 cm nodule beneath the right areola.
density in her left breast that has microcalcifications. A The mass is excised and axillary lymph node sampling
needle biopsy of this area shows ducts containing solid performed. The mass and one lymph node examined
sheets of malignant cells, with central necrosis and microscopically show ductal carcinoma. Which of the
calcification. There is no invasion. A lumpectomy with wide following germline mutations is most likely present in this
excision to clear margins is performed along with axillary man?
lymph node sampling that shows no metastases. Malignant
A APC
cells are positive for HER2 but negative for estrogen
receptor. Which of the following is the most likely outcome B BRCA2
for this woman?
C NF1
A Recurrence in the opposite breast
D TP53
B Cure with no further therapy
E VHL
C Response to therapy with tamoxifen
(B) CORRECT. Familial BRCA2 mutations may be found in
D Development of inflammatory carcinoma
about 10% of male breast cancers. Other risks are the same
E Her children will inherit a BRCA1 mutation as for women: first degree relative, exogenous extrogens,
fatness, prior radiation. In addition, Klinefelter syndrome (1
(B) CORRECT. She has a ductal carcinoma in situ (DCIS). Since in 500 men) is a risk. Most are estrogen receptor positive, and
it is non-invasive at the time of diagnosis, it has a good treatment strategies are the same as for women.
prognosis. Some will recur locally. If left alone, DCIS will often
progress to become an invasive carcinoma. Question 27: A 29-year-old woman notes a lump in her left
breast. The lump remains through 2 menstrual cycles
Question 25: A 69-year-old woman has a screening without change in size. A screening ultrasound examination
mammogram that shows an irregular 1 to 2 cm density in her is performed and there is a 1.5 cm fluid-filled cyst within the
right breast. She has no axillary lymphadenopathy. A needle inner upper quadrant of the left breast. Fine needle
biopsy is performed and on microscopic examination shows aspiration is performed and clear fluid and some cells are
malignant cells floating in mucinous lakes. The nuclei show obtained. A year later there is no palpable lump. Which of
minimal pleomorphism and no mitoses are seen. The cells the following cells were most likely present in her breast
are positive for estrogen receptor and negative for HER2 (c- lesion?
erb B2). A chest x-ray shows no abnormal findings. A bone
A Atypical ductal epithelial cells
scan is negative. What is the most likely designation for grade
and stage of this neoplasm? B Fibroblasts
A Grade I, Stage T1 M0 N0 C Lobular carcinoma cells
B Grade I, Stage T2 M1 N1 D Metaplastic apocrine cells
C Grade II, Stage T3 M0 N0 E Neutrophils
D Grade II, Stage T2 M0 N1 F Small mature lymphocytes
E Grade III, Stage T3 M0 N1
(D) CORRECT. Breast cysts are common and part of fibrocystic
changes. The cyst may be lined by flattened epithelium or
(A) CORRECT. The histologic features are those of a low grade
larger pink cells with apocrine change. Aspiration collapses
colloid carcinoma, a histologic type that typically is ER
the cyst, which may be curative.
positive, without metastases, and with a good prognosis. The
stage is low because there is a small tumor without evidence
of either nodal or distant metastases.