A 41-year-old woman comes
to the physician 3 weeks after a vaginal delivery, complaining of a lump in her
right breast. She states that over
the past few days, she has
noticed increasing redness in the area and that the site is painful and feels
somewhat firm to her. She also
complains of fever and
chills. She is concerned because she is currently breast-feeding her child. She
has no medical or surgical history. She
uses acetaminophen
occasionally for headaches and is allergic to sulfa drugs. Her temperature is
37.8 C (100.1 F), blood pressure is
110/70 mm Hg, pulse is
98/minute, and respirations are 12/minute. The right breast has an area of
erythema and edema that is tender with
no fluctuance.
Question
1 of 4
Which of the following is
the most likely diagnosis?
/ A. Breast carcinoma
/ B. Eczema
/ C. Fibroadenoma
/ D. Mastitis
/ E. Trauma
|
Explanation - Q: 1.1
|
|
The correct answer is D. Mastitis represents a
parenchymatous infection of the mammary glands. It is most often seen in
postpartum women who are breast-feeding, and the symptoms typically appear
3-4 weeks postpartum. Most women with mastitis complain of pain in the breast
with an area of redness and "hardness." Women also often have fever
and chills, myalgias and arthralgias, and tachycardia. Examination shows
erythema, edema, and tenderness.
Patients with breast carcinoma (choice A) often
present with an asymptomatic mass. While it is possible for patients with
breast cancer to have erythema and edema of the breast and tenderness on
exam, this presentation in a postpartum, breast-feeding woman is most
consistent with mastitis.
Eczema (choice B) does not present with a lump,
as this patient has. It is a superficial disorder involving the top part (epidermis
and upper dermis) of the skin only. It is also characterized by scale with
erythema and not associated with fever, chills, and systemic symptoms like
this patient has.
Fibroadenoma (choice C) represents a
proliferation of fibrous tissue in the breast. It is the most common tumor in
young women. Patients with fibroadenoma typically present with complaints of
a breast lump. The mass is usually small, unilateral, firm, and freely
mobile. Patients with fibroadenoma do not usually present with erythema, edema,
pain in the breast, and systemic signs of infection.
Trauma (choice E) to the breast can lead to a
condition called fat necrosis. Patients with breast trauma usually complain
of a firm area of the breast, sometimes mobile, and occasionally with induration.
However, patients with fat necrosis from breast trauma usually recall a prior
incident of trauma.
|
Question
2 of 4
Histological examination
of diagnostic tissue from this patient would reveal which of the following?
/ A. A Iocalized area of acute inflammation
/ B. Cellular, fibroblastic stroma enclosing cystic spaces lined by
epithelium
/ C. Edema fluid within the intercellular spaces of the epidermis
/ D. Hemorrhage enclosed within the tissue
/ E. Strands of infiltrating tumor cells
|
Explanation - Q: 1.2
|
|
The correct answer is A. This patient has a
presentation that is most consistent with mastitis, which represents an acute
localized infection. Histologic evaluation would, therefore, reveal a localized
area of acute inflammation with edema and neutrophil emigration.
Cellular, fibroblastic stroma enclosing cystic spaces
lined by epithelium (choice B) would be the histology of a
fibroadenoma and not mastitis.
Edema fluid within the intercellular spaces of the
epidermis (choice C) is the histologic finding in eczema.
Hemorrhage enclosed within a tissue (choice D)
describes a hematoma and would be the expected histologic finding in a
patient with trauma to the breast with a resultant hematoma. This patient's
presentation is more consistent with mastitis than trauma.
Strands of infiltrating tumor cells (choice E)
would be the expected finding in a patient with certain types of carcinoma of
the breast. This is not the histologic finding in mastitis.
|
Question
3 of 4
Which of the following is
most likely responsible for this pathologic process?
|
Explanation - Q: 1.3
|
|
The correct answer is E. Staphylococcus
aureus is a catalase-positive, coagulase-positive, and beta-hemolytic
organism that is the most common cause of mastitis. The source of the
organism is almost always from the nursing infant's oropharynx. Enterotoxin
F, or Toxic Shock Syndrome Toxin, has been reported to cause toxic shock
syndrome in some patients with mastitis caused by Staphylococcus aureus.
Blunt force injury (choice A) to the breast
might be expected to cause a hematoma or fat necrosis. This patient has a
presentation that is consistent with mastitis, and not traumatic injury to
the breast.
Chlamydia trachomatis(choice B) is an
obligate intracellular organism. It is most commonly found in the genital
tract and is associated with cervicitis and pelvic inflammatory disease in
women, urethritis in men, and pneumonia and conjunctivitis in newborns. It is
not normally associated with mastitis.
Hormonal exposure (choice C) is not considered
causative of mastitis. There is some evidence that hormonal exposure may
contribute to the development of breast cancer. This patient, however, has a
presentation more consistent with mastitis than breast cancer.
Neisseria gonorrhoeae(choice D) is a
gram-negative coccus that can cause cervicitis, pelvic inflammatory disease,
arthritis, pharyngitis, and urethritis. It can also cause neonatal conjunctivitis.
It is not commonly associated with mastitis.
|
Question
4 of 4
The patient is started on
dicloxacillin. This medication works via which of the following mechanisms?
/ A. BIocking cell wall synthesis
/ B. Inhibition of bacterial dihydrofolate reductase
/ C. Inhibition of bacteriaI DNA gyrase
/ D. Inhibition of protein synthesis
/ E. Inhibition of resorption of sodium and chloride
|
Explanation - Q: 1.4
|
|
The correct answer is A. Dicloxacillin belongs
to the general class of penicillin antibiotics. Penicillins interfere with
bacterial cell wall synthesis by binding to bacterial penicillin binding
proteins, resulting in eventual bacterial cell lysis. Bacterial resistance to
penicillins results when bacterial beta-lactamases disrupt the beta-lactam
ring contained within these antibiotics. Dicloxacillin (like methicillin and
nafcillin) is synthesized to be resistant to beta-lactamases. However,
resistance to these antibiotics is increasing as well. If a patient with
mastitis does not respond to dicloxacillin, bacterial resistance should be
suspected and vancomycin should be used.
Inhibition of bacterial dihydrofolate reductase (choice
B) is the mechanism of action of trimethoprim and pyrimethamine.
Inhibition of bacterial DNA gyrase (choice C) is
the mechanism of action of the fluoroquinolones and quinolones.
Inhibition of protein synthesis (choice D) is
the mechanism of action of the lincosamines (clindamycin, lincomycin). These
drugs bind the 50S subunit of ribosomes to inhibit the bacterial protein
synthesis.
Inhibition of resorption of sodium and chloride (choice
E) is the mechanism of furosemide (a loop diuretic).
|
A 37-year-old woman
undergoes a routine breast examination. During the breast examination, the
physician is aware that the skin of the
breast moves together with
the underlying breast tissue, rather than being obviously separate from it.
Question
1 of 6
The breast tissue is
normally attached to the overlying skin via which of the following?
/ A. Cooper's ligaments
/ B. Cruciate ligaments
/ C. Falciform ligament
/ D. Poupart's ligaments
/ E. Rhomboid ligaments
|
Explanation - Q: 2.1
|
|
The correct answer is A. The suspensory
ligaments of Cooper are fibrous condensations of connective tissue stroma
that attach the mammary gland to the dermis of the overlying skin. These are
particularly prominent in the superior aspect of the breast, and help to
support the breast tissue.
The cruciate ligaments(choice B) are in the
knee.
The falciform ligament (choice C) attaches the
peritoneum to the liver.
Poupart's ligament (choice D) is an alternative
name for the inguinal ligament.
The rhomboid ligament (choice E) is another name
for the costoclavicular ligament.
|
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Question
2 of 6
Careful examination of the
central depressed area of the nipple demonstrates multiple small openings.
These openings are from which of the
following?
/ A. Areola
/ B. Lactiferous ducts
/ C. Montgomery's glands
/ D. Sweat glands
/ E. Terminal ductules
|
Explanation - Q: 2.2
|
|
The correct answer is B. The lactiferous ducts
open into the nipples. The area of each of these ducts immediately below the
nipple is usually dilated, forming a lactiferous sinus, which can store a
droplet of milk that helps to initiate the baby's sucking reflex during
nursing.
The areola (choice A) is the ring of darkly
pigmented skin around the nipple.
Sweat glands (choice D) are common in the skin
of the breast generally, but are too small to be able to seen by the unaided
eye.
The terminal ductules (choice E) of the breast
system are at the deep end of the duct system of the breasts, and receive milk
from the lobular tissue.
|
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Question
3 of 6
The physician identifies a
palpable mass in one breast, and the patient is scheduled for a
"Iumpectomy." The reason that "Iumpectomies" for
breast lumps can be safely
performed in some patients is that the breast is divided into multiple lobes,
each of which contains a separate
duct system with
connecting lobules. The normal breast usually contains how many lobes?
/ A. 2 to 3
/ B. 5 to 7
/ C. 10 to 12
/ D. 15 to 25
/ E. 30 to 50
|
Explanation - Q: 2.3
|
|
The correct answer is D. The normal breast
contains 15 to 25 lobes. Each lobe can be thought of as having an
"inverted tree" composed of a "trunk" made of the
lactiferous duct, "branches" made of smaller ducts that feed into
the lactiferous duct, and "leaves" made of lobular tissue.
Depending on the clinical setting, surgeons will also sometimes excise the
duct system under the nipple along with the lump in the breast.
|
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Question
4 of 6
The surgical specimen is
sent fresh from the surgical suite to the laboratory for frozen section
examination. Before cutting into the specimen,
the pathologist makes a
careful gross examination, which demonstrates that most of the specimen has
replacement of the normally fatty
breast tissue with strands
of dense, white, firm tissue. In a few areas, roughly spherical lesions up to
3-cm diameter with a bluish hue to them
are seen. Palpation of
these areas produces a fluctuant sensation. Which of the following is the most
likely diagnosis based on the gross
evaluation?
/ A. Breast cancer
/ B. Changes of pregnancy
/ C. Fibroadenoma
/ D. Fibrocystic disease
/ E. Mastitis
|
Explanation - Q: 2.4
|
|
The correct answer is D. While a careful
pathologist will wait for appropriate frozen or permanent tissue histologic
examination, the description given in the question stem is most suggestive of
fibrocystic disease. The fibrous part of the lesion forms the dense, white
tissue strands, while the blue lesions are what are called "blue-domed
cysts. The blue color comes from the presence of darkly colored fluid (which
usually means old hemorrhage) within the cyst. The interior cyst wall is
usually smooth. These blue-domed cysts are a favorite of examiners because
they produce a distinctive gross picture and should be specifically
associated with fibrocystic disease, but you should be aware that in real
life they do not occur with anything near the frequency of fibrocystic
disease without obvious large cysts grossly (but many smaller cysts on
microscopic examination). Fibrocystic disease of the breast is a very common
lesion, and a frequent source of palpable lumps in the breast, which may
require further evaluation through either excisional biopsy (as in this
case), Tru-cut needle biopsy (producing a thin core about 1 cm long), or
needle aspiration (producing fluid or cells for cytology).
While a diagnosis of breast cancer should obviously be
confirmed microscopically before telling the clinician, invasive breast
cancer (choice A) can be suspected when there is a hard, white,
nodular area of the breast that has irregular (but often reasonably
well-defined - in contrast to the fibrotic areas of fibrocystic disease)
boundaries.
The changes of pregnancy (choice B) cannot be
reliably picked up on gross examination of the breast.
Fibroadenoma (choice C), like breast cancer,
tends to produce a well-defined mass lesion, but it typically has smooth
borders and may have a slightly gray and slightly mucoid (e.g., shiny or oily
appearing) surface on cross-section.
Long-standing mastitis (choice E) can cause
breast fibrosis, but will not cause blue-domed cyst formation. More acutely,
mastitis can produce abscesses (which appear white rather than blue).
|
Question
5 of 6
Frozen section examination
demonstrates fibrosis and cystic spaces. AIso seen are areas of compressed
glands with a lobular orientation.
The glands are lined by a
single layer of epithelial cells with oval nuclei and regular arrangement. No
true invasion of glands into the adjacent
stroma is seen. This
patient probably has which of the following?
/ A. Atypical ductal hyperplasia
/ B. Ductal carcinoma in situ
/ C. Lobular carcinoma in situ
/ D. Sclerosing adenosis
/ E. Usual ductal hyperplasia
|
Explanation - Q: 2.5
|
|
The correct answer is D. The lesion described is
sclerosing adenosis. The tip-offs in the description are the references to
compressed glands and lobular orientation. Sclerosing adenosis is a common
component of fibrocystic disease, and occurs when fibrosis distorts the
normal lobular architecture. The result can be some fairly bizarre, but
completely benign, compressed glands that may mimic carcinoma on both frozen
and permanent sections. Low power examination is often helpful, as this
emphasizes the lobular character of the lesion.
Lesions actually involving the epithelium of the duct
system typically have multiple layers of cells and range from usual ductal
hyperplasia (choice E, with low risk of invasive carcinoma and
characterized by the presence of both myoepithelial cells and epithelial
cells within the duct) through atypical ductal hyperplasia (choice A,
with medium risk of invasive carcinoma and characterized by ductal carcinoma
in situ-like features only involving portions of a duct) to ductal carcinoma
in situ (choice B, with relatively high risk of invasive carcinoma and
characterized by clearly abnormal features such as loss of myoepithelial
cells and formation of cribriform patterns involving complete cross-sections
of ducts).
Lobular carcinoma in situ (choice C) typically
produces lobular units whose lumina are completely filled with epithelial
cells.
In practice, while you may be asked to distinguish
classic examples of the different lesions mentioned in the choices on
examinations, you should be aware that this whole area can be very
problematic in real-life microscopic examinations of breast tissue, and one
piece of breast tissue sent to different experts in breast pathology may be
returned with a variety of diagnoses.
|
Question
6 of 6
Which of the following
breast lesions is considered to have the greatest potential for eventual
progression to a malignant lesion?
/ A. Apocrine metaplasia
/ B. BIue dome cyst
/ C. Epithelial hyperplasia
/ D. Fat necrosis
/ E. Fibrosis
|
Explanation - Q: 2.6
|
|
The correct answer is C. While fibrocystic
disease may have many components, including cyst formation (choice B),
apocrine metaplasia (choice A, a benign alteration of cyst epithelium
to resemble that of apocrine sweat glands), sclerosing adenosis, and fibrosis
(choice E), only the epithelial hyperplasia (usual, atypical, or
carcinoma in situ) is thought to indicate significant premalignant (or
malignant, for carcinoma in situ) potential. For this reason, most
pathologists pay particular attention to the epithelial lining of the ducts
and lobules when evaluating breast biopsy specimens with fibrocystic disease.
Fibrocystic breasts without any evidence of epithelial changes do not appear
to have any significant increased risk of progression to breast cancer. (You should,
however, be aware that a fibrocystic breast may make both breast palpation
and mammography more difficult and make it more likely to miss a small
lesion.)
Fat necrosis (choice D) is seen after breast
trauma, and has no significant malignant potential.
|
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A 47-year-old man presents
to his physician because he has noticed that his right breast is noticeably
larger than his left breast. Breast
examination demonstrates
that the right breast is diffusely enlarged. The breast tissue is freely mobile
and without distinct masses. The
patient reports that the
breast has been slowly enlarging over a period of several years.
Question
1 of 7
Which of the following is
the most likely diagnosis?
/ A. Ductal carcinoma in situ
/ B. Fibroadenoma
/ C. Gynecomastia
/ D. Invasive ductal carcinoma
/ E. Lobular carcinoma in situ
|
Explanation - Q: 3.1
|
|
The correct answer is C. The most common cause
for male breast evaluation in the
The glands in male breasts do not have lobular tissue,
so lobular carcinoma in situ (choice E) does not occur.
|
Question
2 of 7
AIso noted on physical
examination is the presence of multiple spider angiomata. These are most
closely associated with disease of which
of the following organs?
/ A. Liver
/ B. Prostate
/ C. Stomach
/ D. Testes
/ E. Thyroid
|
Explanation - Q: 3.2
|
|
The correct answer is A. Spider angiomas are
small vascular lesions with small blood vessels radiating from a central
point. They are specifically associated with liver disease, particularly due
to alcohol abuse. They are not specifically associated with diseases of the
other organs listed in the choices.
|
Question
3 of 7
The presence of the spider
angiomas should specifically trigger a question to the patient about his
history of use of which of the following?
/ A. AIcohol
/ B. Caffeine
/ C. Cigarettes
/ D. Heroin
/ E. Marijuana
|
Explanation - Q: 3.3
|
|
The correct answer is A. Spider angiomas are
most often associated with liver disease related to alcohol abuse. Abuse of
the other items listed in the choices does not predispose for spider angioma
formation.
|
Question
4 of 7
Which of the following is
the most likely mechanism causing a relative excess of hormone leading to the
breast enlargement in this patient?
/ A. Decreased production of testosterone secondary to primary
hypogonadism
/ B. Drug that inhibits testosterone synthesis
/ C. Drug with estrogen-Iike activity
/ D. Increased peripheral conversion of androgens to estrogens
/ E. Increased production of estrogen by a cancer
|
Explanation - Q: 3.4
|
|
The correct answer is D. Peripheral conversion
of androgens (testosterone and androstenedione) to estrogens occurs mainly in
adipose tissue, muscle, and skin. In patients with chronic liver disease,
malnutrition, and hyperthyroidism, this peripheral conversion is increased,
and may be associated with feminization (seen as changes in hair
distribution, body fat distribution, and breast size).
Conditions that cause primary or secondary hypogonadism
(choice A) can cause gynecomastia by the mechanisms of decreased
production and/or action of testosterone. These conditions can include
Klinefelter syndrome, congenital anorchia, testicular trauma or torsion,
viral orchitis (e.g., mumps), pituitary tumors, and renal failure.
Drugs that can cause gynecomastia by inhibiting
testosterone synthesis (choice B) or action include ketoconazole,
metronidazole, cisplatin, spironolactone, and cimetidine.
Drugs that can cause gynecomastia because of their
estrogen-like activity (choice C) include diethylstilbestrol,
digitalis, and estrogen-containing foods and cosmetics.
Gynecomastia can also be seen as a consequence of
increased estrogen production by some tumors (choice E), including
testicular tumors and cancers secreting ectopic hCG (from lung, kidney, GI
tract, and extragonadal germ cell tumors). Gynecomastia can also occur as a
normal physiologic variant, particularly during puberty and in older men.
|
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Question
5 of 7
Which of the following
enzymes converts androgens to estrogens?
/ A. ALA synthase
/ B. Aromatase
/ C. Branching enzyme
/ D. MethylmalonyI CoA mutase
/ E. PRPP synthetase
|
Explanation - Q: 3.5
|
|
The correct answer is B. The enzyme aromatase is
found in adipose tissue (and hence is increased in fat people), muscle, and
skin. It acts on androgens to form estrogens by adding double bonds to make a
benzene-like ring. It is this enzyme whose activity is relatively increased
in liver disease.
Branching enzyme (choice C) is used in glycogen
formation.
Methylmalonyl CoA mutase (choice D) is involved
in the propionic acid pathway leading to synthesis of succinyl CoA.
PRPP synthetase (choice E) occurs in purine
synthesis.
|
Question
6 of 7
Which of the following is
a genetic syndrome associated with this patient's condition and a 10- to
20-fold increased incidence of breast
cancer?
/ A. Cushing syndrome
/ B. Down syndrome
/ C. Hashimoto disease
/ D. KIinefelter syndrome
/ E. Turner syndrome
|
Explanation - Q: 3.6
|
|
The correct answer is D. The genetic condition
Klinefelter syndrome (47,XXY) is fairly unique among the causes of
gynecomastia in that it is accompanied by an increased incidence of male
breast cancer. In most types of patients with gynecomastia, the incidence of
breast cancer is not increased, and there are no adverse medical
complications of the gynecomastia (although social and psychological problems
may occur). Gynecomastia is usually only treated (with surgery) in patients
in whom the breast either continues to enlarge or is personally troubling to
the patient.
Gynecomastia may occur in Cushing syndrome (choice
A) and hyperthyroidism related to Hashimoto disease (choice C),
but these are not genetic diseases.
Gynecomastia is not usually a feature of Down syndrome (choice
B), or Turner syndrome (choice E).
|
Question
7 of 7
The normal male breast
differs from the normal female breast in which of the following ways?
/ A. Adipose tissue is absent
/ B. Dermis is absent
/ C. Ductal tissue is absent
/ D. Lobular tissue is absent
/ E. Muscle is absent
|
Explanation - Q: 3.7
|
|
The correct answer is D. The normal male breast
(and the male breast with gynecomastia), unlike the normal female breast,
lacks lobular tissue. Both male and female breasts contain ductal tissue (choice
C), adipose tissue (choice A), dermis (choice B), and small
amounts of smooth muscle tissue (choice E).
|
A 53-year-old woman
consults a physician after discovering a mass in her breast. Physical
examination demonstrates a 1.5-cm diameter,
firm mass lesion in the
upper, outer quadrant of her right breast. The mass is surgically removed and
pathologic examination of tissue
obtained at surgery
reveals invasive breast cancer.
Question
1 of 5
What percentage of breast
masses are discovered by the patient, rather than by mammography or physician
examination of the breasts?
/ A. 5%
/ B. 20%
/ C. 50%
/ D. 80%
/ E. 95%
|
Explanation - Q: 1.1
|
|
The correct answer is D. Breast cancer accounts
for the greatest number of new cancer cases in women each year. Mammography
is the screening method used to detect subclinical breast cancer-the stage at
which breast cancer is least likely to have spread, but about 80% of breast
masses are discovered initially by the patient, which it is why it is
important to continue to stress breast self-examination.
|
Question
2 of 5
While about 75% of the
lymphatic fluid from the breast drains first to the axilla, most of the
remaining lymphatic fluid drains first to which of the
following groups of lymph
nodes?
/ A. Anterior internal thoracic nodes
/ B. Internal inferior thoracic nodes
/ C. Lateral intercostal nodes
/ D. Superior mediastinal nodes
/ E. Tracheobronchial nodes
|
Explanation - Q: 1.2
|
|
The correct answer is A. The anterior internal
thoracic nodes, also known as the internal mammary nodes, are a pair of
chained lymph nodes running superiorly to inferiorly along the chest wall
near both sides of the sternum. They are inaccessible for surgical removal
during mastectomy, but may contain metastatic breast cancer. Rarely, the
lateral intercostal nodes (choice C) may contain metastatic breast
cancer.
The inferior internal thoracic nodes (choice B)
drain the liver and diaphragm.
The superior mediastinal nodes (choice D) drain
the trachea, esophagus, and heart.
The tracheobronchial nodes (choice E) drain the
lung.
|
Question
3 of 5
Which of the following
will most likely be identified at pathologic examination of this woman's breast
mass?
/ A. Ductal carcinoma
/ B. Lobular carcinoma
/ C. Medullary carcinoma
/ D. Paget disease
/ E. Tubular carcinoma
|
Explanation - Q: 1.2
|
|
The correct answer is A. The anterior internal
thoracic nodes, also known as the internal mammary nodes, are a pair of
chained lymph nodes running superiorly to inferiorly along the chest wall
near both sides of the sternum. They are inaccessible for surgical removal
during mastectomy, but may contain metastatic breast cancer. Rarely, the
lateral intercostal nodes (choice C) may contain metastatic breast
cancer.
The inferior internal thoracic nodes (choice B)
drain the liver and diaphragm.
The superior mediastinal nodes (choice D) drain
the trachea, esophagus, and heart.
The tracheobronchial nodes (choice E) drain the
lung.
|
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Question
3 of 5
Which of the following
will most likely be identified at pathologic examination of this woman's breast
mass?
/ A. Ductal carcinoma
/ B. Lobular carcinoma
/ C. Medullary carcinoma
/ D. Paget disease
/ E. Tubular carcinoma
|
Explanation - Q: 1.3
|
|
The correct answer is A. There is a cumulative
risk in women of developing breast cancer of 1 in 8 by age 95; 1/3 to 1/2 of
the patients die of the disease. Breast cancer may occur in a ductal
or a lobular pattern. Invasive ductal carcinoma, not otherwise
specified, is the most common histological type of invasive breast cancer.
Risk factors for breast cancer include positive family history, early
menarche, late menopause, late first pregnancy, and history of in situ or
invasive breast cancer. Women who develop breast cancer before age 35 tend to
have more aggressive disease. Two breast cancer genes, BRCA1 and BRCA2, have
been identified; 5% of women with breast cancer carry one or the other of
these genes. Male breast cancer is much less common than female, but has a
high mortality rate
Lobular carcinoma (choice B) is the second most
common type of breast cancer. It may occur bilaterally in some patients.
Medullary carcinoma (choice C) and tubular
carcinoma (choice E) are histological variants of ductal carcinoma
with statistically better prognoses than ductal carcinoma, not otherwise
specified.
Paget disease (choice D) is the presence of
individual adenocarcinoma cells within the skin overlying a breast cancer.
|
Question
4 of 5
Immunohistochemical
examination of paraffin-embedded sections through the tumor demonstrates that
it stains for estrogen receptors (ER)
and progesterone receptors
(PR). This finding specifically suggests that the tumor may respond to which of
the following drugs?
/ A. 5-FIuorouracil
/ B. Cyclophosphamide
/ C. Doxorubicin
/ D. Methotrexate
/ E. Tamoxifen
|
Explanation - Q: 1.4
|
|
The correct answer is E. Treatment with adjuvant
tamoxifen for 5 years in ER positive tumors can reduce the risk of death by
25% in both pre- and postmenopausal women with or without axial lymph node
involvement. Breast cancers that express the Her-2/neu receptor may respond
to a new drug, trastuzumab, which is a monoclonal antibody directed against
the receptor. The other drugs listed are all used for breast cancer chemotherapy,
but work because they are cytotoxic rather than because they affect the
hormonal response of the cancer.
|
Question
5 of 5
The patient's physician
suggests that she immediately begin chemotherapy treatment. The patient
dismisses his suggestion and says, "I do
not need any medicine, all
l need is bedrest." This statement is most consistent with which of the
following responses to illness?
/ A. Acceptance
/ B. Anger
/ C. Bargaining
/ D. Denial
/ E. Grieving
|
Explanation - Q: 1.5
|
|
The correct answer is D. Denial is a coping
mechanism to defend against overwhelming anxiety. Pathologic and extreme
denial can interfere with accurate diagnosis, impede treatment, and
consequently perpetuate the disease state. Denial is common in the early
stages of dealing with a terminal illness and is not necessarily pathologic.
Less extreme forms of denial may even serve the patient in positive ways.
"I'm as strong now as I was when I was 20 and I'm gonna make it." Notably,
the stages of grieving over the loss of a loved one (bereavement) are very
similar to grieving over the loss of one's health (stages of dying).
Acceptance (choice A) is a realistic perspective
concerning the consequences of illness. "Coming to terms" with the
illness restores emotional equilibrium and patients appear to return to their
baseline personality and emotional functioning.
Anger (choice B) is often directed at fate, God,
themselves, their caretakers, and their families and, if taken to the
extreme, may result in isolation from much needed support.
Bargaining (choice C) entails promises to buy
additional time.
Grieving (choice E) is a process of changing
affective states over time and includes five stages as described by Elisabeth
Kubler-Ross (denial, anger, bargaining, depression, and acceptance). Denial,
anger, anxiety, depression, and dependence can all be abnormal responses to
illness (when extreme).
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A 23-year-old woman comes
to the physician because of a lump in her right breast. She states that she
first noted the lump about a year ago
and that it has seemed to
enlarge over the past year. She notes some occasional tenderness in the area,
usually at the same time during her
menstrual cycle. She has
no medical problems. She had an appendectomy at the age of 18. She takes no
medications and is allergic to
penicillin. Examination of
the breast demonstrates a freely mobile, smoothly contoured, discrete mass in
the upper outer quadrant of the
breast. UItrasonography
demonstrates a smooth mass with circumscribed margins and homogeneous echo
pattern, consistent with a solid
Iesion.
Question
1 of 4
Which of the following is
the most likely diagnosis?
/ A. Breast abscess
/ B. Fibroadenoma
/ C. Fibrocystic breast changes
/ D. Mastitis
/ E. Pregnancy
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Explanation - Q: 2.1
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The correct answer is B. Fibroadenomas are the
most common breast lesions found in women under 25 years of age.
Fibroadenomas are the second most common cause of benign breast lesions
(second only to fibrocystic changes) in women of all ages. Patients with a
fibroadenoma typically present complaining of a palpable lump, often with
some gradual growth. There may be some occasional cyclic tenderness.
Management is with biopsy or close observation. If the lesion is palpable,
increasing in size, or psychologically disturbing, biopsy should be
performed. If the woman is less than 25 years of age with small fibroadenomas
that appear "classic" by imaging, then expectant management with
careful continued observation can be considered.
A breast abscess (choice A) can also present as
a lump in the breast. However, an abscess represents a localized collection
of pus resulting from an infection. Therefore, patients with a breast abscess
will often have erythema, edema, pain, and tenderness around the area of the
mass. Such patients may also have systemic signs of infection, including
fever and tachycardia. This patient has no evidence of infection.
Fibrocystic breast changes (choice C) are the
most common, benign condition of the breast. They can be present in young
women, become more common as a woman approaches the menopause, and often
regress during and after the menopause. The most common symptoms are pain and
tenderness, and the masses are usually bilateral. Mammography and ultrasound
of the breast often reveal the fibrocystic changes.
Mastitis (choice D) is an infection of the
breast. It can occur in any woman, but most often occurs in lactating women
during the postpartum period. Patients with mastitis will often present with
tenderness and erythema of the breast along with fever. Treatment is with
antibiotics.
Pregnancy (choice E) is associated with a number
of changes in the breast, especially as the breast prepares for lactation.
Fibroadenomas may grow rapidly during pregnancy, but the primary diagnosis,
and hence the best answer, is still fibroadenoma
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Question
2 of 4
Histological examination
of diagnostic tissue from this patient would reveal which of the following?
/ A. A classic cribriform pattern with neoplastic epithelial cells
/ B. Cystically dilated ducts plus stromal fibrosis
/ C. Irregular steatocytes and intervening necrotic material and
inflammatory cells
/ D. Lobular hypertrophy
/ E. Proliferating ducts and stromal cells
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Explanation - Q: 2.2
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The correct answer is E. Fibroadenomas have a
typical microscopic appearance. The predominant feature is the fibroblastic
stroma. This is a delicate, cellular, fibroblastic stroma resembling
intralobular stroma. Within this fibroblastic stroma are seen proliferating
ducts. These ducts are usually compressed and are lined by benign-appearing
epithelium. If the margin includes surrounding tissue beyond the
fibroadenoma, compressed breast connective tissue forming a
"capsule" to the mass may be seen as well.
A classic cribriform pattern with neoplastic epithelial
cells (choice A) is what would be revealed by histological examination
of an intraductal carcinoma of the breast. The epithelium in a fibroadenoma
is benign-appearing.
Histologic examination of a biopsy specimen from a
patient with fibrocystic breast changes would demonstrate cystically dilated
ducts plus stromal fibrosis (choice B).
Irregular steatocytes and intervening necrotic material
and inflammatory cells (choice C) describes the findings on pathologic
evaluation of a biopsy specimen from a patient with fat necrosis. Fat
necrosis is most commonly caused by trauma, but can also occur after surgery
or radiation therapy.
Lobular hypertrophy (choice D) is seen in
pregnant women. This lobular hypertrophy occurs during the pregnancy to allow
for lactation in the postpartum period.
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Question
3 of 4
If the histologic
examination revealed similar findings as in this patient, but demonstrated
increased cellularity, an elevated mitotic rate,
stromal overgrowth, and
infiltrative borders, then which of the following is the most likely diagnosis?
/ A. Fat necrosis
/ B. Fibrocystic changes
/ C. Mastitis
/ D. Normal breast tissue
/ E. Phyllodes tumor
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Explanation - Q: 2.2
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The correct answer is E. Fibroadenomas have a
typical microscopic appearance. The predominant feature is the fibroblastic
stroma. This is a delicate, cellular, fibroblastic stroma resembling
intralobular stroma. Within this fibroblastic stroma are seen proliferating
ducts. These ducts are usually compressed and are lined by benign-appearing
epithelium. If the margin includes surrounding tissue beyond the fibroadenoma,
compressed breast connective tissue forming a "capsule" to the mass
may be seen as well.
A classic cribriform pattern with neoplastic epithelial
cells (choice A) is what would be revealed by histological examination
of an intraductal carcinoma of the breast. The epithelium in a fibroadenoma
is benign-appearing.
Histologic examination of a biopsy specimen from a
patient with fibrocystic breast changes would demonstrate cystically dilated
ducts plus stromal fibrosis (choice B).
Irregular steatocytes and intervening necrotic material
and inflammatory cells (choice C) describes the findings on pathologic
evaluation of a biopsy specimen from a patient with fat necrosis. Fat
necrosis is most commonly caused by trauma, but can also occur after surgery
or radiation therapy.
Lobular hypertrophy (choice D) is seen in
pregnant women. This lobular hypertrophy occurs during the pregnancy to allow
for lactation in the postpartum period.
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Question
3 of 4
If the histologic
examination revealed similar findings as in this patient, but demonstrated
increased cellularity, an elevated mitotic rate,
stromal overgrowth, and
infiltrative borders, then which of the following is the most likely diagnosis?
/ A. Fat necrosis
/ B. Fibrocystic changes
/ C. Mastitis
/ D. Normal breast tissue
/ E. Phyllodes tumor
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Explanation - Q: 2.3
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The correct answer is E. Phyllodes tumors are
similar to fibroadenomas in that they arise from intralobular stroma.
Furthermore, on pathologic evaluation, low-grade phyllodes tumors can
resemble fibroadenomas. However, there are important differences. First, most
phyllodes tumors present in the sixth decade, whereas fibroadenomas most
commonly present in young women. Also, while most phyllodes tumors are
low-grade tumors that only rarely metastasize, some are aggressive high-grade
lesions that commonly recur locally and do metastasize hematogenously. These
aggressive lesions are often called cystosarcoma phyllodes. Some
phyllodes tumors are small, while others may be large enough to involve
virtually the entire breast. Grossly, these tumors often have leaf-like
projections off of them. On histologic evaluation, the keys to distinguishing
between fibroadenoma and phyllodes tumor are the increased cellularity,
enhanced mitotic rate, stromal overgrowth, nuclear pleomorphism, and
infiltrative borders that are seen in phyllodes tumors and are absent in
fibroadenomas.
Fat necrosis (choice A) demonstrates necrotic
fat cells that are surrounded by lipid-filled macrophages and an infiltration
of neutrophils. It does not resemble a fibroadenoma.
Fibrocystic changes (choice B) are characterized
by cysts, and do not closely resemble fibroadenomas, as low-grade phyllodes
tumors do.
Mastitis (choice C) is an infection of the
breast, usually by Staphylococcus aureus. It is characterized by acute
inflammation and does not resemble fibroadenoma.
Normal breast tissue (choice D) is not
characterized by a pattern similar to fibroadenoma, except with increased
cellularity, elevated mitotic rate, stromal overgrowth, and infiltrative
borders. These are characteristics of phyllodes tumors.
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Question
4 of 4
If the patient were
instead found to have an aggressive breast carcinoma with a poor prognosis, the
Kubler-Ross model predicts that she will
go through which of the
following stages?
/ A. Acceptance, anger, ambivalence, deniaI, depression
/ B. BIues, depression, psychosis, treatment, resolution
/ C. DeniaI, anger, bargaining, depression, acceptance
/ D. DeniaI, anger, psychosis, homicide, suicide
/ E. Realization, infantilization, socialization, condemnation
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Explanation - Q: 2.4
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The correct answer is C. Elisabeth Kubler-Ross
is the psychiatrist who authored the groundbreaking "On Death and
Dying" in 1969. She was born in
None of the other choices correctly describes the stages
proposed by Kubler-Ross.
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