Benign Breast Diseases — MCQs
A 25-year-old lady presents with spontaneous nipple discharge of 3 months duration. On examination, the discharge is bloody and from a single duct. The following statements about management of this patient are true EXCEPT:
A middle-aged female presents with increasing visual loss, breast enlargement, and irregular menses. What is the most appropriate investigation to diagnose the underlying condition?
Munro's microabscesses are seen in all of the following except:
A 40-year-old female presents with an irregular 5 × 6 cm mass in the right breast. Histopathological examination reveals the image shown. What is the most likely diagnosis?
In which of the following situations is breast conservation surgery not indicated?
Treatment of choice for phyllodes tumor is:
Which of the following conditions is not typically treated with a simple mastectomy?
Mondor’s disease is
Which one of the following is not a correct statement with reference to locally advanced carcinoma breast ?
A 22 year old woman comes with a non progressive mass in the left breast since 6 months. There are no associated symptoms. Examination shows a mobile mass not attached to the overlying skin or underlying tissue. The possible diagnosis is
Benign Breast Diseases Indian Medical PG Practice Questions and MCQs
Question 1: A 25-year-old lady presents with spontaneous nipple discharge of 3 months duration. On examination, the discharge is bloody and from a single duct. The following statements about management of this patient are true EXCEPT:
- A. Ultrasound can be a useful investigation.
- B. Galactogram, though useful, is not essential.
- C. Radical duct excision is the operation of choice. (Correct Answer)
- D. Majority of blood-stained nipple discharges are due to papilloma or other benign conditions.
Explanation: ***Radical duct excision is the operation of choice.*** - **Radical duct excision** (also known as a Hadfield procedure) involves the removal of all major ducts and is an older, more extensive procedure generally reserved for cases of **multiple recurrent duct ectasia** or if symptoms persist after prior targeted excision. - For **single-duct bloody discharge**, the standard surgical approach is a **microdochectomy** (single duct excision), which targets the affected duct from which the discharge originates, thereby being less invasive and preserving more breast tissue. *Ultrasound can be a useful investigation.* - **Ultrasound** is a valuable initial imaging modality for nipple discharge, particularly in younger women with dense breasts, as it can help identify **intraductal masses**, cysts, or other abnormalities. - It can guide further investigation and often localize the cause of the discharge, especially if a mass is palpable or visible within the ducts. *Galactogram, though useful, is not essential.* - A **galactogram (ductogram)** is a specialized mammogram where contrast is injected into the discharging duct, allowing visualization of intraductal lesions like **papillomas** or ductal carcinoma in situ (DCIS). - While it can provide precise localization and characterization of intraductal pathology, it is not always performed as other imaging (like ultrasound or MRI) and clinical evaluation often provides sufficient information for management, particularly with **single-duct bloody discharge**. *Majority of blood-stained nipple discharges are due to papilloma or other benign conditions.* - In cases of **pathological nipple discharge**, particularly spontaneous and bloody discharge from a single duct, **intraductal papilloma** is the most common benign cause, accounting for a large percentage of such presentations. - Other benign conditions, such as **duct ectasia** or **fibrocystic changes**, can also cause nipple discharge, although bloody discharge often raises a higher suspicion for papilloma or malignancy.
Question 2: A middle-aged female presents with increasing visual loss, breast enlargement, and irregular menses. What is the most appropriate investigation to diagnose the underlying condition?
- A. S. calcitonin
- B. S. prolactin (Correct Answer)
- C. S. hemoglobin concentration
- D. S. calcium
Explanation: ***S. prolactin*** - **Hyperprolactinemia** is the most likely cause of the presented symptoms: **galactorrhea** (**breast enlargement** with milk production), **amenorrhea** (**irregular menses**), and **visual field defects** due to a pituitary tumor compressing the optic chiasm [1]. - Measuring serum prolactin levels directly confirms or rules out **hyperprolactinemia**, guiding further management, including imaging of the pituitary gland if elevated [1]. *S. calcitonin* - **Calcitonin** is a hormone primarily involved in **calcium regulation** and is typically elevated in medullary thyroid carcinoma. - The presented symptoms (visual loss, breast enlargement, irregular menses) are not characteristic of elevated calcitonin levels or a **medullary thyroid carcinoma**. *S. hemoglobin concentration* - **Hemoglobin concentration** measures the amount of oxygen-carrying protein in red blood cells and is used to diagnose **anemia** or polycythemia. - While general labs might include this, it is not directly relevant to the specific constellation of symptoms pointing towards an **endocrine or pituitary issue**. *S. calcium* - **Serum calcium** levels are checked for disorders of calcium metabolism, such as **hyperparathyroidism** or hypocalcemia. - Though calcium is regulated by hormones, the symptoms of **visual loss**, **breast enlargement**, and **menstrual irregularities** are not typically associated with primary disturbances in calcium levels.
Question 3: Munro's microabscesses are seen in all of the following except:
- A. Benign migratory glossitis.
- B. Psoriasis.
- C. Reiter syndrome.
- D. Pemphigus. (Correct Answer)
Explanation: ***Pemphigus*** - **Pemphigus** is characterized by **acantholysis**, the dissolution of intercellular bridges between keratinocytes, leading to intraepidermal blister formation [1]. - While it involves inflammatory changes, the characteristic neutrophilic collections known as **Munro's microabscesses** (which are collections of neutrophils in the stratum corneum) are not a feature [4]. *Benign migratory glossitis* - Also known as **geographic tongue**, this condition can show histological features similar to psoriasis, including **Munro's microabscesses**. - It involves areas of **atrophic filiform papillae** surrounded by elevated white or yellowish borders, which histologically show features of chronic inflammation and neutrophil accumulation. *Psoriasis* - **Munro's microabscesses** are a classic histological hallmark of **psoriasis**, particularly in the pustular forms [3]. - They represent accumulations of **neutrophils in the stratum corneum** and indicate the inflammatory nature of the disease [2]. *Reiter syndrome* - **Reiter syndrome**, now often referred to as **reactive arthritis**, can present with dermatological manifestations such as **keratoderma blennorrhagicum**, which is histologically indistinguishable from **pustular psoriasis**. - Therefore, **Munro's microabscesses** can be found in the epidermal lesions associated with Reiter syndrome. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Disorders Involving Inflammatory And Haemopoietic Cells, pp. 645-646. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Disorders Involving Inflammatory And Haemopoietic Cells, pp. 640-641. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Disorders Involving Inflammatory And Haemopoietic Cells, pp. 636-637. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Skin, p. 1172.
Question 4: A 40-year-old female presents with an irregular 5 × 6 cm mass in the right breast. Histopathological examination reveals the image shown. What is the most likely diagnosis?
- A. Phyllodes tumor (Correct Answer)
- B. Fibroadenoma
- C. Invasive ductal carcinoma
- D. Intraductal papilloma
Explanation: ***Phyllodes tumor*** - The image demonstrates a characteristic **leaf-like or cleft-like stromal growth pattern** often seen in phyllodes tumors [1]. The stroma is cellular and appears to project into ductal spaces, leading to the formation of slit-like spaces [1]. - Phyllodes tumors are typically **large (5 cm or more)**, firm, and solitary, with a rapid growth rate, consistent with the described 5×6 cm mass [1]. - They show a **biphasic pattern** with both epithelial and stromal components, where the stromal component predominates [1]. *Fibroadenoma* - While fibroadenomas are biphasic like phyllodes tumors, they usually present with a more uniform, less cellular stroma and less pronounced epithelial-stromal clefting [1]. - Fibroadenomas also do not typically grow as large as 5-6 cm with such aggressive stromal patterns in a 40-year-old. - The stroma in fibroadenoma is less cellular and lacks the leaf-like architecture [1]. *Invasive ductal carcinoma* - Invasive ductal carcinoma would show **infiltrating cords, nests, or tubules of malignant epithelial cells** invading through the stroma with associated desmoplasia [2]. - The biphasic leaf-like architecture with stromal fronds protruding into epithelial-lined spaces is not characteristic of carcinoma. - While it can present as a large irregular mass, the histological pattern is distinctly different from the image shown [2]. *Intraductal papilloma* - Intraductal papilloma presents with **arborizing fibrovascular cores lined by epithelial cells** within dilated ducts, typically near the nipple. - They are usually small (a few millimeters to 2-3 cm) and do not typically present as large 5-6 cm masses. - The prominent stromal overgrowth with leaf-like pattern seen in the image is not characteristic of papilloma. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1072-1074. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1066-1068.
Question 5: In which of the following situations is breast conservation surgery not indicated?
- A. SLE
- B. Large pendular breast
- C. Diffuse microcalcification
- D. All of the options (Correct Answer)
Explanation: ***All of the options*** - All listed scenarios—**large pendular breast**, **SLE**, and **diffuse microcalcification**—represent situations where breast conservation surgery is generally contraindicated or challenging. - Their presence often necessitates alternative treatment approaches, such as mastectomy, to achieve optimal oncologic and cosmetic outcomes. *Large pendular breast* - While not an absolute contraindication, a **very large or pendulous breast** can make it difficult to achieve a satisfactory cosmetic outcome after breast conservation surgery. - The disproportionate breast size post-lumpectomy may lead to significant **asymmetry**, requiring further reconstructive procedures. *SLE* - Patients with **Systemic Lupus Erythematosus (SLE)** are at an increased risk of complications from radiation therapy, a mandatory component of breast conservation surgery. - They tend to experience more severe and prolonged **acute and chronic skin reactions** to radiation, which can significantly impair healing and quality of life. *Diffuse microcalcification* - **Diffuse microcalcification** within the breast can indicate widespread in situ carcinoma (e.g., DCIS) or an invasive carcinoma with extensive intraductal component. - In such cases, achieving **clear surgical margins** with breast conservation surgery can be challenging and often leads to multiple re-excisions or an increased risk of local recurrence.
Question 6: Treatment of choice for phyllodes tumor is:
- A. Wide local excision (Correct Answer)
- B. Radical mastectomy
- C. Radiotherapy
- D. Chemotherapy
Explanation: ***Wide local excision*** - The primary treatment for phyllodes tumors is **surgical excision with wide clear margins (at least 1 cm)** to prevent recurrence. - The goal is to remove the tumor completely with adequate margins, as these tumors have a high local recurrence rate (up to 20-30%) if inadequately excised. - Most phyllodes tumors are benign (60-75%), but even benign variants require wide excision due to their infiltrative growth pattern. *Radical mastectomy* - This is an **overly aggressive procedure** for most phyllodes tumors, which are typically benign or borderline and do not require such extensive surgery. - Radical mastectomy may only be considered for very large malignant phyllodes tumors where breast conservation is not feasible. *Radiotherapy* - **Adjuvant radiotherapy** may be considered in cases of malignant phyllodes tumors with close or positive surgical margins or recurrent disease. - However, it is not the primary treatment of choice and is not effective as a standalone treatment for these tumors. *Chemotherapy* - Chemotherapy is **generally not effective** and not routinely indicated for phyllodes tumors, as they are largely resistant to systemic therapy. - It might be considered only in cases of **distant metastatic disease** from a malignant phyllodes tumor, which occurs in less than 5% of cases.
Question 7: Which of the following conditions is not typically treated with a simple mastectomy?
- A. Paget's disease
- B. Fibroadenoma (Correct Answer)
- C. Cystosarcoma phyllodes
- D. None of the options
Explanation: ***Fibroadenoma*** - A **fibroadenoma** is a **benign tumor** of the breast that typically does not require a mastectomy for treatment. - Treatment usually involves **observation**, **excision**, or **cryoablation**, depending on size, symptoms, and patient preference. *Paget's disease* - **Paget's disease of the breast** is a rare form of breast cancer that affects the nipple and areola, and is typically associated with an underlying **ductal carcinoma in situ** (DCIS) or **invasive breast cancer**. - Due to the presence of malignancy and its superficial spread, **mastectomy** (simple or modified radical) is often the recommended treatment, especially for extensive disease. *Cystosarcoma phyllodes* - Formerly known as **phyllodes tumor**, this is a rare **stromal tumor** of the breast that can be benign, borderline, or malignant. - Due to its potential for local recurrence and, in malignant cases, metastasis, **wide local excision with clear margins** is crucial, and a **simple mastectomy** may be necessary for large or recurrent tumors to achieve adequate margin control. *None of the options* - This option is incorrect because fibroadenoma is a condition not typically treated with a simple mastectomy, unlike Paget's disease and cystosarcoma phyllodes.
Question 8: Mondor’s disease is
- A. Multiple breast cysts
- B. Eczema of nipple and areola
- C. Thrombophlebitis of superficial veins of breast (Correct Answer)
- D. Lymphangitis of mammary lymphatics
Explanation: ***Thrombophlebitis of superficial veins of breast*** - Mondor's disease is characterized by **thrombophlebitis**, which is inflammation and clotting, of the **superficial veins of the breast** and sometimes the chest wall. - It often manifests as a **palpable, tender cord-like structure** under the skin. *Multiple breast cysts* - This condition involves the presence of **fluid-filled sacs** within the breast tissue, which can be palpable but do not present as a classic cord-like structure. - Cysts are typically smooth, mobile, and can fluctuate in size with the **menstrual cycle**, unlike Mondor's disease. *Eczema by nipple and areola* - This refers to an **inflammatory skin condition** affecting the **nipple and areola**, characterized by redness, itching, scaling, and sometimes oozing. - It is a **dermatological issue** and does not involve vascular clotting or a palpable cord. *Lymphangitis of mammary lymphatics* - **Lymphangitis** is the inflammation of **lymphatic vessels**, often presenting as red streaks and tenderness. - While it can affect the breast, it involves the **lymphatic system** rather than the superficial venous system and would not typically present as a thrombosed vessel.
Question 9: Which one of the following is not a correct statement with reference to locally advanced carcinoma breast ?
- A. Patients are staged as T3 or T4 with any N, without distant metastasis (M0)
- B. It constitutes the bulk of patients of carcinoma breast in India
- C. Neoadjuvant chemotherapy downgrades the disease
- D. Radical Mastectomy is the treatment of choice (Correct Answer)
Explanation: *Patients are staged as T3 or T4 with any N, without distant metastasis (M0)* - **Locally advanced breast cancer (LABC)** is correctly defined as tumors that are **T3 or T4** or involve regional lymph nodes (**any N**) without distant metastasis (**M0**). - This statement is **correct** regarding LABC staging criteria. *It constitutes the bulk of patients of carcinoma breast in India* - This statement is **correct**. In India, approximately **50-60% of breast cancer patients present with locally advanced disease** at the time of diagnosis. - This is in stark contrast to Western countries where LABC represents less than 10% of cases. - The high prevalence is attributed to lack of screening programs, delayed presentation, limited awareness, and socioeconomic factors. *Neoadjuvant chemotherapy downgrades the disease* - This statement is **correct**. **Neoadjuvant chemotherapy (NACT)** is a cornerstone of LABC management. - NACT aims to **downstage** the tumor, making it more amenable to surgical resection and increasing the feasibility of breast-conserving surgery. - It also provides early treatment of micrometastases and serves as an in vivo test of tumor chemosensitivity. ***Radical Mastectomy is the treatment of choice*** - This statement is **INCORRECT** and is the correct answer to this negation question. - **Radical mastectomy (Halsted mastectomy)** involving removal of breast, pectoral muscles, and axillary nodes is **no longer the standard treatment** for LABC. - Modern treatment involves a **multimodal approach**: neoadjuvant chemotherapy followed by **modified radical mastectomy (MRM)** or breast-conserving surgery with radiation therapy. - MRM preserves the pectoral muscles, providing better functional and cosmetic outcomes while maintaining oncological safety.
Question 10: A 22 year old woman comes with a non progressive mass in the left breast since 6 months. There are no associated symptoms. Examination shows a mobile mass not attached to the overlying skin or underlying tissue. The possible diagnosis is
- A. Fibroadenoma (Correct Answer)
- B. Cystasarcoma Phylloides
- C. Scirrhous Carcinoma
- D. Fibroadenosis
Explanation: ***Fibroadenoma*** - This is the most common benign breast tumor in young women, typically presenting as a **mobile, non-tender, firm mass** with no attachment to surrounding tissues. - The history of a **non-progressive mass** over six months in a 22-year-old woman is highly characteristic of a fibroadenoma. *Cystasarcoma Phylloides* - While it can present as a mobile mass, phyllodes tumors tend to grow **rapidly** and can reach a large size, which contradicts the "non-progressive" nature of the mass described. - Phyllodes tumors often have a **leaf-like architectural pattern** histologically and can be benign, borderline, or malignant. *Scirrhous Carcinoma* - This is a type of invasive ductal carcinoma that typically presents as a **hard, irregular, fixed mass** that is often attached to the skin or underlying tissue, unlike the mobile mass described here. - It is common in older women and often associated with **skin dimpling** or nipple retraction. *Fibroadenosis* - This refers to a group of benign breast changes, often presenting with generalized **lumpiness, pain, or tenderness** that fluctuates with the menstrual cycle, rather than a discrete, solitary mass. - It usually presents as **multiple, diffuse nodules** rather than a single, well-defined mass.
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