Male Breast Disorders — MCQs

10 questions

Which of the following is not true about breast cancer?

All of the following can result in gynecomastia except:

A girl presents with primary amenorrhea, grade V thelarche (mature breast), grade II pubarche (sparse growth of pubic hair) and no axillary hair. Likely diagnosis is:

While investigating a case of gynecomastia, all of the following hormone levels are estimated, except:

Which of the following cancers is least associated with BRCA2 mutations?

Which genetic mutation is most commonly associated with male breast carcinoma?

Which of the following is not a relative contraindication for breast conservative surgery?

Peau d’orange appearance is due to -

Which of the following statements is true regarding the treatment of early breast carcinoma?

Q10

What does the acronym NSABP represent in the context of cancer research?

Male Breast Disorders Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following is not true about breast cancer?

A. Family history is a risk factor
B. Paget’s disease affects the nipple
C. Lobular carcinoma is most common (Correct Answer)
D. Estrogen exposure increases risk

Explanation: ***Lobular carcinoma is most common*** - This statement is **incorrect** because **invasive ductal carcinoma (IDC)** accounts for the majority (**70-80%**) of all breast cancers. - While **invasive lobular carcinoma (ILC)** is the second most common type, it only represents about **5-15%** of cases. *Family history is a risk factor* - A **positive family history**, especially in a first-degree relative, significantly increases the risk of breast cancer due to inherited genetic mutations like **BRCA1** and **BRCA2**. - These mutations impair DNA repair, leading to uncontrolled cell growth. *Paget’s disease affects the nipple* - **Paget's disease of the nipple** is a rare form of breast cancer that presents as an eczematous lesion of the nipple and areola. - It is often associated with an **underlying invasive or in-situ ductal carcinoma**. *Estrogen exposure increases risk* - Prolonged or higher levels of **estrogen exposure** are known risk factors for breast cancer, as estrogen stimulates the growth of hormone-receptor-positive breast cancer cells. - Factors increasing estrogen exposure include **early menarche, late menopause, obesity**, and **hormone replacement therapy**.

Question 2: All of the following can result in gynecomastia except:

A. Spironolactone
B. Digoxin
C. Aromatase inhibitors (Correct Answer)
D. Sulphonamides

Explanation: ***Aromatase inhibitors*** - **Aromatase inhibitors** block the conversion of androgens to estrogens, thereby **decreasing estrogen levels** which would prevent rather than cause gynecomastia. - They are used in estrogen-sensitive breast cancers to reduce estrogen-dependent growth. *Spironolactone* - **Spironolactone** is an aldosterone antagonist that also possesses anti-androgenic effects and can inhibit androgen synthesis, leading to an **increased estrogen-to-androgen ratio** and gynecomastia. - It can also directly stimulate the estrogen receptor in male breast tissue. *Sulphonamides* - Certain **sulphonamides**, particularly sulfasalazine, have been associated with gynecomastia, possibly due to direct toxic effects on testicular function leading to a **relative increase in estrogen activity**. - While less common than with some other drugs, it can alter the estrogen-androgen balance. *Digoxin* - **Digoxin** can cause gynecomastia by mimicking estrogen physiologically or by inhibiting androgen production, leading to an **alteration in the estrogen-to-androgen ratio**. - The risk of gynecomastia is especially noted with prolonged use and higher doses of digoxin.

Question 3: A girl presents with primary amenorrhea, grade V thelarche (mature breast), grade II pubarche (sparse growth of pubic hair) and no axillary hair. Likely diagnosis is:

A. Turner syndrome
B. Testicular feminization (Correct Answer)
C. Gonadal dysgenesis
D. Mullerian agenesis

Explanation: Androgen Insensitivity Syndrome (also known as testicular feminization) is characterized by a phenotype where primary amenorrhea occurs in a girl with mature (Grade V) breast development but sparse or absent pubic and axillary hair (Grade II pubarche). In this condition, androgens are produced but their receptors are non-functional, leading to normal breast development through the peripheral conversion of androgens to estrogens while inhibiting androgen-dependent hair growth [3]. *Turner syndrome* - Characterized by gonadal dysgenesis [1], leading to primary amenorrhea and absent or rudimentary breast development (grade I thelarche). Patients typically present with characteristic physical features such as short stature [1], webbed neck, and coarctation of the aorta, which are not mentioned here. *Gonadal dysgenesis* - This is a broader term for abnormal development of the gonads [2], often leading to primary amenorrhea and lack of secondary sexual characteristics [1]. Unlike the described case, individuals with gonadal dysgenesis would not have mature breast development. *Mullerian agenesis* - Presents with primary amenorrhea due to the absence or hypoplasia of the uterus and upper vagina, but normal ovarian function. Patients with Mullerian agenesis would typically have normal breast development and normal pubic and axillary hair growth, as their androgen receptors are functional.

Question 4: While investigating a case of gynecomastia, all of the following hormone levels are estimated, except:

A. Lutenizing hormone
B. Prolactin
C. Follicle stimulating hormone (Correct Answer)
D. None of the options

Explanation: ***Follicle stimulating hormone*** - While **FSH** levels can be assessed in cases of infertility or hypogonadism, they are generally **not a primary assessment** for gynecomastia. - The direct hormonal imbalance causing gynecomastia typically involves other hormones like testosterone, estrogen, LH, and prolactin. *Lutenizing hormone* - **LH** levels are crucial in assessing **gonadal function** and identifying the cause of altered testosterone production, which is directly linked to gynecomastia [1]. - Elevated or suppressed LH can indicate primary or secondary hypogonadism affecting the **testosterone-estrogen balance**. *Prolactin* - **Prolactin** levels are important to rule out **hyperprolactinemia**, which can lead to hypogonadism and subsequently gynecomastia [1]. - A **prolactinoma** (prolactin-secreting tumor) can suppress GnRH, leading to reduced testosterone and an increased estrogen-to-androgen ratio [1]. *None of the options* - This option is incorrect because there is a specific hormone (FSH) among the choices that is **less commonly estimated** in the initial workup for gynecomastia compared to LH and prolactin. - The workup for gynecomastia commonly involves assessment of other hormones like **testosterone** and **estrogen** along with LH and prolactin [1].

Question 5: Which of the following cancers is least associated with BRCA2 mutations?

A. Breast cancer
B. Prostate cancer
C. Ovarian cancer
D. Vulval cancer (Correct Answer)

Explanation: ***Vulval cancer*** - While there may be some rare, sporadic cases, **vulval cancer** is generally not considered a primary cancer with a strong, well-established association with **BRCA2 mutations**. - Its etiology is more commonly linked to **HPV infection** and other risk factors not directly related to hereditary breast and ovarian cancer syndromes. *Breast cancer* - **BRCA2 mutations** are strongly associated with an increased lifetime risk of developing **breast cancer**, particularly for **male breast cancer**. - These mutations impair DNA repair mechanisms, leading to genomic instability that can result in cancerous transformation of breast tissue. *Prostate cancer* - Men with **BRCA2 mutations** have a significantly elevated risk of developing **prostate cancer**, often at an earlier age and with a more aggressive phenotype. - This association is well-documented, making BRCA2 testing relevant in high-risk prostate cancer populations. *Ovarian cancer* - **BRCA2 mutations** are a significant risk factor for **ovarian cancer**, particularly **high-grade serous ovarian cancer**. - The risk is substantial, though generally lower than that conferred by BRCA1 mutations for ovarian cancer in particular.

Question 6: Which genetic mutation is most commonly associated with male breast carcinoma?

A. BRCA2 mutation (Correct Answer)
B. TP53 mutation
C. PALB2 mutation
D. BRCA1 mutation

Explanation: ***BRCA2 mutation*** - **BRCA2 mutations** are the most common genetic mutations found in men with **breast cancer**, significantly increasing their lifetime risk. - They are also associated with an increased risk of **prostate cancer**, **pancreatic cancer**, and **melanoma** in men. *TP53 mutation* - **TP53 mutations** are associated with **Li-Fraumeni syndrome**, a hereditary cancer syndrome that increases the risk of various cancers, including sarcomas, brain tumors, and early-onset breast cancer in women. - While it can increase breast cancer risk, it is less commonly associated with **male breast carcinoma** compared to BRCA2. *PALB2 mutation* - **PALB2 (Partner And Localizer of BRCA2) mutations** are associated with an increased risk of breast cancer in both men and women, acting in concert with BRCA2. - While impactful, they are less prevalent than **BRCA2 mutations** in male breast cancer overall. *BRCA1 mutation* - **BRCA1 mutations** primarily increase the risk of breast and ovarian cancer in women. While they can increase the risk of **male breast cancer** to some extent, their contribution is much lower than that of **BRCA2 mutations** [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1058-1059.

Question 7: Which of the following is not a relative contraindication for breast conservative surgery?

A. Multicentric disease
B. Previous radiation to breast
C. Large tumor size
D. Small tumor size (<3cm) (Correct Answer)

Explanation: ***Small tumor size (<3cm)*** ✓ - A small tumor size is **NOT a contraindication** for breast-conserving surgery; it is actually a **favorable condition** and an indication for breast conservation. - Small tumors allow for complete tumor removal with good cosmetic outcomes and adequate margins. - This is the **correct answer** as it is the only option that is NOT a relative contraindication. *Multicentric disease* - **Multicentric disease** refers to the presence of multiple tumor foci in **different quadrants** of the breast, making complete surgical removal challenging with breast-conserving surgery. - This is a **relative contraindication** as it increases the risk of **positive margins** and local recurrence, making mastectomy often a more appropriate option. *Previous radiation to breast* - Prior radiation therapy to the breast is a **contraindication** (often considered absolute) for subsequent breast radiation, which is an essential component of breast-conserving therapy. - Re-irradiation carries a high risk of severe **skin and tissue toxicity**, making further breast conservation unfeasible. *Large tumor size* - A large tumor size is a **relative contraindication** as it can make it difficult to achieve **clear surgical margins** while maintaining an acceptable cosmetic result. - However, **neoadjuvant chemotherapy** may downstage large tumors to make them suitable for breast-conserving surgery. - Without tumor reduction, it often requires **mastectomy**.

Question 8: Peau d’orange appearance is due to -

A. Intra-epithelial cancer
B. Vascular embolization
C. Lymphatic permeation (Correct Answer)
D. Sub-epidermal cancer

Explanation: ***Lymphatic permeation*** - **Peau d'orange**, or "orange peel" appearance, is characteristic of advanced breast cancer and is caused by **edema of the skin** due to **blockage of subcutaneous lymphatic drainage**. - The skin over the affected area becomes rigid and swollen, accentuating the hair follicles and leading to a dimpled appearance similar to an orange peel. *Intra-epithelial cancer* - **Intra-epithelial cancer**, such as ductal carcinoma in situ (DCIS), is confined to the epithelium and does not typically directly cause diffuse skin changes like **peau d'orange**. - It involves proliferation of malignant cells within the ducts or lobules without invasion of the **basement membrane**. *Vascular embolization* - **Vascular embolization** refers to the blockage of blood vessels by an embolus, which would cause ischemia or infarction, not diffuse skin edema with a dimpled appearance. - While cancer can spread via blood vessels, this mechanism does not directly result in the specific **peau d'orange** phenomenon. *Sub-epidermal cancer* - **Sub-epidermal cancer** might refer to a tumor lying beneath the epidermis, but this term is not standard for describing the cause of peau d'orange. - The appearance is due to lymphatic obstruction and edema, not merely the presence of a tumor in a specific layer, unless that tumor is causing the **lymphatic blockage**.

Question 9: Which of the following statements is true regarding the treatment of early breast carcinoma?

A. Tamoxifen can be used in postmenopausal women, but aromatase inhibitors are generally preferred.
B. Post mastectomy radiation therapy is indicated when 4 or more lymph nodes are positive. (Correct Answer)
C. Aromatase inhibitors are typically used in premenopausal women only with ovarian suppression.
D. In premenopausal women, multidrug chemotherapy may be considered in high-risk cases, such as hormone receptor-negative or HER2-positive cancers.

Explanation: ***Post mastectomy radiation therapy is indicated when 4 or more lymph nodes are positive.*** - **Post-mastectomy radiation therapy (PMRT)** is **strongly and consistently recommended** in patients with **4 or more involved axillary lymph nodes** to reduce local recurrence and improve survival. - This represents a **Category 1 (uniform consensus) recommendation** in major guidelines (NCCN, ASCO) and is one of the most established indications for PMRT. - While PMRT may also be considered with 1-3 positive lymph nodes (individualized decision), the **≥4 positive nodes** threshold is an **absolute, strong indication** without debate. *Tamoxifen can be used in postmenopausal women, but aromatase inhibitors are generally preferred.* - This statement is **also true** and reflects current practice guidelines. - **Aromatase inhibitors (AIs)** such as anastrozole, letrozole, or exemestane are generally preferred over tamoxifen in **postmenopausal women** with hormone receptor-positive breast cancer due to superior disease-free survival in clinical trials. - However, this is a **relative preference** rather than an absolute indication, as tamoxifen remains a valid and effective option in postmenopausal women, especially when AIs are contraindicated or not tolerated. *Aromatase inhibitors are typically used in premenopausal women only with ovarian suppression.* - This statement is **also true** and medically accurate. - **Aromatase inhibitors** work by blocking peripheral estrogen synthesis and require very low estrogen levels to be effective, which are not naturally present in **premenopausal women** with functioning ovaries. - Therefore, for premenopausal women, AIs are only used alongside **ovarian suppression** (e.g., surgical oophorectomy, GnRH agonists like goserelin) to achieve menopausal-level estrogen suppression. - This is a **conditional statement** (used "only with" ovarian suppression) rather than a primary treatment recommendation. *In premenopausal women, multidrug chemotherapy may be considered in high-risk cases, such as hormone receptor-negative or HER2-positive cancers.* - This statement is accurate but **less specific to the question stem** asking about "early breast carcinoma." - **Multidrug chemotherapy** is a standard treatment for **high-risk breast cancer** regardless of menopausal status (both premenopausal and postmenopausal women receive similar chemotherapy regimens for high-risk features). - The use of "may be considered" is somewhat weak language, as chemotherapy is often **strongly recommended** (not just "may be considered") for triple-negative or HER2-positive early breast cancer. - This statement doesn't provide a distinctive treatment principle specific to breast cancer management. **Key Point:** While multiple statements are technically true, **Option 2** represents the **most definitive, guideline-established, and unequivocal treatment indication** with uniform consensus, making it the best answer in the context of standard treatment protocols for early breast carcinoma.

Question 10: What does the acronym NSABP represent in the context of cancer research?

A. National surgical adjuvant for brain and breast
B. National surgical adjuvant for bowel and brain
C. National surgical adjuvant for breast project
D. National Surgical Adjuvant Breast and Bowel Project (Correct Answer)

Explanation: ***National surgical adjuvant for breast and bowel project*** - **NSABP** stands for **National Surgical Adjuvant Breast and Bowel Project**. - It is a prominent research organization focused on conducting clinical trials for the prevention and treatment of breast and colorectal cancer. *National surgical adjuvant for breast project* - This option is incomplete as it omits the "bowel" component of the organization's focus. - The NSABP's research scope extends beyond just breast cancer to include **colorectal cancer**. *National surgical adjuvant for brain and breast* - This option incorrectly includes "brain" and omits "bowel" from the acronym. - The NSABP's primary research areas are **breast and bowel (colorectal) cancers**, not brain cancer. *National surgical adjuvant for bowel and brain* - This option incorrectly includes "brain" and omits "breast" from the acronym. - The NSABP is known for its extensive work in both **breast and colorectal cancer research**.

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