Breast Surgery US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Breast Surgery. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Breast Surgery US Medical PG Question 1: A 33-year-old woman comes to the physician 1 week after noticing a lump in her right breast. Fifteen years ago, she was diagnosed with osteosarcoma of her left distal femur. Her father died of an adrenocortical carcinoma at the age of 41 years. Examination shows a 2-cm, firm, immobile mass in the lower outer quadrant of the right breast. A core needle biopsy of the mass shows adenocarcinoma. Genetic analysis in this patient is most likely to show a defect in which of the following genes?
- A. BRCA1
- B. KRAS
- C. TP53 (Correct Answer)
- D. Rb
- E. PTEN
Breast Surgery Explanation: ***TP53***
- This patient's presentation with **early-onset breast cancer**, a history of **osteosarcoma** at a young age, and a father's death from **adrenocortical carcinoma** at 41 years strongly suggests **Li-Fraumeni syndrome**.
- Li-Fraumeni syndrome is an autosomal dominant disorder caused by a germline mutation in the **tumor suppressor gene TP53**, increasing the risk for multiple primary cancers at a young age.
*BRCA1*
- While **BRCA1 mutations** are associated with an increased risk of breast and ovarian cancer, they are not typically linked to osteosarcoma or adrenocortical carcinoma.
- The constellation of cancers in this patient is more indicative of Li-Fraumeni syndrome than solely a BRCA1-related cancer syndrome.
*KRAS*
- **KRAS** is an oncogene commonly mutated in several cancers, including pancreatic, colorectal, and lung cancer, but is not primarily associated with either Li-Fraumeni syndrome or the specific tumors seen in this family history.
- Mutations in KRAS are typically somatic mutations acquired during a person's lifetime, not germline mutations causing inherited cancer syndromes like the one suggested here.
*Rb*
- Mutations in the **retinoblastoma (Rb) gene** are associated with retinoblastoma and an increased risk of osteosarcoma, but not typically with adrenocortical carcinoma or breast cancer as part of a classic inherited syndrome.
- The combination of breast cancer, osteosarcoma, and adrenocortical carcinoma points more specifically to TP53.
*PTEN*
- **PTEN mutations** are associated with Cowden syndrome, which increases the risk for breast cancer, thyroid cancer, and endometrial cancer, along with benign growths.
- However, Cowden syndrome does not typically include osteosarcoma or adrenocortical carcinoma as prominent features, making PTEN less likely than TP53 for this specific family history.
Breast Surgery US Medical PG Question 2: The patient undergoes a mammogram, which shows a 6.5mm sized mass with an irregular border and spiculated margins. A subsequent core needle biopsy of the mass shows infiltrating ductal carcinoma with HER2-positive, estrogen-negative, and progesterone-negative immunohistochemistry staining. Blood counts and liver function tests are normal. Laboratory studies show:
Hemoglobin 12.5 g/dL
Serum
Na+ 140 mEq/L
Cl- 103 mEq/L
K+ 4.2 mEq/L
HCO3- 26 mEq/L
Ca2+ 8.9 mg/dL
Urea Nitrogen 12 mg/dL
Glucose 110 mg/dL
Alkaline Phosphatase 25 U/L
Alanine aminotransferase (ALT) 15 U/L
Aspartate aminotransferase (AST) 13 U/L
Which of the following is the most appropriate next step in management?
- A. Breast-conserving therapy and sentinel lymph node biopsy (Correct Answer)
- B. Bilateral mastectomy with lymph node dissection
- C. Trastuzumab therapy
- D. Bone scan
- E. Whole-body PET/CT
Breast Surgery Explanation: ***Breast-conserving therapy and sentinel lymph node biopsy***
- The patient has **early-stage (T1) breast cancer** (6.5mm mass), which is amenable to **breast-conserving therapy (lumpectomy)** as the primary surgical approach.
- A **sentinel lymph node biopsy** is essential to determine nodal status and guide further staging and adjuvant therapy, as the tumor size does not preclude nodal involvement.
*Bilateral mastectomy with lymph node dissection*
- This is an **overly aggressive surgical approach** for a small, unifocal tumor without evidence of multifocality or significant risk factors for recurrence in the contralateral breast.
- While **axillary lymph node dissection** may be indicated if the sentinel node is positive, it is not the initial preferred approach for all patients, especially with no current evidence of nodal metastasis.
*Trastuzumab therapy*
- **Trastuzumab** is a targeted therapy for **HER2-positive breast cancer**, but it is typically administered as **adjuvant therapy** (after surgery) or neoadjuvant therapy (before surgery).
- It is not the most appropriate *initial* next step before surgical management and comprehensive staging have been completed.
*Bone scan*
- A **bone scan** is used to detect **bone metastases**, but it is generally reserved for patients with **advanced-stage cancer** (e.g., T3/T4 tumor, N2/N3 nodes), symptoms suggestive of bony involvement, or significantly elevated alkaline phosphatase.
- Given the patient's small tumor size (6.5mm), normal labs, and lack of symptoms, a bone scan is not indicated as the *next* immediate step.
*Whole-body PET/CT*
- **Whole-body PET/CT** is primarily used for **staging advanced cancer** or investigating suspicious findings in symptomatic patients.
- For this small, early-stage breast cancer with no signs of distant metastasis indicated by normal blood tests, a PET/CT is **not recommended** as routine staging and carries unnecessary radiation exposure and cost.
Breast Surgery US Medical PG Question 3: A 23-year-old woman, gravida 1 para 0, at 16 weeks’ gestation presents to the physician because of swelling of her right breast for 1 month. She has no personal or family history of any serious illnesses. She has taken contraceptive pills over the past few years. Vital signs are within normal limits. Physical examination shows asymmetric breasts with the right breast being enlarged. The palpation of the breast shows a 4 x 5 cm (1.5 x 1.9 in) mass under the skin in the upper outer quadrant. It is nontender and mobile with a rubbery consistency and regular borders. A breast ultrasound shows a round and solid homogeneous mass with well-defined borders and low echogenicity, measuring 5 cm (1.9 in) in diameter. Which of the following is the most likely diagnosis?
- A. Fibroadenoma (Correct Answer)
- B. Invasive ductal carcinoma
- C. Lobular carcinoma
- D. Medullary carcinoma
- E. Fibrocystic changes
Breast Surgery Explanation: ***Fibroadenoma***
- The patient's age (23 years old), pregnancy status, and the description of the mass—**rubbery, mobile, nontender, with regular borders**, and **low echogenicity on ultrasound**—are highly characteristic of a fibroadenoma.
- Fibroadenomas are **benign tumors** common in young women and can grow during pregnancy due to hormonal stimulation.
*Invasive ductal carcinoma*
- This typically presents as a **hard, fixed, irregular mass** that is often **nontender** but may cause skin dimpling or nipple retraction, none of which are described.
- While it is the most common form of breast cancer, its characteristics **do not match** the highly mobile and rubbery nature of the described mass.
*Lobular carcinoma*
- Often presents as a **diffuse thickening** rather than a well-defined mass and can be multifocal or bilateral.
- It's **less common** than invasive ductal carcinoma and its presentation is inconsistent with the clear, round mass described.
*Medullary carcinoma*
- This is a **rare subtype of invasive ductal carcinoma** that can appear well-circumscribed on imaging, mimicking a benign lesion.
- However, it typically presents as a **firm, fixed mass** and is less likely in a young woman with a classic fibroadenoma presentation.
*Fibrocystic changes*
- Characterized by **multiple cysts, tenderness, and fluctuating size** with menstrual cycles; often described as "lumpy" breasts rather than a single, well-defined mass.
- While common, the description of a **single, discrete, rubbery, mobile mass** is not typical for fibrocystic changes.
Breast Surgery US Medical PG Question 4: A 52-year-old woman visits your office complaining about discharge from her left nipple for the past 3 months. The discharge looks like gray greenish and its amount is progressively increasing. She appears to be anxious and extremely uncomfortable with this situation as it is embarrassing for her when it occurs outdoors. Past medical history is insignificant. Her family history is negative for breast and ovarian disorders. She tries to stay active by running for 30 minutes every day on a treadmill, staying away from smoking, and by eating a balanced diet. She drinks alcohol occasionally. During physical examination you find a firm, stable mass under an inverted nipple in her left breast; while on the right breast, dilated subareolar ducts can be noted. There is no lymphadenopathy and remaining of the physical exam is normal. A mammogram is performed which reveals tubular calcifications. Which of the following is the most likely diagnosis?
- A. Duct ectasia (Correct Answer)
- B. Periareolar fistula
- C. Intraductal papilloma
- D. Periductal mastitis
- E. Phyllodes tumor
Breast Surgery Explanation: ***Duct ectasia***
- The patient's presentation with **gray-green nipple discharge**, an **inverted nipple**, and **tubular calcifications on mammogram** are classic signs of duct ectasia in a postmenopausal woman.
- The presence of **dilated subareolar ducts** in the contralateral breast further supports this diagnosis, as it is a benign condition characterized by widening of the breast ducts.
*Periareolar fistula*
- This condition is typically associated with recurrent **subareolar abscesses** and chronic drainage, often from a nipple piercing or previous infection, which are not described here.
- Periareolar fistulas rarely present solely with gray-green discharge and tubular calcifications without a clear history of infection or abscess.
*Intraductal papilloma*
- Intraductal papillomas usually present with **serous or bloody nipple discharge**, rather than the gray-green discharge seen in this patient.
- While they can cause nipple discharge, they are not typically associated with **inverted nipples** or **tubular calcifications** on mammogram.
*Periductal mastitis*
- Periductal mastitis is an inflammatory condition that can cause nipple inversion and discharge, but the discharge is usually **purulent or inflammatory**, and it is often accompanied by signs of infection like pain, redness, and swelling, which are absent in this case.
- It is more commonly seen in **smokers**, whereas this patient is a non-smoker.
*Phyllodes tumor*
- Phyllodes tumors usually present as a **rapidly growing palpable breast mass**, which may be benign or malignant, but they are not typically associated with nipple discharge or tubular calcifications.
- The description of **gray-green discharge** and **tubular calcifications** does not align with the typical presentation of a phyllodes tumor.
Breast Surgery US Medical PG Question 5: Patient 1 – A 26-year-old woman presents to her primary care physician for an annual exam. She currently does not have any acute concerns and says her health has been generally well. Medical history is significant for asthma, which is managed with an albuterol inhaler. Her last pap smear was unremarkable. She is currently sexually active with one male and consistently uses condoms. She occasionally smokes marijuana and drinks wine once per week. Her mother recently passed away from advanced ovarian cancer. Her sister is 37-years-old and was recently diagnosed with breast cancer and ovarian cancer. Physical examination is remarkable for a mildly anxious woman.
Patient 2 – A 27-year-old woman presents to her primary care physician for an annual exam. She says that she would like to be screened for breast cancer since two of her close friends were recently diagnosed. She noticed she has a small and mobile mass on her left breast, which increases in size and becomes tender around her time of menses. Family history is remarkable for hypertension in the father. The physical exam is significant for a small, well-defined, and mobile mass on her left breast that is not tender to palpation.
Which of the following is the best next step in management for patient 1 and 2?
- A. Patient 1 – Breast ultrasound. Patient 2 – Return in 3 months for a clinical breast exam
- B. Patient 1 – Reassurance. Patient 2 – Breast ultrasound
- C. Patient 1 – CA-125 testing. Patient 2 – BRCA testing
- D. Patient 1 – BRCA testing. Patient 2 – Breast ultrasound (Correct Answer)
- E. Patient 1 – Breast and ovarian ultrasound. Patient 2 – Mammography
Breast Surgery Explanation: ***Patient 1 – BRCA testing. Patient 2 – Breast ultrasound***
- Patient 1 has a strong family history of early-onset **breast and ovarian cancer** (**mother and sister**), suggesting a high probability of an inherited genetic mutation, such as **BRCA1/2**, which warrants genetic testing.
- Patient 2 presents with a **small, mobile, well-defined breast mass** that is likely benign, and a **breast ultrasound** is the appropriate initial imaging for further characterization in a young woman.
*Patient 1 – Breast ultrasound. Patient 2 – Return in 3 months for a clinical breast exam*
- Patient 1's primary concern is genetic predisposition due to family history, an **ultrasound** is not the initial or primary screening method for future cancer risk.
- Patient 2 has a palpable mass; waiting 3 months for a **clinical breast exam** without initial imaging (ultrasound) is not appropriate for evaluating a new breast lump.
*Patient 1 – Reassurance. Patient 2 – Breast ultrasound*
- Patient 1's family history of **early-onset breast and ovarian cancer** is a significant risk factor; therefore, simple **reassurance** without further investigation is inappropriate.
- While a **breast ultrasound** is appropriate for Patient 2, the recommendation for Patient 1 is incorrect.
*Patient 1 – CA-125 testing. Patient 2 – BRCA testing*
- **CA-125** is a tumor marker primarily used for monitoring ovarian cancer treatment or recurrence, not for initial screening in asymptomatic individuals, especially in a young woman with no active symptoms.
- **BRCA testing** is indicated for Patient 1 due to family history, but not for Patient 2 who has a likely benign breast mass and no significant family history.
*Patient 1 – Breast and ovarian ultrasound. Patient 2 – Mammography*
- Regular **breast and ovarian ultrasounds** are not recommended as primary screening tools for genetic risk in asymptomatic high-risk individuals like Patient 1.
- **Mammography** is less sensitive in young women (under 30) due to higher breast tissue density, making **ultrasound** the preferred initial imaging for Patient 2.
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