MedCosmos Surgery
Surgery Lecture Notes, Books, MCQ and Good Articles
Friday, September 5, 2008
Breast MCQ
1. After intraductal papilloma, unilateral bloody nipple discharge from
one duct orifice is most commonly caused by which of the following
pathologic conditions?
A. Paget's disease of the nipple.
B. Intraductal carcinoma.
C. Inflammatory carcinoma.
D. Subareolar mastitis.
Answer: B
DISCUSSION: Nipple discharge is surgically significant when it is
grossly bloody and when it appears at a single duct orifice on one
nipple. Bloody discharge is usually due to a benign intraductal
papilloma; however, intraductal carcinoma in the large ducts under
the nipple can be the cause of bloody discharge, and pathologically
the lesion is frequently a large papillary tumor that has become
malignant. Paget's disease of the nipple is also due to intraductal
carcinoma arising in subareolar ducts, but it rarely is associated with
nipple discharge. Subareolar mastitis may produce nipple discharge,
but it is purulent and not bloody. Inflammatory carcinoma is not
associated with nipple discharge.
2. Which of the following conditions is associated with increased risk
of breast cancer?
A. Fibrocystic mastopathy.
B. Severe hyperplasia.
C. Atypical hyperplasia.
D. Papillomatosis.
Answer: C
DISCUSSION: Fibrocystic mastopathy, or fibrocystic disease, was once
thought to increase the risk of breast cancer; however, later studies of
the pathologic findings in fibrocystic complex found an increased
cancer risk only for patients whose biopsies showed atypical
,hyperplasia. “Severe hyperplasia” is a pathologic term that refers to
the amount of hyperplasia and is frequently seen in the biopsy
specimens of young women; it is a misleading term and is not
associated with a disease risk. Papillomatosis is also part of the
fibrocystic complex and is a frequent finding in benign breast
biopsies; it does not confer an increased risk of cancer.
3. Which of the following breast lesions are noninvasive malignancies?
A. Intraductal carcinoma of the comedo type.
B. Tubular carcinoma and mucinous carcinoma.
C. Infiltrating ductal carcinoma and lobular carcinoma.
D. Medullary carcinoma, including atypical medullary lesions.
Answer: A
DISCUSSION: Tubular, mucinous, and medullary carcinomas are
histologic variants of infiltrating ductal cancer and are all invasive
malignancies. Infiltrating lobular cancer is a particular histologic
variant of invasive breast cancer characterized by permeation of the
stroma with small cells that resemble those found in the breast lobule
or acinus. Intraductal carcinoma refers to a malignancy of ductal
origin that remains enclosed within duct structures. This noninvasive
proliferation can undergo central necrosis, which frequently calcifies
to form the microcalcifications seen on mammography. The central
necrosis within enlarged and back-to-back ductal structures
resembles comedoes and gives rise to the term “comedocarcinoma,”
now reserved for this histologic variety of intraductal carcinoma.
4. Which of the following are the most important and clinically useful
risk factors for breast cancer?
A. Fibrocystic disease, age, and gender.
B. Cysts, family history in immediate relatives, and gender.
C. Age, gender, and family history in immediate relatives.
D. Obesity, nulliparity, and alcohol use.
Answer: C
DISCUSSION: The most important risk factors for breast cancer are
the patient's age, gender, and a family history of breast cancer in
immediate relatives (sisters, mother, daughter). The age-adjusted
incidence of breast cancer increases with age. Breast cancer does
occur in males, but the disease is far more common in women. Family
history is important when breast cancer occurs within the immediate
family; history of breast cancer in more distant relatives
(grandmothers, cousins, aunts) is less important. In addition, age
factors into the risk associated with family history. An affected young
primary relative is far more significant as a risk factor than an older
, relative with breast cancer. The other important risk factor not listed
here is a history of breast cancer, either within the conserved
ipsilateral breast or in the contralateral breast. Again, age plays an
important modifying role; as the age at which breast cancer was first
diagnosed increases, the risk of a subsequent second cancer
decreases. Although patients with fibrocystic disease are at increased
risk for breast cancer, risk concentrates in those patients with
fibrocystic disease who show atypical epithelial hyperplasia within
breast ducts. Obesity, nulliparity, and alcohol all appear to increase
risk slightly and are important to the epidemiologic study of breast
cancer; however, the effect of these factors is not sufficient to warrant
their use in common clinical practice.
5. Which of the following pathologic findings is the strongest
contraindication to breast preservation (lumpectomy with breast
radiation) as primary treatment for a newly diagnosed breast cancer?
A. Grade 3, poorly differentiated, infiltrating ductal carcinoma.
B. Extensive intraductal cancer around the invasive lesion.
C. Tumor size greater than 3 cm.
D. Positive surgical margin for invasive cancer.
Answer: D
DISCUSSION: The only firm contraindication to wide excision and
radiation (breast preservation, lumpectomy) as the primary surgical
treatment for a newly discovered breast cancer is the inability to
achieve an uninvolved surgical margin after excision of the tumor. A
positive surgical margin requires, at least, reoperation with an
attempt at re-excision of the cancer. If the margin of removal is
positive after attempts at re-excision, this is a strong reason to
recommend mastectomy in preference to breast conservation. Tumor
size is a relative contraindication when the cancer is so large in
relation to the breast that excision to a clean surgical margin seems
unreasonable. Other histologic findings, such as tumor grade or
vascular invasion, are not strong reasons to recommend mastectomy
if the patient would prefer breast conservation.
6. Axillary lymph node dissection is routinely used for all of the
following conditions except:
A. 2-cm. pure comedo-type intraductal carcinoma.
B. 1-cm. infiltrating lobular carcinoma.
C. 8-mm. infiltrating ductal carcinoma.
D. A pure medullary cancer in the upper inner quadrant.
Answer: A
DISCUSSION: Intraductal carcinoma is carcinoma in situ and does not
Surgery Lecture Notes, Books, MCQ and Good Articles
Friday, September 5, 2008
Breast MCQ
1. After intraductal papilloma, unilateral bloody nipple discharge from
one duct orifice is most commonly caused by which of the following
pathologic conditions?
A. Paget's disease of the nipple.
B. Intraductal carcinoma.
C. Inflammatory carcinoma.
D. Subareolar mastitis.
Answer: B
DISCUSSION: Nipple discharge is surgically significant when it is
grossly bloody and when it appears at a single duct orifice on one
nipple. Bloody discharge is usually due to a benign intraductal
papilloma; however, intraductal carcinoma in the large ducts under
the nipple can be the cause of bloody discharge, and pathologically
the lesion is frequently a large papillary tumor that has become
malignant. Paget's disease of the nipple is also due to intraductal
carcinoma arising in subareolar ducts, but it rarely is associated with
nipple discharge. Subareolar mastitis may produce nipple discharge,
but it is purulent and not bloody. Inflammatory carcinoma is not
associated with nipple discharge.
2. Which of the following conditions is associated with increased risk
of breast cancer?
A. Fibrocystic mastopathy.
B. Severe hyperplasia.
C. Atypical hyperplasia.
D. Papillomatosis.
Answer: C
DISCUSSION: Fibrocystic mastopathy, or fibrocystic disease, was once
thought to increase the risk of breast cancer; however, later studies of
the pathologic findings in fibrocystic complex found an increased
cancer risk only for patients whose biopsies showed atypical
,hyperplasia. “Severe hyperplasia” is a pathologic term that refers to
the amount of hyperplasia and is frequently seen in the biopsy
specimens of young women; it is a misleading term and is not
associated with a disease risk. Papillomatosis is also part of the
fibrocystic complex and is a frequent finding in benign breast
biopsies; it does not confer an increased risk of cancer.
3. Which of the following breast lesions are noninvasive malignancies?
A. Intraductal carcinoma of the comedo type.
B. Tubular carcinoma and mucinous carcinoma.
C. Infiltrating ductal carcinoma and lobular carcinoma.
D. Medullary carcinoma, including atypical medullary lesions.
Answer: A
DISCUSSION: Tubular, mucinous, and medullary carcinomas are
histologic variants of infiltrating ductal cancer and are all invasive
malignancies. Infiltrating lobular cancer is a particular histologic
variant of invasive breast cancer characterized by permeation of the
stroma with small cells that resemble those found in the breast lobule
or acinus. Intraductal carcinoma refers to a malignancy of ductal
origin that remains enclosed within duct structures. This noninvasive
proliferation can undergo central necrosis, which frequently calcifies
to form the microcalcifications seen on mammography. The central
necrosis within enlarged and back-to-back ductal structures
resembles comedoes and gives rise to the term “comedocarcinoma,”
now reserved for this histologic variety of intraductal carcinoma.
4. Which of the following are the most important and clinically useful
risk factors for breast cancer?
A. Fibrocystic disease, age, and gender.
B. Cysts, family history in immediate relatives, and gender.
C. Age, gender, and family history in immediate relatives.
D. Obesity, nulliparity, and alcohol use.
Answer: C
DISCUSSION: The most important risk factors for breast cancer are
the patient's age, gender, and a family history of breast cancer in
immediate relatives (sisters, mother, daughter). The age-adjusted
incidence of breast cancer increases with age. Breast cancer does
occur in males, but the disease is far more common in women. Family
history is important when breast cancer occurs within the immediate
family; history of breast cancer in more distant relatives
(grandmothers, cousins, aunts) is less important. In addition, age
factors into the risk associated with family history. An affected young
primary relative is far more significant as a risk factor than an older
, relative with breast cancer. The other important risk factor not listed
here is a history of breast cancer, either within the conserved
ipsilateral breast or in the contralateral breast. Again, age plays an
important modifying role; as the age at which breast cancer was first
diagnosed increases, the risk of a subsequent second cancer
decreases. Although patients with fibrocystic disease are at increased
risk for breast cancer, risk concentrates in those patients with
fibrocystic disease who show atypical epithelial hyperplasia within
breast ducts. Obesity, nulliparity, and alcohol all appear to increase
risk slightly and are important to the epidemiologic study of breast
cancer; however, the effect of these factors is not sufficient to warrant
their use in common clinical practice.
5. Which of the following pathologic findings is the strongest
contraindication to breast preservation (lumpectomy with breast
radiation) as primary treatment for a newly diagnosed breast cancer?
A. Grade 3, poorly differentiated, infiltrating ductal carcinoma.
B. Extensive intraductal cancer around the invasive lesion.
C. Tumor size greater than 3 cm.
D. Positive surgical margin for invasive cancer.
Answer: D
DISCUSSION: The only firm contraindication to wide excision and
radiation (breast preservation, lumpectomy) as the primary surgical
treatment for a newly discovered breast cancer is the inability to
achieve an uninvolved surgical margin after excision of the tumor. A
positive surgical margin requires, at least, reoperation with an
attempt at re-excision of the cancer. If the margin of removal is
positive after attempts at re-excision, this is a strong reason to
recommend mastectomy in preference to breast conservation. Tumor
size is a relative contraindication when the cancer is so large in
relation to the breast that excision to a clean surgical margin seems
unreasonable. Other histologic findings, such as tumor grade or
vascular invasion, are not strong reasons to recommend mastectomy
if the patient would prefer breast conservation.
6. Axillary lymph node dissection is routinely used for all of the
following conditions except:
A. 2-cm. pure comedo-type intraductal carcinoma.
B. 1-cm. infiltrating lobular carcinoma.
C. 8-mm. infiltrating ductal carcinoma.
D. A pure medullary cancer in the upper inner quadrant.
Answer: A
DISCUSSION: Intraductal carcinoma is carcinoma in situ and does not
