Chapter 18: Breasts and Axillae
1. A 44-year-old female mathematician presents to clinic with a complaint of a mass in the right breast.
Her partner noticed this mass 2 days ago, and the patient feels guilty because she has only had one
mammogram and does not engage in breast self-examination (BSE) on any regular basis. She has no
family history of breast cancer, and her prior mammogram was ordered as a routine screening test at
age 43 years after a brief discussion with her primary care provider. After a thorough investigation
reveals a benign cyst, what advice should be given to this patient about screening for breast cancer in
her age group?
a. BSE is well evidenced, and all recommending agencies agree that it should be taught and reinforced.
b. Clinical breast examination (CBE) is superior to BSE and should be a routine part of
annual examinations starting at age 30 years.
c. This patient was in compliance with the U.S. Preventive Services Task Force (USPSTF)
recommendations for her age group and risk factors prior to her current complaint.
d. Mammography is most sensitive and specific for women in their 40s, when breast tissue is still dense
enough to image accurately.
e. Breast cancer screening is extremely well studied, and no controversy exists on the
recommended norms for screening and follow-up.
2. A 42-year-old female website developer presents for an annual preventive examination with
questions about breast cancer screening. She is concerned about the radiation exposure associated with
mammography and is interested in magnetic resonance imaging (MRI) as a possible alternative for
routine screening. She is otherwise healthy with no family history of breast, ovarian, or colon cancer.
Which of the following is true about MRI as a screening modality for breast cancer in the general
population?
a. Breast cancer screening by MRI has been well studied in the general population.
b. Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity.
c. This patient is an ideal candidate for screening via breast MRI based on current evidence
d. Women at low lifetime risk of breast cancer (<20%) are recommended to undergo screening MRI.
e. Known BRCA1 or BRCA2 mutation is insufficient criteria to justify screening with breast MRI.
3. A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple discharge. This
discharge started several weeks ago and has occurred at irregular intervals since that time. She does not
complain of local tenderness, redness, fever, or any other systemic symptoms aside from slightly
irregular periods over the last few months. On examination, she is able to express a small amount of
discharge, which is sent to the laboratory and found to be consistent with breast milk but without any
signs of blood or pus. Screening laboratories are also sent, which reveal a normal blood count,
metabolic panel, thyroid-stimulating hormone, and human chorionic gonadotropin (HCG) level. Further
laboratories are still pending. Which of the following is the most likely diagnosis?
a. Mastitis
b. Ductal carcinoma in situ
c. Paget disease of the breast
,d. Occult pregnancy
e. Prolactinoma
4. A 22-year-old G0P0 undergraduate student presents to clinic after finding a breast mass on breast
self-examination (BSE) at home. The mass is nontender without skin changes, erythema, or overlying
swelling. She has heard that most breast cancers are found by patients themselves, and she is very
concerned that she may have breast cancer. Which of the following is true about BSE and self-detection
of breast cancer?
a. Most masses that women find at home and bring to a provider’s attention turn out to be malignant.
b. This patient is more likely to find a fibroadenoma than a cancer on self-examination.
c. The most likely breast mass this patient is likely to find in herself is an abscess complicating underlying
mastitis.
d. Because of this patient’s age, breast masses should not be pursued with imaging and diagnosis
because the risk of cancer is so low.
e. BSE is universally recommended because of very high sensitivity and specificity for finding cancerous
lesions.
5. A 48-year-old female psychologist presents to clinic with concerns about her breast cancer risk after
an age-matched cousin was recently diagnosed with this disease. This cousin is the third family member
on her father’s side in as many years to be diagnosed with breast cancer, including the patient’s own
father, who had surgery and subsequent treatment 3 years ago for breast cancer. The patient has little
other knowledge of her family history, only that her grandparents independently arrived from Eastern
Europe near the end of World War II and were among very few members of their family that survived
the war. The patient has read about testing for the breast cancer genes (BRCA1 and BRCA2) and desires
further information about whether this would be appropriate for her. Which of the following is true
about this patient’s indications for BRCA testing?
a. Her familial lineage is irrelevant to her risk of BRCA genes and should be discounted in assessing
her risk for these genes.
b. Breast cancer in a male relative does not add significant weight to the decision to test for the BRCA
genes in this patient.
c. The BRCAPRO calculator does not add any further clinical information to this patient’s risk for carrying
the BRCA gene.
d. This patient carries several risk factors that together justify BRCA testing.
e. Even if this patient is BRCA positive, no changes in screening or treatment are recommended for
patients with this genetic mutation, so the test is not recommended.
6. A 68-year-old former paleontologist presents to clinic with concerns about her breast cancer risk. Her
mother developed the disease in her 50s and died from it in her 60s. A younger cousin developed the
disease a few years ago before the age of 50 years, but this individual was not tested for the BRCA1 and
BRCA2 genes. In addition, the patient suffered from lymphoma in her 20s and had radiation to the chest.
She did take hormone replacement therapy for a few years before data emerged that this may
contribute to breast cancer risk. She has had several abnormal mammograms in her 50s for persistently
, dense breasts with subtle findings, but follow-up biopsies never showed any malignant pathology.
Which of the following is true regarding magnetic resonance imaging (MRI) screening of this patient?
a. No agency recommends breast MRI for a patient such as this one, who has moderately but not
extraordinary risk factors for breast cancer.
b. The U.S. Preventive Services Task Force (USPSTF) recommends against screening with MRI for patients
with such risk factors.
c. Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of markedly
decreased specificity (i.e., the ability to rule out disease in healthy breasts).
d. Mammograms are not affected by breast density and thus density is not a factor in choosing MRIs
over mammograms in patients such as this individual.
e. History of chest radiation is not a risk factor for breast cancer and is thus not relevant to
deciding whether MRI is appropriate in this patient.
7. A 66-year-old female museum curator presents for a routine annual examination. On examination, a
notably enlarged supraclavicular lymph node is appreciated on the right side. The lymph node is
nontender and feels firm and rubbery. She denies any localized or systemic symptoms such as breast
lumps, fevers, or night sweats. She has been taking conjugated estrogen tablets for 9 years since
menopause, though she has not taken progestin compounds since she had a hysterectomy for heavy
bleeding at age 45 years. Which of the following is true about this presentation of lymphadenopathy?
a. Breast cancer always presents with axillary lymphadenopathy because the lymphatics of the breast
uniformly drain into the axilla.
b. Supraclavicular nodes are generally considered benign and require no further evaluation or follow-up.
c. Supraclavicular nodes are found along the anterior edge of the trapezius muscle in the neck.
d. Firm, rubbery lymph nodes are generally considered to be benign.
e. Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular
nodes without first causing notable changes in the axillary nodes.
8. A 24-year-old graphic designer presents to clinic with a concern for a breast mass. A rubbery, mobile,
nontender mass is palpated in the right breast as described by the patient, which is consistent with a
firbroadenoma. In describing the location of the mass, the examiner notes that it is 3 cm proximal to
and 3 cm to the left of the nipple. Which of the following would be the most appropriate way to report
this finding?
a. “Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple”
b. “Rubbery, mobile, nontender mass located in right breast, in the lower outer quadrant”
c. “Rubbery, mobile, nontender mass located in right breast, in the upper inner quadrant”
d. “Rubbery, mobile, nontender mass located in the left breast, upper outer quadrant”
e. “Rubbery, mobile, nontender mass located in right breast, in the 1:30 position from the nipple”
9. A 54-year-old female dietician presents for a routine annual examination. On review of systems, she
reports that she has had many breast findings over several years, including one biopsy with normal
1. A 44-year-old female mathematician presents to clinic with a complaint of a mass in the right breast.
Her partner noticed this mass 2 days ago, and the patient feels guilty because she has only had one
mammogram and does not engage in breast self-examination (BSE) on any regular basis. She has no
family history of breast cancer, and her prior mammogram was ordered as a routine screening test at
age 43 years after a brief discussion with her primary care provider. After a thorough investigation
reveals a benign cyst, what advice should be given to this patient about screening for breast cancer in
her age group?
a. BSE is well evidenced, and all recommending agencies agree that it should be taught and reinforced.
b. Clinical breast examination (CBE) is superior to BSE and should be a routine part of
annual examinations starting at age 30 years.
c. This patient was in compliance with the U.S. Preventive Services Task Force (USPSTF)
recommendations for her age group and risk factors prior to her current complaint.
d. Mammography is most sensitive and specific for women in their 40s, when breast tissue is still dense
enough to image accurately.
e. Breast cancer screening is extremely well studied, and no controversy exists on the
recommended norms for screening and follow-up.
2. A 42-year-old female website developer presents for an annual preventive examination with
questions about breast cancer screening. She is concerned about the radiation exposure associated with
mammography and is interested in magnetic resonance imaging (MRI) as a possible alternative for
routine screening. She is otherwise healthy with no family history of breast, ovarian, or colon cancer.
Which of the following is true about MRI as a screening modality for breast cancer in the general
population?
a. Breast cancer screening by MRI has been well studied in the general population.
b. Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity.
c. This patient is an ideal candidate for screening via breast MRI based on current evidence
d. Women at low lifetime risk of breast cancer (<20%) are recommended to undergo screening MRI.
e. Known BRCA1 or BRCA2 mutation is insufficient criteria to justify screening with breast MRI.
3. A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple discharge. This
discharge started several weeks ago and has occurred at irregular intervals since that time. She does not
complain of local tenderness, redness, fever, or any other systemic symptoms aside from slightly
irregular periods over the last few months. On examination, she is able to express a small amount of
discharge, which is sent to the laboratory and found to be consistent with breast milk but without any
signs of blood or pus. Screening laboratories are also sent, which reveal a normal blood count,
metabolic panel, thyroid-stimulating hormone, and human chorionic gonadotropin (HCG) level. Further
laboratories are still pending. Which of the following is the most likely diagnosis?
a. Mastitis
b. Ductal carcinoma in situ
c. Paget disease of the breast
,d. Occult pregnancy
e. Prolactinoma
4. A 22-year-old G0P0 undergraduate student presents to clinic after finding a breast mass on breast
self-examination (BSE) at home. The mass is nontender without skin changes, erythema, or overlying
swelling. She has heard that most breast cancers are found by patients themselves, and she is very
concerned that she may have breast cancer. Which of the following is true about BSE and self-detection
of breast cancer?
a. Most masses that women find at home and bring to a provider’s attention turn out to be malignant.
b. This patient is more likely to find a fibroadenoma than a cancer on self-examination.
c. The most likely breast mass this patient is likely to find in herself is an abscess complicating underlying
mastitis.
d. Because of this patient’s age, breast masses should not be pursued with imaging and diagnosis
because the risk of cancer is so low.
e. BSE is universally recommended because of very high sensitivity and specificity for finding cancerous
lesions.
5. A 48-year-old female psychologist presents to clinic with concerns about her breast cancer risk after
an age-matched cousin was recently diagnosed with this disease. This cousin is the third family member
on her father’s side in as many years to be diagnosed with breast cancer, including the patient’s own
father, who had surgery and subsequent treatment 3 years ago for breast cancer. The patient has little
other knowledge of her family history, only that her grandparents independently arrived from Eastern
Europe near the end of World War II and were among very few members of their family that survived
the war. The patient has read about testing for the breast cancer genes (BRCA1 and BRCA2) and desires
further information about whether this would be appropriate for her. Which of the following is true
about this patient’s indications for BRCA testing?
a. Her familial lineage is irrelevant to her risk of BRCA genes and should be discounted in assessing
her risk for these genes.
b. Breast cancer in a male relative does not add significant weight to the decision to test for the BRCA
genes in this patient.
c. The BRCAPRO calculator does not add any further clinical information to this patient’s risk for carrying
the BRCA gene.
d. This patient carries several risk factors that together justify BRCA testing.
e. Even if this patient is BRCA positive, no changes in screening or treatment are recommended for
patients with this genetic mutation, so the test is not recommended.
6. A 68-year-old former paleontologist presents to clinic with concerns about her breast cancer risk. Her
mother developed the disease in her 50s and died from it in her 60s. A younger cousin developed the
disease a few years ago before the age of 50 years, but this individual was not tested for the BRCA1 and
BRCA2 genes. In addition, the patient suffered from lymphoma in her 20s and had radiation to the chest.
She did take hormone replacement therapy for a few years before data emerged that this may
contribute to breast cancer risk. She has had several abnormal mammograms in her 50s for persistently
, dense breasts with subtle findings, but follow-up biopsies never showed any malignant pathology.
Which of the following is true regarding magnetic resonance imaging (MRI) screening of this patient?
a. No agency recommends breast MRI for a patient such as this one, who has moderately but not
extraordinary risk factors for breast cancer.
b. The U.S. Preventive Services Task Force (USPSTF) recommends against screening with MRI for patients
with such risk factors.
c. Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of markedly
decreased specificity (i.e., the ability to rule out disease in healthy breasts).
d. Mammograms are not affected by breast density and thus density is not a factor in choosing MRIs
over mammograms in patients such as this individual.
e. History of chest radiation is not a risk factor for breast cancer and is thus not relevant to
deciding whether MRI is appropriate in this patient.
7. A 66-year-old female museum curator presents for a routine annual examination. On examination, a
notably enlarged supraclavicular lymph node is appreciated on the right side. The lymph node is
nontender and feels firm and rubbery. She denies any localized or systemic symptoms such as breast
lumps, fevers, or night sweats. She has been taking conjugated estrogen tablets for 9 years since
menopause, though she has not taken progestin compounds since she had a hysterectomy for heavy
bleeding at age 45 years. Which of the following is true about this presentation of lymphadenopathy?
a. Breast cancer always presents with axillary lymphadenopathy because the lymphatics of the breast
uniformly drain into the axilla.
b. Supraclavicular nodes are generally considered benign and require no further evaluation or follow-up.
c. Supraclavicular nodes are found along the anterior edge of the trapezius muscle in the neck.
d. Firm, rubbery lymph nodes are generally considered to be benign.
e. Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular
nodes without first causing notable changes in the axillary nodes.
8. A 24-year-old graphic designer presents to clinic with a concern for a breast mass. A rubbery, mobile,
nontender mass is palpated in the right breast as described by the patient, which is consistent with a
firbroadenoma. In describing the location of the mass, the examiner notes that it is 3 cm proximal to
and 3 cm to the left of the nipple. Which of the following would be the most appropriate way to report
this finding?
a. “Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple”
b. “Rubbery, mobile, nontender mass located in right breast, in the lower outer quadrant”
c. “Rubbery, mobile, nontender mass located in right breast, in the upper inner quadrant”
d. “Rubbery, mobile, nontender mass located in the left breast, upper outer quadrant”
e. “Rubbery, mobile, nontender mass located in right breast, in the 1:30 position from the nipple”
9. A 54-year-old female dietician presents for a routine annual examination. On review of systems, she
reports that she has had many breast findings over several years, including one biopsy with normal
