Breasts and Axillae CH18
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?
Breast cancer screening is extremely well studied, and no controversy exists on the recommended norms for
screening and follow-up.
Mammography is most sensitive and specific for women in their 40s, when breast tissue is still dense enough to
image accurately.
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.
BSE is well evidenced, and all recommending agencies agree that it should be taught and reinforced.
Clinical breast examination (CBE) is superior to BSE and should be a routine part of annual examinations
starting at age 30 years.
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?
Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity.
This patient is an ideal candidate for screening via breast MRI based on current evidence.
Women at low lifetime risk of breast cancer (<20%) are recommended to undergo screening MRI.
KnownBRCA1orBRCA2mutation is insufficient criteria to justify screening with breast MRI.
Breast cancer screening by MRI has been well studied in the general population.
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?
Because of this patient’s age, breast masses should not be pursued with imaging and diagnosis because the risk
of cancer is so low.
Most masses that women find at home and bring to a provider’s attention turn out to be malignant.
This patient is more likely to find a fibroadenoma than a cancer on self-examination.
The most likely breast mass this patient is likely to find in herself is an abscess complicating underlying
mastitis.
BSE is universally recommended because of very high sensitivity and specificity for finding cancerous lesions.
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?
,Prolactinoma
Occult pregnancy
Mastitis
Ductal carcinoma in situ
Paget disease of the breast
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?
Breast cancer always presents with axillary lymphadenopathy because the lymphatics of the breast uniformly
drain into the axilla.
Firm, rubbery lymph nodes are generally considered to be benign.
Supraclavicular nodes are generally considered benign and require no further evaluation or follow-up.
Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular nodes
without first causing notable changes in the axillary nodes.
Supraclavicular nodes are found along the anterior edge of the trapezius muscle in the neck.
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 theBRCA1andBRCA2genes. 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?
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.
The U.S. Preventive Services Task Force (USPSTF) recommends against screening with MRI for patients with
such risk factors.
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).
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.
No agency recommends breast MRI for a patient such as this one, who has moderately but not extraordinary
risk factors for breast cancer.
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 (BRCA1andBRCA2) and desires further information about whether this would be
appropriate for her. Which of the following is true about this patient’s indications forBRCAtesting?
, Her familial lineage is irrelevant to her risk ofBRCAgenes and should be discounted in assessing her risk for
these genes.
Even if this patient isBRCApositive, no changes in screening or treatment are recommended for patients with
this genetic mutation, so the test is not recommended.
This patient carries several risk factors that together justifyBRCAtesting.
The BRCAPRO calculator does not add any further clinical information to this patient’s risk for carrying
theBRCAgene.
Breast cancer in a male relative does not add significant weight to the decision to test for theBRCAgenes in this
patient.
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?
Rubbery, mobile, nontender mass located in right breast, in the lower outer quadrant”
“Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple”
“Rubbery, mobile, nontender mass located in right breast, in the upper inner quadrant”
“Rubbery, mobile, nontender mass located in right breast, in the 1:30 position from the nipple”
“Rubbery, mobile, nontender mass located in the left breast, upper outer quadrant”
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 pathology. She feels that
her breasts have become far less lumpy since she underwent menopause 3 years ago. Which of the following is
true regarding changes in the breasts with menopause?
Breast density has no genetic component and is entirely due to estrogen dose from endogenous and exogenous
sources over the lifetime.
Transformation of breasts to primarily fatty tissue with menopause decreases the sensitivity and specificity of
mammograms.
Estrogen in hormone replacement therapy (HRT) has no effect on breast density after menopause.
Mammography performs most poorly in the menopausal and postmenopausal age group and should be limited
for that reason.
Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of
lobules.
Abdomen CH 19
A 76-year-old retired man with a history of prostate cancer and hypertension has been screened annually for
colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow-up of his
hypertension, during which the clinician scans his chart to ensure he is up to date with his preventive health
care. He has a positive FOBT on one occasion at age 66 years and subsequently went for a colonoscopy.
Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no first-degree relatives with a
history of colorectal cancer or adenomatous polyps. What are the U.S. Preventive Services Task Force
(USPSTF) screening recommendations for this patient?
Sigmoidoscopy every 5 years with FOBT every 3 years
Continue annual FOBT screening until age 80 years
Repeat colonoscopy this year
Do not screen routinely
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?
Breast cancer screening is extremely well studied, and no controversy exists on the recommended norms for
screening and follow-up.
Mammography is most sensitive and specific for women in their 40s, when breast tissue is still dense enough to
image accurately.
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.
BSE is well evidenced, and all recommending agencies agree that it should be taught and reinforced.
Clinical breast examination (CBE) is superior to BSE and should be a routine part of annual examinations
starting at age 30 years.
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?
Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity.
This patient is an ideal candidate for screening via breast MRI based on current evidence.
Women at low lifetime risk of breast cancer (<20%) are recommended to undergo screening MRI.
KnownBRCA1orBRCA2mutation is insufficient criteria to justify screening with breast MRI.
Breast cancer screening by MRI has been well studied in the general population.
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?
Because of this patient’s age, breast masses should not be pursued with imaging and diagnosis because the risk
of cancer is so low.
Most masses that women find at home and bring to a provider’s attention turn out to be malignant.
This patient is more likely to find a fibroadenoma than a cancer on self-examination.
The most likely breast mass this patient is likely to find in herself is an abscess complicating underlying
mastitis.
BSE is universally recommended because of very high sensitivity and specificity for finding cancerous lesions.
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?
,Prolactinoma
Occult pregnancy
Mastitis
Ductal carcinoma in situ
Paget disease of the breast
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?
Breast cancer always presents with axillary lymphadenopathy because the lymphatics of the breast uniformly
drain into the axilla.
Firm, rubbery lymph nodes are generally considered to be benign.
Supraclavicular nodes are generally considered benign and require no further evaluation or follow-up.
Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular nodes
without first causing notable changes in the axillary nodes.
Supraclavicular nodes are found along the anterior edge of the trapezius muscle in the neck.
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 theBRCA1andBRCA2genes. 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?
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.
The U.S. Preventive Services Task Force (USPSTF) recommends against screening with MRI for patients with
such risk factors.
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).
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.
No agency recommends breast MRI for a patient such as this one, who has moderately but not extraordinary
risk factors for breast cancer.
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 (BRCA1andBRCA2) and desires further information about whether this would be
appropriate for her. Which of the following is true about this patient’s indications forBRCAtesting?
, Her familial lineage is irrelevant to her risk ofBRCAgenes and should be discounted in assessing her risk for
these genes.
Even if this patient isBRCApositive, no changes in screening or treatment are recommended for patients with
this genetic mutation, so the test is not recommended.
This patient carries several risk factors that together justifyBRCAtesting.
The BRCAPRO calculator does not add any further clinical information to this patient’s risk for carrying
theBRCAgene.
Breast cancer in a male relative does not add significant weight to the decision to test for theBRCAgenes in this
patient.
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?
Rubbery, mobile, nontender mass located in right breast, in the lower outer quadrant”
“Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple”
“Rubbery, mobile, nontender mass located in right breast, in the upper inner quadrant”
“Rubbery, mobile, nontender mass located in right breast, in the 1:30 position from the nipple”
“Rubbery, mobile, nontender mass located in the left breast, upper outer quadrant”
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 pathology. She feels that
her breasts have become far less lumpy since she underwent menopause 3 years ago. Which of the following is
true regarding changes in the breasts with menopause?
Breast density has no genetic component and is entirely due to estrogen dose from endogenous and exogenous
sources over the lifetime.
Transformation of breasts to primarily fatty tissue with menopause decreases the sensitivity and specificity of
mammograms.
Estrogen in hormone replacement therapy (HRT) has no effect on breast density after menopause.
Mammography performs most poorly in the menopausal and postmenopausal age group and should be limited
for that reason.
Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of
lobules.
Abdomen CH 19
A 76-year-old retired man with a history of prostate cancer and hypertension has been screened annually for
colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow-up of his
hypertension, during which the clinician scans his chart to ensure he is up to date with his preventive health
care. He has a positive FOBT on one occasion at age 66 years and subsequently went for a colonoscopy.
Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no first-degree relatives with a
history of colorectal cancer or adenomatous polyps. What are the U.S. Preventive Services Task Force
(USPSTF) screening recommendations for this patient?
Sigmoidoscopy every 5 years with FOBT every 3 years
Continue annual FOBT screening until age 80 years
Repeat colonoscopy this year
Do not screen routinely
