Chapter 18: Breast 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.
Rationale: This patient was in compliance with the USPSTF recommendations for her age group and risk
factors prior to her current complaint. The USPSTF recommends that women age <50 years discuss risks
and benefits with their provider and decide on appropriate screening for their individual preferences and
needs. These recommendations are controversial and likely to change again over time, but they are
underpinned by one key issue: Mammograms have low sensitivity and specificity in younger women with
higher
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. Rationale:
Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity. Increased
sensitivity (in this case, higher-resolution imaging to pick up subtler disease) is often traded for reduced
specificity (in the form of discovering many small items of no pathological significance). This is a core
concept in designing screening tests—very sensitive tests often pick up false positives, while very specific
tests often rule out disease effectively by missing many actual cases. Balance must be sought between these
two when setting thresholds for positive and negative screens. Breast cancer screening by MRI has been
well studied in the general population is incorrect. This screening modality has only been studied in high-
risk populations. This patient is an ideal candidate for screening via breast MRI based on current evidence is
incorrect. This patient meets no known criteria for screening with breast MRI (known BRCA mutation,
history of chest radiation, etc.). Women at low lifetime risk of breast cancer (<20%) are recommended to
undergo screening MRI is incorrect. Only women at high lifetime risk (>20%) are current recommended to
utilize breast MRI as a screening tool. Known BRCA1 or BRCA2 mutation is insufficient criteria to justify
screening with breast MRI is incorrect. The BRCA1 or BRCA2 mutation confers a risk >20% of breast
cancer over a lifetime, which is considered sufficient criteria for screening with MRI rather than
mammogram.
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
Rationale: Prolactinomas are pituitary tumors that secrete prolactin, which causes the production of breast milk
and can suppress menstruation. Mastitis is incorrect. Mastitis is a breast infection that is typically painful and
characterized by a focal area of redness and tenderness in one breast. Ductal carcinoma in situ is incorrect.
While nipple discharge should raise suspicion for breast cancer, in this case the discharge is neither bloody nor
purulent, and it is notably bilateral. A prudent provider may still order a mammogram and/or ultrasound, but the
answer is unlikely to be breast cancer. Paget disease of the breast is incorrect. This condition may present with
nipple discharge, but it is usually bloody. Occult pregnancy is incorrect. This patient has a negative HCG test,
which is the standard hormonal laboratory examination used to determine pregnancy in both urine and serum
tests.
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.
Rationale: This patient is more likely to find a fibroadenoma than a cancer on self-examination. In this patient’s
age range (15–25 years), palpable masses are most likely to be benign fibroadenomas. Most masses that women
find at home and bring to a provider’s attention turn out to be malignant is incorrect. About 11% of complaints
of breast masses turn out to be malignant, leaving the vast majority (89%) noncancerous. The most likely breast
mass this patient is likely to find in herself is an abscess complicating underlying mastitis is incorrect. This
patient has neither the symptoms of mastitis (localized swelling/erythema/tenderness with generalized fever)
nor the risk factors for this condition (pregnancy and/or breastfeeding), making mastitis a very unlikely
diagnosis. Because of this patient’s age, breast masses should not be pursued with imaging and diagnosis
because the risk of cancer is so low is incorrect. Though the risk of cancer in this patient is low, the
consequence of missing a cancer diagnosis is quite high; for that reason, definitive diagnosis should be pursued
for almost all breast masses. Because of this patient’s age, breast masses should not be pursued with imaging
and diagnosis because the risk of cancer is so low is incorrect. BSE suffers from notoriously low sensitivity and
specificity, making it a very controversial recommendation as it tends to overestimate disease in healthy breasts
and miss cancer in breasts with subtle disease.
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.
Rationale: This patient has both a first-degree male relative with breast cancer and several relatives in the same
lineage with breast cancer. Both of these suggest risk for the BRCA genes, but the BRCAPRO calculator can
further refine the numerical risk and help decide if screening might be helpful. Her familial lineage is irrelevant
to her risk of BRCA genes, and should be discounted in assessing her risk for these genes is incorrect.
Ashkenazi-Jewish heritage is a risk factor for carrying the BRCA genes, and for obvious reasons, historical
events in the last century obscured the family history of many Jewish families from Europe. Though this patient
does not overtly describe Jewish heritage, her family’s story certainly raises concern that she may carry some
genetic lineage that is at risk for this mutation. Breast cancer in a male relative does not significant weight to the
decision to test for the BRCA genes in this patient is incorrect. Breast cancer is quite rare in men, and any case
of it should raise concerns for the presence of the BRCA genes. The BRCAPRO calculator does not add any
further clinical information to this patient’s risk for carrying the BRCA gene is incorrect. The BRCAPRO
calculator offers a numerical estimation of the patient’s risk of carrying a BRCA gene based on risk factors. It
does not, however, analyze risk of developing breast cancer based on those risks. 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 is incorrect. BRCA positive individuals may undergo prophylactic mastectomy,
oophorectomy, and increased screening with magnetic resonance imaging instead of mammography to find
early cases of breast cancer.
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.
Rationale: 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 health breasts). Sensitivity and specificity of
screening test are almost always trade-offs; that is, a test that picks up more true cases is also very likely to then
pick up more false positives, and vice versa. With breast MRI, the pick-up rate of true disease is almost double
, that of mammograms, but at the expense of double the false positives. No agency recommends breast MRI for a
patient such as this one, who has moderately but not extraordinary risk factors for breast cancer is incorrect.
This patient presents with an extraordinary risk profile, including strong family history of breast cancer
(suggestive of BRCA linkage to disease but without clear diagnosis), history of chest radiation, and dense
breasts requiring prior biopsies to rule out malignancy. She meets the American Cancer Society (ACS) criteria
for annual breast MRI, though the USPSTF does not agree that the evidence exists to support this
recommendation. The USPSTF recommends against screening with MRI for patients with such risk factors is
incorrect. The USPSTF, recognizing the limited data available on this screening test, states that there is
insufficient evidence to state one way or another whether this test is appropriate for high-risk patients.
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 is incorrect. Breast density is both a risk factor for breast
cancer and a factor that hampers effective screening with mammograms; per the ACS, it may be criteria to
screen by MRI. 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 is incorrect. Chest radiation between the ages of 10 and 30
years confers high risk of later breast cancer; per the ACS, this risk is sufficient to warrant screening by MRI.
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.
Rationale: Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular
nodes without first causing notable changes in the axillary nodes. Though axillary lymphadenopathy should be
evaluated with age-appropriate imaging to rule out breast cancer, cells that are metastasizing from the breasts
can pass directly to the infraclavicular, then supraclavicular nodes. Lack of axillary adenopathy should not be
considered grounds to exclude a breast cancer diagnosis. Breast cancer always presents with axillary
lymphadenopathy because the lymphatics of the breast uniformly drain into the axilla is incorrect for reasons
noted above. Supraclavicular nodes are generally considered benign and require no further evaluation or follow-
up is incorrect. Supraclavicular lymph nodes are uniformly considered malignant until proven otherwise. The
differential diagnosis for these malignancies is wide but includes cancers of the breast, lung, head, and neck,
esophagus, pancreas, etc. Supraclavicular nodes are found along the anterior edge of the trapezius muscle in the
neck is incorrect. This describes the location of the posterior cervical chain of lymph nodes. Supraclavicular
nodes are found deep in the angle formed by the clavicle and the sternocleidomastoid muscle. Firm, rubbery
lymph nodes are generally considered to be benign is incorrect. Firm or fixed lymph nodes are of concern for
malignancy; tender nodes suggest inflammation.
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”
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.
Rationale: This patient was in compliance with the USPSTF recommendations for her age group and risk
factors prior to her current complaint. The USPSTF recommends that women age <50 years discuss risks
and benefits with their provider and decide on appropriate screening for their individual preferences and
needs. These recommendations are controversial and likely to change again over time, but they are
underpinned by one key issue: Mammograms have low sensitivity and specificity in younger women with
higher
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. Rationale:
Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity. Increased
sensitivity (in this case, higher-resolution imaging to pick up subtler disease) is often traded for reduced
specificity (in the form of discovering many small items of no pathological significance). This is a core
concept in designing screening tests—very sensitive tests often pick up false positives, while very specific
tests often rule out disease effectively by missing many actual cases. Balance must be sought between these
two when setting thresholds for positive and negative screens. Breast cancer screening by MRI has been
well studied in the general population is incorrect. This screening modality has only been studied in high-
risk populations. This patient is an ideal candidate for screening via breast MRI based on current evidence is
incorrect. This patient meets no known criteria for screening with breast MRI (known BRCA mutation,
history of chest radiation, etc.). Women at low lifetime risk of breast cancer (<20%) are recommended to
undergo screening MRI is incorrect. Only women at high lifetime risk (>20%) are current recommended to
utilize breast MRI as a screening tool. Known BRCA1 or BRCA2 mutation is insufficient criteria to justify
screening with breast MRI is incorrect. The BRCA1 or BRCA2 mutation confers a risk >20% of breast
cancer over a lifetime, which is considered sufficient criteria for screening with MRI rather than
mammogram.
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
Rationale: Prolactinomas are pituitary tumors that secrete prolactin, which causes the production of breast milk
and can suppress menstruation. Mastitis is incorrect. Mastitis is a breast infection that is typically painful and
characterized by a focal area of redness and tenderness in one breast. Ductal carcinoma in situ is incorrect.
While nipple discharge should raise suspicion for breast cancer, in this case the discharge is neither bloody nor
purulent, and it is notably bilateral. A prudent provider may still order a mammogram and/or ultrasound, but the
answer is unlikely to be breast cancer. Paget disease of the breast is incorrect. This condition may present with
nipple discharge, but it is usually bloody. Occult pregnancy is incorrect. This patient has a negative HCG test,
which is the standard hormonal laboratory examination used to determine pregnancy in both urine and serum
tests.
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.
Rationale: This patient is more likely to find a fibroadenoma than a cancer on self-examination. In this patient’s
age range (15–25 years), palpable masses are most likely to be benign fibroadenomas. Most masses that women
find at home and bring to a provider’s attention turn out to be malignant is incorrect. About 11% of complaints
of breast masses turn out to be malignant, leaving the vast majority (89%) noncancerous. The most likely breast
mass this patient is likely to find in herself is an abscess complicating underlying mastitis is incorrect. This
patient has neither the symptoms of mastitis (localized swelling/erythema/tenderness with generalized fever)
nor the risk factors for this condition (pregnancy and/or breastfeeding), making mastitis a very unlikely
diagnosis. Because of this patient’s age, breast masses should not be pursued with imaging and diagnosis
because the risk of cancer is so low is incorrect. Though the risk of cancer in this patient is low, the
consequence of missing a cancer diagnosis is quite high; for that reason, definitive diagnosis should be pursued
for almost all breast masses. Because of this patient’s age, breast masses should not be pursued with imaging
and diagnosis because the risk of cancer is so low is incorrect. BSE suffers from notoriously low sensitivity and
specificity, making it a very controversial recommendation as it tends to overestimate disease in healthy breasts
and miss cancer in breasts with subtle disease.
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.
Rationale: This patient has both a first-degree male relative with breast cancer and several relatives in the same
lineage with breast cancer. Both of these suggest risk for the BRCA genes, but the BRCAPRO calculator can
further refine the numerical risk and help decide if screening might be helpful. Her familial lineage is irrelevant
to her risk of BRCA genes, and should be discounted in assessing her risk for these genes is incorrect.
Ashkenazi-Jewish heritage is a risk factor for carrying the BRCA genes, and for obvious reasons, historical
events in the last century obscured the family history of many Jewish families from Europe. Though this patient
does not overtly describe Jewish heritage, her family’s story certainly raises concern that she may carry some
genetic lineage that is at risk for this mutation. Breast cancer in a male relative does not significant weight to the
decision to test for the BRCA genes in this patient is incorrect. Breast cancer is quite rare in men, and any case
of it should raise concerns for the presence of the BRCA genes. The BRCAPRO calculator does not add any
further clinical information to this patient’s risk for carrying the BRCA gene is incorrect. The BRCAPRO
calculator offers a numerical estimation of the patient’s risk of carrying a BRCA gene based on risk factors. It
does not, however, analyze risk of developing breast cancer based on those risks. 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 is incorrect. BRCA positive individuals may undergo prophylactic mastectomy,
oophorectomy, and increased screening with magnetic resonance imaging instead of mammography to find
early cases of breast cancer.
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.
Rationale: 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 health breasts). Sensitivity and specificity of
screening test are almost always trade-offs; that is, a test that picks up more true cases is also very likely to then
pick up more false positives, and vice versa. With breast MRI, the pick-up rate of true disease is almost double
, that of mammograms, but at the expense of double the false positives. No agency recommends breast MRI for a
patient such as this one, who has moderately but not extraordinary risk factors for breast cancer is incorrect.
This patient presents with an extraordinary risk profile, including strong family history of breast cancer
(suggestive of BRCA linkage to disease but without clear diagnosis), history of chest radiation, and dense
breasts requiring prior biopsies to rule out malignancy. She meets the American Cancer Society (ACS) criteria
for annual breast MRI, though the USPSTF does not agree that the evidence exists to support this
recommendation. The USPSTF recommends against screening with MRI for patients with such risk factors is
incorrect. The USPSTF, recognizing the limited data available on this screening test, states that there is
insufficient evidence to state one way or another whether this test is appropriate for high-risk patients.
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 is incorrect. Breast density is both a risk factor for breast
cancer and a factor that hampers effective screening with mammograms; per the ACS, it may be criteria to
screen by MRI. 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 is incorrect. Chest radiation between the ages of 10 and 30
years confers high risk of later breast cancer; per the ACS, this risk is sufficient to warrant screening by MRI.
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.
Rationale: Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular
nodes without first causing notable changes in the axillary nodes. Though axillary lymphadenopathy should be
evaluated with age-appropriate imaging to rule out breast cancer, cells that are metastasizing from the breasts
can pass directly to the infraclavicular, then supraclavicular nodes. Lack of axillary adenopathy should not be
considered grounds to exclude a breast cancer diagnosis. Breast cancer always presents with axillary
lymphadenopathy because the lymphatics of the breast uniformly drain into the axilla is incorrect for reasons
noted above. Supraclavicular nodes are generally considered benign and require no further evaluation or follow-
up is incorrect. Supraclavicular lymph nodes are uniformly considered malignant until proven otherwise. The
differential diagnosis for these malignancies is wide but includes cancers of the breast, lung, head, and neck,
esophagus, pancreas, etc. Supraclavicular nodes are found along the anterior edge of the trapezius muscle in the
neck is incorrect. This describes the location of the posterior cervical chain of lymph nodes. Supraclavicular
nodes are found deep in the angle formed by the clavicle and the sternocleidomastoid muscle. Firm, rubbery
lymph nodes are generally considered to be benign is incorrect. Firm or fixed lymph nodes are of concern for
malignancy; tender nodes suggest inflammation.
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”
