BREAST SURGERY PROGRESS TEST Name:

General Surgery Residency Program Excellent surgeons BREAST SURGERY PROGRESS TEST Name: Choose the BEST answer for the following questions. 1. All of the following factors are associated with an increased risk for the development of breast cancer EXCEPT: A atypical hyperplasia on breast biopsy B presence of BRCA1 defect C conjugated estrogen therapy after hysterectomy D increased bone density E increased breast density 2. A 42-year-old woman undergoes a stereotactic core biopsy of a 1-cm mammographically detected lesion in her left breast that demonstrates infiltrating ductal breast cancer (grade 2, ER/PR negative, HER2/neu positive). A paternal aunt had breast cancer at age 55 and a second paternal aunt had ovarian cancer at age 51. The next step in this patient's management should be: A MRI of both breasts B simple mastectomy with sentinel node biopsy C needle localization lumpectomy with sentinel node biopsy D genetic counseling E neoadjuvant chemotherapy 3. A 14-year-old girl presents with a 6-month history of sudden, rapid, asymmetric enlargement of the right breast. On physical examination, there is a large palpable mass occupying the breast with marked nipple-areolar stretching, prominent dilated veins, and skin ulceration. Mammography and ultrasonography show a dense, well-circumscribed 7-cm homogenous mass occupying the left breast. The most likely diagnosis is: A invasive ductal carcinoma B hemangioma C giant fibroadenoma D juvenile breast hypertrophy E phyllodes tumor Page 1 of 9

4. A patient undergoes a segmental mastectomy and negative margins are obtained. Two sentinel lymph nodes are identified. On final histologic evaluation, a 6-mm region of macrometastases is found on H&E staining within two of the lymph nodes. The next step should be: A completion mastectomy B completion axillary dissection C axillary dissection and breast radiation therapy D systemic chemotherapy alone E no further axillary operation 5. A 38-year-old woman has a 1.5-cm mass in her left breast. Clinical examination reveals no suspicious adenopathy. Mammogram-guided biopsy demonstrates infiltrating ductal carcinoma. The patient would prefer a lumpectomy followed by radiation therapy. Which of the following statements about sentinel lymph node biopsy (SLNB) is TRUE: A It is only indicated in women with a clinically positive axilla B It is associated with a survival advantage over routine axillary dissection C Neoadjuvant chemotherapy does not affect reliability of SLNB D It is best performed with blue dye alone E It is not indicated because of her premenopausal status 6. Which of the following statements about HER2/neu is TRUE: A Overexpression is ideally determined from the leukocyte DNA B It is an oncogene located on the long arm of chromosome 17 C It is a transmembrane, surface-bound Toll-like receptor D It has been designated as a CD340 (cluster of differentiation) and Erb-2 protein E Overexpression in breast cancer increases response to anthracyclines compared with other breast tumors 7. Which of the following statements BEST describes the activity of trastuzumab (Herceptin): A It is a humanized, monoclonal antibody agains the extracellular domain of the Erb-2 protein B Blinding of the cell surface receptor with the agent produces phosphorylation of the tyrosine kinase portion of the receptor C The agent is equally effective for treating testicular germ cell tumors that express overamplification of the HER2/neu gene D Tumors exposed to trastuzumab undergo arrest in the M phase of cell proliferation E Breast cancers that do not overexpress HER2/neu respond to high doses of trastuzumab Page 2 of 9

8. A 34-year-old trucker presents with the lesion shown. He says the problem began with an "infection" under the areola about 3 weeks ago. He was treated with antibiotics, which he took for 10 days and which improved his breast tenderness. Two days ago, spontaneous drainage from the opening as depicted occurred. He says he has had breast "infections" in the past. He has no other pertinent medical history. He is a heavy smoker. The most likely diagnosis is: A Paget s disease B atypical mycobacterium infection C granulomatous mastitis D inflammatory carcinoma E periductal mastitis 9. Breast cancer is diagnosed in a 28-year-old nulliparous woman who wishes to have children. Which of the following statements about her care is TRUE: A Mastectomy rather than partial mastectomy is the preferred surgical treatment B The chance of regular menstrual cycles returning after completion of chemotherapy correlates inversely with age C Future pregnancy and childbirth should be avoided D Embryo harvesting and/or cryopreservation should be postponed until after completion of cytotoxic chemotherapy E Tamoxifen will not affect her ability to conceive 10. A postmenopausal woman chooses mastectomy and sentinel lymph node biopsy (SLNB) for a new diagnosis of breast carcinoma. Final pathology reveals a 1-cm infiltrating ductal carcinoma with negative SLN; it is estrogen receptor/progesterone receptor (ER/PR) positive and HER2/neu negative. The most appropriate adjuvant therapy would be: A aromatase inhibitor B tamoxifen C postoperative breast radiation therapy D prophylactic oophorectomy E cytotoxic chemotherapy Page 3 of 9

11. Which of the following statements about lobular carcinoma in situ (LCIS) is NOT true: A Tamoxifen decreases the risk of invasive cancer B Patients have an increased risk of breast cancer bilaterally C Calcifications or a palpable mass are usually absent D Resection with negative margins is required E It is most common in premenopausal women 12. A 34-year-old woman in her 14th week of gestation has a 2.5-cm invasive ductal carcinoma. There are no palpable lymph nodes. The best treatment now would be: A modified radical mastectomy, adjuvant chemotherapy B modified radical mastectomy, radiotherapy, adjuvant chemotherapy C modified radical mastectomy D lumpectomy with axillary lymph node dissection, adjuvant chemotherapy E lumpectomy with sentinel lymph node biopsy, radiotherapy 13. Sentinel lymph node biopsy (SLNB) is NOT recommended for patients with: A invasive lobular carcinoma B prior excisional biopsy of the tumor C inflammatory breast cancer D male breast cancer E multicentric breast cancer 14. Which of the following statements about breast cancer in men is MOST accurate: A African American men have a better prognosis than white men B Klinefelter s syndrome (XXY) is associated with reduced risk of male breast cancer C The risk of contralateral breast cancer is higher in men than women D Breast cancer in men presents at an earlier age than in women E Men have a worse prognosis than women 15. A 55-year-old man presents with a 2-month history of progressive unilateral breast enlargement. He takes no medications and does not drink or smoke. On examination, he has a firm, tender, left-sided concentric subareolar mass. The remainder of his examination is normal. The next step in his diagnostic work-up should be: A fine-needle aspiration B treatment with oral antibiotics C mammography D ACTH measurement E serum testosterone to estradiol ratio 16. Which of the following statements about wound seromas after breast surgery is TRUE: A Seromas occur in 75% of patients having major breast surgery B Daily aspirations resolve seromas more quickly than aspirations only for symptoms C Intraoperative local wound application of tetracycline increases seroma formation D Iodine toxicity has been reported when povidone iodine is used as a sclerosing agent E Drain placement after one aspiration is recommended Page 4 of 9

17. Compared with women, men with breast cancer: A are more likely to have ER/PR positive disease B have a better long-term prognosis C are more likely to have lobular carcinoma D rarely receive hormonal treatment E are not accurately staged with sentinel node biopsy 18. A 40-year-old premenopausal African American woman presents with a hard 4-cm mass in the upper outer quadrant of the left breast. Core biopsy reveals intermediate-grade infiltrating ductal carcinoma that is estrogen and progesterone receptor (ER/PR) negative. The patient is taken to the operating room for port placement and sentinel node biopsy prior to chemotherapy. The sentinel node shows isolated tumor cells. Which of the following statements about this patient is TRUE: A Her prognosis will be better if her tumor is HER2/neu negative B She is considered node positive C A 21 gene recurrence score is recommended D Preoperative chemotherapy will increase her chance for breast conservation therapy E Postoperative anastrozole (Arimidex) therapy will improve her outcome 19. A 35-year-old woman whose breast examination is normal has a family history of breast cancer. Her mother died of breast cancer at age 45. Her 40-year-old sister was recently diagnosed with breast cancer, and was found to be positive for BRCA1 mutation. Which of the following statements is TRUE: A If she is BRCA1 negative, she should be screened according to general population guidelines B A full sequencing test for BRCA1 is indicated C Screening with MRI alone is appropriate D She has an equal probability of BRCA1 and BRCA2 mutations E A formal genetic risk assessment will likely increase her psychological distress 20. A 30-year-old woman who is 20 weeks pregnant has a 2.5-cm dominant, slightly tender mass in the left breast. Biopsy shows grade II infiltrating ductal carcinoma. This patient should be advised that: A preoperative tamoxifen therapy is safe and effective B chemotherapy now is contraindicated C breast conservation is an option D sentinel node biopsy is significant risk to the fetus E she should avoid all future pregnancies 21. A postmenopausal woman with a new diagnosis of breast cancer in her left breast elects to undergo mastectomy. Which of the following statements about contralateral prophylactic mastectomy is TRUE: A Overall mortality is improved B There is a survival advantage for patients with higher stage cancers C The incidence of contralateral breast cancer is significantly reduced D Sentinel lymph node biopsy should be done bilaterally E Reconstruction should be delayed until final histopathology is available Page 5 of 9

22. A 51-year-old perimenopausal woman undergoes lumpectomy and sentinel lymph node biopsy for invasive ductal carcinoma. Pathology reveals a 1.0-cm grade II ER /PR positive, HER2/neu negative carcinoma. The lateral margin of the lumpectomy specimen is positive for carcinoma. An intramammary lymph node within the lumpectomy specimen is infiltrated with cancer. Her sentinel lymph node shows no evidence of cancer. The next step in her management should be: A testing the specimen for Oncotype DX B re-excision of lumpectomy margin C simple mastectomy D radiation therapy followed by tamoxifen E re-excision and axillary lymph node dissection 23. A 90-year-old woman who is wheelchair-bound due to chronic obstructive pulmonary disease (COPD) presents with the lesion shown. Core biopsy shows well-differentiated ER /PR positive invasive ductal carcinoma. Physical examination demonstrates no palpable axillary adenopathy. The next step in her management should be: A modified radical mastectomy B radiation therapy C chemotherapy with adriamycin/cytoxan D aromatase inhibitors E wide local excision and sentinel lymph node biopsy 24. Breast MRI screening is appropriate for all of the following women EXCEPT: A 40-year-old BRCA2 mutation carrier B 55-year-old with scattered fibroglandular breast tissue on negative screening mammography C 38-year-old 13 years after mantle radiation therapy for Hodgkin s disease with normal clinical breast examination D 45-year-old with a 28% lifetime risk of breast cancer E 42-year-ol sister of BRCA1 mutation who has refused genetic testing Page 6 of 9

25. An asymptomatic 53-year-old woman undergoes an ultrasound-guided core needle biopsy for a new nonpalpable right breast nodule detected on mammography. Pathology demonstrates a papilloma with atypia. The next step in management should be: A tamoxifen for 5 years B raloxifene (Evista) for 5 years C dye-directed central duct excision D wire localization right breast excisional biopsy E observation 26. A 42-year-old woman presents with the acute onset of erythema and edema in her left breast. She was treated with oral antibiotics for 10 days without resolution of symptoms. Mammography shows skin edema and a masslike area at 12 o'clock in her left breast. Core and punch biopsies demonstrate infiltrating carcinoma, grade III ER/PR negative, HER2/neu 3+(FISH positive). The next step in treatment should be: A simple mastectomy and sentinel node biopsy B modified radical mastectomy C whole breast irradication D neoadjuvant hormonal therapy E neoadjuvant chemotherapy and monoclonal antibody infusion 27. An asymptomatic premenopausal 45-year-old woman undergoes lumpectomy and sentinel node biopsy for a grade III, 0.9-cm ER/PR positive, HER2/neu negative infiltrating ductal carcinoma. All four sentinel nodes are negative and the closest surgical margin is 5 mm. Her Ki-67 is 3+, 56%. The next step in management should be: A PET scan B topoisomerase II alpha gene analysis C Oncotype Dx assay D bilateral whole breast ultrasound E bone scan 28. Which of the following statements about the role of operation for patients presenting with synchronous stage IV breast cancer is TRUE: A Resection of the primary site to a free margin may improve survival B Resection of metastatic disease sites does not improve survival C The primary site and progression-free survival do not affect the timing of operation D Palliative resections for symptom control are increasing E Survival is not affected by the site of distant metastases Page 7 of 9

29. An 86-year-old woman undergoes lumpectomy and sentinel node biopsy, followed by external-beam radiation therapy, for an ER/PR negative, HER2/neu negative 3-cm node-negative infiltrating ductal carcinoma. Eight years later, she presents with the breast changes pictured. Which of the following statements about her disease process is NOT true: A Positive immunochemical staining for CD31 assists with the diagnosis B The average time for appearance of this lesion varies from 3 to 12 years after initial operation C Chemotherapeutic agents are routinely used after resection D The most common site of metastasis is lung E Wide surgical excision is recommended 30. Needle localization lumpectomy required for lesions identified on core biopsy: A Lobular carcinoma in situ (LCIS) B Atypical ductal hyperplasia (ADH) 31. Part of spectrum of histologic transformation of ductal epithelium from normal tissue to invasive breast cancer: A Lobular carcinoma in situ (LCIS) B Atypical ductal hyperplasia (ADH) 32. Increased risk of developing breast: A Lobular carcinoma in situ (LCIS) B Atypical ductal hyperplasia (ADH) Page 8 of 9

33. Associated with smoking: A Idiopathic granulomatous mastisis (IGM) B Periductal mastisis (PDM) 34. Associated with pregnancy within 5 years of: A Idiopathic granulomatous mastisis (IGM) B Periductal mastisis (PDM) 35. Radiation therapy: A Idiopathic granulomatous mastisis (IGM) B Periductal mastisis (PDM) SCORE: /35 Page 9 of 9