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signs of infection.
Trauma (choice E) to the breast can lead to a condition called fat necrosis.
Patients with breast trauma usually complain of a firm area of the breast,
sometimes mobile, and occasionally with induration. However, patients with
fat necrosis from breast trauma usually recall a prior incident of trauma.
Question 2 of 4
Histological examination of diagnostic tissue from this patient would reveal which
of the following?
/A. A Iocalized area of acute inflammation
/B. Cellular, fibroblastic stroma enclosing cystic spaces lined by epithelium
/C. Edema fluid within the intercellular spaces of the epidermis
/D. Hemorrhage enclosed within the tissue
/E. Strands of infiltrating tumor cells
Explanation - Q: 1.2
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Which of the following is most likely responsible for this pathologic process?
Explanation - Q: 1.3
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The patient is started on dicloxacillin. This medication works via which of the
following mechanisms?
/A. BIocking cell wall synthesis
/B. Inhibition of bacterial dihydrofolate reductase
/C. Inhibition of bacteriaI DNA gyrase
/D. Inhibition of protein synthesis
/E. Inhibition of resorption of sodium and chloride
Explanation - Q: 1.4
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The breast tissue is normally attached to the overlying skin via which of the
following?
/A. Cooper's ligaments
/B. Cruciate ligaments
/C. Falciform ligament
/D. Poupart's ligaments
/E. Rhomboid ligaments
Explanation - Q: 2.1
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The correct answer is B. The lactiferous ducts open into the nipples. The
area of each of these ducts immediately below the nipple is usually dilated,
forming a lactiferous sinus, which can store a droplet of milk that helps to
initiate the baby's sucking reflex during nursing.
The areola (choice A) is the ring of darkly pigmented skin around the nipple.
Montgomery's glands (choice C) are modified eccrine glands (described
incorrectly by some authors as sebaceous glands) that provide oil and
moisture for the skin of the nipple and areola. They open into the areola in
small tubercles rather than the nipple.
Sweat glands (choice D) are common in the skin of the breast generally, but
are too small to be able to seen by the unaided eye.
The terminal ductules (choice E) of the breast system are at the deep end of
the duct system of the breasts, and receive milk from the lobular tissue.
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Question 3 of 6
The physician identifies a palpable mass in one breast, and the patient is
scheduled for a "Iumpectomy." The reason that "Iumpectomies" for
breast lumps can be safely performed in some patients is that the breast is
divided into multiple lobes, each of which contains a separate
duct system with connecting lobules. The normal breast usually contains how
many lobes?
/A. 2 to 3
/B. 5 to 7
/C. 10 to 12
/D. 15 to 25
/E. 30 to 50
Explanation - Q: 2.3
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The surgical specimen is sent fresh from the surgical suite to the laboratory for
frozen section examination. Before cutting into the specimen,
the pathologist makes a careful gross examination, which demonstrates that
most of the specimen has replacement of the normally fatty
breast tissue with strands of dense, white, firm tissue. In a few areas, roughly
spherical lesions up to 3-cm diameter with a bluish hue to them
are seen. Palpation of these areas produces a fluctuant sensation. Which of the
following is the most likely diagnosis based on the gross
evaluation?
/A. Breast cancer
/B. Changes of pregnancy
/C. Fibroadenoma
/D. Fibrocystic disease
/E. Mastitis
Explanation - Q: 2.4
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The correct answer is D. While a careful pathologist will wait for appropriate
frozen or permanent tissue histologic examination, the description given in the
question stem is most suggestive of fibrocystic disease. The fibrous part of
the lesion forms the dense, white tissue strands, while the blue lesions are
what are called "blue-domed cysts. The blue color comes from the presence
of darkly colored fluid (which usually means old hemorrhage) within the cyst.
The interior cyst wall is usually smooth. These blue-domed cysts are a
favorite of examiners because they produce a distinctive gross picture and
should be specifically associated with fibrocystic disease, but you should be
aware that in real life they do not occur with anything near the frequency of
fibrocystic disease without obvious large cysts grossly (but many smaller
Frozen section examination demonstrates fibrosis and cystic spaces. AIso seen
are areas of compressed glands with a lobular orientation.
The glands are lined by a single layer of epithelial cells with oval nuclei and
regular arrangement. No true invasion of glands into the adjacent
stroma is seen. This patient probably has which of the following?
/A. Atypical ductal hyperplasia
/B. Ductal carcinoma in situ
/C. Lobular carcinoma in situ
/D. Sclerosing adenosis
/E. Usual ductal hyperplasia
Explanation - Q: 2.5
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multiple layers of cells and range from usual ductal hyperplasia (choice E,
with low risk of invasive carcinoma and characterized by the presence of both
myoepithelial cells and epithelial cells within the duct) through atypical ductal
hyperplasia (choice A, with medium risk of invasive carcinoma and
characterized by ductal carcinoma in situ-like features only involving portions
of a duct) to ductal carcinoma in situ (choice B, with relatively high risk of
invasive carcinoma and characterized by clearly abnormal features such as
loss of myoepithelial cells and formation of cribriform patterns involving
complete cross-sections of ducts).
Lobular carcinoma in situ (choice C) typically produces lobular units whose
lumina are completely filled with epithelial cells.
In practice, while you may be asked to distinguish classic examples of the
different lesions mentioned in the choices on examinations, you should be
aware that this whole area can be very problematic in real-life microscopic
examinations of breast tissue, and one piece of breast tissue sent to different
experts in breast pathology may be returned with a variety of diagnoses.
Question 6 of 6
Which of the following breast lesions is considered to have the greatest potential
for eventual progression to a malignant lesion?
/A. Apocrine metaplasia
/B. BIue dome cyst
/C. Epithelial hyperplasia
/D. Fat necrosis
/E. Fibrosis
Explanation - Q: 2.6
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A 47-year-old man presents to his physician because he has noticed that his right
breast is noticeably larger than his left breast. Breast
examination demonstrates that the right breast is diffusely enlarged. The breast
tissue is freely mobile and without distinct masses. The
patient reports that the breast has been slowly enlarging over a period of several
years.
Question 1 of 7
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The correct answer is C. The most common cause for male breast
evaluation in the United States is gynecomastia, or benign breast
enlargement. Gynecomastia may involve one or both breasts. Male breasts
can also develop ductal carcinoma in situ (choice A), invasive ductal
carcinoma (choice D), and fibroadenoma (choice B), but these lesions are
much less common than gynecomastia.
The glands in male breasts do not have lobular tissue, so lobular carcinoma in
situ (choice E) does not occur.
Question 2 of 7
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The correct answer is A. Spider angiomas are small vascular lesions with
small blood vessels radiating from a central point. They are specifically
associated with liver disease, particularly due to alcohol abuse. They are not
specifically associated with diseases of the other organs listed in the choices.
Question 3 of 7
The presence of the spider angiomas should specifically trigger a question to the
patient about his history of use of which of the following?
/A. AIcohol
/B. Caffeine
/C. Cigarettes
/D. Heroin
/E. Marijuana
Explanation - Q: 3.3
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The correct answer is A. Spider angiomas are most often associated with
liver disease related to alcohol abuse. Abuse of the other items listed in the
choices does not predispose for spider angioma formation.
Question 4 of 7
Which of the following is the most likely mechanism causing a relative excess of
hormone leading to the breast enlargement in this patient?
/A. Decreased production of testosterone secondary to primary hypogonadism
/B. Drug that inhibits testosterone synthesis
/C. Drug with estrogen-Iike activity
/D. Increased peripheral conversion of androgens to estrogens
/E. Increased production of estrogen by a cancer
Explanation - Q: 3.4
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Question 6 of 7
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The normal male breast differs from the normal female breast in which of the
following ways?
/A. Adipose tissue is absent
/B. Dermis is absent
/C. Ductal tissue is absent
/D. Lobular tissue is absent
/E. Muscle is absent
Explanation - Q: 3.7
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The correct answer is D. The normal male breast (and the male breast with
gynecomastia), unlike the normal female breast, lacks lobular tissue. Both
male and female breasts contain ductal tissue (choice C), adipose tissue
(choice A), dermis (choice B), and small amounts of smooth muscle tissue
(choice E).
What percentage of breast masses are discovered by the patient, rather than by
mammography or physician examination of the breasts?
/A. 5%
/B. 20%
/C. 50%
/D. 80%
/E. 95%
Explanation - Q: 1.1
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The correct answer is D. Breast cancer accounts for the greatest number of
new cancer cases in women each year. Mammography is the screening
method used to detect subclinical breast cancer-the stage at which breast
cancer is least likely to have spread, but about 80% of breast masses are
discovered initially by the patient, which it is why it is important to continue to
stress breast self-examination.
Question 2 of 5
While about 75% of the lymphatic fluid from the breast drains first to the axilla,
most of the remaining lymphatic fluid drains first to which of the
following groups of lymph nodes?
/A. Anterior internal thoracic nodes
/B. Internal inferior thoracic nodes
/C. Lateral intercostal nodes
/D. Superior mediastinal nodes
/E. Tracheobronchial nodes
Explanation - Q: 1.2
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The correct answer is A. The anterior internal thoracic nodes, also known as
the internal mammary nodes, are a pair of chained lymph nodes running
superiorly to inferiorly along the chest wall near both sides of the sternum.
They are inaccessible for surgical removal during mastectomy, but may
contain metastatic breast cancer. Rarely, the lateral intercostal nodes (choice
C) may contain metastatic breast cancer.
The inferior internal thoracic nodes (choice B) drain the liver and diaphragm.
The superior mediastinal nodes (choice D) drain the trachea, esophagus, and
heart.
The tracheobronchial nodes (choice E) drain the lung.
Question 3 of 5
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The correct answer is A. The anterior internal thoracic nodes, also known as
the internal mammary nodes, are a pair of chained lymph nodes running
superiorly to inferiorly along the chest wall near both sides of the sternum.
They are inaccessible for surgical removal during mastectomy, but may
contain metastatic breast cancer. Rarely, the lateral intercostal nodes (choice
C) may contain metastatic breast cancer.
The inferior internal thoracic nodes (choice B) drain the liver and diaphragm.
The superior mediastinal nodes (choice D) drain the trachea, esophagus, and
heart.
The tracheobronchial nodes (choice E) drain the lung.
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Question 3 of 5
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not need any medicine, all l need is bedrest." This statement is most consistent
with which of the following responses to illness?
/A. Acceptance
/B. Anger
/C. Bargaining
/D. Denial
/E. Grieving
Explanation - Q: 1.5
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Histological examination of diagnostic tissue from this patient would reveal which
of the following?
/A. A classic cribriform pattern with neoplastic epithelial cells
/B. Cystically dilated ducts plus stromal fibrosis
/C. Irregular steatocytes and intervening necrotic material and inflammatory
cells
/D. Lobular hypertrophy
/E. Proliferating ducts and stromal cells
Explanation - Q: 2.2
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/E.
Phyllodes tumor
Explanation - Q: 2.3
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If the patient were instead found to have an aggressive breast carcinoma with a
poor prognosis, the Kubler-Ross model predicts that she will
go through which of the following stages?
/A. Acceptance, anger, ambivalence, deniaI, depression
/B. BIues, depression, psychosis, treatment, resolution
/C. DeniaI, anger, bargaining, depression, acceptance
/D. DeniaI, anger, psychosis, homicide, suicide
/E. Realization, infantilization, socialization, condemnation
Explanation - Q: 2.4
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