Practice question Pathology of breast II

Practice question

Pathology of breast II

© Jun Wang, MD, PhD

1. Use this case for the next two questions. A 42-year-old woman presents with a pruritic rash on her left nipple for 2 weeks. She has a history of type 2 diabetes and multiple skin melanomas. Physical examination reveals a 0.3 ulcerated area of the left nipple in a background of eczematous changes. No palpable breast mass or axillary lymphadenopathy is identified. Biopsy of the nipple reveals scattered large atypical cells with pale cytoplasm and enlarged irregular hyperchromic nuclei in the epidermis. Scattered neutrophils and lymphocytes are seen at the dermal epidermal junction. Per immunohistochemistry studies, these large pale cells are positive for cytokeratin, but negative for S-100. Special stain reveals no evidence of fungal hyphae. What is the diagnosis?

A. Contact dermatitis

B. Dermatophytosis

C. Melanoma in situ

D. Mycosis fungoides

E. Paget’s disease

2. A 42-year-old woman presents with a pruritic rash on her left nipple for 2 weeks. She has a history of type 2 diabetes and multiple skin melanomas. Physical examination reveals a 0.3 ulcerated area of the left nipple in a background of eczematous changes. No palpable breast mass or axillary lymphadenopathy is identified. Biopsy of the nipple reveals scattered large atypical cells with pale cytoplasm and enlarged irregular hyperchromic nuclei in the epidermis. Scattered neutrophils and lymphocytes are seen at the dermal epidermal junction. Per immunohistochemistry studies, these large pale cells are positive for cytokeratin, but negative for S-100. Special stain reveals no evidence of fungal hyphae. What is the cause of these findings?

A. Abnormal insulin activity

B. Allergic reaction

C. Fungal infection

D. Underlying breast malignancy

E. UV light

3. Use this case for the next two questions. A 43-year-old woman presents with microcalcifications identified by mammogram screening. Her past medical history is unremarkable. Physical examination reveals no abnormalities. Stereotactic biopsy reveals dilated ducts filled with relatively monomorphic cells forming round to oval spaces. These cells have slightly enlarged nuclei.  Microcalcification is seen within these ducts. No necrosis nor mitosis is noted. P63 stain reveals positive reactivity at the periphery of these ducts. The lesion is at least 1 cm in greatest dimension. What is the diagnosis?

A. Atypical ductal hyperplasia

B. Ductal carcinoma in situ

C. Invasive ductal carcinoma

D. Lobular carcinoma in situ

E. Mucinous carcinoma

4. A 43-year-old woman presents with microcalcifications identified by mammogram screening. Her past medical history is unremarkable. Physical examination reveals no abnormalities. Stereotactic biopsy reveals dilated ducts filled with relatively monomorphic cells forming round to oval spaces. These cells have slightly enlarged nuclei.  Microcalcification is seen within these ducts. No necrosis nor mitosis is noted. P63 stain reveals positive reactivity at the periphery of these ducts. The lesion is at least 1 cm in greatest dimension. What additional marker is likely to be expressed by these cells?

A. E-cadherin

B. Her2

C. Keratin 903

D. p53

5. A 37-year-old woman presents with a right breast nodule identified by self-exam. She denies other symptoms. She has a family history of breast and ovarian cancers in the maternal side. Physical examination reveals a 2.5 cm mobile mass at the upper outer quadrant. Biopsy reveals markedly dilated ducts filled with markedly atypical cells. Central necrosis is noted. Focally the ductal contours are irregular. Per immunohistochemistry studies, these cells are positive for E-cadherin, but negative for estrogen receptor. P63 stain reveals positive reactivity at the periphery of these ducts. What is the diagnosis?

A. Atypical ductal hyperplasia

B. Ductal carcinoma in situ

C. Invasive ductal carcinoma

D. Lobular carcinoma in situ

E. Mucinous carcinoma

6. A 44-year-old woman presents with a firm right breast mass. She has a history of diabetes and obesity. Her family history reveals multiple members with colon and lung cancers. Physical examination reveals a firm mobile mass at the outer lower quadrant. Radiologic examination reveals a 1.5 cm retroareolar mass with calcification. Biopsy reveal a few dilated ducts with complex finger like projects almost occupied the entire lumen. These projects have fibrovascular cores that are covered by atypical cells with slightly enlarged hyperchromic nuclei. Mitosis is seen. Per immunohistochemistry studies, these cells are positive for E-cadherin but negative for keratin 903. P63 stain reveals positive reactivity at the periphery of these ducts. What is the diagnosis?

A. Atypical ductal hyperplasia

B. Ductal carcinoma in situ

C. Intraductal papilloma

D. Invasive papillary carcinoma

E. Lobular carcinoma in situ

7. Use this case for the next two questions. A 42-year-old woman presents with painful nodules of both breast for a year. The pain is cyclical. Her past medical history is unremarkable. Mammographic examination reveals foci of increased density with associated microcalcification. Biopsy reveals cystically dilated ducts lined by flat epithelial cells with small round nuclei in a fibrotic background. Calcification is associated with cyst contents. Focally there are dilated solid glandular structures filled with small, monotonous loosely cohesive cells. No significant cytological atypia is noted. Per immunohistochemistry studies, these small monotonous cells are focally positive for keratin 903, and negative for E-cadherin. What is the diagnosis?

A. Atypical ductal hyperplasia

B. Ductal carcinoma in situ

C. Lobular carcinoma in situ

D. Medullary carcinoma

E. Usual ductal hyperplasia

8. A 42-year-old woman presents with painful nodules of both breast for a year. The pain is cyclical. Her past medical history is unremarkable. Mammographic examination reveals foci of increased density with associated microcalcification. Biopsy reveals cystically dilated ducts lined by flat epithelial cells with small round nuclei in a fibrotic background. Calcification is associated with cyst contents. Focally there are dilated solid glandular structures filled with small, monotonous loosely cohesive cells. No significant cytological atypia is noted. Per immunohistochemistry studies, these small monotonous cells are focally positive for keratin 903, and negative for E-cadherin. What is the next step for management?

A. Excisional biopsy

B. Lumpectomy with axillary lymph node dissection

C. Mastectomy

D. Observation

E. Radiation therapy

9. Use this case for the next two questions. A 55-year-old woman presents with left breast mass for a month. She has a history of lung adenocarcinoma 5 years ago that was treated with surgery and chemotherapy. She smoked cigarette 1 pack a day for 30 year until she was diagnosed with lung cancer. She does not drink alcohol. Physical examination reveals a firm fixed mass at the lower inner quadrant. Biopsy reveals irregularly distributed glands in a fibrotic background, some are in mature adipose tissue. These glands are lined by slightly atypical cells. No necrosis is noted. Per immunohistochemistry studies, these cells are positive for E-cadherin and negative for TTF-1. What is the diagnosis?

A. Atypical ductal hyperplasia

B. Ductal carcinoma in situ

C. Invasive ductal carcinoma

D. Invasive lobular carcinoma

E. Metastatic adenocarcinoma of lung

10. A 55-year-old woman presents with left breast mass for a month. She has a history of lung adenocarcinoma 5 years ago that was treated with surgery and chemotherapy. She smoked cigarette 1 pack a day for 30 year until she was diagnosed with lung cancer. She does not drink alcohol. Physical examination reveals a firm fixed mass at the lower inner quadrant. Biopsy reveals irregularly distributed glands in a fibrotic background, some are in mature adipose tissue. These glands are lined by slightly atypical cells. No necrosis is noted. Per immunohistochemistry studies, these cells are positive for E-cadherin and negative for TTF-1. What is the most likely marker status for this lesion?

A. ER negative, Her2 negative

B. ER negative, Her2 positive

C. ER positive, Her2 negative

D. ER positive, Her2 positive

11. Use this case for the next two questions. A 57-year-old woman presents with a left breast mass for three months. Her past medical history is unremarkable. Physical examination reveals a firm fixed mass at the upper outer quadrant. Biopsy reveals irregularly distributed glands in a fibrotic background, some are in mature adipose tissue. These glands are lined by atypical cells with enlarged nuclei that are markedly different in size, shape and chromatin pattern. Solid cords and brisk mitosis are seen. What is the diagnosis?

A. Atypical ductal hyperplasia

B. Ductal carcinoma in situ

C. Invasive ductal carcinoma

D. Invasive lobular carcinoma

E. Papillary carcinoma

12. A 57-year-old woman presents with a left breast mass for three months. Her past medical history is unremarkable. Physical examination reveals a firm fixed mass at the upper outer quadrant. Biopsy reveals irregularly distributed glands in a fibrotic background, some are in mature adipose tissue. These glands are lined by atypical cells with enlarged nuclei that are markedly different in size, shape and chromatin pattern. Solid cords and brisk mitosis are seen. What is the most likely marker status for this lesion?

A. ER negative, Her2 negative

B. ER negative, Her2 positive

C. ER positive, Her2 negative

D. ER positive, Her2 positive

13. A 62-year-old woman presents with a right breast mass for one month. Her past medical history and family history are unremarkable. Physical examination reveals a 3 cm firm mass at the upper outer quadrant. No axillary lymphadenopathy is noted. Biopsy reveals cords and nests of markedly atypical cells infiltrating a fibrotic stroma and adipose tissue. Per immunohistochemistry studies, these cells are strongly positive for E-cadherin and Her2, but negative for ER. BRCA mutation studies are negative. What should be included for her management, besides local surgery?

A. Endocrine therapy

B. Follow up if the margin is clear

C. Herceptin

D. Prophylactic contralateral mastectomy

E. Radiation therapy

14. Use this case for the next two questions. A 74-year-old woman presents with a painless left breast mass for 2 months. She has a history of atypical ductal hyperplasia with subsequent biopsy reveals no evidence of malignancy 10 years ago. She was diagnosed with chronic lymphocytic leukemia 5 years ago. Physical examination reveals a poorly circumscribed mass in the upper outer quadrant. Radiologic examination reveals a 1.5 cm mass without microcalcification. Stereotactic biopsy reveals a few mildly dilated ducts lined by two layers of ductal cells. No significant cytological atypia is noted. In the background connective tissue there are slightly enlarged cells with round to oval nuclei lined in single lines. No tubular structures are seen. Per immunohistochemistry studies, these cells are positive for cytokeratin and negative for CD45. What is the most likely diagnosis?

A. Atypical ductal hyperplasia

B. Invasive ductal carcinoma

C. Invasive lobular carcinoma

D. Medullary carcinoma

E. Small lymphocytic lymphoma

15. A 74-year-old woman presents with a painless left breast mass for 2 months. She has a history of atypical ductal hyperplasia with subsequent biopsy reveals no evidence of malignancy 10 years ago. She was diagnosed with chronic lymphocytic leukemia 5 years ago. Physical examination reveals a poorly circumscribed mass in the upper outer quadrant. Radiologic examination reveals a 1.5 cm mass without microcalcification. Stereotactic biopsy reveals a few mildly dilated ducts lined by two layers of ductal cells. No significant cytological atypia is noted. In the background connective tissue there are slightly enlarged cells with round to oval nuclei in single lines. No tubular structures are seen. Per immunohistochemistry studies, these cells are positive for cytokeratin and negative for CD45. Mutation of what gene is likely associated with these findings?

A. BRCA1

B. CDH1

C. Her2

D. p53

E. ZAP70

16. A 54-year-old woman presents with itchy swollen left breast for 1 day. She has type II diabetes for 15 years. Her family history is positive for breast and ovarian cancers. Physical examination reveals widespread dermal edema of the left breast. There is an ill-defined firm area in the subareolar region. A few enlarged left axillary lymph nodes are noted. Biopsy of the area reveals dilated vessels containing large atypical cells. These atypical cells are positive for cytokeratin and Her2. What is the diagnosis?

A. Acute mastitis

B. Dermatophytosis

C. Diabetic mastopathy

D. Inflammatory carcinoma

E. Lymphangiosarcoma

17. Use this case for the next three questions. A 51-year-old woman presents with a right breast lump for 4 months. She has a history of follicular lymphoma of neck 6 years ago. Her family history is significant for multiple breast and ovarian cancers diagnosed at young age. Physical examination reveals a well-circumscribed mobile soft mass in the upper outer quadrant. No abnormalities are noted in nipple and axillary region. Biopsy of the mass reveals irregular cords and sheets of markedly atypical cells in a background of diffuse lymphoplasmacytic infiltrate. Many mitosis are seen. These atypical cells are positive for cytokeratin but negative for CD45. No light chain restriction is identified. What is the most likely diagnosis?

A. Diffuse large B cell lymphoma

B. Follicular lymphoma

C. Invasive ductal carcinoma

D. Lymphocytic mastopathy

E. Medullary carcinoma

18. A 51-year-old woman presents with a right breast lump for 4 months. She has a history of follicular lymphoma of neck 6 years ago. Her family history is significant for multiple breast and ovarian cancers diagnosed at young age. Physical examination reveals a well-circumscribed mobile soft mass in the upper outer quadrant. No abnormalities are noted in nipple and axillary region. Biopsy of the mass reveals irregular cords and sheets of markedly atypical cells in a background of diffuse lymphoplasmacytic infiltrate. Many mitosis are seen. These atypical cells are positive for cytokeratin but negative for CD45. No light chain restriction is identified. What is the most likely ancillary test results?

A. ER negative, Her2 negative

B. ER negative, Her2 positive

C. ER positive, Her2 negative

D. ER positive, Her2 positive

19. A 51-year-old woman presents with a right breast lump for 4 months. She has a history of follicular lymphoma of neck 6 years ago. Her family history is significant for multiple breast and ovarian cancers diagnosed at young age. Physical examination reveals a well-circumscribed mobile soft mass in the upper outer quadrant. No abnormalities are noted in nipple and axillary region. Biopsy of the mass reveals irregular cords and sheets of markedly atypical cells in a background of diffuse lymphoplasmacytic infiltrate. Many mitosis are seen. These atypical cells are positive for cytokeratin but negative for CD45. No light chain restriction is identified. Abnormality of what gene is likely to be associated with these findings?

A. Bcl2

B. BRCA1

C. CDH1

D. Her2

E. MLL2

20. A 55-year-old woman presents with a large left breast ulcer for 5 months. She lives in a remote area and never saw a physician for the past 30 years. Her family history is unremarkable. Physical examination reveals a 2.5 cm ulcer at the upper outer quadrant with a firm 4 cm mass underneath. A few enlarged lymph nodes are noted in the left axilla. Biopsy of the mass reveals compact growth of complex finger-like structures with a fibrovascular core that are covered by atypical cells with markedly pleomorphic nuclei. Necrosis and hemorrhage are seen. Negative reactivity to p63 and CD10 is noted at many foci. What is the diagnosis?

A. Intraductal papilloma

B. Invasive ductal carcinoma

C. Invasive lobular carcinoma

D. Papillary carcinoma

E. Zuska disease

21. A 61-year-old woman presents with newly identified left breast mass for 2 weeks. She has a history of bilateral breast fibrocystic changes and has been routinely followed up. Her family history is unremarkable. Physical examination reveals a 2 cm mass at the upper outer quadrant. No other abnormality is noted. Core biopsy reveal majority of the specimen are mucous like material. A few clusters of slightly atypical cells are seen in the center of these material. What is the most likely diagnosis?

A. Benign cyst

B. Ductal ectasia

C. Ductal carcinoma in situ

D. Invasive micropapillary carcinoma

E. Mucinous carcinoma

22. A 35-year-old woman presents with a left breast lump for 3 months. Her past medical history and family history are unremarkable. Physical examination reveals a soft mass in the lower inner quadrant. Biopsy reveals many singly atypical cells with large intracellular vacuole that pushes the enlarged nuclear to on end of the cells. Some of these atypical cells form a single line. No ductal differentiation is seen. No mucin pool is noted. What is the diagnosis?

A. Invasive ductal carcinoma

B. Lobular carcinoma in situ

C. Mucinous carcinoma

D. Papillary carcinoma

E. Signet ring cell carcinoma

23. A 22-year-old woman presents with left breast lump for 1 month. She has a family history of breast, endometrial and ovarian cancers. Her own past medical history is unremarkable. Physical examination reveals a firm mobile mass within the upper outer quadrant. Sonographic examination reveals a 1.5 cm well circumscribed mass. The lesion was resected and grossly it is a sharply demarcated firm mass with regular border and bulging trabecular cut surfaces. No necrosis or hemorrhage are noted. Microscopically it is composed predominantly by fibrous tissue with scattered spindle cells. There are stretched ducts lined by two layers of flat to low-cuboidal cells. No significant cytological atypia is noted. What is the diagnosis?

A. Atypical ductal hyperplasia

B. Fibroadenoma

C. Fibrocystic changes

D. Invasive ductal carcinoma

E. Phyllodes tumor

24. A 49-year-old woman presents with a firm left breast mass for 8 months. The mass has been growing in the last two months. Her past medical history and family history are unremarkable. Physical examination reveals an irregular firm mass in the upper outer quadrant. No skin changes nor axillary lymphadenopathy are noted. Sonographic examination reveals a well demarcated lobulated mass. No microcalcification is noted. A core biopsy reveals hypercellular stroma packed with atypical spindle cells. A few ducts lined by slightly atypical ductal cells are seen. What is the most likely diagnosis?

A. Fibroadenoma

B. Fibrocystic changes

C. Invasive papillary carcinoma

D. Phyllodes tumor

E. Usual ductal hyperplasia

Answers

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