Practice questions I Pathology of breast

Practice question

Pathology of breast I

© Jun Wang, MD, PhD

1. Use this case for the next three questions. A 22-year-old woman presents with left breast pain for 2 days. She delivered a normal boy 3 months ago and is currently breast feeding him. Her past medical history is unremarkable. Her mother was diagnosed with invasive ductal carcinoma at age of 49. Physical examination reveals a tender left breast with erythematous and edematous changes at inner lower quadrant. No discrete mass is noted. A small crack is seen at her left nipple. A few small left axillary lymph nodes are noted. Laboratory tests and radiologic examinations are unremarkable. What are the most likely pathological findings if biopsy is performed?

A. Atypical cells forming single files

B. Calcifications

C. Diffuse infiltrate of neutrophils

D. Finger likely projects covered by normal appearing epithelium

E. Irregular glands infiltrating stroma

2. A 22-year-old woman presents with left breast pain for 2 days. She delivered a normal boy 3 months ago and is currently breast feeding him. Her past medical history is unremarkable. Her mother was diagnosed with invasive ductal carcinoma at age of 49. Physical examination reveals a tender left breast with erythematous and edematous changes at inner lower quadrant. No discrete mass is noted. A small crack is seen at her left nipple. A few small left axillary lymph nodes are noted. Laboratory tests and radiologic examinations are unremarkable. What is the most likely associated with her condition?

A. Bacterial infection

B. BRCA mutation

C. Glucose intolerance

D. High level of testosterone

E. Unopposed estrogen effects

3. A 22-year-old woman presents with left breast pain for 2 days. She delivered a normal boy 3 months ago and is currently breast feeding him. Her past medical history is unremarkable. Her mother was diagnosed with invasive ductal carcinoma at age of 49. Physical examination reveals a tender left breast with erythematous and edematous changes at inner lower quadrant. No discrete mass is noted. A small crack is seen at her left nipple. A few small left axillary lymph nodes are noted. Laboratory tests and radiologic examinations are unremarkable. What is the most likely diagnosis?

A. Acute mastitis

B. Inflammatory carcinoma

C. Invasive ductal carcinoma

D. Invasive lobular carcinoma

E. Papilloma

4. Use this case for the next two questions. A 35-year-old woman presents with painless lump at her left breast for 2 months. She has a history of type I diabetes since age 15, and was diagnosed with cervical high-grade dysplasia 6 months ago. She smokes cigarette one pack a day for 15 years and drinks wine one glass a day for 10 years. Physical examination reveals a 1.5 cm firm subareola mass. No other abnormalities are seen. Core biopsy of the mass reveal dense lymphocytic infiltration surrounding normal appearing ducts in a fibrotic background. No cytological atypia is seen. What is the most likely diagnosis?

A. Acute mastitis

B. Ductal ectasia

C. Fibroadenoma

D. Lymphocytic mastopathy

E. Small lymphocytic lymphoma

5. A 35-year-old nulliparous woman presents with painless lump at her left breast for 2 months. She has a history of type I diabetes since age 15, and was diagnosed with cervical high-grade dysplasia 6 months ago. She smokes cigarette one pack a day for 15 years and drinks wine one glass a day for 10 years. Physical examination reveals a 1.5 cm firm subareola mass. No other abnormalities are seen. Core biopsy of the mass reveal dense periductal lymphocytic infiltration in a fibrotic background. No cytological atypia is seen. What in her history is most likely associated with her breast mass?

A. Alcohol usage

B. Cigarette smoking

C. HPV infection

D. Nulliparous status

E. Type I diabetes

6. A 33-year-old woman presents with painful retroareolar mass and bloody nipple discharge for 1 week. Her past medical history is unremarkable. She smokes cigarette 1 pack a day for 7 years. She denies alcohol or other illicit drug use. Biopsy reveals a few dilated ducts lined by flat to cuboid cells in a background fibrosis. The dilated ducts contains foamy macrophages and proteinaceous debris. A few lymphocytes are seen within the surrounding stroma. No cytological atypia is noted. What is the diagnosis?

A. Ductal ectasia

B. Fat necrosis

C. Intraductal papilloma

D. Lobular carcinoma in situ

E. Lymphocytic mastopathy

7. A 67-year-old woman presents with a painless mass at her right breast for 1 week. She had a history of invasive ductal carcinoma of right breast and was treated with lumpectomy and radiation therapy 6 months ago. Physical examination reveal a 3.5 cm irregular firm mass underneath the lumpectomy scar with surface erythematous changes and focal ulceration. Biopsy reveals solid nests of slightly atypical cells with foamy cytoplasm. Multinucleated giant cells are seen. No keratin positive epithelial cells are noted per immunohistochemistry studies. What is the diagnosis?

A. Angiosarcoma

B. Ductal ectasia

C. Fat necrosis

D. Intraductal papilloma

E. Inflammatory carcinoma

8.  A 26-year-old woman presents with a painful left breast mass for 1 month. She denies any history of nipple discharge or fever. She has a history of acute mastitis 1 year ago, 1 month after she delivered her last child. Her past medical is otherwise unremarkable. Her mother was diagnosed with breast cancer at age of 51 and was treated with lumpectomy and radiation therapy. She does not smoke cigarette or drink alcohol. Physical examination reveal a 5 cm firm irregular mass at the upper outer quadrant of left breast, with erythematous skin changes. A fistula with purulent exudates is seen at the center of the erythematous area. Biopsy of the mass reveal diffuse lymphoplasmacytic infiltrate with scattered multinucleated giant cells. Immunohistochemistry studies reveal a mix T-cell and B-cell population. No atypical epithelial cells nor foamy macrophages are seen. Special stains reveal no evidence of microorganism. What is the diagnosis?

A. Acid fast bacilli infection

B. Fat necrosis

C. Idiopathic granulomatous mastitis

D. Inflammatory carcinoma

E. Zuska’s disease

9. A 48-year-old woman presents with bilateral breast pain for 3 months. The pain was cyclical. She has a history of right fibroadenoma 10 years ago that was treated with surgery. She does not have nipple discharge. Her past medical history is otherwise unremarkable. She has a family of multiple female members with breast, ovarian or endometrial tumors. Physical examination reveals multiple nodular growth in both breasts. No axillary lymphadenopathy nor skin abnormalities are noted. Mammographic exam reveals foci of architectural distortion and microcalcifications. Biopsy reveals cystically dilated ducts in a fibrotic background. Focally there are clusters of small ducts. The ducts are lined by single layer of benign appearing epithelial cells. No cytological atypia is noted. Calcification is seen in association with proteinaceous duct contents. What is the diagnosis?

A. Ductal hyperplasia

B. Fibrocystic changes

C. Intraductal papilloma

D. Invasive ductal carcinoma

E. Lymphocytic mastopathy

10. A 25-year-old man presents with painless left retroareolar mass for 3 months. His past medical history is unremarkable. Physical examination reveal a 1.5 cm well demarcated firm mass. Core biopsy reveal a few slightly irregular ducts lined by a single layer of ductal cells in a fibrotic background. No cytological atypia is noted. What is the diagnosis?

A. Ductal ectasia

B. Gynecomastia

C. Invasive ductal carcinoma

D. Invasive lobular carcinoma

E. Tubular carcinoma

11. Use this case for the next two questions. A 45-year-old woman presents with mammographic findings of left breast architectural distortion. Her past history is unremarkable. Stereotactic biopsy reveals foci of slightly dilated ducts that are almost completely filled with mildly atypical ductal cells. Irregular spaces are seen at periphery. There is no evidence of necrosis. Immunohistochemistry studies reveals positive reactivity to keratin 903 and E-cadherin. CD10 stain highlights intact myoepithelial layers. What is the diagnosis?

A. Atypical ductal hyperplasia

B. Ductal carcinoma in situ

C. Fibrocystic changes

D. Invasive lobular carcinoma

E. Usual ductal hyperplasia

12. A 45-year-old woman presents with mammographic findings of left breast architectural distortion. Her past history is unremarkable. Stereotactic biopsy reveals foci of slightly dilated ducts that are almost completely filled with mildly atypical ductal cells. Irregular spaces are seen at periphery. There is no evidence of necrosis. Immunohistochemistry studies reveals positive reactivity to keratin 903 and E-cadherin. CD10 stain highlights intact myoepithelial layers. What is the next step of management?

A. Excisional biopsy

B. Hormonal therapy

C. Mastectomy

D. No treatment needed

E. Radiation therapy

13. Use this case for the next two questions.  A 28-year-old woman presents with a left breast lump for 2 months. Her past medical history is unremarkable. She has multiple female family members with breast, ovarian and endometrial cancers. Physical examination reveals a 1.5 cm mobile firm mass at the upper outer quadrant. No axillary lymphadenopathy is noted. Radiological examination reveals foci of microcalcification within the mass. Core biopsy reveals a few dilated ducts that are filled with relatively monotonous ductal cells. Round spaces are seen between these ductal cells. Per immunohistochemistry studies, these cells are positive for E-cadherin and negative for keratin 903. CD10 stain reveals positive reactivity at the periphery of these ducts. What is the diagnosis?

A. Atypical ductal hyperplasia

B. Fibrocystic changes

C. Invasive ductal carcinoma

D. Invasive lobular carcinoma

E. Usual ductal hyperplasia

14. A 28-year-old woman presents with a left breast lump for 2 months. Her past medical history is unremarkable. She has multiple female family members with breast, ovarian and endometrial cancers. Physical examination reveals a 1.5 cm mobile firm mass at the upper outer quadrant. No axillary lymphadenopathy is noted. Radiological examination reveals foci of microcalcification within the mass. Core biopsy reveals a few dilated ducts that are filled with relatively monotonous ductal cells. Round spaces are seen between these ductal cells. Per immunohistochemistry studies, these cells are positive for E-cadherin and negative for keratin 903. CD10 stain reveals positive reactivity at the periphery of these ducts. What is the next step of management?

A. Excisional biopsy

B. Hormonal therapy

C. Lumpectomy with axillary lymph node dissection

D. No treatment needed

E. Radiation therapy

15. A 48-year-old woman presents with abnormal mammographic findings of focal microcalcification in her left breast. She a history of polycystic ovary disease. Her history is otherwise unremarkable. Stereotactic biopsy reveal a few ducts that are completely filled with relatively monotonous small to intermediate sized cells with round to oval nuclei. Per immunohistochemistry studies, these cells are positive for E-cadherin and negative for keratin 903. CD10 stain reveals positive reactivity at the periphery of these ducts. What is the diagnosis?

A. Atypical ductal hyperplasia

B. Fibrocystic changes

C. Invasive ductal carcinoma

D. Lobular carcinoma in situ

E. Usual ductal hyperplasia

16. Use this case for the next two questions.  A 25-year-old woman presents with a right breast lump for 2 weeks. Her past medical history is unremarkable. She has a family history of breast and ovarian cancers in multiple members. Radiologic examination reveals a 1.6 cm hypoechoic area with ill-defined margins. Core biopsy reveals markedly increased number of small ducts in a vaguely nodular area with background fibrosis. Some ducts appear to be distorted. CD10 stain reveals positive reactivity at the periphery of these ducts. What is the diagnosis?

A. Fibroadenoma

B. Invasive ductal carcinoma

C. Radial scar

D. Sclerosing adenosis

E. Tubular carcinoma

17. A 25-year-old woman presents with a right breast lump for 2 weeks. Her past medical history is unremarkable. She has a family history of breast and ovarian cancers in multiple members. Radiologic examination reveals a 1.6 cm hypoechoic area with ill-defined margins. Core biopsy reveals markedly increased number of small ducts in a vaguely nodular area with background fibrosis. Some ducts appear to be distorted. CD10 stain reveals positive reactivity at the periphery of these ducts. No other abnormality is noted. What is the next step of management?

A. Excisional biopsy

B. Hormonal therapy

C. Mastectomy

D. No treatment needed

E. Radiation therapy

18. Use this case for the next two questions.  A 49-year-old woman presents with a mass at her right breast. Her past medical history and family history are unremarkable. Physical examination reveals a firm mobile mass at the upper outer quadrant of right breast, approximately 2.5 cm from the nipple. No abnormality is noted on the skin and nipple. No axillary lymphadenopathy is noted. Radiological examination reveals a 2.5 cm mildly hypoechoic mass with poorly defined margins and associated architectural distortion and microcalcification. Core biopsy reveals a central fibrotic area with narrow ducts extending outwards. These ducts are lined by flat to cuboidal cells without cytological atypia. No other abnormality is noted. CD10 stain reveals positive reactivity at the periphery of these ducts. What is the diagnosis?

A. Fibroadenoma

B. Invasive ductal carcinoma

C. Radial scar

D. Sclerosing adenosis

E. Tubular carcinoma

19.  A 49-year-old woman presents with a mass at her right breast. Her past medical history and family history are unremarkable. Physical examination reveals a firm mobile mass at the upper outer quadrant of right breast, approximately 2.5 cm from the nipple. No abnormality is noted on the skin and nipple. No axillary lymphadenopathy is noted. Radiological examination reveals a 2.5 cm mildly hypoechoic mass with poorly defined margins and associated architectural distortion and microcalcification. Core biopsy reveals a central fibrotic area with narrow ducts extending outwards. These ducts are lined by flat to cuboidal cells without cytological atypia. No other abnormality is noted. CD10 stain reveals positive reactivity at the periphery of these ducts. What is the next step of management?

A. Excisional biopsy

B. Hormonal therapy

C. Lumpectomy with axillary lymph node dissection

D. No treatment needed

E. Radiation therapy

20. Use this case for the next two questions.  A 45-year-old woman presents with bloody nipple discharge for a week. Her past medical history, family history and physical examination are unremarkable. Sonographic examination reveals a 2 mm retroareolar solid nodule within a dilated duct. Core biopsy reveal a dilated duct containing an intraductal finger like growth with a fibrovascular core covered by two layers of cells. The cells have round to oval nuclei. No significant cytological atypia or necrosis are seen. No other abnormalities are noted. CD10 stain reveals positive reactivity at the periphery of these ducts. What is the diagnosis?

A. Fibrocystic changes

B. Intraductal papilloma

C. Lobular carcinoma in situ

D. Papillary carcinoma

E. Sclerosing adenosis

21. A 45-year-old woman presents with bloody nipple discharge for a week. Her past medical history, family history and physical examination are unremarkable. Sonographic examination reveals a 2 mm retroareolar solid nodule within a dilated duct. Core biopsy reveal a dilated duct containing an intraductal finger like growth with a fibrovascular core covered by two layers of cells. The cells have round to oval nuclei. No significant cytological atypia or necrosis are seen. No other abnormalities are noted. CD10 stain reveals positive reactivity at the periphery of these ducts. What is the next step of management?

A. Excisional biopsy

B. Hormonal therapy

C. Lumpectomy with axillary lymph node dissection

D. No treatment needed

E. Radiation therapy

Answers

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