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Question 1
Incorrect
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A 34 year old woman from the Indian origin presents to the clinic with a diffuse swelling of the left breast. She has a baby boy, four months old. On examination, she has jaundice and her left breast shows erythema. Which of the following options is the most likely?
Your Answer: Invasive ductal carcinoma
Correct Answer: Inflammatory carcinoma
Explanation:Inflammatory breast cancer is a rare form of advanced, invasive carcinoma, characterized by dermal lymphatic invasion of tumour cells. Most commonly a ductal carcinoma.
Clinical features include erythematous and oedematous (peau d’orange) skin plaques over a rapidly growing breast mass. Tenderness, burning sensation, blood-tinged nipple discharge. Axillary lymphadenopathy is usually present. 25% of patients have metastatic disease at the time of presentation.
Differential diagnosis includes mastitis, breast abscess, Paget disease of the breast
Treatment is usually done with chemotherapy + radiotherapy + radical mastectomy. This type of cancer is usually associated with a poor prognosis. 5-year survival with treatment: ∼ 50% (without treatment: < 5%) -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 2
Incorrect
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A 30-year-old male presents to the clinic with a recurrent thyroid cyst. It has been drained on three different occasions. Each time the cyst is aspirated and cytology is reassuring. What is the most appropriate course of action?
Your Answer:
Correct Answer: Resection of the ipsilateral thyroid lobe
Explanation:Aspiration is the treatment of choice in thyroid cysts, but the recurrence rates are high (60%–90% of patients), particularly with repeated aspirations and large-volume cysts.
Percutaneous ethanol injection (PEI) has been studied in several large randomized controlled studies, with reported success in 82–85% of the cases after an average of 2 sessions, with a volume reduction of more than 85% from baseline size.
PEI may also be considered for hyperfunctioning nodules, particularly if a large fluid component is present. It has a success rate ranging from 64% to 95%, with a mean volume reduction of 66%, but recurrences are more common and the number of sessions required to achieve good response is higher (about 4 sessions per patient). PEI is a safe procedure, with the most common reported adverse effects being local pain, dysphonia, flushing, dizziness, and, rarely, recurrent laryngeal nerve damage.
Surgery, Lobectomy is also a reasonable therapy for cystic lesions, as an alternative to the previously mentioned procedures. -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 3
Incorrect
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A 37 year old woman has recently undergone a mastectomy along with axillary node clearance for an invasive ductal carcinoma. Histological analysis show a completely excised grade III lesion measuring 3.5cm. Two of the axillary nodes are significant for metastatic spread. The tumour is found to be oestrogen receptor negative. Which of the following would be the next best step in the management of this patient?
Your Answer:
Correct Answer: Administration of cytotoxic chemotherapy
Explanation:Chemotherapy is offered to patients to help downstage advanced lesions to facilitate breast conserving surgery i.e. in grade 3 tumours with axillary node metastasis.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 4
Incorrect
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An 18 year old man is admitted to the intensive care unit with severe meningococcal sepsis. He is on maximal inotropic support and a CT scan of his chest and abdomen is performed. The adrenal glands show evidence of diffuse haemorrhage. Which of the following is the best explanation?
Your Answer:
Correct Answer: Waterhouse- Friderichsen syndrome
Explanation:Answer: Waterhouse- Friderichsen syndrome
Waterhouse-Friderichsen syndrome is a condition characterized by the abrupt onset of fever, petechiae, arthralgia, weakness, and myalgias, followed by acute haemorrhagic necrosis of the adrenal glands and severe cardiovascular dysfunction. The syndrome is most often associated with meningococcal septicaemia but may occur as a complication of sepsis caused by other organisms, including certain streptococcal species. This disorder may be associated with a history of splenectomy.
Fulminant infection from meningococcal bacteria in the bloodstream is a medical emergency and requires emergent treatment with vasopressors, fluid resuscitation, and appropriate antibiotics. Benzylpenicillin was once the drug of choice with chloramphenicol as a good alternative in allergic patients. Ceftriaxone is an antibiotic commonly employed today. Hydrocortisone can sometimes reverse the adrenal insufficiency. Amputations, reconstructive surgery, and tissue grafting are sometimes needed as a result of tissue necrosis (typically of the extremities) caused by the infection.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 5
Incorrect
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A 29-year-old lady who is a known case of Graves' disease presents with a relapse on stopping the antithyroid drugs. Radioiodine is offered as the next treatment by the endocrinologists.
Which of the following statements regarding such treatment is false?Your Answer:
Correct Answer: It increases the risk of parathyroid carcinoma
Explanation:All of the listed options are true regarding radioiodine therapy, except for the first option. Treatment with radioiodine does not increase the risk of parathyroid carcinoma.
Recurrence of Graves’ disease is treated similar to normal Graves’ disease. However, some patients may need definitive treatment with radioiodine or thyroidectomy. These patients are usually hypothyroid post treatment and are treated with L-thyroxine until their TSH values are within normal parameters.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 6
Incorrect
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A 59 year old woman presents to the hospital with a 2.1cm mobile breast mass. A mammogram is indeterminate (M3), an ultrasound scan shows benign changes (U2), and clinical examination is also indeterminate (P3). What is the next best course of action?
Your Answer:
Correct Answer: Image guided core biopsy
Explanation:Image guided core biopsy (US-directed biopsy) is performed for lesions that are palpable, but also for non-palpable, mammogram-detected lesions with a corresponding abnormality visualized on US. US-guided core biopsy is technically easier than stereotactic-guided biopsy as real-time imaging allows the surgeon to visualize the biopsy as it occurs. Using sterile technique and local anaesthesia, a small puncture is made with an 11-knife blade and the needle is placed near the edge of the lesion and fired, which inserts it into the lesion for a sample to be retrieved. When placed parallel to the needle the position of the needle can be visualized on US.
If the core biopsy result is benign and is concordant with imaging findings, continued surveillance is acceptable. If the result is indeterminate or image-discordant, surgical excision is indicated to rule out malignancy. In order to determine the appropriate management and surveillance of a lesion, the histologic, imaging, and clinical findings must be taken into account for an assessment of concordance to be performed. In addition, surgical excision is indicated for a core biopsy that demonstrates atypical hyperplasia (lobular or ductal) or lobular carcinoma in situ or neoplasia as the incidence of coexisting ductal carcinoma in situ or invasive carcinoma may be as high as 30% due to potential sampling error.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 7
Incorrect
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A 39 year old lady presents with a mass in the upper outer quadrant of her left breast. Imaging, histology and clinical examination confirm a 1.4cm malignant mass lesion with no clinical evidence of axillary nodal disease. Which treatment would be the most appropriate?
Your Answer:
Correct Answer: Wide local excision and sentinel node biopsy
Explanation:Sentinel lymph node biopsy has become the gold standard for axillary staging for patients with clinically and radiologically node negative axilla. The recommended technique is the dual technique of blue dye/radioisotope and this is associated with high sentinel node identification rates (> 95 %). However, in centres where radioisotope is not available, blue dye guided four node sampling appears to be a reasonable alternative. Sentinel node biopsy was shown to be an accurate technique for axillary node staging in the ALMANAC Trial with less associated morbidity and strong health economic arguments for its use.
The tumour in this patient is small so a wide local excision should be done.
Lumpectomy or breast wide local excision is a surgical removal of a discrete portion or lump of breast tissue, usually in the treatment of a malignant tumour or breast cancer. It is considered a viable breast conservation therapy, as the amount of tissue removed is limited compared to a full-breast mastectomy, and thus may have physical and emotional advantages over more disfiguring treatment. Sometimes a lumpectomy may be used to either confirm or rule out that cancer has actually been detected. A lumpectomy is usually recommended to patients whose cancer has been detected early and who do not have enlarged tumours. -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 8
Incorrect
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A 66 year old retired judge has recently undergone a wide local excision and sentinel lymph node biopsy for breast cancer. Which of the factors listed below will provide the most important prognostic information?
Your Answer:
Correct Answer: Nodal status
Explanation:Even in the era of gene-expression profiling, the nodal status still remains the primary prognostic discriminant in breast cancer patients. The exclusion of node involvement using non-invasive methods could reduce the rate of axillary surgery, thereby preventing from suffering complications.
Lymph node status is highly related to prognosis (chances for survival).
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 9
Incorrect
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A 39 year old man presents to the clinic with a headache. His blood pressure is found to be 175/110 on routine screening. Examination shows no abnormalities. However, further investigations show a left-sided adrenal mass on CT. Labs reveal an elevated plasma level of metanephrines. Which of the following would be the most likely cause of this presentation?
Your Answer:
Correct Answer: Pheochromocytoma
Explanation:Hypertension in a young patient without any obvious cause should be investigated.
A pheochromocytoma is a catecholamine-secreting tumour typically located in the adrenal medulla. Pheochromocytomas are usually benign (∼ 90% of cases) but may also be malignant. Classic clinical features are due to excess sympathetic nervous system stimulation and involve episodic blood pressure crises with paroxysmal headaches, diaphoresis, heart palpitations, and pallor. However, a pheochromocytoma may also present asymptomatically or with persistent hypertension. Elevated catecholamine metabolites in the plasma or urine confirm the diagnosis, while imaging studies in patients with positive biochemistry are used to determine the location of the tumour. Surgical resection is the treatment of choice, but is only carried out once alpha blockade with phenoxybenzamine has become effective.
Pheochromocytoma is said to follow a 10% rule:
,10% are extra-adrenal
,10% are bilateral
,10% are malignant
,10% are found in children
,10% are familial
,10% are not associated with hypertension
,10% contain calcification -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 10
Incorrect
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A 19 year old female presents with a firm mobile mass in the upper outer quadrant of her left breast. Which of the following could be the underlying disease process?
Your Answer:
Correct Answer: Fibroadenoma
Explanation:A fibroadenoma is a painless, unilateral, benign (non-cancerous) breast tumour that is a solid, not fluid-filled, lump. It occurs most commonly in women between the age of 14 to 35 years but can be found at any age. Fibroadenomas shrink after menopause, and therefore, are less common in post-menopausal women. Fibroadenomas are often referred to as a breast mouse due to their high mobility. Fibroadenomas are a marble-like mass comprising both epithelial and stromal tissues located under the skin of the breast. These firm, rubbery masses with regular borders are often variable in size.
Duct ectasia, also known as mammary duct ectasia, is a benign (non-cancerous) breast condition that occurs when a milk duct in the breast widens and its walls thicken. This can cause the duct to become blocked and lead to fluid build-up. It’s more common in women who are getting close to menopause. But it can happen after menopause, too.
Fat necrosis is a benign condition and does not increase the risk of developing breast cancer. It can occur anywhere in the breast and can affect women of any age. Men can also get fat necrosis, but this is very rare.
Breast cysts are a benign condition. They’re one of the most common causes of a breast lump, and can develop in either one or both breasts. It’s thought they develop naturally as the breast changes with age due to normal changes in hormone levels. It’s common to have more than one cyst. Breast cysts can feel soft or hard and can be any size, ranging from a few millimetres to several centimetres. They’re usually oval or round in shape and can develop quickly.
Atypical hyperplasia is a precancerous condition that affects cells in the breast. Atypical hyperplasia describes an accumulation of abnormal cells in the breast.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 11
Incorrect
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A 35 year old woman with uncontrolled hypertension presents with a thyroid nodule. Family history is significant for total thyroidectomies of both sisters. Which of the following would be the most likely underlying pathology of her thyroid lesion?
Your Answer:
Correct Answer: Medullary thyroid cancer
Explanation:Multiple endocrine neoplasia type 2 (MEN2) is a hereditary condition associated with 3 primary types of tumours: medullary thyroid cancer, parathyroid tumours, and pheochromocytoma. MEN2 is classified into subtypes based on clinical features. Virtually all patients with classical MEN2A develop medullary thyroid carcinoma (MTC), which is often the first manifestation of the disease and usually occurs early in life. Pheochromocytomas (PHEOs) tend to be diagnosed several years later or simultaneously with the MTC.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 12
Incorrect
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A 40 year old female presents to her family doctor with a goitre. On examination, the goitre feels 'lumpy'. Blood tests done show a TSH of 12 and a free T4 of 2 and her antithyroid peroxidase antibodies are high. Which of the following is the most likely cause?
Your Answer:
Correct Answer: Hashimoto's
Explanation:Hashimoto thyroiditis is part of the spectrum of autoimmune thyroid diseases (AITDs) and is characterized by the destruction of thyroid cells by various cell- and antibody-mediated immune processes.
The thyroid gland may become firm, large, and lobulated in Hashimoto’s thyroiditis, but changes in the thyroid can also be nonpalpable. Enlargement of the thyroid is due to lymphocytic infiltration and fibrosis, rather than tissue hypertrophy.Laboratory studies and potential results for patients with suspected Hashimoto thyroiditis include the following:
– Serum thyroid-stimulating hormone (TSH) levels: Sensitive test of thyroid function; levels are invariably raised in hypothyroidism due to Hashimoto thyroiditis and in primary hypothyroidism from any cause
– Free T4 levels: Needed to correctly interpret the TSH in some clinical settings; low total T4 or free T4 level in the presence of an elevated TSH level further confirms diagnosis of primary hypothyroidism
– T3 levels: Low T3 level and high reverse T3 level may aid in the diagnosis of nonthyroidal illnessThyroid autoantibodies: Presence of typically anti-TPO (anti-thyroid peroxidase) and anti-Tg (anti-thyroglobulin) antibodies delineates the cause of hypothyroidism as Hashimoto thyroiditis or its variant; however, 10-15% of patients with Hashimoto thyroiditis may be antibody negative.
While their role in the initial destruction of the follicles is unclear, antibodies against thyroid peroxidase (TPO) (also called TPOAb) or thyroglobulin are relevant, as they serve as markers for detecting the disease and its severity. They are hypothesized to be the secondary products of the T cell mediated destruction of the gland. -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 13
Incorrect
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A 41 year old woman presents with discomfort in her left breast. On examination, she has a discrete, soft, fluctuant area in the upper outer quadrant of her left breast. A halo sign is observed on the mammogram. What is the most likely explanation for this process?
Your Answer:
Correct Answer: Breast cyst
Explanation:A breast cyst is a fluid-filled sac within the breast. They are often described as round or oval lumps with distinct edges. In texture, a breast cyst usually feels like a soft grape or a water-filled balloon, but can also feel firm.
Breast cysts can be painful and may be worrisome but are generally benign. They are most common in pre-menopausal women in their 30s or 40s. They usually disappear after menopause, but may persist or reappear when using hormone therapy. They are also common in adolescents. Breast cysts can be part of fibrocystic disease. The pain and swelling is usually worse in the second half of the menstrual cycle or during pregnancy.
The halo sign, described as a complete or partial radiolucent ring surrounding the periphery of a breast mass, has long been considered a mammographic sign indicating a benign process. The phenomenon is most frequently seen with cysts and fibroadenomas.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 14
Incorrect
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A 30-year-old female presents with a painless lump in the upper outer quadrant of her left breast. Ultrasound is indeterminate (U3). Two core biopsies show normal breast tissue (B1). What is the most appropriate course of action?
Your Answer:
Correct Answer: Undertake an excision biopsy of the lump
Explanation:Discrete masses graded P3 or R3/M3 or U3 and above should be triple assessed using core biopsy rather than FNAC unless core biopsy is not feasible.
When cytology or biopsy has been reported as C1 or B1 it will require a further biopsy to delineate the pathology in most instances.
The exceptions are when the lesion is suspected to be a lipoma or hamartoma following imaging and discussion. Following triple assessment, if there is non-concordance by more than one grade then further biopsy and or investigations should be undertaken.
In this case, Excisional biopsy is the next required biopsy to delineate the pathology. -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 15
Incorrect
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A 21-year-old woman presents with an episode of greenish discharge from the left nipple. Clinical examination of the breast is normal. Her breast USS report is U1 (normal).
What should be the best course of action?Your Answer:
Correct Answer: Reassure and discharge
Explanation:This is likely to be a case of simple duct ectasia. Normal USS report coupled with normal examination would favour discharge from the clinic. Mammography is generally not helpful in this age group.
Possible causes of nipple discharge include:
1. Abscess
2. Birth control pills
3. Breast cancer
4. Ductal carcinoma in situ (DCIS)
5. Endocrine disorders
6. Excessive breast stimulation
7. Fibrocystic breasts (lumpy or rope-like breast tissue)
8. Galactorrhoea
9. Injury or trauma to the breast
10. Intraductal papilloma (benign, wart-like growth in a milk duct)
11. Mammary duct ectasia
12. Mastitis (an infection in breast tissue that most commonly affects women who are breast-feeding)
13. Medication use
14. Menstrual cycle hormone changes
15. Paget’s disease of the breast
16. Periductal mastitis
17. Pregnancy and breast-feeding
18. ProlactinomaAssessment and management of non-malignant nipple discharge includes:
1. Exclude endocrine disease
2. Nipple cytology is not carried out as it would be unhelpful
3. Smoking cessation advice given for duct ectasia
4. Total duct excision may be warranted for duct ectasia with severe symptoms -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 16
Incorrect
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A 34 year old woman underwent a wide local excision for her breast carcinoma. Histology reveals an invasive lobular carcinoma present at three of the resection margins. Cavity shavings that were taken at the original operation are also involved. The sentinel lymph node biopsy was reported to be negative. Which of the following management plans would be the most appropriate for this patient?
Your Answer:
Correct Answer: Arrange for completion mastectomy alone
Explanation:Mastectomy should ideally be done in this patient. This patient has extensive spread of disease and tumour margins are unclear which makes radiotherapy the less likely option. Mastectomy is the safest option in this scenario. Patients who have undergone mastectomy may be offered a reconstructive procedure either in conjunction with their primary resection or as a staged procedure at a later date.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 17
Incorrect
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A 30 year old clerk who has had recurrent episodes of periductal mastitis presents to the hospital with persistent green nipple discharge. Clinical examination reveals green nipple discharge, but no discrete lump. Her medical history shows that she has received multiple courses of antibiotics. Imaging with mammography and ultrasound is reassuring (U2, M2). Which of the following is the most appropriate course of action?
Your Answer:
Correct Answer: Undertake a Hadfields procedure
Explanation:Duct ectasia is the cause of nipple discharge, with different percentages recorded in different articles (>10%, >30% and >50%). Duct ectasia differs from cystic disease since it is an inflammatory process, usually affecting the ducts below the nipple. It develops gradually, either through the ductal system or the breast lobes. The acute inflammation may be caused by epithelial rupture and diffusion of the contents into the fibrous duct-wall and the underlying structures. These contents consist of neutral fat and lipid crystals that are typical of duct ectasia. The chronic granulation-type reaction may develop foreign body-like giant cells and a multiform inflammatory cell population. Since the whole process in duct ectasia is long in duration, plasma cells are sometimes dominant in the inflammatory infiltrations. Other findings in duct ectasia include the following:
-Serous or green-white nipple discharge in 20% of cases;
-Nipple inversion that leads to fibrosis and development of ring or tubular calcification (this finding is typical in the mammogram and especially when the disease is in its advanced stages);
-Apocrine metaplasia with or without epithelial hyperplasia. The epithelial layer consists of widened atrophic cells.
The condition may be managed symptomatically and/or with antibiotics, but in persistent or recurrent cases it is managed with surgical excision of the ducts below the nipple. A focused excision is preferred to a complete subareolar excision since the later technique is associated with higher rates of seroma formation, nipple numbness and nipple inversion. The Hadfield’s procedure (major duct excision) is an option. -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 18
Incorrect
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A 56 year old female is placed on Tamoxifen for the treatment of ER-positive breast cancer. Which malignancy is associated with Tamoxifen use?
Your Answer:
Correct Answer: Endometrial cancer
Explanation:A meta-analysis found that there was a twofold increase in the risk of endometrial cancer following extended versus standard adjuvant tamoxifen therapy in patients with breast cancer.
The systematic review of four randomized controlled trials showed that the absolute risk of endometrial cancer in patients receiving adjuvant tamoxifen for 10 years was 3.2% compared with 1.5% in patients receiving 5-year standard therapy (cumulative risk ratio [RR] 2.29, 1.60 to 3.28, P<0.001).
The breast cancer treatment tamoxifen (sometimes called by its brand name, Nolvadex) increases the risk of developing endometrial cancer, but not nearly enough to outweigh its benefits against breast cancer in most women. This risk occurs because of the way tamoxifen works: Even as it acts against the growth-promoting effects of the female hormone oestrogen in breast tissue, it acts like an oestrogen in other tissues, such as the bones and the uterus. This can be good news for the bones because oestrogen helps preserve bone density, but it may slightly increase the risk of cancer in the uterus. According to the American Cancer Society, the risk of developing endometrial cancer from tamoxifen is about 1 in 500 — a small risk, but higher than that for women in the general population. Tamoxifen also slightly increases the risk of uterine sarcoma, a cancer that begins in the muscle of the uterine wall.Tamoxifen belongs to a class of medications known as selective oestrogen response modifiers (SERMs). Another SERM called Fareston (chemical name: toremifene) has been found to increase the risk of endometrial hyperplasia, or the overgrowth of cells lining the uterus. Hyperplasia itself is not cancer but can sometimes develop into cancer. Evista (chemical name: raloxifene), another SERM used to lower the risk of breast cancer in high-risk women, does not have oestrogen-like effects on the uterus and does not increase endometrial cancer risk.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 19
Incorrect
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A 62 year old retired teacher is diagnosed as having a malignant lesion in the inferior aspect of her left breast. On examination, there is palpable axillary lymphadenopathy. Which of the following is the best course of action?
Your Answer:
Correct Answer: Image guided fine needle aspiration of the axillary nodes
Explanation:Fine-needle aspiration (FNA) cytology of axillary lymph nodes is a simple, minimally invasive technique that can be used to improve preoperative determination of the status of the axillary lymph nodes in patients with breast cancer, thereby serving as a tool with which to triage patients for sentinel versus full lymph node dissection procedures. FNA of axillary lymph nodes is a sensitive and very specific method with which to detect metastasis in breast cancer patients. Because of its excellent positive predictive value, full axillary lymph node dissection can be planned safely instead of a sentinel lymph node dissection when a preoperative positive FNA result is rendered.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 20
Incorrect
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A 30-year-old female presents with a breast lump. She has previously undergone a breast augmentation with an implant. What is the imaging technique of choice?
Your Answer:
Correct Answer: Ultrasound
Explanation:Patients with breast implants present the radiologist with specific challenges, such as the identification and distinction of implant and breast tissue, diagnosis of implant defects and implant-related complications as well as diagnosis and follow-up of unrelated breast diseases such as mastitis or breast cancer.
Whereas mammography is the first-line method before surgery, ultrasound is the mainstay of post-procedural imaging, unless there is concern about rupture.
Although mammography and ultrasonography are the standard first steps in the diagnostic workup, magnetic resonance imaging (MRI) is the most useful imaging modality for the characterisation of breast implants because of its high spatial resolution and contrast between implants and soft tissues and absence of ionising radiation. -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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