Breast Surgery

Question 1
A 35 year old lady presents with painless bleeding from her left nipple over the past 2 days. No
mass can be palpated on the breast. There are no skin changes of the breast. What is the SINGLE
most likely diagnosis?

A. Duct ectasia
B. Paget’s disease
C. Intraductal papilloma
D. Nipple abscess
E. Fat necrosis
Answer
Intraductal papilloma

Explanation
Intraductal papilloma is a benign breast condition and the most common cause of bloody nipple
discharge in women. Although cancer is a concern with bloody nipple discharge, the cause is
usually a benign Intraductal papilloma. A papilloma is a growth a bit like a wart. These can grow
inside the ducts of the breast, often near the nipple. The masses are often too small to be
palpated. They do not show up on a mammogram due to their small size. A galactogram is
therefore necessary to rule out the lesion.

The other options are less likely to be the answer.

Duct Ectasia –> is suggested by a green or brown nipple discharge

Paget’s disease of nipple –> is suggested by breast nipple ‘eczema’. The lesion begins in the
nipple and may spread to the areola and then the skin of the breast. It is a rare condition, most
commonly diagnosed in women over 50.

Nipple abscess –> is suggested with a painful collection of pus forming in the breast tissue or
around the nipple, usually as a result of bacterial infection

Fat necrosis –> is suggested by a firm and solitary localized lump usually with a history of
trauma.
Question 2
A 67 year old woman presents with a firm, round, painless 5cm lump in her right breast. She has
a bruise on the surface and there is no discharge. What is the SINGLE most likely diagnosis?

A. Fat necrosis
B. Fibroadenoma
C. Fibroadenosis
D. Duct ectasia
E. Breast cancer
Answer
Fat necrosis

Explanation
Fat necrosis feels like a firm, round lump (or lumps) and is usually painless, but in some people
it may feel tender or even painful. The skin around the lump may look red, bruised or
occasionally dimpled. Like in this question, there was a bruise noticed on the surface.
Occasionally fat necrosis can cause the nipple to be pulled in (retracted). Sometimes within an
area of fat necrosis cysts containing an oily fluid can occur.

Fat necrosis –> is suggested by a firm and solitary localized lump usually with a history of
trauma.

Fibroadenoma –> is suggested by a smooth and mobile lump (‘breast mouse’), usually in ages
15-30 years old. They are sometimes described as “breast mice” because they can easily move
around within the breast.

Fibroadnosis (or fibrocystic disease) –> is the most common cause of breast lumps in women of
reproductive age. The peak incidence is between 35 and 50 years of age. It is a term used to
describe a group of benign conditions that affect the breast. The symptoms of fibroadenosis
include breast pain (mastalgia or mastodynia), increase in breast size and lumpiness of the breast
(nodularity), particularly just before or during a period.

Duct Ectasia –> is suggested by a green or brown nipple discharge

Breast Cancer –> is suggested by fixed, irregular, hard, painless lump, nipple retraction, fixed
to skin (peau d’orange) or muscle and local, hard or firm, fixed nodes in axilla.

Reference:

Oxford Handbook of Clinical Diagnosis 3rd Edition page 106

https://breastcancernow.org/about-breast-cancer/breast-lumps-and-benign-not-cancer-breast-
conditions/fat-necrosis/

https://www.nhs.uk/conditions/breast-lump/

Benign breast disease

Question 3
A 64 year old woman has been treated for breast cancer with tamoxifen. What SINGLE
medication should be added to her regime?

A. Bisphosphonates
B. Calcium
C. Vitamin D
D. Calcitonin
E. Phosphate binders
Answer
Bisphosphonates

Explanation
There is actually no guideline that says any of the above medication should be started as an
adjuvant to her regime. However, given the choices provided, bisphosphonates is probably the
best choice as it is shown in some studies to reduce the risk of bone metastasis in breast cancers.
Question 4
A 26 year old woman has breast tenderness for the past 3 months. It occurs on both sides of the
breast equally. She has been taking combined oral contraceptives for the past 18 months. She
notices it worsen a few days before her menstrual cycle starts and it resolves after her menstrual
cycle finishes. She feels generalized swelling throughout both breasts. On examination, there are
no palpable lumps and skin discolouration. What is the SINGLE most appropriate action?

A. Advice to take primrose oil

B. Advice for a better-fitting bra during the day
C. Advice on the consumption of vitamin E
D. Stop combined oral contraceptives for a duration of 3 months and restart again
E. Stop combined oral contraceptives and start progestogen-only contraceptives
Answer
Advice for a better-fitting bra during the day

Explanation
This stem describes cyclical mastalgia. Treatment options include a better-fitting bra during the
day and a soft support bra at night. Oral paracetamol, ibuprofen or topical NSAIDs can also be
used to manage cyclical mastalgia.

There is no evidence to support using primrose oil or vitamin E for the management of cyclical
breast pain. NICE CKS (2016) suggest not to routinely recommend changing or stopping
combined oral contraception.

Further reading:

https://cks.nice.org.uk/topics/breast-pain-cyclical/management/management/

Cyclical vs noncyclical mastalgia

Question 5
A 39 year old smoker has a thick creamy brown discharge coming from her left nipple. It has
been on going for the past two weeks. She has been experiencing left breast pain for the past few
months. On examination, there is a palpable subareolar mass with nipple retraction on her left
breast. There are no palpable lymph nodes. Her temperature is 37.1`C. What is the SINGLE most
likely diagnosis?

A. Breast abscess
B. Fibroadenoma
C. Duct ectasia
D. Duct papilloma
E. Ductal fistula
Answer
Duct ectasia

Explanation
Duct ectasia refers to dilatation of the large and intermediate breast ducts and it is suggested by a
green or brown nipple discharge. The subareolar mammary ducts become chronically inflamed,
dilated and scarred. The first clue given is that she is a smoker. Duct ectasia is associated with
smoking.

The other options in this question are less likely.

Breast abscess –> is suggested by a fluctuant lump, hot and tender, acute presentation often in
puerperium, chronic after antibiotics.

Fibroadenomas –> firm, non-tender, highly mobile palpable lumps which are usually painless

Duct papilloma –> is suggested by bleeding from nipple

Ductal fistula (Mammillary fistula) –> is an abnormal communication between a mammary

duct and the skin surface, usually near the areola is suggested by discharge from para-areolar
region.

Further reading:

https://patient.info/doctor/mammary-duct-ectasia-and-periductal-mastitis

https://gpnotebook.com/pages/surgery/mammary-duct-ectasia

Benign breast disease

Question 6
A 35 year old woman presents to her GP’s office with the complaint of a lump in her left breast.
She first noticed the mass two weeks ago in the shower and the patient says that she has not
noticed whether the mass appears and disappears with the occurrence of her menses. The
patient’s past medical history was insignificant and she claims that she is on no long term
medication. Further questioning reveals that the patient has no further complaints of night
sweats, weight loss or a fever and this is the first breast mass that she has noticed. She has no
family history of breast cancer. On physical examination, it was revealed that a 2.5 cm by 1.5 cm
mass is present in the left lower quadrant of her left breast. The mass was regular and firm in
consistency and was non-tender and mobile. The skin over her left nipple appeared to be normal
and no discharge from her left nipple could be appreciated. The rest of the breast examination
was unremarkable with no enlarged lymph nodes palpated in her neck or axillary region.
Examination of her right breast was unremarkable. Fine needle aspiration cytology (FNAC) was
subsequently done. The results show duct-like epithelium surrounded by fibrous bridging. What
is the SINGLE most likely diagnosis?

A. Fibroadenoma
B. Fibroadenosis
C. Breast cancer
D. Fat necrosis
E. Sclerosing adenosis
Answer
Fibroadenoma

Explanation
Fibroadenoma are the most common type of breast lesion in young women. Although this
women is not very young, based on her past medical history, family history and examination
results, a fibroadenoma is the single most likely diagnosis for her.

Fibroadenomas arise in breast lobules and are composed of fibrous and epithelial tissue. They
present as firm, non-tender and highly mobile masses. The woman in this scenario has the
classical picture of a fibroadenoma.

Fibroadnosis can present as a breast lump too or sometimes pain in the breast. Fibroadenosis is
not the answer because the biopsy of fibroadenosis reveals fibrosis, adenosis, epitheliosis and
cyst formation.

Breast cancinoma is the most common cause of a breast mass in postmenopausal patients. In
malignancy, there is an abundant pure population of tumour cells, singly and in clusters.

Further reading:

https://patient.info/doctor/benign-breast-disease

Fibroadenomas

Benign breast disease

Question 7
A 50 year old woman who was treated for breast cancer 3 years ago now presents with increased
thirst and confusion. She has recently become very drowsy. She complains of left shoulder pain
for the past few months. She has a blood test which has recently been reported as abnormal.
What is the SINGLE most likely metabolic abnormality?

A. Hypercalcaemia
B. Hyperkalaemia
C. Hypoglycaemia
D. Hyperglycaemia
E. Hypocalcaemia
Answer
Hypercalcaemia

Explanation
The most common causes of hyercalcaemia are malignancy and primary hyperparathyroidism. In
this scenario, breast cancer has metastasis to the bone. Bone metastases are one of most common
causes of hypercalcaemia.

This is a hot topic in the exam and you should be able to associate breast cancer with bone
metastases and hypercalcaemia.

Note: If in this question they were to ask about management of hypercalcaemia, intravenous
saline would be the correct answer. The first step in management in hypercalcaemia is always
rehydration with IV fluids.

Clinical features

Mnemonic: “moans, stones, groans and bones”.

 Neuro and psych: Hypercalcemia results in decreased mental activity leading to lethargy,
confusion and depression. (Groans)
 Gastrointestinal: Hypercalcemia results in decreased bowel activity such as constipation.
(Moans)
 Renal: Hypercalcemia results in polyuria and polydispsia because of the induction of
nephrogenic diabetes insipidus. Calcium also precipitates in the kidney, resulting in both
kidney stones as well as nephrolithiasis. (Stones)
 Bone pain is only seen when it is hyperparathyroidism which is causing hypercalcaemia
(Bones)
 Cardiovascular: The ECG shows a short QT

Hypercalcaemia
Question 8
A 29 year old woman has breast tenderness for the past 3 months. It occurs on both sides of the
breast but worse on the left side. She notices it worsen a few days before her menstrual cycle
starts and it resolves after her menstrual cycle finishes. She feels generalized swelling throughout
both breasts. On examination, there are no palpable lumps. What is the SINGLE most
appropriate action?

A. Advice to take primrose oil

B. Advice to wear a supportive bra
C. Prescribe gabapentin
D. Prescribe amitriptyline
E. Prescribe pyridoxine
Answer
Advice to wear a supportive bra

Explanation
This stem describes cyclical mastalgia.

Wearing a supportive bra like a sports bra can often help with cyclical mastalgia.

There is no evidence for pyridoxine or primrose oil in the management of cyclical breast pain.

Gabapentine and amitriptyline is used for neuropathic pain which is occasionally seen in non-
cyclical mastalgia.

Refers to Cyclical vs noncyclical mastalgia

Question 9
A 24 year old woman presents with a 1 cm small smooth, firm, mobile mass in her left breast.
The mass is tender. She is very anxious and wants a form of investigation. What is the SINGLE
most appropriate initial investigation to perform?

A. Mammography
B. Ultrasound scan of breast
C. Fine needle aspiration cytology
D. Excision biopsy
E. Punch biopsy
Answer
Ultrasound scan of breast

Explanation
Generally, for a woman younger than 40 years old, an ultrasound scan is the preferred
radiological assessment. This is because young women have increased tissue density which
reduces sensitivity and specificity of a mammography.

Further reading:

https://associationofbreastsurgery.org.uk/media/1416/best-practice-diagnostic-guidelines-for-
patients-presenting-with-breast-symptoms.pdf

Oxford Handbook of Clinical Surgery 4th Edition page 241

Benign breast disease

Question 10
A 27 year old woman visits the general practitioner for a routine annual examination. She has
had a lump in her breast for two years but has not sought any medical advice. The mass has
remained the same size for the past two years. On examination, the mass is located on the right
upper outer quadrant and it felt as a firm 3cm by 2 cm mass. It is non-tender and mobile. What is
the SINGLE most likely diagnosis?

A. Fat necrosis
B. Atypical hyperplasia
C. Phyllodes tumor
D. Cyclical mastalgia
E. Fibroadenoma
Answer
Fibroadenoma

Explanation
The fact that the size has not changed and the mass is mobile in a young woman is very
reassuring. Fibroadenomas are the most common benign breast tumour in young woman of this
age.

Fibroadenomas

Benign breast disease

Question 11
A 35 year old woman presents with complaints of persistent nipple discharge from her left
breast. The discharge is non-bloody and occasionally milky in appearance.. she reports that the
discharge occurs spontaneously and is not related to breast manipulation or stimulation. On
physical examination, there is no palpable breast mass or lymphadenopathy. No skin changes or
nipple retraction are noted. Based on the clinical presentation, what is the most likely diagnosis?

A. Duct ectasia
B. Mammillary duct fistula
C. Intraductal papilloma
D. Fibroystic changes
E. Breast abscess
Answer
Mammillary duct fistula

Explanation
The patient’s complaint of persistent nipple discharge, which is non-bloody and occasionally
milky, along with the absence of palpable breast mass, lymphadenopathy, skin changes, or nipple
retraction, is consistent with a mammillary duct fistula.

A mammillary duct fistula is an abnormal connection between the lactiferous ducts of the breast
and the skin surface, resulting in spontaneous nipple discharge. It is typically non- purulent and
can be associated with milky or serous fluid.

The other options are incorrect.

Duct ectasia is a condition characterized by dilation and inflammation of the subareolar ducts
which can present with nipple discharge, but it often includes other clinical features such as
nipple retraction and skin changes. The discharge is typically thick, sticky and may appear
greenish or brownish in colour.

Intraductal papilloma can cause nipple discharge, but it is usually accompanied by a palpable
mass.

Fibrocystic changes can lead to nipple discharge, but it is typically bilateral and may present with
breast nodularity.

Breast abscess is characterized by localized pain, swelling, erythema and fever which are not
present in this case.
Question 12
A 37 year old woman had a right mastectomy with removal of axillary lymph nodes for a
primary breast angiosarcoma 7 years ago. She also received chemotherapy and radiotherapy for
her cancer. She presents to the breast clinic with a new development of purple coloured nodules
on her right chest that she noticed 6 weeks ago. She has noticed enlargement of the nodule
together with a discolouration surrounding it over the past few weeks. Clinical examination
shows an irregular purple nodule with surrounding ring-shaped purple-blue pigmentation with
indistinct borders. The diameter of the nodule is 0.9 by 1.1 cm. A biopsy was taken. What is the
SINGLE most likely tissue diagnosis?

A. Melanoma
B. Angiosarcoma
C. Lymphoma
D. Lipoma
E. Basal cell carcinoma
Answer
Angiosarcoma

Explanation
The history of angiosarcoma would put a recurrence very high on the list of differentials. The
features of a purple discolouration surrounding a nodule are suggestive of angiosarcoma.

Nodular melanoma is another consideration but in general they are dome-shaped, symmetrical
and firm. Nodular melanomas do NOT present with the typical ABCDE criteria that melanomas
often present with.

ABCDE criteria –> (Asymmetry, Border irregularity, Colour irregularity, Diameter ≥ 7 mm,
Evolving over time).
Question 13
A 28 year old woman presents to the breast clinic after having noticed a lump in the left breast
which has been present for one month. On examination, there are 2 smooth, regular, firm, mobile
lumps on the upper outer quadrant of the left breast. Both lumps are non-tender and measure 2
cm by 2 cm. Her last menstrual period was 2 weeks ago. Her mother had breast cancer. What is
the SINGLE most likely diagnosis?

A. Sclerosing adenosis
B. Intraductal papilloma
C. Breast cancer
D. Cyclical mastalgia
E. Fibroadenoma
Answer
Fibroadenoma

Explanation
Fibroadenomas are the most common breast tumours and found especially in young women.

A history of breast cancer in the family is a risk factor for breast malignancy, however, this
breast lump has no features of malignancy.

Refers to Fibroadenomas

Benign breast disease

Question 14
A 50 year old man had surgery to remove cancer in his left breast. The mass was removed
successfully surgically with safety margins, no penetration and no lymph node metastasis. What
is the best adjunctive therapy to give?

A. Radiotherapy
B. Bisphosphonates
C. Tamoxifen
D. Letrozole
E. No further treatment
Answer
Tamoxifen

Explanation
Not every question in the exam is written well and so we wanted to represent the level of the
exam by writing sub-par questions, too. This is one of the sub-par leveled questions (or perhaps
even lower than sub-par) that our PLABABLE team decided to write. We occasionally do this on
purpose so you have the same feeling of confusion when you do our question bank.

We think that this is one of the most unfair questions that you encounter for a couple of reasons:

1. The mass size was not mentioned and that is a crucial and deciding factor in planning the
proper adjuvant therapy following surgery.
2. The type of surgery was not mentioned. Was it a lumpectomy (breast-conserving surgery)
or modified radical mastectomy?
3. The receptor status was not mentioned. Was ER, PR and HER2 status positive in this
patient? These are predictive factors which help tailor the adjuvant therapy plan.

Deciding to give adjuvant therapy not only requires a specialist decision but this kind of
treatment is planned by a multi-disciplinary team of different specialties and with the aid of
guidelines and specific tools.

What is adjuvant therapy?

Adjuvant therapy is treatment given after an operation where cancer cells are no longer visible
and the surgeon removed all cancer at the time of the operation to eliminate any cancer cells that
might be left behind. This includes radiation therapy, chemotherapy, hormone therapy and
targeted therapy after surgery.

NICE guidelines states that radiotherapy can be omitted if:

1. Breast- conserving surgery for invasive breast cancer was done with clear margins
2. Very low absolute risk of local recurrence
3. Adjuvant endocrine therapy (e.g. tamoxifen) for a minimum of 5 years

Most breast cancers in men (around 9 in 10) are “oestrogen receptor positive”, which means the
cancer cells need oestrogen to grow. Tamoxifen would be beneficial and recommended for breast
cancer in men who are oestrogen receptor positive (ER positive) taking into consideration the
side effects such as hot flashes and impotence. Although the ER status is not mentioned here,
most of us would pick tamoxifen since 9 out of 10 men would have positive ER receptors in the
breast cancer tissue.

Letrozole is an aromatase inhibitor mainly used to treat hormone-responsive breast cancer in

postmenopausal women.

Bisphosphonates as adjuvant therapy are offered to postmenopausal women with positive lymph
node metastatic invasive breast cancer, or negative lymph node metastasis with a high risk of
recurrence.

Further reading:

https://www.nice.org.uk/guidance/ng101

https://breast.predict.nhs.uk/tool

https://www.cancer.org/cancer/types/breast-cancer-in-men/treating/by-stage.html

https://www.nice.org.uk/guidance/ng101/chapter/recommendations#radiotherapy

https://cancer.gov/types/breast/patient/male-breast-treatment-pdq#_2469
Question 15
A 31 year old woman has undergone a removal of a 4 cm breast lump on the upper outer
quadrant of her left breast. The histology report states:

“Well circumscribed and unencapsulated with clear margins and separate from the surrounding
fatty tissue. There are overgrowths of fibrous and glandular tissue. There is a small degree of
stromal cellularity and overgrowth”

What is the SINGLE most likely interpretation of this report?

A. Fibroadenosis
B. Ductal carcinoma in situ
C. Cyclical mastalgia
D. Fibroadenoma
E. Fat necrosis
Answer
Fibroadenoma

Explanation
The histology findings are consistent with a fibroadenoma.

Refers to Fibroadenomas

Benign breast disease

Question 16
A 29 year old woman has 1.5 cm discrete tender lump on her left breast. The lump has been
present for the past 3 months. She denies any fever. She has no family history of breast cancer.
On inspection, the lump cannot be seen but a 1.5 cm lump can be palpated on the upper outer
quadrant of her left breast. There are no skin changes around the lump. Which is the most
appropriate action?

A. Request an MRI
B. Perform a fine needle aspiration cytology
C. Request an ultrasound
D. Prescribe antibiotics
E. Request a mammogram
Answer
Request an ultrasound

Explanation
Generally, for a woman younger than 40 years old, an ultrasound scan is the preferred
radiological assessment. This is because young women have increased tissue density which
reduces sensitivity and specificity of a mammography.

Further reading:

https://associationofbreastsurgery.org.uk/media/1416/best-practice-diagnostic-guidelines-for-
patients-presenting-with-breast-symptoms.pdf

Benign breast disease

Question 17
A 52 year old woman presents to her GP with a 6-month history of changes to the skin of her left
nipple. She describes the area as red, itchy and occasionally scaly. There is no discharge and she
denies any history of trauma or application of new creams or lotions. She has no pain or palpable
masses within the breast. What is the most likely diagnosis?

A. Bowen’s disease
B. Seborrheic dermatitis
C. Lichen sclerosus
D. Psoriasis
E. Paget’s disease of the breast
Answer
Paget’s disease of the breast

Explanation
Paget’s disease of the breast is a rare form of breast cancer that involves the skin of the nipple
and usually the darker circle of skin around it, known as the areola. It is commonly mistaken for
eczema. Eczema was not an option to choose from which makes it easy to answer this question.
Symptoms often include persistent redness, itching and sometimes scaling – exactly as described
in the stem.

Refers to Paget’s disease of the breast

Question 18
A 67 year old female underwent a radical mastectomy. She now comes with the complaint of
swelling and redness in her right upper limb. Which of the following structure(s) can cause these
symptoms after being removed in surgery?

A. Epitrochlear lymph node

B. Cephalic vein
C. Subclavian artery
D. Axillary lymph node
E. Long thoracic nerve
Answer
Axillary lymph node

Explanation
Axillary node clearance

Axillary node clearance increases risk of lymphedema.

The extent of axillary node clearance performed in invasive breast cancer is dependent on the
likelihood of finding involved lymph nodes. The more lymph nodes that are cleared, the higher
the risk of lymphedema. This usually presents less than a year following the operation.

Indications

 Invasive breast cancer

 Positive sentinel lymph node biopsy

Common problems associated with axillary node clearance

 Numbness around the scar and upper arm (can be permanent)

 Lymphoedema
 Seroma (fluid collection at the site of opertation)
 Frozen shoulder

Further reading:

https://www.guysandstthomas.nhs.uk/health-information

Operative surgery 2nd Edition page 156

Oxford Handbook of Clinical Surgery 4th Edition page 242

Question 19
A 53 year old woman presents to the GP surgery with a 2 cm small smooth, firm mass in her left
breast. The mass is non-tender and there is no nipple discharge or nipple retraction. She first
noticed the lump 2 weeks ago. She has no family history of breast cancer. She is a non-smoker
and does not have any medical problems. She had a mammogram 2 months ago which results
have been satisfactory. There are no associated skin changes in the breast. The lump is slightly
mobile on examination. What is the SINGLE most appropriate next step in management?

A. Refer for a repeat mammography

B. Request an ultrasound scan of the breast
C. Refer to the breast clinic for an appointment to be seen within 2 weeks
D. Refer to the breast clinic routinely
E. Reassure and reassess in 3 months
Answer
Refer to the breast clinic for an appointment to be seen within 2 weeks

Explanation
Women in the UK aged 50 to 70 years old are routinely invited for breast cancer screening
involving mammograms every 3 years.

A normal mammogram 2 months ago does not exclude a cancerous mass that presents today.
Women aged 30 years and over should be referred to the breast clinic using a suspected cancer
pathway referral (2-week wait referral) if they have an unexplained breast lump.

Once they are seen in the breast clinic, a decision for a mammogram or ultrasound would need to
be made. Ultrasounds are more suitable for younger women (under age 40) because their breast
is denser and therefore mammogram is not as effective in picking up cancer. Mammogram
would be more appropriate after age 40 or above. After imaging, either a fine-needle aspiration
cytology or core biopsy may take place.

Remember, patients with suspected breast cancer need to undergo a triple assessment:

 Clinical assessment – History and examination

 Imaging – Mammography or ultrasound (or both)
 Biopsy – Fine needle aspiration cytology (FNAC) or core biopsy

Further reading:

https://www.nice.org.uk/cks-uk-only
Question 20
A 50 year old woman presents with a unilateral sore nipple. There is itching. There is no
discharge. She has noticed changes of her nipple over the past few months. A picture of the
nipple can be seen below:

What is the SINGLE most likely diagnosis?

A. Paget’s disease of the breast

B. Melanoma of the nipple
C. Invasive ductal carcinoma
D. Nipple adenoma
E. Bowen’s disease
Answer
Paget’s disease of the breast

Explanation
This is a classic picture of Paget’s disease of the breast. It is an uncommon breast malignancy.
The lesion is pruritic and appears red and scaly often located in the nipple spreading to the
areola. The skin appearance can mimic dermatitis like eczema or psoriasis but one should always
consider Paget’s disease of the breast first before considering eczema.

Bowen’s disease which is the next most commonly picked option also presents with red, scaly
patches but the majority of the lesions are found on lower limbs usually in sun-exposed areas.

Refers to Paget’s disease of the breast

Question 21
A 32 year old female presents with intermittent pain in the upper outer quadrant of her left breast
which radiates to the axilla. The pain is described as stabbing pain. On examination, there are no
palpable lumps or palpable lymph nodes. What is the SINGLE most likely diagnosis?

A. Cyclical Mastalgia
B. Non-cyclical mastalgia
C. Fibroadenoma
D. Breast cyst
E. Mondor’s disease
Answer
Non-cyclical mastalgia

Explanation
Non-cyclical mastalgia is defined as pain that does not coincide with the menstrual cycle. It
occurs usually around 30 to 50 years of age. It is usually unilateral and localized to one part of
the breast. It is described as having a burning or stabbing pain.

While true that non-cyclical mastalgia can occasionally be caused by a fibroadenoma or cyst,
there is no lump in this stem to point us in the direction of that. Both fibroadenoma and cyst
would have a palpable lump.

As this stem tells us that the pain is intermittent and there is no mention of menstrual cycles, the
likely answer is non-cyclical mastalgia. The exam is non-cyclical mastalgia.

The exam is built for difficulty. Often question writers would omit information like the
relationship of mastalgia to menstrual cycles. If that piece of information was provided, it would
make the question too easy. Another take-home point to remember is cyclical mastalgia usually
occurs bilaterally whereas non-cyclical mastalgia is likely to be unilateral or focal.

Further reading:

https://patient.info/doctor/breast-pain-pro

Cyclical vs noncyclical mastalgia

Question 22
A 41 year old female presents to her GP concerned about the possibility of her having breast
cancer. Her family history is significant for her grandmother having passed away from breast
cancer, her mother having had a right mastectomy last year and her sister who was diagnosed
with breast cancer at age 38 who is currently in remission from breast cancer. Gene typing was
done based on her family history and the presence of the BRCA1 gene mutation was shown in
this patient. Her last mammogram was 6 months ago and was found to be normal. Examination
of the breast revealed no skin changes, no nipple changes and no masses. A 1 cm by 1 cm,
smooth and non-tender lymph node was found in her left axilla. What is the SINGLE most
appropriate next step for this patient?

A. Mammogram
B. Ultrasound of the breast
C. Sentinel node biopsy
D. Fine needle aspiration
E. Offer prophylactic mastectomy
Answer
Offer prophylactic mastectomy

Explanation
A prophylactic mastectomy might seem drastic at this stage but with her family history and
genetic mutations, she is at a very high risk of developing breast cancer. There are four instances
in which a prophylactic mastectomy of either one or both breasts should be carried out. These are
as follows:

 Strong family history of breast cancer

 Presence of inherited mutations in one of two breast cancer susceptibility genes (BRCA1
and BRCA2)
 Previous cancer in one breast
 Biopsies showing lobular carcinoma in situ and/or atypical hyperplasia of the breast

As we can see from the scenario, this patient ticks two out of the four boxes. The next best step
for her would be a referral to a surgeon for prophylactic mastectomy.

Women in the UK aged 50 to 70 years old are routinely invited for breast cancer screening
involving mammograms every 3 years. In cases like this patient where there is a BRCA1
mutation, a mammogram would be offered annually from ages 40 to 69. Since she just had it 6
months ago, it is not the right answer. The NHS takes breast cancer risk very seriously, and
would take precautionary steps such as organizing MRI scans of the breast annually as well as
mammograms for those who have a BRCA1 mutation.

An ultrasound of the breast is used in cases in which a breast lump is found during examination
of the breast.

A sentinel node biopsy is done for the staging of cancers. The sentinel lymph node is the first
lymph node or group of lymph nodes that drain a cancer site.

Fine needle aspiration is done if a lump was found during breast examination. It is done after an
ultrasound of the breast.

Remember, prophylactic bilateral mastectomies and prophylactic bilateral oophorectomies can

be offered in cases in which the patient has a strong family history of cancer and has genetic
markers for the cancer.

Further reading:

https://www.nice.org.uk/cks-uk-only#!scenario
https://www.nice.org.uk/cks-uk-only#!scenario

https://www.nice.org.uk/cks-uk-only#!scenario

https://patient.info/doctor/familial-breast-cancer

https://www.crd.york.ac.uk/crdweb/ShowRecord.asp?LinkFrom=OAI&ID=32014000371

https://www.sciencedirect.com/journal/annals-of-oncology
Question 23
A 50 year old woman with a history of breast carcinoma and a left-sided mastectomy with
ipsilateral axillary lymph node clearance 2 years ago presents to her general practitioner (GP)
with a 2-week history of left upper limb swelling. She complains of tightness of the hand. She
had an insect bite on her left hand 4 weeks ago. There is no rash and she is not complaining of
itch. She is afebrile. What is the SINGLE most likely reason for her swelling?

A. Recurrent breast cancer

B. Lymphoedema
C. Urticaria
D. Contact dermatitis
E. Angioedema
Answer
Lymphoedema

Explanation
Around 1 out of 5 women who have had breast cancer treatment develop lymphedema usually
during the first 2 years after treatment. It occurs as a result of damage to the lymphatic system
during surgery so it affects only the side of where the lymph node clearance took place. Swelling
from lymphedema can be gradual overtime but can be worsened by an infection at the affected
side.

Angioedema is incorrect. There are many types of angioedema but the ones caused by insect
venom are “acute allergic angioedema”. Swelling typically starts 1 to 2 hours after the insect bite
and almost always is accompanied by urticarial. Symptoms last 1 to 3 days. The time frame does
not fit that of acute allergic angioedema and there is no itching rash.

Further reading:

https://patient.info/doctor/peripheral-oedema

https://www.pcds.org.uk/clinical-guidance/lymphoedema

https://www.cancerresearchuk.org/about-cancer/coping/physically/lymphoedema-and-
cancer/treating/exercise
Question 24
A 29 year old woman presents with a single 2 cm by 2 cm lump in the breast. The lump is mobile
and hard in consistency. On examination, the mass is painless and there is also a palpable lymph
node in the axilla. An ultrasound was performed which shows a mass with hypoechoic, ill-
defined, speculated and microlobulated margins. A mammogram shows ill-defined, speculate
borders. A fine needle aspiration cytology was performed which results came back as normal.
What is the SINGLE most appropriate investigation to confirm the diagnosis?

A. Repeat fine needle aspiration cytology

B. Magnetic resonance imaging
C. Punch biopsy
D. Genetic testing and counseling
E. Core biopsy
Answer
Core biopsy

Explanation
Breast fine needle aspirations are not 100% accurate. The lump is definitely suspicious. The most
appropriate investigation to confirm the diagnosis is core biopsy. A core biopsy uses a hollow
needle to take one or more samples of breast tissue from the area of concern. Because tissue is
taken rather than cells, it gives more detailed information compared to a fine needle aspiration.

A fine needle aspiration (FNA) involves taking one or more samples of breast cells using a fine
needle and syringe. The sample of fluid or cells is smeared on a glass slide and sent to a
pathology laboratory to be examined. It is usually done under ultrasound guidance or
occasionally mammogram guidance. Fine needle aspirations only take a small amount of cells
and thus they cannot be used to definitely rule out cancer as sometimes the cells that are taken
may have arisen from normal tissue.

A punch biopsy may be done when there is a change to the skin of the breast or nipple. It
involves taking a very small cylindrical piece of tissue from the changed area.

Refers to Benign breast disease

Question 25
A 58 year old woman presents with a sore nipple and a peri-areolar rash. She has been
complaining of a growing rash at her nipple which is itchy. She has clear fluid discharge from
her left nipple over the past few months which have recently been a little bloodstained. On
examination, her left nipple is dry, cracked and has a scaly erythematous area surrounding the
nipple. Her right nipple appears normal and no lymphadenopathy was seen. A mammogram done
3 years ago was normal. What is the SINGLE most likely diagnosis?

A. Paget’s disease of the breast

B. Contact dermatitis
C. Invasive ductal carcinoma
D. Intraductal papilloma
E. Bowen’s disease
Answer
Paget’s disease of the breast

Explanation
The signs and symptoms here are consistent with Paget’s disease of the breast. This is an
uncommon breast malignancy. The lesion is pruritic and appears red and scaly often located in
the nipple spreading to the areola. The skin appearance can mimic dermatitis like eczema or
psoriasis. The discharge may occur which may include blood stained discharge.

Contact dermatitis –> a very unusual place to have contact dermatitis

Invasive ductal carcinoma –> usually asymptomatic and an abnormal area picked up on
mammogram screening or may present as a new lump or mass in the breast

Intraductal papilloma –> is suggested by bleeding from the nipple

Bowen’s disease –> also presents with red, scaly patches but the majority of the lesions are
found on lower limbs usually in sun-exposed areas.

Refers to Paget’s disease of the breast

Question 26
A 29 year old woman is seen in the breast clinic with redness around her right areola for the past
5 weeks. There is slight nipple retraction at the site with a small palpable mass on the bottom of
the nipple. Her periareolar area is tender. There is greenish discharge from the nipple. Her past
medical history includes smoking half a pack of cigarettes for the past 10 years. She was
investigated in the breast clinic and prescribed flucloxacillin which improved her symptoms.
What is the SINGLE most likely diagnosis?

A. Periductal mastitis
B. Breast cancer
C. Intraductal papilloma
D. Paget’s disease
E. Breast abscess
Answer
Periductal mastitis

Explanation
Periductal mastitis occurs when the ducts under the nipple become inflamed and infected. It
presents with periareolar inflammation, nipple retraction at the site of the diseased duct, with
greenish discharge from the nipple. Occasionally a mass may be palpable.
It is commoner in young woman like in this stem. Smoking is one of the risk factors for
periductal mastitis as smoke damages the ducts and causes inflammation. Smoking also reduces
the healing process in periductal mastitis.

Periductal mastitis is considered a subclass of duct ectasia. The main difference between the two
is that periductal mastitis has a mass that develops around the nipple whereas duct ectasia has a
mass that develops behind the nipple. Although they are different terms, they are considered
different stages in the same disease process.

Periductal mastitis is completely benign but features of its clinical and mammographic
appearance may resemble breast cancer. It would be common practice for this woman to be
referred to the breast clinic for thorough examinations to exclude breast cancer.

Periductal mastitis is treated with antibiotics. If left untreated, there is a risk of it developing into
an abscess which may require draining using a fine needle. Breast abscesses usually need
drainage and rarely respond to antibiotics.

Further reading:

https://www.nice.org.uk/cks-uk-only#!diagnosisSub

Benign breast disease

Question 27
A 65 year old woman presents to the breast clinic having noticed that she has had a blood stained
discharge from the left nipple. She also has dry skin over the left areola which resembles eczema.
On examination, a blood stained discharge with dry flaky skin is noted on the left areola and the
nipple was ulcerated. What is the SINGLE most appropriate investigation?

A. Fine needle aspiration cytology

B. Magnetic resonance imaging
C. Punch biopsy
D. Open biopsy
E. Stereotactic biopsy
Answer
Punch biopsy

Explanation
There is a suspicion of Paget’s disease of the breast/nipple here. These are usually diagnosed by
having a simple skin punch biopsy.

Refers to Paget Disease of the Breast and Nipple

Question 28
A 37 year old woman is seen in the breast clinic with a lump felt on her right breast. There is
periareolar redness. A palpable lump can be felt behind the nipple and the breast feels hot and
tender. She is afebrile. She has been a heavy smoker since she was a teenager. She had a similar
episode in the past which oral antibiotics help subside her symptoms. A fine needle aspiration
reveals 1 ml of green discharge in the syringe. What is the SINGLE most likely diagnosis?

A. Benign fluid-filled cyst

B. Periductal mastitis
C. Intraductal papilloma
D. Fibroadenoma
E. Breast abscess
Answer
Periductal mastitis

Explanation
Periductal mastitis occurs when the ducts under the nipple become inflamed and infected.
Features include periareolar redness, palpable mass, greenish discharge (either from nipple or
from aspirate). Other features to look out for as well are nipple retraction but this is not seen in
this stem.
Smoking is one of the risk factors for periductal mastitis as smoke damages the ducts and causes
inflammation. Smoking also reduces the healing process in periductal mastitis.

Periductal mastitis is completely benign but features of its clinical and mammographic
appearance may resemble breast cancer. It would be common practice for this woman to be
referred to the breast clinic for thorough examinations to exclude breast cancer.

Periductal mastitis is treated with antibiotics. If left untreated, there is a risk of it developing into
an abscess which may require draining using a fine needle. Breast abscesses usually need
drainage and rarely respond to antibiotics.

Further reading:

https://www.nice.org.uk/cks-uk-only#!diagnosisSub

Benign breast disease

Question 29
A 38 year old woman presents with itching around the breast and greenish foul smelling
discharge from the nipple. She had a similar episode a year ago. What is the SINGLE most likely
diagnosis?

A. Breast abscess
B. Duct ectasia
C. Duct papilloma
D. Fat necrosis
E. Paget’s disease of nipple
Answer
Duct ectasia

Explanation
Duct ectasia is suggested by a green or brown nipple discharge. The other options in this
question do not present with greenish foul smelling discharge from the nipple.

Breast abscess –> is suggested by a fluctuant lump, hot and tender, acute presentation often in
puerperium, chronic after antibiotics.

Duct papilloma –> is suggested by bleeding from nipple

Fat necrosis –> is suggested by a firm and solitary localized lump.

Paget’s disease of nipple –> is suggested by breast nipple ‘eczema’.

Reference:

Oxford Handbook of Clinical Diagnosis 3rd Edition page 106

Benign breast disease

Question 30
A 33 year old woman is found to have a hormone receptor-positive, early-stage breast cancer of
her left breast. The tumour is seen to be 10 mm in diameter. There is no evidence of metastatic
spread of her breast cancer. She is booked for a left mastectomy. On pre-assessment, she was
found to be 6 weeks pregnant. She has no other significant medical history. What is the SINGLE
most appropriate action?

A. Postpone her surgery until she delivers at term

B. Postpone her surgery until the second trimester
C. Cancel her surgery and start tamoxifen
D. Terminate pregnancy and proceed with surgery
E. Proceed with surgery
Answer
Proceed with surgery

Explanation
Breast surgery is considered safe in all trimesters of pregnancy. As this is a malignant tumour, a
delay in surgery could result in growth and possible metastatic spread.

Tamoxifen is contraindicated in pregnancy.

There is no need to terminate the pregnancy for this patient. The only situation where termination
is required is if chemotherapy is needed. In those specific situations, the mother would be
advised to consider ending her pregnancy.

Many breast cancers are estrogen receptor-positive but there is no evidence that hormones from
pregnancy would worsen the prognosis.

Further reading:

https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/pregnancy-and-
breast-cancer-green-top-guideline-no-12/
Question 31
A 48 year old female with a history of breast carcinoma and a left-sided mastectomy with
ipsilateral axillary lymph node clearance 2 years ago presents to her general practitioner (GP)
with a three-day history of left upper limb swelling. An examination is unremarkable except for
the presence of a small insect bite located in her left anterior upper arm. What is the SINGLE
most likely mechanism for the swelling in this patient’s upper limb?

A. Ascending lymphangitis
B. Lymphoedema
C. Cellulitis
D. Hypoalbuminaemia
E. Delayed hypersensitivity
Answer
Lymphoedema

Explanation
Around 1 out of 5 women who have had breast cancer treatment develop lymphedema usually
during the first 2 years after treatment.

The function of the lymphatic system is to return fluid from the interstitium to the intravascular
space. In a diseased state, the capacity to the interstitial fluid exceeds the rate of lymphatic return
which results in fluid accumulating in the rate of lymphatic return which results in fluid
accumulating in the interstitium. Because the lymph fluid in the interstitium contains a high
concentration of protein, the resulting high oncotic pressure causes additional water to
accumulate in the interstitum. The accumulation of interstitial fluid eventually leads to fluid
build-up in the surrounding tissues.

There are two causes of lymphedema: primary (inherited) and secondary (caused by damage or
disease). The most common secondary cause in the developed world is due to malignancy and
cancer treatment, especially after regional lymph node dissection.

An upper limb infection (which may be elicited by an insect bite) on the affected side at any time
after breast cancer treatment is a risk factor for lymphedema.

Further reading:

https://patient.info/doctor/peripheral-oedema

https://www.pcds.org.uk/clinical-guidance/lymphoedema

https://www.cancerresearchuk.org/about-cancer/coping/physically/lymphoedema-and-
cancer/treating/exercise
Question 32
A 46 year old woman has offensive yellow discharge from around the left nipple area over A 46
year old woman has offensive yellow discharge from around the left nipple area over the past
few days. She has a history of a subareolar abscess 6 months ago which was treated surgically.
There are no abnormal skin changes on the breast or lumps palpable. What is the SINGLE most
likely diagnosis?

A. Duct papilloma
B. Duct ectasia
C. Ductal fistula
D. Breast abscess
E. Paget’s disease
Answer
Ductal fistula

Explanation
Ductal fistula (Mammillary fistula) is an abnormal communication between a mammary duct
and the skin surface, usually near the areola and is suggested by discharge from para-areolar
region. A fistula may form following an incision and drainage of an abscess hence the reason
that a subareolar abscess is included in the history in this stem.

Occasionally, there may be a history of a spontaneous rupture of an inflammatory mass

preceding the development of the mammillary fistula. It is managed by excising and providing
antibiotic cover. Recurrence of the ductal fistula is common.

Mammary duct ectasia is also another consideration as an answer. Duct ectasia refers to
dilatation of the large and intermediate breast ducts and it is suggested by a green or brown
nipple discharge. The ducts become blocked and secretions stagnate. Occasionally, nipple
retraction and a lump with local pain is seen. Duct ectasia also occurs in patients with recurrent
breast abscesses. The infection is usually mixed anaerobic based.

Breast abscess would usually present with unilateral localized pain, This was not seen in this
stem. Note that breast abscess may be due to mammary duct ectasia.
Question 33
A 28 year old pregnant woman o 28 weeks gestation had sustained a minor chest injury three
weeks ago caused by direct trauma from her seat belt during a car accident. She presents with a
left subareolar mass. The mass is painless and firm and has dimpling. What is the SINGLE most
likely diagnosis?

A. Fibroadenoma
B. Pregnancy related enlargement
C. Breast cancer
D. Sclerosing adenosis
E. Fat necrosis of the breast
Answer

Fat necrosis of the breast

Explanation

Fat necrosis feels like a firm, round lump (or lumps) and is usually painless, but in some people
it may feel tender or even painful. The skin around the lump may look red, bruised or
occasionally dimpled.

It is more likely to occur in high BMI women and it usually follows trauma like in this stem. It
usually develops months after an injury but can occur at any time (even 3 weeks).

It is unlikely that this patient would present with breast cancer. She is below 30 years old with a
breast lump and without any mention of breast cancer in the family. In any case, she would be
referred to a breast clinic for imaging, but the referral would be a non-urgent referral given the
unlikely chance of breast cancer.

Further reading:

Oxford Handbook of Clinical Diagnosis 3rd Edition page 106

https://breastcancernow.org/about-breast-cancer/breast-lumps-and-benign-not-cancer-breast-
conditions/fat-necrosis/

https://www.nhs.uk/conditions/breast-lump/

https://patient.info/doctor/benign-breast-disease

Benign breast disease

Question 34
A 29 year old woman has bilateral breast tenderness for the past 6 months. It occurs 2 weeks
before her menstrual cycle starts and improves after her menses. She describes the pain as dull
and achy in mature. She takes the combined oral contraceptive pills. On examination, there are
no palpable lumps or skin discolouration. She drinks a cup of tea every morning. What is the
SINGLE most appropriate action?

A. Advice to take primrose oil

B. Advise to reduce caffeine
C. Start antibiotics
D. Advise to stop combined oral contraceptives
E. Advise to take paracetamol
Answer
Advice to take paracetamol

Explanation
This stem describes cyclical mastalgia.

Oral paracetamol, ibuprofen or topical NSAIDs can also be used to manage cyclical mastalgia.

NICE CKS (2016) suggest the following:

 Changing or stopping combined oral contraception is not a recommended treatment

 A diet low in caffeine is not a recommended treatment
 Primrose oil is not a recommended treatment
 Antibiotics is not recommended

Further reading:

https://www.nice.org.uk/cks-uk-only

Cyclical vs noncyclical mastalgia

Question 35
A 53 year old lady was sent for investigations including biopsy after being found to have a breast
lump and associated changes to the skin overlying this lump that appeared red and dimpled. The
biopsy result was suggestive of cancer. What is the SINGLE most likely statement that would
describe the histopathological findings?

A. Invasive intraductal carcinoma of the breast extending to the epithelium

B. In situ carcinoma involving the nipple epidermis
C. Encapsulated adipocytes within a fibrotic stroma
D. Proliferation and expansion of the stroma with low cellularity
E. Cystic formations with mild epithelial hyperplasia in ducts
Answer
Invasive intraductal carcinoma of the breast extending to the epithelium

Explanation
The correct answer is A. Invasive intraductal carcinoma of the breast extending to the epithelium
as this is a histopathological description of the most common type of breast cancer. Given that
there is an indication this is cancer in the question stem and that the question is asking for the
most likely statement to be correct, the most common form of cancer should be considered.

Option B. In situ carcinoma involving the nipple epidermis is incorrect as it describes Paget’s
disease of the breast which is one of the more rarer types of breast cancer affecting the nipple.

Option C. Encapsulated adipocytes within a fibrotic stroma is incorrect it describes a Harmatoma

which is a benign breast tissue disorder.

Option D. Proliferation and expansion of the stroma with low cellularity is incorrect. This
describes the appearances of a fibroadenoma, which are a benign cause of breast lumps.

Option E. Cystic formations with mild epithelial hyperplasia in ducts is incorrect. This describes
another type of benign breast tissue disease known as fibrocystic changes.

Refers to Benign breast disease

Question 36
A 39 year old woman presents to the clinic with a concern about a palpable lump in her left
breast. On examination, the lump is firm and fixed. An ultrasound reveals a hypoechoic mass
with irregular borders and posterior acoustic shadowing. No associated lymphadenopathy is
identified in the axillary region. Given the ultrasound findings and clinical presentation which is
the most appropriate next step in the management of this patient?

A. Observe and review in 6 months

B. Refer for mammography
C. Core biopsy
D. Fine needle aspiration cytology (FNAC)
E. Refer for MRI breast
Answer
Core biopsy

Explanation
The ultrasound findings of a hypoechoic mass with irregular borders and posterior acoustic
shadowing raise suspicion for malignancy. Given these findings and the firm, fixed nature of the
lump on examination, the next step is a core biopsy.

Between the two options for tissue sampling – core biopsy and FNAC – a core biopsy is
generally preferred in this scenario. Core biopsy provides a larger tissue sample than FNAC and
allows for a better histological assessment. This, in turn, ensures a more definitive diagnosis,
especially in cases with suspicious radiological findings.

In recent years, core biopsy has generally been favoured over fine needle aspiration cytology
(FNAC) for the evaluation of breast lesions. A core biopsy provides more tissue for evaluation.
This allows for not only a diagnosis of malignancy but also provides information on the type and
grade of the tumour. Core biopsies have a higher diagnostic accuracy compared to FNAC.

Is FNAC still done in clinical practice? Yes, FNAC is still a valuable tool in certain clinical
scenarios and has its own set of advantages. If abreast lesion is suspected to be a simple cyst,
FNAC can be employed to aspirate the fluid and confirm the cystic nature. If the cyst collapses
after fluid aspiration, no further evaluation might be needed.

Why is a mammogram incorrect?

The priority here is for tissue sampling, given that imaging has already shown malignancy
potential.

Plabable tip: In the context of suspicious breast lesions identified on imaging or clinical
examination, core biopsy is often preferred

Benign breast disease