23 The Breast
1 A 36-year-old woman has noticed a bloody discharge from the nipple of her right breast for the past 3 days. On physical examination, the skin of the breasts appears normal, and no masses are palpable. There is no axillary lymphadenopathy. The patient has regular menstrual cycles and is using oral contraceptives. Excisional biopsy is most likely to show which of the following lesions in her right breast?
(A) 
(B) 
(C) 
(D) 
(E) 2 A 28-year-old woman in the third trimester of her third pregnancy discovered a lump in her left breast. The physician palpated a 2-cm, discrete, freely movable mass beneath the nipple. After the birth of a term infant, the mass appears to decrease slightly in size. The infant breastfeeds without difficulty. What is the most likely diagnosis?
(A) 
(B) 
(C) 
(D) 
(E) 3 A 30-year-old woman sustained a traumatic blow to her right breast. Initially, there was a 3-cm contusion that resolved within 3 weeks, but she then felt a firm lump that persisted below the site of the bruise 1 month later. What is the most likely diagnosis for this lump?
(A) 
(B) 
(C) 
(D) 
(E) 4 A 55-year-old man has developed bilateral breast enlargement over the past year. On physical examination, the enlargement is symmetric and is not painful to palpation. There are no masses. The patient is not obese and is not taking any medications. Which of the following underlying conditions best accounts for these findings?
(A) 
(B) 
(C) 
(D) 
(E) 5 A 44-year-old woman sees her physician because she felt a lump in her left breast 1 week ago. The physician palpates a firm, irregular mass in the upper outer quadrant of the left breast. There are no overlying skin lesions. The gross appearance of the excisional biopsy specimen is shown in the figure. Which of the following additional findings is most likely to be present on physical examination?
(A) 
(B) 
(C) 
(D) 
(E) 
6 A 25-year-old woman sees her physician because she has noticed a lump in her right breast. The physician palpates a 2-cm, firm, circumscribed mass in the lower outer quadrant. The figure shows the excised mass (A) and the mammogram (B). What is the most likely diagnosis?
(A) 
(B) 
(C) 
(D) 
(E) 
(F) 7 A 47-year-old woman has noticed a red, scaly area of skin on her left breast that has grown slightly larger over the past 4 months. On physical examination, there is a 1-cm area of eczematous skin just lateral to the areola. The figure shows the microscopic appearance of the skin biopsy specimen. What is the most likely diagnosis?
(A) 
(B) 
(C) 
(D) 
(E) 8 Three weeks after giving birth to a normal term infant, a 24-year-old woman is breastfeeding the infant and notices fissures in the skin around her left nipple. Over the next 3 days, the region around the nipple becomes erythematous and tender. Purulent exudate from a small abscess drains through a fissure. Which of the following organisms is most likely to be cultured from the exudate?
(A) 
(B) 
(C) 
(D) 
(E) 9 A 27-year-old woman feels a lump in her right breast. She has normal menstrual cycles, she is G3, P3, and her last child was born 5 years ago. The physician palpates a 2-cm, irregular, firm area beneath the lateral edge of the areola. The mass is not painful and does not feel firm. There are no lesions of the overlying skin and no axillary lymphadenopathy. A biopsy specimen shows microscopic evidence of an increased number of ducts, which are compressed because of proliferation of fibrous connective tissue. Dilated ducts with apocrine metaplasia also are present. What is the most likely diagnosis?
(A) 
(B) 
(C) 
(D) 
(E) 10 A 44-year-old woman noticed a lump in her right breast. On examination, she has an ill-defined, 1-cm mass in the upper outer quadrant. The mass is cystic on ultrasound. An excision is done, and the mass shows predominantly fibrocystic changes, but carcinoma also is present. Fine-needle aspirates of both breasts reveal additional foci of similar malignant cells. Which of the following breast carcinomas is most likely to produce these findings?
(A) 
(B) 
(C) 
(D) 
(E) 11 A 56-year-old woman sees her physician for a routine health examination. There are no remarkable findings on physical examination. A mammogram shows a 0.5-cm irregular area of increased density with scattered microcalcifications in the upper outer quadrant of the left breast. Excisional biopsy shows atypical lobular hyperplasia. The patient has been on postmenopausal estrogen-progesterone therapy for the past 10 years. She has smoked 1 pack of cigarettes per day for the past 35 years. Which of the following conclusions is most pertinent to these findings?
(A) 
(B) 
(C) 
(D) 
(E) 12 A 54-year-old woman sees her physician after feeling a lump in her left breast. The physician palpates a firm, irregular mass in the lower outer quadrant just beneath the lateral margin of the areola. A mammogram shows a 2-cm density with focal microcalcifications. Excisional biopsy shows intraductal and invasive components of a breast carcinoma. Immunohistochemical staining shows that the cells are positive for HER2/neu expression, but negative for estrogen receptor and progesterone receptor expression. Flow cytometry shows a small aneuploid peak and a low S-phase. When combined with doxorubicin, which of the following drugs is most likely to be useful in treating this patient?
(A) 
(B) 
(C) 
(D) 
(E) 13 A 55-year-old woman has felt a poorly defined lump in her right breast for the past year. On examination, she has a nontender, firm, 6-cm mass in the upper inner quadrant. There are no lesions of the overlying skin and no axillary lymphadenopathy. Needle biopsy is done, and microscopic examination of the specimen shows cellular stroma protruding into spaces lined by a single-layer cuboidal epithelium. The mass is excised with a wide margin, but recurs 1 year later. After further excision, the lesion does not recur. What is the most likely diagnosis?
(A) 
(B) 
(C) 
(D) 
(E) 14 A 51-year-old woman has noticed an area of swelling with tenderness in her right breast that has worsened over the past 2 months. On physical examination, the 7-cm area of erythematous skin is tender and firm. There is swelling of the right breast, nipple retraction, and right axillary lymphadenopathy. Excisional biopsy is most likely to show which of the following lesions?
(A) 
(B) 
(C) 
(D) 
(E) 15 A 39-year-old woman has noticed an enlarging mass in her left breast for the past 2 years. The physician palpates a 4-cm firm mass. A simple mastectomy is performed with axillary lymph node sampling and plastic reconstruction of the breast. On gross sectioning, the mass has a soft, tan, fleshy surface. Histologically, the mass is composed of large cells with vesicular nuclei and prominent nucleoli. There is a marked lymphocytic infiltrate within the tumor, and the tumor has a discrete, noninfiltrative border. No axillary node metastases are present. The tumor cells are negative for estrogen receptor and progesterone receptor. What is the most likely diagnosis?
(A) 
(B) 
(C) 
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