EBSQ Breast Surgery examination, 15th September 2010, Bordeaux, France

Name 1 Triple diagnosis is the gold standard in breast cancer and consists of A) clinical examination, mammography and CT scan B) clinical examination, surgical biopsy and CT scan C) clinical examination, breast imaging and needle biopsy D) breast imaging, CT scan and bone scan E) breast MRI, PET scan and CT scan 2. Breast MRI provides additional value over conventional breast imaging A) in surveillance of women with a high breast cancer risk B) in patients with axillary metastases and negative mammography and breast ultrasound C) in assessing the response to neoadjuvant treatment D) In imaging breasts with silicone implants E) all the alternatives are correct 3. Microcalcifications A) are almost always an indication for surgical biopsy B) surgical biopsy should be performed when core needle biopsy shows atypical ductal hyperplasia C) malignancy can be detected or ruled out using fine needle aspiration cytology D) invasive cancer can be detected or ruled out using core needle biopsy in practically all patients E) none of the alternatives is correct 4. Microcalcifications that are usually benign are A) casting type B) teacup type C) crushed stone like D) horse shoe type E) both A and C are correct 5. A 55-year old woman complains persistent green discharge from both nipples A) you perform clinical examination, mammography and breast ultrasound, and when negative tell the patient that the symptom is harmless B) you perform a clinical examination and nipple discharge cytology, and when negative, tell the patient that the symptom is harmless C) you perform clinical examination, order mammography and breast ultrasound and when negative, also a ductography of all ducts with discharge D) you examine serum prolactine level to rule out prolactinoma E) this symptom is a side effect of hormone replacement therapy and you suggest cessation of this medication

6. A 55-year old woman complains persistent bloody discharge from one breast A) you perform clinical examination, order mammography and breast ultrasound, and when negative tell the patient that the symptom is harmless B) you perform a clinical examination and nipple discharge cytology, and when negative, tell the patient that the symptom is harmless C) you perform clinical examination, order mammography and breast ultrasound, and even when negative recommend the patient mastectomy because of a high risk of an underlying cancer invisible in breast imaging D) you perform clinical examination, mammography and breast ultrasound and when negative, also a galactography of the duct with discharge E) you do not do anything, because the best examination is ductoscopy and you do not have these facilities 7. PET-scan is a feasible method A) in breast cancer screening B) when excluding distant metastases prior major surgery due to extensive local recurrence C) to replace sentinel node biopsy in nodal staging D) A, B and C are all correct E) none of the alternatives is correct 8. Premalignant histopathological alteration reflecting an increased breast cancer risk A) atypical ductal hyperplasia B) columnar cell hyperplasia C) sclerosing adenosis D) both A and B are correct E) A, B and C are all correct 9. A 55- year woman has a BI-RADS 4 lesion in breast ultrasound. The core needle biopsy shows fibrocystic mastopathy. You A) inform the patient that the lesion is harmless B) recommend a control ultrasound after one year C) consider a new core needle biopsy or surgical biopsy D) inform the patient that the lesion is harmless, but only if the lesion is impalpable and if there are no findings in mammography E) recommend wide local excision and sentinel node biopsy 10) A 55- year woman has used hormone replacement therapy for 3 years. She has no clinical findings. Her gynaecologist has ordered routine breast imaging, which shows a probably benign lesion in mammography and breast ultrasound. The radiologist has taken a core needle biopsy to confirm the benign diagnosis. The core needle biopsy shows apocrine metaplasia. You recommend A) an ultrasound control after 2 months B) a surgical biopsy of the lesions C) a new core needle biopsy or vacuum assisted biopsy D) cessation of hormone replacement therapy due to exceptionally high cancer risk E) none of the alternatives is correct

11) A 35- year woman has a discrete lump in her breast, but there are neither benign nor malignant focal lesions in mammography and breast ultrasound. You would absolutely NOT A) tell the patient that there is no need to worry, because the imaging is negative B) perform core needle biopsy in palpation control C) perform breast MRI D) perform surgical biopsy E) perform fine needle aspiration cytology in palpation control 12. The status of internal mammary lymph nodes A) has similar impact on survival as axillary lymph node status B) has less impact on survival than axillary lymph node status C) has more impact on survival than axillary lymph node status D) has similar impact on survival as axillary lymph node status, but only in medially located tumours E) has a negligible impact on survival 13. DCIS important is A) to perform sentinel node biopsy in all patients to exclude invasive cancer B) meticulous examination of the surgical specimen to exclude invasion C) consider radiotherapy after breast conservation in all patients D) A,B and C are all correct E) both B and C are correct 14. Breast conservation in DCIS- which proportion of the local recurrences are invasive ? A) less than 5% B) 5-10% C) 20% D) 50% E) 70% 15. Sentinel node is A) the first node on the direct lymphatic pathway from the tumour site B) is the node with the highest radioactivity C) is the node which is blue D) is any node with radioactivity exceeding 10% of the activity of the hottest node E) all the alternatives are correct 16. In sentinel node biopsy A) all the radioactive and blue nodes should be harvested in order to optimise the sensitivity B) the metastasis is almost always located in the three nodes harvested first C) the metastasis is almost always located in the node with the highest radioactivity D) the sensitivity is not remarkably improved after removal of five nodes E) both B and D are correct 17. After negative sentinel node biopsy A) there is an absolute survival disadvantage of 5% when compared with axillary clearance B) the risk of lymphedema is practically 0% C) the risk of axillary recurrence is usually less than 1% D) the risk of significant arm morbidity is about 20% E) both B and C are correct 18. In sentinel node biopsy: superficial tracer injection compared with the intraparenchymal injection A) is associated with a higher false negative rate B) is associated with a higher risk of axillary recurrences C) is associated with a better visualisation of axillary sentinel node D) A, B and C are all correct E) both A and B are correct

19. When axillary clearance is performed after positive sentinel node biopsy, further metastases are found in the axillary clearance specimen more often A) when the primary tumour is large B) when the primary tumour is oestrogen receptor positive C) when the primary tumour is invasive tubular carcinoma D) when the primary tumour is DCIS E) when the sentinel node finding is a micrometastasis 20. Phyllodes tumour of the breast A) sentinel node biopsy should be performed in all patients B) sentinel node biopsy should be performed in patients with borderline and malignant phyllodes C) sentinel node biopsy should be performed only in patients with malignant phyllodes D) sentinel node biopsy is not indicated E) axillary clearance should be performed in patients with malignant phyllodes 21. A 45 year old breast cancer patient has a negative axillary sentinel node but a 3 mm metastasis in a parasternal sentinel node, your recommendation is A) axillary clearance B) axillary clearance and radiotherapy to the parasternal nodes C) radiotherapy to the axillary, subclavicular and parasternal nodes D) radiotherapy to the parasternal nodes E) extended radical mastectomy 22. 100 breast cancer patients are included in sentinel node biopsy and routine back-up axillary clearance. 40 patients have tumour positive sentinel nodes. 60 patients have tumour negative sentinel nodes, but 5 of them have nodal metastases in the back-up axillary clearance. The false negative rate of sentinel node biopsy in this study is A) 5% B) 8% C) 11% D) 12,5% E) none of the alternatives is correct 23. According to the report from path lab, your patient has a bifocal ductal grade 2 cancer. The size of the index tumour is 20 mm and the size of the additional focus is 9mm. In the sentinel node, there is a 5 mm metastasis, the axillary lymph node dissection reveals 2 metastatic lymph nodes out of 19 examined. The TNM classification in this case is A) T2 N2 B) T1 N2 C) T1 N1 D) T2 N1 E) T2 N3

24) Stage migration A) means tumour progression due to the migration of cancer cells along the tumour stroma B) means that the prognosis looks better due to more accurate staging, without a real improvement in the outcome C) is a synonym to Will Rogers phenomenon D) is a synonym to Elias Smith phenomenon E) both B and C are correct 25. BRCA mutation A) breast cancer in BRCA1 mutation carriers is usually hormone receptor positive B) breast cancer in BRCA 2 mutation is not associated with ovarial cancer risk C) salpingo-oophorectomy effectively prevents both breast cancer and ovarial cancer and should be performed before the age of 25 D) testing for BRCA mutation should be performed in young women concerned about their breast cancer risk E) none of the alternatives is correct 26. Prophylactic mastectomy in BRCA mutation carriers A) provides 100% risk reduction B) provides 90% risk reduction C) provides 75% risk reduction D) provides 60 % risk reduction E) provides 50% risk reduction 27. Alternatives for management of BRCA mutation carriers A) prophylactic mastectomy B) surveillance with mammography C) surveillance with mammography breast ultrasound and MRI D) chemoprevention with trastuzumab E) both A and C are correct 28. Immediate breast reconstruction is associated with following risks? A) a relatively high risk of local recurrence, especially when preserving the nipple-areola complex B) a relatively high risk of distant recurrence C) a relative high risk of local and distant recurrence D) a risk of post-operative complications higher than 20% E) none of the alternatives is correct 29. Breast reconstruction should be performed A) in all patients with mastectomy B) in all patients with mastectomy, but only when younger than 60 years C) in all patients who wish reconstruction, but only when younger than 60 years D) in all patients with mastectomy, but without distant metastases E) none of the alternatives is correct 30. Brava-reconstruction means breast reconstruction applying A) a special suction device and free fat graft B) a special type of silicone implant designed by Alberto Brava C) a modification of a pediculated TRAM flap by Alberto Brava D) a microvascular, contralateral latissimus dorsi flap E) such a reconstruction does not exist 31. Implant loss occurs after breast reconstruction with silicone implants in approximately A) 50% B) 20-30% C) 10-20% D) 5-10% E) implants last forever, these are not biodegradable

32. The risk of total flap loss after breast reconstruction with microvascular abdominal flap is approximately A) less than 0,1 % B) 1-2 % C) 5-10% D) 10-20% E) 33% 33. Local recurrences after skin sparing/ nipple sparing mastectomy A) occur most often in the preserved nipple-areola complex B) the risk is approximately 10% in 10 years C) the risk is approximately 1% in 5 years D) the risk is approximately 25% in 10 years E) both A and B are correct 34. Optimal candidate for nipple sparing mastectomy A) has large, ptotic breasts B) has a small centrally located tumour C) has a relatively large tumour in a large, but not ptotic breast E) has extensive DCIS D) does not have large, ptotic breasts 35. Common risk factors for local recurrence after breast conservation include A) invasive ductal cancer B) young patient age C) invasive lobular cancer D) old patient age E) both B and C are correct 36. The impalpable breast tumour can be localized using A) metal guide wire B) peri- or intratumoural radioisotope injection C) radioactive seed D) intraoperative ultrasound E) all these methods are feasible 37. Neoadjuvant chemotherapy A) enables breast conservation in all responders B) response rate is highest in oestrogen receptor positive tumours, because these are associated with a favourable prognosis C) responders have usually a better prognosis than non-responders D) response rate is poor in HER-2 positive cancer E) both B and C are correct

38. Optimal candidates for breast conservation after neoadjuvant chemotherapy are usually patients with A) a multicentric invasive lobular cancer B) a small invasive cancer and an extensive intraductal component C) DCIS D) an invasive tubular cancer E) none of the alternatives is correct 39. Neoadjuvant chemotherapy is A) beneficial in locally advanced breast cancer, because it improves operability B) beneficial also in less advanced cases, because it may facilitate breast conservation C) is practically always beneficial D) both A and B are correct E) is hardly ever necessary, if the surgeon is skilful and has attitude 40. Breast conservation in elderly patients A) is contraindicated, when radiotherapy is not possible due to serious co-morbidities B) is seldom a treatment option, because breasts are not important to elderly patients C) is seldom a treatment option, the best treatment option in the elderly is endocrine therapy D) is associated with a lower local recurrence risk when compared with young patients E) the local recurrences translate to poor survival, because radiotherapy is not often possible 41. Contraception during breast cancer treatment A) is important and the hormonal methods should be used because these are most effective B) is important, but hormonal methods are not recommended C) is not important, because the majority of the patients are postmenopausal D) is not important, because the premenopausal patients receive either chemotherapy or endocrine therapy or both, which decrease fertility E) both C and D are correct 42. Breast cancer in male patients A) sentinel node biopsy is not safe B) is often associated with testicular cancer C) sentinel node biopsy is used similarly as in female patients D) family history regarding breast and ovarian cancer is particularly important E) both C and D are correct 43. Apoptosis means A) programmed cell death B) typical breast configuration in slim elderly patients C) non-restricted tumour growth due to high mitotic activity D) spiritual support for patients with advanced breast cancer E) tumour progression due regulatory T-cells 44. Angiosarcoma is a rare complication after A) radiotherapy B) tamoxifen C) aromatase inhibitors D) capestabine E) trastuzumab 45. Radiotherapy- side effects include A) pulmonary fibrosis B) increased risk of lung cancer C) increased risk of contralateral breast cancer D) increased risk of angiosarcoma E) all the alternatives are correct

46 The lung cancer risk in breast cancer patients with radiotherapy when compared with patients without radiotherapy A) the risk is not increased B) the risk is about 1-2 fold C) the risk is about 5 fold D) the risk is about 10 fold E) the risk is about 20 fold 47. Radiotherapy after breast conservation A) the relative benefit is similar regardless tumour and patient characteristics and therefore radiotherapy improves survival in 25% of all patients B) both the relative and the absolute benefit is similar regardless tumour and patient characteristics C) the absolute benefit is similar regardless tumour and patient characteristics and therefore radiotherapy improves survival in 5% of all patients D) the relative benefit is similar regardless tumour and patient characteristics, but the absolute benefit is lower in patients with a low risk of local recurrences E) the absolute benefit is similar regardless tumour and patient characteristics, but the relative benefit is lower in patients with a low risk of local recurrences 48. Endocrine treatment A) Aromatase inhibitors are more effective than tamoxifen B) All breast cancer patients should receive aromatase inhibitors C) Aromatase inhibitors are associated with bone and muscle pain more often than tamoxifen D) both A and C are correct E) A, B and C are all correct 49 Trastuzumab (Herceptin) is A) an anti-apoptotic agent used in HER-2 positive breast cancer B) HER-2 specific tyrosine kinase inhibitor C) monoclonal anti-HER-2 antibody D) HER-2 enzyme inhibitor E) HER-2 specific tyrosine kinase activator 50. A randomized trial compares two medicines DRUG 1 and DRUG 2. The 5-year breast cancer specific survival is 90% with DRUG 1 and 93% with DRUG 2. Therefore DRUG 2 A) provides an absolute benefit of 33% B) provides a relative benefit of 3% C) provides a relative benefit of 33% D) to prevent one breast cancer death, the number need to treat is 33 E) both C and D are correct 51. The follow-up visits in breast cancer survivors are important A) to detect a local recurrence or new primary breast cancer B) to detect distant metastases before symptomatic C) to assess and treat the long-time morbidity caused by the treatment D) both A and C are correct E) the follow-up visits are not beneficial