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CHAPTER 17
4. Lesions with malignant potential include all of the following EXCEPT:
A. lntraductal papilloma.
B. Atypical ductal hyperplasia (ADH).
C. Sclerosing adenosis.
D. Atypical lobular hyperplasia (ALH).
Breast
of the nipple with reference to the inframammary fold and the
degree of breast ptosis and skin redundancy: Grade 1: Mild
breast enlargement without skin redundancy; Grade Ila: Moderate breast enlargement without skin redundancy; Grade
llb: Moderate breast enlargement with skin redundancy; and
Grade 3: Marked breast enlargement with skin redundancy
and ptosis. (See Schwartz 11th ed., p. 549.)
Answer: C
Sclerosing adenosis is prevalent during the childbearing and
premenopausal years and has no malignant potential. Multiple
intraductal papillomas, which occur in younger women and
are less frequently associated with nipple discharge, are susceptible to malignant transformation. Individuals with a diagnosis
of ADH are at increased risk for development of breast cancer
and should be counseled appropriately regarding risk reduction strategies. ALH results in minimal distention of lobular
units with cells that are similar to those seen in lobular carcinoma in situ (LCIS). (See Schwartz 11th ed., pp. 552–553.)
5. Risk factors for the development of breast cancer include:
A. Early menarche
B. Nulliparity
C. Late menopause
D. Longer lactation periods
6. All of the following are TRUE concerning breast lobular
carcinoma in situ (LCIS) EXCEPT:
A. Develops only in the female breast.
B. Cytoplasmic mucoid globules are a distinctive cellular
feature.
C. Frequency of LCIS cannot be reliably determined.
D. The average age at diagnosis is 65 to 70 years.
7. Which of the following concerning breast cancer staging
is correct?
A. Stage I tumors have no metastases to either lymph
nodes or distant sites.
B. Stage Ill tumors include some with distant metastases
(M1 disease).
C. Inflammatory carcinoma is considered T4 disease.
D. N4 disease includes metastases to highest contralat-
eral axillary nodes.
Answer: D
Increased exposure to estrogen is associated with an increased
risk for developing breast cancer, whereas reducing exposure
is thought to be protective. Correspondingly, factors that
increase the number of menstrual cycles, such as early menarche, nulliparity, and late menopause are associated with
increased risk. Moderate levels of exercise and a longer lactation period, factors that decrease the total number of menstrual cycles, are protective. (See Schwartz 11th ed., p. 555.)
Answer: D
LCIS originates from the terminal duct lobular units and
develops only in the female breast. Cytoplasmic mucoid globules are a distinctive cellular feature. The frequency of LCIS in
the general population cannot be reliably determined because
it usually presents as an incidental finding. The average age at
diagnosis is 45 years, which is approximately 15 to 25 years
younger than the age at diagnosis for invasive breast cancer.
(See Schwartz 11th ed., pp. 553–554.)
Answer: C
See Schwartz 11th ed., pp. 576–578.
8. Which of the following statements about the management of distal carcinoma in situ (DCIS) is TRUE?
A. DCIS treated by mastectomy has a local recurrence
rate of <2%.
B. Extensive DCIS should be treated with tamoxifen fol-
lowed by lumpectomy.
C. Specimen mammography is only useful for patients
with small amounts of DCIS.
D. Postoperative tamoxifen is useful in DCIS patients
whose tumors are estrogen receptor negative.
Answer: A
Women with DCIS and evidence of extensive disease
(>4 cm of disease or disease in more than one quadrant) usually require mastectomy. For women with limited disease,
lumpectomy and radiation therapy are generally recommended. For no palpable DCIS, needle localization or other
image-guided techniques are used to guide the surgical resection. Specimen mammography is performed to ensure that all
visible evidence of cancer is excised. Adjuvant tamoxifen therapy is considered for DCIS patients with estrogen-receptor
(ER)-positive disease. The gold standard against which breast
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conservation therapy for DCIS is evaluated is mastectomy.
Women treated with mastectomy have local recurrence and
mortality rates of <2%. (See Schwartz 11th ed., pp. 580–582.)
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9. Patients not suitable for sentinel node biopsy include all
of the following EXCEPT:
A. Inflammatory carcinoma of the breast
B. Prior axillary surgery
C. Biopsy proven distant metastases
D. Breast lower inner quadrant carcinoma
10. Which of the following is TRUE concerning breast cancer during pregnancy?
A. Metastases to lymph nodes occurs in approximately
75% of these patients.
B. Approximately 50% of breast nodules developing
during pregnancy are malignant.
C. Mammography is especially useful in localizing small
lesions.
D. There is risk of chemotherapy teratogenicity if used
during the second, but not the third, trimester of
pregnancy.
11. Which of the following statements about breast anatomy
are TRUE?
A. The lateral border of the breast is the posterior axil-
lary line.
B. The largest breast quadrant is the inner lower
guardant.
C. Vascular supply is via posterior intercostal arter-
ies, the internal mammary arteries, and the axillary
ar ter y.
D. Cooper ligaments are only found in the upper quad-
rants of the breast.
Answer: D
Clinical situations where sentinel lymph node (SLN) dissection is not recommended include patients with inflammatory
breast cancers, those with palpable axillary lymphadenopathy
and biopsy proven metastasis, DCIS without mastectomy, or
prior axillary surgery. Although limited data are available, SLN
dissection appears to be safe in pregnancy when performed
with radioisotope alone. (See Schwartz 11th ed., p. 590.)
Answer: A
Breast cancer occurs in 1 of every 3000 pregnant women, and
axillary lymph node metastases are present in up to 75% of
these women. Less than 25% of the breast nodules developing
during pregnancy and lactation will be cancerous. Mammography is rarely indicated because of its decreased sensitivity
during pregnancy and lactation; however, the fetus can be
shielded if mammography is needed. Chemotherapy administered during the first trimester carries a risk of spontaneous
abortion and a 12% risk of birth defects. There is no evidence
of teratogenicity resulting from administration of chemotherapeutic agents in the second and third trimesters. (See
Schwartz 11th ed., p. 600.)
Answer: C
Fibrous bands of connective tissue travel through the breast
(Cooper suspension ligaments), insert perpendicularly into
the dermis, and promote structural support. The mature
female breast extends from the level of the second or third
rib to the inframammary fold to the sixth or seventh rib. It
extends transversely from the border of the sternum to the
anterior axillary line. The upper outer quadrant of the breast
contains a greater volume of tissue than the other quadrants. The breast receives its principal blood supply from:
(a) perforating branches of the internal mammary artery;
(b) lateral branches of the posterior intercostal arteries; and
(c) branches from the axillary artery, including highest thoracic, lateral thoracic, and pectoral branches of the thoracoacromial artery. The second, third, and fourth anterior intercostal
perforators, and branches of the internal mammary artery,
arborize in the breast. (See Schwartz 11th ed., pp. 544–545.)
CHAPTER 17
Breast
12. Which of the following hormonal effects on the breast is
correct?
A. Estrogen is responsible for lobule development.
B. Progesterone initiates ductal development.
C. Prolactin is responsible for milk letdown.
D. Oxytocin initiates contraction of myoepitherium.
Answer: D
Estrogen initiates ductal development, whereas progesterone
is responsible for differentiation of epithelium and for lobular development. Prolactin is the primary hormonal stimulus
for lactogenesis in late pregnancy and the postpartum period.
Oxytocin release is due to auditory, visual, and olfactory
stimuli associated with nursing. Oxytocin initiates contraction, which results in compression of alveoli and expulsion
of milk into the lactiferous sinuses. (See Schwartz 11th ed.,
pp. 547–548.)
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13. All of the following are mechanisms underlying development of gynecomastia EXCEPT:
A. Neoplasms of testis
B. Lung carcinoma
C. Cirrhosis
D. Marfan syndrome
14. Concerning infections of the breast, which of the follow-
CHAPTER 17
Breast
ing are TRUE?
A. Most common organism is Escherichia coli.
B. Operative drainage is the most common therapeutic
approach.
C. Fungal infections of the breast are most commonly
initiated by nursing infants.
D. Bilateral Mondor disease is more common than uni-
lateral disease.
15. Correct statements about risk of developing breast cancer include all of the following EXCEPT:
A. Lifetime risk in US females is 20%.
B. Increased risk with exposure to therapeutic radiation
in adolescence.
C. Early menarche.
D. Older age at first live birth.
Answer: D
(See Schwartz 11th ed., p. 549 [see chart].)
Answer: C
Staphylococcus aureus and Streptococcus species are the organisms most frequently recovered from nipple discharge from
an infected breast. Previously almost all breast abscesses were
treated by operative incision and drainage, but now the initial
approach is antibiotics and repeated aspiration of the abscess,
usually ultrasound-guided aspiration. Intraoral fungi that are
introduced into the breast tissue by the suckling infant can
initiate infection which presents as mammary abscesses in
close proximity to the nipple-areola complex. Mondor disease is a variant of thrombophlebitis involving the superficial
veins of the anterior chest wall and breast. The presentation is
rarely bilateral. (See Schwartz 11th ed., p. 550.)
Answer: A
The average lifetime risk of breast cancer for newborn US
females is 12%. Gail et al developed the model most frequently used in the United States, which incorporates age, age
at menarche, age at first live birth, the number of breast biopsy
specimens, any history of atypical hyperplasia, and number of
first-degree relatives with breast cancer. (See Schwartz 11th
ed., p. 555.)
16. Which of the following are correct concerning BRCA
mutations?
A. Fifteen percent of breast cancers are caused by BRCA
mutations.
B. BRCA mutations play a role in DNA damage response
pathways.
C. Male BRCA2 mutation carriers have an equal risk
of developing breast cancer compared to noncarrier
males.
D. Twenty-five percent of women with BRCA mutation
have inherited the mutation from their fathers.
17. Therapeutic options for early invasive breast cancer
include all of the following EXCEPT:
A. Mastectomy with axillary staging.
B. Neoadjuvant systemic therapy with radiation.
C. Lumpectomy with axillary staging and radiation.
D. Mastectomy with axillary staging and immediate
reconstruction.
Answer: B
Up to 5% of breast cancers are caused by inheritance of germline mutations, such as BRCA1 and BRCA2, which are inherited in an autosomal dominant fashion with varying degrees
of penetrance. Data accumulated from the isolation of the
BRCA1 gene suggest a role in cell cycle control and DNA
damage repair pathways. Female mutation carriers have been
reported to have up to 85% lifetime risk for developing breast
cancer. Unlike male carriers of BRCA1 mutations, men with
germline mutations in BRCA2 have an estimated breast cancer risk of 6%, which represents a 100-fold increase over the
risk in general male population. Fifty percent of the women
with a BRCA mutation have inherited the mutation from
their fathers. (See Schwartz 11th ed., pp. 558–560.)
Answer: B
NSABP B-06 compared total mastectomy to lumpectomy
with or without radiation therapy in the treatment of women
with stages I and II breast cancer. After 5- and 8-year followup periods, the disease-free, distance disease-free, and overall
survival rates for lumpectomy with or without radiation therapy were similar to those observed after total mastectomy.
However, the incidence of ipsilateral breast cancer recurrence
was higher in the group not receiving radiation therapy. For
most patients with early stage disease, reconstruction can be
performed immediately at the time of the mastectomy. Immediate reconstruction allows for skin-sparing, thus optimizing
cosmetic outcomes. (See Schwartz 11th ed., pp. 582–583.)
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18. Which of the following are true concerning mastectomy?
A. Skin-sparing mastectomy removes all breast tissue,
the nipple-areola complex, and previous biopsy scars.
B. Extended simple mastectomy removes all breast tis-
sue, nipple-areola complex, and level I and II axillary
lymph nodes.
C. Modified radical mastectomy removes all breast tis-
sue, nipple-areola complex, and level I and II axillary
lymph nodes.
D. Radical mastectomy removes all breast tissue, nipple-
areola complex, and levels I, II, and III axillary lymph
nodes, the pectoralis major muscle, and internal
mammary lymph nodes sampling.
Answer: A
A skin-sparing mastectomy removes all breast tissue, the
nipple-areola complex, and scars from any prior biopsy procedures. A total (simple) mastectomy without skin sparing
removes all breast tissue, the nipple-areola complex, and skin.
An extended simple mastectomy removes all breast tissue,
the nipple-areola complex, skin, and the level I axillary lymph
nodes. A modified radical (“Patey”) mastectomy removes all
breast tissue, the nipple-areola complex, skin, and Ievel I, II,
and Ill axillary lymph nodes. The Halsted radical mastectomy
removes all breast tissue and skin, the nipple-areola complex,
the pectoralis major and pectoralis minor muscles, and the
levels I, II, and Ill axillary lymph nodes. (See Schwartz 11th ed.,
p. 591.)
CHAPTER 17
Breast
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CHAPTER 18
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Head and Neck
1. Which of the following statements are TRUE about leukoplakia of the vocal cords?
A. Up to 40% risk of progression to invasive carcinoma.
B. Ulceration is particularly suggestive of possible
malignancy.
C. Initial therapy includes antihistamines.
D. Biopsy should be considered only after 6 months of
conservative therapy.
2. Factors associated with increased incidence of head and
neck cancers include all of the following EXCEPT:
A. Human papillomavirus (HPV) exposure.
B. Ultraviolet light exposure.
C. Plummer-Vinson syndrome.
D. Reflux esophagitis.
Answer: B
Leukoplakia of the vocal fold represents a white patch (which
cannot be wiped off) on the mucosaI surface, usually on the
superior surface of the true vocal cord. Rather than a diagnosis
per se, the term leukoplakia describes a finding on laryngoscopic examination. The significance of this finding is that it
may represent squamous hyperplasia, dysplasia, and/or carcinoma. Lesions exhibiting hyperplasia have a 1% to 3% risk
of progression to malignancy. In contrast, that risk is 10% to
30% for those demonstrating dysplasia.
Furthermore, leukoplakia may be observed in association
with inflammatory and reactive pathologies, including polyps,
nodules, cysts, granulomas, and papillomas. Features of ulceration and erythroplasia are particularly suggestive of possible
malignancy. A history of smoking and alcohol abuse should
also prompt a malignancy work-up. In the absence of suspected
malignancy, conservative measures are used for 1 month. Any
lesions that progress, persist, or recur should be considered for
excisional biopsy specimen. (See Schwartz 11th ed., p. 625.)
Answer: D
HPV is an epitheliotropic virus that has been detected to various
degrees within samples of oral cavity squamous cell carcinoma.
Infection alone is not considered sufficient for malignant conversion; however, results of multiple studies suggest a role for
HPV in a subset of head and neck squamous cell carcinoma.
Multiple reports reflect that up to 40% to 60% of current diagnoses of tonsillar carcinoma demonstrate evidence of HPV
types 16 or 18. Environmental ultraviolet light exposure has
been associated with the development of lip cancer. The projection of the lower lip, as it relates to this solar exposure, has
been used to explain why the majority of squamous cell carcinomas arise along the vermilion border of the lower lip. In
addition, pipe smoking also has been associated with the development of lip carcinoma. Factors such as mechanical irritation,
thermal injury, and chemical exposure have been described
as an explanation for this finding. Other entities associated
with oral malignancy include Plummer-Vinson syndrome
(achlorhydria, iron-deficiency anemia, mucosal atrophy of
mouth, pharynx, and esophagus), chronic infection with syphilis, and immunocompromised status (30-fold increase with
renal transplant). (See Schwartz 11th ed., p. 630.)
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3. All of the following are TRUE about tracheostomy
EXCEPT:
A. Should be performed in patients anticipated to be
intubated more than 2 weeks.
B. Improves patient discomfort as compared to long-
term oropharyngeal intubation.
C. Usually spontaneously close within 2 months of
removal.
CHAPTER 18
D. Does not obligate patient to loss of speech.
Head and Neck
4. Which of the following is TRUE concerning facial
fractures?
A. The angle of the mandible is the most common site of
facial fracture.
B. Zygoma fractures are typically displaced inferiorly
and/or medially.
C. Midface fractures are classified as Le Fort I, II, III, or IV.
D. Temporal bone fractures, especially with cerebrospi-
nal fluid (CSF) leakage, usually require open repair.
Answer: C
The avoidance of prolonged orotracheal intubation decreases
the risk of laryngeal and subglottic injury and potential stenosis, facilitates oral and pulmonary suctioning, and decreases
patient discomfort. When the tracheostomy is no longer
needed, the tube is removed and closure of the opening usually occurs spontaneously over a 2-week period. Placement of
a tracheostomy does not obligate a patient to loss of speech.
When a large-cuffed tracheostomy tube is in place, expecting a patient to be capable of normal speech is impractical.
However, after a patient is downsized to an uncuffed tracheostomy tube, intermittent finger occlusion or Pass-Muir valve
placement will allow a patient to communicate while using
the tracheostomy to bypass the upper airway. (See Schwartz
11th ed., pp. 652–654.)
Answer: B
The most common facial fracture involves the mandible; the
most common sites of mandibular fracture include the condyle (36%), body (35%), and angle (20%). Midface fractures
are rarely isolated and include multiple subsites. However,
isolated zygoma fractures are typically displaced inferiorly
and medially with disruption of the suture lines between the
temporal, frontal, and maxillary bones and the zygoma. There
are three classic patterns of more extensive mid face fractures:
Le Fort I, II, and III. In patients with optic capsule involving
temporal bone fractures, typically caused by occipitomastoid
impact, sensorineural hearing loss, facial nerve paralysis, and
CSF leak are common. Regardless of the fracture pattern,
when a CSF leak is suspected, it usually resolves with conservative management including bed rest, elevation of the head
of the bed, stool softeners, and avoiding sneezing or straining.
(See Schwartz 11th ed., p. 628.)
5. Concerning head and neck malignancy, which of the following is FALSE?
A. Risk of developing second primary or recurrent
tumor is fourfold greater with continued smoking.
B. Lychee nut chewing predisposes to tumor
development.
C. Marijuana smoking predisposes to tumor
development.
D. RNA virus exposure, such as human papillomavirus
(HPV), predisposes to tumor development.
6. The management of laryngeal cancer depends on all of
the following EXCEPT:
A. Stage of disease.
B. Patient comorbidities.
C. Quality of life preferences.
D. Patient gender.
Answer: B
Continued smoking after completion of treatment is associated with a three- to fourfold increased risk of developing a
second primary or recurrent tumor. Betel nut/quid chewing is
endemic to some parts of Asia and India, and in these regions
oral cavity malignancy is one of the most common cancers.
In Europe and North America, there has been an increasing
interest in decriminalizing marijuana smoking; there is a
strong correlation between this activity and head and neck
cancers. (See Schwartz, 11th ed., p. 630.)
Answer: D
The primary management of laryngeal cancer depends on a
variety of factors, including tumor extent, patient comorbidities, and surgeon/center experience. Stage-specific treatment
recommendations are not dependent on patient gender. (See
Schwartz 11th ed., p. 641.)
CHAPTER 19
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Chest Wall, Lung, Mediastinum, and Pleura
1. The tracheal blood supply includes all the following
EXCEPT:
A. Inferior thyroid artery.
B. Subclavian artery.
C. Internal thoracic.
D. Common carotid artery.
Answer: D
The tracheal blood supply, which includes the inferior thyroid,
subclavian, supreme intercostal, internal thoracic, innominate, and superior and middle bronchial arteries, enters the
airway near the junction of the membranous and cartilaginous
portions. Each arterial branch supplies a segment of 1.0 to
2.0 cm, thereby limiting circumferential mobilization to that
same distance. The vessels are interconnected along the lateral
surface of the trachea by an important longitudinal vascular
anastomosis that feeds transverse segmental vessels to the soft
tissues between the cartilages. The common carotid artery
does not give rise to an arterial blood supply to the trachea
(Fig. 19-1). (See Schwartz 11th ed., p. 663, Fig. 19-2.)
Inferior
thyroid a.
Branch from
internal thoracic a.
Superior bronchial a.
3
2
1
Lateral longitudinal
anastomosis
FIG. 19-1. Arterial blood supply to the larynx and upper
trachea. a. = artery.
Middle bronchial a.
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Epiglottis
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CHAPTER 19
Internal
laryngeal n.
Aryepiglottic m.
Transverse, oblique
arytenoid mm.
Chest Wall, Lung, Mediastinum, and Pleura
FIG. 19-2. Anatomy of the larynx and upper trachea.
m. = muscle; n. = nerve.
2. The narrowest part of the trachea which measures
approximately 2 cm in adults is:
A. Level of the carina.
B. Subglottic space.
C. Level of cricoid cartilage.
D. Mid trachea (~ 10th tracheal ring).
cricoarytenoid m.
Posterior
cricoarytenoid m.
Thyroid cartilage
facet
Recurrent
laryngeal n.
Answer: B
The trachea is composed of cartilaginous and membranous
portions, beginning with the cricoid cartilage, the first complete cartilaginous ring of the airway. The cricoid cartilage
consists of an anterior arch and a posterior broad-based plate.
Articulating with the posterior cricoid plate are the arytenoid
cartilages. The vocal cords originate from the arytenoid cartilages and then attach to the thyroid cartilage. The subglottic space, the narrowest part of the trachea with an internal
diameter of approximately 2 cm, begins at the inferior surface
of the vocal cords and extends to the first tracheal ring. The
remainder of the distal trachea is 10.0 to 13.0 cm long, consists of 18 to 22 rings, and has an internal diameter of 2.3 cm
(Fig. 19-2). (See Schwartz 11th ed., p. 663, Fig. 19-1.)
Lateral
Thyroepiglottic m.
Thyroarytenoid m.
Cricothyroid m.
(cut)
3. All of the following increase the risk for tracheal stenosis
EXCEPT:
A. Age > 70 years.
B. Radiation.
C. Male gender.
D. Excessive corticosteroid therapy.
Answer: C
Intubation-related risk factors include: prolonged intubation;
high tracheostomy through the first tracheal ring or cricothyroid membrane; transverse rather than vertical incision
on the trachea; oversized tracheostomy tube; prior tracheostomy or intubation; and traumatic intubation. Stenosis is also
more common in older patients, in females, after radiation,
or after excessive corticosteroid therapy, and in the setting of
concomitant diseases such as autoimmune disorders, severe
reflux disease, or obstructive sleep apnea and the setting of
severe respiratory failure. However, even a properly placed
tracheostomy can lead to tracheal stenosis because of scarring and local injury. Mild ulceration and stenosis are frequently seen after tracheostomy removal. Use of the smallest
tracheostomy tube possible, rapid downsizing, and a vertical
tracheal incision minimize the risk for posttracheostomy stenosis. (See Schwartz 11th ed., p. 663.)
4. The tracheobronchial tree consists of approximately
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23 airway divisions to the level of the alveoli. Mucus production in the airways is derived from which cell type?
A. Clara cells
B. Kulchitsky cells
C. Goblet cells
D. Type 1 pneumocytes
The lung can be conveniently viewed as two linked components: The tracheobronchial tree (or conducting airways
component) and the alveolar spaces (or gas exchange component). The tracheobronchial tree consists of approximately
23 airway divisions to the level of the alveoli. It includes the
main bronchi, lobar bronchi, segmental bronchi (to designated
bronchopulmonary segments), and terminal bronchioles
(ie, the smallest airways still lined by bronchial epithelium and
without alveoli). The tracheobronchial tree is normally lined
by pseudostratified ciliated columnar cells and mucous (or
goblet) cells, which both derive from basal cells (Fig. 19-3).
Ciliated cells predominate. Goblet cells, which release mucus,
can significantly increase in number in acute bronchial
injury, such as exposure to cigarette smoke. The normal bronchial epithelium also contains bronchial submucosal glands,
which are mixed salivary-type glands containing mucous
cells, serous cells, and neuroendocrine cells called Kulchitsky
cells, which are also found within the surface epithelium. The
bronchial submucosal glands can give rise to salivary gland–
type tumors, including mucoepidermoid carcinomas and
adenoid cystic carcinomas. (See Schwartz 11th ed., p. 668.)
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CHAPTER 19
Chest Wall, Lung, Mediastinum, and Pleura
FIG. 19-3. Normal lung histology.
A. Pseudostratified ciliated columnar
cells and mucous cells normally line the
tracheobronchial tree. B. A Kulchitsky cell
is depicted (arrow).
A
B
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