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Contributors
xxiii
Patrick Murphy Divisions of Trauma and Acute Care Surgery, Department of Surgery,
Medical College of Wisconsin, Milwaukee, WI, USA
QuinnMurray Division of Acute Care Surgery, Department of Surgery, Thomas Jefferson
University, Philadelphia, PA, USA
Salvatore Nardello Division of Surgical Oncology and Breast Surgery, Department of
Surgery,Tufts Medical Center,, Boston, MA, USA
WissamNasser Department of Surgery, Thomas Jefferson University Hospital, Philadelphia,
PA, USA
RaduAlexandruNedelcoviciu Division of Acute Care Surgery, Thomas Jefferson University
Hospital, Philadelphia, PA, USA
MarcNeff Department of Surgery, Jefferson Health of New Jersey, Cherry Hill, NJ, USA
Khaled Noueihed Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
Olugbenga T. Okusanya Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
DevonPace Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson
University, Philadelphia, PA, USA
DavidPalange Division of Surgery, Christiana Care Health System, Newark, DE, USA
General Surgery, Christiana Care Health System, Newark, DE, USA
RachaelPalumbo Department of Surgery, Yale School of Medicine, New Haven, CT, USA
LindseyL.Perea Division of Trauma and Acute Care Surgery, Department of Surgery, Penn
Medicine Lancaster General Health, Lancaster, PA, USA
Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
SouravPodder Department of Surgery, Thomas Jefferson University Hospital, Philadelphia,
PA, USA
AndreaS.Porpiglia Fox Chase Cancer Center, Philadelphia, PA, USA
Jesse Powell Division of Surgical Critical Care and Trauma, Department of Emergency
General Surgery, Christiana Care Hospital, Newark, DE, USA
MichaelPryor General Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, USA
Odessa R. Pulido Division of Trauma and Acute Care Surgery, Department of Surgery,
Cooper Medical Center, Camden, NJ, USA
Division of Trauma and Acute Care Surgery, Department of Surgery, University of Nevada Las
Vegas, Las Vegas, NV, USA
Asanthi Ratnasekera Trauma, Emergency General Surgery, and Surgical Critical Care,
Newark, DE, USA
Wendy Y.Rockne Division of Trauma, Burns and Surgical Critical Care, Department of
Surgery, University of California, Irvine Medical Center, Irvine, CA, USA
EricaRoth Department of Surgery, Temple University Hospital, Philadelphia, PA, USA
JohnathanSadeh General Surgery, Jefferson Einstein Hospital, Philadelphia, PA, USA
Department of Surgery, Jefferson Einstein Hospital, Philadelphia, PA, USA
xxiv
PeterSantoro General Surgery, Department of Surgery, Christiana Care Hospital, Wilmington,
DE, USA
IsaacSchmied Trinity Health Ann Arbor Hospital, Ypsilanti, MI, USA
JosephA.Sciacca Division of Surgery, Christiana Care Health System, Newark, DE, USA
General Surgery Residency,Christiana Care Hospital, Newark, DE, USA
SirivanSeng Department of Surgery, Northwestern Memorial Hospital, Chicago, IL, USA
VictoriaSharp Trauma, Acute, and Critical Care Surgery, Trinity Health Ann Arbor Hospital,
Ypsilanti, MI, USA
CharlesShearer Florida International University College of Medicine, Miami, FL, USA
Hannah Shin Department of Surgery, Philadelphia College of Osteopathic Medicine,
Philadelphia, PA, USA
AnnaShu Trauma, Acute, and Critical Care Surgery Central Michigan University College of
Medicine, Saginaw, MI, USA
Trauma, Acute, and Critical Care Surgery,Trinity Health Ann Arbor, Ypsilanti, MI, USA
Alexander Simmonds Department of Surgery, Virginia Commonwealth University,
Richmond, VA, USA
HannahSoeld Department of Surgery, Cooper University Hospital, Camden, NJ, USA
Contributors
TaherehSoleimani Department of Surgery, Indiana University, Indianapolis, IN, USA
LeahSteinmetz Department of Surgery, Cooper University Hospital, Camden, NJ, USA
Matthew Sturdivant Division of Surgical Critical Care and Trauma, Department of
Emergency General Surgery, Christiana Care Hospital, Newark, DE, USA
LeahC.Tatebe Department of Surgery, Northwestern University, Chicago, IL, USA
DarshakThosani Department of Surgery, Thomas Jefferson University Hospital, Philadelphia,
PA, USA
Pranjal Thosani Department of Surgery, Main Line Health—Lankenau Medical Center,
Philadelphia, PA, USA
AleyTohamy Mercy Fitzgerald Hospital, Darby, PA, USA
SageA.Vincent Department of Surgery, Thomas Jefferson University Hospital, Philadelphia,
PA, USA
Abdullah Wafa,MD Division of Trauma and Acute Care Surgery, Inova Fairfax Medical
Campus, Falls Church, VA, USA
Natalie Wall Department of Surgery, Virginia Commonwealth University, Richmond, VA,
USA
CandaceL.Ward Department of Surgery, Einstein Healthcare Network, Philadelphia, PA,
USA
Department of Surgery, Jefferson Einstein Medical Center Philadelphia, Philadelphia, PA,
USA
CarlyWareham Department of Surgery, Tufts Medical Center, Boston, MA, USA
Lindsay Weil Department of General Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
Contributors
xxv
JohnWilliamson Department of Surgery, Cooper University Hospital, Camden, NJ, USA
NathanWong Medstar Georgetown University Hospital, Washington, DC, USA
Conemaugh Memorial Medical Center, Johnstown, PA, USA
JacobWoodroof Department of Surgery, Thomas Jefferson University Hospital, Philadelphia,
PA, USA
Kahyun Yoon-Flannery Cooper University Hospital, Cooper Medical School of Rowan
University, Camden, NJ, USA
Breast Surgery, Cooper University Hospital, Cooper Medical School of Rowan University,
Camden, NJ, USA
Amy Young Department of Surgery, Philadelphia College of Osteopathic Medicine,
Philadelphia, PA, USA
RadiZaki Department of Surgery, Einstein Healthcare Network, Philadelphia, PA, USA
ClaraZhu Department of Surgery, Cooper University Healthcare, Camden, NJ, USA
Part I
Breast
Nipple Discharge
JennaMancinelli andAdrianLopez
1
Concept
Among breast-associated complaints from patients, nipple
discharge is the third most common, and it is also a frequent
cause of referral to a surgeon; therefore, it is a potential scenario on the General Surgery Oral Boards.
Nipple discharge has a variety of etiologies, ranging from
benign to malignant, and can be categorized as physiologic or
pathologic. During the Oral Boards, a breast scenario that
includes a patient with nipple discharge will likely lead to the
diagnosis of malignancy; however, that does not mean that
the examinee should only focus on ruling out that possibility
since there are other sources of nipple discharge, not related
to malignancy that also need special attention. Some of the
systemic conditions associated with nipple discharge and not
related to malignancy are pregnancy/breastfeeding, medications (antidepressants, antiemetics, calcium channel blockers,
among others), hypothyroidism, and pituitary tumors like
prolactinoma. History and physical are key in ruling out these
causes, so, asking questions like date of last menstrual period,
any relevant medications, any recent weight gain, neck
masses, and headaches or visual disturbances would likely be
enough to allow the examiner to guide you on where the case
is going: lactation/physiologic/systemic origin VS pathologic/breast origin.
Indicators of nipple discharge associated with pathologic
causes like tumors include unilateral discharge, bloody discharge, and an associated mass and/or skin or nipple changes
of the breast. The most common causes of pathologic discharge are intraductal papilloma (35–48%), ductal ectasia
(17–36%), malignancy (5–21%), and infection (<5%).
Although most nipple discharge is benign, it is imperative to
identify patients with pathologic discharge and ensure that
they are thoroughly evaluated and appropriately managed.
J. Mancinelli · A. Lopez (*)
Department of Surgery, Cooper University Hospital,
Camden, NJ, USA
e-mail: mancinelli-jenna@cooperhealth.edu;
lopez-adrian@cooperhealth.edu
Oral Board Scenario
“A 52-year-old female is referred to you by her primary care
provider for a complaint of persistent bloody nipple
discharge.”
As said before, for all questions regarding nipple discharge, it is important to obtain a thorough history and physical examination to establish whether the discharge is
physiologic or pathologic and to identify any risk factors for
malignancy. Inquire whether the discharge is spontaneous or
non-spontaneous, bilateral or unilateral, and what other associated symptoms or life events there may be. Determine the
quality of the discharge (e.g., bloody, clear, purulent) if it is
not stated in the question.
How toAnswer?
Full History
• Quality (e.g., bloody, clear, milky, serous, purulent) and
duration of the discharge
• Laterality of the discharge
• Does it occur spontaneously or with stimulation
• Recent or current pregnancy or lactation
• Recent trauma or injury to the breast
• Associated mass(es), skin changes, pain
• Associated symptoms or changes to health (e.g. amenor-
rhea, hot ashes) or new medications
• Risk factors for malignancy, including family history
Full Physical Examination
• Inspect and palpate both breasts in upright and supine
positions to assess for skin changes, nipple retraction,
masses, tender areas, lesions of the nipple-areolar
complex
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_1
3
4
J. Mancinelli and A. Lopez
• Examine the axillary and supraclavicular lymph nodes
bilaterally
• It is reasonable to attempt to express discharge (by the
physician or patient herself) from the nipples bilaterally
to identify how many and which ducts may be involved,
as well as to assess the quality of the uid
– Involvement of a single duct is more likely to be a
malignant process
Diagnostic Tests
• Diagnostic mammogram—rst line in all males and all
females >30years old
• Focused breast ultrasound—often in combination with
mammogram, but can be used as rst line in females
<30years old
*These 2 methods will diagnose the vast majority of
structural causes of nipple discharge in the breast and
likely they will be enough for the examiner to guide you
where the case is going*
• MRI of b/l breast W/WO contrast—excellent imaging
method if mammogram and ultrasound are both
negative
• Galactography—only applicable if discharge is reproducible, technically challenging study (generally not a correct answer)
• Ductoscopy—only applicable if discharge is reproducible,
minimally invasive, painful (generally not a correct answer)
• Cytology—not recommended, cannot exclude malignancy if negative and false negative rate of around 50%
• Skin punch biopsy—Acceptable option if there is a skin/
nipple-areola complex visible lesion (e.g., Paget’s
disease)
A valid alternative to surgery for biopsy proven benign
lesions like broadenomas is to monitor the lesion
with breast imaging every 6months for 2years. This is
particularly reasonable in patients that are asymptomatic or have signicant medical problems for what surgery might represent a higher risk than leaving the
benign lesion in the breast.
• If no suspicious lesion is detected on imaging (including MRI), then excisional biopsy of the discharging
ducts or retro-areolar tissue with duct exploration is
a reasonably safe option. Alternatively, repeating
images in 3–6months (mammogram, US or MRI are
all safe answers) will also be an acceptable way to manage the case.
• For pathologic discharge with a palpable breast
mass, follow the standard evaluation and management of a breast mass. (H/P, imaging and core needle
biopsy).
Surgical Procedure
Subareolar Duct Excision
• Periareolar incision along lateral areola
• Elevate the areola skin ap
• Dissect the ducts leading to the areola
• Choose to identify the abnormal duct (dilate, wire, methylene blue, physical abnormality) or excise the entire ductal complex sharply from immediately beneath the nipple
dermis to a depth of 4–5cm within the breast tissue
• Ligate the distal ducts to prevent formation of stulas
• Orient specimen and send to pathology for analysis
Common Curveballs
Treatment
In the majority of cases during the Oral Board, a patient presenting with nipple discharge will have a suspicious nding
on mammogram or US.
• If a suspicious lesion is detected on imaging, obtain core
needle biopsy with placement of biopsy clip.
– If biopsy is positive for malignancy, then treat the can-
cer (see breast cancer chapter).
– If biopsy is benign (broadenoma, intraductal papil-
loma, etc.), the safest answer is to perform an exci-
sional biopsy of the lesion in the OR. (Do not forget
that a localization method like a wire or a wireless
localization will be needed for non-palpable lesions).
• Special patient populations (e.g., pregnant, lactating,
male, teenager)
• Pathology returns as malignancy
• Persistent nipple discharge after subareolar excision
(seroma vs. need for additional excision vs. check physiologic causes if not done before)
• Post-operative complication (duct stula, nipple necrosis,
infection)
Clean Kills
• Performing surgery for physiologic nipple discharge
(bilateral, milky, clear)
• Failing to perform full physical examination, including
both breasts
1 Nipple Discharge
5
• Failing to assess risk factors for malignancy
• Failing to obtain appropriate imaging (mammogram,
ultrasound)
• Discussing ductoscopy or galactography
• Utilizing or relying on cytology results
• Focusing on prolactinoma work-up
• Failing to treat an identied malignancy or suspicious
lesion
• Inability to shift into discussion of malignancy
Summary
In the evaluation and work-up of nipple discharge, it is
important to perform a thorough history and physical
examination to determine whether the discharge is physiologic or pathologic, as well as to identify risk factors for
malignancy. Diagnostic mammogram is the rst line
imaging for most patient populations and it should be
coupled with ultrasound. Breast imaging, core needle
biopsy, and surgical excision are the tenets of treatment
for pathologic nipple discharge. It is essential to rule out
malignancy in these cases and to know how to manage
malignant ndings since it is very likely that a nipple discharge case will ultimately lead to a breast cancer
discussion.
Bibliography
Golshan M. Nipple discharge. UpToDate. https://www.uptodate.com/
contents/nipple- discharge. Accessed 18 Oct 2023.
Gray RJ, Pockaj BA, Karstaedt PJ. Navigating murky waters: a
modern treatment algorithm for nipple discharge. Am J Surg.
2007;194:850–5.
King TA, Carter KM, etal. A simple approach to nipple discharge. Am
Surg. 2000;66:960–6.
Lee S, Trikha S, etal. ACR appropriateness criteria evaluation of nipple
discharge. J Am Coll Radiol. 2017;14(5):S138–53.
Rao R.Surgical management of pathologic nipple discharge. UpToDate.
https://www.uptodate.com/contents/surgical- management- ofpathologic- nipple- discharge. Accessed 18 Oct 2023.
Santen RJ, Mansel R. Benign breast disorders. N Engl J Med.
2005;353:275.
Vargas HI, Vargas MP, etal. Outcomes of clinical and surgical assess-
ment of women with pathological nipple discharge. Am Surg.
2006;72:124–8.
Abnormal Mammogram
JennaMancinelli andAdrianLopez
2
Concept
Breast cancer is the most common cancer, not only in the
USA but also worldwide. The average risk of developing
breast cancer is estimated to be 13% in a lifetime. The advent
of screening mammography has greatly increased the early
detection of breast cancer and subsequently decreased mortality and morbidity related to breast cancer. It remains the
gold standard for breast cancer screening. The National
Comprehensive Cancer Network (NCCN) and the American
College of Radiology (ACR) recommend women have
annual screening mammograms beginning at age 40.
The two standard views performed during a screening
mammogram are the craniocaudal (CC) view and the mediolateral oblique (MLO) view. The ndings from mammography are categorized according to the Breast Imaging
Reporting and Data System (BI-RADS) classication system and it is very important for the Oral Boards to know this
classication and the different steps that follow after each
result (see BI-RADS classication and management below).
This is often combined with a focused breast ultrasound, particularly in young women and dense breast tissue on
mammograms.
concerning or suspicious and understand how they may be
categorized. Concerning ndings include irregular border,
asymmetry, spiculated mass, architectural distortion, and
internal vascularity.
How toAnswer?
Full History
• Risk factors for malignancy (estrogen exposure, family
history of cancer, previous history of breast biopsy, history of radiation to the chest)
• Symptoms (pain, palpable mass, skin changes)
• Recent changes to overall health (unintended weight loss,
night sweats, fevers)
• Recent or current pregnancy or lactation
• Recent or remote trauma to the breast
• Compliance with screening mammogram schedule
• Full review of systems
Full Physical Examination
• Inspect and palpate both breasts in upright and supine
Way Question May BeAsked?
“A 44-year-old female presents to your ofce after getting
her annual screening mammogram with a nding of a
0.9 cm area of architectural distortion with associated
microcalcications.”
The BI-RADS category likely will be given to you; however, this might not be the case in all breast cases and it is
important to understand which mammogram ndings are
J. Mancinelli · A. Lopez (*)
Department of Surgery, Cooper University Hospital,
Camden, NJ, USA
e-mail: mancinelli-jenna@cooperhealth.edu;
lopez-adrian@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_2
positions
• Assess for skin changes, nipple retraction, masses, tender
areas
• Attempt to elicit nipple discharge bilaterally
• Examine the axillary and supraclavicular lymph nodes
bilaterally
Diagnostic Tests
• Diagnostic mammogram (this is the next best step after an
abnormal screening mammogram)
• Focused breast ultrasound (usually performed in combination with diagnostic mammogram)
7
8
J. Mancinelli and A. Lopez
• MRI breast (if extremely dense breast tissue, or a suspicious breast physical exam that has normal diagnostic
mammogram/US)
• Biopsy (stereotactic vs ultrasound guided, core needle vs
ne needle vs excisional)
BIRADS Classication
BI-RADS 0: incomplete evaluation, requires additional
imaging (typical case is a screening mammogram with an
abnormal nding. Even if the nding is highly suspicious,
it will be categorized as BI-RADS 0 and having diagnostic mammogram +/− US will be the next best step)
BI-RADS 1: negative, continue with regular surveillance
schedule
BI-RADS 2: benign, continue with regular surveillance
schedule
BI-RADS 3: probably benign (<2% probability for malig-
nancy), short-term follow-up imaging is the next best
step. This usually means a repeat mammogram, US or
both at 3–6months. (The typical case is a round, small
mass with regular borders which is suggestive of a broadenoma). Generally these probably benign lesions are
followed every 6months for a total of 2years and if they
remain stable during that period, they get re-categorized
as benign BI-RADS 2. In the other hand, if there is growth
of the lesion or it develops suspicious features (irregular
borders, internal vascularity, spiculations, etc), they get
re-categorized as BI-RADS 4 and core needle biopsy is
recommended).
BI-RADS 4: suspicious for malignancy, it requires core nee-
dle biopsy (guided by US or stereotactic depending on
what imaging study was able to identify the suspicious
lesion). FNA is not the optimal biopsy method, given that
it cannot differentiate between in situ vs invasive carcinoma; however, there might be some value in FNA of a
suspicious lymph node since the presence of carcinoma
cells alone in the lymph node can only mean that the carcinoma is invasive. However, false negative rates in FNA
are higher than core needles and that is why core needle
biopsy is the safest answer when choosing a biopsy
approach in breast pathology.
BI-RADS 4A: 2–9% probability for malignancy (low
yield)
BI-RADS 4B: 10–49% probability for malignancy
(low yield)
BI-RADS 4C: 50–94% probability for malignancy
(low yield)
BI-RADS 5: highly suggestive of malignancy (>95% proba-
bility), requires core needle biopsy (the relevant aspect of
BI-RADS 5 vs BI-RADS 4 is that although both are managed the same way, with a core needle biopsy as the next
step. If the biopsy results come back benign in a BI-RADS
5, likely this will be considered a non-concordant result
from missing the target during the biopsy procedure and
surgical excision of the lesion would be the next best step
in that situation).
BI-RADS 6: imaging performed in patient with a known
malignancy.
Surgical Procedure
Excisional Biopsy
• Indicated in non-cancer lesions for symptomatic relief,
growth or patient’s preference, non-concordant results on
needle biopsy and high risk lesions (ADH, ALH, LCIS)
• Choose a localizer for the lesion (ultrasound guidance,
needle localizer, tag/seed/SAVI) and review images
pre-operatively
• Circumareolar incision or incision over the mass or along
a natural curve of the breast
• Develop aps circumferentially around the lesion
• Excise the mass
• Orient the specimen and send it to pathology
• Obtain hemostasis
• Cosmetic skin closure
Common Curveballs
• Discordant ndings on two types of imaging or on imaging and biopsy
• Special patient populations (pregnant, lactating, male,
teenager, geriatric)
• Pathology returns as malignancy
• Pathology returns as a high risk lesion
• Lost or broken localizer
• Previous biopsy clip not within specimen
• Post-operative complications (hematoma, missed lesion,
positive margins)
Clean Kills
• Failure to perform full physical examination, including
both breast
• Failing to assess for risk factors of malignancy
• Lack of knowledge of BI-RADS categories and incorrect
management on each case
• Performing surgery for benign lesions without clear
indication
• Failure to obtain diagnostic imaging
• Failure to obtain biopsy when indicated
• Inability to shift into discussion of malignancy
2 Abnormal Mammogram
9
Summary
Mammography is the gold standard screening modality
for breast cancer. Women are recommended to have
annual mammograms beginning at age 40 or sooner if
they are considered high-risk. It is important to understand common suspicious ndings on mammograms and
how they are classied according to BI-RADS, as well as
the treatment recommendations for each BI-RADS category. Although many abnormal ndings will be amenable
to core needle biopsies, some lesions may require excisional biopsy to be performed. Knowing how to interpret
mammogram ndings and when and how to perform an
excisional biopsy are some of the main tenets of breast
surgery.
Bibliography
Caumo F, Zorzi M, etal. Digital breast tomosynthesis with synthesized
two-dimensional images versus full-eld digital mammography for
population screening: outcomes from the Verona screening program. Radiology. 2018;287(1):37.
Lee JM, Arao FR, etal. Performance of screening ultrasonography as
an adjunct to screening mammography in women across the spectrum of breast cancer risk. JAMA Intern Med. 2019;179(5):658.
Reeves RA, Kaufman T. Mammography. In: StatPearls. Treasure
Island, FL: StatPearls Publishing; 2023. https://www.ncbi.nlm.nih.
gov/books/NBK559310/.
Slanetz PJ, Lee CI. Breast imaging for cancer screening: mammog-
raphy and ultrasonography. UptoDate. https://www.uptodate.com/
contents/breast- imaging- for- cancer- screening- mammography- andultrasonography. Accessed 22 Oct 2023.
Weerakkody Y, Manning T, etal. Breast imaging-reporting and data
system (BI-RADS). Radiopaedia.org. Accessed 22 Oct 2023.