NBME 22 Answers : Block 2 : #15 = A 62-year-old woman comes to the physician 3 days ...

NBME 22 Answers

nbme22/Block 2/Question#15

A 62-year-old woman comes to the physician 3 days ...

Carcinoma of the breast

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submitted by usmleuser007(131),

Per Pathoma:

Most common in postmenopausal women:

1) fibrocystic changes, intraductal papilloma, Fibroadenoma

More likely in postmenopausal women: 1) phyllodes tumor (fibroadenoma-like tumor) 2) Breast cancers increased risk d/t 1) increased age, duration of estrogen throughout life (early menarche, late menopause, obesity) 2) Atypical hyperplasia 3) First degree relatives

Question states presents it as: a) 2cm firm, nontender mass b) no axillary lymphadenopathy or nipple discharge c) extremly radiodense mass with irregular margins clustered irregular microcalcifications

so what can it be: 1) DICS = does not usually produce mass

2) Comedo type = high- grade cells with necrosis & dystrophic calcifications at center of duct

3) Paget Disease = involves the skin of the nipple (underlying carcinoma)

4) IDC = a) forms duct-like structures (>80% of cases) b) mass detected by physical examination (check) c) usually 1cm or greater (check) d) Desmoplastic stroma = connective tissue growing with tumor (supports tumor) ~~~ (check -- irregular margins) e) Medullary Carcinome (IDC) = mimics fibroadenoma

5) LCIS & ILC = DO NOT produce calcifications or mass a) ILC - cells have "single-file pattern" think of a beaded necklace and you cut it in middle (lack E-cadherin)

usmleuser007 correction Most common in premenopausal women: 1) fibrocystic changes, intraductal papilloma, Fibroadenoma +

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submitted by joker4eva76(11),

Could also use the patient's age to make the differential. Age is a risk factor related to breast cancer (common in post-menopausal women, unless there's a history of breast cancer in the family).

Fibrocystic changes and fibroadenomas are usually common in premenopausal women.

No discharge noted, so it's not an intraductal papilloma.

yotsubato Intraductal papillomas are also under the areola +1

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submitted by airhead5(2),

The answer is carcinoma of the breast. I get that, but I’m having trouble figuring out which Carcinoma of Breast it is. I’m stuck between DCIS, and Invasive Ductal Carcinoma. I’m leaning towards Invasive Ductal Carcinoma, just because it’s (1) most common and (2) the mass with irregular margins in clusters sounds like it could be ‘stellate infiltration’, seen in Invasive Ductal Carcinoma. But I’m not sure. Can anyone help?

liverdietrying There is not enough information in the question stem to determine what kind of cancer it is. You would need a biopsy and histology information to determine that. However, this is definitely not DCIS since there *is* a mass. DCIS usually just shows up as small microcalcifications on XR (I’d google an image so you can see it). All the words they use here describe an invasive cancerous scary mass -- what kind of cancer can’t be known until they biopsy it! +

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submitted by oznefu(7),

What are the words that point to Carcinoma rather than Fibrocystic or Fibroadenoma or Fat Necrosis (not an answer)?

Those can have masses and calcifications right? Is it only the irregular margins?

mnemonia Fibrocystic changes doesn’t technically encompass sclerosing adenosis, which is the one where you would get calcifications. Cysts and fibrosis don’t usually present with calcifications. Fat necrosis I’m sure they would give history of trauma in the stem. +

mnemonia Calcifications = fat necrosis, sclerosing adenosis, and DCIS/IDC. Microcalcifications specifically I would venture to say is a buzzword ductal carcinoma specifically. Either way, of these 3, only cancer is an answer choice. +

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submitted by seagull(446),

The mass is in the outer upper quadrant, this is why it want DCIS. Nice and simple

seagull *wasn't +