Surgery IV Final-exam PDF

Surgery IV MCQ Book 2023-2024 Exclusive Modern Luxury  BFOM 39 Surgery IV Final-exam Index Topics...

Surgery IV MCQ Book 2023-2024 Exclusive Modern Luxury  BFOM 39 Surgery IV Final-exam Index Topics Page Number Department “Tricks” 4 Breast Schwartz “11th edition” 16 Lange “Q& A” 26 Department “Tricks” 43 Vascular Schwartz “11th edition” 66 “Arterial, Venous& Lymphatic” Lange “Q& A” 91 Bank 121 Anesthesia& preoperative care Schwartz “11th edition” 131 Lange “Q& A” 140 Bank 187 Hemorrhage, Blood transfusion, Schwartz “11th edition” 208 shock& Polytraumatized patient Lange “Q& A” 251  BFOM 39 Breast  BFOM 39 Department “Tricks” The axillary lymph nodes are divided into three levels I, II and III by A. The axillary artery. B. The axillary vein. C. The pectoralis minor muscle. D. The clavicle. About acute lactational breast abscess, one statement only is true: A. Is commonly multilocular. B. Weaning the baby is mandatory C. Aspirating pus by a wide bore needle is superior to incisional drainage as it avoids injury to lactiferous ducts D. Mammography is indicated if an abscess is suspected The following statements about fibrocystic breast are all true, except: A. May be asymptomatic B. May cause nipple retraction. C. Is a cause of breast pain D. Produces breast nodularity. Treatment of cyclic mastalgia may include all the following, except: A. Exclusion of malignancy and reassurance B. Avoidance of breast support C. Giving up caffeine consumption D. Bromocriptine 2.5 mg bid The following statements about fibroadenoma of the breast are all true, except: A. Usually affects females in the second and third decades of life. B. May be multiple. C. Freely mobile. D. If left untreated it turns malignant in 9% of cases within 15 years.  BFOM 39 Regarding breast cysts, one statement is true: A. The commonest is galactocele. B. Malignancy is suspected if the cyst is tense. C. Malignancy is suspected if the lump does not totally disappear after complete aspiration of fluid. D. Multiplicity of cysts raises suspicion of malignancy. The following statements about mammary duct ectasia are all true, except: A. May produce a mass similar to carcinoma in the axillary tail of the breast. B. May produce non-lactational mastitis and abscess. C. May produce a mamillary fistula. D. Anaerobic bacteria are commonly implicated. The commonest histological type of breast cancer is: A. Duct carcinoma in situ. B. Lobular carcinoma in situ. C. Invasive duct carcinoma. D. Invasive lobular carcinoma. A woman has a 3 cm breast mass. There are neither palpable axillary lymph nodes nor clinical evidence of metastasis. FNAC proves the presence of invasive duct carcinoma. TNM clinical staging is: T (Tumor): Describes the size of the primary tumor. A. T1 Nl Ml T1: Tumor is ≤ 2 cm in greatest dimension. T2: Tumor is > 2 cm but ≤ 5 cm in greatest dimension. B. T1 NO MO N (Nodes): Indicates whether cancer has spread to nearby lymph nodes. N0: No regional lymph node involvement. N1: Metastasis to movable ipsilateral axillary lymph nodes. C. T2 N2 MO N2: Metastasis to ipsilateral axillary lymph nodes that are fixed or matted. M (Metastasis): Indicates whether the cancer has spread to distant sites. D. T2 NO MO M0: No distant metastasis. M1: Distant metastasis present. Breast self-examination: A. Is recommended for all women above the age of twenty. B. Is recommended for women above the age of 40 only. C. Is recommended to be done monthly in the immediate premenstrual period. D. Is recommended to be done twice yearly.  BFOM 39 The following statements about mammography are all true, except: A. Indicated for the diagnosis of a breast lump. B. Indicated for regular screening of women who are at high-risk of development of breast cancer. C. Indicated for follow-up of contralateral breast after mastectomy for breast cancer. D. More informative in young women below the age of 35 years. US The following statements about breast cancer prognosis are all true, except: A. Is worsened by the detection of axillary node deposits. B. Is better in estrogen receptor +ve cases. C. Is better for tumours in the medial than in the lateral half of the breast. D. Is worse for invasive duct carcinoma than for cystosarcoma phylloides. The following statements about Paget's disease of the nipple are all true, except: A. Is lobular carcinoma arising at the opening of a lactiferous duct on the nipple. B. Should be differentiated from eczema of the nipple. C. Sometimes there is no palpable mass. D. Mastectomy is indicated. Regarding axillary node involvement in cancer of the breast, All of the following statements are true, except: A. Clinical assessment of the axilla is commonly inaccurate. B. Prognosis is affected by the number of affected nodes. C. Is an indication for adjuvant chemotherapy in early cases. Chemotherpy not irridiation D. Is an indication for adding irradiation of the axilla after its surgical evacuation. The following statements about pulmonary metastases of breast cancer are all true, Except: A. May be asymptomatic. B. May produce persistent cough. C. May produce dyspnea. D. If localized to one lung while the other lung shows good function, pneumonectomy is indicated.  BFOM 39 Haematogenous spread of breast cancer may produce any of the following, except: A. Brain metastases B. Fracture of the spine C. Pleural effusion D. Hypocalcaemia Hypercalcemia The following statements about lymphatic drainage of the breast are all true, except: A. Lymph from medial half of the breast may drain in internal mammary nodes. B. From anywhere in the breast lymphatics drain mostly to axillary nodes. C. Division of axillary nodes into levels I, II, and III depends upon the anatomical relationship with the pectoralis minor muscle. 3 D. Level one axillary nodes is the highest in the axilla. the lowest in the axilla. 2 1 Regarding duct carcinoma in situ of the breast, one statement only is true: A. May be discovered on screening mammography for asymptomatic women. B. Is not a true malignancy. C. It does not progress to invasive cancer but is a powerful marker of increased cancer risk. D. Close observation is all that is needed. Early breast cancer: A. Means a T1 N1 M0 tumor or less. B. Means that cure is impossible. C. Means that microscopic metastases are not present. D. Primary treatment is by surgery ± radiotherapy. For modified radical mastectomy all the following statements are true, except: A. The areola and nipple are removed. B. The whole breast tissue is removed. C. Block dissection of the axillary nodes requires excision of axillary vein. D. Nerve to serratus anterior should be spared. axillary lymph nodes are removed, the axillary vein is not excised.  BFOM 39 The following statements about post-mastectomy arm oedema are all true, except: A. Is always transient. B. Adding radiotherapy to the axilla after clearance of lymph nodes increases the risk of oedema. C. Rough dissection of the axillary vein at surgery is one of the causes. D. Insertion of an IV line in the ipsilateral upper limb is a predisposing factor. Acute hypercalcaemia in a patient with advanced breast cancer: A. Is caused by parathyroid hyperplasia. B. Is better treated at home. C. Bilateral lower limb oedema is a constant feature. D. IV fluid administration is an important line of treatment. Neo-adjuvant therapy for malignancy means: A. Treatment with modern methods. B. Giving chemo and/or radiotherapy before surgery. C. Giving chemotherapy after radical excision. D. Giving radiotherapy after palliative excision. When screening females for breast carcinoma what is the most significant risk? A. Three previous breast biopsies in premenopausal females. B. More than 2 first degree relatives with ovarian or breast carcinoma. C. Hyperplasia in breast biopsy. D. None of the above. Breast lymphatics drain into: a- Axillary nodes. b- Internal mammary nodes. c- Pectoral and subscapular nodes. d- All of the above.  BFOM 39 Which of the following advantages breast ultrasound enjoys: a- Can localize impalpable breast lumps. b- Can distinguish solid from cystic lesion. c- Better yield in young dense breast than mammogram. d- All of the above. Mammographic lesions that are strongly associated with malignancy include all of the following EXCEPT: Large and coarse calcifications are typically indicative of benign conditions a- Large and coarse calcifications. b- Thickened epidermis. c- Poorly defined mass lesions. d- Fine stapled calcifications. Which of the following about MRI breast imaging is True: a- Distinguishes scar from recurrence. b- Gold standard for imaging with breast implants. c- Management of axilla in breast cancer and recurrent disease. d- All of the above. All are True of breast FNAC EXCEPT: a- Safe and reliable. b- Least invasive for cell diagnosis. c- Very accurate. d- Invasive cancer can be diagnosed from in situ disease. What is True about breast abscess: a- Rare during lactation. incision and drainage > antibotics b- Usually unilocular. c- Best treated with antibiotics. d- Requires incision and break up of all trabeculae.  BFOM 39 What is common consensus about breast abscess: a- Fluctuation is late sign. b- Area of induration is sector shaped. c- Must be drained if no resolution within 48 hours of antibiotics. d- All of the above Breast mouse refers to: a. Fibroadenosis. b. Fibrocystic disease. c. Hard fibroadenoma. d. All of the above. Most common cause of blood discharge from nipple is: a- Fibroadenoma. b- Fibro-adenosis. c- Ductal papilloma. d- Ductal carcinoma. Greenish discharge from nipple indicates: a- Carcinoma. b- Duct papilloma. c- Duct carcinoma. d- Fibroadenosis. Massive swellings of the breast include the following EXCEPT: a. Cystosarcoma phyllodes b. Atrophic scirrhous carcinoma. c. Diffuse hypertrophy. d. Giant fibroadenoma. The treatment of choice for cystosarcoma phyllodes is: a. Radical mastectomy. b. Simple mastectomy. c. Radiation therapy. d. Hormonal ablation.  BFOM 39 Mondor's disease is: a. An obscure type of thrombophlebitis particularly affecting veins of the breast. b. Lymphoedema of the arm. c. Chondritis of a costal cartilage. d. Pectus excavatum. Non-malignant conditions of the breast include all the following EXCEPT: a. Cystosarcoma phyllodes, b. Duct ectasia. c. Giant fibroadenoma. d. Paget's disease of the nipple. Protective factors for breast cancer include all EXCEPT: a. Nulliparity. Decrese Hormones exposure b. Breast feeding. c. Late menarche. d. Early menopause. Factors associated with increased relative risk of breast cancer include all EXCEPT: a. Nulliparity. b. Menopause before 40 protective factor c. Fibrocystic disease with epithelial proliferation. d. Early menarche. Common site of breast cancer is: a. Upper inner quadrant. b. Upper outer quadrant. c. Lower inner quadrant. d. Lower outer quadrant. The risk of bilateral breast cancer is HIGHEST if the first breast shows: a. Inflammatory carcinoma. b. Lobular carcinoma. c. Medullary carcinoma. d. Infiltrating ductal carcinoma.  BFOM 39 Regarding Ductal carcinoma in situ (DClS) of the breast all the following are true EXCEPT: a- Can be distinguished from invasive carcinoma on fine-needle aspiration cytology (FNAC). b- Accounts for around 15-20% of screen-detected breast cancers. c- Is associated with axillary node metastases in 1 % of cases. d- Can be treated by mastectomy or lumpectomy with or without radiotherapy Regarding Lobular carcinoma in situ (LCIS) all are true EXCEPT: a- Multi local, multicentric and affects both breasts b- Is a marker of an increased risk for developing invasive breast cancer c- Has a characteristic mammographic appearance. d- LCIS found incidentally in breast biopsy taken for another indication. The size of a stage IIIa breast tumor is: a. 2 cm. b. 2-5 cm. c. > 5 cm. d. All of the above. In the management of early breast cancer all the following are true EXCEPT: a- Mastectomy is associated with significantly higher survival rates than conservative surgery. breast-conserving surgery (lumpectomy) followed by radiation therapy has equivalent survival rates compared to mastectomy for early-stage breast cancer. b- Postoperative radiotherapy reduces the incidence of local recurrence. c- Adjuvant tamoxifen improves survival in both pre- and post- menopausal patients for ER +ve tumours. d- Adjuvant Systemic chemotherapy has reduced mortality by 30%. Absolute Contraindications of Breast-Conserving Therapy includes all the following EXCEPT: (Lumpectomy) a- Pregnancy in the first and second trimester. b- Multicentric disease with two or more gross tumors in separate quadrants. c- Diffuse microcalciflcations that are malignant-appearing. d- DCIS discovered by mammography.  BFOM 39 The acronym QUART stands for: a. Quadrantectomy and radiotherapy. b. Quadrantectomy, axillary dissection and radiotherapy. c. Quadrant resection and chemotherapy. d. None of the above. What is not true about role of axillary surgery in carcinoma of breast: a. Axillary lymph node metastasis is best marker for prognosis. b. Treatment of axillary lymph nodes positively influences survival. c. Axillary surgery should not be combined with radiotherapy to axilla. edema of the arm d. All are true. Five Benefits of Tamoxifen in breast carcinoma include all the following EXCEPT: a. Tamoxifen can reduce recurrence. b. Tamoxifen can halt the progression of metastatic breast cancer. c. Tamoxifen can reduce the risk of cancer in the other breast. d. Decrease incidence of endometrial carcinoma. Regarding radiotherapy for breast cancer all are true EXCEPT: a- Has been clearly shown to improve overall survival. b- Has been clearly shown to reduce local recurrence rates following conservative breast surgery. c- Should not be applied to the axilla, if axillary clearance is performed. d- Is the treatment of choice for the palliation of painful bone metastases. Adjuvant chemotherapy for breast cancer: a- Single-agent chemotherapy has a significantly greater beneficial effect on survival than combination chemotherapy. b- Is the treatment of choice for metastases. c- Has little role in the treatment of inflammatory cancers. d- Has a clinical response limited to premenopausal women  BFOM 39 Lymphatic obstruction of advanced breast cancer leads to: a. Peau d'orange. b. Oedema of arm. c. Lymphangiosarcoma. d. All of the above. What is not true of inflammatory carcinoma: a. Highly aggressive. combined inflammation and cancer b. Very common. c. Breast is painful, warm and edematous. d. Mistaken for mastitis. In carcinoma of breast, a secondaries deposit is most common in: a. Bone b. Brain. c. Liver d. Lung. In carcinoma of the breast, most common site of bony metastasis is: a- Sacral vertebra. b- Lumbar vertebra. c- Thoracic vertebra d- Cervical vertebra. Which of the following genes predisposes to breast cancer: a- BRCA1 b- BRCA2 c- TP 53 d- All of the above Causes of gynaecomastia include: a- Idiopathic b- Liver failure c- Leprosy d- All of the above  BFOM 39 Regarding male breast cancer spot the wrong statement: a- It is about 1 % of all cases of breast cancer b- Predisposing causes include gynaecornastia c- Caused by excess endogenous and exogenous oestrogen d- It has a better prognosis than the female breast cancer Breast cancer may cause the following skin lesions except: a- Skin nodules b- Peau d`orange c- Fungation d- Kaposi sarcoma Involvement of ipsilateral axillary lymph node in cancer breast indicates: a- Inoperability. b- Hormonal treatment is indicated. c- N1M1 in TNM. T0N1M0 d- None of the above. The commonest cause of bleeding per nipple is: a- Trauma to the nipple. b- Duct papilloma. c- Mammary duct ectasia. d- Traumatic fat necrosis.  BFOM 39 Schwartz “11th edition” Which of the following changes in the breast is not associated with pregnancy? a. Accumulation of lymphocytes, plasma cells, and eosinophils within the breast b. Enlargement of breast alveoli c. Release of colostrum d. Accumulation of secretory products in minor duct lumina With pregnancy, the breast undergoes proliferative and developmental maturation. As the breast enlarges in response to hormonal stimulation, lymphocytes, plasma cells, and eosinophils accumulate within the connective tissues. The minor ducts branch and alveoli develop. Development of the alveoli is asymmetric, and variations in the degree of development may occur within a single lobule. With parturition, enlargement of the breasts occurs via hypertrophy of alveolar epithelium and accumulation of secretory products in the lumina of the minor ducts. Alveolar epithelium contains abundant endoplasmic reticulum, large mitochondria, Golgi complexes, and dense lysosomes. Two distinct substances are produced by the alveolar epithelium: (a) the protein component of milk, which is synthesized in the endoplasmic reticulum (exocrine secretion); and (b) the lipid component of milk (apocrine secretion), which forms as free lipid droplets in the cytoplasm. Milk released in the first few days after parturition is called colostrum and has low lipid content but contains considerable quantities of antibodies. Which of the following statements is incorrect? a. Level I lymph nodes are those that are lateral to the pectoralis minor muscle. b. Level II lymph nodes are located deep to the pectoralis minor muscle. c. Level III lymph nodes are located medial to the pectoralis minor muscle. d. Level IV lymph nodes are the ipsilateral internal mammary lymph nodes. Axillary lymph node groups are as follows: Level I includes lymph nodes located lateral to the pectoralis minor muscle; level II includes lymph nodes located deep to the pectoralis minor; and level Ill includes lymph nodes located medial to the pectoralis minor.  BFOM 39 Concerning gynecomastia, which of the following is TRUE? a. During senescence gynecomastia is usually unilateral. p not with b b. During puberty gynecomastia is usually bilateral. c. Gynecomastia is associated with breast cancer in Klinefelter syndrome patients. d. Gynecomastia is classified as per a three-grade system. In gynecomastia, the ductal structures of the male breast enlarge, elongate, and branch with a concomitant increase in epithelium. During puberty, the condition often is unilateral and typically occurs between ages 12 and 15 years. In contrast, senescent gynecomastia is usually bilateral. Gynecomastia generally does not predispose the male breast to cancer. However, the hypoandrogenic state of Klinefelter syndrome (XXY), in which gynecomastia is usually evident, is associated with an increased risk of breast cancer. Gynecomastia is graded based on the degree of breast enlargement, the position 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 IIa: Moderate breast enlargement without skin redundancy; Grade IIb: Moderate breast enlargement with skin redundancy; and Grade 3: Marked breast enlargement with skin redundancy and ptosis. Lesions with malignant potential include all of the following EXCEPT: a. Intraductal papilloma. b. Atypical ductal hyperplasia (ADH). c. Sclerosing adenosis. d. Atypical lobular hyperplasia (ALH). 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).  BFOM 39 Risk factors for the development of breast cancer include all of the following Except: a. Early menarche b. Nulliparity c. Late menopause d. Longer lactation periods 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. 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. 45 years 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.  BFOM 39 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 III tumors include some with distant metastases (M1 disease). c. Inflammatory carcinoma is considered T4 disease. d. N4 disease includes metastases to highest contralateral axillary nodes. According to TNM staging system for breast cancer: Stage IB tumors have micro-metastases to the regional lymph nodes. If a patient presents with M1 disease prior to neoadjuvant systemic therapy, the stage is Stage IV and remains Stage IV regardless of response to neoadjuvant therapy. Inflammatory carcinoma is considered T4d disease. Any histologically proven metastases in distant organs; or if in non-regional nodes, metastases greater than 0.2 mm, disease is considered pM1. 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 followed 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. Tamoxifen is a selective estrogen receptor modulator (SERM) 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 conservation therapy for DCIS is evaluated is mastectomy. Women treated with mastectomy have local recurrence and mortality rates of < 2%.  BFOM 39 Patients not suitable for sentinel node biopsy include all of the following EXCEPT: Ductal carcinoma in situ (DCIS) a. Inflammatory carcinoma of the breast Sentinel node biopsy (SNB) is a surgical procedure used to determine whether b. Prior axillary surgery cancer has spread to the lymph nodes, c. Biopsy proven distant metastases d. Breast lower inner quadrant carcinoma 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. 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. 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.  BFOM 39 Which of the following statements about breast anatomy are TRUE? a. The lateral border of the breast is the posterior axillary line. anterior axillary line b. The largest breast quadrant is the inner lower guardant. c. Vascular supply is via posterior intercostal arteries, the internal mammary arteries, and the axillary artery. d. Cooper ligaments are only found in the upper quadrants of the breast. 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 thoraco-acromial artery. The second, third, and fourth anterior intercostal perforators, and branches of the internal mammary artery, arborize in the breast. Which of the following hormonal effects on the breast is correct? a. Estrogen is responsible for lobule development. DE b. Progesterone initiates ductal development. c. Prolactin is responsible for milk letdown. d. Oxytocin initiates contraction of myoepithelium. 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.  BFOM 39 All of the following are mechanisms underlying development of gynecomastia EXCEPT: a. Neoplasms of testis b. Lung carcinoma c. Cirrhosis d. Marfan syndrome  BFOM 39 Concerning infections of the breast, which of the following are TRUE? a. Most common organism is Escherichia coli. "Nursing infants" refers to babies who are being breastfed by their mothers b. Operative drainage is the most common therapeutic approach. c. Fungal infections of the breast are most commonly initiated by nursing infants. Candida d. Bilateral Mondor disease is more common than unilateral disease. 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. Correct statements about risk of developing breast cancer include all of the following EXCEPT: a. Lifetime risk in US females is 20%. 12% b. Increased risk with exposure to therapeutic radiation in adolescence. c. Early menarche. d. Older age at first live birth. 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.  BFOM 39 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. 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. 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. 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 follow up 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.  BFOM 39 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 tissue, nipple-areola complex, and level I and II axillary lymph nodes. c. Modified radical mastectomy removes all breast tissue, 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. 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 level 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 III axillary lymph nodes. Skin-Sparing Mastectomy: Removes all breast tissue, the nipple-areola complex, and scars from prior biopsies. Preserves skin for potential cosmetic benefits. Total (Simple) Mastectomy: Removes all breast tissue, the nipple-areola complex, and skin. Does not preserve any skin. Extended Simple Mastectomy: Removes all breast tissue, the nipple-areola complex, skin, and level I axillary lymph nodes. Modified Radical Mastectomy (Patey) : Removes all breast tissue, the nipple-areola complex, skin, and level I, II, and III axillary lymph nodes. (Radical Mastectomy)(Halsted) : Removes all breast tissue and skin, the nipple-areola complex, pectoralis major and minor muscles, and levels I, II, and III axillary lymph nodes.  BFOM 39 Lange “Q& A” A 35-year-old professional dancer presents with a well-defined, tense, smooth mass in the upper outer quadrant of the left breast. She states that the mass becomes larger just before onset of her periods. Aspiration yields a clear yellow fluid and the mass disappears. The most likely diagnosis is: a. Fibroadenoma is a cyst. b. Fibrocystic disease of the breast. c. Carcinoma in a cyst. d. Lipoma. e. Galactocele. Breast cysts are often well demarcated and tend to get larger and contain non-bloody fluid, which is usually acellular and cytology is rarely indicated. Galactoceles present in pregnant and nursing women are filled with milky fluid. An 18-year-old presents with a well-circumscribed 2-cm mass in her right breast. The mass is painless and has a rubbery consistency and discrete borders. It appears to move freely through the breast tissue. What is the likeliest diagnosis? a. Carcinoma b. Cyst c. Fibroadenoma d. Cystosarcoma phyllodes e. Intramammary lymph node Fibroadenomas are most often found in teenage girls. They are firm in consistency, clearly defined , and very mobile. The typical feature on palpation is that they appear to move freely through the breast tissue (“breast mouse”).  BFOM 39 Galactorrhea, a milky discharge from the nipple in nonpregnant women, is most likely to be associated with which of the following? a. Fibroadenoma b. Tubular adenoma c. Pituitary adenoma d. Hyperparathyroidism e. Breast abscess Galactorrhea is fairly common up to old age. The discharge may vary in color from brown to milky. Hormonal causes are associated with elevated prolactin levels or with pituitary or thyroid disorders. Tranquilizers have also been implicated. Simple abscesses do not cause galactorrhea. A 28-year-old female figure skater presents several weeks after having sustained an injury to her left breast. She has a painful mass in the upper outer quadrant. Skin retraction is noticed, and a hard mass, 3-4 cm in diameter, can easily be palpated. What is the most likely diagnosis? a. Infiltrating carcinoma b. Breast abscess c. Hematoma d. Fat necrosis e. Sclerosing adenosis Fat necrosis is a rare condition that follows injury. Diagnosis may be difficult, and mammography and excision may be necessary to rule out carcinoma. Sclerosing adenosis is a variant of fibrocystic disease and may present with a hard mass. In a hematoma, evidence of resolving ecchymosis may be present.  BFOM 39 A 35-year-old patient presents to your office with chronic draining subcutaneous periareolar abscesses, which have been incised and drained many times in the past 5 years but keep recurring. What is the best treatment of choice? a. Repeat incision and drainage (I and D) since the previous procedures were inadequate b. Long-term antibiotics c. Major duct excision d. Complete excision of the drainage tract e. Tell the patient there is nothing to do and that this will eventually resolve with age Mammary fistula also known as Zuska’s disease is felt to represent dilated laciferous ducts, which develop chronic inflammation presenting with these periareolar draining sinuses. They will continue to recur until completely excised, which may require removal of the terminal duct into the nipple, leaving the wound open. A patient presents 1 month after a benign right breast biopsy with a lateral subcutaneous cord felt just under the skin and causing pain. The etiology of this condition is? a. Fat necrosis b. Infection c. Superficial thrombophlebitis d. Suture granuloma e. Misdiagnosed breast cancer This entity is known as Mondor’s disease and is caused by superficial thrombophlebitis usually induced by surgery, infection, or trauma. The process is self-limiting and resolves within 2-10 weeks.  BFOM 39 A 36-year-old woman complains of a 3-month history of bloody discharge from the nipple. At examination, a small nodule is found, deep to the areola. Careful palpation of the nippleareolar complex results in blood arrearing at the 3 O’clock position. Mammogram findings are normal. What is the likeliest diagnosis? a. Intraductal papilloma b. Breast cyst c. Intraductal carcinoma d. Carcinoma in situ e. Fat necrosis Intraductal papilloma is the most common cause of bloody discharge from the nipple. The lesion is treated by excision and is benign in most cases. Cancer is present in 5% of cases. Preoperative ductography can be used to help locate the offending duct. A 36-year-old woman presents with a substantial unilateral breast enlargement. She had presumed that this was normal, but on examination, a large, firm tumor is palpated by the attending physician. There is early erosion on the skin. A favorable outlook can be anticipated if the lesion is which of the following? a. Sarcoma b. Cystosarcoma phyllodes c. Colloid carcinoma d. Infiltrating carcinoma e. Inflammatory carcinoma Cystosarcoma phyllodes is a tumor that is very slow growing and has a good prognosis if treated by mastectomy. It is characterized by large polygonal cells with abundant cytoplasm and lymphoid infiltration.  BFOM 39 During a routine screening mammography, a 62-year-old teacher is informed that she has changes on her mammography, and she should consult her physician. She can be reassured that the findings that indicate a benign condition are which of the following? a. Discrete, stellate mass b. Fine, clustered calcifications c. Coarse calcifications d. Solid, clearly defined mass with irregular edges e. Discrete, nonpalpable mass that has enlarged when compared with a mass shown on a mammogram taken 1 year previously Coarse calcifications are usually benign. Fine, clustered calcifications are often malignant and require biopsy. Solid tumors of the breast, especially those that have increased in size or have changed in appearance, are suspicious for carcinoma and require biopsy. A 40-year-old lawyer comes into your office after seeing some information on the Internet relating to breast cancer. Which of the following factors has not shown to increase a woman’s risk for breast cancer? a. Smoking b. Previous history of benign breast biopsies c. Atypia seen on pathology from previous breast biopsy d. First-degree relative with history of breast cancer e. Increasing age Any history of previous breast biopsy, even benign, does show an increase risk of breast cancer. Atypia, family history, and increasing age also increase a woman’s risk. Smoking has not shown an increase risk for breast cancer.  BFOM 39 A 53-year-old waitress inquires about the implications of positive estrogen receptors (ER+) in an invasive carcinoma that is excised from her left breast. She should be informed of what? a. They are more often positive in patients under 50 years of age. b. If the receptors are positive, antiestrogen therapy is not indicated. c. If the receptors are positive, the prognosis is more unfavorable. d. ER and progesterone receptor (PR) status should be determined in all cases of breast carcinoma. e. ER are usually negative when PR are positive. ER and PR status should be determined in all cases of breast carcinoma. Positive ER and PR are indicative of an improved outlook and likelihood of response with antiestrogen medication. PR+ do not predict negative ER status. A 53-year-old waitress inquires about the implications of positive estrogen receptors (ER+) in an invasive carcinoma that is excised from her left breast. The patient is postmenopausal. She should be informed that which of the following hormonal therapy has been shown to be most effective? a. Tamoxifen b. Raloxifene (premenopasual) c. Toremifene d. Megace (metastasis) e. Aromatase inhibitors (postmenopasual) Recent studies are showing aromatase inhibitors to be more beneficial than tamoxifen in preventing breast cancer recurrence in postmenopausal women. Tamoxifen, raloxifene, and toremifene are all selective ER modulators (SERMS), which act by competitively blocking estrogen binding sites and thus reducing estrogen stimulation of breast tissue. Megace (megestrol acetate) has been used for metastatic breast cancer.  BFOM 39 A 52-year-old undergoes a left modified radical mastectomy for a 2-cm breast cancer. She should be informed that the factor which has the greatest impact on her prognosis is? a. The size of the primary tumor b. The histological type of the carcinoma c. The number of axillary nodes positive for metastasis d. Hormonal receptor status of the primary tumor e. Positive findings on tests for the presence of the BRCA (breast cancer) 1 gene The number of positive axillary nodes remains one of the best prognostic indicators in breast carcinoma. The current American Joint Committee on Cancer (AJCC) staging classification now defines patients with 1-3 positive nodes (N1), 4-9 positive nodes (N2), and 10 or more positive nodes (N3) due to their different prognosis. A 46-year-old woman presents with a mammogram that shows a 1-cm cluster of fine calcification in the right breast. Following mammographic wire localization, the lesion is excised and the pathology reported as ductal carcinoma in situ (DCIS) with comedo features and free margins. What advice should be given to the patient? a. If untreated, about 30% of such lesions become invasive over a 10-year period. b. Comedo DCIS is less aggressive than non-comedo DCIS. c. Bilateral mastectomy and radiotherapy are the preferred treatments. d. Axillary node dissection is always indicated. e. Total mastectomy carries a high (50%) risk of carcinoma recurrence. DCIS is a noninvasive lesion. Comedo DCIS is more aggressive than non-comedo DCIS. Axillary disease in uncommon is DCIS, and lymph node staging is generally not required. Breast conserving procedures can be performed as long as extensive or multicentric disease is not present. Radiation therapy is generally indicated after breast conserving therapy for DCIS.  BFOM 39 A 43-year-old premenopausal patient has a biopsy showing focal lobular carcinoma in situ (LCIS) in the area of calcification. With regard to the LCIS, you should tell the patient which of the following? a. She needs a simple mastectomy. b. She must be placed on tamoxifen and chemotherapy. c. This is a premalignant lesion, and she requires additional lumpectomy and radiotherapy. d. She is at increased risk of breast cancer, and she should just be observed closely. e. LCIS often presents with a mass. accidental when biopsy She is at increased risk for breast cancer and should be followed closely. LCIS is usually in incidental finding. Although multifocal throughout both breasts, it is thought not to be precancerous itself but rather an indicator of increased cancer risk. Therefore, wide resection is not indicated. Careful examinations, every 6 months and yearly mammograms are done to detect invasive carcinoma at the earliest time. Lifetime breast cancer risk is about 30%. A partially blind 65-year-old mother presents with a slight change in color of the areola of her left breast. An eczematous rash of the left areola has persisted for the last 3 months. Biopsy of the nipple reveals Paget’s disease. In Paget’s disease of the nipple which of the following is TRUE? a. Carcinoma of the breast is rarely found. carcinoma of the breast is commonly found b. Surgical therapy often fails to cure Paget’s disease. surgical therapy is often curative c. The diagnosis should be made by nipple biopsy when suspected. the underlying carcinoma, when d. The underlying carcinoma when present is very large. present, may not necessarily be large. e. Paget’s disease of the bone is commonly encountered. Paget’s disease of the nipple is unrelated to Paget’s disease of the bone. The diagnosis should be made by nipple biopsy when suspected. Paget’s disease represents a ductal carcinoma that has grown along the ducts into the nipple/areolar region. The lesion often presents with an eczematous rash, which does not resolve and can be diagnosed with a small incisional biopsy. Typically swollen vacuolated Paget’s cells are found on histological examination. Many cases involve small breast cancers, which are missed on clinical examination and mammogram. Surgical therapy is often curative. This is unrelated to Paget’s disease of the bone.  BFOM 39 A 39-year-old patient presents to your office with a left 3.5-cm breast tumor, which on core needle biopsy, is shown to be an invasive ductal cancer. On left axillary examination, she has a hard nonfixed lymph node. A biopsy of a left supraclavicular node is positive for malignancy. Her stage is currently classified as? a. III C b. IV c. II B d. III B e. II A Ipsilateral supraclavicular lymph node disease is stage IIIC in breast cancer. The new AJCC staging system includes ipsilateral supraclavicular nodes as IIIC and not IV. These patients require appropriate metastatic workup and often get neoadjuvant chemotherapy. A 40-year-old patient is diagnosed with a localized 1-cm infiltrating ductal cancer after a needle core biopsy of the lesion. She is clinical node negative; a lumpectomy and sentinel lymph node biopsy are performed. The patient develops an anaphylactic response during the case. Which of the following substances was the likely causative agent? a. Fluorescein b. 99 Tc radiolabeled colloid c. Isosulfan blue dye d. Methylene blue dye e. Indigo carmine Both methylene blue or isosulfan (lymphazurin) blue dye can be used for sentinel lymph node identification and have been associated with some allergic reactions. Isosulfan blue has been associated with rare anaphylactic reactions in < 1% of patients. Methylene blue can cause skin necrosis if injected too superficially. Fluorenscein and indigo carmine are not given in these surgeries. 99 Tc is given for the lymphoscintigraphy and gamma probe isolation of the sentinel node and has no known anaphylactic reactions.  BFOM 39 A 65-year-old woman undergoes a lumpectomy and sentinel lymph node biopsy and is found to have a 5-mm tubular cancer ER and PR positive and a negative sentinel lymph node. What adjuvant treatment should be recommended? a. Chemotherapy and radiation b. Radiation treatment only c. Hormonal therapy only d. Radiotherapy and hormonal therapy e. Partial breast irradiation Generally patients with small (< 1 cm) breast cancers, which are pathologically node negative, are spared from chemotherapy. Radiation and hormonal therapy is indicated. Partial breast irradiation can be offered though there is no current randomized data to show the best modality of treatment (currently an ongoing NSABP/RTOG trial). A 41-year-old patient presents to your office with a biopsy proven invasive ductal cancer in the upper outer aspect of her left breast, a suspicious palpable left axillary lymph node, and diffuse calcifications throughout the rest of the breast proven to be DCIS on stereotactic biopsy. The best surgical option is: a. Modified radical mastectomy b. Simple mastectomy c. Lumpectomy with sentinel lymph node biopsy d. Radical mastectomy e. Total mastectomy with sentinel lymph node biopsy This patient has a palpable axillary lymph node making sentinel node biopsy contraindicated. The multicentricity of the disease also makes the use of sentinel lymph node biopsy relatively contraindicated. Radical mastectomies are no longer performed unless gross tumor invasion into the pectoralis muscle is found.  BFOM 39 A premenopausal 44-year-old woman undergoes a quadrantectomy and node dissection for a 2-cm infiltrating carcinoma of the left breast. The margins are clear, and 5 out of 15 lymph nodes are involved. ER and PR are positive. Recommended adjuvant therapy should include which of the following? a. Radiotherapy alone b. Estrogen therapy alone c. Modified radical mastectomy d. Chemotherapy alone e. Chemotherapy, radiotherapy, and tamoxifen Current National Institute of Health (NIH) consensus conference advises chemotherapy for all invasive cancers >1 cm as well as for node-positive cancers. Radiotherapy is required whenever breast conserving surgery is undertaken and tamoxifen should be given for all ER+ and/or PR+ invasive tumors whose patients are premenopausal. An 18-week pregnant, 35-year-old woman presents after undergoing a modified radical mastectomy for a 2-cm ductal cancer with one out of fifteen positive axillary lymph nodes. What should she be informed of regarding breast cancer during pregnancy? a. She cannot undergo chemotherapy until after she delivers. b. She should have a therapeutic abortion in order to proceed with radiotherapy. c. Breast cancer is the most common cancer during pregnancy. d. Radiotherapy is indicated. e. Most of these cancers are ER+. Breast cancer is the most common cancer during pregnancy. It is usually ER–/PR–. Patients can undergo chemotherapy (non-methotrexate regimens) starting after the first trimester and continue on with the pregnancy. Radiotherapy cannot be given during pregnancy, so mastectomy is often indicated unless the patient is toward the end of the pregnancy, and the radiotherapy can be given postpartum.  BFOM 39 After undergoing modified radical mastectomy for cancer of the right breast, a 52- year-old female teacher becomes aware that the medial end of her scapula becomes prominent in protraction movements at the shoulder. She also complains of some weakness in complete abduction of the same shoulder. What nerve was injured? a. Long thoracic b. Thoracodorsal c. Ulnar d. Median e. Intercostobrachial Axillary dissection during modified radical mastectomy requires exposing the long thoracic and thoracodorsal nerves. Injury to the long thoracic nerve that supplies the serratus anterior muscle causes “winging of the scapula”. The intercostobrachial nerve supplies sensory innervation to the skin in the axilla and proximal upper extremity. The medial and ulnar nerves are outside of the usually axillary dissection field. A 50-year-old patient has recently undergone a mastectomy for a 2.5-cm multicentric breast cancer with three positive axillary lymph nodes (stage IIB). A metastatic survey is done, and is negative, and she receives adjuvant chemotherapy. The most common site for distant metastasis would be: a. Brain b. Bone c. Lung d. Gastrointestinal tract e. Liver Bone metastasis is the most common distant metastatic site for breast cancer. They are typically osteolytic lesions and can be treated by biphosphonates, which inhibit bone demineralization and have been shown to reduce the pathologic fracture frequency and need of radiation.  BFOM 39 A 45-year-old premenopausal woman undergoes a left breast lumpectomy for a 1.5- cm, lymph node positive, hormone sensitive invasive breast cancer. She receives chemotherapy, radiotherapy, and is on tamoxifen. Recommended follow-up after therapy should always include: a. Blood tumor markers drawn every 3-6 months after treatment. b. Routine monitoring of liver function tests (LFTs) every 3-6 months after treatment. c. Yearly bone scans. d. Routine clinical examination every 3-6 months for the first 5 years after treatment as well as continued yearly mammography. e. Yearly breast MRI with gadolinium. Follow-up after breast cancer treatment is very variable. There is no consensus, and no follow-up test has shown a survival advantage. Routine 3-6 month clinical examinations and yearly mammography should always be performed. The use of tumor markers such as a CA 15-3 has not shown any proven significant value and may lead to unnecessary worry. A 43-year-old female requests breast augmentation surgery. She has no family history of breast cancer and her clinical examination fails to reveal any evidence of pathology. What should she be informed about the procedure? a. In the United States only silicone gel-filled and not saline-filled implants are performed. b. Breast implants increase the incidence of malignancy of the breast. c. The occurrence of subsequent breast cancer occurs at a later stage than those without implants. d. Saline implants have a more natural appearance than silicone gel-filled implants. e. Implants in the submuscular plane allow better mammographic findings than those placed in the sub-glandular position. There is no evidence that long-term insertion of breast implants leads to an increased incidence of breast cancer or detection of the cancer at an inappropriate late stage. Although the use of silicone gel implants is still confined by the Food and Drug Administration (FDA) to select circumstances (e.g., breast reconstruction following mastectomy), retrospective studies to date have failed to demonstrate a significant increase in the incidence of collagen disease in patients who have had a silicone breast implant.  BFOM 39 A 56-year-old male patient develops an accentric hard breast lump over the past few months and a biopsy proves this to be breast carcinoma. Of all breast cancers, the rate of occurrence in males is which of the following? a. < 1 % b. 4 % c. 7 % d. 10 % e. > 10 % Cancer of the breast in males constitutes < 1% of total cases. It tends to present at a more advanced stage in men than in women, because it is often overlooked. It may easily be confused with the more commonly occurring condition of gynecomastia. Careful clinical radiological follow-up studies are indicated. A 25-year-old nonalcoholic man has noticeable right gynecomastia since age 20. He is most uncomfortable and reluctant to swim or exercise at a gym for fear of being an object of derision. He should be advised to have which of the following? a. Right mastectomy b. Observation c. Needle biopsy of the breast d. Endocrine workup and right subcutaneous mastectomy e. Testosterone therapy by transdermal patch In general, persistent gynecomastia should be evaluated to rule out endocrine abnormalities. In most cases, none are found. Subcutaneous mastectomy is indicated if the patient is self- conscious.  BFOM 39 Microscopic examination of this malignancy shows large vacuolated cells. A) Tubular B) Medullary C) Colloid D) Inflammatory carcinoma E) Paget’s disease Paget’s disease is characterized by these large vacuolated intra-dermoid cells usually arising from a ductal carcinoma that is thought to have grown along the duct to the nipple. Clinical findings of this breast cancer typically include a rash-like erythema, which spreads throughout the skin of the breast. A) Tubular B) Medullary C) Colloid D) Inflammatory carcinoma E) Infiltrating ductal carcinoma Inflammatory breast cancer is a very aggressive form of breast cancer characterized by intradermal lymphatic spread of tumor. This histologic variant is characterized by a linear “Indian-file” arrangement of tumor cells and a tendency to grow circumferentially around ducts and lobules. (A) Tubular (B) Medullary (C) Colloid (D) Infiltrating ductal carcinoma (E) Infiltrating lobular carcinoma Infiltrating lobular cancers have this typical linear (“indian-file”) arrangement of cells. There is a higher incidence of multifocality and bilaterality with lobular cancers. These cancers have a greater tendency to be hormone sensitive.  BFOM 39 The histology that shows an intense lymphoplasmacytic reaction around and within the tumor, which is usually poorly differentiated with a high mitotic rate. A) Tubular B) Medullary C) Colloid D) Infiltrating ductal carcinoma E) Infiltrating lobular carcinoma Medullary tumors have an intense surrounding lymphoid reaction and though poorly differentiated, have a favorable prognosis compared to other invasive cancers. They tend to be hormone receptor negative.  BFOM 39 Vascular  BFOM 39 Department “Tricks” A 66-year-old woman has a 5.5-cm infrarenal abdominal aortic aneurysm. What is the most common manifestation of such an aneurysm? (A) Abdominal or back pain (B) Acute leak or rupture (C) Incidental finding on abdominal examination (D) Atheroembolism Claudication is: a- Pain at rest. b- Pain relieved by rest. c- Constant pain. d- Pain not relieved by rest. Rest pain refers to pain: a- Anywhere in the body at rest. b- In the thigh of the patient with Buerger's disease. c- In the back d- In the foot of a patient of severe vascular disease. By definition, which of the following patients is having critical limb ischemia: a- A patient presenting with acute limb ischemia and impending gangrene b- A patient presenting with a chronic ischemic foot ulcer and rest pain c- A patient presenting with calf claudication progressing over the past 3 months d- A patient presenting with infective gangrene of his toe and intact pedal pulse All the following statements describe ischemic rest pain EXCEPT: a- Continuous severe aching, or burning pain that becomes worth at night b-Sudden cramping pain in the calf that awakens the patient from sleep intermittent claudication c- Partially relieved by putting the leg below the level of the heart d- Increases if there is superadded infection in the ischemic foot  BFOM 39 One of the following statements describes an ischemic ulcer: venous a- Superficial painful ulcer above the ankle surrounded with pigmented eczematous skin ulcer neuropathic b- Deep painless ulcer in the sole reaching down to the bone with intact pedal pulse (diabetic) ulcer c- Superficial painful ulcer on the heal of a diabetic patient with absent pedal pulse d- Deep painless ulcer between the toes of 11 diabetic patient with gangrenous floor and intact pedal pulse All of the following statements concerning popliteal artery aneurysms are true EXCEPT a- Approximately 50% are associated- with aneurysms at other sites b- Rupture into the popliteal space is a frequent complication c- Associated thrombosis carries a high risk of amputation d- Associated distal embolization may result in tissue loss A diabetic patient presented with advanced ischemic gangrene of the foot and rest pain. On examination, the pedal pulses were absent, but the popliteal pulse was felt. Angiography showed occlusion of the tibial arteries with no distal runoff. The classical treatment for this patient is: a- Popliteal-to-distal bypass b- Syme's amputation c- Below knee amputation d- Above knee amputation In lower limb acute embolic ischemia, the embolus may originate from all of the following sites EXCEPT: a- The heart over recent myocardial infarction b- The deep veins from extensive lower limb DVT c- The heart with mitral valve disease and atrial fibrillation d- The abdominal aorta with aortic aneurysm Diabetic patients are more prone to develop foot ulcers. All the following are important contributing causes EXCEPT: a- Diabetic patients usually have peripheral neuropathy affecting their feet b- Diabetic foot deformities renders the foot more susceptible to trauma c- Diabetic patients have exaggerated inflammatory response to infection impaired immune response d- Diabetic patients may have concomitant chronic ischemia  BFOM 39 If a diabetic patient presents with gangrene of one of his toes, the first thing that should be done is to: a- Amputate the gangrenous toe to prevent spread of gangrene b- Ask for fasting blood sugar to control blood sugar level c- Ask for serum lipid profile to correct possible hyperlipidemia d- Look for pedal pulses to evaluate foot circulation Once you diagnose acute lower limb ischemia, the first thing to do is: a- Angiography to differentiate between embolic and thrombotic ischemia b- Catheter directed embolectomy under local anesthesia c- Give the patient heparin to avoid clot propagation d- Transfer the patient to a vascular surgery center One of the following is NOT a component of "Leriche Syndrome" (infrarenal-aorto- iliac occlusion): Triad a- Bilateral absent femoral pulse b- Bilateral feet parathesia c- Buttock& thigh claudication d- Impotence In acute ischemia, catheter directed thrombolysis can be used in all of the following conditions EXCEPT: a- Recent acute thrombosis of less than 3 days duration b- Viable limbs with lax muscles and intact sensations c- Patient with history of major surgery one and a half months ago d- Patient with history of cerebral stroke one and half months ago due to the increased risk of bleeding complications All the following can result in acute limb ischemia, EXCEPT: a- Embolism originating from the heart with chronic atrial fibrillation b- Acute hemolysis of RBCs in a patient with known spherocytosis c- Thrombosis of a diseased artery on top of chronic lower limb ischemic d- Traumatic fracture of bones with injury to nearby arteries  BFOM 39 In acute ischemia, one of the following is a sign of irreversible ischemia that will need amputation: a- Marked delay in the capillary refilling time b- Marked swelling& turgidity of calf muscles compartment syndrome c- Loss of foot superficial and deep sensation d- Paralysis of the small muscles of the foot Reconstructive arterial surgery is recommended for patients with the following manifestations of ischemia EXCEPT: a- Ischemic neuropathy. b- Trophic ulceration. c- Toe gangrene. d- Claudication. Which reconstructive surgery has good long-term outcome: a- Aortoiliac. b- Femoropopliteal. c- Femorodistal. d- All of the above. The graft used in aortoiliac bypass is: a- Long saphenous vein graft b- Dacron c- PTFE d- Umbilical vein The most satisfactory graft material for femoropopliteal bypass grafting is: a- Autogenous vein graft. b- Woven dacron. c- Knitted dacron. d- Gortex. In arterial by-pass surgery the best vein to use is: a- Cephalic vein b- Femoral vein c- Long saphenous vein d- Short saphenous vein  BFOM 39 The MOST common site at which arterial emboli lodge is the: a- Aortic bifurcation. b- Common iliac bifurcation. c- Common femoral bifurcation. d- Cerebral circulation. Fogarty catheter is used for: a- IV nutrition b- Ureteric catheterization c- Arteriography d- Arterial embolectomy In acute embolic occlusion, heparin is given to: a- Dissolve embolus. b- Reduce extension. c- Maintain patency of distal vessels. d- All of the above. The most important prognostic sign of acute ischaemia of a limb is: a- Pallor. b- Cold skin. c- Cutaneous anaethesia. d- Muscle turgor. Indicate the Incorrect statement about arterial embolism: a- It results in acute ischaemia. b- Is always due to a detectable site of thrombosis. c- Is often due to lodgement of an embolism at the bifurcation of a main artery. d- Is associated with a much higher incidence of gangrene than simple ligation of the same artery. Intra-arterial thrombolysis is best achieved with: a- Streptokinase. b- Urokinase. c- tPA infusion. d- Pulse-spray tPA (tissue plasminogen activator). faster  BFOM 39 In fat embolism, the fat is most likely to arise from: a- Bone marrow. b- Adipose tissue. c- Chylomicrons. d- None of the above. Therapeutic embolization is used for: a- Arrest of haemorrhage from GI& urinary tract. b- Treatment of A-V malformation. c- Shrinkage of tumour growth. d- All of the above. Moist gangrene occurs in presence of: a- Venous and arterial occlusion. b- Embolism. c- Diabetes. d- All of the above. Peripheral aneurysm most commonly involves: a- Femoral artery. b- Axillary artery. c- Popliteal artery. d- Brachial artery. Lumbar sympathectomy is of value in the management of: a- Intermittent claudication b- A-V fistula c- Diabetic neuropathy d- Distal ischemia affecting skin of toes Sympathectomy is not advised for: a- Raynaud's disease of the fingers. b- Hyperhidrosis of the feet. c- Intermittent claudication. d- Acrocyanosis.  BFOM 39 An overdose of Heparin is treated by: a- Prostaglandins. b- Phenidione. c- Protamine sulphate. d- Prostigmine. In Buerger's disease, the following statements are correct EXCEPT: a- Phlebitis migrans may occur. b- Intermittent claudication is the most common symptom. c- Rest pain is a grave symptom. d- Only the lower limbs are affected. In Buerger's disease, the following statements are true EXCEPT: a- Severe pain never occurs. b- Recurrent exacerbations and remissions are characteristic. c- Intermittent claudication is usually the first symptom. d- May end in gangrene. Which statement is untrue concerning Raynaud's disease: a- Occurs equally in both sexes. b- Usually manifests itself in the third decade. c- Affects the lingers and hands and rarely the feet. d- Is characterized by recurrent episodes initiated by cold or emotional stress. Concerning abdominal aortic aneurysms, which of the following statements is untrue: a- Are commonest in the sixth and seventh decades. b- Have a much higher incidence in males than females. c- Characteristically originate below the renal arteries. d- Never extend beyond the aortic bifurcation. The cardinal signs and symptoms of sudden peripheral ischemia include: a- Pain. b- Paresthesia c- Paralysis d- All of the above  BFOM 39 Cause of A-V fistula: a- Congenital b- Blunt trauma c- Penetrating trauma d- All of the above The haemodynamic effects of an arteriovenous fistula in the thigh include the following Except: a- Decreased peripheral resistance. b- Reduced cardiac output. c- Increased venous pressure. d- Reduced diastolic pressure. Branham's sign refers to: a- Bruit heard over an arteriovenous fistula. b- The increased growth of the limb involved with the arterio-venous fistula a child. c- The occurrence of heart failure where there is a large arterio-venous fistula present. d- A sharp decrease in the pulse rate when the arterio-venous fistula is closed by digital pressure. The Adson maneuver for thoracic outlet syndrome is positive with: a- Numbness and tingling in the hand. b- Pallor of the hand. c- Disappearance of radial pulse. d- Acrocyanosis in the hand. In lumbar sympathectomy which of the following ganglia is spared: a- L4 b- L3 c- L1 d- L2 Where are the Cockett perforators present? A. Lateral thigh. B. Medial lower leg. C. Lateral lower leg. D. Femoral triangle.  BFOM 39 Thrombolysis is achieved by: A. Decreased activity of thrombin. B. Converting thrombin to fibrin. C. Converting plasminogen to plasmin. D. All of the above. Inherited predisposition to deep vein thrombosis includes all the following causes, except: A. Factor V Leiden mutation (heterozygous and homozygous) B. Antithrombin deficiency. C. Protein 5 excess. D. Protein C deficiency. All the following factors increase the susceptibility to postoperative deep vein thrombosis (DVT) except: A. Anaemia. B. Obesity. C. The intake of contraceptive pills. D. Malignancy. Which of the following veins are valveless? A. Great saphenous vein. B. Short saphenous vein. C. Portal vein. D. Common femoral vein. Which of the following should be monitored in patients who are anticoagulated with heparin? A. Bleeding time. B. PT. C. APTT. D. None of the above. Which of the following is monitored during anticoagulation with Warfarin? A. Platelet count. B. Bleeding time. C. INR. D. APTT.  BFOM 39 About peri-operative anticoagulant prophylaxis, all the following are true, except: A. Should be started immediately after surgery. B. Is indicated for obese patients. C. Heparin is the usual agent. D. Prophylaxis is continued for one week after surgery. What is the initial dose of heparin in the patients with DVT? A. 45 units/kg. B. 60 units/kg. C. 80 units/kg. D. None of the above. What is the preferred method of treatment of ulceration due to chronic venous insufficiency? A. Compression therapy (elastic stocking). B. Saphenous vein ligation and stripping. C. Ligation of perforating veins (Linton operation). D. None of the above. Which of the following is an indication for inferior vena cava (IVC) filter insertion? A. Recurrent DVT despite adequate anticoagulation. B. Contraindication of anticoagulation in proximal DVT with a suspected one episode of PE. C. Pulmonary showering in patients with DVT and moderate pulmonary hypertension. D. All of the above. In the first episode of DVT following a major operation, how long should the patient be given warfarin? A. 4 weeks. B. 6 weeks. C. 3-6 months. D. One year.  BFOM 39 The laboratory test that is used for diagnosis of DVT and/or pulmonary embolism is: A. D-dimer. B. ESR. C. Platelet count. D. Prothrombin time. The imaging study of choice for the diagnosis of suspected deep vein thrombosis is: A. Ascending venography. B. Duplex scan. C. Isotope scan. D. CT angiography. About stripping of the long saphenous vein, all the following statements are true, except: A. It is not an essential part of operations for primary varicose veins. B. It can cause injury of the saphenous vein. C. It can cause injury of the sural nerve. D. It deprives the patient of a vein that could be used for coronary bypass. The term venous pump refers to: a- A part of autotransfusion apparatus. b- The left atrium. c- The apparatus for rapid transfusion of blood. d- Musculofascial anatomy and physiology of calf. Pressure in superficial veins in leg during standing is: a- 20 mmHg. b- 40mmHg. c- 80 mmHg. d- 120 mmHg. What happens to superficial venous pressure during exercise: a- Rises. b- Falls. c- Unchanged. d- None of the above.  BFOM 39 Regarding varicose veins all statements are true EXCEPT: a- Occurs only in the legs. b- Are dilated lengthened veins. c- Are results of valvular incompetence d- May follow venous thrombosis. All the following are venous symptoms EXCEPT: a- Aching. b- Leg cramps. c- Palpitation. d- Tiredness. The best operation for varicose vein is: a- Multiple subcutaneous ligations b- Injecting sclerosants throughout. c- Sub-fascial ligatures. d- Division or ligation at sites of communication from deep to superficial system. The Brodie-Trendelenburg test is used to detect: a- The presence of deep femoral vein thrombosis. b- The integrity of the long saphenous vein. c- The presence of an incompetent valve at the saphenofemoral junction. d- The presence of valves in the inferior vena cava. A patient is receiving anticoagulation for treatment of deep venous thrombosis. Which of the following findings suggest that he is given warfarin a- Anticoagulation is monitored by measuring the prothrombin time b- Anticoagulation can be reversed by giving protamine sulfate c- Anticoagulation is achieved within one hour of drug administration d- The anticoagulant is administered by subcutaneous injection A patient with primary varicose veins and normal deep system can present by any of the following EXCEPT: a- Discomfort on prolonged standing b- Lower limb muscle cramps c- Severe lower limb edema d- Venous ulcer  BFOM 39 A patient with dilated tortuous veins over his lower abdomen filling predominantly from below upwards. This clinical finding can be associated with: a- Chronic Superior vena-cava obstruction b- Chronic inferior vena-cava obstruction c- Chronic portal hypertension d- Chronic pelvic congestion In a patient with chronic venous insufficiency due to residual deep venous obstruction, which of the following describes the clinical picture of his limb? a- Soft pitting edema with pigmentation and eczema b- Hard pitting edema without pigmentation and eczema c- Soft pitting edema without pigmentation and eczema d- Hard pitting edema with pigmentation and eczema Which of the following statements describes infected venous ulcer? a- Painless superficial ulcer with skin pigmentation around it b- Painful superficial ulcer with absent peripheral pulsations c- Painless deep ulcer with absent peripheral pulsations d- Painful superficial ulcer with skin pigmentation around it Severe prolonged venous congestion of the lower limbs may result in an acute inflammatory condition known as acute lipodermatosclerosis. The main line of treatment in this condition is: a- Anti-inflammatory drugs and external compression b- Broad spectrum antibiotic and external compression c- Anti-inflammatory drugs and broad-spectrum antibiotic d- Venotonic drugs and broad-spectrum antibiotic Which of the following best describes a healing ulcer? a- Small ulcer with undermined edge and red granulating floor b- Large ulcer with sloping edge and red granulating floor c- Small ulcer with raged edge and bleeding floor d- Large ulcer with raised edge and necrotic floor  BFOM 39 One of the complications of 1ry varicose veins is acute superficial thrombophlebitis. The main line of treatment for this condition is: a- Systemic anti-inflammatory drugs and external compression b- Local anti-inflammatory ointments and external compression c- Systemic broad-spectrum antibiotic and external compression d- Local antibiotic ointments and external compression The main aim of investigations in a patient with chronic venous insufficiency is to: a- Identify coagulation defects and hyper coagulable states b-Identify major systemic problems that may alter the operative decision c- Identify venous reflux and confirm deep venous patency d- Identify congenital arterio-venous fistula to avoid operating on them The accurate dynamic investigation used to evaluate superficial and deep venous reflux is: a- Pocket Doppler b- Ascending venography c- Duplex ultrasound d- Descending venography A 32-year-old healthy male presented with symptomatic varicosity of the long saphenous vein. Duplex ultrasound showed severe saphenofemoral reflux normal deep venous system and competent leg perforators. What treatment would you advise? a- Sapheno-femoral disconnection (Trendelenburg operation) b- Stripping of the long saphenous in the thigh only c- Stripping of the long saphenous in the leg and thigh d- Elastic compression stocking In acute deep venous thrombosis, the recommended treatment protocol is: a- Low molecular weight heparin for the whole duration of treatment b- Initial heparin anticoagulation followed by warfarins c- Oral anticoagulants for the whole duration of treatment d- Initial heparin anticoagulation followed by low dose salicylates.  BFOM 39 Thrombolytic therapy is effective in all of the following patients Except: a- Chronic ilio-femoral deep venous thrombosis with severe edema b- Massive pulmonary embolism with acute pulmonary hypertension c- Acute deep venous thrombosis with impending venous gangrene d- Acute arterial thrombosis with a viable non-critical limb ischemia Spontaneous superficial thrombophlebitis occurs in: a- Polycythemia. b- Polyarteritis. c- Buerger's disease. d- All of the above. The appropriate management of thrombophlebitis of superficial veins is: a- Supportive bandages and ambulation. b- Supportive bandages and strict bed rest. c- Anticoagulants and bed rest. d- Anticoagulants and ambulation. High risk patient for DVT include: a- Neoplasia. b- Pelvic surgery. c- Congestive heart failure. d- All of the above Post-operative deep venous thrombosis is suspected from the following EXCEPT: a- Unexplained post-operative fever or tachycardia. b- Pain in the sole or calf. c- Swelling or oedema of the calf or leg. d- Pain on plantar flexion of the foot. Phlegmasia albs dolens or white leg is due to: a- Lymphatic obstruction. b- Femoral deep vein thrombosis. c- Thrombosis of IVC and lymphatic obstruction d- Iliofemoral vein thrombosis plus lymphatic obstruction.  BFOM 39 Phlegmasia cerulae dolens or painful purple swelling is characterized by all the following EXCEPT: a- Extensive iliofemoral thrombosis b- Propagation of the thrombosis proximally and distally c- Reduced arterial inflow d- Treated by anticoagulants The treatment of phlegmasia cerulae dolens is: a- Nearly always surgical (i.e. venous thrombectomy, catheter-directed lytic therapy, or both) b- Anticoagulation. c- Low molecular weight dextran. d- Supportive. The commonest cause of fatal pulmonary embolism is: a- Iliac vein thrombosis. b- Thrombophlebitis of the femoral vein. c- Calf vein thrombosis. d- Axillary vein thrombosis. Pulmonary embolism is best diagnosed by: a- Chest x-ray. b- Spiral CT. c- MRI. d- Doppler. The following are clinical features of a large pulmonary embolism EXCEPT: a- Pleuritic chest pain b- Haemoptysis c- low grade fever d- Collapsed neck veins In patients with a proven pulmonary embolus all are true EXCEPT: a- Only 10% have clinical evidence of deep venous thrombosis b- The classic ECG features are described S I Q3T3 c- Arterial blood gases are abnormal in all patients d- Low molecular weight heparins are as effective a heparin infusion  BFOM 39 What is the normal ankle brachial index (ABI)? A. More than 1 B. Less than 0.8 C. 0.9 D. 1 Which artery supplies collateral flow between the celiac artery (CA) and superior mesenteric artery (SMA)? A. Middle colic artery. B. Pancreaticoduodenal arteries. C. Left colic artery. D. Marginal artery of Drummond. Which arteries supply collateral flow between the superior mesenteric artery (SMA) and inferior mesenteric artery (IMA)? A. Marginal artery of Drummond. B. Inferior pancreaticoduodenal artery. C. Left gastric artery. D. Splenic artery. What is the best conduit to be used in femoropopliteal bypass operations? A. Human umbilical vein. B. Gore-Tex PTFE. C. Dacron. D. Autogenous vein. Occlusion of which of the following arteries causes amaurosis fugax? A. Internal carotid artery (ICA). B. External carotid artery (ECA). C. Middle meningeal artery. D. None of the above. Diagnosis of renal artery hypertension is best achieved by: A. Renal artery duplex ultrasound. B. Selective angiography. C. MRA D. None of the above.  BFOM 39 Which is true regarding endovascular abdominal aortic aneurysm repair? A. It costs the same as open repair: B. Requires lifelong follow-up imaging. C. Results in longer hospital stay than open repair. D. Requires more blood transfusion than open repair. About revascularization procedures, all the following statements are true, except: A. The patency rate of aortobifemoral bypass is lower than that of femoro-popliteal bypass. B. Short-segment iliac artery stenosis can be successfully treated by percutaneous angioplasty. C. A synthetic graft is used for aortobifemoral bypass. D. Reversed saphenous vein is used for femoropopliteal bypass. What is the initial treatment in patients with acute lower limb ischemia? A. Thrombolysis. B. Surgical embolectomy. C. Heparinization. D. None of the above. The following statements about abdominal aortic aneurysms (AAA) are all true, except: A. The commonest cause is atherosclerosis B. They are usually present above the level of renal arteries C. The main risk is rupture D. Mural thrombi can migrate to cause distal embolization About abdominal aortic aneurysm (AAA), all the following statements are true, except: A. Normal diameter of the abdominal aorta is 2-3 cm. B. Aortic aneurysms with a diameter of 5 cm are advised to have urgent repair. C. The main risk of abdominal aortic aneurysm is rupture. D. One of its complications is distal embolization. About Buerger's disease, all the following statements are true, except: A. It mostly affects the iliac arteries. B. It affects male only. C. It affects smokers only. D. Pain is an early symptom.  BFOM 39 All the following are strong signs of arterial injury, except: A. Any haematoma in the course of an artery. B. External arterial bleeding. C. Absent distal pulses. D. A palpable thrill at the site of trauma. The commonest source of arterial lower limb emboli is: A. Thrombus in thoracic aortic aneurysm. B. Thrombus in abdominal aortic aneurysm. C. Cardiac mural thrombus on top of myocardial infarction. D. Left atrial thrombus. About arterial embolism, all the following statements are true, except: A. The commonest are thrombemboli. B. A throl1lembolus usually impacts at the bifurcation of an artery. C. Embolectomy can be done under local anaesthesia. D. Tense calf muscles are a bad prognostic sign. Virchow`s triad is: a- Three malignant lymph nodes enlargement in the left supraclavicular fossa. b- Three malignant lymph nodes enlargement in the right supraclavicular fossa. c- Venous blood stasis, venous endothelial injury and hypercoagulability. d- Obstructed jaundice, porta hepatis lymphadenopathy and septicemia. Which of the following doesn’t apply to 1ry varicose veins of lower limbs: a- May lead to disfigurement of lower limbs. b- Intermittent claudication is a prominent feature in their presentations. c- Associated with sapheno-femoral incompetence in most cases. d- One must test for patency of deep system before doing surgery. The term "venous pump" refers to: a- The apparatus used for rapid blood transfusion. b- The left atrium. c- The presence of valves in the inferior vena cava. d- The musclofascial anatomy and physiology of the calf.  BFOM 39 The saphenous nerve is liable to be injured during long saphenous vein stripping: a- Behind the knee. b- In the groin. c- In the leg. d- In the mid-thigh. Which of the following should be performed in a patient with a suspected Marjoline ulcer? (A) Hyperbaric therapy for 6 weeks (B) Zinc supplementation (C) Oral tetracyclin for 6 weeks (D) Biopsy Which of the following is considered the most effective therapy for venous stasis ulcer? (A) Supplemental vitamin A (B) Topical antibiotic ointment (C) Compression therapy (D) Hyperbaric therapy Which of the following is most likely to cause a diabetic ulcer? (A) Uncontrolled hyperglycemia (B) Large vessel ischemia (C) Small vessel ischemia (D) Neuropathy A Marjolin's ulcer arises in areas exposed to : (A) External beam radiation (B) Thermal injury (C) Pressure (D) Lymphedema Angiosarcoma associated with Steward-Treves syndrome arises in areas exposed to: (A) External beam radiation (B) Thermal injury (C) Pressure (D) Lymphedema  BFOM 39 Cervical rib may present by which of the followings a- Numbness in fingers. b- Bruit around clavicle. c- Lump in lower neck. d- All of the above. Pain in the arm due to cervical rib is caused by: a- Compression of T1 b- Compression of C7 c- Muscle ischemia d- All of the above Potato tumor is a: a- Carotid body tumor. b- Sternomastoid tumor. c- Cystic hygroma. d- Branchial cyst. Which statement is incorrect concerning varicose ulcers: a- Are always chronic and often recurrent.. b- Occur most often on the medial aspect of the lower third of the leg. c- Are always associated with superficial varicosities. d- Are often surrounded by an area of induration, pigmentation, oedema and dermatitis. Marjolin`s ulcer is: a- Tuberculous ulcer. b- Fungal ulcer. c- Scar carcinoma. d- Syphilitic ulcer. All are features of Marjolin's ulcer EXCEPT: a- Slow growth. b- Pain. c- Associated with chronic scar. d- Lymph node involvement is a late feature.  BFOM 39 The usual treatment of diabetic foot infection includes the following except: A. Urgent arteriography B. Antibiotics C. Control of diabetes mellitus D. Wide incisions to drain pus A pulsatile lump on the side of the neck in an 80-years-old man is: a- Mobile cervical lymph node. b- Branchial cyst. c- Carotid body tumor d- Cystic hygroma In Hodgkin's lymphoma, spot the wrong statement: a. It has a better prognosis than NHL. b. It is characterized by presence of few malignant cells outnumbered by inflammatory cells. c. It is characterized by presence of Reed-Sternberg cells. d. Diagnostic laparotomy is essential in all patients. Most common site of enlargement of lymph nodes in Hodgkin's lymphoma is: a- Abdominal. b- Cervical. c- Axillary. d- Mediastinal. Most common presentation of Hodgkin's lymphoma is: a- Leukocytosis. b- Fever. c- Painless enlargement of lymph nodes. d- Pruritus.  BFOM 39 Hodgkin's lymphoma with right sided neck nodes and left inguinal node without fever is of: a- Stage I a b- Stage III a c- Stage II a d- Stage IV a B symptoms of Hodgkin's lymphoma include all the following EXCEPT: a- Pruitus b- Headache c- Weight loss d- Fever Worst prognosis in Hodgkin's lymphoma is: a- Lymphocytic depletion b- Mixed cellularity c- Lymphocyte predominance d- Nodular sclerosis  BFOM 39 Schwartz “11th edition” Arterial Disease Which of the following is TRUE about computed tomography angiography (CTA) in evaluation of arterial disease? A. CTA is more accurate than angiography and evaluation of lower extremity arterial occlusive disease. B. Blooming artifact is the term used to describe artifact secondary to thrombus formation in the aorta and arteries. C. As a low dose of contrast is used, it is unlikely to be associated with kidney complications. D. CTA has sensitivity, specificity, and accuracy that is equivalent to invasive angiography. CTA is a noninvasive contrast-dependent method of imaging arterial system. The contrast- filled vessels can be extracted from the slices and rendered in the three-dimensional format. CTA is increasingly being used to image the carotid bifurcation, and as computing power increases, the speed of image acquisition and the resolution will continue to increase. The major limitations of multidetector CTA are use of contrast and presence of artifacts caused by calcification and stents. CTA can overestimate the degree of in-stent stenosis, while heavy calcification can limit the diagnostic accuracy of the method by causing a “blooming artifact.” The artifact can be overcome with alteration in image acquisition technique. There are no randomized trials to document the superiority of multidetector CTA of compared to traditional angiography, but there is emerging evidence to support the claim that multidetector CTA has sensitivity, specificity, and accuracy that rival invasive angiography.  BFOM 39 Vascular stents can be used in the vascular system for inadequate angioplasty with dissection or elastic recoil of an arterial stenosis. Which of the following statements appropriately describes vascular stents? A. All vascular stents are made of metals that contain stainless steel that will help self- expanding. B. Vascular stents should be oversized by 1 to 2 mm relative to the largest diameter of the normal vessel adjacent to the lesion in order to prevent immediate migration. C. Vascular stents are used in short stenotic segments because of their ability to expand and accommodate the area of stenosis without shortening or lengthening. D. Balloon expandable stents have a longer time to complete endothelialization. Vascular stents are commonly used after inadequate angioplasty with dissection or elastic recall of arterial stenosis. Appropriate indications for primary stenting of the lesion without an initial trial of angioplasty alone are evolving and managed that are dependent on the extent and the site of the lesion. Stents are manufactured from a variety of metals including stainless steel, tantalum, cobalt basaloid, and Nitinol. Vascular stents are classified into two basic categories: balloon-expandable stents and self-expanding stents. These stents are always oversized by 1 to 2 mm relative to the largest diameter of normal vessel adjacent to the lesion in order to prevent immediate migration. With the involvement of the cisterns, there is some degree of shortening that has to be taken into account when choosing the area of deployment. Self-expanding stents can continually expand after delivery; this allows them to accommodate adjacent vessels of different size. Balloon-expandable stents are usually composed of stainless steel, mounted on an angioplasty balloon, and deployed by a balloon inflation. Shortening of balloon-expandable stent during deployment depends on both the stent geometry and the final diameter to which the balloon is expanded. The cisterns are more rigid and are associated with a shorter time to complete endothelialization. They are often of limited flexibility and have a higher degree of crush resistance when compared to the self-expanding stents.  BFOM 39 An evaluation of the arterial segments of the lower extremities, pulse volume recording (PVR) has which of the following characteristics? A. The cuff is inflated to above systolic pressure to detect pulse volume changes. B. Brisk upstroke of the waveform in the pulse volume recording is suggestive of proximal disease. C. When compared with angiography, PVR has an accuracy of 30%. D. Its best application is in patients with noncompressible vessels that would interfere with accurate measurement of segmental pressures. PVR is used specifically in patients with noncompressible vessels where segmental plethysmography can be used to determine the underlying arterial occlusive disease. Pressure measurement in such patients is not accurate because of non-compressibility. Capsule placed at different levels on the leg detect changes in blood volume and he produced a graft. To obtain accurate PVR waveforms, the cuff is inflated to a pressure of 60 to 65 mm Hg, so as to detect volume changes without causing arterial occlusion. Pulse volume tracings are suggestive of proximal disease of the upstroke of the pulse is not brisk, the peak of the wave tracing is rounded, and there is disappearance of the dicrotic notch. Although isolated segmental limb pressures and PVR measurements are 85% accurate when compared with angiography in detecting and localizing significant atherosclerotic lesions, when using combination, accuracy reaches 95%. Which of the following is TRUE about patients with a stroke? A. Eighty-five percent of all strokes are hemorrhagic and 15% are ischemic. B. The commonest cause of the stroke is lacunar stroke. It occurs in about 30% of the patients. C. Cerebrovascular accident is used interchangeably with hemorrhagic stroke. D. Prior history of neurological symptoms such as transient ischemic attack (TIA) or stroke is a predictor for recurrent ipsilateral stroke. Approximately 700,000 Americans suffer an annual or recurrent stroke each year. Eighty- five percent of all strokes are ischemic and 15% are hemorrhagic. Common causes of ischemic stroke are cardiogenic emboli in 35%, carotid artery stenosis in 30%, lacunar in 10%, miscellaneous in 10%, and idiopathic in 15%. The term “cerebrovascular accident” is often used interchangeably to refer to an ischemic stroke. The severity of carotid artery stenosis is a strong predictor for stroke with more severe occlusive disease is associated with a higher incidence of stroke. A prior history of neurologic symptoms such as TIA or stroke is an important determinant for recurrent ipsilateral stroke.  BFOM 39 The following conditions qualify patients for being high surgical risk for carotid endarterectomy EXCEPT: A. High carotid bifurcation above C2 vertebral body. B. Low common carotid artery, below clavicle. C. Ipsilateral laryngeal nerve palsy. D. Tracheostomy. Since carotid artery stenting was approved by the US Food and Drug Administration (FDA) for the clinical application in 2004, the procedure has become a treatment alternative in patients who are considered high risk f