100+ Free TEMa (SBM / AMB) Practice Questions

Anatomia, Fisiologia e Propedêutica Mamária

Encompasses mammary embryology (milk line development, amastia, polymastia, polythelia), functional anatomy of the terminal ductal lobular unit (TDLU as the origin of most carcinomas), Cooper's suspensory ligaments, arterial vascularization (internal thoracic/mammary artery perforators, lateral thoracic artery, intercostal perforators), venous drainage (internal thoracic vein, axillary vein, vertebral venous plexus of Batson as a route for spine metastases), lymphatic drainage pathways (Level I: lateral to pectoralis minor, Level II: posterior to pectoralis minor, Level III: medial/superior to pectoralis minor; Rotter's interpectoral nodes; internal mammary lymphatic chain), endocrine regulation (estrogen receptor alpha/beta, progesterone receptor A/B, prolactin, oxytocin, placental lactogen, thyroid hormones), physiological changes during puberty, menstrual cycle, pregnancy, lactation, and postmenopausal involution, and clinical physical examination of the breast and regional nodal basins.

Doenças Benignas da Mama e Processos Inflamatórios

Evaluates diagnosis and evidence-based management of benign mammary conditions: fibroadenomas (clinical observation vs surgical excision indications, juvenile/giant fibroadenomas, complex fibroadenomas), simple and complicated/complex cysts (aspiration criteria, cytologic indications), periductal mastitis / Zuska's disease (squamous metaplasia of lactiferous ducts, subareolar abscess, smoking association, fistulectomy), puerperal mastitis and breast abscess (Staphylococcus aureus, ultrasound-guided needle aspiration vs open drainage, continuation of breastfeeding), idiopathic granulomatous lobular mastitis (IGLM: differential diagnosis with tuberculosis, core biopsy granulomas without caseation, corticosteroid therapy, methotrexate, surgical restraint), solitary intraductal papilloma vs multiple papillomatosis, pathologic nipple discharge workup (spontaneous, uniductal, unilateral, bloody or serous; major duct excision / Urban operation vs microdochectomy), Mondor's disease (superficial thrombophlebitis of thoracoepigastric veins, conservative management), traumatic fat necrosis (mammographic and sonographic appearance, oil cysts), and gynecomastia (physiological vs secondary etiology, Simon grading, medical and surgical subcutaneous mastectomy).

Rastreamento, Diagnóstico por Imagem e BI-RADS (6ª Edição)

Covers breast cancer screening guidelines in Brazil: INCA/Ministério da Saúde public health recommendations (biennial mammography from age 50 to 69 for average risk) versus joint recommendations from the Sociedade Brasileira de Mastologia (SBM), Colégio Brasileiro de Radiologia (CBR), and FEBRASGO (annual screening mammography from age 40 for average-risk women). Evaluates digital mammography positioning and views (craniocaudal [CC], mediolateral oblique [MLO], spot magnification, spot compression, rolled views), digital breast tomosynthesis (DBT / 3D mammography advantages in dense breasts), breast ultrasound descriptors (mass shape, margins, echogenicity, posterior acoustic features, vascularity, elastography), contrast-enhanced dynamic breast magnetic resonance imaging (MRI indications: annual screening for high genetic risk BRCA1/2, TP53, chest irradiation at age 10-30; evaluation of occult primary breast cancer Tx N1; assessment of residual disease and response to neoadjuvant chemotherapy; silicon implant rupture evaluation), ACR BI-RADS 6th edition classification categories (BI-RADS 0 to 6, positive predictive value of malignancy, management recommendations), and interventional percutaneous diagnostic procedures (FNAC, core needle biopsy, vacuum-assisted biopsy / mammotomy, preoperative wire, radioactive seed, or magnetic seed localization).

Lesões Precursoras, Lesões de Risco e Neoplasias Não Invasivas

Focuses on high-risk precursor lesions and non-invasive mammary proliferations: usual ductal hyperplasia (UDH) versus atypical ductal hyperplasia (ADH: histology, upgrade rate to invasive cancer on vacuum/core biopsy, surgical excision indication), flat epithelial atypia (FEA), atypical lobular hyperplasia (ALH) and classic lobular carcinoma in situ (LCIS: marker of bilateral increased risk, observation vs chemoprevention vs surgical excision when radiologic-pathologic discordance exists), pleomorphic LCIS (comedo necrosis, pleomorphism, management akin to DCIS with clear margins), radial scar / complex sclerosing lesion (differential diagnosis with tubular carcinoma, excision criteria), phyllodes tumors (classification into benign, borderline, and malignant based on stromal cellularity, atypia, mitotic index, overgrowth, and infiltrative borders; wide local excision with ≥ 1 cm clear margin without routine axillary dissection), Ductal Carcinoma In Situ (DCIS: architectural patterns comedo vs non-comedo, nuclear grade, necrosis, Van Nuys Prognostic Index, surgical margins ≥ 2 mm standard SSO/ASTRO, whole-breast radiotherapy indications and benefit, endocrine prevention with tamoxifen or aromatase inhibitors), and pharmacologic breast cancer chemoprevention (NSABP P-1, STAR, MAP.3, IBIS-II trials: tamoxifen, raloxifene, anastrozole, exemestane).

Câncer de Mama Infiltrante: Histopatologia, Estadiamento e Classificação Molecular

Comprehensive evaluation of infiltrating breast neoplasms: invasive carcinoma of no special type (NST / invasive ductal carcinoma), invasive lobular carcinoma (ILC: discohesive linear 'single-file' growth pattern, loss of E-cadherin expression via CDH1 gene alterations, multimodality imaging subtleties, multifocality/multicentricity, bilateral predilection, atypical metastatic sites: peritoneum, retroperitoneum, GI tract, ovaries), special histologic types (tubular, cribriform, mucinous/colloid, medullary-like, metaplastic spindle cell/squamous, invasive micropapillary carcinoma, adenoid cystic carcinoma), inflammatory breast cancer (T4d: clinical presentation of erythema, edema, peau d'orange involving ≥ 1/3 of the breast, dermal lymphatic tumor emboli, mandatory trimodality therapy: neoadjuvant chemotherapy followed by modified radical mastectomy and post-mastectomy radiotherapy), Nottingham histologic grading system (Elston-Ellis modification of Bloom-Richardson score: tubule/gland formation, nuclear pleomorphism, mitotic count per mm²), AJCC/UICC 8th Edition TNM staging system (clinical and pathological anatomical stage vs prognostic stage integrating T, N, M, histologic grade, ER, PR, HER2, and multigene assays), surrogate intrinsic molecular subtypes (Luminal A: ER+, PR ≥ 20%, HER2-, low Ki-67 < 14-20%; Luminal B HER2-negative: ER+, PR < 20% and/or high Ki-67 ≥ 20%; Luminal B HER2-positive: ER+, any PR, HER2+, any Ki-67; HER2-enriched: ER-, PR-, HER2+; Triple-Negative / Basal-like: ER-, PR-, HER2-), immunohistochemical guidelines (ASCO/CAP standards: ER/PR positivity threshold ≥ 1%; HER2 scoring algorithm: IHC 0, 1+, 2+ equivocal requiring in situ hybridization / ISH, 3+ positive; HER2-low category: IHC 1+ or IHC 2+/ISH-negative), and genomic multianalyte prognostic and predictive assays (Oncotype DX 21-gene Recurrence Score, TAILORx and RxPONDER trial thresholds; MammaPrint 70-gene signature, MINDACT trial; Prosigna PAM50; EndoPredict).

Tratamento Cirúrgico do Câncer de Mama e Manejo Axilar

In-depth review of surgical oncology principles in mastology: breast-conserving surgery (BCS / setorectomia / segmentectomia), absolute and relative contraindications for BCS, surgical margin definitions according to the SSO/ASTRO consensus ('no ink on tumor' for invasive carcinoma; 2 mm clear margin for pure DCIS), total simple mastectomy, skin-sparing mastectomy (SSM), nipple-areola-sparing mastectomy (NSM / adenomastectomia: oncologic safety criteria, retroareolar sub-nipple frozen section biopsy, ischemia prevention), sentinel lymph node biopsy (SLNB: radiocolloid Technetium-99m sulfur/phytate, patent blue dye / isosulfan blue, indocyanine green fluorescence, dual tracer technique advantages), indications and contraindications for SLNB, paradigm-shifting axillary de-escalation clinical trials (ACOSOG Z0011: T1-T2 cN0, breast-conserving surgery, whole-breast radiation therapy, 1-2 positive sentinel nodes: omission of completion axillary lymph node dissection without compromising local control or overall survival; AMAROS trial: axillary radiotherapy non-inferior to axillary dissection with lower lymphedema rates; IBCSG 23-01: isolated micrometastases ≤ 2mm), complete axillary lymph node dissection (ALND: anatomical boundaries of Berg levels I, II, and III, preservation of long thoracic nerve of Bell, thoracodorsal nerve and vessel bundle, and medial pectoral nerve; intercostobrachial nerve preservation vs sensory loss), and axillary staging following neoadjuvant systemic therapy (ACOSOG Z1071, SENTINA, GANEA-2 trials: management of cN0 pre-NAC vs cN+ converting to ycN0, false-negative rate reduction strategies including dual mapping, retrieval of ≥ 3 sentinel lymph nodes, and Targeted Axillary Dissection / TAD with localization and excision of the pre-treatment clipped positive lymph node).

Cirurgia Oncoplástica e Reconstrução Mamária

Oncoplastic breast surgery and post-mastectomy reconstructive techniques: classification into Level 1 oncoplastic surgery (< 20% breast volume resection, glandular mobilization, periareolar adjustments) and Level 2 oncoplastic surgery (20% to 50% volume resection, specialized mammoplasty techniques including superior, inferior, superomedial, or central pedicle designs, crescent mastopexy, batwing mastopexy, Benelli / round-block periareolar technique, vertical scar and inverted-T mammaplasty, Grisotti advancement/rotational flap for central quadrant and retroareolar defects), contralateral breast symmetrization principles, post-mastectomy prosthetic reconstruction (direct-to-implant vs two-stage tissue expander/implant, prepectoral implant placement with acellular dermal matrix / ADM or synthetic mesh vs subpectoral dual-plane placement, radiation impact on capsular contracture and implant failure), autologous tissue reconstruction (pedicled and free Transverse Rectus Abdominis Myocutaneous / TRAM flap, Deep Inferior Epigastric Perforator / DIEP flap with Hartrampf vascular zones I-IV, Latissimus dorsi myocutaneous flap with or without implant), autologous fat grafting (lipofilling: harvesting, processing, oncologic safety, interval from primary surgery), and nipple-areola complex (NAC) reconstruction techniques (local skin flaps: skate flap, star flap, arrow flap; intradermal tattooing).

Tratamento Sistêmico (Quimioterapia, Terapia-Alvo, Hormonioterapia, Imunoterapia) e Radioterapia

Comprehensive oncologic therapy principles: indications for neoadjuvant systemic therapy (NAC: downstaging large tumors to enable breast-conserving surgery, assessing in vivo chemosensitivity, early eradication of micrometastases, especially indicated in HER2-positive and Triple-Negative tumors ≥ T1c or N+), assessment of pathological complete response (pCR: absence of residual invasive disease in breast and axilla, ypT0/is ypN0) and Residual Cancer Burden (RCB score), adjuvant and neoadjuvant chemotherapy regimens (dose-dense anthracycline and cyclophosphamide followed by paclitaxel: ddAC-T; TC: docetaxel and cyclophosphamide), anti-HER2 targeted therapies (trastuzumab, pertuzumab, T-DM1 / trastuzumab emtansine for residual invasive disease post-NAC based on KATHERINE trial, trastuzumab deruxtecan / T-DXd in HER2-positive and HER2-low metastatic/advanced disease [DESTINY-Breast], tucatinib for brain metastases [HER2CLIMB]), adjuvant endocrine therapy (selective estrogen receptor modulators / SERMs: tamoxifen 20 mg daily for 5-10 years; aromatase inhibitors: anastrozole, letrozole, exemestane in postmenopausal women for 5-10 years; ovarian function suppression / OFS with GnRH agonists [goserelin, leuprolide] in high-risk premenopausal women based on SOFT and TEXT trials; CDK4/6 inhibitors: abemaciclib 150 mg bid for 2 years in high-risk HR+/HER2- early breast cancer based on monarchE trial, ribociclib in NATALEE trial), PARP inhibitors (olaparib 300 mg bid for 1 year in germline BRCA1/2-mutated high-risk early breast cancer post-NAC or post-surgery based on OlympiA trial), immune checkpoint inhibitors (pembrolizumab added to neoadjuvant chemotherapy and continued as adjuvant monotherapy in high-risk early TNBC based on KEYNOTE-522 trial), and radiation oncology principles (whole-breast radiotherapy / WBI following BCS, moderate hypofractionation standard 40.05 Gy in 15 fractions or ultra-hypofractionation 26 Gy in 5 fractions [FAST-Forward trial], tumor bed boost indications, post-mastectomy radiation therapy / PMRT indications [≥ 4 positive lymph nodes, T3/T4 tumors, positive margins, select 1-3 positive nodes], and Regional Nodal Irradiation / RNI covering supraclavicular, infraclavicular, internal mammary, and axillary apex nodes).

Genética do Câncer Hereditário, Situações Especiais e Qualidade de Vida

Explores hereditary cancer syndromes, genetics, and special clinical scenarios in mastology: Hereditary Breast and Ovarian Cancer syndrome (HBOC: BRCA1 on chromosome 17q21, BRCA2 on chromosome 13q12, DNA double-strand break homologous recombination repair deficiency, lifetime breast cancer risk 50-85% and ovarian cancer risk 20-40% for BRCA1 and 10-20% for BRCA2; PALB2 gene mutations; Li-Fraumeni syndrome / TP53; Cowden syndrome / PTEN; Hereditary Diffuse Gastric and Lobular Breast Cancer / CDH1; Peutz-Jeghers / STK11; moderate-penetrance genes ATM and CHEK2), clinical criteria for germline genetic testing referral according to SBM and NCCN guidelines, risk-reducing bilateral mastectomy (RRBM: > 90% risk reduction) and risk-reducing bilateral salpingo-oophorectomy (RRSO: recommended at age 35-40 for BRCA1 and 40-45 for BRCA2), high-risk surveillance protocol (annual contrast-enhanced breast MRI starting at age 25, alternating with annual mammography at age 30), male breast cancer (clinical presentation, higher association with BRCA2 mutations, Klinefeter syndrome, tamoxifen as adjuvant standard of care), pregnancy-associated breast cancer (PABC: diagnostic ultrasound and mammography with abdominal shielding, MRI without gadolinium, staging CXR/liver US, surgery safe in all trimesters, chemotherapy with anthracyclines and taxanes safe in 2nd and 3rd trimesters, strict contraindication of radiotherapy, endocrine therapy, and trastuzumab during active pregnancy), Paget's disease of the nipple (intraepidermal adenocarcinoma cells, association with underlying DCIS or invasive cancer, wedge/punch biopsy, central resection vs mastectomy), occult primary breast cancer presenting with axillary lymph node metastasis (Tx N1: workup with breast MRI, PET-CT, systemic and locoregional management), Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL: rare T-cell lymphoma associated with textured implants, delayed late-onset seroma > 1 year post-op, CD30 positive and ALK negative, total capsulectomy and implant removal), lymphedema prevention and management (axillary reverse mapping / ARM, LYMPHA lymphovenous bypass), and adjuvant bone-targeted therapy (zoledronic acid or denosumab in postmenopausal patients to prevent aromatase inhibitor-induced bone loss and reduce distant bone metastases).