Axillary Surgery Indian Medical PG Practice Questions and MCQs
Practice Indian Medical PG questions for Axillary Surgery. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Axillary Surgery Indian Medical PG Question 1: Sentinel lymph node biopsy in carcinoma breast is done if -
- A. LN palpable
- B. Breast lump with palpable axillary node
- C. Metastatic CA breast
- D. Breast mass but no lymph node palpable (Correct Answer)
Axillary Surgery Explanation: ***Breast mass but no lymph node palpable***
- Sentinel lymph node biopsy is primarily performed in patients with **clinically negative axillae** (no palpable lymph nodes) to assess for microscopic metastatic disease.
- The goal is to avoid full axillary lymph node dissection if the sentinel nodes are negative, thus reducing the risk of **lymphedema** and other complications.
*LN palpable*
- If a lymph node is palpable, it is often considered **clinically suspicious** and may warrant a direct fine-needle aspiration (FNA) or core biopsy rather than a sentinel node biopsy.
- A positive biopsy from a palpable node would typically lead directly to an **axillary lymph node dissection** or neoadjuvant therapy, as the sentinel node procedure offers less benefit in this scenario.
*Breast lump with palpable axillary node*
- Similar to a palpable LN, a **palpable axillary node** in the presence of a breast lump suggests established nodal involvement.
- In such cases, **sentinel lymph node biopsy** is often not the initial step; rather, direct biopsy of the palpable node or upfront axillary dissection (sometimes after neoadjuvant treatment) is considered.
*Metastatic CA breast*
- In **metastatic breast cancer** (stage IV disease), the focus shifts to systemic treatment, and axillary lymph node dissection, including sentinel node biopsy, is generally not indicated for staging purposes.
- The primary goal is palliative care or controlling systemic disease, not regional lymph node staging.
Axillary Surgery Indian Medical PG Question 2: N3a TNM staging of head and neck tumors (AJCC 8th edition) shows:
- A. Metastasis in a lymph node >6 cm (Correct Answer)
- B. Metastasis in lymph nodes >2 cm
- C. Metastasis in lymph nodes >5 cm
- D. None of the options
Axillary Surgery Explanation: ***Metastasis in a lymph node >6 cm***
- **N3a disease** in head and neck cancer staging (AJCC 8th edition) specifically refers to metastasis in a single lymph node larger than 6 cm in greatest dimension **without extranodal extension (ENE)**.
- This applies to oral cavity, oropharynx (HPV-negative), hypopharynx, and larynx cancers.
- **Note:** N3 staging also includes **N3b** (metastasis in any node with clinically overt ENE), but this question specifically asks about N3a criteria.
*Metastasis in lymph nodes >2 cm*
- Lymph nodes in the 2-3 cm range typically fall within **N1 or N2a categories**, depending on laterality and number of involved nodes.
- **N3a disease** requires a single lymph node to exceed 6 cm in greatest dimension without ENE.
*Metastasis in lymph nodes >5 cm*
- A lymph node between 3-6 cm is usually classified as **N2 disease** (N2a if single ipsilateral ≤6 cm, N2b if multiple ipsilateral ≤6 cm, N2c if bilateral or contralateral ≤6 cm).
- To be classified as **N3a**, the lymph node must be **>6 cm** without extranodal extension.
*None of the options*
- This option is incorrect because the first option accurately describes the size criterion for **N3a TNM staging** in head and neck tumors according to AJCC 8th edition guidelines.
- While N3 staging has two subcategories (N3a and N3b), the size criterion of >6 cm correctly defines N3a disease.
Axillary Surgery Indian Medical PG Question 3: Which of the following walls of axilla is formed by the surgical neck of humerus:
- A. Medial
- B. Lateral (Correct Answer)
- C. Anterior
- D. Posterior
Axillary Surgery Explanation: ***Lateral***
- The **lateral wall** of the axilla is formed by the **surgical neck of the humerus** and the coracobrachialis and biceps brachii muscles as they pass down into the arm.
- This wall provides the main connection between the axilla and the arm proper.
*Anterior*
- The **anterior wall** is formed by the **pectoralis major** [1] and **pectoralis minor** muscles [1], along with the clavipectoral fascia.
- This wall also forms the anterior axillary fold.
*Posterior*
- The **posterior wall** is comprised of the **subscapularis**, **teres major**, and **latissimus dorsi** muscles [1].
- It forms the posterior axillary fold.
*Medial*
- The **medial wall** of the axilla is formed by the **upper four or five ribs** along with the **serratus anterior muscle**.
- This wall lies against the chest wall.
Axillary Surgery Indian Medical PG Question 4: What is a late complication of elbow dislocation?
- A. Median nerve injury
- B. Brachial artery injury
- C. Myositis ossificans (Correct Answer)
- D. None of the options
Axillary Surgery Explanation: **Myositis ossificans**
- **Myositis ossificans** is the abnormal formation of **heterotopic bone** within muscle or other soft tissues, often developing weeks to months after joint trauma such as an elbow dislocation.
- It typically presents as a painful, firm mass with restricted joint movement, especially **flexion** and **extension** at the elbow.
*Median nerve injury*
- **Median nerve injury** can occur at the time of the initial elbow dislocation (an **acute complication**), but it is not typically considered a late complication that develops over weeks or months.
- Symptoms include numbness in the thumb, index, and middle fingers, as well as weakness in **thumb opposition** and **flexion** of the index finger.
*Brachial artery injury*
- **Brachial artery injury** is an **acute complication** of severe elbow dislocation, leading to compromise of distal blood flow.
- Signs include absence of pulses, pallor, paresthesia, and pain in the forearm and hand, requiring immediate surgical intervention.
*None of the options*
- This option is incorrect because **myositis ossificans** is a well-recognized late complication of elbow dislocation.
Axillary Surgery Indian Medical PG Question 5: Axillary Nerve Injury is least likely in:
- A. Intramuscular injection
- B. Shoulder dislocation
- C. Improper use of crutch (Correct Answer)
- D. Fracture proximal humerus
Axillary Surgery Explanation: Improper use of crutch
- **Improper crutch usage** primarily affects the **radial nerve** in the axilla due to direct compression against the humerus.
- While it can cause nerve damage, the **axillary nerve** is less commonly injured by crutch use as it lies more distally and laterally, protected by the deltoid muscle.
*Intramuscular injection*
- Injections in the **deltoid muscle** can directly injure the **axillary nerve** due to its superficial course around the surgical neck of the humerus. [1]
- This risk is higher with improper technique or very deep injections, leading to **deltoid weakness** and **sensory loss** over the lateral shoulder.
*Shoulder dislocation*
- **Anterior shoulder dislocations** are a common cause of **axillary nerve injury** due to the stretching or tearing of the nerve as the humeral head displaces.
- The nerve wraps around the **surgical neck of the humerus**, making it vulnerable during dislocation.
*Fracture proximal humerus*
- Fractures of the **surgical neck of the humerus** often lead to **axillary nerve damage** because the nerve lies in close proximity to this region.
- The blunt force or displacement of bone fragments can directly compress or lacerate the nerve.
Axillary Surgery Indian Medical PG Question 6: A patient with head and neck cancer has a contralateral lymph node of 3 cm size. What is the N staging?
- A. N2a
Single
Ipsilateral
3 to 6 cm
- B. N1
Single
Ipsilateral
Equal to or <3 cm
- C. N3
Single or Multiple
Ipsilateral, Bilateral or Contralateral
Any node >6 cm
- D. N2c
Single or Multiple
Bilateral or Contralateral
None > 6 cm (Correct Answer)
Axillary Surgery Explanation: ***N2c (Single or Multiple, Bilateral or Contralateral, None > 6 cm)***
- A 3 cm **contralateral** lymph node falls under the **N2c** category according to the AJCC staging system for head and neck cancers.
- **N2c** indicates involvement of **contralateral** or **bilateral lymph nodes**, with the largest node being **no greater than 6 cm**.
- This is the correct staging for the described clinical scenario.
*N2a (Single, Ipsilateral, 3 to 6 cm)*
- This option incorrectly describes an **ipsilateral** lymph node, whereas the question specifies a **contralateral** node.
- **N2a** is defined by a single **ipsilateral** lymph node between **3 and 6 cm** in greatest dimension.
- The key differentiator is **laterality** (ipsilateral vs contralateral).
*N1 (Single, Ipsilateral, Equal to or <3 cm)*
- This option refers to an **ipsilateral** lymph node that is **3 cm or smaller**, which does not match the contralateral location provided in the question.
- **N1** describes a single **ipsilateral** lymph node that is **≤ 3 cm** in greatest dimension.
- This fails on both **laterality** (ipsilateral vs contralateral) and **size criteria** (the node is exactly 3 cm, at the boundary).
*N3 (Single or Multiple, Ipsilateral/Bilateral/Contralateral, Any node >6 cm)*
- While it includes contralateral involvement, **N3** is specifically for a lymph node **greater than 6 cm**, which is not the case for a 3 cm node.
- A **N3** classification applies when **any** regional lymph node (ipsilateral, bilateral, or contralateral) exceeds **6 cm** in greatest dimension.
- The described 3 cm node does not meet the **size threshold** for N3 staging.
Axillary Surgery Indian Medical PG Question 7: A patient presents to the OPD with a right-sided ulcerated breast lesion. Radiological imaging shows liver metastasis, as seen in the provided ultrasound image. What is the most appropriate management?
- A. Simple mastectomy
- B. Modified Radical Mastectomy (MRM)
- C. Radical mastectomy
- D. Neoadjuvant chemotherapy followed by surgery (Correct Answer)
Axillary Surgery Explanation: ***Neoadjuvant chemotherapy followed by surgery***
- The presence of **distant metastasis** (liver metastasis) indicates **Stage IV breast cancer**, where **systemic treatment is the primary goal**.
- In Stage IV disease, **palliative systemic chemotherapy** is the mainstay of treatment to control distant disease and improve survival.
- Surgery in metastatic breast cancer may be considered for **local control of symptomatic disease** (ulceration, bleeding, pain), typically after initiating systemic therapy.
- The combination of systemic therapy followed by local surgery for the ulcerated lesion addresses both the metastatic disease and provides local symptom relief.
*Simple mastectomy*
- While this could provide local control of the ulcerated lesion, it does **not address the distant metastasis**.
- In Stage IV disease, **systemic therapy must be prioritized** before considering any local surgical intervention.
- Surgery alone without systemic treatment would be inadequate for metastatic disease.
*Modified Radical Mastectomy (MRM)*
- MRM involves removal of the entire breast tissue, skin, nipple-areolar complex, and level I and II axillary lymph nodes.
- While this provides comprehensive local-regional control, it **does not address distant metastasis**.
- In Stage IV disease, extensive locoregional surgery without systemic therapy first would be inappropriate, as the primary issue is systemic disease.
*Radical mastectomy*
- This extensive procedure involves removal of the breast, axillary lymph nodes, and pectoralis muscles.
- It is **rarely performed today** due to significant morbidity and no survival benefit over less extensive procedures.
- Like other surgical options alone, it fails to address the systemic nature of Stage IV disease.
Axillary Surgery Indian Medical PG Question 8: A 45-year-old woman with early-stage breast cancer is discussing treatment options with her surgeon. Which of the following statements regarding breast conservation surgery is NOT true?
- A. Post-operative radiotherapy
- B. Axillary dissection (Correct Answer)
- C. Wide local excision
- D. Sentinel lymph node biopsy
Axillary Surgery Explanation: ***Axillary dissection***
- **Axillary dissection is NOT a routine component of breast conservation surgery** for early-stage breast cancer.
- In early-stage disease, **sentinel lymph node biopsy (SLNB)** has largely replaced routine axillary dissection as it provides accurate staging with significantly less morbidity.
- Axillary dissection is only performed when there is **proven extensive lymph node involvement** or when SLNB shows metastatic disease requiring further assessment.
- Therefore, this statement is **NOT true** regarding routine breast conservation surgery.
*Wide local excision*
- **Wide local excision (lumpectomy)** is the primary surgical component of breast conservation therapy.
- It involves removing the cancerous tumor along with a margin of healthy breast tissue to achieve clear margins while preserving the breast.
*Sentinel lymph node biopsy*
- **SLNB** is a standard procedure performed with breast conservation surgery to assess for regional lymph node metastasis.
- It identifies and removes the first few lymph nodes draining the tumor, allowing accurate staging with minimal morbidity.
*Post-operative radiotherapy*
- **Post-operative radiotherapy** to the preserved breast is a critical and essential component of breast conservation therapy.
- It significantly reduces the risk of local recurrence by treating any microscopic tumor cells that may remain after surgery.
Axillary Surgery Indian Medical PG Question 9: Which of the following is a contraindication to breast conservation surgery?
- A. Presence of multicentric tumors (Correct Answer)
- B. Involvement of axillary lymph nodes
- C. Tumor size greater than 4 cm
- D. Presence of diffuse microcalcifications
Axillary Surgery Explanation: ***Presence of multicentric tumors***
- **Multicentric tumors** are defined as two or more discrete tumors in different quadrants of the breast, which cannot be removed with a single lumpectomy.
- This condition is a contraindication for breast conservation surgery (BCS) because complete removal of all tumor foci while maintaining an acceptable cosmetic outcome is highly unlikely.
*Involvement of axillary lymph nodes*
- **Axillary lymph node involvement** is an important prognostic factor in breast cancer and influences adjuvant therapy decisions, but it is not a direct contraindication to BCS.
- Patients with positive nodes often undergo axillary dissection or sentinel lymph node biopsy, followed by radiation and/or systemic therapy, which can be combined with BCS.
*Tumor size greater than 4 cm*
- While larger tumor size (e.g., >4-5 cm) can make achieving negative surgical margins and a good cosmetic outcome more challenging with BCS, it is not an absolute contraindication.
- **Neoadjuvant chemotherapy** can often downstage larger tumors, making BCS a viable option for many patients.
*Presence of diffuse microcalcifications*
- **Diffuse microcalcifications** can sometimes indicate extensive ductal carcinoma in situ (**DCIS**) or invasive lobular carcinoma with a widespread component.
- However, if the microcalcifications represent a single focus of disease that can be entirely excised with negative margins, BCS may still be an option, especially if guided by stereotactic biopsy and imaging.
Axillary Surgery Indian Medical PG Question 10: In which of the following situations is breast conservation surgery not indicated?
- A. SLE
- B. Large pendular breast
- C. Diffuse microcalcification
- D. All of the options (Correct Answer)
Axillary Surgery Explanation: ***All of the options***
- All listed scenarios—**large pendular breast**, **SLE**, and **diffuse microcalcification**—represent situations where breast conservation surgery is generally contraindicated or challenging.
- Their presence often necessitates alternative treatment approaches, such as mastectomy, to achieve optimal oncologic and cosmetic outcomes.
*Large pendular breast*
- While not an absolute contraindication, a **very large or pendulous breast** can make it difficult to achieve a satisfactory cosmetic outcome after breast conservation surgery.
- The disproportionate breast size post-lumpectomy may lead to significant **asymmetry**, requiring further reconstructive procedures.
*SLE*
- Patients with **Systemic Lupus Erythematosus (SLE)** are at an increased risk of complications from radiation therapy, a mandatory component of breast conservation surgery.
- They tend to experience more severe and prolonged **acute and chronic skin reactions** to radiation, which can significantly impair healing and quality of life.
*Diffuse microcalcification*
- **Diffuse microcalcification** within the breast can indicate widespread in situ carcinoma (e.g., DCIS) or an invasive carcinoma with extensive intraductal component.
- In such cases, achieving **clear surgical margins** with breast conservation surgery can be challenging and often leads to multiple re-excisions or an increased risk of local recurrence.
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