Interventional Breast Procedures — MCQs
What is the main contraindication for performing a liver biopsy?
Which of the following is a contraindication to breast conservation surgery?
The most appropriate technique for mammography is:
What is the treatment of choice for a post-operative abscess?
Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?
Best investigation to detect rupture of silicone breast implants is-
Current gold standard to detect ductal carcinoma in situ breast is:
What is not an advantage of USG over mammography?
Which of the following ultrasound features of a thyroid nodule is not suggestive of malignancy?
Which of the following is the most sensitive investigation for ductal carcinoma in situ (DCIS) of the breast?
Interventional Breast Procedures Indian Medical PG Practice Questions and MCQs
Question 1: What is the main contraindication for performing a liver biopsy?
- A. Severe thrombocytopenia
- B. Liver hemangioma
- C. Presence of ascites
- D. Severe coagulopathy (Correct Answer)
Explanation: ***Severe coagulopathy*** - **Severe coagulopathy** is the main contraindication for liver biopsy due to a significantly increased risk of **hemorrhage** [1]. - A **prothrombin time (PT)** or **activated partial thromboplastin time (aPTT)** significantly prolonged beyond the normal range, or an **INR > 1.5**, should be corrected before the procedure [1]. *Severe thrombocytopenia* - While **thrombocytopenia** (platelet count <50,000/µL) does increase bleeding risk, it is often correctable with a **platelet transfusion** prior to biopsy, making it a relative rather than an absolute contraindication [1]. - The risk of major bleeding is typically lower with isolated thrombocytopenia compared to severe coagulopathy. *Liver hemangioma* - The presence of a **liver hemangioma** at the biopsy site is a contraindication as biopsying it can lead to massive hemorrhage. - However, if the biopsy can be performed safely away from the hemangioma, it is not an absolute contraindication to the procedure itself. *Presence of ascites* - **Ascites** can complicate a liver biopsy by increasing the risk of **peritoneal bleeding** and difficulty in targeting the liver [1]. - However, it is often manageable by draining the ascites or using imaging guidance, making it a relative contraindication rather than an absolute one [1].
Question 2: 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
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.
Question 3: The most appropriate technique for mammography is:
- A. Spot Compression view
- B. Lateral view
- C. Mediolateral oblique view (Correct Answer)
- D. Craniocaudal view
Explanation: ***Mediolateral oblique view*** - This view captures the **most breast tissue**, from the axilla down to the inframammary fold, as it visualizes both the upper outer quadrant and the posterior breast. - It allows for comprehensive imaging of the breast, which is crucial for **screening and diagnostic mammography**, enabling detection of abnormalities that might be missed on other views. *Spot Compression view* - This technique is used for **further evaluation of suspicious areas**, not as a primary screening or diagnostic view. - It applies localized compression to a smaller area of breast tissue to improve lesion visibility and definition. *Lateral view* - While it provides an orthogonal view to the craniocaudal projection, the standard lateral view (specifically, the medial lateral projection) **does not include as much axillary tissue** as the mediolateral oblique view. - It is often used as a supplementary view to help **localize lesions** in the mediolateral dimension. *Craniocaudal view* - This view is a standard part of mammography, providing a superior-inferior projection, but it **misses a significant portion of the axillary tail and posterior breast tissue**, especially in the upper outer quadrant. - It is usually performed in conjunction with the mediolateral oblique view to provide a **two-dimensional assessment** of the breast.
Question 4: What is the treatment of choice for a post-operative abscess?
- A. Hydration
- B. IV antibiotics
- C. Image guided aspiration (Correct Answer)
- D. Reexploration
Explanation: ***Image-guided aspiration*** - This is often the **first-line treatment** for a post-operative abscess, especially if it is well-localized. - It involves **draining the pus** under imaging guidance, relieving pressure and removing the infectious material. *Hydration* - While important for overall patient management, especially in cases of infection or sepsis, **hydration alone does not treat an abscess**. - It is a supportive measure but does not address the **localized collection of pus**. *IV antibiotics* - Antibiotics are typically indicated as an **adjunct to drainage**, especially in cases of systemic infection or cellulitis. - However, **antibiotics alone are often insufficient** to resolve an abscess as they have difficulty penetrating the necrotic core and thick capsule. *Reexploration* - **Surgical reexploration** is a more invasive option usually reserved for abscesses that are **large, multiloculated, not amenable to percutaneous drainage**, or when initial drainage attempts fail. - It carries greater risks and is not the initial treatment of choice for every post-operative abscess.
Question 5: Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?
- A. Anaplastic carcinoma of thyroid
- B. Medullary carcinoma of thyroid
- C. Follicular carcinoma of thyroid (Correct Answer)
- D. Papillary carcinoma of thyroid
Explanation: ***Follicular carcinoma of thyroid*** - The definitive diagnosis of **follicular carcinoma** requires the presence of **capsular or vascular invasion**, which cannot be assessed through **fine needle aspiration cytology (FNAC)** alone [1], [5]. - FNA may show features suggestive of follicular neoplasm (e.g., hypercellularity with microfollicles), but differentiation from **follicular adenoma** requires histological examination of the excised specimen [1], [4]. *Anaplastic carcinoma of thyroid* - **Anaplastic carcinoma** is highly aggressive and characterized by **pleomorphic, bizarre cells** that are easily identifiable on FNAC [2], [5]. - The distinctive cytological features, including **spindle cells, giant cells, and rapid cellular atypia**, allow for a relatively straightforward diagnosis via FNAC [2]. *Medullary carcinoma of thyroid* - **Medullary carcinoma** cells have characteristic cytological features, such as **plasmacytoid appearance**, **amyloid deposition**, and **neuroendocrine granules**, which can be identified on FNAC [5]. - Confirmation can be made by **immunohistochemical staining for calcitonin** on the FNA sample [5]. *Papillary carcinoma of thyroid* - **Papillary carcinoma** has distinct cytological features, including **orphan Annie eye nuclei**, **intranuclear grooves**, **pseudoinclusions**, and **papillary structures**, readily identified by FNAC [3]. - These features are highly specific and often allow for a definitive diagnosis of papillary thyroid carcinoma [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1100-1101. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1101-1102. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 429-430. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 428-429. [5] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 430-431.
Question 6: Best investigation to detect rupture of silicone breast implants is-
- A. Mammography
- B. X-ray
- C. MRI (Correct Answer)
- D. USG
Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** is considered the **gold standard** for detecting silicone breast implant ruptures due to its superior soft tissue contrast and ability to differentiate silicone from other tissues. - It can accurately identify both **intracapsular** (linguine sign) and **extracapsular** ruptures, as well as associated silicone granulomas. *Mammography* - While useful for breast cancer screening, **mammography** has limited sensitivity for detecting silicone implant ruptures, especially subtle ones. - It can show indirect signs like implant contour abnormalities or increased implant density but is often inconclusive for rupture diagnosis. *X-ray* - **X-rays** provide very little information regarding the integrity of silicone breast implants because silicone is radiolucent and does not show up clearly on standard radiographs. - Its utility is primarily for detecting calcifications or foreign bodies, not implant rupture. *USG* - **Ultrasound (USG)** can be a useful initial screening tool for detecting implant ruptures, showing signs like the **"stepladder sign"** for intracapsular rupture or anechoic collections (silicone outside the capsule). - However, its accuracy is highly operator-dependent, and it may miss subtle ruptures or be limited by poor visualization due to scar tissue, making MRI a more definitive choice.
Question 7: Current gold standard to detect ductal carcinoma in situ breast is:
- A. Mammography (Correct Answer)
- B. CT/PET
- C. MRI
- D. USG
Explanation: ***Mammography*** - **Mammography** is the gold standard for detecting **ductal carcinoma in situ (DCIS)**, often visible as microcalcifications. - It plays a crucial role in early detection and has been a cornerstone of breast cancer screening for decades. *CT/PET* - **CT scans** are primarily used for evaluating tumor extent and metastasis, not for initial DCIS detection. - **PET scans** are not routinely used for DCIS due to their lower resolution for subtle changes and higher false-negative rates for small lesions. *MRI* - While **MRI** is highly sensitive for breast cancer, its specificity for **DCIS** is lower, often leading to false positives. - It is typically used as an adjunct to mammography for high-risk screening or for evaluating the extent of known cancer, not as a primary screening tool for DCIS. *USG* - **Ultrasound (USG)** is effective for evaluating palpable masses or specific areas of concern identified on mammography, but it is not sensitive enough to reliably detect **microcalcifications** characteristic of DCIS. - It is often used to differentiate between solid and cystic lesions or guide biopsies, but not as a primary screening tool for DCIS.
Question 8: What is not an advantage of USG over mammography?
- A. Can be used for guided biopsy
- B. Superior detection of microcalcifications (Correct Answer)
- C. In young females with dense breasts
- D. Can be used to differentiate solid VS cystic
Explanation: ***Superior detection of microcalcifications*** - **Mammography** is the gold standard for detecting **microcalcifications**, which can be a key indicator of **ductal carcinoma in situ (DCIS)** or early invasive breast cancer. - **Ultrasound (USG)** has limited sensitivity for detecting and characterizing microcalcifications. *Can be used for guided biopsy* - **USG-guided biopsy** is a common and advantageous technique for obtaining tissue samples from suspicious lesions in the breast or other organs. - This allows for **real-time visualization** of the needle, improving accuracy and reducing complications. *Can be used to differentiate solid VS cystic* - **USG** excels at distinguishing between **solid masses and fluid-filled cysts** due to differences in sound wave reflection. - This capability is crucial in characterizing breast lesions and often eliminates the need for further invasive procedures for benign cysts. *In young females with dense breasts* - **Dense breast tissue** in young females can obscure lesions on mammography, making interpretation difficult. - **USG** is particularly valuable in this population because it is not hindered by breast density and can provide a clearer view of underlying pathology.
Question 9: Which of the following ultrasound features of a thyroid nodule is not suggestive of malignancy?
- A. Hypoechogenicity
- B. Hyperechogenicity (Correct Answer)
- C. Microcalcification
- D. Nonhomogeneous
Explanation: ***Hyperechogenicity*** - A **hyperechoic** thyroid nodule appears brighter than the surrounding parenchyma on ultrasound, typically indicating a benign lesion, such as a **colloid nodule**. - This feature suggests a higher reflection of sound waves, characteristic of tissues rich in **fluid or colloid material**. *Hypoechogenicity* - **Hypoechoic** nodules appear darker than the surrounding thyroid tissue, which is a strong indicator of malignancy due to their often dense cellular structure. - This feature is associated with a higher risk of thyroid cancer and often prompts further investigation with **fine-needle aspiration (FNA)**. *Microcalcification* - The presence of **microcalcifications** (tiny, bright spots) within a thyroid nodule is one of the most specific ultrasound signs of **papillary thyroid carcinoma**. - These calcifications, often punctate, represent psammoma bodies, which are a histopathological hallmark of this common thyroid cancer. *Nonhomogeneous* - A **nonhomogeneous** (heterogeneous) echotexture within a thyroid nodule, characterized by irregular internal architecture, can be suggestive of malignancy. - This often indicates disorganized cellular growth, fibrosis, or cystic degeneration with solid components, which are features seen in various thyroid cancers.
Question 10: Which of the following is the most sensitive investigation for ductal carcinoma in situ (DCIS) of the breast?
- A. PET Scan
- B. Ultrasound
- C. Mammography (Correct Answer)
- D. MRI
Explanation: ***Mammography*** - **Mammography** is the **gold standard** and **primary imaging modality** for detecting **ductal carcinoma in situ (DCIS)**, primarily because it excels at visualizing **microcalcifications**, which are the hallmark of DCIS. - Approximately **80-90% of DCIS cases** present as **microcalcifications** on mammograms, making it the most important screening and diagnostic tool. - Mammography has **high sensitivity (85-95%)** for detecting DCIS, especially calcified forms, and is widely available and cost-effective. *MRI* - While **MRI** has high sensitivity for invasive breast cancer and can detect non-calcified DCIS, it is **not the primary screening tool** for DCIS detection. - MRI is typically used for **staging known DCIS**, evaluating **extent of disease**, detecting **additional foci**, and screening **high-risk patients**. - However, MRI has lower specificity and higher false-positive rates compared to mammography, limiting its use as a primary diagnostic tool. *PET Scan* - **PET scans** are generally **not sensitive** for detecting **DCIS** because DCIS lesions typically have a **low metabolic rate** and do not avidly take up the **FDG tracer**. - PET scans are primarily used for detecting **invasive cancers** and assessing **metastatic disease**, not for non-invasive lesions like DCIS. *Ultrasound* - **Ultrasound** has **limited sensitivity** for detecting **DCIS** because DCIS often does not present as a palpable mass or a distinct sonographic abnormality. - While ultrasound can be useful for evaluating palpable masses or guiding biopsies, it frequently **misses microcalcifications** that are characteristic of DCIS. - Ultrasound is mainly used as a **complementary tool** to mammography, not as a primary diagnostic modality for DCIS.
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