Breast Surgery — MCQs

Breast Surgery Indian Medical PG Practice Questions and MCQs

Question 111: What is the treatment for Paget's disease of the breast?

A. Simple mastectomy (Correct Answer)
B. Radical mastectomy
C. Microdochectomy
D. Hadfield's operation

Explanation: **Explanation:** **Paget’s Disease of the Breast** is a condition characterized by the presence of malignant Paget cells within the epidermis of the nipple-areola complex. It is almost always (95-98% of cases) associated with an underlying **Ductal Carcinoma In Situ (DCIS)** or invasive carcinoma elsewhere in the breast. 1. **Why Simple Mastectomy is correct:** Because Paget’s disease is frequently associated with an underlying malignancy that is often **multifocal or multicentric**, a **Simple Mastectomy** (which involves removal of the entire breast tissue including the nipple-areola complex) is the traditional gold standard treatment. While Breast Conserving Surgery (BCS) followed by radiotherapy is an evolving alternative, Simple Mastectomy remains the definitive answer for exams when multicentricity is suspected. 2. **Why other options are incorrect:** * **Radical Mastectomy:** This involves removal of the pectoralis muscles and is now obsolete in modern surgical practice. * **Microdochectomy:** This is the surgical removal of a single lactiferous duct, typically used for treating **spontaneous nipple discharge** from a single duct (e.g., intraductal papilloma). * **Hadfield’s Operation (Total Duct Excision):** This involves the excision of all major ducts and is used for **recurrent periductal mastitis** or multiductal discharge, not malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Often misdiagnosed as eczema. A key differentiator is that Paget’s **destroys the nipple-areola complex**, whereas eczema usually spares the nipple. * **Pathology:** Paget cells are large, PAS-positive, and contain clear cytoplasm (vacuolated). * **Diagnosis:** Confirmed by a **wedge biopsy** or punch biopsy of the nipple. * **Prognosis:** Depends entirely on the stage and nature of the underlying associated carcinoma.

Question 112: What is the investigation performed?

A. MRI breast
B. Mammography (Correct Answer)
C. X-ray
D. Clinical examination

Explanation: ***Mammography*** - The image shows **craniocaudal (CC)** and **mediolateral oblique (MLO) views** with **breast compression**, which are characteristic features of mammography. - Uses a **dedicated breast X-ray unit** with specialized **compression paddles** to spread breast tissue for optimal visualization of masses and calcifications. *MRI breast* - Requires **intravenous contrast** and produces **cross-sectional images** in multiple planes (axial, sagittal, coronal). - Shows **soft tissue contrast** and **enhancement patterns** rather than the compressed, flattened breast tissue seen in this image. *X-ray* - A **plain chest X-ray** would show the **thoracic cavity** including lungs, ribs, and mediastinum in a single projection. - Lacks the **specialized breast positioning** and **compression techniques** used in dedicated breast imaging. *Clinical examination* - Involves **physical palpation** and **visual inspection** of the breast without any imaging equipment. - Does not produce any **radiographic images** or require **radiation exposure** like the investigation shown.

Question 113: Molecular classification of breast cancer is based on?

A. Serum hormone levels
B. Expression of hormone receptors (ER/PR)
C. In-vitro response to chemotherapeutic agents
D. Gene expression profiling (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Gene expression profiling** **1. Why Gene Expression Profiling is Correct:** The molecular classification of breast cancer (Perou and Sorlie classification) is based on **microarray-based gene expression profiling**. This technique analyzes the mRNA levels of hundreds of genes simultaneously to categorize tumors into distinct biological subtypes. This classification is superior to traditional morphology because it reflects the underlying genetic driver of the tumor, providing better prognostic and therapeutic insights. The four main molecular subtypes are: * **Luminal A:** High ER/PR, low Ki-67 (Best prognosis). * **Luminal B:** ER+, but may have lower PR or higher Ki-67/HER2+. * **HER2-enriched:** Overexpression of the HER2 gene. * **Basal-like:** Usually "Triple Negative" (ER-, PR-, HER2-); worst prognosis. **2. Why Other Options are Incorrect:** * **A. Serum hormone levels:** Breast cancer behavior is determined by the receptors *on the tumor cells*, not the circulating levels of hormones in the blood. * **B. Expression of hormone receptors (ER/PR):** While we use Immunohistochemistry (IHC) for ER/PR/HER2 in clinical practice as a **surrogate** for molecular classification, the *actual* molecular classification is defined by gene expression, not protein expression. * **C. In-vitro response to chemotherapy:** Chemosensitivity is a result of the molecular subtype, not the basis for the classification itself. **3. Clinical Pearls for NEET-PG:** * **Surrogate Markers:** In routine labs, we use **IHC** (protein expression) to approximate molecular subtypes because gene profiling (Oncotype DX/MammaPrint) is expensive. * **Luminal A** is the most common subtype and has the best prognosis. * **Basal-like** tumors are often associated with **BRCA1** mutations. * **Ki-67** is a marker of cellular proliferation; high Ki-67 (>20%) distinguishes Luminal B from Luminal A.

Question 114: A 14-week postpartum woman presents with a fluctuant breast swelling. What is the most appropriate initial treatment?

A. Incision and drainage
B. Continue breastfeeding with antibiotics
C. Analgesics
D. Repeated aspirations under antibiotic cover (Correct Answer)

Explanation: **Explanation:** The clinical presentation of a fluctuant breast swelling in a postpartum woman is diagnostic of a **Lactational Breast Abscess**. **1. Why Option D is Correct:** The current gold standard for the management of lactational breast abscesses is **repeated needle aspiration** (often ultrasound-guided) combined with appropriate **antibiotics** (usually targeting *Staphylococcus aureus*). This approach is preferred over surgical drainage because it results in less scarring, does not require general anesthesia, avoids the risk of a milk fistula, and allows the mother to continue breastfeeding comfortably. **2. Why Other Options are Incorrect:** * **Option A (Incision and Drainage):** While traditionally the treatment of choice, it is now reserved for cases where needle aspiration fails, the skin is thinned/necrotic, or the abscess is very large (>5 cm). It carries a higher risk of milk fistula and prolonged healing. * **Option B (Continue breastfeeding with antibiotics):** This is the treatment for **Mastitis** (cellulitis of the breast). Once a fluctuant mass (abscess) has formed, antibiotics alone are insufficient; the pus must be evacuated. * **Option C (Analgesics):** These are supportive measures but do not treat the underlying infection or the collection of pus. **Clinical Pearls for NEET-PG:** * **Most common organism:** *Staphylococcus aureus*. * **Breastfeeding:** Should **always be continued** from the affected breast (unless there is purulent discharge from the nipple) to prevent milk stasis, which worsens the condition. * **Antibiotic of choice:** Flucloxacillin or Dicloxacillin (Erythromycin if penicillin-allergic). * **Investigation of choice:** Ultrasound is the best modality to differentiate between mastitis and a formed abscess.

Question 115: Which of the following is true for triple-negative breast cancer?

A. Aggressive tumor (Correct Answer)
B. Negative for estrogen and progesterone receptors
C. Good prognosis with chemotherapy
D. Tamoxifen is a chemotherapeutic agent

Explanation: **Explanation:** Triple-negative breast cancer (TNBC) is defined by the lack of expression of **Estrogen Receptor (ER)**, **Progesterone Receptor (PR)**, and **HER2/neu** amplification. **Why Option A is correct:** TNBC is characterized by an **aggressive clinical course**. It typically presents in younger women, has a higher histological grade, and exhibits a higher rate of visceral metastasis (especially to the brain and lungs) compared to hormone-positive subtypes. It also shows a "peak" in recurrence risk within the first 3–5 years after diagnosis. **Why the other options are incorrect:** * **Option B:** While TNBC is negative for ER and PR, the definition *must* also include negativity for **HER2/neu**. Option B is incomplete as it ignores the HER2 status. * **Option C:** Although TNBC often shows a good initial response to chemotherapy (the "Triple Negative Paradox"), the overall prognosis is **poor** due to high relapse rates and the lack of targeted maintenance therapies. * **Option D:** Tamoxifen is a **Selective Estrogen Receptor Modulator (SERM)**, which is a form of hormonal therapy, not a cytotoxic chemotherapeutic agent. Furthermore, it is ineffective in TNBC because the tumor lacks estrogen receptors. **High-Yield Clinical Pearls for NEET-PG:** * **Genetic Association:** Strongly associated with **BRCA1 mutations**. * **Morphology:** Often presents as a "medullary-like" pattern on histology. * **Investigation of Choice:** IHC (Immunohistochemistry) is used to confirm the triple-negative status. * **Treatment:** Surgery followed by platinum-based chemotherapy is the mainstay; targeted therapies like PARP inhibitors (Olaparib) are used in BRCA-positive cases.

Question 116: The "Van Nuys grading" is used for which of the following conditions?

A. Lobular carcinoma in situ (LCIS)
B. Ductal carcinoma in situ (DCIS) (Correct Answer)
C. Medullary carcinoma of the breast
D. Invasive ductal carcinoma (IDC)

Explanation: The **Van Nuys Prognostic Index (VNPI)** is a clinical tool specifically designed to predict the risk of local recurrence in patients with **Ductal Carcinoma in Situ (DCIS)** after breast-conserving surgery. ### Why Option B is Correct DCIS is a non-invasive (in-situ) malignancy where cells are confined to the ducts. The Van Nuys grading helps surgeons decide whether excision alone is sufficient or if adjuvant radiotherapy is required. It scores four key parameters (each from 1 to 3): 1. **Tumor Size** (Smaller is better) 2. **Margin Width** (Wider is better) 3. **Pathologic Classification** (Nuclear grade and presence of comedo-necrosis) 4. **Age of the Patient** (Older is better) A higher total score indicates a higher risk of recurrence, suggesting that mastectomy or radiotherapy may be necessary. ### Why Other Options are Incorrect * **A. Lobular Carcinoma in Situ (LCIS):** LCIS is generally considered a risk factor for developing invasive cancer in either breast rather than a direct precursor. It is not graded by the Van Nuys system. * **C & D. Medullary and Invasive Ductal Carcinoma (IDC):** These are invasive cancers. Invasive breast cancers are typically graded using the **Nottingham Modification of the Bloom-Richardson system** (based on tubule formation, nuclear pleomorphism, and mitotic count), not Van Nuys. ### High-Yield Clinical Pearls for NEET-PG * **Van Nuys Score 4-6:** Low risk; usually treated with excision alone. * **Van Nuys Score 10-12:** High risk; often requires mastectomy. * **Comedo-necrosis:** A high-grade feature of DCIS associated with a higher Van Nuys score and worse prognosis. * **Most common site of DCIS:** Upper outer quadrant of the breast.

Question 117: What is true about a modified radical mastectomy?

A. Pectoralis major is removed
B. Axillary lymph nodes are preserved
C. Pectoralis minor is divided (Correct Answer)
D. Internal mammary lymph nodes are removed

Explanation: **Explanation:** Modified Radical Mastectomy (MRM) is the current standard surgical procedure for operable breast cancer. It involves the removal of the entire breast tissue (including the nipple-areola complex and fascia of the pectoralis major) along with an axillary lymph node dissection. **Why Option C is Correct:** In the **Auchincloss modification** of MRM, the pectoralis minor is retracted. However, in the **Patey modification**, the **pectoralis minor is either divided or removed** to facilitate complete access to the Level III (apical) axillary lymph nodes. This allows for a thorough clearance of the axilla while still preserving the pectoralis major muscle. **Analysis of Incorrect Options:** * **A. Pectoralis major is removed:** This is a feature of the **Halsted Radical Mastectomy**, not MRM. In MRM, the pectoralis major is strictly preserved, which leads to better cosmetic and functional outcomes. * **B. Axillary lymph nodes are preserved:** This is incorrect. MRM by definition includes the clearance of Level I, II, and sometimes Level III axillary lymph nodes. Preservation occurs in Simple (Total) Mastectomy. * **D. Internal mammary lymph nodes are removed:** These are removed in an **Extended Radical Mastectomy** (Urban’s procedure), which is rarely performed today due to high morbidity and lack of survival benefit. **NEET-PG High-Yield Pearls:** * **Patey’s MRM:** Removes Pectoralis minor + Level I, II, III nodes. * **Auchincloss MRM:** Preserves Pectoralis minor + removes Level I, II nodes. * **Nerves at risk during MRM:** Long thoracic nerve (Serratus anterior - Winging of scapula), Thoracodorsal nerve (Latissimus dorsi), and Intercostobrachial nerve (most commonly injured; causes numbness of the inner arm).

Question 118: All of the following are true about accelerated partial breast irradiation (APBI) except?

A. APBI is delivered in an abbreviated fashion and a lower total dose than a standard course of whole breast radiation.
B. Suitable patients for APBI include women older than or equal to 60 years.
C. Suitable patients for APBI include patients whose tumor margins are negative by at least 2 mm.
D. Suitable patients for APBI include those with multifocal disease. (Correct Answer)

Explanation: **Explanation:** Accelerated Partial Breast Irradiation (APBI) is a localized form of radiation therapy delivered only to the lumpectomy bed rather than the entire breast. It is designed for patients with a very low risk of local recurrence. **Why Option D is the Correct Answer (The False Statement):** According to the **ASTRO (American Society for Radiation Oncology) guidelines**, patients with **multifocal or multicentric disease** are considered **unsuitable** for APBI. Multifocality increases the risk of occult disease in other quadrants of the breast, necessitating Whole Breast Irradiation (WBI) to ensure oncological safety. APBI is strictly reserved for unicentric, unifocal tumors. **Analysis of Other Options:** * **Option A:** This is a defining feature of APBI. While standard WBI takes 3–6 weeks, APBI is delivered in an **abbreviated fashion** (usually 5 days) using a **lower total dose** (but higher dose per fraction) because it targets a smaller volume of tissue. * **Option B:** Age is a critical selection criterion. Patients **≥ 60 years** are categorized as "Suitable" (low risk), while those aged 40–49 are "Cautionary" and <40 are "Unsuitable." * **Option C:** Adequate local control requires clear margins. For APBI suitability, margins must be **negative by at least 2 mm**. **High-Yield Clinical Pearls for NEET-PG:** * **Ideal Candidate (ASTRO "Suitable" Group):** Age ≥ 60 years, tumor size ≤ 2 cm (T1), ER-positive, clinically Node Negative, and Unifocal disease. * **Invasive Lobular Carcinoma (ILC):** Generally placed in the "Cautionary" or "Unsuitable" group due to its tendency for diffuse growth. * **DCIS:** Low-risk DCIS (screen-detected, small size) is now considered "Suitable" in recent updates, provided it meets specific criteria. * **Purely Localized:** APBI can be delivered via interstitial brachytherapy, intracavitary balloons (e.g., MammoSite), or external beam radiation (3D-CRT).

Question 119: Prognosis of carcinoma breast depends on?

A. Lymph node status (Correct Answer)
B. Size of tumor
C. Skin involvement
D. Orange peel appearance

Explanation: **Explanation:** The prognosis of breast carcinoma is determined by several factors, but the **axillary lymph node status** is universally recognized as the **single most important independent prognostic factor**. 1. **Why Lymph Node Status is Correct:** The presence and number of involved lymph nodes directly reflect the tumor's metastatic potential and systemic spread. It is the primary determinant used in the TNM staging system to predict disease-free survival and overall survival. Patients with zero involved nodes have a significantly better 10-year survival rate compared to those with even 1–3 positive nodes. 2. **Why Other Options are Incorrect:** * **Size of Tumor (Option B):** While tumor size is the second most important prognostic factor and correlates with the likelihood of nodal involvement, it is less predictive of overall survival than the nodal status itself. * **Skin Involvement (Option C):** This indicates locally advanced disease (T4 category). While it signifies a poor prognosis, it is a clinical stage descriptor rather than the primary determinant of long-term survival. * **Orange Peel Appearance (Peau d'orange) (Option D):** This is a clinical sign of inflammatory breast cancer or lymphatic obstruction. While it carries a very grave prognosis, it is a specific clinical presentation rather than the gold-standard prognostic indicator used for all breast cancers. **High-Yield Clinical Pearls for NEET-PG:** * **Most important prognostic factor:** Axillary lymph node status. * **Second most important factor:** Tumor size. * **Most important histological factor:** Histological grade (Nottingham Grading System/Scarff-Bloom-Richardson scale). * **Best prognostic molecular subtype:** Luminal A (ER/PR positive, HER2 negative). * **Worst prognostic subtype:** Triple-negative breast cancer (TNBC).

Question 120: A 56-year-old male patient develops an eccentric hard breast lump over the past few months. A biopsy proves this to be breast carcinoma. What is the approximate incidence of breast cancer in males as a percentage of all breast cancers?

A. Less than 1% (Correct Answer)
B. 4%
C. 7%
D. 10%

Explanation: **Explanation:** **1. Why the Correct Answer is Right:** Male breast cancer (MBC) is a rare clinical entity. Epidemiological data consistently shows that it accounts for **less than 1%** of all breast cancer cases worldwide and approximately 0.1% of all cancer deaths in men. The low incidence is primarily due to the lack of acini and lobules in the normal male breast, which consists mainly of rudimentary ducts. The most common histological subtype in males is **Invasive Ductal Carcinoma (IDC)**, as lobular carcinoma is extremely rare due to the absence of lobules. **2. Why the Incorrect Options are Wrong:** * **B (4%), C (7%), and D (10%):** These percentages significantly overestimate the prevalence. While the incidence of breast cancer in women is high (1 in 8 lifetime risk), the male-to-female ratio remains approximately **1:100**. Choosing these higher values would imply that male breast cancer is a common clinical encounter, which contradicts global oncological statistics. **3. Clinical Pearls & High-Yield Facts for NEET-PG:** * **Risk Factors:** The strongest risk factor for MBC is **BRCA2 mutation** (more common than BRCA1 in males). Other factors include Klinefelter syndrome (highest relative risk), radiation exposure, and hyperestrogenism (e.g., liver cirrhosis, obesity). * **Clinical Presentation:** Typically presents as a **painless, firm, eccentric subareolar lump**. Because of the lack of breast tissue, skin involvement and nipple retraction occur earlier than in females. * **Diagnosis:** Triple assessment (Clinical, Imaging, Core Biopsy) is standard. Mammography in men has high sensitivity. * **Management:** Modified Radical Mastectomy (MRM) is the traditional surgical treatment of choice. Tamoxifen is the mainstay of hormonal therapy, as ~90% of male breast cancers are ER-positive.

Practice by Chapter

Breast Anatomy and Physiology

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Benign Breast Diseases

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Breast Cancer Screening

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Breast Cancer: Diagnosis and Staging

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Surgical Management of Breast Cancer

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Oncoplastic Breast Surgery

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Sentinel Lymph Node Biopsy

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Axillary Surgery

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Breast Reconstruction Techniques

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Male Breast Disorders

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Phyllodes Tumors

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Management of Ductal Carcinoma In Situ

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