Breast Surgery — MCQs

Breast Surgery Indian Medical PG Practice Questions and MCQs

Question 121: Which of the following has the best prognosis?

A. <1 cm Size, Node -ve, ER/PR +ve, Her 2 Negative (Correct Answer)
B. <1 cm Size, Node -ve, ER/PR -ve, Her 2 Positive
C. <2 cm Size, Node -ve, ER/PR +ve, Her 2 Negative
D. <2 cm Size, Node -ve, ER/PR -ve, Her 2 positive

Explanation: ### Explanation The prognosis of breast cancer is determined by a combination of **anatomical staging** (TNM) and **biological markers** (molecular subtypes). **1. Why Option A is Correct:** This option represents the most favorable combination of prognostic factors: * **Size (<1 cm):** Smaller tumor size (T1a/T1b) correlates with a lower risk of distant metastasis. * **Node Negative:** Nodal status is the **single most important prognostic factor** for recurrence and survival. Being node-negative significantly improves the 5-year survival rate. * **ER/PR Positive:** These tumors belong to the **Luminal A** subtype. They are generally low-grade, slow-growing, and highly responsive to endocrine therapy (e.g., Tamoxifen). * **HER2 Negative:** The absence of HER2 overexpression implies a less aggressive clinical course compared to HER2-enriched or Triple Negative subtypes. **2. Why the Other Options are Incorrect:** * **Option B:** While the size and nodal status are favorable, the molecular profile (ER/PR -ve, HER2 +ve) is more aggressive. HER2-positive tumors have a higher proliferative index and a greater tendency for early systemic spread. * **Option C:** Although this has a favorable molecular profile (Luminal A), the tumor size (<2 cm) is larger than in Option A. In oncology, smaller is always better when all other factors are equal. * **Option D:** This is the least favorable option among the four, combining a larger size (<2 cm) with an aggressive HER2-positive/hormone-negative profile. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most important prognostic factor:** Number of axillary lymph nodes involved. * **Best molecular subtype prognosis:** Luminal A (ER+, PR+, HER2-, low Ki-67). * **Worst molecular subtype prognosis:** Triple Negative (Basal-like). * **Nottingham Prognostic Index (NPI):** Uses tumor size, lymph node stage, and histological grade to predict survival. * **Sentinel Lymph Node Biopsy (SLNB):** The gold standard for staging the axilla in clinically node-negative (cN0) patients.

Question 122: What is the most malignant type of carcinoma of the breast?

A. Paget's disease
B. Anaplastic carcinoma
C. Scirrhous carcinoma
D. Mastitis carcinomatosa (Correct Answer)

Explanation: **Explanation:** **Mastitis carcinomatosa**, also known as **Inflammatory Breast Cancer (IBC)**, is the most aggressive and malignant form of breast cancer. It is characterized by rapid clinical onset, where the breast appears red, swollen, and warm, mimicking an infection (mastitis). The underlying pathology involves the widespread blockage of **dermal lymphatics** by tumor emboli, rather than true inflammation. It is classified as T4d in the TNM staging system and is considered systemic at the time of diagnosis, carrying the poorest prognosis among all breast malignancies. **Analysis of Incorrect Options:** * **Paget’s Disease:** This is a superficial manifestation of an underlying ductal carcinoma (usually DCIS or invasive ductal carcinoma). While it indicates malignancy, it is localized to the nipple-areola complex and is not inherently the "most malignant" form. * **Anaplastic Carcinoma:** While these tumors show high-grade cytological features and poor differentiation, they do not typically exhibit the rapid, diffuse lymphatic spread and dismal survival rates characteristic of inflammatory breast cancer. * **Scirrhous Carcinoma:** This is an older term for Invasive Carcinoma of No Special Type (NST) with significant desmoplasia (fibrosis). It is the most common type of breast cancer but is less aggressive than the inflammatory variant. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Hallmark:** *Peau d'orange* (orange peel appearance) due to cutaneous edema from lymphatic obstruction. * **Diagnosis:** Requires a full-thickness **punch biopsy** of the skin to demonstrate tumor emboli in dermal lymphatics. * **Management:** It is never treated with primary surgery. The standard of care is **Neoadjuvant Chemotherapy (NACT)** followed by Modified Radical Mastectomy (MRM) and Radiotherapy.

Question 123: A 9-week pregnant lady presents with a 2.5 cm mass in the upper outer quadrant of her left breast. Ultrasound did not reveal any abnormality. What is the ideal management?

A. Aspiration of the cyst and reassurance
B. Finger-guided core biopsy (Correct Answer)
C. Follow-up one month after delivery
D. Mammography

Explanation: ### **Explanation** The core principle in managing a palpable breast mass during pregnancy is that it must be investigated with the same urgency as in a non-pregnant patient. **Pregnancy-Associated Breast Cancer (PABC)** is often diagnosed at an advanced stage due to physiological changes (engorgement and hypertrophy) that mask tumors. **Why Option B is Correct:** When a clinical mass is palpable but **ultrasound (USG) is negative**, the "Triple Assessment" must still be completed. Since USG failed to localize the lesion, a **finger-guided (palpation-guided) core needle biopsy** is the gold standard. Core biopsy is preferred over Fine Needle Aspiration (FNA) because pregnancy-induced cellular atypia often leads to false-positive results on cytology. Biopsy is safe during all trimesters of pregnancy. **Why Other Options are Incorrect:** * **Option A:** Aspiration is only indicated if the mass is cystic on imaging. Since the USG was negative/inconclusive and the mass is solid/palpable, aspiration is not diagnostic for malignancy. * **Option C:** Delaying diagnosis until after delivery is a common clinical error. PABC is often aggressive; a delay of even a few months can significantly worsen the prognosis. * **Option D:** While mammography with fetal shielding is safe in pregnancy, its sensitivity is significantly decreased (approx. 25% false-negative rate) due to increased breast density. It is not the definitive next step when a biopsy can be performed. ### **Clinical Pearls for NEET-PG:** * **Triple Assessment in Pregnancy:** Clinical examination + Ultrasound (first-line imaging) + Core Biopsy. * **Imaging:** Ultrasound is the preferred initial imaging modality. Mammography is safe but less sensitive. * **Management:** Surgery (Mastectomy or BCS) is safe in all trimesters. Radiotherapy is contraindicated until after delivery. Chemotherapy is contraindicated in the 1st trimester but generally safe in the 2nd and 3rd trimesters. * **Rule of Thumb:** Any breast mass persisting for more than 2 weeks during pregnancy or lactation must be biopsied.

Question 124: A 4 cm breast nodule with an ipsilateral mobile lymph node in the axilla, what is the correct TNM staging?

A. T2N1M0 (Correct Answer)
B. T2N2M0
C. T1N1M0
D. T3N2M1

Explanation: ### Explanation The TNM staging system for breast cancer is a cornerstone of surgical oncology. To solve this question, we must break down the clinical findings based on the AJCC 8th Edition criteria. **1. Why T2N1M0 is correct:** * **T (Tumor Size):** The nodule is **4 cm**. T2 is defined as a tumor >2 cm but ≤5 cm in its greatest dimension. * **N (Nodal Status):** The presence of an **ipsilateral mobile lymph node** in the axilla corresponds to **N1**. (N2 would involve fixed/matted nodes or internal mammary involvement). * **M (Metastasis):** In the absence of mentioned distant spread, it is staged as **M0**. * Combining these, the stage is **T2N1M0**. **2. Why other options are incorrect:** * **T2N2M0:** Incorrect because N2 requires "fixed" or "matted" axillary nodes, or clinically detected internal mammary nodes in the absence of axillary nodes. "Mobile" nodes are strictly N1. * **T1N1M0:** Incorrect because T1 is defined as a tumor ≤2 cm. This patient’s tumor is 4 cm. * **T3N2M1:** Incorrect on all counts. T3 is >5 cm; N2 implies fixed nodes; M1 implies distant metastasis (not mentioned). **Clinical Pearls for NEET-PG:** * **T-Staging Cheat Sheet:** T1 (≤2 cm), T2 (2–5 cm), T3 (>5 cm), T4 (Extension to chest wall/skin, regardless of size). * **N-Staging Key:** N1 = Mobile axillary nodes; N2 = Fixed/Matted axillary nodes; N3 = Supraclavicular, infraclavicular, or internal mammary + axillary nodes. * **Inflammatory Carcinoma:** Always staged as **T4d**, regardless of the actual size of the underlying mass. * **Dimpling vs. Peau d'orange:** Skin dimpling (tethering to Cooper’s ligament) does not change T-stage, but *Peau d'orange* or skin ulceration classifies it as T4.

Question 125: Which of the following statements regarding Paget's disease of the breast is true?

A. It usually precedes the development of Paget's disease of bone.
B. It presents with nipple-areolar eczematous changes. (Correct Answer)
C. It does not involve axillary lymph nodes because it is a manifestation of intraductal carcinoma only.
D. It accounts for 10-15% of all newly diagnosed breast cancers.

Explanation: **Explanation:** **Paget’s disease of the breast** is a rare manifestation of breast cancer characterized by the presence of malignant **Paget cells** (large, pale cells with prominent nucleoli) within the epidermis of the nipple-areolar complex. 1. **Why Option B is Correct:** The hallmark clinical presentation is an **eczematous-like lesion** of the nipple that may spread to the areola. It typically presents with erythema, scaling, crusting, or ulceration. Unlike simple eczema, Paget’s disease usually starts at the nipple and spreads peripherally, and it does not respond to topical steroids. 2. **Why the Other Options are Incorrect:** * **Option A:** There is **no clinical or pathological link** between Paget’s disease of the breast and Paget’s disease of the bone (a disorder of bone remodeling). They simply share the same namesake (Sir James Paget). * **Option C:** While Paget’s disease is associated with underlying **Ductal Carcinoma in Situ (DCIS)** in about 40% of cases, the remaining 60% have an underlying **Invasive Ductal Carcinoma (IDC)**. Therefore, axillary lymph node involvement is possible and depends on the stage of the underlying malignancy. * **Option D:** It is rare, accounting for only **1–4%** of all newly diagnosed breast cancers, not 10–15%. **High-Yield Clinical Pearls for NEET-PG:** * **Pathogenesis:** The "Epidermotropic Theory" suggests cancer cells migrate from underlying lactiferous ducts to the nipple skin. * **Diagnosis:** A **full-thickness punch biopsy** of the nipple is the gold standard. * **Key Histology:** PAS-positive, diastase-resistant cells (due to mucin content). * **Management:** Requires evaluation for underlying malignancy via mammography/MRI. Treatment involves mastectomy or breast-conserving surgery (central lumpectomy) plus radiotherapy.

Question 126: In inflammatory carcinoma of the breast with axillary metastasis, what is the treatment of choice?

A. Radical mastectomy plus chemotherapy
B. Radical mastectomy plus radiotherapy
C. Simple mastectomy plus radiotherapy
D. None of the above (Correct Answer)

Explanation: **Explanation:** The treatment of choice for **Inflammatory Breast Cancer (IBC)** is a multimodal approach, and the correct sequence is critical. The correct answer is "None of the above" because all listed options suggest primary surgery (mastectomy) as the first step, which is contraindicated in IBC. **1. Why "None of the above" is correct:** Inflammatory Breast Cancer is considered **Locally Advanced Breast Cancer (LABC)** and is staged as **T4d**. Because it is characterized by dermal lymphatic invasion and high systemic risk, the standard of care is **Multimodal Therapy** in a specific sequence: * **Step 1:** Neoadjuvant Chemotherapy (NACT) – to downstage the tumor and treat micrometastases. * **Step 2:** Modified Radical Mastectomy (MRM) – performed only if there is a good clinical response to NACT. * **Step 3:** Post-operative Radiotherapy – to reduce local recurrence. **2. Why other options are incorrect:** * **Options A, B, and C** all propose immediate surgery (Radical or Simple Mastectomy). In IBC, the skin is heavily involved with "cancerous lymphangitis." Primary surgery is avoided because it often results in positive margins, poor wound healing, and rapid local recurrence. Simple mastectomy (Option C) is also inappropriate as it does not address the axillary metastasis. **Clinical Pearls for NEET-PG:** * **Hallmark Sign:** *Peau d'orange* (due to dermal lymphatic obstruction). * **Diagnosis:** Requires a full-thickness **skin punch biopsy** showing tumor emboli in dermal lymphatics. * **Staging:** Always Stage IIIB (if N0-N2) or Stage IIIC (if N3). It is the most aggressive form of breast cancer. * **Surgery Type:** If surgery is performed after NACT, it must be **MRM**. Breast-conserving surgery is contraindicated in IBC.

Question 127: A 65-year-old woman with a 5 mm tubular cancer, ER positive, PR positive, and a negative sentinel lymph node, undergoes a lumpectomy and sentinel lymph node biopsy. What adjuvant treatment should be recommended?

A. Chemotherapy and radiation
B. Radiation treatment only
C. Hormonal therapy only
D. Radiotherapy and hormonal therapy (Correct Answer)

Explanation: ### Explanation The management of early-stage breast cancer is determined by the tumor size, nodal status, and receptor profile. This patient has a **T1a (5 mm), N0, ER/PR-positive** breast cancer. **1. Why Option D is Correct:** * **Radiotherapy:** The patient underwent a **Lumpectomy** (Breast Conserving Surgery - BCS). A fundamental principle in breast surgery is that BCS must always be followed by **Whole Breast Irradiation (WBI)** to reduce the risk of local recurrence. * **Hormonal Therapy:** Since the tumor is **ER/PR positive**, adjuvant endocrine therapy (e.g., Aromatase Inhibitors or Tamoxifen) is indicated to reduce the risk of both ipsilateral recurrence and contralateral new primary breast cancers. **2. Why Other Options are Incorrect:** * **Option A:** Chemotherapy is generally omitted in "favorable" histologies like **Tubular carcinoma**, especially when the tumor is <1 cm, node-negative, and hormone-receptor positive. * **Option B:** While radiation is necessary after BCS, omitting hormonal therapy in an ER-positive patient significantly increases the risk of systemic and local recurrence. * **Option C:** Hormonal therapy alone is only considered in very specific subsets (e.g., women >70 years with small, node-negative, ER+ tumors) where the absolute benefit of radiation is minimal. At 65, radiotherapy remains the standard of care post-BCS. **3. Clinical Pearls for NEET-PG:** * **Tubular Carcinoma:** A "favorable" histological subtype of invasive ductal carcinoma with an excellent prognosis. * **BCS Equation:** BCS + Radiotherapy = Modified Radical Mastectomy (MRM) in terms of overall survival. * **Sentinel Lymph Node Biopsy (SLNB):** Indicated for all clinically N0 patients to avoid the morbidity of Axillary Lymph Node Dissection (ALND). * **Adjuvant Endocrine Therapy:** Standard duration is 5 years; Aromatase Inhibitors (Anastrozole/Letrozole) are preferred in postmenopausal women.

Question 128: Paget's disease of the breast is associated with which of the following?

A. Ductal carcinoma in situ (Correct Answer)
B. Lobular carcinoma in situ
C. Phyllodes tumor
D. Mondor's disease

Explanation: **Explanation:** **Paget’s Disease of the Breast** is a rare manifestation of breast cancer characterized by an eczematous, crusting lesion of the nipple-areola complex. **Why Option A is correct:** The underlying pathophysiology involves the migration of malignant cells (**Paget cells**) from the underlying lactiferous ducts to the epidermis of the nipple. In approximately **85–90% of cases**, Paget’s disease is associated with an underlying malignancy. The most common underlying pathology is **Ductal Carcinoma In Situ (DCIS)**, though it can also be associated with invasive ductal carcinoma. The Paget cells are large, pale-staining cells with prominent nucleoli that are PAS-positive, indicating their glandular origin. **Why other options are incorrect:** * **B. Lobular Carcinoma In Situ (LCIS):** This is typically an incidental finding and is not associated with the migration of cells to the nipple epidermis. * **C. Phyllodes Tumor:** This is a fibroepithelial tumor arising from the intralobular stroma, not the ductal epithelium, and presents as a large, mobile breast lump rather than a nipple lesion. * **D. Mondor’s Disease:** This is a self-limiting superficial thrombophlebitis of the breast veins (usually the lateral thoracic vein), presenting as a palpable "cord-like" structure. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Often mistaken for eczema. **Key differentiator:** Eczema usually involves the areola first and is bilateral; Paget’s involves the **nipple first** and is typically unilateral. * **Diagnosis:** Confirmed by **Full-thickness Punch Biopsy** of the nipple. * **Immunohistochemistry (IHC):** Paget cells are typically **HER2/neu positive** and **CK7 positive**. * **Management:** If no mass is palpable, a mammogram and MRI are essential to locate the underlying DCIS/carcinoma. Treatment usually involves mastectomy or breast-conserving surgery with nipple-areola complex resection.

Question 129: Which of the following is NOT a treatment for gynecomastia?

A. Hormonal therapy
B. Simple mastectomy
C. Subcutaneous liposuction mastectomy
D. None of the above (Correct Answer)

Explanation: **Explanation:** Gynecomastia is the benign proliferation of glandular breast tissue in males. The management strategy depends on the underlying cause, the duration of the condition, and the patient's symptoms (pain or cosmetic distress). **Why "None of the above" is correct:** All the listed options (A, B, and C) are recognized and valid treatment modalities for gynecomastia. Since the question asks which is **NOT** a treatment, and all provided options are indeed treatments, "None of the above" is the correct choice. **Analysis of Options:** * **Hormonal Therapy (Option A):** Used primarily in the early "florid" phase (usually <1 year). Selective Estrogen Receptor Modulators (SERMs) like **Tamoxifen** are the most common medical treatments. Other options include Aromatase inhibitors or Danazol. * **Simple Mastectomy (Option B):** This involves the surgical removal of the breast tissue and is indicated for severe (Grade III) gynecomastia or when malignancy is suspected. * **Subcutaneous Liposuction Mastectomy (Option C):** This is the preferred surgical approach for cosmetic results. It combines liposuction (to remove fatty tissue) with a periareolar incision to excise the glandular disc (Webster’s incision). **NEET-PG High-Yield Pearls:** * **Most common cause:** Idiopathic, followed by persistent pubertal gynecomastia. * **Drugs causing gynecomastia:** Remember the mnemonic **"DISCO"**: **D**igoxin, **I**soniazid, **S**pironolactone (most common drug cause), **C**imetidine, **O**estrogens. * **Grading:** Simon’s Classification is used to grade the severity. * **Pathology:** Characterized by an increase in stroma and ducts; notably, **males do not develop acini/lobules** unless exposed to extreme progestational stimulation.

Question 130: Triple assessment of a breast lump includes all EXCEPT:

A. Fine Needle Aspiration Cytology (FNAC)
B. Bone scan (Correct Answer)
C. Clinical examination
D. Mammography

Explanation: **Explanation:** The **Triple Assessment** is the gold standard protocol for the evaluation of any palpable breast lump. It is designed to achieve a diagnostic accuracy of over 99%. It consists of three essential components: 1. **Clinical Examination:** A detailed history and physical examination (palpation) by a clinician. 2. **Imaging:** Usually **Mammography** (in women >35 years) or **Ultrasonography** (in women <35 years or during pregnancy/lactation). 3. **Pathology:** Tissue diagnosis via **Fine Needle Aspiration Cytology (FNAC)** or, more commonly now, **Core Needle Biopsy (CNB)**. **Why Bone Scan is the correct answer:** A **Bone scan** is a staging investigation used to detect distant metastasis in confirmed cases of advanced breast cancer. It is *not* part of the initial diagnostic "triple assessment" used to determine whether a lump is benign or malignant. **Analysis of other options:** * **Clinical Examination (Option C):** The first step in assessment; helps categorize the lump as "benign," "suspicious," or "malignant." * **Mammography (Option D):** The radiological component. It helps identify microcalcifications and architectural distortions. * **FNAC (Option A):** The pathological component. While Core Biopsy is now preferred for providing architecture and receptor status (ER/PR/HER2), FNAC remains a classic component of the triple assessment mentioned in standard textbooks. **Clinical Pearls for NEET-PG:** * If all three components of the triple assessment suggest a benign lesion, the chance of malignancy is **<1%**. * If there is a **discordance** (e.g., clinical exam suggests malignancy but imaging is benign), an excisional biopsy is mandatory. * **Modified Triple Assessment:** Includes Core Needle Biopsy instead of FNAC. Core biopsy is superior as it can distinguish between *in-situ* and invasive carcinoma.

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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