Breast Surgery Practice Questions

Q: A 51-year-old female with ductal carcinoma in situ of the breast is best managed by:

Simple mastectomy. **Explanation:** The management of **Ductal Carcinoma in Situ (DCIS)** is based on the fact that it is a non-invasive, pre-malignant condition confined within the basement membrane. Because the cancer cells have not invaded the stroma, there is no risk of lymphatic spread. **1. Why Simple Mastectomy is Correct:** A **Simple (Total) Mastectomy** involves the removal of the entire breast tissue including the nipple-areola complex, but **without axillary lymph node dissection**. This is considered the "gold standard" for extensive DCIS or when the patient prefers to avoid radiotherapy, as it provides a near 100% cure rate by removing all potential sites of disease. **2. Why other options are incorrect:** * **Breast Conservative Surgery (BCS):** While BCS (Wide Local Excision) is an option for small, localized DCIS, it must always be followed by **Radiotherapy** to reduce the risk of local recurrence. Since the option only mentions BCS alone, Simple Mastectomy is the more definitive and "best" surgical answer in a general context. * **Modified Radical Mastectomy (MRM):** MRM includes axillary lymph node dissection (Level I, II). Since DCIS is non-invasive, the risk of nodal metastasis is <1%, making MRM an unnecessary over-treatment. * **Radical Mastectomy:** This involves removing the pectoralis muscles and is obsolete for almost all breast cancers, especially a non-invasive one like DCIS. **Clinical Pearls for NEET-PG:** * **Van Nuys Prognostic Index:** Used to decide between BCS and Mastectomy in DCIS based on size, margin width, grade, and age. * **Comedo Necrosis:** A high-grade subtype of DCIS with a higher risk of progression to invasive cancer. * **Sentinel Lymph Node Biopsy (SLNB):** Not routine for DCIS, but recommended if a mastectomy is planned (as a later SLNB is impossible once breast tissue is removed) or if there is high suspicion of occult invasion.

Q: All of the following are poor prognostic markers of CA Breast except?

ER positivity. ### Explanation The prognosis of breast cancer is determined by a combination of clinical, histological, and molecular markers. This question tests the ability to distinguish between **favorable** and **unfavorable** prognostic factors. **Why ER Positivity is the Correct Answer:** Estrogen Receptor (ER) and Progesterone Receptor (PR) positivity are **favorable prognostic markers**. Tumors expressing these receptors are generally well-differentiated, grow more slowly, and, most importantly, are responsive to **hormonal therapy** (e.g., Tamoxifen or Aromatase Inhibitors). Patients with ER+ tumors typically have a better disease-free survival rate compared to those with ER-negative tumors. **Analysis of Incorrect Options (Poor Prognostic Markers):** * **DNA Aneuploidy:** An abnormal amount of DNA within tumor cells (aneuploidy) indicates high genetic instability and is associated with aggressive tumor behavior and a higher risk of recurrence. * **Her2/neu Positivity:** Overexpression of the human epidermal growth factor receptor 2 (HER2) is associated with rapid cell proliferation, increased risk of metastasis, and historically poorer outcomes (though targeted therapy like Trastuzumab has improved this). * **p53 Overexpression:** Mutations in the *TP53* tumor suppressor gene lead to the accumulation of defective p53 protein. This is a marker of high-grade tumors, poor differentiation, and resistance to certain chemotherapies. **NEET-PG High-Yield Pearls:** * **Most Important Prognostic Factor:** Number of axillary lymph nodes involved. * **Most Important Predictive Factor:** ER/PR status (predicts response to hormone therapy). * **Triple Negative Breast Cancer (TNBC):** ER-, PR-, and Her2-negative; carries the worst prognosis due to lack of targeted therapy options. * **Other Poor Markers:** High S-phase fraction, Cathepsin D overexpression, and high Ki-67 index (marker of proliferation).

Q: In Patey's modified mastectomy, which of the following is preserved?

Pectoralis major. In Modified Radical Mastectomy (MRM), the goal is to remove the entire breast tissue along with the axillary lymph nodes while preserving the chest wall muscles. **Why Pectoralis Major is the Correct Answer:** In **Patey’s Modified Radical Mastectomy**, the **Pectoralis major muscle is preserved**, but the **Pectoralis minor muscle is sacrificed (removed)**. The removal of the pectoralis minor allows for easier access to Level III (apical) axillary lymph nodes, ensuring a more thorough oncological clearance of the axilla. **Explanation of Incorrect Options:** * **Pectoralis minor:** This is specifically removed in Patey’s version to facilitate complete axillary dissection. (Note: In **Auchincloss** modification, both Pectoralis major and minor are preserved). * **Intercostobrachial nerve:** This nerve provides sensation to the medial aspect of the upper arm. It is frequently sacrificed during axillary dissection to ensure adequate clearance of Level I and II nodes, leading to postoperative numbness. * **Axillary fascia:** This is routinely removed as part of the axillary lymphadenectomy to ensure all lymph-bearing fatty tissue is cleared. **NEET-PG High-Yield Pearls:** 1. **Halsted Radical Mastectomy:** Removes breast, Pectoralis major, Pectoralis minor, and all axillary nodes. 2. **Auchincloss Modification:** Preserves **both** Pectoralis major and minor (most common MRM performed today). 3. **Nerves to preserve:** Long thoracic nerve (Bell’s nerve) to prevent winged scapula, and Thoracodorsal nerve to prevent weakness in latissimus dorsi. 4. **Madden’s Modification:** Similar to Auchincloss; preserves both muscles but involves a different dissection plane.

Q: A 57-year-old woman presents with left breast pain. On examination, the left breast is markedly erythematous, swollen, and warm to touch. There is also significant dimpling of the breast (peau d'orange), and the left nipple is completely retracted. Which of the following is the likely diagnosis?

Inflammatory carcinoma. **Explanation:** The clinical presentation of a warm, erythematous, and swollen breast in an older woman, associated with **peau d’orange** and nipple retraction, is a classic description of **Inflammatory Breast Cancer (IBC)**. 1. **Why Inflammatory Carcinoma is correct:** IBC is a highly aggressive clinical diagnosis. The hallmark "peau d’orange" (orange peel appearance) is caused by the **obstruction of dermal lymphatics by tumor emboli**, leading to lymphedema and thickening of the skin. The warmth and erythema mimic mastitis, but the absence of fever and the presence of nipple retraction in a postmenopausal woman strongly point toward malignancy. 2. **Why other options are incorrect:** * **Granulomatous mastitis:** Usually presents as a firm, tender mass in younger women (often postpartum). While it can cause skin changes, it lacks the diffuse lymphatic obstruction characteristic of IBC. * **Micropapillary carcinoma:** This is a histological subtype of invasive ductal carcinoma. While aggressive, it does not specifically present with the diffuse inflammatory signs described unless it has progressed to IBC. * **Fibrocystic disease:** A benign condition typically seen in premenopausal women, characterized by cyclical mastalgia and "lumpy" breasts, not acute inflammatory changes or peau d'orange. **High-Yield Clinical Pearls for NEET-PG:** * **TNM Staging:** Inflammatory breast cancer is automatically classified as **T4d**, making it at least Stage IIIB at presentation. * **Diagnosis:** It is primarily a **clinical diagnosis**, but a skin punch biopsy showing tumor emboli in dermal lymphatics confirms it. * **Management:** The standard of care is **Neoadjuvant Chemotherapy (NACT)** followed by Modified Radical Mastectomy (MRM) and Radiotherapy. * **Differential:** Always rule out IBC in any patient suspected of "mastitis" that does not respond to a one-week course of antibiotics.

Q: What is the most sensitive and specific investigation for carcinoma breast?

Mammography. **Explanation:** **Mammography** is the gold standard and the most sensitive and specific investigation for the detection of breast carcinoma, especially in women over the age of 35. Its primary strength lies in its ability to detect **microcalcifications** and soft tissue masses before they become clinically palpable. For screening purposes, it has a sensitivity of approximately 85–90%. **Analysis of Options:** * **CT Scan:** While useful for staging (detecting distant metastasis to lungs or liver), it is not used for primary breast imaging due to poor resolution of breast parenchyma and high radiation exposure. * **Thermography:** This measures infrared heat patterns. It has a very high false-positive rate and lacks the specificity required for diagnosis; it is currently not recommended in standard clinical practice. * **USG (Ultrasonography):** This is the investigation of choice for women **under 35 years** (due to dense breast tissue) and for differentiating cystic from solid lesions. However, it is less sensitive than mammography for detecting early microcalcifications. **Clinical Pearls for NEET-PG:** * **Triple Assessment:** The definitive protocol for diagnosing a breast lump includes: 1. Clinical Examination, 2. Imaging (Mammography/USG), and 3. Pathology (FNAC/Core Needle Biopsy). * **BI-RADS Score:** Mammography results are reported using the Breast Imaging-Reporting and Data System (0-6 scale). * **MRI Breast:** Though more sensitive than mammography, it is less specific. It is the investigation of choice for screening high-risk patients (BRCA mutations), evaluating breast implants, or detecting occult primary tumors. * **Best Diagnostic Investigation:** While mammography is the best *imaging*, the "Gold Standard" for definitive diagnosis remains **Core Needle Biopsy**.

Q: In Radical mastectomy, which of the following is spared?

Supraclavicular lymph nodes. In breast surgery, understanding the anatomical extent of different types of mastectomies is high-yield for NEET-PG. ### **Explanation of the Correct Answer** The question refers to the **Halsted Radical Mastectomy (RM)**. By definition, this procedure involves the en-bloc removal of the entire breast tissue, the overlying skin, the **pectoralis major**, the **pectoralis minor**, and the **axillary lymph nodes** (Levels I, II, and III). **Supraclavicular lymph nodes (Option D)** are considered Level IV nodes. In the staging of breast cancer (AJM/TNM), involvement of supraclavicular nodes is classified as **N3c (Stage IIIC)** and is traditionally viewed as regional spread that is beyond the scope of standard radical surgery. These nodes are **not** part of a Radical Mastectomy. ### **Analysis of Incorrect Options** * **A. Pectoralis major:** This is the hallmark of the Halsted Radical Mastectomy. It is removed to ensure a deep clear margin and to facilitate access to the apex of the axilla. * **B. Pectoralis minor:** This is also removed in a Radical Mastectomy to allow complete clearance of the Level II and III axillary lymph nodes. (Note: In a *Modified* Radical Mastectomy, this muscle is either retracted or divided, but not necessarily removed). * **C. Axillary lymph nodes:** Complete axillary dissection (Levels I-III) is a mandatory component of any radical surgical approach for breast cancer. ### **High-Yield Clinical Pearls for NEET-PG** * **Halsted Radical Mastectomy:** Removes Breast + Both Pectorals + Axillary nodes. * **Patey’s Modified Radical Mastectomy (MRM):** Removes Breast + **Pectoralis minor** + Axillary nodes (Pectoralis major is **spared**). * **Auchincloss MRM:** Removes Breast + Axillary nodes (Both Pectoralis major and minor are **spared**). * **Nerves at risk during surgery:** Long thoracic nerve (Serratus anterior - Winging of scapula) and Thoracodorsal nerve (Latissimus dorsi).

Question 1

A 51-year-old female with ductal carcinoma in situ of the breast is best managed by:

Accepted Answer

Simple mastectomy

Answer

Breast conservative surgery

Answer

Modified radical mastectomy

Answer

Radical mastectomy

Question 2

All of the following are poor prognostic markers of CA Breast except?

Accepted Answer

ER positivity

Answer

DNA aneuploidy

Answer

Her 2 neu positivity

Answer

p53 over expression

Question 3

A 10-week pregnant female presents with a 3x1 cm breast lump lateral to the areola. Ultrasound of the breast is normal. What is the next step in management?

Accepted Answer

Fine Needle Aspiration Cytology (FNAC)

Answer

Lumpectomy

Answer

MRI

Answer

Mammogram

Question 4

Which of the following statements about male breast cancer is FALSE?

Accepted Answer

It is most commonly invasive ductal carcinoma.

Answer

It accounts for less than 2% of all breast cancer cases.

Answer

Gynaecomastia is not a risk factor.

Answer

Exocrine or endocrine estrogen exposure can predispose to it.

Question 5

In Patey's modified mastectomy, which of the following is preserved?

Accepted Answer

Pectoralis major

Answer

Intercostobrachial nerve

Answer

Pectoralis minor

Answer

Axillary fascia

Question 6

A 57-year-old woman presents with left breast pain. On examination, the left breast is markedly erythematous, swollen, and warm to touch. There is also significant dimpling of the breast (peau d'orange), and the left nipple is completely retracted. Which of the following is the likely diagnosis?

Accepted Answer

Inflammatory carcinoma

Answer

Granulomatous mastitis

Answer

Micropapillary carcinoma

Answer

Fibrocystic disease of the breast

Question 7

What is the most sensitive and specific investigation for carcinoma breast?

Accepted Answer

Mammography

Answer

CT scan

Answer

Thermography

Answer

USG

Question 8

On which of the following does prognosis in male breast cancer depend?

Accepted Answer

Lymph node status

Answer

Duration of disease

Answer

Nipple discharge

Answer

Ulceration of nipple

Question 9

In Radical mastectomy, which of the following is spared?

Accepted Answer

Supraclavicular lymph nodes

Answer

Pectorialis major

Answer

Pectoralis minor

Answer

Axillary lymph nodes

Question 10

A female patient presents with a hard, mobile lump in her right breast. Which investigation would be most helpful in making the diagnosis?

Accepted Answer

Excision biopsy

Answer

Fine Needle Aspiration Cytology (FNAC)

Answer

Needle biopsy

Answer

Mammography

Breast Surgery — MCQs

Breast Surgery — MCQs

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