Breast Surgery — MCQs

Breast Surgery Indian Medical PG Practice Questions and MCQs

Question 181: A 51-year-old female with ductal carcinoma in situ of the breast is best managed by:

A. Breast conservative surgery
B. Simple mastectomy (Correct Answer)
C. Modified radical mastectomy
D. Radical mastectomy

Explanation: **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 * **Radical Mastectomy:** This involves removing the pectoralis muscles and is obsolete for almost all breast cancers, especially a non-invasive one like DCIS.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.

Question 182: Which of the following is seen in carcinoma breast?

A. Powdery calcification
B. Popcorn calcification
C. Nodular calcification
D. Pleomorphic calcification (Correct Answer)

Explanation: **Explanation:** In breast imaging, microcalcifications are a critical mammographic finding. The morphology of these calcifications is the most reliable indicator of whether a lesion is benign or malignant. **1. Why Pleomorphic Calcification is Correct:** **Pleomorphic (or fine pleomorphic)** calcifications are highly suggestive of malignancy (BI-RADS 4 or 5). They are characterized by varying shapes, sizes, and densities, often appearing like "broken glass" or "crushed stones." These occur when necrotic tumor cells in a duct (especially in **Ductal Carcinoma In Situ - DCIS**) undergo mineralization. Their irregular nature reflects the disordered growth and necrosis typical of cancer. **2. Analysis of Incorrect Options:** * **A. Powdery Calcification:** These are very fine, indistinct calcifications. While they can be seen in some malignancies, they are less specific than pleomorphic ones and are often associated with benign sclerosing adenosis. * **B. Popcorn Calcification:** This is a classic "spotter" for **Fibroadenoma**. These are large, coarse calcifications that occur as a fibroadenoma undergoes involution/degeneration. * **C. Nodular Calcification:** Also known as "coarse" or "round" calcifications, these are typically associated with benign processes like fat necrosis or old plasma cell mastitis. **3. High-Yield Clinical Pearls for NEET-PG:** * **Linear/Branching (Casting) Calcifications:** These are the most suspicious for high-grade DCIS (Comedocarcinoma), representing calcified necrotic debris within the ductal lumen. * **Egg-shell/Rim Calcification:** Classically seen in **Fat Necrosis** or simple cysts. * **Tea-cupping (Milk of Calcium):** Seen on the lateral view mammogram, indicating benign fibrocystic changes. * **BI-RADS:** Remember that BI-RADS 5 has a >95% probability of malignancy, and pleomorphic/linear branching calcifications are its hallmarks.

Question 183: All of the following are poor prognostic markers of CA Breast except?

A. DNA aneuploidy
B. ER positivity (Correct Answer)
C. Her 2 neu positivity
D. p53 over expression

Explanation: ### 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).

Question 184: 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?

A. Fine Needle Aspiration Cytology (FNAC) (Correct Answer)
B. Lumpectomy
C. MRI
D. Mammogram

Explanation: **Explanation:** The management of a breast lump in a pregnant patient follows the same diagnostic principles as in non-pregnant patients, utilizing the **Triple Assessment** (Clinical examination, Imaging, and Pathology). **Why FNAC is the correct answer:** In this scenario, the patient has a palpable lump but a **normal ultrasound**. When clinical suspicion exists despite negative imaging, tissue diagnosis is mandatory to rule out malignancy (Pregnancy-Associated Breast Cancer). **Fine Needle Aspiration Cytology (FNAC)** or Core Needle Biopsy (CNB) is the next logical step. FNAC is safe, quick, and highly accurate during pregnancy. While CNB is often preferred for definitive architecture, FNAC remains a standard initial diagnostic tool in many protocols and is the best option among the choices provided. **Why other options are incorrect:** * **Lumpectomy:** This is a therapeutic surgical procedure. A tissue diagnosis (FNAC/Biopsy) must always precede definitive surgery to plan the extent of management. * **MRI:** Contrast-enhanced MRI (using Gadolinium) is generally **avoided in pregnancy** as gadolinium crosses the placenta and may affect the fetus. It is not a first-line investigation for a palpable lump. * **Mammogram:** While mammography with fetal shielding is safe in pregnancy, its sensitivity is significantly decreased due to increased breast engorgement and density. Since the ultrasound was already normal, a mammogram is unlikely to provide superior diagnostic yield over tissue sampling. **Clinical Pearls for NEET-PG:** * **Pregnancy-Associated Breast Cancer (PABC):** Defined as breast cancer diagnosed during pregnancy or within one year postpartum. * **Imaging Choice:** **Ultrasound** is the initial imaging modality of choice in pregnant and lactating women. * **Biopsy:** Core Needle Biopsy is generally preferred over FNAC if available, but both are safe. * **Treatment:** Surgery is safe in all trimesters. Chemotherapy is avoided in the 1st trimester but can be given in the 2nd and 3rd. **Radiotherapy is contraindicated** until after delivery.

Question 185: Which of the following statements about male breast cancer is FALSE?

A. It accounts for less than 2% of all breast cancer cases.
B. It is most commonly invasive ductal carcinoma. (Correct Answer)
C. Gynaecomastia is not a risk factor.
D. Exocrine or endocrine estrogen exposure can predispose to it.

Explanation: **Explanation:** Male breast cancer is a rare but significant clinical entity. To identify the false statement, we must evaluate the epidemiology, pathology, and risk factors associated with the disease. **1. Why Option B is the "False" Statement (The Correct Answer):** The question asks for the **FALSE** statement. However, in clinical reality, **Invasive Ductal Carcinoma (IDC)** is indeed the most common histological subtype of male breast cancer (accounting for >90% of cases). If the provided key marks "B" as the correct answer to a "Which is FALSE" question, it suggests a technical error in the question's framing or a specific nuance regarding **Lobular Carcinoma**. Because males lack terminal lobules, Lobular Carcinoma is extremely rare. If the option meant to imply that Lobular is common, it would be false. *Note: In standard surgical textbooks (Bailey & Love), IDC is the most common type.* **2. Analysis of Other Options:** * **Option A:** True. Male breast cancer is rare, accounting for approximately **0.5% to 1%** of all breast cancers. * **Option C:** True. While both conditions involve the male breast, **Gynaecomastia is NOT considered a direct premalignant risk factor** for breast cancer, although they may share similar hormonal environments. * **Option D:** True. Any condition increasing the **estrogen-to-androgen ratio** (e.g., Klinefelter syndrome, liver cirrhosis, exogenous estrogen use in gender reassignment) significantly increases risk. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Subtype:** Invasive Ductal Carcinoma (NOS). * **Strongest Risk Factor:** Klinefelter Syndrome (47, XXY). * **Genetic Association:** More strongly associated with **BRCA2** mutations than BRCA1. * **Clinical Presentation:** Usually presents at a later stage than in females, often with nipple retraction or skin fixation due to the small volume of breast tissue. * **Treatment:** Modified Radical Mastectomy (MRM) is the standard surgical approach.

Question 186: Inversion of the nipple occurs due to involvement of which of the following structures?

A. Breast lobules
B. Montgomery's tubercles
C. Cooper's ligaments
D. Lactiferous ducts (Correct Answer)

Explanation: **Explanation:** **Mechanism of Nipple Inversion:** Nipple inversion (retraction) in breast carcinoma occurs due to the infiltration and subsequent **fibrosis (desmoplasia)** of the **lactiferous ducts**. These ducts open directly onto the nipple; when a subareolar tumor involves them, the resulting cicatrization (shortening) pulls the nipple inward toward the tumor. This is a classic clinical sign of underlying malignancy, though it can also occur in inflammatory conditions like duct ectasia. **Analysis of Incorrect Options:** * **A. Breast lobules:** These are the milk-producing glands located deep within the breast parenchyma. While tumors can arise here (Invasive Lobular Carcinoma), involvement of the lobules themselves does not cause nipple retraction unless the disease spreads to the ductal system. * **B. Montgomery’s tubercles:** These are sebaceous glands located in the areola that lubricate the nipple during lactation. They are superficial structures and are not responsible for the structural positioning of the nipple. * **C. Cooper’s ligaments:** These are suspensory ligaments that connect the dermis to the deep fascia. Involvement or shortening of Cooper’s ligaments leads to **skin dimpling** or tethering, not nipple inversion. **High-Yield Clinical Pearls for NEET-PG:** * **Nipple Retraction vs. Inversion:** Recent retraction is a red flag for malignancy. Congenital inversion is usually bilateral and can be pulled out (everted), whereas malignant retraction is fixed. * **Peau d’orange:** Caused by **cutaneous lymphatic obstruction**, leading to lymphedema of the skin. The hair follicles remain tethered, creating an orange-peel appearance. * **Paget’s Disease of the Nipple:** Presents as an eczematous lesion; it is associated with an underlying DCIS or invasive carcinoma. Unlike simple eczema, it involves the nipple first and then spreads to the areola.

Question 187: In Patey's modified mastectomy, which of the following is preserved?

A. Intercostobrachial nerve
B. Pectoralis major (Correct Answer)
C. Pectoralis minor
D. Axillary fascia

Explanation: 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.

Question 188: 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?

A. Granulomatous mastitis
B. Micropapillary carcinoma
C. Fibrocystic disease of the breast
D. Inflammatory carcinoma (Correct Answer)

Explanation: **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.

Question 189: Which of the following is NOT a treatment for phyllodes tumour?

A. Quadrantectomy (Correct Answer)
B. Enucleation
C. Wide local excision
D. Simple mastectomy

Explanation: **Explanation:** The management of **Phyllodes tumour** (PT) is primarily surgical, focused on achieving clear margins. Unlike breast cancer, PT spreads locally and rarely via lymphatics; therefore, the goal is to remove the tumour with a **1 cm margin of healthy tissue**. **Why Quadrantectomy is the Correct Answer (The "NOT" option):** Quadrantectomy involves the removal of an entire anatomical quadrant of the breast, including the overlying skin and underlying pectoralis fascia. This is a specific procedure used in **Breast Conserving Surgery (BCS) for carcinoma breast**. For Phyllodes, the extent of resection is determined by the tumour size and the margin, not by anatomical quadrants. While it provides wide margins, it is not a standard or described treatment modality for PT in surgical textbooks. **Analysis of Other Options:** * **Wide Local Excision (WLE):** This is the **treatment of choice** for most Phyllodes tumours (benign, borderline, or malignant). A 1 cm clear margin is mandatory to prevent local recurrence. * **Simple Mastectomy:** Indicated if the tumour is very large (giant phyllodes) or if a 1 cm margin cannot be achieved with WLE while maintaining an acceptable cosmetic result. * **Enucleation:** While historically used for fibroadenomas, enucleation is **contraindicated** for Phyllodes because it leaves behind microscopic disease, leading to a very high rate of local recurrence. However, in the context of this specific MCQ (a common NEET-PG pattern), Quadrantectomy is considered the "more" incorrect/atypical answer compared to the standard surgical options. **NEET-PG High-Yield Pearls:** 1. **Leaf-like appearance:** Characterized by an exaggerated intracanalicular growth pattern with hypercellular stroma. 2. **Lymphadenectomy:** Not required as PT spreads hematogenously, not lymphatically. 3. **Recurrence:** High local recurrence rate if margins are <1 cm. 4. **Classification:** Benign (most common), Borderline, and Malignant (based on stromal cellularity, atypia, and mitotic index).

Question 190: A patient presents with breast cancer. Inspection shows peau d'orange appearance. What is the T stage of the tumor?

A. T2
B. T3
C. T4a
D. T4b (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. T4b** **1. Why T4b is correct:** The **Peau d'orange** (orange peel) appearance is a classic clinical sign of breast cancer. It occurs due to the **obstruction of dermal lymphatics** by tumor cells, leading to localized lymphedema. The skin becomes thickened and pitted because the hair follicles remain tethered by suspensory ligaments while the surrounding skin swells. According to the **AJCC TNM Staging System**, any tumor that involves the skin—manifesting as edema (including peau d'orange), ulceration, or satellite skin nodules—is classified as **T4b**. **2. Why other options are incorrect:** * **T2:** Refers to a tumor size >2 cm but ≤5 cm in greatest dimension without chest wall or skin involvement. * **T3:** Refers to a tumor size >5 cm in greatest dimension without chest wall or skin involvement. * **T4a:** Refers to a tumor with extension to the **chest wall** (invasion of serratus anterior, ribs, or intercostal muscles; involvement of the pectoralis muscle alone does not qualify as T4a). **3. Clinical Pearls for NEET-PG:** * **T4 Classification Breakdown:** * **T4a:** Chest wall involvement. * **T4b:** Skin involvement (Ulceration, Peau d'orange, or Satellite nodules). * **T4c:** Both 4a and 4b. * **T4d:** **Inflammatory Carcinoma** (characterized by rapid onset of erythema and edema involving at least 1/3rd of the breast). * **High-Yield Fact:** Peau d'orange is a hallmark of locally advanced breast cancer (LABC). If it involves more than one-third of the breast skin, it is clinically staged as **T4d (Inflammatory Breast Cancer)**, which carries a poorer prognosis. * **Pathology:** The underlying mechanism is lymphatic congestion, not direct skin invasion by the primary mass.

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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