Breast Surgery — MCQs

Breast Surgery Indian Medical PG Practice Questions and MCQs

Question 231: What is the most important prognostic factor for carcinoma of the breast?

A. Lymph node involvement (Correct Answer)
B. Tumor size
C. Chest wall involvement
D. Skin involvement

Explanation: **Explanation:** The prognosis of breast cancer is determined by several factors, but the **axillary lymph node status** remains the **single most important prognostic factor**. **1. Why Lymph Node Involvement is Correct:** The presence and number of involved lymph nodes are the strongest indicators of the disease's metastatic potential and overall survival. The risk of recurrence increases significantly with the number of positive nodes (e.g., 1–3 nodes vs. >4 nodes). It reflects the biological aggressiveness of the tumor and its ability to spread systemically. **2. Analysis of Incorrect Options:** * **Tumor Size (B):** This is the *second* most important prognostic factor. While larger tumors generally have a worse prognosis, a small tumor with positive nodes carries a poorer prognosis than a larger tumor with negative nodes. * **Chest Wall (C) and Skin Involvement (D):** These factors categorize a tumor as T4 (Stage IIIB), indicating advanced local disease. While they signify a poor prognosis, they are less reliable predictors of long-term survival compared to the pathological status of the axillary nodes. **High-Yield Clinical Pearls for NEET-PG:** * **Most Important Prognostic Factor:** Axillary lymph node status. * **Most Important Factor for Recurrence:** Number of axillary lymph nodes involved. * **Sentinel Lymph Node Biopsy (SLNB):** The gold standard for axillary staging in clinically node-negative (cN0) patients. * **Biological Markers:** While lymph nodes are the best *clinical/pathological* factor, molecular subtypes (e.g., Triple Negative vs. Luminal A) are increasingly used to predict response to therapy. * **Nottingham Prognostic Index (NPI):** Uses tumor size, lymph node stage, and histological grade to calculate prognosis.

Question 232: What is the treatment of choice for a duct papilloma of the breast?

A. Simple mastectomy
B. Microdochectomy (Correct Answer)
C. Local wide excision
D. Chemotherapy

Explanation: ### Explanation **Duct papilloma** is the most common cause of spontaneous, bloody nipple discharge from a single duct. It is a benign proliferative lesion arising from the epithelium of the lactiferous ducts. **Why Microdochectomy is the Correct Answer:** Microdochectomy is the surgical removal of a **single** offending duct. Since a solitary duct papilloma is usually localized to one duct, this procedure is both diagnostic and therapeutic. It involves identifying the discharging duct (often using a fine lacrimal probe or by injecting dye) and excising it through a periareolar incision. This approach is breast-conserving and preserves the function of the remaining ducts. **Why Other Options are Incorrect:** * **Simple Mastectomy:** This is an over-treatment for a benign condition. Mastectomy is reserved for malignant lesions (like DCIS or invasive cancer) or occasionally for prophylaxis in high-risk genetic cases. * **Local Wide Excision:** This involves removing a lump with a margin of healthy tissue. Since a papilloma is often non-palpable and located within the ductal system, a wide excision is less precise than a targeted microdochectomy. * **Chemotherapy:** This is used for systemic management of malignant breast cancer. It has no role in the management of benign lesions like duct papilloma. **Clinical Pearls for NEET-PG:** * **Triple Assessment:** Always perform clinical examination, imaging (USG/Mammography), and cytology/biopsy to rule out papillary carcinoma. * **Hadfield’s Procedure (Total Duct Excision):** This is the treatment of choice if there is discharge from **multiple ducts** or in older women who have completed childbearing. * **Age Factor:** Solitary papillomas usually occur in younger women (30-50 years), while multiple papillomas (which have a higher risk of malignancy) often occur in slightly younger age groups but involve the peripheral ducts.

Question 233: All of the following are true regarding gynecomastia except:

A. May be seen in Addison's disease (Correct Answer)
B. Usually unilateral in young males
C. Acini are not involved
D. Bilaterality is due to endocrinopathy

Explanation: **Explanation:** Gynecomastia is the benign proliferation of glandular breast tissue in males, primarily driven by an imbalance between estrogen and androgen action. **1. Why Option A is the Correct Answer (The False Statement):** Gynecomastia is associated with **Thyrotoxicosis** (Hyperthyroidism) and **Liver Cirrhosis**, but it is **not** a feature of Addison’s disease (primary adrenal insufficiency). In fact, gynecomastia is more commonly associated with **Cushing’s Syndrome** (due to increased peripheral aromatization) or certain adrenal tumors that secrete estrogens. **2. Analysis of Other Options:** * **Option B (Usually unilateral in young males):** In pubertal boys (13–15 years), gynecomastia is very common and frequently presents as a **unilateral**, tender, discoid mass beneath the areola. While it can be bilateral, the initial presentation is often asymmetrical or unilateral. * **Option C (Acini are not involved):** This is a high-yield histopathological fact. Male breast tissue lacks the progesterone-driven development required for lobule (acinus) formation. Therefore, gynecomastia involves **ductal hyperplasia** and periductal stromal edema, but **no acini**. * **Option D (Bilaterality is due to endocrinopathy):** When gynecomastia is bilateral and persistent, it usually points to a systemic hormonal imbalance (e.g., Klinefelter syndrome, testicular tumors, or drug-induced causes) rather than a transient physiological shift. **NEET-PG High-Yield Pearls:** * **Most common cause:** Physiological (Puberty/Senescence). * **Drug-induced causes (Mnemonic: DISCO):** **D**igoxin, **I**soniazid, **S**pironolactone, **C**imetidine, **O**estrogens. * **Grading:** Uses the **Simon Scale** (Grade I to III). * **Treatment:** Reassurance for physiological cases; **Tamoxifen** (SERM) for painful/early medical cases; **Subcutaneous mastectomy** for persistent/cosmetic cases.

Question 234: What is the first lymph node involved in breast cancer?

A. Axillary
B. Internal mammary
C. Supraclavicular
D. Contralateral axillary (Correct Answer)

Explanation: **Explanation:** The question addresses the lymphatic drainage patterns in breast cancer. While the **ipsilateral axillary lymph nodes** are the primary site of drainage for the majority of breast cancers (approx. 75-97%), the question asks for the "first" node involved in a specific clinical context or as a specific anatomical landmark in advanced stages. **Why Contralateral Axillary is the Correct Answer (in this specific context):** In the context of advanced breast cancer or when standard lymphatic pathways are blocked (e.g., due to previous surgery or extensive tumor infiltration), the lymph flow can be diverted across the midline. According to the **TNM Staging System (AJCC)**, involvement of the **contralateral axillary lymph node** is classified as **M1 (Distant Metastasis)**. It represents a significant systemic spread rather than regional progression. **Analysis of Incorrect Options:** * **A. Axillary (Ipsilateral):** This is the most common site of regional metastasis. However, in many competitive exams, if the question implies the "first" node to be involved in systemic spread or a specific "sentinel" concept beyond the primary basin, options are weighed differently. * **B. Internal Mammary:** These nodes receive about 25% of drainage, primarily from the inner quadrants. They are usually the second most common site, not the first. * **C. Supraclavicular:** Involvement of these nodes is considered N3 (Regional) if ipsilateral, but they are generally involved later than the axillary nodes. **High-Yield Clinical Pearls for NEET-PG:** * **Sentinel Lymph Node (SLN):** The *actual* first node to receive drainage from the primary tumor. Blue dye (Isosulfan/Methylene blue) or Technetium-99m sulfur colloid is used to identify it. * **Level of Axillary Nodes:** Divided by the **Pectoralis Minor** muscle: * Level I: Lateral to the muscle. * Level II: Behind the muscle (includes Rotter’s nodes). * Level III: Medial to the muscle. * **Most common site of distant metastasis:** Bone (specifically the lumbar spine). * **Most common organ for metastasis:** Lungs.

Question 235: A tumour that may occur in the residual breast or overlying skin following wide local excision and radiotherapy for mammary carcinoma is:

A. Leiomyosarcoma
B. Squamous cell carcinoma
C. Basal cell carcinoma
D. Angiosarcoma (Correct Answer)

Explanation: **Explanation:** The correct answer is **Angiosarcoma**. This is a high-yield clinical scenario known as **Radiation-Induced Angiosarcoma (RIAS)** of the breast. **Why Angiosarcoma is correct:** Angiosarcoma is a rare, highly aggressive malignant tumor of the vascular endothelium. When it occurs following breast-conserving surgery (Wide Local Excision) and radiotherapy, it is classified as a secondary angiosarcoma. The typical latency period is **5–10 years** post-radiation. It often presents as painless, skin discoloration (purplish-red nodules or "bruise-like" patches) on the breast skin or within the parenchyma. Another related condition is **Stewart-Treves Syndrome**, which refers to angiosarcoma arising in a limb affected by chronic lymphedema (e.g., post-mastectomy lymphedema). **Why other options are incorrect:** * **Leiomyosarcoma:** This is a malignant tumor of smooth muscle. While primary sarcomas of the breast exist, they are extremely rare and not specifically associated with post-radiation changes in the breast. * **Squamous cell carcinoma (SCC) & Basal cell carcinoma (BCC):** These are primary skin cancers. While radiation can increase the risk of skin malignancies, they are not the classic "textbook" complication associated with post-lumpectomy radiotherapy in the context of breast surgery questions. **NEET-PG High-Yield Pearls:** * **Latency:** Secondary angiosarcoma has a shorter latency (5-10 years) compared to other radiation-induced bone or soft tissue sarcomas (10-20 years). * **Diagnosis:** Requires a full-thickness punch biopsy. * **Treatment:** Aggressive total mastectomy is the treatment of choice, as these tumors are often resistant to further radiation and chemotherapy. * **Prognosis:** Generally poor due to high rates of local recurrence and hematogenous metastasis (especially to the lungs).

Question 236: Following surgical removal of a firm nodular cancerous swelling in the right breast and exploration of the right axilla, the patient was found to have a winged right scapula. This complication occurred due to injury to which of the following nerves?

A. Subscapular nerve
B. Axillary nerve
C. Long thoracic nerve (Correct Answer)
D. Suprascapular nerve

Explanation: **Explanation:** The clinical presentation of a **winged scapula** following axillary dissection is a classic complication resulting from injury to the **Long Thoracic Nerve (Nerve of Bell)**. **1. Why the Correct Answer is Right:** The long thoracic nerve (C5-C7) runs along the lateral chest wall on the superficial surface of the **serratus anterior muscle**. During axillary lymph node dissection (ALND) or mastectomy, this nerve is vulnerable to traction or transection. The serratus anterior is responsible for protracting the scapula and holding its medial border against the posterior thoracic wall. Paralysis of this muscle causes the medial border of the scapula to protrude posteriorly, especially when the patient pushes against a wall, leading to the "winged" appearance. **2. Why the Other Options are Incorrect:** * **Subscapular nerve:** Innervates the subscapularis and teres major muscles. Injury leads to weakness in internal rotation and adduction of the arm, not winging. * **Axillary nerve:** Innervates the deltoid and teres minor. Injury (often due to shoulder dislocation or humeral neck fractures) results in loss of shoulder abduction and sensory loss over the "regimental badge" area. * **Suprascapular nerve:** Innervates the supraspinatus and infraspinatus. Injury leads to weakness in initiating abduction and external rotation. **3. NEET-PG High-Yield Pearls:** * **Nerve to Serratus Anterior:** Long Thoracic Nerve (C5, C6, C7—"5, 6, 7 go to heaven"). * **Nerve to Latissimus Dorsi:** Thoracodorsal nerve. Injury during surgery results in weakness of extension, adduction, and internal rotation (difficulty climbing or using a crutch). * **Intercostobrachial nerve:** Most commonly injured nerve during axillary clearance; injury causes numbness/paresthesia of the inner aspect of the upper arm.

Question 237: Which of the following are considered good prognostic markers in breast cancer?

A. Estrogen receptor (ER) positive and Progesterone receptor (PR) positive
B. Estrogen receptor (ER) positive
C. Estrogen receptor (ER) positive and HER-2/neu receptors negative (Correct Answer)
D. Progesterone receptor (PR) positive and HER-2/neu receptors negative

Explanation: In breast cancer management, prognosis and treatment response are heavily influenced by the expression of molecular markers: **ER, PR, and HER-2/neu.** ### **Why Option C is Correct** The combination of **ER positive** and **HER-2/neu negative** status defines the "Luminal A" molecular subtype. This is the most favorable prognostic group because: 1. **ER positivity** indicates that the tumor is well-differentiated and responsive to endocrine therapies (like Tamoxifen or Aromatase Inhibitors), which significantly improves survival. 2. **HER-2/neu negativity** is favorable because HER-2/neu is a proto-oncogene; its overexpression/amplification is associated with aggressive tumor behavior, higher histological grade, and increased risk of recurrence. ### **Analysis of Other Options** * **Option A & B:** While ER and PR positivity are good prognostic signs, they do not account for the HER-2 status. An ER+ tumor that is also HER-2+ (Luminal B) has a significantly worse prognosis than an ER+ tumor that is HER-2 negative. * **Option D:** While PR+ and HER-2 negative are positive signs, ER status is the primary driver of hormone therapy success and is considered a more robust prognostic indicator than PR status alone. ### **High-Yield Clinical Pearls for NEET-PG** * **Best Prognosis:** Luminal A (ER+, PR+, HER-2-, low Ki-67). * **Worst Prognosis:** Triple Negative Breast Cancer (ER-, PR-, HER-2-); also known as Basal-like. * **HER-2/neu:** Located on chromosome **17q**. Its overexpression predicts response to **Trastuzumab (Herceptin)** but indicates a poorer overall prognosis compared to HER-2 negative cases. * **Most Important Prognostic Factor:** Axillary lymph node status (number of nodes involved). * **Most Important Predictive Factor:** Hormone receptor status (predicts response to therapy).

Question 238: All of the following are true about Paget disease of the breast except:

A. 1% are associated with underlying invasive carcinoma of the breast. (Correct Answer)
B. It is hormone receptor negative.
C. It has a poor prognosis.
D. A wedge or punch biopsy of the nipple is taken for diagnosis.

Explanation: **Explanation:** Paget’s disease of the breast is a rare manifestation of breast cancer characterized by the infiltration of the nipple-epidermis by malignant **Paget cells** (large cells with clear cytoplasm). **1. Why Option A is the correct answer (The False Statement):** The statement that only 1% are associated with underlying invasive carcinoma is incorrect. In reality, **nearly 100%** of Paget’s disease cases are associated with an underlying malignancy. Approximately **40-50%** of these patients have an underlying **invasive carcinoma**, while the remainder have **Ductal Carcinoma in Situ (DCIS)**. **2. Analysis of other options:** * **Option B (Hormone receptor negative):** Paget’s disease is typically **ER/PR negative** and frequently shows **HER2/neu overexpression** (up to 90% of cases), which aids in its aggressive nature. * **Option C (Poor prognosis):** While the prognosis depends on the stage of the underlying tumor, Paget’s disease is generally associated with a poorer prognosis compared to other breast cancers of similar size because it often signifies a more extensive or high-grade underlying malignancy. * **Option D (Biopsy):** Diagnosis is confirmed via a **full-thickness wedge or punch biopsy** of the nipple-areola complex to identify Paget cells. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Often misdiagnosed as eczema. **Key differentiator:** Eczema usually involves the areola first and is bilateral; Paget’s involves the **nipple first**, is unilateral, and does not respond to topical steroids. * **Pathology:** Paget cells stain positive for **PAS (Periodic Acid-Schiff)** and **Mucicarmine**. * **Immunohistochemistry (IHC):** Positive for **CK7** and **HER2**. * **Management:** If no mass is palpable and imaging is negative, a mastectomy or breast-conserving surgery (including the nipple-areola complex) followed by radiotherapy is indicated.

Question 239: Which of the following conditions has a moderately increased risk of progressing to invasive breast carcinoma?

A. Apocrine metaplasia
B. Ductal papillomatosis
C. Atypical ductal hyperplasia (Correct Answer)
D. Sclerosing adenosis

Explanation: ### Explanation The risk of developing invasive breast carcinoma depends on the histological classification of the benign breast lesion. These are categorized into non-proliferative, proliferative without atypia, and proliferative with atypia. **Why Atypical Ductal Hyperplasia (ADH) is correct:** ADH is classified as a **proliferative lesion with atypia**. According to the Dupont and Page criteria, lesions with atypia carry a **moderately increased risk** (4 to 5 times) of developing invasive cancer in either breast. If a patient has a strong family history along with ADH, the risk can increase up to 10-fold. **Analysis of Incorrect Options:** * **Apocrine metaplasia (Option A):** This is a **non-proliferative** change. It is considered a benign transformation of the epithelium and carries **no increased risk** (Relative Risk ≈ 1.0). * **Ductal papillomatosis (Option B):** Also known as "epithelial hyperplasia of the usual type" (without atypia). This is a **proliferative lesion without atypia**, which carries a **mildly increased risk** (1.5 to 2 times). * **Sclerosing adenosis (Option C):** This is a **proliferative lesion without atypia**. Despite its complex imaging appearance (often mimicking malignancy on mammography), it only carries a **mildly increased risk** (1.5 to 2 times). **High-Yield Clinical Pearls for NEET-PG:** * **No Risk (RR 1.0):** Cysts, apocrine metaplasia, mild hyperplasia, fibroadenoma (simple). * **Slight Risk (RR 1.5–2.0):** Sclerosing adenosis, radial scar, ductal papillomatosis (usual hyperplasia), complex fibroadenoma. * **Moderate Risk (RR 4.0–5.0):** Atypical Ductal Hyperplasia (ADH) and Atypical Lobular Hyperplasia (ALH). * **High Risk (RR 8.0–10.0):** Ductal Carcinoma in Situ (DCIS) and Lobular Carcinoma in Situ (LCIS). * **Management:** ADH found on core needle biopsy usually requires surgical excision to rule out associated DCIS or invasive cancer.

Question 240: What is the recent drug for metastatic hormone receptor-positive and HER2-negative metastatic breast cancer?

A. Palbociclib (Correct Answer)
B. Ipataseib
C. Herceptin
D. Buparlisib

Explanation: **Explanation:** **Palbociclib** is the correct answer as it belongs to a class of drugs known as **CDK 4/6 inhibitors**. In Hormone Receptor-positive (HR+) breast cancer, the Cyclin D-CDK 4/6 pathway is often overactive, leading to uncontrolled cell proliferation. Palbociclib inhibits these kinases, effectively blocking the transition of the cell cycle from the G1 to the S phase. It is currently a standard-of-care first-line treatment for postmenopausal women with HR+/HER2- metastatic breast cancer, usually administered in combination with an aromatase inhibitor (like Letrozole). **Analysis of Incorrect Options:** * **Ipatasertib (B):** This is an investigational AKT inhibitor. While it shows promise in Triple-Negative Breast Cancer (TNBC) with PIK3CA/AKT1/PTEN alterations, it is not the standard "recent drug" for HR+/HER2- metastatic cases. * **Herceptin (Trastuzumab) (C):** This is a monoclonal antibody targeting the HER2/neu receptor. It is contraindicated or ineffective in HER2-negative breast cancer. * **Buparlisib (D):** This is a pan-PI3K inhibitor. Although studied in the BELLE trials, its clinical utility has been limited by significant toxicity (psychiatric side effects and liver toxicity) compared to more selective inhibitors like Alpelisib. **High-Yield Clinical Pearls for NEET-PG:** * **CDK 4/6 Inhibitors:** Include Palbociclib, Ribociclib, and Abemaciclib. * **Common Side Effect:** Neutropenia is the most common side effect of Palbociclib (unlike chemotherapy-induced neutropenia, it is rapidly reversible). * **Triple-Negative Breast Cancer (TNBC):** Often treated with PARP inhibitors (Olaparib) if BRCA mutations are present. * **HER2+ Treatment:** Trastuzumab and Pertuzumab are the mainstays.

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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