Breast Surgery Practice Questions

Q: Paresthesia following MRM (Modified Radical Mastectomy) develops due to involvement of which nerve?

Medial cutaneous nerve of arm. ### Explanation **1. Why the Correct Answer is Right:** During a Modified Radical Mastectomy (MRM), specifically during **axillary lymph node dissection (ALND)**, the **intercostobrachial nerve** (the lateral cutaneous branch of the second intercostal nerve) is frequently encountered. This nerve communicates with the **medial cutaneous nerve of the arm**. Injury, traction, or intentional sacrifice of these sensory fibers leads to postoperative **paresthesia, numbness, or chronic pain** along the posteromedial aspect of the upper arm and axilla. This is the most common sensory complication following MRM. **2. Why the Other Options are Incorrect:** * **A. Long Thoracic Nerve (Nerve of Bell):** This is a motor nerve supplying the **Serratus Anterior**. Injury leads to **"Winging of Scapula"** and inability to abduct the arm above 90 degrees, not sensory paresthesia. * **B. Medial Pectoral Nerve:** This is a motor nerve supplying the **Pectoralis Major and Minor**. Injury leads to atrophy of these muscles. * **D. Thoracodorsal Nerve:** This is a motor nerve supplying the **Latissimus Dorsi**. Injury leads to weakness in internal rotation, adduction, and extension of the arm (difficulty in "climbing" or "scratching the back"). **3. Clinical Pearls for NEET-PG:** * **Most commonly injured nerve in MRM:** Intercostobrachial nerve (causing sensory loss). * **Nerve most commonly preserved in MRM:** Long thoracic and Thoracodorsal nerves (to maintain shoulder function). * **Nerve of Bell (Long Thoracic):** Runs on the medial wall of the axilla (over the serratus anterior). * **Thoracodorsal Nerve:** Runs in the posterior wall of the axilla (with the subscapular vessels). * **Halsted’s Sign:** Loss of the pectoral fold due to injury to the pectoral nerves.

Q: What is the standard treatment for cystosarcoma phyllodes?

Simple mastectomy. **Explanation:** **Cystosarcoma Phyllodes** (Phyllodes tumor) is a rare fibroepithelial breast tumor characterized by a "leaf-like" growth pattern. The standard treatment is **Simple Mastectomy** (or wide local excision with >1 cm margins) because these tumors spread locally and via the hematogenous route, rather than through the lymphatic system. * **Why Simple Mastectomy is correct:** Since Phyllodes tumors rarely involve axillary lymph nodes (less than 1% incidence), a simple mastectomy—which removes the entire breast tissue without axillary clearance—is sufficient for large or malignant tumors to ensure clear margins and prevent local recurrence. * **Why Radical/Modified Radical Mastectomy (MRM) are wrong:** These procedures involve axillary lymph node dissection. Because Phyllodes tumors behave like sarcomas (spreading via blood, not lymphatics), routine axillary dissection is unnecessary and adds morbidity without improving survival. * **Why Antibiotics are wrong:** Phyllodes is a neoplastic condition, not an inflammatory or infectious process like mastitis or a breast abscess. **High-Yield Clinical Pearls for NEET-PG:** * **Classification:** Can be Benign, Borderline, or Malignant based on stromal cellularity, atypia, and mitotic index. * **Clinical Feature:** Typically presents as a large, painless, mobile mass with rapid growth; the overlying skin may be shiny with prominent veins. * **Key Distinction:** Unlike Fibroadenomas, Phyllodes tumors occur in older women (35–50 years) and have a high risk of local recurrence if margins are inadequate. * **Treatment Rule:** Wide local excision (margin >1 cm) for small tumors; Simple Mastectomy for large tumors or high tumor-to-breast ratio.

Q: Regarding cystic disease of the breast, which one of the following statements is true?

Aspiration is the treatment. **Explanation:** Cystic disease of the breast, often part of **Fibrocystic Change (ANDI - Aberrations of Normal Development and Involution)**, is a benign condition characterized by fluid-filled sacs resulting from the involution of breast lobules. **Why Option D is correct:** **Fine Needle Aspiration (FNA)** is both diagnostic and therapeutic. If the aspirated fluid is non-bloody and the lump disappears completely without recurrence, no further treatment is required. This makes aspiration the primary management strategy for symptomatic or large cysts. **Why other options are incorrect:** * **Option A:** Cystic disease is most common in the **perimenopausal age group (35–50 years)**, not 25. It is rare after menopause unless the patient is on Hormone Replacement Therapy (HRT). * **Option B:** Excision is not the first-line treatment. Surgery is only indicated if the cyst recurs repeatedly after aspiration, contains blood-stained fluid, or shows a residual solid mass (intracystic papilloma/carcinoma). * **Option C:** Simple cysts are **benign** and do not carry an increased risk of malignancy. Only complex cysts with solid components or proliferative changes with atypia (found on biopsy) increase the risk of future breast cancer. **NEET-PG High-Yield Pearls:** * **Triple Assessment:** Clinical examination, Imaging (Ultrasound is preferred for cysts), and Pathology (FNA/Core Biopsy). * **Blue-Domed Cysts of Bloodgood:** A classic pathological description of large, tense cysts containing brownish-blue fluid. * **Management Rule:** If the fluid is bloody or the mass persists after aspiration, a core needle biopsy is mandatory to rule out malignancy.

Q: Which of the following statements regarding Paget's disease of the breast is true, except?

None of the above. **Explanation:** Paget’s disease of the breast is a rare manifestation of breast cancer characterized by the infiltration of the epidermis by malignant cells (Paget cells). The question asks for the "false" statement, but since all options (A, B, and C) are clinically accurate, the correct answer is **"None of the above."** **1. Why the options are correct:** * **Option B (Represents underlying malignancy):** This is a hallmark of the disease. In over 95% of cases, Paget’s disease is associated with an underlying **Ductal Carcinoma In Situ (DCIS)** or invasive carcinoma. The Paget cells migrate from the underlying lactiferous ducts to the nipple skin. * **Option C (Presents as eczema):** The classic clinical presentation is a chronic, crusting, scaling, or eroding lesion of the nipple-areola complex that mimics **eczema**. A key differentiating factor is that Paget’s typically involves the **nipple first** and may spread to the areola, whereas cutaneous eczema usually involves the areola and spares the nipple. * **Option A (Treated by simple mastectomy):** While Breast Conserving Surgery (BCS) followed by radiotherapy is an option for localized disease, **Simple Mastectomy** (with or without axillary evaluation) remains a standard and definitive surgical treatment, especially when the underlying malignancy is multicentric. **High-Yield Clinical Pearls for NEET-PG:** * **Pathology:** Paget cells are large, pale cells with granular cytoplasm and pleomorphic nuclei. They are **PAS positive** (diastase resistant) and stain positive for **Her2/neu** and **CK7**. * **Diagnosis:** The gold standard for diagnosis is a **full-thickness punch biopsy** of the nipple-areola complex. * **Prognosis:** The prognosis depends entirely on the stage and characteristics of the underlying breast cancer, not the skin changes themselves.

Q: Unilateral breast involvement with scaly skin around the nipple and intermittent bleeding is suggestive of:

Paget's disease. **Explanation:** The clinical presentation of unilateral, scaly, or eczematous lesions of the nipple-areola complex, especially when associated with intermittent bleeding or ulceration, is a classic hallmark of **Paget’s disease of the breast**. **1. Why Paget’s Disease is Correct:** Paget’s disease is an intraepidermal manifestation of an underlying breast malignancy (usually Ductal Carcinoma In Situ or invasive ductal carcinoma). Malignant "Paget cells" migrate from the lactiferous ducts into the epidermis of the nipple. Key diagnostic features include: * **Unilateral involvement** (unlike constitutional eczema). * **Destruction of the nipple-areola complex** (starts at the nipple and spreads to the areola). * **Palpable mass** present in approximately 50% of cases. **2. Why Other Options are Incorrect:** * **Eczema:** Typically **bilateral**, involves the areola first (sparing the nipple), and presents with intense pruritus without destruction of the nipple architecture. It responds to topical steroids, whereas Paget’s does not. * **Galactocoele:** A milk-containing cyst occurring in lactating women. It presents as a painless, fluctuant mass rather than a surface skin lesion. * **Sebaceous Cysts:** These are common cutaneous lumps that may occur on the breast skin but do not cause diffuse scaling or bleeding of the nipple-areola complex. **Clinical Pearls for NEET-PG:** * **Pathology:** Look for **Paget cells** (large, PAS-positive, pale-staining cells with prominent nucleoli) on skin biopsy. * **Management:** Mammography is mandatory to locate the underlying malignancy. * **Rule of Thumb:** Any "eczema" of the nipple that does not heal with topical treatment within 2–3 weeks must be biopsied to rule out Paget’s disease.

Question 1

Paresthesia following MRM (Modified Radical Mastectomy) develops due to involvement of which nerve?

Accepted Answer

Medial cutaneous nerve of arm

Answer

Long thoracic nerve

Answer

Medial pectoral nerve

Answer

Thoracodorsal nerve

Question 2

What is the standard treatment for cystosarcoma phyllodes?

Accepted Answer

Simple mastectomy

Answer

Radical mastectomy

Answer

Modified radical mastectomy

Answer

Antibiotics with conservative treatment

Question 3

Regarding cystic disease of the breast, which one of the following statements is true?

Accepted Answer

Aspiration is the treatment

Answer

Common in 25 years of age

Answer

Excision is the treatment

Answer

May turn into malignant

Question 4

A 40-year-old female presents with a 2 cm breast nodule and a proven metastatic axillary lymph node. What is the recommended treatment?

Accepted Answer

Patey's mastectomy with adjuvant chemotherapy

Answer

Quadrantectomy

Answer

Mastectomy with local radiotherapy

Answer

Halsted's radical mastectomy with tamoxifen

Question 5

Which of the following pathologic findings is the strongest contraindication to breast preservation (lumpectomy with breast radiation) as primary treatment for a newly diagnosed breast cancer?

Accepted Answer

Positive surgical margin for invasive cancer

Answer

Grade 3, poorly differentiated, infiltrating ductal carcinoma

Answer

Extensive intraductal cancer around the invasive lesion

Answer

Tumor size less than 3 cm

Question 6

Which of the following statements regarding Paget's disease of the breast is true, except?

Accepted Answer

None of the above

Answer

Treated by simple mastectomy

Answer

Represents underlying malignancy

Answer

Presents as eczema

Question 7

Unilateral breast involvement with scaly skin around the nipple and intermittent bleeding is suggestive of:

Accepted Answer

Paget's disease

Answer

Galactocoele

Answer

Eczema

Answer

Sebaceous cysts

Question 8

Which of the following statements is FALSE regarding breast cancer during pregnancy?

Accepted Answer

Mammography has reduced sensitivity during pregnancy.

Answer

Axillary lymph node metastases are present in 75% of affected women.

Answer

Radiation therapy cannot be considered for treatment during pregnancy.

Answer

Less than 25% of breast nodules discovered are cancerous.

Question 9

Fibrocystic disease of the breast has been associated with elevated blood levels of which hormone?

Accepted Answer

Estrogen

Answer

Testosterone

Answer

Progesterone

Answer

Luteinizing hormone

Question 10

Self breast examination by females is advisable to be done at which of the following times?

Accepted Answer

7-10 days after menses

Answer

Premenstrual period

Answer

During menses

Answer

Ovulatory period

Breast Surgery — MCQs

Breast Surgery — MCQs

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