Breast Surgery Practice Questions

Q: A 51-year-old woman has noticed an area of swelling with tenderness in her right breast that has worsened over the past 2 months. On physical examination, the 7-cm area of erythematous skin is tender with a rough, firm surface resembling an orange peel. There is swelling of the right breast, nipple retraction, and right axillary non-tender lymphadenopathy. Excisional biopsy of skin and breast is most likely to show which of the following lesions?

Infiltrating ductal carcinoma. **Explanation:** The clinical presentation described is a classic case of **Inflammatory Breast Cancer (IBC)**, which is a clinical subtype of **Infiltrating Ductal Carcinoma (IDC)**. **1. Why Infiltrating Ductal Carcinoma is correct:** The patient presents with the hallmark sign of **"Peau d'orange"** (orange peel appearance). This occurs because the underlying carcinoma (IDC) invades and obstructs the **dermal lymphatics**, leading to lymphedema of the skin. The skin becomes thickened and tethered by the suspensory ligaments of Cooper, creating the pitted appearance. The presence of nipple retraction and axillary lymphadenopathy further points toward a malignant process rather than a simple infection. **2. Why the other options are incorrect:** * **Acute Mastitis:** While it causes redness and tenderness, it typically occurs in lactating women and is associated with systemic signs of infection (fever, chills). It does not cause peau d'orange or nipple retraction. * **Atypical Epithelial Hyperplasia:** This is a microscopic premalignant finding. It does not present as a large (7-cm), palpable, erythematous mass with skin changes. * **Fat Necrosis:** Usually follows trauma. While it can cause skin tethering and a firm mass, it does not typically cause diffuse erythema, peau d'orange, or significant axillary lymphadenopathy. **Clinical Pearls for NEET-PG:** * **Peau d'orange = Dermal Lymphatic Invasion.** This automatically classifies the tumor as **T4d** (Stage IIIB), regardless of the tumor size. * **Inflammatory Breast Cancer** is a clinical diagnosis; however, the underlying pathology is most commonly **Infiltrating Ductal Carcinoma (High Grade).** * **Differential Diagnosis:** Always rule out a breast abscess in a non-lactating woman presenting with "mastitis" symptoms; if it doesn't resolve with antibiotics, suspect IBC and perform a biopsy.

Q: What is true regarding male breast carcinoma?

The majority of cases are estrogen receptor positive.. **Explanation:** Male breast carcinoma is a rare malignancy, accounting for less than 1% of all breast cancers. Understanding its unique hormonal and pathological profile is crucial for NEET-PG. **1. Why Option B is Correct:** The vast majority of male breast cancers are hormone receptor-positive. Approximately **90% of cases are Estrogen Receptor (ER) positive**, and about 80% are Progesterone Receptor (PR) positive. This frequency is significantly higher than in female breast cancer, making endocrine therapy (like Tamoxifen) a cornerstone of treatment. **2. Why Other Options are Incorrect:** * **Option A:** The most common histological type in men is **Invasive Ductal Carcinoma (IDC)**, accounting for over 80% of cases. Invasive Lobular Carcinoma (ILC) is extremely rare in men because the male breast lacks well-developed terminal lobules. * **Option C:** Paget’s disease of the nipple can occur in men, but it is **much more common in women** simply due to the higher overall incidence of breast cancer in females. However, because men have less breast tissue, nipple involvement often occurs earlier in the disease course. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** The strongest risk factor is **Klinefelter syndrome (47, XXY)**, which increases risk by 50-fold. Other factors include BRCA2 mutations (more common than BRCA1 in men), cirrhosis, and radiation exposure. * **Presentation:** Usually presents as a painless, firm subareolar mass. Eccentric masses are more likely to be gynecomastia. * **Staging & Treatment:** Staging is the same as in females. **Modified Radical Mastectomy (MRM)** is the standard surgical approach due to the central location and proximity to the chest wall. * **BRCA2:** Men with breast cancer should be offered genetic counseling, as BRCA2 mutations are found in approximately 10% of cases.

Q: Winging of the scapula is typically seen after mastectomy due to injury to which nerve?

Long thoracic nerve. **Explanation:** **1. Why the Long Thoracic Nerve is Correct:** The **Long Thoracic Nerve (Nerve of Bell)** originates from the nerve roots C5, C6, and C7. It runs along the lateral chest wall on the superficial surface of the **Serratus Anterior** muscle. During an Axillary Lymph Node Dissection (ALND) as part of a Modified Radical Mastectomy (MRM), this nerve is vulnerable to injury. The Serratus Anterior is responsible for protracting the scapula and holding its medial border against the thoracic wall. Denervation leads to paralysis of this muscle, causing the medial border of the scapula to protrude posteriorly—a clinical sign known as **"Winging of the Scapula."** Patients often complain of difficulty in lifting the arm above the shoulder level. **2. Why the Other Options are Incorrect:** * **Musculocutaneous Nerve:** This nerve (C5-C7) supplies the coracobrachialis, biceps brachii, and brachialis. It is not encountered during routine breast surgery. * **Intercostobrachial Nerve:** This is the most commonly injured nerve during mastectomy/ALND. Injury results in **numbness or paresthesia** of the skin on the upper inner aspect of the arm, but it does not cause motor deficits like winging. * **Thoracodorsal Nerve:** This nerve supplies the **Latissimus Dorsi** muscle. Injury leads to weakness in internal rotation, adduction, and extension of the arm (difficulty in "climbing" or "scratching the back"), but not winging of the scapula. **3. Clinical Pearls for NEET-PG:** * **Nerve of Bell:** Long Thoracic Nerve (Supplies Serratus Anterior $\rightarrow$ Winging). * **Nerve to Latissimus Dorsi:** Thoracodorsal Nerve (Injury $\rightarrow$ Weak adduction/extension). * **Most commonly injured nerve in MRM:** Intercostobrachial nerve (Sensory loss only). * **Halsted’s Sign:** If the medial pectoral nerve is injured, it leads to atrophy of the Pectoralis major muscle.

Q: Hadfield operation is done for which condition?

Duct Ectasia. **Explanation:** **Hadfield’s Operation (Total Duct Excision)** is the definitive surgical treatment for **Duct Ectasia** (also known as periductal mastitis). This condition involves the dilation of the major subareolar ducts, leading to chronic inflammation and symptoms such as cheesy/colored nipple discharge, nipple retraction, or recurrent subareolar abscesses. * **Why Option A is correct:** When medical management fails or when there is multi-duct discharge/recurrent fistula formation, Hadfield’s operation is performed. It involves a circumareolar incision to excise the entire major duct system (cone excision) from the base of the nipple. This removes the diseased tissue and prevents recurrence. **Why other options are incorrect:** * **B. Fibroadenoma:** These are benign "breast mice" typically managed by observation or simple **enucleation** if they are large or symptomatic. * **C. Mondor’s Disease:** This is a self-limiting thrombophlebitis of the superficial veins of the breast/chest wall. It is managed conservatively with **NSAIDs** and warm compresses; surgery is not indicated. * **D. Breast Cancer:** Management involves Wide Local Excision (Breast Conservation Surgery) or Modified Radical Mastectomy (MRM), depending on the stage. Hadfield’s is a benign duct procedure, not an oncological resection. **High-Yield Clinical Pearls for NEET-PG:** * **Microdochectomy:** If the discharge is from a **single duct** (e.g., Intraductal Papilloma), only that specific duct is excised (Urban’s procedure). * **Hadfield’s:** Indicated for **multiple ducts** or recurrent periductal mastitis. * **Zuska’s Disease:** Another name for recurrent retroareolar abscess associated with squamous metaplasia of lactiferous ducts, often requiring Hadfield’s operation. * **Smoking:** The strongest risk factor for the development of Duct Ectasia/Periductal mastitis.

Q: Which of the following statements regarding fibroadenoma is FALSE?

Responds well to hormone. **Explanation:** Fibroadenoma is the most common benign tumor of the female breast, typically occurring in women aged 15–35 years. It is a fibroepithelial tumor characterized by the proliferation of both glandular and stromal elements. **Why Option C is the Correct (False) Statement:** While fibroadenomas are hormonally sensitive—meaning they may enlarge during pregnancy or fluctuate slightly during the menstrual cycle—they **do not "respond well" to hormonal therapy** in a clinical or therapeutic sense. There is no standard medical treatment involving hormones (like OCPs or SERMs) that reliably shrinks or eliminates a fibroadenoma. Management is typically conservative (observation) or surgical excision. **Analysis of Other Options:** * **A. Painless:** Most fibroadenomas are characteristically painless, smooth, and discrete. * **B. Unilateral:** Although they can be bilateral in 10–15% of cases, the vast majority present as a single, unilateral lump. * **D. Firm:** On palpation, they have a classic firm, rubbery consistency. **NEET-PG High-Yield Pearls:** * **"Breast Mouse":** Due to high mobility within the breast tissue (not fixed to skin or chest wall). * **Mammography:** May show a well-defined mass with "Popcorn calcification" (seen in older, involuted fibroadenomas). * **Histology:** Two patterns are described—**Intracanalicular** (stroma compresses ducts into slits) and **Pericanalicular** (ducts remain patent). * **Giant Fibroadenoma:** Defined as a fibroadenoma >5 cm in size or >500g in weight. * **Phyllodes Tumor:** The most important differential diagnosis; it grows rapidly and has higher stromal cellularity.

Question 1

A woman is diagnosed to have breast carcinoma. What is the recommended investigation for the contralateral breast?

Accepted Answer

Mammography

Answer

Random Fine Needle Aspiration Cytology (FNAC)

Answer

No investigation needed

Answer

Clinical breast examination

Question 2

A 51-year-old woman has noticed an area of swelling with tenderness in her right breast that has worsened over the past 2 months. On physical examination, the 7-cm area of erythematous skin is tender with a rough, firm surface resembling an orange peel. There is swelling of the right breast, nipple retraction, and right axillary non-tender lymphadenopathy. Excisional biopsy of skin and breast is most likely to show which of the following lesions?

Accepted Answer

Infiltrating ductal carcinoma

Answer

Acute mastitis

Answer

Atypical epithelial hyperplasia

Answer

Fat necrosis

Question 3

A 60-year-old lady presents with blood-stained nipple discharge and a family history of breast cancer. What is the next best step in her management?

Accepted Answer

MRI

Answer

Ductoscopy

Answer

Nipple discharge cytology

Answer

Sono-mammogram

Question 4

What is true regarding male breast carcinoma?

Accepted Answer

The majority of cases are estrogen receptor positive.

Answer

Invasive lobular carcinoma is the most common histological type.

Answer

Paget's disease of the nipple is more common in men than in women.

Answer

All of the above

Question 5

Winging of the scapula is typically seen after mastectomy due to injury to which nerve?

Accepted Answer

Long thoracic nerve

Answer

Musculocutaneous nerve

Answer

Intercostobrachial nerve

Answer

Thoracodorsal nerve

Question 6

A 45-year-old female presented to the OPD with a 4 cm breast lump in the left breast. On examination, left axillary lymph nodes were fixed and matted. Which of the following is the preferred treatment option?

Accepted Answer

Neoadjuvant chemotherapy + Modified radical mastectomy + Radiotherapy

Answer

Breast conservation surgery + Axillary LN sampling + Radiotherapy

Answer

Simple mastectomy + Axillary LN sampling

Answer

Halsted radical mastectomy followed by Radiotherapy

Question 7

Hadfield operation is done for which condition?

Accepted Answer

Duct Ectasia

Answer

Fibroadenoma

Answer

Mondor's disease

Answer

Breast cancer

Question 8

Which of the following statements regarding fibroadenoma is FALSE?

Accepted Answer

Responds well to hormone

Answer

Painless

Answer

Unilateral

Answer

Firm

Question 9

A 55-year-old female patient presents with a 3 cm fungating breast mass and palpable ipsilateral axillary lymph nodes. There is no evidence of distant metastases. What is the most appropriate surgical management?

Accepted Answer

Modified radical mastectomy with axillary lymph node dissection

Answer

Radical mastectomy

Answer

Hormonal therapy

Answer

Palliative therapy

Question 10

A 35-year-old woman who underwent a modified radical mastectomy of her right breast 2 years ago for infiltrating ductal carcinoma presents with enlargement of her right breast. The breast has a swollen, red-discolored appearance, is diffusely indurated and tender on palpation, and has multiple palpable axillary lymph nodes in the lower axilla. The working clinical diagnosis is inflammatory carcinoma. Microscopic sections from this red, indurated area are most likely to reveal?

Accepted Answer

Extensive invasion of dermal lymphatics

Answer

Duct ectasia with numerous plasma cells

Answer

Infiltrating malignant ducts surrounded by numerous neutrophils

Answer

Malignant vascular tumor forming slitlike spaces

Breast Surgery — MCQs

Breast Surgery — MCQs

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