Breast Surgery — MCQs
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A woman is diagnosed to have breast carcinoma. What is the recommended investigation for the contralateral breast?
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?
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?
What is true regarding male breast carcinoma?
Winging of the scapula is typically seen after mastectomy due to injury to which nerve?
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?
Hadfield operation is done for which condition?
Which of the following statements regarding fibroadenoma is FALSE?
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?
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?
Breast Surgery Indian Medical PG Practice Questions and MCQs
Question 281: A woman is diagnosed to have breast carcinoma. What is the recommended investigation for the contralateral breast?
- A. Random Fine Needle Aspiration Cytology (FNAC)
- B. No investigation needed
- C. Mammography (Correct Answer)
- D. Clinical breast examination
Explanation: **Explanation:** The correct answer is **Mammography**. **1. Why Mammography is the Correct Choice:** Breast cancer is known for its potential for **multicentricity** (multiple foci in the same breast) and **synchronous occurrence** (simultaneous cancer in the contralateral breast). Approximately 2–5% of women diagnosed with breast cancer will have a synchronous malignancy in the opposite breast that is clinically occult. Bilateral mammography is the standard of care to: * Screen for synchronous lesions in the contralateral breast. * Assess the extent of disease in the ipsilateral breast. * Establish a baseline for future follow-up. **2. Analysis of Incorrect Options:** * **A. Random FNAC:** This is not a screening tool. FNAC is a diagnostic procedure used only when a specific, palpable, or radiologically visible lump is identified. Randomly sampling normal-feeling tissue has a very low yield and high false-negative rate. * **B. No investigation needed:** This is incorrect because the risk of contralateral cancer is significantly higher in women who already have a primary breast malignancy compared to the general population. * **D. Clinical Breast Examination (CBE):** While CBE is a vital part of the initial workup, it cannot detect non-palpable, early-stage cancers or microcalcifications. Mammography is more sensitive than CBE for detecting early synchronous lesions. **Clinical Pearls for NEET-PG:** * **Synchronous Cancer:** Defined as a second primary cancer detected at the same time or within 6 months of the first. * **Metachronous Cancer:** A second primary cancer detected more than 6 months after the first. * **Lobular Carcinoma:** Invasive Lobular Carcinoma (ILC) has a higher propensity for bilaterality and multicentricity compared to Invasive Ductal Carcinoma (IDC). * **MRI Breast:** While more sensitive, it is not the initial "recommended investigation" unless the patient is high-risk (e.g., BRCA mutation) or has dense breasts where mammography is limited.
Question 282: 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?
- A. Acute mastitis
- B. Atypical epithelial hyperplasia
- C. Fat necrosis
- D. Infiltrating ductal carcinoma (Correct Answer)
Explanation: **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.
Question 283: 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?
- A. Ductoscopy
- B. Nipple discharge cytology
- C. Sono-mammogram
- D. MRI (Correct Answer)
Explanation: **Explanation:** The management of pathological nipple discharge (spontaneous, unilateral, single duct, and bloody/serous) in a postmenopausal woman with a positive family history requires a high index of suspicion for malignancy. **Why MRI is the Correct Answer:** While conventional imaging (mammography and ultrasound) is the traditional first-line approach, **MRI Breast** has emerged as the most sensitive modality for evaluating nipple discharge when initial imaging is negative or inconclusive. In a 60-year-old patient with a high-risk profile (family history), MRI is superior for detecting occult lesions, particularly **Ductal Carcinoma in Situ (DCIS)** or small peripheral cancers that may not be visible on a sono-mammogram. Current surgical trends favor MRI to accurately map the extent of disease before surgical intervention (Microdochectomy or Total Duct Excision). **Why other options are incorrect:** * **Sono-mammogram (Option C):** Although often the initial step in clinical practice, it has a significant false-negative rate for intraductal pathologies. In the context of high-risk features, MRI is the "next best step" to ensure no malignancy is missed. * **Nipple discharge cytology (Option B):** This has very low sensitivity and a high rate of false negatives. A negative cytology never rules out malignancy; therefore, it is not a definitive diagnostic step. * **Ductoscopy (Option A):** This allows direct visualization of the ducts but is technically demanding, not widely available, and less comprehensive than MRI for staging or detecting parenchymal lesions. **Clinical Pearls for NEET-PG:** * **Most common cause of bloody nipple discharge:** Intraductal Papilloma (Benign). * **Most common cause of nipple discharge overall:** Duct Ectasia. * **Triple Assessment:** Clinical examination, Imaging (Mammography/USG), and Pathology (FNAC/Biopsy). * **Surgical Management:** If a single duct is involved, **Microdochectomy** is performed. If multiple ducts are involved or the patient is older, **Hadfield’s Procedure** (Total Duct Excision) is preferred.
Question 284: What is true regarding male breast carcinoma?
- A. Invasive lobular carcinoma is the most common histological type.
- B. The majority of cases are estrogen receptor positive. (Correct Answer)
- C. Paget's disease of the nipple is more common in men than in women.
- D. All of the above
Explanation: **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.
Question 285: Winging of the scapula is typically seen after mastectomy due to injury to which nerve?
- A. Musculocutaneous nerve
- B. Long thoracic nerve (Correct Answer)
- C. Intercostobrachial nerve
- D. Thoracodorsal nerve
Explanation: **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.
Question 286: 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?
- A. Breast conservation surgery + Axillary LN sampling + Radiotherapy
- B. Simple mastectomy + Axillary LN sampling
- C. Neoadjuvant chemotherapy + Modified radical mastectomy + Radiotherapy (Correct Answer)
- D. Halsted radical mastectomy followed by Radiotherapy
Explanation: ### Explanation **1. Why Option C is Correct:** The patient presents with **Locally Advanced Breast Cancer (LABC)**. The presence of **fixed and matted axillary lymph nodes (N2 disease)** is a hallmark of LABC. In such cases, the standard of care is a multimodality approach: * **Neoadjuvant Chemotherapy (NACT):** Administered first to downstage the tumor and the axillary nodes, making the disease more amenable to surgery. * **Modified Radical Mastectomy (MRM):** The surgical procedure of choice for LABC after downstaging. * **Radiotherapy:** Post-operative radiotherapy is mandatory in LABC to reduce the risk of local recurrence. **2. Why Other Options are Incorrect:** * **Option A:** Breast Conservation Surgery (BCS) is generally contraindicated in LABC with fixed nodes unless significant downstaging occurs. Furthermore, **Axillary Sampling** is inadequate; a formal **Axillary Lymph Node Dissection (ALND)** is required for N2 disease. * **Option B:** Simple mastectomy removes only the breast tissue, ignoring the axillary nodes. In the presence of matted nodes, ALND (Levels I, II, and III) is essential. * **Option D:** Halsted Radical Mastectomy (removing the pectoralis major and minor) is an obsolete procedure. MRM (Patey’s or Auchincloss modification) provides similar oncological outcomes with significantly less morbidity. **3. Clinical Pearls for NEET-PG:** * **Staging:** Fixed/matted nodes (N2) automatically place the patient in Stage IIIA or higher (LABC). * **Management Sequence:** For LABC, the sequence is **NACT → Surgery → Adjuvant Therapy (RT/Hormonal/Chemo)**. * **Matted Nodes:** If nodes are matted, Sentinel Lymph Node Biopsy (SLNB) is **not** indicated; proceed directly to ALND. * **Triple Negative/HER2+:** These subtypes often show the best response to NACT.
Question 287: Hadfield operation is done for which condition?
- A. Duct Ectasia (Correct Answer)
- B. Fibroadenoma
- C. Mondor's disease
- D. Breast cancer
Explanation: **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.
Question 288: Which of the following statements regarding fibroadenoma is FALSE?
- A. Painless
- B. Unilateral
- C. Responds well to hormone (Correct Answer)
- D. Firm
Explanation: **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 289: 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?
- A. Radical mastectomy
- B. Modified radical mastectomy with axillary lymph node dissection (Correct Answer)
- C. Hormonal therapy
- D. Palliative therapy
Explanation: ### Explanation **Correct Answer: B. Modified Radical Mastectomy (MRM) with Axillary Lymph Node Dissection (ALND)** The patient presents with a **Locally Advanced Breast Cancer (LABC)**, characterized by a 3 cm fungating mass (T4b) and palpable axillary lymph nodes (N1). In the absence of distant metastases (M0), the goal of treatment is **curative**, not palliative. **Modified Radical Mastectomy (MRM)** is the standard surgical approach for LABC. It involves the removal of the entire breast tissue along with the axillary lymph nodes (Levels I, II, and often III), while **preserving the pectoralis major muscle**. This provides local control and essential nodal staging. **Why other options are incorrect:** * **A. Radical Mastectomy (Halsted):** This involves removing the pectoralis major and minor muscles. It is now obsolete and reserved only for cases where the tumor directly invades the pectoralis major muscle. * **C. Hormonal Therapy:** While used as adjuvant or neoadjuvant therapy in ER/PR-positive cases, it is not a primary surgical management. It cannot replace the surgical removal of a localized mass. * **D. Palliative Therapy:** This is reserved for Stage IV (metastatic) disease. Since there is no evidence of distant metastasis, the patient should be treated with curative intent. --- ### NEET-PG High-Yield Pearls * **TNM Staging:** A fungating mass or skin ulceration automatically classifies the tumor as **T4b**, regardless of size. * **Patey’s MRM:** Removes the pectoralis minor to access Level III nodes. * **Auchincloss MRM:** Preserves the pectoralis minor (most common). * **Standard of Care for LABC:** The current preferred sequence is often **Neoadjuvant Chemotherapy (NACT)** to downstage the tumor, followed by MRM and Radiotherapy. * **Nerves at risk during MRM:** Long thoracic nerve (Serratus anterior - Winging of scapula) and Thoracodorsal nerve (Latissimus dorsi).
Question 290: 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?
- A. Duct ectasia with numerous plasma cells
- B. Extensive invasion of dermal lymphatics (Correct Answer)
- C. Infiltrating malignant ducts surrounded by numerous neutrophils
- D. Malignant vascular tumor forming slitlike spaces
Explanation: ### Explanation **1. Why Option B is Correct:** The clinical presentation of a swollen, red, indurated breast with a "peau d'orange" appearance (implied by diffuse induration) is the hallmark of **Inflammatory Breast Carcinoma (IBC)**. The underlying pathophysiology of IBC is not primary inflammation, but rather the **blockage of dermal lymphatic channels by tumor emboli**. This obstruction leads to lymphatic congestion and edema, which manifests clinically as the characteristic erythema and warmth. Therefore, the microscopic hallmark is the presence of malignant cells within the dermal lymphatics. **2. Why Other Options are Incorrect:** * **Option A (Duct ectasia):** This is a benign condition characterized by the dilation of large ducts and periductal inflammation dominated by plasma cells (Plasma Cell Mastitis). It does not present with the rapid, diffuse malignant features described. * **Option C (Neutrophils):** While the breast appears "inflamed," IBC is a clinicopathological diagnosis of cancer, not a bacterial infection (like acute mastitis). The redness is due to lymphatic backup, not an acute purulent inflammatory infiltrate. * **Option D (Malignant vascular tumor):** This describes **Angiosarcoma**, which can occur post-radiation (Stewart-Treves syndrome usually refers to lymphangiosarcoma in chronic lymphedema). While it presents with skin discoloration, the classic "inflammatory" presentation of a primary or recurrent carcinoma is defined by dermal lymphatic invasion. **3. Clinical Pearls for NEET-PG:** * **Peau d’orange:** Caused by cutaneous edema where the skin is tethered by sweat glands/hair follicles, creating a "dimpled" orange-peel appearance. * **TNM Staging:** Inflammatory breast cancer is automatically classified as **T4d**, regardless of the size of the underlying tumor. * **Differential Diagnosis:** Always rule out **Acute Mastitis** in non-lactating women; if "infection" does not respond to antibiotics within 1–2 weeks, a biopsy is mandatory to rule out IBC. * **Prognosis:** IBC is highly aggressive and usually presents with axillary lymphadenopathy (as seen in this patient).
Practice by Chapter
Breast Anatomy and Physiology
Practice Questions
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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