Breast Surgery Practice Questions

Q: Milan trial, NSABP trial and EORTC trial in breast cancer compared:

Breast conservative therapy vs Mastectomy. **Breast conservative therapy vs Mastectomy** * The **Milan trial**, **NSABP trial (B-04 and B-06)**, and **EORTC trial** were pivotal studies that compared the efficacy and outcomes of **breast conservative therapy (BCT)** followed by radiation therapy against **mastectomy** for early-stage breast cancer. * These trials established that BCT with radiation offers comparable survival rates to mastectomy, transforming the surgical management of breast cancer. *Neo adjuvant chemotherapy vs Adjuvant chemotherapy* * While these are important questions in breast cancer management, the specific trials mentioned (**Milan, NSABP B-04/B-06, EORTC**) did not primarily focus on comparing neo-adjuvant versus adjuvant chemotherapy strategies. * Their main objective was to evaluate surgical approaches: lumpectomy plus radiation versus mastectomy. *Hormonal vs Chemotherapy* * The trials mentioned did not directly compare hormonal therapy against chemotherapy. These are distinct systemic treatment modalities used in different contexts. * The focus was on the extent of surgical intervention, with systemic therapies often applied in addition to surgery based on tumor characteristics. *Chemotherapy vs Radiotherapy in breast cancer* * These trials did not compare chemotherapy directly against radiotherapy. Radiotherapy was an integral component of the **breast-conserving therapy** arm, used to reduce local recurrence after lumpectomy. * Chemotherapy is a systemic treatment, while radiotherapy is a local treatment, and their roles are generally complementary rather than mutually exclusive or directly competitive in these study designs.

Q: A 35 year old female has inflammatory carcinoma of left breast, with clinically palpable two left axillary lymph nodes and no clinically or radiologically detectable metastasis. Her TNM staging will be:

T4d N1 M0. ***T4d N1 M0*** - **Inflammatory carcinoma** of the breast is by definition staged as **T4d**, irrespective of tumor size or extent. - **Palpable two left axillary lymph nodes** would be considered N1 disease, representing metastases to 1-3 axillary lymph nodes. *T4 N2 M0* - While T4 is correct for inflammatory carcinoma, **N2 disease** implies involvement of 4-9 axillary lymph nodes or clinically apparent internal mammary nodes and is not consistent with "two clinically palpable axillary lymph nodes." - The M0 component (no distant metastasis) is correct. *T4d N2 M0* - **T4d** correctly identifies inflammatory breast cancer. - However, **N2 disease** is characterized by involvement of 4-9 ipsilateral axillary lymph nodes or clinically apparent ipsilateral internal mammary lymph nodes in the absence of axillary lymph node metastases, which does not fit the description of "two palpable axillary lymph nodes." *T4b N2 M0* - **T4b** refers to breast cancer with chest wall involvement, ulceration, or ipsilateral satellite skin nodules, but not inflammatory carcinoma, which is specifically **T4d**. - **N2** disease is incorrect here based on the number of palpable nodes described.

Q: A 43 year old woman presented with serous discharge from a single duct of the nipple of her right breast which was sent for evaluation. She is unlikely to be suffering from

Fibrocystic disease. ***Fibrocystic disease*** - **Fibrocystic changes** usually present with **lumpy breasts**, pain, and sometimes **multiple** duct nipple discharge, which can be clear or milky. - A **single duct serous discharge** is not a typical presentation, making it less likely given the details. *Intraductal Papilloma* - **Intraductal papilloma** is the **most common cause** of **serous or bloody nipple discharge** from a **single duct**. - This benign tumor grows within the milk ducts and is a frequent finding with the described symptoms. *Carcinoma* - **Ductal carcinoma in situ (DCIS)** or **invasive ductal carcinoma** can present with **unilateral, bloody or serous nipple discharge** from a **single duct**. - The type of discharge and its unilateral, single-duct nature are concerning features that warrant malignancy exclusion. *Duct Ectasia* - **Duct ectasia** can cause nipple discharge which is often **thick, sticky, and multicolored** (green, black, or brown), and may be associated with **nipple inversion**. - While it can be from a single duct, the discharge is typically **not serous** and is more characteristic of a **dilated or inflamed duct**.

Q: A 52 year old female underwent MRM (Modified Radical Mastectomy). After few years, she developed lymphedema of the ipsilateral arm. Which of the following malignancies can develop in her arm?

Lymphangiosarcoma. ***Lymphangiosarcoma*** - This is a rare, aggressive **vascular tumor** that can develop in chronically lymphedematous limbs, particularly after **mastectomy** for breast cancer. - The chronic lymphatic obstruction and inflammation are thought to be predisposing factors, leading to the condition known as **Stewart-Treves syndrome**. *Malignant Melanoma* - This cancer arises from **melanocytes** in the skin and is primarily associated with UV radiation exposure or existing nevi, not chronic lymphedema. - While it can occur anywhere on the body, there is no direct causal link between modified radical mastectomy and the development of melanoma in the arm. *Lymphoma* - Lymphoma is a cancer of the **lymphocytes** within the lymphatic system, typically presenting as swollen lymph nodes or B-symptoms. - Although lymphedema involves the lymphatic system, it generally predisposes to angiosarcoma rather than lymphoma in this specific clinical context. *Malignant fibrous histiocytoma* - This is a type of **soft tissue sarcoma** that can occur in various locations, but it is not specifically linked to chronic lymphedema following mastectomy. - While its etiology can be complex, it does not have the well-established association with chronic lymphedema that lymphangiosarcoma does.

Q: A 30 year old lady comes with history of bloody discharge from her right nipple while taking bath. On examination, there is a cystic swelling in the subareolar region. The clinical diagnosis would be:

Intraductal papilloma. ***Intraductal papilloma*** - **Bloody nipple discharge**, especially unilateral and spontaneous, is the hallmark symptom of an **intraductal papilloma**. - The presence of a **subareolar cystic swelling** further supports this diagnosis, as papillomas are benign growths arising within the breast ducts. *Duct ectasia* - This condition typically presents with a **thick, sticky, multi-colored nipple discharge**, not usually bloody. - It is more common in **perimenopausal** or postmenopausal women and is often associated with inflammation and nipple retraction. *Fibrocystic disease* - Characterized by **cyclic breast pain**, tenderness, and multiple palpable masses, often bilateral. - Nipple discharge, if present, is usually **clear, green, or brown**, but rarely bloody. *Intraductal carcinoma* - While it can cause bloody nipple discharge, it is less common in this age group (30-year-old). - More likely to present with a **firm or hard palpable mass** rather than a cystic swelling, and often accompanied by skin changes or nipple retraction. - The benign cystic nature of the swelling makes intraductal papilloma more likely in this clinical scenario.

Q: Nottingham prognostic Index is used for:

Cancer breast. ***Cancer breast*** - The **Nottingham Prognostic Index (NPI)** is a well-established tool used specifically for assessing the prognosis of **early invasive breast cancer**. - It combines three key pathological features: **tumor size**, **lymph node status**, and **histological grade**, to provide a prognostic score. *Cancer stomach* - Prognostic indices for gastric cancer typically involve factors like **tumor depth (T stage)**, **lymph node involvement (N stage)**, **metastasis (M stage)**, and **histological type**. - The NPI is not validated or used for gastric cancer. *Cancer colon* - Prognosis in colorectal cancer is primarily determined by the **Dukes' staging system** or the **TNM staging system**, which consider tumor invasion depth, lymph node spread, and distant metastasis. - The NPI is not applicable to colorectal cancer. *Cancer lung* - Lung cancer prognosis depends heavily on the **TNM staging system**, differentiating between **non-small cell lung cancer** and **small cell lung cancer**, and considering factors like tumor size, nodal involvement, and metastases. - There is no role for the NPI in assessing lung cancer prognosis.

Q: Which of the following statements regarding Paget's disease of nipple are correct? 1. It represents benign pathology of nipple areola complex 2. It is eczema like condition of nipple and areola 3. Erosion of nipple is seen 4. Nipple biopsy is required for definitive diagnosis Select the correct answer using the code given below:

2, 3 and 4. ***2, 3 and 4*** - **Paget's disease** presents as an **eczema-like rash** on the nipple and areola, and is characterized by **nipple erosion** [1] and ulceration. - It is an **intraepithelial adenocarcinoma** of the nipple [1], and a definitive diagnosis requires a **nipple biopsy** [1] to identify Paget's cells [2]. *2 and 4 only* - This option is incomplete as it misses the important clinical feature of **nipple erosion**, which is a common presentation of Paget's disease. - While it correctly identifies the eczema-like appearance and the need for biopsy, it understates the full clinical picture. *1, 2 and 3* - Statement 1 is incorrect because Paget's disease of the nipple is a **malignant condition** [2], not a benign one. - It arises from **ductal carcinoma in situ** [1] or invasive breast cancer extending to the nipple epidermis. *1, 3 and 4* - Statement 1 is incorrect as **Paget's disease is malignant**, representing an underlying breast cancer [2], not a benign pathology. - This option incorrectly classifies the disease as benign, which is a critical misunderstanding of its nature. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1061-1062. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 456-457.

Question 1

Regarding breast conservative therapy and issue of post operative local recurrence, all are true except:

Accepted Answer

Margins should be clear for lobular carcinoma in situ (LCIS)

Answer

Margins should be clear for ductal carcinoma in situ (DCIS)

Answer

Margins should be clear for invasive cancer

Answer

Lumpectomy can be considered in any size provided the tumour can be excised with clear margins and acceptable cosmetic results

Question 2

Milan trial, NSABP trial and EORTC trial in breast cancer compared:

Accepted Answer

Breast conservative therapy vs Mastectomy

Answer

Neoadjuvant chemotherapy vs Adjuvant chemotherapy

Answer

Hormonal vs Chemotherapy

Answer

Chemotherapy vs Radiotherapy in breast cancer

Question 3

A 35 year old female has inflammatory carcinoma of left breast, with clinically palpable two left axillary lymph nodes and no clinically or radiologically detectable metastasis. Her TNM staging will be:

Accepted Answer

T4d N1 M0

Answer

T4 N2 M0

Answer

T4d N2 M0

Answer

T4b N2 M0

Question 4

Mondor’s disease is:

Accepted Answer

Thrombophlebitis of superficial veins of the breast and anterior chest wall

Answer

Named after the scientist who first coined the term “Actinomycosis of Breast”

Answer

Other name for tuberculosis of breast

Answer

Rare type of chronic intramammary abscess

Question 5

A 43 year old woman presented with serous discharge from a single duct of the nipple of her right breast which was sent for evaluation. She is unlikely to be suffering from

Accepted Answer

Fibrocystic disease

Answer

Intraductal Papilloma

Answer

Carcinoma

Answer

Duct Ectasia

Question 6

A 52 year old female underwent MRM (Modified Radical Mastectomy). After few years, she developed lymphedema of the ipsilateral arm. Which of the following malignancies can develop in her arm?

Accepted Answer

Lymphangiosarcoma

Answer

Malignant Melanoma

Answer

Lymphoma

Answer

Malignant fibrous histiocytoma

Question 7

A 30 year old lady comes with history of bloody discharge from her right nipple while taking bath. On examination, there is a cystic swelling in the subareolar region. The clinical diagnosis would be:

Accepted Answer

Intraductal papilloma

Answer

Duct ectasia

Answer

Fibrocystic disease

Answer

Intraductal carcinoma

Question 8

Which is the most commonly used chemotherapy regimen in the adjuvant treatment following modified radical mastectomy in the estrogen receptor negative 35 year old female with breast cancer?

Accepted Answer

Cyclophosphamide + Adriamycin + 5-Fluorouracil

Answer

Adriamycin + 5-Fluorouracil

Answer

Cyclophosphamide + 5-Fluorouracil

Answer

Cyclophosphamide + Methotrexate + 5-Fluorouracil

Question 9

Nottingham prognostic Index is used for:

Accepted Answer

Cancer breast

Answer

Cancer stomach

Answer

Cancer colon

Answer

Cancer lung

Question 10

Which of the following statements regarding Paget's disease of nipple are correct?

1. It represents benign pathology of nipple areola complex
2. It is eczema like condition of nipple and areola
3. Erosion of nipple is seen
4. Nipple biopsy is required for definitive diagnosis

Select the correct answer using the code given below:

Accepted Answer

2, 3 and 4

Answer

2 and 4 only

Answer

1, 2 and 3

Answer

1, 3 and 4

Breast Surgery — MCQs

Breast Surgery — MCQs

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