Breast Surgery Practice Questions

Q: Which of the following statements regarding lymphoedema following breast cancer treatment are correct? 1. Incidence has decreased due to rarely combined therapy of axillary LN dissection and radiotherapy 2. Precipitating cause like LN metastasis is a major determinant 3. The condition is often painful 4. Oedematous limb is susceptible to bacterial infection Select the correct answer using the code given below:

1, 2 and 4. ***Correct: 1, 2 and 4*** **Statement 1 is correct:** The incidence of post-treatment lymphoedema has decreased primarily due to the shift from routine **axillary lymph node dissection (ALND)** to **sentinel lymph node biopsy (SLNB)**. The combined therapy of ALND and radiotherapy, historically a major risk factor, is now rarely used, significantly reducing lymphoedema incidence. **Statement 2 is correct:** The presence of **lymph node metastases** is a major precipitating factor as it necessitates more extensive surgery (ALND) and/or radiation therapy, increasing the risk of lymphatic damage and subsequent lymphoedema. **Statement 4 is correct:** The oedematous limb has impaired lymphatic drainage leading to reduced immune surveillance and skin changes, making it highly **susceptible to bacterial infections** like cellulitis and erysipelas. *Statement 3 is incorrect:* Lymphoedema itself is typically **not acutely painful** but may cause a feeling of heaviness, tightness, or discomfort. Pain usually indicates complications such as bacterial infection (cellulitis), not the lymphoedema itself. Therefore, statements 1, 2, and 4 are correct, making option **"1, 2 and 4"** the correct answer.

Q: A patient presents to the OPD with a right-sided ulcerated breast lesion. Radiological imaging shows liver metastasis, as seen in the provided ultrasound image. What is the most appropriate management?

Neoadjuvant chemotherapy followed by surgery. ***Neoadjuvant chemotherapy followed by surgery*** - The presence of **distant metastasis** (liver metastasis) indicates **Stage IV breast cancer**, where **systemic treatment is the primary goal**. - In Stage IV disease, **palliative systemic chemotherapy** is the mainstay of treatment to control distant disease and improve survival. - Surgery in metastatic breast cancer may be considered for **local control of symptomatic disease** (ulceration, bleeding, pain), typically after initiating systemic therapy. - The combination of systemic therapy followed by local surgery for the ulcerated lesion addresses both the metastatic disease and provides local symptom relief. *Simple mastectomy* - While this could provide local control of the ulcerated lesion, it does **not address the distant metastasis**. - In Stage IV disease, **systemic therapy must be prioritized** before considering any local surgical intervention. - Surgery alone without systemic treatment would be inadequate for metastatic disease. *Modified Radical Mastectomy (MRM)* - MRM involves removal of the entire breast tissue, skin, nipple-areolar complex, and level I and II axillary lymph nodes. - While this provides comprehensive local-regional control, it **does not address distant metastasis**. - In Stage IV disease, extensive locoregional surgery without systemic therapy first would be inappropriate, as the primary issue is systemic disease. *Radical mastectomy* - This extensive procedure involves removal of the breast, axillary lymph nodes, and pectoralis muscles. - It is **rarely performed today** due to significant morbidity and no survival benefit over less extensive procedures. - Like other surgical options alone, it fails to address the systemic nature of Stage IV disease.

Q: A patient presents with upper limb swelling after undergoing a modified radical mastectomy (MRM). What is the most likely cause?

Upper limb Lymphedema. ***Upper limb Lymphedema*** - **Lymphedema** is a common complication after **modified radical mastectomy (MRM)** due to the removal of axillary lymph nodes and subsequent disruption of lymphatic drainage pathways. - This disruption leads to an accumulation of lymphatic fluid in the interstitial tissues, causing **swelling** in the ipsilateral upper limb. *Angiosarcoma* - **Angiosarcoma** (Stewart-Treves syndrome) is a very rare, aggressive tumor that can occur in the chronic lymphedematous limb after mastectomy. - It presents as multiple **violaceous nodules or plaques** in the affected limb, which is not described as the initial finding. *Recurrence* - **Recurrence** of breast cancer in the axilla or chest wall could cause swelling, but it would typically involve a palpable mass, skin changes, or pain, which are not mentioned as the primary symptom. - While recurrence can lead to lymphatic obstruction, **lymphedema** is a more direct and common post-operative complication. *Metastasis* - **Metastasis** to the axillary or supraclavicular lymph nodes could cause lymphatic obstruction and swelling. - However, lymphedema from direct surgical disruption of lymphatics is a more immediate and common cause of upper limb swelling following MRM, especially without other signs of widespread disease.

Q: Which of the following is not a relative contraindication for breast conservative surgery?

Small tumor size (<3cm). ***Small tumor size (<3cm)*** ✓ - A small tumor size is **NOT a contraindication** for breast-conserving surgery; it is actually a **favorable condition** and an indication for breast conservation. - Small tumors allow for complete tumor removal with good cosmetic outcomes and adequate margins. - This is the **correct answer** as it is the only option that is NOT a relative contraindication. *Multicentric disease* - **Multicentric disease** refers to the presence of multiple tumor foci in **different quadrants** of the breast, making complete surgical removal challenging with breast-conserving surgery. - This is a **relative contraindication** as it increases the risk of **positive margins** and local recurrence, making mastectomy often a more appropriate option. *Previous radiation to breast* - Prior radiation therapy to the breast is a **contraindication** (often considered absolute) for subsequent breast radiation, which is an essential component of breast-conserving therapy. - Re-irradiation carries a high risk of severe **skin and tissue toxicity**, making further breast conservation unfeasible. *Large tumor size* - A large tumor size is a **relative contraindication** as it can make it difficult to achieve **clear surgical margins** while maintaining an acceptable cosmetic result. - However, **neoadjuvant chemotherapy** may downstage large tumors to make them suitable for breast-conserving surgery. - Without tumor reduction, it often requires **mastectomy**.

Q: A 55-year-old female smoker presents with a breast lump and is seeking medical evaluation. On examination, a palpable mass is detected in the breast. The patient's smoking history is significant, with a 30-year smoking habit. Which of the following conditions is strongly associated with smoking in relation to breast health?

Breast cancer. ***Breast cancer*** - **Smoking** is a well-established risk factor for various cancers, including **breast cancer**, due to the presence of carcinogens in tobacco smoke [1]. - The patient's age and palpable lump further raise suspicion for malignancy, prompting thorough investigation. [1] *Duct ectasia* - Characterized by widening and inflammation of the **milk ducts**, which can cause nipple discharge, tenderness, and a palpable mass. - While smoking can be a risk factor, the more significant association in this age group and with a palpable lump leans towards malignancy. *Fibroadenoma* - These are **benign breast tumors** composed of glandular and stromal tissue, most common in younger women. - They are typically rubbery, mobile masses and are not strongly linked to smoking. *Mondor disease* - This is a rare, **benign condition** characterized by thrombophlebitis of the superficial veins of the breast or chest wall. - It typically presents as a painful, cord-like structure and is not directly associated with smoking.

Q: A 45-year-old woman with early-stage breast cancer is discussing treatment options with her surgeon. Which of the following statements regarding breast conservation surgery is NOT true?

Axillary dissection. ***Axillary dissection*** - **Axillary dissection is NOT a routine component of breast conservation surgery** for early-stage breast cancer. - In early-stage disease, **sentinel lymph node biopsy (SLNB)** has largely replaced routine axillary dissection as it provides accurate staging with significantly less morbidity. - Axillary dissection is only performed when there is **proven extensive lymph node involvement** or when SLNB shows metastatic disease requiring further assessment. - Therefore, this statement is **NOT true** regarding routine breast conservation surgery. *Wide local excision* - **Wide local excision (lumpectomy)** is the primary surgical component of breast conservation therapy. - It involves removing the cancerous tumor along with a margin of healthy breast tissue to achieve clear margins while preserving the breast. *Sentinel lymph node biopsy* - **SLNB** is a standard procedure performed with breast conservation surgery to assess for regional lymph node metastasis. - It identifies and removes the first few lymph nodes draining the tumor, allowing accurate staging with minimal morbidity. *Post-operative radiotherapy* - **Post-operative radiotherapy** to the preserved breast is a critical and essential component of breast conservation therapy. - It significantly reduces the risk of local recurrence by treating any microscopic tumor cells that may remain after surgery.

Q: A 55-year-old female patient presented with a $4 \times 3 \mathrm{~cm}$ lump in the right upper outer quadrant, with no axillary lymph node involvement. Mammography revealed BIRADS 4b staging. She underwent breast conservation surgery, and the final HPE report showed high nuclear-grade DCIS with necrosis and 10 mm margin clearance. What is the further management?

Adjuvant radiotherapy. ***Adjuvant radiotherapy*** - For **high-grade DCIS** with necrosis after breast conservation surgery, adjuvant radiotherapy significantly reduces the risk of **local recurrence** (by approximately 50%). - Even with adequate margin clearance (10 mm), radiotherapy is recommended to treat **potential residual microscopic disease** elsewhere in the breast tissue. - This is the **standard of care** for high-grade DCIS post-BCS, particularly when necrosis is present. *Follow up 6 monthly for 2 years and then yearly follow up* - While regular follow-up is essential for all breast cancer patients, it is **not sufficient alone** for high-grade DCIS treated with breast conservation. - **Adjuvant radiotherapy** is necessary to reduce recurrence risk before initiating the follow-up schedule. *Trastuzumab therapy* - **Trastuzumab** is specifically indicated for **HER2-positive invasive breast cancer**. - The patient has **DCIS**, which is **non-invasive (in situ)**, making trastuzumab inappropriate. - There is no role for targeted therapy in DCIS management. *Adjuvant chemotherapy* - **Adjuvant chemotherapy** is generally reserved for **invasive breast cancers**, especially those with high-risk features like lymph node involvement or aggressive tumor biology. - For **DCIS**, even high-grade with necrosis, chemotherapy is **not indicated** as it provides no proven benefit for non-invasive disease.

Q: Dye for Sentinel Lymph Node Biopsy is injected in which of the following sites?

Areola. ***Areola*** - The **areola** is the primary site for injecting dye in sentinel lymph node biopsy because it is rich in **lymphatic vessels** that directly drain into the regional lymph nodes. - This method ensures the dye follows the natural lymphatic drainage pathway, accurately identifying the **first lymph node** to receive drainage from the tumor. *Nipple* - While the nipple is part of the breast, it has a less dense network of **lymphatic vessels** compared to the areola. - Injection directly into the nipple may not consistently identify the sentinel lymph node as effectively as periareolar or intratumoral injections. *Axilla* - The **axilla** contains the regional lymph nodes that are the *target* for identification, not the site of dye injection. - Injecting dye directly into the axilla would bypass the lymphatic drainage from the tumor, making the biopsy ineffective. *Tail of spence* - The **tail of Spence** is an extension of breast tissue into the axilla, and while it contains breast tissue, it is not the most optimal or primary site for dye injection. - The lymphatic drainage from the tail of Spence would still rely on the broader lymphatic network, which is best accessed via the central breast regions like the areola.

Question 1

Which of the following statements regarding lymphoedema following breast cancer treatment are correct?

1. Incidence has decreased due to rarely combined therapy of axillary LN dissection and radiotherapy
2. Precipitating cause like LN metastasis is a major determinant
3. The condition is often painful
4. Oedematous limb is susceptible to bacterial infection

Select the correct answer using the code given below:

Accepted Answer

1, 2 and 4

Answer

1, 3 and 4

Answer

2, 3 and 4

Answer

1, 2 and 3

Question 2

A 32-year-old woman presents with a 2 cm breast mass. Core needle biopsy shows invasive ductal carcinoma, ER+, PR+, HER2-. Sentinel lymph node biopsy reveals 2 positive nodes with no extracapsular extension. What is the most appropriate next step in management?

Accepted Answer

No further axillary surgery if planning whole breast radiation

Answer

Completion axillary lymph node dissection

Answer

Repeat sentinel lymph node biopsy

Answer

Radiation therapy to the axilla without further surgery

Question 3

A 45-year-old woman with BRCA1 mutation has completed childbearing and requests prophylactic surgery. She has no evidence of breast or ovarian cancer. Her mother died of ovarian cancer at age 50, and her sister had breast cancer at age 35. Evaluate the optimal prophylactic surgical strategy.

Accepted Answer

Bilateral mastectomy with immediate reconstruction and bilateral salpingo-oophorectomy

Answer

Unilateral mastectomy with contralateral surveillance

Answer

Bilateral mastectomy only

Answer

Enhanced screening without prophylactic surgery

Question 4

A patient presents to the OPD with a right-sided ulcerated breast lesion. Radiological imaging shows liver metastasis, as seen in the provided ultrasound image. What is the most appropriate management?

Accepted Answer

Neoadjuvant chemotherapy followed by surgery

Answer

Simple mastectomy

Answer

Modified Radical Mastectomy (MRM)

Answer

Radical mastectomy

Question 5

A patient presents with upper limb swelling after undergoing a modified radical mastectomy (MRM). What is the most likely cause?

Accepted Answer

Upper limb Lymphedema

Answer

Angiosarcoma

Answer

Recurrence

Answer

Metastasis

Question 6

Which of the following is not a relative contraindication for breast conservative surgery?

Accepted Answer

Small tumor size (<3cm)

Answer

Multicentric disease

Answer

Previous radiation to breast

Answer

Large tumor size

Question 7

A 55-year-old female smoker presents with a breast lump and is seeking medical evaluation. On examination, a palpable mass is detected in the breast. The patient's smoking history is significant, with a 30-year smoking habit. Which of the following conditions is strongly associated with smoking in relation to breast health?

Accepted Answer

Breast cancer

Answer

Duct ectasia

Answer

Fibroadenoma

Answer

Mondor disease

Question 8

A 45-year-old woman with early-stage breast cancer is discussing treatment options with her surgeon. Which of the following statements regarding breast conservation surgery is NOT true?

Accepted Answer

Axillary dissection

Answer

Post-operative radiotherapy

Answer

Wide local excision

Answer

Sentinel lymph node biopsy

Question 9

A 55-year-old female patient presented with a $4 	imes 3 \mathrm{~cm}$ lump in the right upper outer quadrant, with no axillary lymph node involvement. Mammography revealed BIRADS 4b staging. She underwent breast conservation surgery, and the final HPE report showed high nuclear-grade DCIS with necrosis and 10 mm margin clearance. What is the further management?

Accepted Answer

Adjuvant radiotherapy

Answer

Follow up 6 monthly for 2 years and then yearly follow up

Answer

Trastuzumab therapy

Answer

Adjuvant chemotherapy

Question 10

Dye for Sentinel Lymph Node Biopsy is injected in which of the following sites?

Accepted Answer

Areola

Answer

Nipple

Answer

Axilla

Answer

Tail of spence

Breast Surgery — MCQs

Breast Surgery — MCQs

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