Breast Surgery Practice Questions

Q: A 40-year-old patient is diagnosed with a localized 1 cm infiltrating ductal cancer after a needle core biopsy of the lesion. She is clinical node negative; a lumpectomy and sentinel lymph node biopsy are performed. The patient develops an anaphylactic response during the case. Which of the following substances was the likely causative agent?

Isosulfan blue dye. ***Isosulfan blue dye*** - **Isosulfan blue dye** is commonly used in sentinel lymph node biopsy procedures for its ability to stain lymphatic channels, but it carries the **highest risk of anaphylactic reactions** among lymphatic mapping agents. - The incidence of anaphylaxis with isosulfan blue ranges from **0.07-2%**, significantly higher than other tracers. - The patient's development of an **anaphylactic response** during the case strongly points to isosulfan blue as the causative agent due to its documented allergenicity. *Patent blue dye* - **Patent blue dye** is another lymphatic mapping dye used for sentinel lymph node biopsy, particularly in European practice. - While it can also cause allergic reactions, the incidence of **severe anaphylaxis** is lower than with isosulfan blue, making it a less likely culprit in this case. - Patent blue and isosulfan blue are structurally similar, but isosulfan blue has higher reported anaphylaxis rates in clinical practice. *99 Tc radiolabeled colloid* - **Technetium-99m (99mTc) radiolabeled colloid** is widely used in sentinel lymph node mapping due to its excellent lymphatic tracking and low incidence of allergic reactions. - Anaphylaxis to **radiopharmaceuticals** is extremely rare compared to reactions to blue dyes, with virtually no reported cases during SLNB. *Methylene blue dye* - **Methylene blue dye** is an alternative to isosulfan blue for sentinel lymph node mapping, especially in patients with a history of isosulfan blue allergy. - While allergic reactions can occur, **methylene blue** is generally associated with a significantly lower incidence of severe anaphylaxis than isosulfan blue.

Q: Peau d’orange appearance is due to -

Lymphatic permeation. ***Lymphatic permeation*** - **Peau d'orange**, or "orange peel" appearance, is characteristic of advanced breast cancer and is caused by **edema of the skin** due to **blockage of subcutaneous lymphatic drainage**. - The skin over the affected area becomes rigid and swollen, accentuating the hair follicles and leading to a dimpled appearance similar to an orange peel. *Intra-epithelial cancer* - **Intra-epithelial cancer**, such as ductal carcinoma in situ (DCIS), is confined to the epithelium and does not typically directly cause diffuse skin changes like **peau d'orange**. - It involves proliferation of malignant cells within the ducts or lobules without invasion of the **basement membrane**. *Vascular embolization* - **Vascular embolization** refers to the blockage of blood vessels by an embolus, which would cause ischemia or infarction, not diffuse skin edema with a dimpled appearance. - While cancer can spread via blood vessels, this mechanism does not directly result in the specific **peau d'orange** phenomenon. *Sub-epidermal cancer* - **Sub-epidermal cancer** might refer to a tumor lying beneath the epidermis, but this term is not standard for describing the cause of peau d'orange. - The appearance is due to lymphatic obstruction and edema, not merely the presence of a tumor in a specific layer, unless that tumor is causing the **lymphatic blockage**.

Q: Triple assessment for carcinoma breast includes:

Clinical examination, Mammography, biopsy/cytology. ***Clinical examination, Mammography, biopsy/cytology*** - The **triple assessment** for breast carcinoma is a gold standard diagnostic approach comprising **clinical evaluation**, **imaging studies**, and **histopathological assessment**. - **Clinical examination** assesses physical signs, **mammography** provides imaging, and **biopsy/cytology** offers definitive tissue diagnosis. *Observation, Ultrasonography, biopsy/cytology* - **Observation** is not a formal component of the triple assessment; it lacks the specific diagnostic purpose of clinical examination. - While **ultrasonography** is an important imaging modality, particularly for younger women or dense breasts, **mammography** is typically the primary imaging component for initial screening in the triple assessment. *History, clinical examination, biopsy/cytology* - **History** is crucial for understanding risk factors and symptom presentation but is considered part of the broader clinical workup rather than one of the specific "triple" components. - This option omits crucial **imaging**, which is a mandatory part of the triple assessment. *History, clinical examination, Ultrasonography* - While history and clinical examination are vital, this option completely lacks a **histopathological component (biopsy/cytology)**, which is essential for definitive diagnosis of malignancy. - This option also specifies **ultrasonography** over mammography, which, while useful, may not be the primary initial imaging component in all triple assessments.

Q: 20 years old female came with complaint of a palpable painless mass in right breast. On examination, mass was mobile and hard in consistency. Ultrasound of right breast was performed . Most likely diagnosis is?

Fibroadenoma. ***Fibroadenoma*** - A **painless**, **mobile**, and **hard mass** in a 20-year-old female is highly characteristic of a fibroadenoma, which is a common **benign breast tumor**. - Its **mobility** (often described as "breast mouse") is a key distinguishing feature from malignant masses. *Breast cyst* - While breast cysts can be **palpable** and **painless**, they are typically **soft or fluctuant** on palpation, not hard. - Cysts are fluid-filled sacs, and their mobile nature is less pronounced than the discrete, solid feel of a fibroadenoma. *Phyllodes tumor* - Phyllodes tumors can present as a **palpable mass**, but they usually grow **rapidly** and tend to be larger, often feeling lobulated. - While they can be benign, they have a potential for **malignant transformation** and are less common than fibroadenomas, especially in a 20-year-old. *Ductal papilloma* - Ductal papillomas are typically very small, located within milk ducts, and often present with **nipple discharge**, particularly bloody discharge, rather than a palpable mass. - They are rarely felt as a discrete, mobile, hard mass on routine physical examination.

Q: Bilateral carcinoma breast is common in which of the following types of breast cancer?

Lobular. ***Lobular*** - **Invasive lobular carcinoma (ILC)** accounts for 5-15% of all invasive breast cancers and is characterized by its common presentation as bilateral disease. - The cells in lobular carcinoma often infiltrate in a single-file pattern, which can make it more challenging to detect on imaging and contributes to its higher incidence of bilaterality and multifocality. *Scirrhous* - This term refers to the **desmoplastic stromal reaction** common in many invasive ductal carcinomas, causing a firm, gritty feel. - While it's a common histological feature, it does not specifically indicate a higher risk of bilateral involvement. *Inflammatory* - **Inflammatory breast cancer (IBC)** is an aggressive and rare form of breast cancer characterized by rapid onset of edema, erythema, and warmth without a palpable mass. - It does not have a higher predilection for bilateral presentation compared to lobular carcinoma. *Colloid* - **Colloid (mucinous) carcinoma** is a rare subtype of invasive ductal carcinoma characterized by tumor cells floating in pools of extracellular mucin. - It tends to have a more favorable prognosis but is not known for a significantly increased risk of bilaterality.

Q: Using a small fine probe, a single lactiferous duct is excised. What is the name of the procedure:

Microdochectomy. ***Microdochectomy*** - This procedure involves the **excision of a single, lactiferous duct** often identified using a fine probe or ductoscope. - It is typically performed to investigate or treat **pathological nipple discharge** originating from a specific duct. *Hadfield operation* - This is a more extensive procedure known as a **total duct excision** or **subareolar duct excision**. - It involves the removal of **all major lactiferous ducts** under the nipple, not just a single one. *Webster operation* - The Webster operation refers to an **inferior pedicle reduction mammoplasty** technique. - It is a type of **breast reduction surgery** and is not related to the excision of an isolated lactiferous duct. *Macrodochectomy* - This term is **not a recognized medical procedure** in the context of duct excision. - While "macro" implies large, it does not describe a specific surgical technique for duct removal.

Q: Which is the most conspicuous sign in breast cancer?

Peau d'orange. ***Peau d'orange*** - This sign, characterized by **pitted, dimpled skin resembling an orange peel**, is the most conspicuous and widely recognized sign of breast cancer, particularly in locally advanced or inflammatory breast cancer. [1] - It results from **lymphatic obstruction** and **edema** of the skin due to tumor invasion, pulling on the suspensory ligaments. *Puckering* - While an important sign, **puckering** (also known as **dimpling**) is often more subtle and may require specific positioning or palpation to be evident. - It is caused by the tumor invading and shortening the **suspensory ligaments (Cooper's ligaments)**, which pull on the overlying skin. [1] *Nipple retraction* - **Nipple retraction** can be a significant sign of breast cancer, but it can also be a **normal variant** or due to benign conditions like **mastitis** or **mammary duct ectasia**. - Its presence alone is not as uniquely conspicuous or indicative of malignancy as *peau d'orange*. *Cancer en-cuirasse* - **Cancer en-cuirasse** is a rare and advanced form of *cutaneous metastasis* from breast cancer, where the chest wall becomes encased in a **hard, fibrotic, leathery tumor shell**. - While very conspicuous once developed, it represents a **late-stage manifestation** and is not the most common or earliest conspicuous sign of breast cancer.

Q: Which of the following is not true about breast cancer?

Lobular carcinoma is most common. ***Lobular carcinoma is most common*** - This statement is **incorrect** because **invasive ductal carcinoma (IDC)** accounts for the majority (**70-80%**) of all breast cancers. - While **invasive lobular carcinoma (ILC)** is the second most common type, it only represents about **5-15%** of cases. *Family history is a risk factor* - A **positive family history**, especially in a first-degree relative, significantly increases the risk of breast cancer due to inherited genetic mutations like **BRCA1** and **BRCA2**. - These mutations impair DNA repair, leading to uncontrolled cell growth. *Paget’s disease affects the nipple* - **Paget's disease of the nipple** is a rare form of breast cancer that presents as an eczematous lesion of the nipple and areola. - It is often associated with an **underlying invasive or in-situ ductal carcinoma**. *Estrogen exposure increases risk* - Prolonged or higher levels of **estrogen exposure** are known risk factors for breast cancer, as estrogen stimulates the growth of hormone-receptor-positive breast cancer cells. - Factors increasing estrogen exposure include **early menarche, late menopause, obesity**, and **hormone replacement therapy**.

Question 1

A 40-year-old patient is diagnosed with a localized 1 cm infiltrating ductal cancer after a needle core biopsy of the lesion. She is clinical node negative; a lumpectomy and sentinel lymph node biopsy are performed. The patient develops an anaphylactic response during the case. Which of the following substances was the likely causative agent?

Accepted Answer

Isosulfan blue dye

Answer

Patent blue dye

Answer

99 Tc radiolabeled colloid

Answer

Methylene blue dye

Question 2

Peau d’orange appearance is due to -

Accepted Answer

Lymphatic permeation

Answer

Intra-epithelial cancer

Answer

Vascular embolization

Answer

Sub-epidermal cancer

Question 3

Triple assessment for carcinoma breast includes:

Accepted Answer

Clinical examination, Mammography, biopsy/cytology

Answer

Observation, Ultrasonography, biopsy/cytology

Answer

History, clinical examination, biopsy/cytology

Answer

History, clinical examination, Ultrasonography

Question 4

20 years old female came with complaint of a palpable painless mass in right breast. On examination, mass was mobile and hard in consistency. Ultrasound of right breast was performed . Most likely diagnosis is?

Accepted Answer

Fibroadenoma

Answer

Breast cyst

Answer

Phylloid's tumour

Answer

Ductal papilloma

Question 5

Bilateral carcinoma breast is common in which of the following types of breast cancer?

Accepted Answer

Lobular

Answer

Scirrhous

Answer

Inflammatory

Answer

Colloid

Question 6

Using a small fine probe, a single lactiferous duct is excised. What is the name of the procedure:

Accepted Answer

Microdochectomy

Answer

Hadfield operation

Answer

Webster operation

Answer

Macrodochectomy

Question 7

Which is the most conspicuous sign in breast cancer?

Accepted Answer

Peau d'orange

Answer

Puckering

Answer

Nipple retraction

Answer

Cancer en-cuirasse

Question 8

Which of the following is not true about breast cancer?

Accepted Answer

Lobular carcinoma is most common

Answer

Family history is a risk factor

Answer

Paget’s disease affects the nipple

Answer

Estrogen exposure increases risk

Question 9

What factors should be considered when choosing between implant-based and autologous breast reconstruction options for a patient after mastectomy?

Accepted Answer

Patient's body image concerns, availability of donor tissue, recovery time, and medical comorbidities.

Answer

Patient's aesthetic preferences and desired breast size.

Answer

Financial implications and insurance coverage.

Answer

Oncological factors and timing of adjuvant therapy.

Question 10

What is the impact of sentinel lymph node biopsy (SLNB) compared to axillary lymph node dissection (ALND) on lymphedema rates in patients with breast carcinoma?

Accepted Answer

SLNB is associated with lower lymphedema rates compared to ALND.

Answer

SLNB is less effective in controlling cancer compared to ALND.

Answer

ALND is associated with lower lymphedema rates than SLNB.

Answer

SLNB and ALND have similar rates of lymphedema.

Breast Surgery — MCQs

Breast Surgery — MCQs

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