Breast Surgery Practice Questions

Q: Which of the following statements regarding the Oncotype DX test is true?

It is a 21-gene assay. **Explanation:** The **Oncotype DX** is a genomic test used primarily in early-stage breast cancer to guide the decision regarding adjuvant chemotherapy. **1. Why Option B is correct:** Oncotype DX is a **21-gene expression assay** (16 cancer-related genes and 5 reference genes). It uses reverse-transcriptase polymerase chain reaction (RT-PCR) on paraffin-embedded tumor tissue to calculate a **Recurrence Score (RS)** ranging from 0 to 100. This score quantifies the risk of distant recurrence at 10 years. **2. Why the other options are incorrect:** * **Option A:** It is specifically indicated for **Hormone Receptor-positive (ER/PR+), HER2-negative** cancers. It is not used for triple-negative or HER2-positive cancers. * **Option C:** While it predicts the risk of recurrence, its primary clinical utility is predicting the **benefit of adjuvant chemotherapy**, not hormonal therapy (hormonal therapy is generally indicated for all ER+ patients). * **Option D:** Traditionally, it is used for **Lymph Node-negative** disease. While its use has expanded to some post-menopausal patients with 1–3 positive nodes (based on the RxPONDER trial), its classic and most high-yield indication for exams remains node-negative disease. **Clinical Pearls for NEET-PG:** * **TAILORx Trial:** This landmark study established that patients with an RS of 0–25 generally do not benefit from chemotherapy and can be treated with endocrine therapy alone. * **MammaPrint:** Another genomic test, but it is a **70-gene assay** (uses microarray). * **Indication Summary:** Early-stage, ER+, HER2-, Node-negative breast cancer.

Q: Paresthesia following MRM (Modified Radical Mastectomy) develops due to involvement of which nerve?

Medial cutaneous nerve of arm. ### Explanation **1. Why the Correct Answer is Right:** During a Modified Radical Mastectomy (MRM), specifically during **axillary lymph node dissection (ALND)**, the **intercostobrachial nerve** (the lateral cutaneous branch of the second intercostal nerve) is frequently encountered. This nerve communicates with the **medial cutaneous nerve of the arm**. Injury, traction, or intentional sacrifice of these sensory fibers leads to postoperative **paresthesia, numbness, or chronic pain** along the posteromedial aspect of the upper arm and axilla. This is the most common sensory complication following MRM. **2. Why the Other Options are Incorrect:** * **A. Long Thoracic Nerve (Nerve of Bell):** This is a motor nerve supplying the **Serratus Anterior**. Injury leads to **"Winging of Scapula"** and inability to abduct the arm above 90 degrees, not sensory paresthesia. * **B. Medial Pectoral Nerve:** This is a motor nerve supplying the **Pectoralis Major and Minor**. Injury leads to atrophy of these muscles. * **D. Thoracodorsal Nerve:** This is a motor nerve supplying the **Latissimus Dorsi**. Injury leads to weakness in internal rotation, adduction, and extension of the arm (difficulty in "climbing" or "scratching the back"). **3. Clinical Pearls for NEET-PG:** * **Most commonly injured nerve in MRM:** Intercostobrachial nerve (causing sensory loss). * **Nerve most commonly preserved in MRM:** Long thoracic and Thoracodorsal nerves (to maintain shoulder function). * **Nerve of Bell (Long Thoracic):** Runs on the medial wall of the axilla (over the serratus anterior). * **Thoracodorsal Nerve:** Runs in the posterior wall of the axilla (with the subscapular vessels). * **Halsted’s Sign:** Loss of the pectoral fold due to injury to the pectoral nerves.

Q: What is the method of breast examination depicted in the video? The clinician was palpating with the tips of fingers, except the thumb, starting from the 2 o'clock position posteriorly and palpating at 3 points on a line joining the periphery to the nipple. Then, the clinician returned to the 3 o'clock position directly and came back to the center while palpating at 3 points again on the line joining the periphery and the nipple.

Clockwise method. ### Explanation The method described is the **Clockwise method** (also known as the radial or spoke-of-a-wheel method). In this technique, the breast is visualized as a clock face. The clinician begins at a specific position (e.g., 12 or 2 o'clock) and moves the finger pads in a straight line from the periphery toward the nipple (centripetal) or vice versa. After completing one "spoke," the clinician moves to the next hour position and repeats the process until all 360 degrees of the breast tissue are covered. This ensures systematic coverage of all lactiferous ducts radiating toward the nipple. **Why other options are incorrect:** * **Vertical strip method:** This is currently considered the most effective technique for Clinical Breast Examination (CBE). The clinician moves fingers up and down in parallel vertical lines (strips) across the entire breast, from the clavicle to the inframammary fold and from the sternum to the mid-axillary line. * **Concentric method:** Also called the "Circular method," the clinician palpates in increasing or decreasing concentric circles starting from the nipple and moving outward (or vice versa). * **Quadrant method:** This involves dividing the breast into four quadrants (Upper Outer, Upper Inner, Lower Outer, Lower Inner) and palpating each section individually. It is less systematic than the clockwise or vertical strip methods. **Clinical Pearls for NEET-PG:** * **Gold Standard:** The **Vertical Strip Method** is preferred by the American Cancer Society as it is most likely to cover all breast tissue, including the "Tail of Spence." * **Positioning:** For a proper CBE, the patient should be supine with the ipsilateral arm raised above the head to flatten the breast tissue against the chest wall. * **Palpation Technique:** Use the **pads** of the middle three fingers (2nd, 3rd, and 4th), applying three levels of pressure (light, medium, and deep) at every point.

Q: What is the standard treatment for cystosarcoma phyllodes?

Simple mastectomy. **Explanation:** **Cystosarcoma Phyllodes** (Phyllodes tumor) is a rare fibroepithelial breast tumor characterized by a "leaf-like" growth pattern. The standard treatment is **Simple Mastectomy** (or wide local excision with >1 cm margins) because these tumors spread locally and via the hematogenous route, rather than through the lymphatic system. * **Why Simple Mastectomy is correct:** Since Phyllodes tumors rarely involve axillary lymph nodes (less than 1% incidence), a simple mastectomy—which removes the entire breast tissue without axillary clearance—is sufficient for large or malignant tumors to ensure clear margins and prevent local recurrence. * **Why Radical/Modified Radical Mastectomy (MRM) are wrong:** These procedures involve axillary lymph node dissection. Because Phyllodes tumors behave like sarcomas (spreading via blood, not lymphatics), routine axillary dissection is unnecessary and adds morbidity without improving survival. * **Why Antibiotics are wrong:** Phyllodes is a neoplastic condition, not an inflammatory or infectious process like mastitis or a breast abscess. **High-Yield Clinical Pearls for NEET-PG:** * **Classification:** Can be Benign, Borderline, or Malignant based on stromal cellularity, atypia, and mitotic index. * **Clinical Feature:** Typically presents as a large, painless, mobile mass with rapid growth; the overlying skin may be shiny with prominent veins. * **Key Distinction:** Unlike Fibroadenomas, Phyllodes tumors occur in older women (35–50 years) and have a high risk of local recurrence if margins are inadequate. * **Treatment Rule:** Wide local excision (margin >1 cm) for small tumors; Simple Mastectomy for large tumors or high tumor-to-breast ratio.

Q: Estrogen receptor activity is clinically useful in predicting:

Response to hormonal manipulation. **Explanation:** **Why Option D is Correct:** Estrogen Receptors (ER) and Progesterone Receptors (PR) are nuclear transcription factors found in breast cancer cells. Their presence indicates that the tumor growth is driven by hormonal signaling. Clinically, ER/PR status is the most important **predictive factor** for response to endocrine (hormonal) therapies such as Tamoxifen (Selective Estrogen Receptor Modulator) or Aromatase Inhibitors (e.g., Anastrozole). Patients who are ER-positive have a 50-60% response rate to hormonal manipulation, which increases to nearly 80% if they are both ER and PR positive. **Why Other Options are Incorrect:** * **Option A:** While some ovarian cancers express ER, ER testing in breast surgery is specific to breast malignancy management and is not a screening or diagnostic tool for ovarian cancer. * **Option B:** ER status does not predict the *presence* of metastasis; however, it may predict the *site* of metastasis (ER+ tumors often spread to bones, while ER- tumors favor visceral organs). * **Option C:** Response to chemotherapy is generally higher in "Triple Negative" or ER-negative tumors because they have higher proliferation rates. ER status specifically predicts hormonal, not cytotoxic, sensitivity. **NEET-PG High-Yield Pearls:** * **Best Prognostic Factor:** Number of involved axillary lymph nodes (most important for overall survival). * **Best Predictive Factor:** ER/PR status (for hormonal therapy) and HER2/neu status (for Trastuzumab). * **Luminal A Subtype:** ER+, PR+, HER2-, low Ki-67. This subtype has the best prognosis. * **Triple Negative (Basal-like):** ER-, PR-, HER2-. This subtype has the worst prognosis and is often associated with BRCA1 mutations.

Q: What is the treatment for Paget's disease of the nipple?

Biopsy and simple mastectomy. **Explanation:** **Paget’s Disease of the Nipple** is a rare manifestation of breast cancer characterized by malignant cells (Paget cells) infiltrating the epidermis of the nipple-areola complex. In over 90% of cases, it is associated with an underlying **Ductal Carcinoma In Situ (DCIS)** or invasive carcinoma. 1. **Why Option C is Correct:** The management begins with a **wedge or punch biopsy** to confirm the presence of Paget cells (large cells with clear cytoplasm and prominent nuclei). Once confirmed, the standard surgical treatment is a **Simple Mastectomy** (with or without sentinel lymph node biopsy) because the underlying malignancy is often multicentric or located deep within the breast tissue. Breast-conserving surgery (BCS) is an alternative only if the underlying tumor is localized and can be excised with clear margins followed by radiotherapy. 2. **Why Other Options are Incorrect:** * **Radiotherapy (A):** It is an adjuvant treatment used after BCS to reduce recurrence but is not the primary definitive treatment for the disease itself. * **Radical Mastectomy (B):** This involves removing the pectoralis muscles and is now obsolete. Even Modified Radical Mastectomy (MRM) is reserved only if invasive cancer is confirmed with axillary lymphadenopathy. * **Chemotherapy (D):** This is a systemic therapy used for invasive or metastatic disease, not the primary local treatment for Paget’s disease. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Often misdiagnosed as eczema; however, Paget’s **destroys the nipple** and does not respond to topical steroids. * **Pathology:** Paget cells are PAS positive, Diastase resistant, and Alcian blue positive. * **Immunohistochemistry:** Typically positive for **HER2/neu** and **CK7**. * **Key Distinction:** Unlike eczema, Paget’s disease starts on the nipple and spreads to the areola.

Question 1

Breast examination is done yearly in patients with which of the following conditions?

Accepted Answer

Family history of breast cancer

Answer

Multiple fibroadenoma

Answer

Carcinoma cervix

Answer

Endometrial carcinoma

Question 2

A 45-year-old premenopausal woman undergoes a left breast lumpectomy for a 1.5 cm, lymph node positive, hormone sensitive invasive breast cancer. She receives chemotherapy, radiotherapy, and is on tamoxifen. What is the recommended follow-up after therapy?

Accepted Answer

Routine clinical examination every 3-6 months for the first 5 years after treatment as well as continued yearly mammography.

Answer

Blood tumor markers drawn every 3-6 months after treatment.

Answer

Routine monitoring of liver function tests (LFTs) every 3-6 months after treatment.

Answer

Yearly bone scans.

Question 3

Which of the following statements regarding the Oncotype DX test is true?

Accepted Answer

It is a 21-gene assay

Answer

Used for hormone receptor-negative cancers

Answer

Predicts the benefit of adjuvant hormonal therapy

Answer

Used for lymph node-positive cancers

Question 4

Paresthesia following MRM (Modified Radical Mastectomy) develops due to involvement of which nerve?

Accepted Answer

Medial cutaneous nerve of arm

Answer

Long thoracic nerve

Answer

Medial pectoral nerve

Answer

Thoracodorsal nerve

Question 5

Galactorrhea, a milky discharge from the nipple in nonpregnant women, is most likely to be associated with which of the following?

Accepted Answer

Pituitary adenoma

Answer

Fibroadenoma

Answer

Tubular adenoma

Answer

Hyperparathyroidism

Question 6

What is the method of breast examination depicted in the video? The clinician was palpating with the tips of fingers, except the thumb, starting from the 2 o'clock position posteriorly and palpating at 3 points on a line joining the periphery to the nipple. Then, the clinician returned to the 3 o'clock position directly and came back to the center while palpating at 3 points again on the line joining the periphery and the nipple.

Accepted Answer

Clockwise method

Answer

Vertical strip method

Answer

Concentric method

Answer

Quadrant method

Question 7

What is the standard treatment for cystosarcoma phyllodes?

Accepted Answer

Simple mastectomy

Answer

Radical mastectomy

Answer

Modified radical mastectomy

Answer

Antibiotics with conservative treatment

Question 8

Estrogen receptor activity is clinically useful in predicting:

Accepted Answer

Response to hormonal manipulation

Answer

The presence of ovarian cancer

Answer

The presence of metastatic disease

Answer

Response to chemotherapy

Question 9

A 40-year-old female presents with a 2 cm breast nodule and a proven metastatic axillary lymph node. What is the recommended treatment?

Accepted Answer

Patey's mastectomy with adjuvant chemotherapy

Answer

Quadrantectomy

Answer

Mastectomy with local radiotherapy

Answer

Halsted's radical mastectomy with tamoxifen

Question 10

What is the treatment for Paget's disease of the nipple?

Accepted Answer

Biopsy and simple mastectomy

Answer

Radiotherapy

Answer

Radical mastectomy

Answer

Chemotherapy

Breast Surgery — MCQs

Breast Surgery — MCQs

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