Breast Surgery Practice Questions

Q: Microdochectomy is the treatment for which of the following?

Duct papilloma. ***Duct papilloma*** - **Microdochectomy** is a targeted surgical procedure designed to remove a single, involved **milk duct**, which is the standard treatment for a **duct papilloma**. - A duct papilloma is a benign growth within a milk duct that often causes a **bloody or serous nipple discharge**. *Duct ectasia* - **Duct ectasia** typically involves multiple ducts and is often managed conservatively; if surgery is needed, a **total duct excision** (Hadfield's procedure) is usually performed. - This condition is characterized by dilatation of the mammary ducts, often leading to nipple discharge, but not usually addressed with microdochectomy. *Breast abscess* - A **breast abscess** is a collection of pus that requires **drainage** (either by needle aspiration or incision and drainage) and antibiotics, not duct excision. - It is an infectious process, distinct from a ductal lesion requiring surgical extirpation. *DCIS* - **Ductal Carcinoma In Situ (DCIS)** is a non-invasive form of breast cancer that requires broader surgical excision, such as **lumpectomy with clear margins**, often followed by radiation therapy. - Microdochectomy is too limited a procedure for DCIS, as it only removes a single duct segment and would not ensure complete removal of potentially multifocal or widespread disease.

Q: Favorable prognosis with > 90% 5 year survival rate for carcinoma breast is seen in which of the following?

Screen detected ductal carcinoma in situ (DCIS). **Screen detected ductal carcinoma in situ (DCIS)** - **DCIS** is a non-invasive breast cancer confined to the milk ducts, meaning it has not spread to surrounding tissues. [1] - When detected through screening, it has an excellent prognosis with a **5-year survival rate often exceeding 90%** after appropriate treatment (e.g., lumpectomy with or without radiation). *Node negative tumor with favorable histology* - While a **node-negative tumor** generally indicates a better prognosis than node-positive disease, the specific "favorable histology" isn't precisely defined to guarantee a >90% 5-year survival on its own as universally as DCIS. - **Histology** can vary greatly, and even node-negative invasive cancers can have less favorable subtypes that reduce 5-year survival below this high threshold. *Triple-negative breast cancer* - **Triple-negative breast cancer (TNBC)** lacks estrogen receptors, progesterone receptors, and HER2 overexpression, making it an aggressive subtype. - TNBC has a **poorer prognosis** compared to other breast cancer types and is not associated with a >90% 5-year survival rate, especially once it becomes invasive. *Screen detected lobular carcinoma in situ (LCIS)* - **LCIS** is considered a high-risk marker for developing invasive breast cancer in either breast, rather than a true cancer itself. [1] - While it doesn't directly metastasize, its presence indicates a **significantly increased lifetime risk** of developing invasive lobular or ductal carcinoma, and it's not treated as a "cancer" with a 5-year survival in the same way as DCIS. [1]

Q: A female patient underwent mastectomy with axillary lymph node dissection for left breast cancer 3 years ago. She subsequently developed chronic lymphedema of the left arm. She now presents with a blue nodule on the left arm. What is the most likely diagnosis?

Lymphangiosarcoma (Stewart-Treves syndrome). ***Lymphangiosarcoma (Stewart-Treves syndrome)*** - The development of a **blue nodule** in a limb affected by **chronic lymphedema** following mastectomy for breast cancer is highly characteristic of **Stewart-Treves syndrome**. - This rare, aggressive soft tissue sarcoma arises from lymphatic vessels within the chronically edematous tissue. *Recurrence of breast cancer* - While breast cancer can recur locally, it typically presents as a **red or skin-colored nodule**, palpable mass, or inflammatory changes, not usually a distinct blue nodule associated with chronic lymphedema. - A blue appearance is more suggestive of a vascular or lymphatic origin. *Cellulitis (skin infection)* - Cellulitis presents as a **red, warm, tender, and spreading area of infection** of the skin, often accompanied by fever and malaise. - It does not typically form a localized, blue nodule, and the clinical presentation of infection is usually more acute. *Hemangioma (benign vascular tumor)* - Hemangiomas are **benign vascular proliferations** that are either present from birth or appear in early childhood and tend to regress. - While they can be blue, developing a new hemangioma in adulthood, especially in a post-mastectomy lymphedematous limb, is highly unlikely to be the cause of such a lesion and lacks the malignant potential suggested by the history.

Q: Which of the following statements about Patey's mastectomy is incorrect?

All lymph nodes of axilla are removed. ***All lymph nodes of axilla are removed*** - This statement is incorrect because, in **Patey's mastectomy** (a type of **modified radical mastectomy**), **axillary lymph node dissection** (ALND) aims to remove all **level I and II lymph nodes**, but some level III nodes might be preserved or remain, especially those medial to the pectoralis minor. - The goal is **therapeutic axillary clearance**, which usually includes removing most, but not absolutely all, of the axillary nodes, particularly sparing the **axillary vein** and **neurovascular structures**. *Pectoralis muscle is either divided or retracted* - The **pectoralis minor muscle** is typically **divided or retracted** in **Patey's mastectomy** to gain access to the **axillary lymph nodes**, particularly level II and III nodes. - This approach allows for a more complete **axillary lymph node dissection** while preserving the **pectoralis major muscle**. *Intercosto brachial nerves are usually preserved* - The **intercostobrachial nerves** are generally identified and **preserved** during axillary dissection in **Patey's mastectomy**. - Preservation of these nerves helps to reduce **postoperative numbness** or pain in the upper arm, although injury can still occur. *It is also called modified radical mastectomy* - **Patey's mastectomy** is indeed a specific type of **modified radical mastectomy** (MRM). - It involves removal of the breast, **axillary lymph nodes (levels I and II, and often III with pectoralis minor division/retraction)**, while preserving the **pectoralis major muscle**.

Q: Which of the following is the PRIMARY hormonal factor that influences the development of benign breast disease?

Estrogen. ***Estrogen*** - **Estrogen** plays a primary role in the proliferation of breast epithelial cells, and sustained or elevated levels are associated with an increased risk of several types of **benign breast disease (BBD)** due to its mitotic effects. - The effects of estrogen on breast tissue, including ductal and lobular development, contribute to the histological changes seen in BBD, such as **fibrosis** and **cystic changes**. *Progesterone* - While progesterone is important for **terminal differentiation** of mammary glands and often mediates some of its effects via estrogen, its role in the *primary* development of BBD is less direct compared to estrogen's proliferative influence. - In some contexts, progesterone may even *counteract* some of the proliferative effects of estrogen, particularly in the later phase of the menstrual cycle. *Luteinizing hormone* - **Luteinizing hormone (LH)** primarily regulates ovarian function, triggering ovulation and the production of progesterone and some estrogen, but it does not directly act on breast tissue as a primary factor in BBD development. - Its effects on breast tissue are indirect, mediated through the sex steroids (estrogen and progesterone) it stimulates. *Testosterone* - **Testosterone** is an androgen and a precursor to estrogen in women, but its direct role in the *development* of benign breast disease is not considered primary; it is more often metabolized into active estrogens which then exert effects. - High levels of androgens can sometimes be associated with specific benign breast conditions, but it is not the main hormonal driver.

Q: Hadfield's operation is performed for which of the following pathology?

Duct ectasia. ***Duct ectasia*** - **Hadfield's operation** (microdochectomy) involves excision of a **single dilated lactiferous duct** along with the terminal duct lobular unit. When **duct ectasia** affects a single duct causing persistent nipple discharge, microdochectomy (Hadfield's operation) may be performed. - **Duct ectasia** involves dilatation and inflammation of breast ducts with periductal fibrosis and can present with nipple discharge, nipple retraction, or a palpable mass. - When duct ectasia is limited to a single duct with troublesome discharge, Hadfield's operation is appropriate. For more extensive disease involving multiple ducts, **major duct excision** (also called Urban's operation or Hadfield's procedure in some texts) may be needed. - **Note:** While some sources associate Hadfield's operation primarily with **duct papilloma**, the procedure of single duct excision (microdochectomy) is also used for symptomatic single-duct ectasia. *Fibroadenoma* - A **fibroadenoma** is a benign tumor of the breast composed of both glandular and stromal tissue. - Surgical removal is by simple excision or enucleation, not Hadfield's operation, which is specifically a duct excision procedure. *Mondor's disease* - **Mondor's disease** is a rare, benign condition characterized by **thrombophlebitis** of the superficial veins of the breast or chest wall, presenting as a palpable cord-like structure. - It is typically self-limiting and managed conservatively with NSAIDs; surgery is not indicated. *Inflammatory breast carcinoma* - **Inflammatory breast carcinoma (IBC)** is an aggressive form of breast cancer characterized by diffuse erythema and edema (peau d'orange) of the breast, often without a discrete mass. - Treatment involves multimodal therapy: neoadjuvant chemotherapy, followed by mastectomy with axillary clearance, and radiation therapy. Hadfield's operation has no role in IBC management.

Q: A 59-year-old lady presents with a progressive, painless lump in the breast. What is the cause of the skin change associated with breast cancer?

Infiltration of subdermal lymphatics. ***Infiltration of subdermal lymphatics*** - The skin change described often refers to **peau d'orange**, which is caused by the **blockage of superficial lymphatic vessels** by tumor cells [1]. - This lymphatic obstruction leads to **edema** and dimpling of the skin, resembling an orange peel [1]. *Infiltration of the lactiferous duct* - While cancer can arise in or infiltrate lactiferous ducts, this primarily causes symptoms like **nipple discharge**, inversion, or a palpable mass. - It does not directly explain the specific **skin dimpling** or **peau d'orange** appearance. *Involvement of Cooper's ligament* - Involvement of **Cooper's ligaments** (suspensory ligaments of the breast) can cause skin dimpling or retraction [1]. - However, the image depicts widespread **peau d'orange**, which is more commonly associated with lymphatic involvement than direct ligamentous retraction [1]. *Spread of the tumor to the anterior chest wall* - Tumor extension to the **anterior chest wall** signifies advanced disease and can cause **fixation of the breast** to underlying structures or skin ulceration [2]. - This typically results in **immobility of the breast** or an ulcerated lesion, not the widespread edematous and dimpled appearance of **peau d'orange**. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 453-454. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 456-457.

Q: Which of the following factors is NOT a component of the Van Nuys prognostic index?

Estrogen receptor (ER) status. ***Estrogen receptor (ER) status*** - The **Van Nuys prognostic index** (VNPI) for **ductal carcinoma in situ (DCIS)** assesses factors related to local recurrence risk after breast-conserving therapy. - The VNPI includes: **tumor size, margin width, pathologic classification (nuclear grade and necrosis), and age**. - While ER status is an important prognostic factor in **invasive breast cancer**, it is **not included** in the VNPI scoring system for DCIS. *Age* - **Age** is a key component of the VNPI, with younger patients having higher risk of local recurrence. - Patients **under 40 years** receive score 3, **40-60 years** receive score 2, and **over 60 years** receive score 1. *Tumor size* - The **size of the DCIS lesion** is a critical component of the VNPI. - Lesions **≥41 mm** receive score 3, **16-40 mm** receive score 2, and **≤15 mm** receive score 1. *Margin width* - **Surgical margin width** is an essential component of the VNPI. - Margins **<1 mm** receive score 3, **1-9 mm** receive score 2, and **≥10 mm** receive score 1.

Question 1

Microdochectomy is the treatment for which of the following?

Accepted Answer

Duct papilloma

Answer

Duct ectasia

Answer

Breast abscess

Answer

DCIS

Question 2

Favorable prognosis with > 90% 5 year survival rate for carcinoma breast is seen in which of the following?

Accepted Answer

Screen detected ductal carcinoma in situ (DCIS)

Answer

Node negative tumor with favorable histology

Answer

Triple-negative breast cancer

Answer

Screen detected lobular carcinoma in situ (LCIS)

Question 3

A female patient underwent mastectomy with axillary lymph node dissection for left breast cancer 3 years ago. She subsequently developed chronic lymphedema of the left arm. She now presents with a blue nodule on the left arm. What is the most likely diagnosis?

Accepted Answer

Lymphangiosarcoma (Stewart-Treves syndrome)

Answer

Cellulitis (skin infection)

Answer

Recurrence of breast cancer

Answer

Hemangioma (benign vascular tumor)

Question 4

Which of the following statements about Patey's mastectomy is incorrect?

Accepted Answer

All lymph nodes of axilla are removed

Answer

Pectoralis minor muscle is either divided or retracted

Answer

Intercosto brachial nerves are usually preserved

Answer

It is also called modified radical mastectomy

Question 5

Which of the following is the PRIMARY hormonal factor that influences the development of benign breast disease?

Accepted Answer

Estrogen

Answer

Progesterone

Answer

Luteinizing hormone

Answer

Testosterone

Question 6

Hadfield's operation is performed for which of the following pathology?

Accepted Answer

Duct ectasia

Answer

Fibroadenoma

Answer

Mondor's disease

Answer

Inflammatory breast carcinoma

Question 7

In which of the following conditions is breast conservation surgery not indicated?

Accepted Answer

Widespread microcalcifications on imaging

Answer

Autoimmune conditions requiring careful radiation planning

Answer

All of the options are suitable for BCS

Answer

Large breast size posing technical challenges

Question 8

A 59-year-old lady presents with a progressive, painless lump in the breast. What is the cause of the skin change associated with breast cancer?

Accepted Answer

Infiltration of subdermal lymphatics

Answer

Infiltration of the lactiferous duct

Answer

Involvement of Cooper’s ligament

Answer

Spread of the tumor to the anterior chest wall

Question 9

Which of the following represents the most definitive guideline-based indication for adjuvant therapy in early breast carcinoma?

Accepted Answer

Post mastectomy radiation therapy is indicated when 4 or more lymph nodes are positive.

Answer

In premenopausal women, multidrug chemotherapy is given based on tumor characteristics and risk factors.

Answer

Aromatase inhibitors are used in premenopausal women only with ovarian suppression.

Answer

Tamoxifen is useful in postmenopausal women, but aromatase inhibitors are generally preferred.

Question 10

Which of the following factors is NOT a component of the Van Nuys prognostic index?

Accepted Answer

Estrogen receptor (ER) status

Answer

Age

Answer

Tumor size

Answer

Margin width

Breast Surgery — MCQs

Breast Surgery — MCQs

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