Breast Surgery Practice Questions

Q: In the context of inflammatory breast cancer, what is the TNM stage associated with the peau d'orange appearance?

T4b. ***T4b*** * The **TNM staging system** classifies T4b specifically for inflammatory breast cancer, which is characterized by the presence of **peau d'orange** (edema) of the skin of the breast. * This T stage also encompasses **ulceration of the skin** of the breast or satellite nodules confined to the same breast. *T4a* * T4a describes an **extension to the chest wall**, which includes the ribs, intercostal muscles, and serratus anterior muscle, but **not** the pectoralis muscle, which is generally not considered part of the chest wall for this classification. * This stage does **not** include the characteristic skin changes associated with inflammatory breast cancer. *T3* * T3 describes a tumor with a **size greater than 5 cm** in its greatest dimension, without direct extension to the chest wall or skin involvement. * This stage is based solely on tumor size and **does not account for the skin changes** like peau d'orange. *T2* * T2 describes a tumor with a **size greater than 2 cm but not more than 5 cm** in its greatest dimension. * Similar to T3, this stage is also based on tumor size and **does not include any skin involvement** or inflammatory features.

Q: Which of the following is NOT a standard component of the triple test for breast cancer detection?

Breast self examination. ***Breast self examination*** - While **breast self-examination (BSE)** is important for **personal awareness** and **early detection**, it is not considered a standard component of the diagnostic "triple test" for breast cancer, which aims for definitive diagnosis. - The traditional triple test comprises **clinical examination**, **imaging** (mammography/ultrasound), and **pathological assessment** (FNAC/biopsy). *USG/ mammography* - **Mammography** and **ultrasonography (USG)** are crucial imaging modalities and an integral part of the **triple test**, providing detailed anatomical information about breast lesions. - They help characterize masses detected clinically and guide biopsy procedures, contributing significantly to diagnosis. *FNAC/ trucut biopsy* - **Fine needle aspiration cytology (FNAC)** and **tru-cut biopsy** are essential for **histopathological diagnosis**, confirming malignancy and determining tumor characteristics. - This is the third component of the triple test, providing a definitive cellular or tissue diagnosis. *Clinical examination* - A **thorough clinical breast examination** by a healthcare professional is the first step in the triple test, identifying palpable masses or other suspicious signs. - It involves **inspection** and **palpation** to assess breast tissue and lymph nodes.

Q: Which muscle flap is commonly used for autologous breast reconstruction after mastectomy?

Latissimus dorsi. ***Latissimus dorsi*** - The **latissimus dorsi** muscle is commonly used in **autologous breast reconstruction** due to its rich blood supply and ample tissue volume which can be transferred as a **pedicled flap** to the chest. - This flap includes muscle, skin, and subcutaneous fat, providing a good aesthetic outcome for **breast mound reconstruction** after mastectomy. *Deltopectoral* - The **deltopectoral flap** is primarily used for **head and neck reconstruction**, specifically for oral cavity and pharyngeal defects. - It involves muscle and skin from the **chest and shoulder region**, but its size and location make it less suitable for comprehensive breast reconstruction. *Serratus anterior* - The **serratus anterior** muscle is occasionally used as a **free flap** for small soft tissue defects, but it is not typically the first choice for large-volume breast reconstruction. - Its primary role is in **shoulder movement** and it does not provide sufficient tissue bulk for a complete breast mound. *Trapezius* - The **trapezius flap** is more commonly employed in **head and neck reconstruction** or for covering defects in the posterior shoulder region. - While it offers a good blood supply, its bulk and orientation are not ideal for **breast reconstruction**, which requires a more anterior and hemispheric shape.

Q: Which of the following is an acquired condition?

Mastitis. ***Mastitis*** - **Mastitis** is an **inflammatory condition** of the breast, often caused by bacterial infection, particularly common during **lactation** [1]. - It is an **acquired condition** as it develops after birth due to external or internal factors, not present at birth. *Polymastia (supernumerary breasts)* - **Polymastia** is a **congenital condition** where additional breast tissue develops along the **milk line**. - This condition is present at birth and results from *embryological development anomalies*, not acquired later in life. *Polythelia (extra nipples)* - **Polythelia** refers to the presence of **accessory nipples** along the embryonic milk line and is a **congenital anomaly**. - Like polymastia, it is present from birth due to *developmental errors* and is not an acquired condition. *Amastia (absence of breast tissue)* - **Amastia** is a rare **congenital anomaly** characterized by the complete absence of breast tissue, nipple, and areola. - It is a **birth defect**, meaning it is present from birth and not an acquired condition.

Q: Nipple retraction in Ca breast is due to infiltration of:

Suspensory ligaments. ***Suspensory ligaments*** - **Malignant cells** infiltrate and shorten the **suspensory ligaments (of Cooper)**, which extend from the deep fascia to the skin. - This shortening pulls the skin inward, causing characteristic **nipple retraction** or **peau d'orange** appearance. *Lactiferous ducts* - While cancer can involve and obstruct lactiferous ducts, its primary role in causing **nipple retraction** is less direct. - Obstruction of lactiferous ducts might lead to **nipple discharge** or a mass, but not typically retraction as a primary mechanism. *Lymphatics* - Infiltration of lymphatics can lead to **lymphedema** and **peau d'orange** (skin thickening) due to fluid accumulation. - However, direct **nipple retraction** is more specifically attributed to the shortening of the connective tissue framework rather than lymphatic involvement itself. *Pectoralis fascia* - Infiltration of the **pectoralis fascia** would indicate deep tumor invasion and can cause fixation of the breast to the chest wall. - This might restrict breast movement but does not directly cause **nipple retraction**; rather, it indicates a more advanced stage of disease.

Q: A 25-year-old female complains of discharge of blood from a single duct in her breast. The most appropriate treatment is:

Microdochectomy. **Microdochectomy** - **Microdochectomy** involves the surgical excision of a single lactiferous duct identified as the source of discharge, which is the most appropriate treatment for persistent or bloody solitary duct discharge. - This procedure aims to remove the **etiologic duct** and any underlying benign lesion (e.g., papilloma) while preserving the remaining breast tissue. *Radical excision* - This term is broad and doesn't specify the extent or nature of the excision in the context of a single duct discharge. **Radical excision** usually implies removal of a larger tissue volume and is typically reserved for malignancies or extensive benign disease, which is not indicated here. - Simply calling it radical excision without further specification makes it inappropriate as an initial treatment given the localized nature of the problem. *Radical mastectomy* - **Radical mastectomy** involves removal of the entire breast, overlying skin, and axillary lymph nodes. This is an extensive and disfiguring procedure indicated only for large or aggressive breast cancers, not for isolated single-duct discharge unless malignancy is strongly suspected and proven. - It is **overtreatment** for this presentation, as the vast majority of single-duct bloody discharges are due to benign causes like intraductal papillomas. *Biopsy to rule out carcinoma* - While ruling out carcinoma is important, a **biopsy** (e.g., core needle biopsy) of a duct for discharge is often technically challenging and may not yield representative tissue. - The definitive diagnosis and treatment for a persistent or bloody single-duct discharge is typically **surgical excision (microdochectomy)**, which serves both diagnostic and therapeutic purposes by removing the entire duct and allowing for pathological analysis.

Q: Treatment of choice for phyllodes tumor is:

Wide local excision. ***Wide local excision*** - The primary treatment for phyllodes tumors is **surgical excision with wide clear margins (at least 1 cm)** to prevent recurrence. - The goal is to remove the tumor completely with adequate margins, as these tumors have a high local recurrence rate (up to 20-30%) if inadequately excised. - Most phyllodes tumors are benign (60-75%), but even benign variants require wide excision due to their infiltrative growth pattern. *Radical mastectomy* - This is an **overly aggressive procedure** for most phyllodes tumors, which are typically benign or borderline and do not require such extensive surgery. - Radical mastectomy may only be considered for very large malignant phyllodes tumors where breast conservation is not feasible. *Radiotherapy* - **Adjuvant radiotherapy** may be considered in cases of malignant phyllodes tumors with close or positive surgical margins or recurrent disease. - However, it is not the primary treatment of choice and is not effective as a standalone treatment for these tumors. *Chemotherapy* - Chemotherapy is **generally not effective** and not routinely indicated for phyllodes tumors, as they are largely resistant to systemic therapy. - It might be considered only in cases of **distant metastatic disease** from a malignant phyllodes tumor, which occurs in less than 5% of cases.

Q: A woman noticed a mass in her left breast with bloody discharge. Histopathology revealed duct ectasia. What is the treatment?

Hadfield operation. ***Hadfield operation*** - The Hadfield operation, also known as **total duct excision** or **microdochectomy**, is indicated for **benign duct ectasia** with pathological nipple discharge, especially if persistent, bloody, or associated with a discrete mass. - This procedure removes the affected duct system, preventing recurrence of the discharge and addressing the mass. *Simple mastectomy* - This involves the removal of the entire breast and is typically reserved for **malignant conditions** (breast cancer). - It is an **overly aggressive** treatment for a benign condition like duct ectasia. *Microdochectomy* - This term usually refers to the **excision of a single duct** and is a type of duct excision, often used interchangeably with total duct excision. - While it addresses the issue, the Hadfield operation generally implies a more comprehensive removal of the major duct system via a circumareolar incision. *Lobectomy* - Lobectomy is typically associated with **lung surgery** (removal of a lung lobe) and is not a breast surgical procedure. - It describes the removal of an entire lobe of an organ, which is not applicable to breast duct disease in this context.

Q: Which one of the following statements is true about cystosarcoma phylloides?

It is usually bulky and may fungate through the skin. ***It is usually bulky and may fungate through the skin*** - **Cystosarcoma phylloides** (also known as phyllodes tumor) are characterized by their rapid growth and tendency to become **very large**, often leading to the skin becoming stretched, thin, and potentially **ulcerated or fungating**. - Their rapid, expansive growth patterns contribute to their bulky appearance, which can be alarming to patients and clinicians. *It is a malignant tumour* - While it can be malignant, **the majority of phyllodes tumors are benign (60-75%)**; about 20-25% are borderline, and only 10-15% are frankly malignant. - Therefore, stating it "is a malignant tumor" is inaccurate, as it implies all tumors of this type are malignant. *It often metastasises to axillary nodes* - **Metastasis to regional lymph nodes, including axillary nodes, is rare** even in malignant phyllodes tumors [1]. - When metastasis occurs, it typically involves **hematogenous spread** to distant sites like the lungs, bone, and liver, rather than lymphatic spread [1], [2]. *It is treated by radical mastectomy* - **Radical mastectomy is generally not the primary treatment** for phyllodes tumors. The preferred treatment is **wide local excision** with clear margins due to the tumor's tendency for local recurrence [1]. - For very large or recurrent tumors, or those with significant suspicion of malignancy, a simple mastectomy may be performed, but **radical mastectomy is reserved for invasive breast cancer** and rarely indicated for phyllodes tumors [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, p. 1074. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 458-459.

Question 1

In the context of inflammatory breast cancer, what is the TNM stage associated with the peau d'orange appearance?

Accepted Answer

T4b

Answer

T4a

Answer

T3

Answer

T2

Question 2

Which of the following is NOT a standard component of the triple test for breast cancer detection?

Accepted Answer

Breast self examination

Answer

USG/ mammography

Answer

Clinical examination

Answer

FNAC/ trucut biopsy

Question 3

Which muscle flap is commonly used for autologous breast reconstruction after mastectomy?

Accepted Answer

Latissimus dorsi

Answer

Deltopectoral

Answer

Serratus anterior

Answer

Trapezius

Question 4

Which of the following is an acquired condition?

Accepted Answer

Mastitis

Answer

Polymastia (supernumerary breasts)

Answer

Polythelia (extra nipples)

Answer

Amastia (absence of breast tissue)

Question 5

Nipple retraction in Ca breast is due to infiltration of:

Accepted Answer

Suspensory ligaments

Answer

Lymphatics

Answer

Pectoralis fascia

Answer

Lactiferous ducts

Question 6

A 25-year-old female complains of discharge of blood from a single duct in her breast. The most appropriate treatment is:

Accepted Answer

Microdochectomy

Answer

Radical excision

Answer

Radical mastectomy

Answer

Biopsy to rule out carcinoma

Question 7

Treatment of choice for phyllodes tumor is:

Accepted Answer

Wide local excision

Answer

Radical mastectomy

Answer

Radiotherapy

Answer

Chemotherapy

Question 8

A 25-year-old lady presents with spontaneous nipple discharge of 3 months duration. On examination, the discharge is bloody and from a single duct. The following statements about management of this patient are true EXCEPT:

Accepted Answer

Radical duct excision is the operation of choice.

Answer

Ultrasound can be a useful investigation.

Answer

Galactogram, though useful, is not essential.

Answer

Majority of blood-stained nipple discharges are due to papilloma or other benign conditions.

Question 9

A woman noticed a mass in her left breast with bloody discharge. Histopathology revealed duct ectasia. What is the treatment?

Accepted Answer

Hadfield operation

Answer

Lobectomy

Answer

Simple mastectomy

Answer

Microdochectomy

Question 10

Which one of the following statements is true about cystosarcoma phylloides?

Accepted Answer

It is usually bulky and may fungate through the skin

Answer

It is a malignant tumour

Answer

It often metastasises to axillary nodes

Answer

It is treated by radical mastectomy

Breast Surgery — MCQs

Breast Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?