Breast Surgery Practice Questions

Q: Mondor's disease is characterized by which of the following?

Thrombophlebitis of superficial veins of the breast. **Explanation:** **Mondor’s disease** is a rare, benign condition characterized by **superficial thrombophlebitis** of the veins of the breast and anterior chest wall. It most commonly involves the **lateral thoracic vein**, **thoracoepigastric vein**, or the **superior epigastric vein**. 1. **Why Option D is correct:** The underlying pathology is the inflammation and subsequent thrombosis of these superficial veins. Clinically, it presents as a sudden onset of a painful, palpable, "cord-like" structure under the skin of the breast. When the arm is elevated, a skin groove or tethering may become visible over the cord. It is usually self-limiting and managed with NSAIDs and warm compresses. 2. **Why other options are incorrect:** * **Option A:** Migratory thrombophlebitis associated with visceral malignancy (especially pancreatic cancer) is known as **Trousseau sign of malignancy**. * **Option B:** **Thromboangiitis obliterans (Buerger’s disease)** is an inflammatory occlusive disease of small and medium-sized arteries and veins, strongly associated with smoking and typically affecting the extremities. * **Option C:** Thrombosis of deep veins of the leg refers to **Deep Vein Thrombosis (DVT)**, which carries a high risk of pulmonary embolism, unlike the superficial involvement in Mondor’s. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Often idiopathic, but can be triggered by local trauma, vigorous exercise, breast surgery, or tight-fitting brassieres. * **Association with Malignancy:** While usually benign, in rare cases, it can mask an underlying breast cancer (approx. 5% association). Therefore, a mammogram is often recommended to rule out occult malignancy. * **Management:** Reassurance is key. It typically resolves spontaneously within 4 to 6 weeks.

Q: A 35-year-old woman, 10 years after mastectomy, notices gradual swelling and heaviness in her right upper limb without pain. On examination, bluish nodules on the skin with no infections are noted. What is the most likely cause of her symptoms?

Lymphangiosarcoma. ***Lymphangiosarcoma*** - The appearance of **bluish-purple cutaneous nodules** in a limb affected by long-standing **chronic lymphedema** (secondary to mastectomy and likely axillary dissection) is the classic presentation of **Stewart-Treves syndrome**, or post-mastectomy lymphangiosarcoma. - This is a rare, highly aggressive form of **angiosarcoma** arising from lymphatic endothelial cells in chronically static fluid, which aligns perfectly with the patient's history (10 years post-mastectomy). *Thoracic outlet syndrome* - This condition typically results from compression of the neurovascular bundle, causing symptoms like pain, paresthesias, weakness, or vascular changes (e.g., *Raynaud phenomenon*). - While mild edema can occur, it does not explain the significant history of chronic post-operative lymphedema or the development of highly specific **bluish cutaneous tumor nodules**. *Chronic venous insufficiency* - CVI typically affects the **lower limbs** and is characterized by edema, **skin hyperpigmentation**, and potential venous ulceration or stasis dermatitis, rather than post-mastectomy lymphedema. - The primary pathology here is lymphatic blockage following surgery, not incompetence of the venous valves, and CVI does not lead to the formation of sarcomatous skin nodules. *Recurrent breast cancer* - While recurrence can cause new lymphedema through **lymphatic obstruction**, the appearance of aggressive, rapidly growing **bluish vascular nodules** is highly suggestive of a secondary sarcoma (lymphangiosarcoma) rather than typical epithelial recurrence. - Recurrence often presents as a firm, ill-defined mass or local inflammatory changes, unlike the descriptive appearance of an **angiomatous tumor**.

Q: A 51-year-old lady presents with complaints of a mass in the right breast. On examination, the mass was larger than 5 cm and ipsilateral mobile axillary lymph nodes were present. What is the staging, considering the mass is malignant?

cT3N1M0. ***cT3N1M0*** **Correct answer based on TNM staging for breast cancer:** **T (Tumor) - T3:** - Tumor **>5 cm** in greatest dimension = T3 - The patient has a mass **larger than 5 cm**, meeting T3 criteria **N (Nodes) - N1:** - **Ipsilateral mobile axillary lymph nodes** = N1 - Mobile nodes without fixation to surrounding structures **M (Metastasis) - M0:** - **No mention of distant metastasis** = M0 **Clinical vs Pathological Staging:** - **"c" prefix** = clinical staging (based on physical examination, imaging) - **"p" prefix** = pathological staging (after surgery, histopathological examination) - This case uses **clinical examination findings**, so "c" prefix is appropriate *pT4N1M0* - Incorrect because: - Uses pathological prefix "p" without surgical specimen - T4 indicates chest wall/skin involvement, not present here *cT4N1M0* - Incorrect because: - T4 requires tumor extension to chest wall or skin ulceration/nodules - This tumor is only >5 cm without local extension *pT3N1M0* - Incorrect because: - Uses pathological staging prefix "p" when only clinical examination performed - Correct T and N staging but wrong staging type

Q: A 43-year-old female presents to OPD due to changes in breast and a lump in breast as given below. What is the diagnosis?

T4d. ### ***T4d*** - The image displays characteristic findings of **Inflammatory Breast Cancer** (IBC), including **erythema** (redness), **edema**, and **peau d'orange** (orange peel appearance) involving more than one-third of the skin of the breast. - According to the **AJCC TNM Staging** system (8th edition), T4d specifically denotes a tumor size equivalent to Inflammatory Breast Cancer, regardless of the actual tumor dimension or nodal status. ### *T4a* - T4a describes a tumor of any size with direct extension to the **chest wall** (ribs, intercostal muscles, or serratus anterior muscle) but **not** including the pectoralis muscle. - The primary feature in the image is **skin involvement** (**edema** and **erythema**), **not** direct extension to the underlying chest wall structures, which is why this is not T4a. ### *T1c* - T1c describes an invasive carcinoma where the maximum tumor dimension is **greater than 10 mm but less than or equal to 20 mm**. - This staging category is based on the size of the primary tumor mass and does not account for the extensive skin changes (**inflammatory signs**) visible in the image, which immediately mandate a T4 classification. ### *T3* - T3 describes an invasive carcinoma where the maximum tumor dimension is **greater than 50 mm**. - While the tumor size might be large, the presence of **Inflammatory breast symptoms** (**erythema**, **edema**, **peau d'orange**) overrides tumor size for T staging, escalating the stage to **T4d**.

Q: A 45-year-old lady presents with history of a painless lump in the right breast since 1 month. On examination, the lump is hard, 3 x 4 cm in size in the upper outer quadrant and is not fixed to the skin or the underlying structures. The axilla reveals firm mobile lymph nodes (level I). Rest of systemic examination is normal. The clinical stage of this disease is :

cT₂ N₁ Mₓ. **cT₂ N₁ Mₓ** - The tumor size of **3 x 4 cm** falls within the T2 classification (>2 cm but ≤5 cm). The description of the lump being "not fixed to the skin or the underlying structures" further supports a T2 (or lower) classification, as fixation would suggest a more advanced T stage (T4). - The presence of "firm mobile lymph nodes (level I)" indicates involvement of regional lymph nodes, which is classified as **N1** in breast cancer staging. An "Mx" designation means that distant metastasis cannot be assessed clinically without further investigation. *cT₃ N₁ Mₓ* - A **T3 classification** would apply if the tumor measured **greater than 5 cm** in its largest dimension, which is not the case here, as the lump is 3 x 4 cm. - While the **N1 and Mx** components are consistent with the findings, the T component is incorrect for the given tumor size. *cT₁ N₁ Mₓ* - A **T1 classification** is used for tumors that are **2 cm or less in greatest dimension**. The given tumor size of 3 x 4 cm clearly exceeds this limit. - The **N1 and Mx** components are consistent, but the T component is inappropriate for the described tumor size. *cT₃ N₂ Mₓ* - This option is incorrect on two counts: the **T3 classification** is wrong for a 3 x 4 cm tumor (should be >5 cm), and the **N2 classification** is also incorrect. - **N2** would indicate metastases to **ipsilateral axillary lymph nodes that are fixed or matted**, or in ipsilateral internal mammary lymph nodes in the absence of clinically apparent axillary lymph node metastases. The description states "firm mobile lymph nodes (level I)," which corresponds to N1, not N2.

Q: The best cosmetic result following breast reconstruction is achieved with :

Transverse rectus abdominis myocutaneous flap. ***Transverse rectus abdominis myocutaneous flap*** - The **TRAM flap** offers excellent aesthetic outcomes by utilizing the patient's own **abdominal tissue**, providing a natural look and feel that mimics breast tissue. - This method results in a soft, pliable breast mound with good long-term stability and can provide a **simultaneous abdominoplasty** effect. *Latissimus dorsi flap* - While a viable option, the **latissimus dorsi flap** is typically smaller and may require an **implant** to achieve adequate breast volume, potentially leading to a less natural result than a TRAM flap. - It uses tissue from the back, which can leave a noticeable scar and may cause **weakness in the shoulder** or back. *Silicone gel implant with reconstruction* - Implants can provide good cosmetic results but carry risks such as **capsular contracture**, rupture, and the need for future revisions, which can affect long-term satisfaction. - They do not offer the same **natural feel or warmth** as autologous tissue reconstruction, as the reconstructed breast is not made of living tissue. *Acellular dermal matrix flap* - **Acellular dermal matrix (ADM)** is often used as an adjunct in implant-based reconstruction to support and reinforce the breast tissue, rather than as a primary reconstructive flap for optimal cosmetic results. - While it aids in tissue expansion and support, it does not provide the **volume or natural contour** that an autologous flap like the TRAM can achieve on its own.

Q: Which of the following is the FIRST step in triple assessment of breast lumps? 1. Clinical assessment 2. Radiological assessment 3. Histopathological assessment 4. Sentinel lymph node biopsy

Clinical assessment. ***Clinical assessment*** - The **first step** in triple assessment involves taking a thorough history and performing a physical examination to identify concerning features of a breast lump. - This step helps to guide the subsequent radiological and histopathological investigations. *Radiological assessment* - This is the **second step** of triple assessment and typically involves mammography, ultrasound, or MRI to characterize the lump's features and extent. - It provides imaging information but does not precede the initial clinical evaluation. *Histopathological assessment* - This is the **third step**, involving a biopsy (fine needle aspiration, core needle biopsy) to obtain tissue for microscopic examination and definitive diagnosis. - While crucial for diagnosis, it follows both clinical and radiological assessments in the triple assessment pathway. *Sentinel lymph node biopsy* - This procedure is performed to determine if **cancer cells have spread** to the regional lymph nodes, typically after a confirmed diagnosis of breast cancer. - It is not part of the initial diagnostic triple assessment for a breast lump but rather a staging procedure.

Question 1

Mondor's disease is characterized by which of the following?

Accepted Answer

Thrombophlebitis of superficial veins of the breast

Answer

Migratory thrombophlebitis seen in pancreatic carcinoma

Answer

Thromboangiitis obliterans

Answer

Thrombosis of deep veins of the leg

Question 2

A 35-year-old woman, 10 years after mastectomy, notices gradual swelling and heaviness in her right upper limb without pain. On examination, bluish nodules on the skin with no infections are noted. What is the most likely cause of her symptoms?

Accepted Answer

Lymphangiosarcoma

Answer

Recurrent breast cancer

Answer

Thoracic outlet syndrome

Answer

Chronic venous insufficiency

Question 3

A 51-year-old lady presents with complaints of a mass in the right breast. On examination, the mass was larger than 5 cm and ipsilateral mobile axillary lymph nodes were present. What is the staging, considering the mass is malignant?

Accepted Answer

cT3N1M0

Answer

pT4N1M0

Answer

cT4N1M0

Answer

pT3N1M0

Question 4

Which of the following is not included in T4b classification of breast cancer?

Accepted Answer

Cellulitis/erythema over one-third of the breast (inflammatory breast cancer)

Answer

Satellite nodule

Answer

Ulceration

Answer

Peau d'orange

Question 5

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

Accepted Answer

Multiple cancer in one quadrant

Answer

Scleroderma

Answer

History of radiation

Answer

Persistent positive margin

Question 6

A 43-year-old female presents to OPD due to changes in breast and a lump in breast as given below. What is the diagnosis?

Accepted Answer

T4d

Answer

T3

Answer

T1c

Answer

T4a

Question 7

A 45-year-old lady presents with history of a painless lump in the right breast since 1 month. On examination, the lump is hard, 3 x 4 cm in size in the upper outer quadrant and is not fixed to the skin or the underlying structures. The axilla reveals firm mobile lymph nodes (level I). Rest of systemic examination is normal. The clinical stage of this disease is :

Accepted Answer

cT₂ N₁ Mₓ

Answer

cT₃ N₁ Mₓ

Answer

cT₁ N₁ Mₓ

Answer

cT₃ N₂ Mₓ

Question 8

The best cosmetic result following breast reconstruction is achieved with :

Accepted Answer

Transverse rectus abdominis myocutaneous flap

Answer

Latissimus dorsi flap

Answer

Silicone gel implant with reconstruction

Answer

Acellular dermal matrix flap

Question 9

Which of the following is the FIRST step in triple assessment of breast lumps?

1. Clinical assessment
2. Radiological assessment
3. Histopathological assessment
4. Sentinel lymph node biopsy

Accepted Answer

Clinical assessment

Answer

Radiological assessment

Answer

Sentinel lymph node biopsy

Answer

Histopathological assessment

Question 10

Which of the following vital structures in the axilla should always be preserved in modified radical mastectomy?

Accepted Answer

Axillary vein

Answer

Intercostobrachial nerves

Answer

Nerve to serratus anterior

Answer

Nerve to latissimus dorsi

Breast Surgery — MCQs

Breast Surgery — MCQs

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