Breast Surgery — MCQs

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 :

Q368

The best cosmetic result following breast reconstruction is achieved with :

Q369

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

Q370

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

Breast Surgery Indian Medical PG Practice Questions and MCQs

Question 361: Mondor's disease is characterized by which of the following?

A. Migratory thrombophlebitis seen in pancreatic carcinoma
B. Thromboangiitis obliterans
C. Thrombosis of deep veins of the leg
D. Thrombophlebitis of superficial veins of the breast (Correct Answer)

Explanation: **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.

Question 362: 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?

A. Recurrent breast cancer
B. Lymphangiosarcoma (Correct Answer)
C. Thoracic outlet syndrome
D. Chronic venous insufficiency

Explanation: ***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**.

Question 363: 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?

A. pT4N1M0
B. cT4N1M0
C. pT3N1M0
D. cT3N1M0 (Correct Answer)

Explanation: ***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

Question 364: Which of the following is not included in T4b classification of breast cancer?

A. Satellite nodule
B. Ulceration
C. Peau d'orange
D. Cellulitis/erythema over one-third of the breast (inflammatory breast cancer) (Correct Answer)

Explanation: ***Cellulitis/erythema over one-third of the breast (inflammatory breast cancer)*** - This description corresponds to a **T4d** tumor, which is classified as **Inflammatory Breast Cancer (IBC)**. - IBC is a separate classification from T4b and is characterized by erythema, edema, and peau d'orange involving at least one-third of the breast, often with rapid onset. - T4d is **not included in T4b classification**; it is a distinct category within T4 tumors. *Incorrect: Satellite nodule* - **Satellite skin nodules** are a feature that can be included in **T4b** classification according to AJCC staging. - T4b includes ulceration and/or ipsilateral satellite nodules and/or edema of the skin (including peau d'orange). *Incorrect: Ulceration* - **Skin ulceration** is a specific defining feature of **T4b** tumors. - It represents direct tumor extension causing breakdown of the overlying skin. *Incorrect: Peau d'orange* - **Peau d'orange** (skin edema due to lymphatic obstruction) is a characteristic feature of **T4b** classification. - It gives the skin an orange-peel appearance and indicates locally advanced disease.

Question 365: Which of the following is not a contraindication for breast conservation surgery?

A. Scleroderma
B. History of radiation
C. Multiple cancer in one quadrant (Correct Answer)
D. Persistent positive margin

Explanation: ***Multiple cancer in one quadrant*** - This presentation is defined as **multifocal carcinoma**, where multiple tumor foci are located within the same quadrant of the breast. - Unlike true multicentric disease (carcinoma in two or more quadrants), multifocal disease is **not an absolute contraindication** for breast conservation surgery (BCS), provided all lesions can be excised with clear margins and the planned cosmetic result is acceptable. ***Scleroderma*** - Active connective tissue disorders like **scleroderma** or active **Systemic Lupus Erythematosus (SLE)** are absolute contraindications for BCS due to a high risk of adverse reactions to post-operative radiotherapy. - Radiation in these patients can lead to severe complications, including high rates of **fibrosis**, edema, and poor cosmetic outcomes. ***History of radiation*** - A **previous history of therapeutic radiation** to the breast or chest wall (e.g., for Hodgkin's lymphoma or previous breast cancer) is an absolute contraindication. - Re-irradiating the same tissue increases the risk of severe cumulative dose toxicity, local complications, and potentially **radiation-induced malignancy**. ***Persistent positive margin*** - The inability to achieve tumor-free margins of excision, even after **multiple re-excisions** (usually 2-3 attempts), remains an absolute contraindication to BCS. - Performing BCS despite persistently positive margins results in an unacceptably high risk of local recurrence, necessitating a complete **mastectomy**.

Question 366: 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?

A. T4d (Correct Answer)
B. T3
C. T1c
D. T4a

Explanation: ### ***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**.

Question 367: 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 :

A. cT₃ N₁ Mₓ
B. cT₂ N₁ Mₓ (Correct Answer)
C. cT₁ N₁ Mₓ
D. cT₃ N₂ Mₓ

Explanation: **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.

Question 368: The best cosmetic result following breast reconstruction is achieved with :

A. Latissimus dorsi flap
B. Silicone gel implant with reconstruction
C. Acellular dermal matrix flap
D. Transverse rectus abdominis myocutaneous flap (Correct Answer)

Explanation: ***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.

Question 369: 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

A. Radiological assessment
B. Sentinel lymph node biopsy
C. Histopathological assessment
D. Clinical assessment (Correct Answer)

Explanation: ***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 370: Which of the following vital structures in the axilla should always be preserved in modified radical mastectomy?

A. Intercostobrachial nerves
B. Nerve to serratus anterior
C. Nerve to latissimus dorsi
D. Axillary vein (Correct Answer)

Explanation: ***Axillary vein*** - The **axillary vein** is the only structure that must be preserved in **all cases** of modified radical mastectomy without exception. - It is a major conduit for venous return from the upper limb; its injury or sacrifice would cause **severe venous congestion** and **marked lymphedema** of the arm, representing a major surgical complication. - Unlike the nerves listed below, there is **no acceptable clinical scenario** where the axillary vein can be intentionally sacrificed during MRM. *Intercostobrachial nerves* - The **intercostobrachial nerves** provide sensation to the axilla and medial aspect of the arm. - While their preservation minimizes **postoperative numbness** and discomfort, they are **frequently sacrificed** during level II axillary dissection to achieve adequate lymph node clearance. - Their sacrifice is an accepted consequence of thorough axillary dissection. *Nerve to serratus anterior (Long thoracic nerve)* - The **long thoracic nerve** innervates the serratus anterior muscle, which is crucial for scapular stability. - Its injury causes **winged scapula**, significantly impairing shoulder movement. - While preservation is **attempted and highly desirable**, it may need to be sacrificed if there is **direct tumor involvement** or to achieve adequate oncologic clearance. - Preservation is the goal but not absolute in all cases. *Nerve to latissimus dorsi (Thoracodorsal nerve)* - The **thoracodorsal nerve** innervates the latissimus dorsi muscle, important for shoulder function and potential breast reconstruction. - While preservation is **strongly preferred**, it may need to be sacrificed if there is **lymph node involvement along its course** or direct tumor invasion. - Like the long thoracic nerve, preservation is attempted but not guaranteed in all cases. **Key Distinction:** The question asks what "should **always** be preserved" - the axillary vein is the only structure where preservation is absolute and non-negotiable. The motor nerves (long thoracic and thoracodorsal) are critical structures that surgeons attempt to preserve, but their sacrifice may be necessary for oncologic reasons in some cases.

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