Breast Surgery — MCQs

Breast Surgery Indian Medical PG Practice Questions and MCQs

Question 371: Which one of the following is not a correct statement with reference to locally advanced carcinoma breast ?

A. Patients are staged as T3 or T4 with any N, without distant metastasis (M0)
B. It constitutes the bulk of patients of carcinoma breast in India
C. Neoadjuvant chemotherapy downgrades the disease
D. Radical Mastectomy is the treatment of choice (Correct Answer)

Explanation: *Patients are staged as T3 or T4 with any N, without distant metastasis (M0)* - **Locally advanced breast cancer (LABC)** is correctly defined as tumors that are **T3 or T4** or involve regional lymph nodes (**any N**) without distant metastasis (**M0**). - This statement is **correct** regarding LABC staging criteria. *It constitutes the bulk of patients of carcinoma breast in India* - This statement is **correct**. In India, approximately **50-60% of breast cancer patients present with locally advanced disease** at the time of diagnosis. - This is in stark contrast to Western countries where LABC represents less than 10% of cases. - The high prevalence is attributed to lack of screening programs, delayed presentation, limited awareness, and socioeconomic factors. *Neoadjuvant chemotherapy downgrades the disease* - This statement is **correct**. **Neoadjuvant chemotherapy (NACT)** is a cornerstone of LABC management. - NACT aims to **downstage** the tumor, making it more amenable to surgical resection and increasing the feasibility of breast-conserving surgery. - It also provides early treatment of micrometastases and serves as an in vivo test of tumor chemosensitivity. ***Radical Mastectomy is the treatment of choice*** - This statement is **INCORRECT** and is the correct answer to this negation question. - **Radical mastectomy (Halsted mastectomy)** involving removal of breast, pectoral muscles, and axillary nodes is **no longer the standard treatment** for LABC. - Modern treatment involves a **multimodal approach**: neoadjuvant chemotherapy followed by **modified radical mastectomy (MRM)** or breast-conserving surgery with radiation therapy. - MRM preserves the pectoral muscles, providing better functional and cosmetic outcomes while maintaining oncological safety.

Question 372: The inflammatory breast carcinoma is staged as

A. T4d (Correct Answer)
B. T4c
C. T1a
D. T1b

Explanation: ***T4d*** - **Inflammatory breast carcinoma** is by definition a **T4d tumor** in the TNM staging system, regardless of tumor size. - This designation reflects the aggressive nature and characteristic features of erythema and edema involving a substantial portion of the breast. *T4c* - **T4c** refers to either **T4a** (chest wall invasion) and **T4b** (ulceration, edema, or skin nodules) combined. - While these can be features of advanced breast cancer, they do not specifically define inflammatory breast carcinoma. *T1a* - **T1a** describes a tumor size of **greater than 0.5 cm but not more than 1 cm** in greatest dimension. - Inflammatory breast carcinoma is not staged based on tumor size in this manner due to its diffuse nature. *T1b* - **T1b** describes a tumor size of **greater than 1 cm but not more than 2 cm** in greatest dimension. - Inflammatory breast carcinoma is characterized by diffuse involvement of the breast skin and does not fit into typical size-based T categories like T1b.

Question 373: A patient has a 6-cm breast tumor with mobile, clinically positive, ipsilateral axillary lymph nodes and no evidence of distant metastasis. The stage of the breast cancer is

A. Stage IIIb
B. Stage I
C. Stage IIb (Correct Answer)
D. Stage IIIa

Explanation: ***Stage IIb*** - A 6-cm tumor (T3) in the presence of mobile, clinically positive, ipsilateral axillary lymph nodes (N1) and no distant metastasis (M0) fits the criteria for **Stage IIB** according to the AJCC 8th edition TNM classification. - The TNM classification defines T3 as a tumor >5 cm and N1 as metastasis to **ipsilateral movable axillary lymph nodes**. - **T3N1M0 = Stage IIB** definitively. *Stage IIIa* - Stage IIIA would require **T3 with N2 nodes** (fixed/matted axillary nodes or clinically detected internal mammary nodes without axillary involvement), or **T0-T2 with N2**, or **T4 with N1**. - N2 nodes refer to **fixed/matted axillary nodes** or internal mammary nodes, which are not described here. - The patient has **N1 nodes** (mobile), not N2. *Stage IIIb* - Stage IIIB would involve **T4 disease** (tumor of any size with direct extension to chest wall or skin involvement like ulceration, ipsilateral satellite nodules, or inflammatory breast cancer). - The given tumor does not show signs of **locally advanced disease** such as chest wall invasion or skin involvement. *Stage I* - Stage I describes **small tumors** (T1, ≤2 cm) with no lymph node involvement (N0) or micrometastases only (N1mi). - The tumor size of 6 cm and presence of **clinically evident axillary lymph node involvement** preclude a Stage I diagnosis.

Question 374: Which of the following does not alter the T stage in breast cancer?

A. Pectoral muscle involvement
B. Nipple retraction (Correct Answer)
C. Skin ulceration
D. Peau d'orange

Explanation: ***Nipple retraction*** - Nipple retraction, while a significant clinical sign that can indicate an underlying malignancy, does **not alter the T stage** (tumor size and extent) of breast cancer. - It is considered a local sign of tumor proximity or involvement but does not classify the tumor into a T4 category according to AJCC TNM staging. - Nipple retraction may be seen with various T stages and is **not a criterion for upstaging**. *Pectoral muscle involvement* - **Important note**: Involvement of the **pectoralis muscle alone does NOT alter T stage** according to current AJCC TNM classification. - Only **chest wall involvement** (ribs, intercostal muscles, serratus anterior) qualifies as **T4b**. - This is a common point of confusion, but pectoralis muscle is **not considered chest wall** for staging purposes. *Skin ulceration* - **Skin ulceration** directly reflects tumor invasion through the skin of the breast. - This finding is a criterion for classifying the tumor as **T4b**, indicating advanced local disease. - Clearly **alters the T stage** regardless of tumor size. *Peau d'orange* - **Peau d'orange** (orange peel appearance) is caused by obstruction of dermal lymphatics by tumor cells, leading to **skin edema**. - This sign is a criterion for classifying the tumor as **T4b** (edema of the skin including peau d'orange). - Clearly **alters the T stage** and indicates advanced local disease.

Question 375: In carcinoma breast, adjuvant radiotherapy is indicated after modified radical mastectomy in all of the following, except

A. more than four positive axillary lymph nodes
B. positive margins
C. tumour size more than 5 cm
D. ER, PR hormone receptor negative tumour (Correct Answer)

Explanation: ***ER, PR hormone receptor negative tumour*** - While **ER/PR negative** tumors (including triple-negative breast cancers) are often more aggressive and have higher recurrence rates, **adjuvant radiotherapy** post-mastectomy is primarily dictated by **local-regional anatomic and pathologic factors**, not solely by receptor status. - **ER/PR negative status is NOT a standalone indication** for post-mastectomy radiation therapy (PMRT) in guidelines. The decision for radiotherapy is based on **tumor burden, nodal involvement, and surgical margins**. - Receptor status influences systemic therapy choices but does not independently determine the need for radiotherapy after adequate surgical resection. *more than four positive axillary lymph nodes* - The presence of **four or more positive axillary lymph nodes** is one of the **strongest indications** for post-mastectomy radiation therapy. - This degree of nodal involvement significantly increases the risk of locoregional recurrence, and **PMRT is standard of care** in this scenario. - Guidelines consistently recommend radiotherapy to the chest wall and regional nodal basins when ≥4 nodes are positive. *positive margins* - **Positive surgical margins** after mastectomy indicate residual tumor cells along the resection edges, representing an **absolute indication** for adjuvant radiotherapy if re-excision is not feasible. - This is a **pathologic criterion** that directly indicates microscopic residual disease requiring radiation for local control. - PMRT significantly reduces local recurrence risk in this high-risk scenario. *tumour size more than 5 cm* - A **tumor size greater than 5 cm** (T3 classification) is an **established indication** for post-mastectomy radiation therapy, independent of nodal status. - This substantial tumor burden is associated with higher locoregional recurrence risk even after complete surgical resection. - **PMRT improves locoregional control** and overall outcomes in patients with T3 tumors.

Question 376: Which of the following is NOT correct for breast abscess?

A. Antibiotic is given if pus is already present
B. A counterincision is made in the dependant part (Correct Answer)
C. Drainage of abscess by a radial incision
D. Dressings are changed frequently

Explanation: ***A counterincision is made in the dependant part*** - For breast abscesses, making a **counterincision** is generally *not* the standard practice unless there are specific, complex circumstances requiring additional drainage. - The primary goal is to **incise and drain** the abscess in one go, without the need for additional counterincisions. *Antibiotic is given if pus is already present* - **Antibiotics** are typically initiated *before* pus formation and continue **post-drainage** to manage infection. - If pus is already present, drainage is the primary treatment, but antibiotics are also necessary to treat the underlying infection and prevent recurrence. *Drainage of abscess by a radial incision* - **Radial incisions** are the preferred method for draining breast abscesses as they align with the natural **ductal architecture** of the breast. - This approach minimizes damage to milk ducts and reduces the risk of **fistula formation** while promoting better cosmetic outcomes. *Dressings are changed frequently* - **Frequent dressing changes** (e.g., daily or every shift) are crucial for managing an open wound after abscess drainage. - This helps to remove **exudate**, monitor for signs of infection, and ensure proper **wound healing** by allowing the cavity to heal from the inside out.

Question 377: Mondor’s disease is

A. Multiple breast cysts
B. Eczema of nipple and areola
C. Thrombophlebitis of superficial veins of breast (Correct Answer)
D. Lymphangitis of mammary lymphatics

Explanation: ***Thrombophlebitis of superficial veins of breast*** - Mondor's disease is characterized by **thrombophlebitis**, which is inflammation and clotting, of the **superficial veins of the breast** and sometimes the chest wall. - It often manifests as a **palpable, tender cord-like structure** under the skin. *Multiple breast cysts* - This condition involves the presence of **fluid-filled sacs** within the breast tissue, which can be palpable but do not present as a classic cord-like structure. - Cysts are typically smooth, mobile, and can fluctuate in size with the **menstrual cycle**, unlike Mondor's disease. *Eczema by nipple and areola* - This refers to an **inflammatory skin condition** affecting the **nipple and areola**, characterized by redness, itching, scaling, and sometimes oozing. - It is a **dermatological issue** and does not involve vascular clotting or a palpable cord. *Lymphangitis of mammary lymphatics* - **Lymphangitis** is the inflammation of **lymphatic vessels**, often presenting as red streaks and tenderness. - While it can affect the breast, it involves the **lymphatic system** rather than the superficial venous system and would not typically present as a thrombosed vessel.

Question 378: Regarding breast conservative therapy and issue of post operative local recurrence, all are true except:

A. Margins should be clear for ductal carcinoma in situ (DCIS)
B. Margins should be clear for invasive cancer
C. Lumpectomy can be considered in any size provided the tumour can be excised with clear margins and acceptable cosmetic results
D. Margins should be clear for lobular carcinoma in situ (LCIS) (Correct Answer)

Explanation: ***Margins should be clear for lobular carcinoma in situ (LCIS)*** - This statement is incorrect because **LCIS** is considered a **risk indicator** rather than a true malignant entity requiring clear margins. It represents an increased risk for invasive carcinoma in either breast. - While clear margins are crucial for invasive and in-situ ductal cancers, the presence of LCIS at a margin is not typically an indication for re-excision. *Margins should be clear for ductal carcinoma in situ (DCIS)* - This statement is true. Achieving **negative margins** (no tumor cells at the inked surgical margin) is critical for **DCIS** to minimize local recurrence risk. - Positive or close margins for DCIS often necessitate re-excision or a boost in radiation therapy to improve local control. *Margins should be clear for invasive cancer* - This statement is true. For **invasive breast cancer**, a **negative margin** (no tumor on ink) is a standard of care to reduce the risk of **local recurrence**. - Consensus guidelines recommend that "no ink on tumor" is an adequate negative margin for invasive cancer treated with breast-conserving therapy. *Lumpectomy can be considered in any size provided the tumour can be excised with clear margins and acceptable cosmetic results* - This statement is true. The **absolute size** of the tumor is less important than the **ratio** of tumor size to breast size that allows for **clear margins** and an **acceptable cosmetic outcome**. - Large tumors in large breasts or smaller tumors in very small breasts can both be candidates for lumpectomy if these criteria are met.

Question 379: Milan trial, NSABP trial and EORTC trial in breast cancer compared:

A. Neoadjuvant chemotherapy vs Adjuvant chemotherapy
B. Hormonal vs Chemotherapy
C. Chemotherapy vs Radiotherapy in breast cancer
D. Breast conservative therapy vs Mastectomy (Correct Answer)

Explanation: **Breast conservative therapy vs Mastectomy** * The **Milan trial**, **NSABP trial (B-04 and B-06)**, and **EORTC trial** were pivotal studies that compared the efficacy and outcomes of **breast conservative therapy (BCT)** followed by radiation therapy against **mastectomy** for early-stage breast cancer. * These trials established that BCT with radiation offers comparable survival rates to mastectomy, transforming the surgical management of breast cancer. *Neo adjuvant chemotherapy vs Adjuvant chemotherapy* * While these are important questions in breast cancer management, the specific trials mentioned (**Milan, NSABP B-04/B-06, EORTC**) did not primarily focus on comparing neo-adjuvant versus adjuvant chemotherapy strategies. * Their main objective was to evaluate surgical approaches: lumpectomy plus radiation versus mastectomy. *Hormonal vs Chemotherapy* * The trials mentioned did not directly compare hormonal therapy against chemotherapy. These are distinct systemic treatment modalities used in different contexts. * The focus was on the extent of surgical intervention, with systemic therapies often applied in addition to surgery based on tumor characteristics. *Chemotherapy vs Radiotherapy in breast cancer* * These trials did not compare chemotherapy directly against radiotherapy. Radiotherapy was an integral component of the **breast-conserving therapy** arm, used to reduce local recurrence after lumpectomy. * Chemotherapy is a systemic treatment, while radiotherapy is a local treatment, and their roles are generally complementary rather than mutually exclusive or directly competitive in these study designs.

Question 380: A 35 year old female has inflammatory carcinoma of left breast, with clinically palpable two left axillary lymph nodes and no clinically or radiologically detectable metastasis. Her TNM staging will be:

A. T4 N2 M0
B. T4d N2 M0
C. T4b N2 M0
D. T4d N1 M0 (Correct Answer)

Explanation: ***T4d N1 M0*** - **Inflammatory carcinoma** of the breast is by definition staged as **T4d**, irrespective of tumor size or extent. - **Palpable two left axillary lymph nodes** would be considered N1 disease, representing metastases to 1-3 axillary lymph nodes. *T4 N2 M0* - While T4 is correct for inflammatory carcinoma, **N2 disease** implies involvement of 4-9 axillary lymph nodes or clinically apparent internal mammary nodes and is not consistent with "two clinically palpable axillary lymph nodes." - The M0 component (no distant metastasis) is correct. *T4d N2 M0* - **T4d** correctly identifies inflammatory breast cancer. - However, **N2 disease** is characterized by involvement of 4-9 ipsilateral axillary lymph nodes or clinically apparent ipsilateral internal mammary lymph nodes in the absence of axillary lymph node metastases, which does not fit the description of "two palpable axillary lymph nodes." *T4b N2 M0* - **T4b** refers to breast cancer with chest wall involvement, ulceration, or ipsilateral satellite skin nodules, but not inflammatory carcinoma, which is specifically **T4d**. - **N2** disease is incorrect here based on the number of palpable nodes described.

Practice by Chapter

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