Breast Surgery Practice Questions

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

Radical Mastectomy is the treatment of choice. *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.

Q: The inflammatory breast carcinoma is staged as

T4d. ***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.

Q: 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

Stage IIIa. ***Stage IIIa*** - A **6-cm tumor (T3)** with **mobile, clinically positive ipsilateral axillary lymph nodes (N1)** and **no distant metastasis (M0)** classifies as **T3N1M0 = Stage IIIA** according to AJCC TNM staging. - Stage IIIA includes **T3N1M0** among other combinations, representing locally advanced breast cancer with significant tumor burden and regional nodal involvement. *Stage IIb* - Stage IIB is classified as **T2N1M0** (2-5 cm tumor with mobile axillary nodes) or **T3N0M0** (>5 cm tumor with no nodal involvement). - This patient has **T3N1M0**, which exceeds Stage IIB criteria due to the combination of large tumor size and positive lymph nodes. *Stage I* - Stage I involves **small tumors (T1, ≤2 cm)** with **no lymph node involvement (N0)** or only micrometastases. - The **6-cm tumor size** and **clinically evident axillary lymph node involvement** far exceed Stage I parameters. *Stage IIIb* - Stage IIIB requires **T4 disease** with chest wall invasion, skin involvement (ulceration, satellite nodules), or inflammatory breast cancer features. - This case shows **T3 disease** without signs of **locally advanced features** like chest wall fixation or skin changes.

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

Nipple retraction. ***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.

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

A counterincision is made in the dependant part. ***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.

Q: Mondor’s disease is

Thrombophlebitis of superficial veins of breast. ***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.

Q: Milan trial, NSABP trial and EORTC trial in breast cancer compared:

Breast conservative therapy vs Mastectomy. **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.

Q: 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:

T4d N1 M0. ***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.

Question 1

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

Accepted Answer

Radical Mastectomy is the treatment of choice

Answer

Patients are staged as T3 or T4 with any N, without distant metastasis (M0)

Answer

It constitutes the bulk of patients of carcinoma breast in India

Answer

Neoadjuvant chemotherapy downgrades the disease

Question 2

The inflammatory breast carcinoma is staged as

Accepted Answer

T4d

Answer

T4c

Answer

T1a

Answer

T1b

Question 3

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

Accepted Answer

Stage IIIa

Answer

Stage IIIb

Answer

Stage I

Answer

Stage IIb

Question 4

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

Accepted Answer

Nipple retraction

Answer

Pectoral muscle involvement

Answer

Skin ulceration

Answer

Peau d'orange

Question 5

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

Accepted Answer

ER, PR hormone receptor negative tumour

Answer

more than four positive axillary lymph nodes

Answer

positive margins

Answer

tumour size more than 5 cm

Question 6

Which of the following is NOT correct for breast abscess?

Accepted Answer

A counterincision is made in the dependant part

Answer

Antibiotic is given if pus is already present

Answer

Drainage of abscess by a radial incision

Answer

Dressings are changed frequently

Question 7

Mondor’s disease is

Accepted Answer

Thrombophlebitis of superficial veins of breast

Answer

Multiple breast cysts

Answer

Eczema of nipple and areola

Answer

Lymphangitis of mammary lymphatics

Question 8

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

Accepted Answer

Margins should be clear for lobular carcinoma in situ (LCIS)

Answer

Margins should be clear for ductal carcinoma in situ (DCIS)

Answer

Margins should be clear for invasive cancer

Answer

Lumpectomy can be considered in any size provided the tumour can be excised with clear margins and acceptable cosmetic results

Question 9

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

Accepted Answer

Breast conservative therapy vs Mastectomy

Answer

Neoadjuvant chemotherapy vs Adjuvant chemotherapy

Answer

Hormonal vs Chemotherapy

Answer

Chemotherapy vs Radiotherapy in breast cancer

Question 10

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:

Accepted Answer

T4d N1 M0

Answer

T4 N2 M0

Answer

T4d N2 M0

Answer

T4b N2 M0

Breast Surgery — MCQs

Breast Surgery — MCQs

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