Breast Surgery — MCQs
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A 55-year-old female patient presented with a $4 \times 3 \mathrm{~cm}$ lump in the right upper outer quadrant, with no axillary lymph node involvement. Mammography revealed BIRADS 4b staging. She underwent breast conservation surgery, and the final HPE report showed high nuclear-grade DCIS with necrosis and 10 mm margin clearance. What is the further management?
Dye for Sentinel Lymph Node Biopsy is injected in which of the following sites?
A 40-year-old patient is diagnosed with a localized 1 cm infiltrating ductal cancer after a needle core biopsy of the lesion. She is clinical node negative; a lumpectomy and sentinel lymph node biopsy are performed. The patient develops an anaphylactic response during the case. Which of the following substances was the likely causative agent?
Peau d’orange appearance is due to -
Triple assessment for carcinoma breast includes:
Using a small fine probe, a single lactiferous duct is excised. What is the name of the procedure:
Which of the following is not true about breast cancer?
What factors should be considered when choosing between implant-based and autologous breast reconstruction options for a patient after mastectomy?
What is the impact of sentinel lymph node biopsy (SLNB) compared to axillary lymph node dissection (ALND) on lymphedema rates in patients with breast carcinoma?
A 45-year-old female presents with a lump in the breast and axillary lymphadenopathy. What is the most likely diagnosis?
Breast Surgery Indian Medical PG Practice Questions and MCQs
Question 391: A 55-year-old female patient presented with a $4 \times 3 \mathrm{~cm}$ lump in the right upper outer quadrant, with no axillary lymph node involvement. Mammography revealed BIRADS 4b staging. She underwent breast conservation surgery, and the final HPE report showed high nuclear-grade DCIS with necrosis and 10 mm margin clearance. What is the further management?
- A. Follow up 6 monthly for 2 years and then yearly follow up
- B. Trastuzumab therapy
- C. Adjuvant chemotherapy
- D. Adjuvant radiotherapy (Correct Answer)
Explanation: ***Adjuvant radiotherapy*** - For **high-grade DCIS** with necrosis after breast conservation surgery, adjuvant radiotherapy significantly reduces the risk of **local recurrence** (by approximately 50%). - Even with adequate margin clearance (10 mm), radiotherapy is recommended to treat **potential residual microscopic disease** elsewhere in the breast tissue. - This is the **standard of care** for high-grade DCIS post-BCS, particularly when necrosis is present. *Follow up 6 monthly for 2 years and then yearly follow up* - While regular follow-up is essential for all breast cancer patients, it is **not sufficient alone** for high-grade DCIS treated with breast conservation. - **Adjuvant radiotherapy** is necessary to reduce recurrence risk before initiating the follow-up schedule. *Trastuzumab therapy* - **Trastuzumab** is specifically indicated for **HER2-positive invasive breast cancer**. - The patient has **DCIS**, which is **non-invasive (in situ)**, making trastuzumab inappropriate. - There is no role for targeted therapy in DCIS management. *Adjuvant chemotherapy* - **Adjuvant chemotherapy** is generally reserved for **invasive breast cancers**, especially those with high-risk features like lymph node involvement or aggressive tumor biology. - For **DCIS**, even high-grade with necrosis, chemotherapy is **not indicated** as it provides no proven benefit for non-invasive disease.
Question 392: Dye for Sentinel Lymph Node Biopsy is injected in which of the following sites?
- A. Nipple
- B. Axilla
- C. Areola (Correct Answer)
- D. Tail of spence
Explanation: ***Areola*** - The **areola** is the primary site for injecting dye in sentinel lymph node biopsy because it is rich in **lymphatic vessels** that directly drain into the regional lymph nodes. - This method ensures the dye follows the natural lymphatic drainage pathway, accurately identifying the **first lymph node** to receive drainage from the tumor. *Nipple* - While the nipple is part of the breast, it has a less dense network of **lymphatic vessels** compared to the areola. - Injection directly into the nipple may not consistently identify the sentinel lymph node as effectively as periareolar or intratumoral injections. *Axilla* - The **axilla** contains the regional lymph nodes that are the *target* for identification, not the site of dye injection. - Injecting dye directly into the axilla would bypass the lymphatic drainage from the tumor, making the biopsy ineffective. *Tail of spence* - The **tail of Spence** is an extension of breast tissue into the axilla, and while it contains breast tissue, it is not the most optimal or primary site for dye injection. - The lymphatic drainage from the tail of Spence would still rely on the broader lymphatic network, which is best accessed via the central breast regions like the areola.
Question 393: A 40-year-old patient is diagnosed with a localized 1 cm infiltrating ductal cancer after a needle core biopsy of the lesion. She is clinical node negative; a lumpectomy and sentinel lymph node biopsy are performed. The patient develops an anaphylactic response during the case. Which of the following substances was the likely causative agent?
- A. Isosulfan blue dye (Correct Answer)
- B. Patent blue dye
- C. 99 Tc radiolabeled colloid
- D. Methylene blue dye
Explanation: ***Isosulfan blue dye*** - **Isosulfan blue dye** is commonly used in sentinel lymph node biopsy procedures for its ability to stain lymphatic channels, but it carries the **highest risk of anaphylactic reactions** among lymphatic mapping agents. - The incidence of anaphylaxis with isosulfan blue ranges from **0.07-2%**, significantly higher than other tracers. - The patient's development of an **anaphylactic response** during the case strongly points to isosulfan blue as the causative agent due to its documented allergenicity. *Patent blue dye* - **Patent blue dye** is another lymphatic mapping dye used for sentinel lymph node biopsy, particularly in European practice. - While it can also cause allergic reactions, the incidence of **severe anaphylaxis** is lower than with isosulfan blue, making it a less likely culprit in this case. - Patent blue and isosulfan blue are structurally similar, but isosulfan blue has higher reported anaphylaxis rates in clinical practice. *99 Tc radiolabeled colloid* - **Technetium-99m (99mTc) radiolabeled colloid** is widely used in sentinel lymph node mapping due to its excellent lymphatic tracking and low incidence of allergic reactions. - Anaphylaxis to **radiopharmaceuticals** is extremely rare compared to reactions to blue dyes, with virtually no reported cases during SLNB. *Methylene blue dye* - **Methylene blue dye** is an alternative to isosulfan blue for sentinel lymph node mapping, especially in patients with a history of isosulfan blue allergy. - While allergic reactions can occur, **methylene blue** is generally associated with a significantly lower incidence of severe anaphylaxis than isosulfan blue.
Question 394: Peau d’orange appearance is due to -
- A. Intra-epithelial cancer
- B. Vascular embolization
- C. Lymphatic permeation (Correct Answer)
- D. Sub-epidermal cancer
Explanation: ***Lymphatic permeation*** - **Peau d'orange**, or "orange peel" appearance, is characteristic of advanced breast cancer and is caused by **edema of the skin** due to **blockage of subcutaneous lymphatic drainage**. - The skin over the affected area becomes rigid and swollen, accentuating the hair follicles and leading to a dimpled appearance similar to an orange peel. *Intra-epithelial cancer* - **Intra-epithelial cancer**, such as ductal carcinoma in situ (DCIS), is confined to the epithelium and does not typically directly cause diffuse skin changes like **peau d'orange**. - It involves proliferation of malignant cells within the ducts or lobules without invasion of the **basement membrane**. *Vascular embolization* - **Vascular embolization** refers to the blockage of blood vessels by an embolus, which would cause ischemia or infarction, not diffuse skin edema with a dimpled appearance. - While cancer can spread via blood vessels, this mechanism does not directly result in the specific **peau d'orange** phenomenon. *Sub-epidermal cancer* - **Sub-epidermal cancer** might refer to a tumor lying beneath the epidermis, but this term is not standard for describing the cause of peau d'orange. - The appearance is due to lymphatic obstruction and edema, not merely the presence of a tumor in a specific layer, unless that tumor is causing the **lymphatic blockage**.
Question 395: Triple assessment for carcinoma breast includes:
- A. Observation, Ultrasonography, biopsy/cytology
- B. History, clinical examination, biopsy/cytology
- C. History, clinical examination, Ultrasonography
- D. Clinical examination, Mammography, biopsy/cytology (Correct Answer)
Explanation: ***Clinical examination, Mammography, biopsy/cytology*** - The **triple assessment** for breast carcinoma is a gold standard diagnostic approach comprising **clinical evaluation**, **imaging studies**, and **histopathological assessment**. - **Clinical examination** assesses physical signs, **mammography** provides imaging, and **biopsy/cytology** offers definitive tissue diagnosis. *Observation, Ultrasonography, biopsy/cytology* - **Observation** is not a formal component of the triple assessment; it lacks the specific diagnostic purpose of clinical examination. - While **ultrasonography** is an important imaging modality, particularly for younger women or dense breasts, **mammography** is typically the primary imaging component for initial screening in the triple assessment. *History, clinical examination, biopsy/cytology* - **History** is crucial for understanding risk factors and symptom presentation but is considered part of the broader clinical workup rather than one of the specific "triple" components. - This option omits crucial **imaging**, which is a mandatory part of the triple assessment. *History, clinical examination, Ultrasonography* - While history and clinical examination are vital, this option completely lacks a **histopathological component (biopsy/cytology)**, which is essential for definitive diagnosis of malignancy. - This option also specifies **ultrasonography** over mammography, which, while useful, may not be the primary initial imaging component in all triple assessments.
Question 396: Using a small fine probe, a single lactiferous duct is excised. What is the name of the procedure:
- A. Microdochectomy (Correct Answer)
- B. Hadfield operation
- C. Webster operation
- D. Macrodochectomy
Explanation: ***Microdochectomy*** - This procedure involves the **excision of a single, lactiferous duct** often identified using a fine probe or ductoscope. - It is typically performed to investigate or treat **pathological nipple discharge** originating from a specific duct. *Hadfield operation* - This is a more extensive procedure known as a **total duct excision** or **subareolar duct excision**. - It involves the removal of **all major lactiferous ducts** under the nipple, not just a single one. *Webster operation* - The Webster operation refers to an **inferior pedicle reduction mammoplasty** technique. - It is a type of **breast reduction surgery** and is not related to the excision of an isolated lactiferous duct. *Macrodochectomy* - This term is **not a recognized medical procedure** in the context of duct excision. - While "macro" implies large, it does not describe a specific surgical technique for duct removal.
Question 397: Which of the following is not true about breast cancer?
- A. Family history is a risk factor
- B. Paget’s disease affects the nipple
- C. Lobular carcinoma is most common (Correct Answer)
- D. Estrogen exposure increases risk
Explanation: ***Lobular carcinoma is most common*** - This statement is **incorrect** because **invasive ductal carcinoma (IDC)** accounts for the majority (**70-80%**) of all breast cancers. - While **invasive lobular carcinoma (ILC)** is the second most common type, it only represents about **5-15%** of cases. *Family history is a risk factor* - A **positive family history**, especially in a first-degree relative, significantly increases the risk of breast cancer due to inherited genetic mutations like **BRCA1** and **BRCA2**. - These mutations impair DNA repair, leading to uncontrolled cell growth. *Paget’s disease affects the nipple* - **Paget's disease of the nipple** is a rare form of breast cancer that presents as an eczematous lesion of the nipple and areola. - It is often associated with an **underlying invasive or in-situ ductal carcinoma**. *Estrogen exposure increases risk* - Prolonged or higher levels of **estrogen exposure** are known risk factors for breast cancer, as estrogen stimulates the growth of hormone-receptor-positive breast cancer cells. - Factors increasing estrogen exposure include **early menarche, late menopause, obesity**, and **hormone replacement therapy**.
Question 398: What factors should be considered when choosing between implant-based and autologous breast reconstruction options for a patient after mastectomy?
- A. Patient's aesthetic preferences and desired breast size.
- B. Financial implications and insurance coverage.
- C. Oncological factors and timing of adjuvant therapy.
- D. Patient's body image concerns, availability of donor tissue, recovery time, and medical comorbidities. (Correct Answer)
Explanation: ***Patient's body image concerns, availability of donor tissue, recovery time, and medical comorbidities.*** - This option encompasses the **most comprehensive set of factors** influencing the choice between implant-based and autologous reconstruction, addressing **patient-centered, surgical feasibility, and medical safety considerations**. - **Body image concerns** directly impact patient satisfaction and psychological outcomes, which are paramount in reconstructive surgery. - **Donor tissue availability** (adequate abdominal tissue, back tissue, or other donor sites) determines the **feasibility of autologous reconstruction**—patients with insufficient donor tissue may not be candidates. - **Recovery time** is significantly different between methods: autologous reconstruction involves longer operative time and recovery (6-8 weeks) vs implant-based (2-4 weeks), impacting patient's ability to return to work and daily activities. - **Medical comorbidities** (diabetes, smoking, obesity, vascular disease) extensively influence surgical risk, healing capacity, and complication rates for both methods, making this a critical determinant of safety and outcomes. *Patient's aesthetic preferences and desired breast size.* - While **aesthetic preferences** and **desired breast size** are important for patient satisfaction, they represent only a subset of considerations and can often be achieved with either reconstruction method. - These factors alone do not address the **surgical feasibility, medical safety, or recovery implications** that are essential for appropriate patient selection. *Financial implications and insurance coverage.* - **Financial implications** and **insurance coverage** are practical considerations that affect accessibility, but they do not determine which reconstruction method is **medically appropriate or clinically superior** for a given patient's health profile. - In the Indian context, while cost matters, clinical decision-making should prioritize medical suitability and patient safety over financial factors. *Oncological factors and timing of adjuvant therapy.* - **Oncological factors** and **timing of adjuvant therapy** are indeed important considerations. Post-mastectomy radiation therapy (PMRT) can influence outcomes, as **radiation increases implant complication rates** and may favor autologous reconstruction or delayed timing. - However, these factors primarily dictate the **timing** (immediate vs delayed) and **sequencing** of reconstruction, and can often be accommodated with either method through appropriate planning (e.g., delayed-immediate reconstruction, tissue expanders). - While important, this option is **narrower in scope** compared to Option 1, which addresses multiple critical domains (patient factors, surgical feasibility, medical safety, and recovery) that comprehensively determine the appropriate reconstruction approach for an individual patient.
Question 399: What is the impact of sentinel lymph node biopsy (SLNB) compared to axillary lymph node dissection (ALND) on lymphedema rates in patients with breast carcinoma?
- A. SLNB is associated with lower lymphedema rates compared to ALND. (Correct Answer)
- B. SLNB is less effective in controlling cancer compared to ALND.
- C. ALND is associated with lower lymphedema rates than SLNB.
- D. SLNB and ALND have similar rates of lymphedema.
Explanation: ***SLNB is associated with lower lymphedema rates compared to ALND.*** - **Sentinel lymph node biopsy (SLNB)** involves removing only the first few lymph nodes (typically 1-3) to which cancer cells are most likely to spread, reducing the extent of lymphatic tissue removal. - This less invasive approach significantly lowers the risk of damaging the **lymphatic drainage system**, thereby reducing the incidence of **lymphedema** compared to **axillary lymph node dissection (ALND)**. - Studies show lymphedema rates of **5-7% with SLNB** versus **20-30% with ALND**. *SLNB is less effective in controlling cancer compared to ALND.* - This is **incorrect**. **SLNB** is considered equally effective as **ALND** for staging and treatment planning in patients with clinically negative axillae. - Major trials (ACOSOG Z0011, IBCSG 23-01) demonstrate that **SLNB** provides comparable oncological outcomes to **ALND** in early-stage breast cancer patients. *SLNB and ALND have similar rates of lymphedema.* - This is **incorrect**. The lymphedema rates differ significantly between the two procedures. - **ALND** removes 10-40 lymph nodes versus 1-3 nodes in **SLNB**, resulting in substantially higher lymphedema risk with ALND. *ALND is associated with lower lymphedema rates than SLNB.* - This is **incorrect** and the opposite of the truth. - **ALND** is associated with **significantly higher** rates of lymphedema (20-30%) compared to **SLNB** (5-7%) due to extensive removal of axillary lymph nodes and disruption of lymphatic drainage.
Question 400: A 45-year-old female presents with a lump in the breast and axillary lymphadenopathy. What is the most likely diagnosis?
- A. Breast cancer (Correct Answer)
- B. Fibroadenoma
- C. Mastitis
- D. Breast cyst
Explanation: ***Breast cancer*** - The presence of a **breast lump** and **axillary lymphadenopathy** in a 45-year-old woman is highly suggestive of breast cancer. - **Axillary lymphadenopathy** in this context often indicates metastatic spread. *Fibroadenoma* - While fibroadenomas cause breast lumps, they are typically **benign** and do not present with associated **lymphadenopathy**. - They are more common in younger women and often feel rubbery and mobile. *Mastitis* - This is an **inflammatory condition** of the breast, usually associated with pain, redness, warmth, and fever. - Although it can cause a lump, it rarely presents with **axillary lymphadenopathy** without prominent inflammatory signs. *Breast cyst* - Breast cysts are **fluid-filled sacs** that can present as breast lumps, often feeling smooth and mobile. - They are benign and do not typically cause **axillary lymphadenopathy** unless severely inflamed or infected, which would present with other symptoms.
Practice by Chapter
Breast Anatomy and Physiology
Practice Questions
Benign Breast Diseases
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Breast Cancer Screening
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Breast Cancer: Diagnosis and Staging
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Surgical Management of Breast Cancer
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Oncoplastic Breast Surgery
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Sentinel Lymph Node Biopsy
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Axillary Surgery
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Breast Reconstruction Techniques
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Male Breast Disorders
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Phyllodes Tumors
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Management of Ductal Carcinoma In Situ
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