Breast Surgery Practice Questions

Q: 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?

Adjuvant radiotherapy. ***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.

Q: Dye for Sentinel Lymph Node Biopsy is injected in which of the following sites?

Areola. ***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.

Q: 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?

Isosulfan blue dye. ***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.

Q: Peau d’orange appearance is due to -

Lymphatic permeation. ***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**.

Q: Triple assessment for carcinoma breast includes:

Clinical examination, Mammography, biopsy/cytology. ***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.

Q: Using a small fine probe, a single lactiferous duct is excised. What is the name of the procedure:

Microdochectomy. ***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.

Q: Which of the following is not true about breast cancer?

Lobular carcinoma is most common. ***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**.

Q: A 45-year-old female presents with a lump in the breast and axillary lymphadenopathy. What is the most likely diagnosis?

Breast cancer. ***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.

Question 1

A 55-year-old female patient presented with a $4 	imes 3 \mathrm{~cm}$ 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?

Accepted Answer

Adjuvant radiotherapy

Answer

Follow up 6 monthly for 2 years and then yearly follow up

Answer

Trastuzumab therapy

Answer

Adjuvant chemotherapy

Question 2

Dye for Sentinel Lymph Node Biopsy is injected in which of the following sites?

Accepted Answer

Areola

Answer

Nipple

Answer

Axilla

Answer

Tail of spence

Question 3

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?

Accepted Answer

Isosulfan blue dye

Answer

Patent blue dye

Answer

99 Tc radiolabeled colloid

Answer

Methylene blue dye

Question 4

Peau d’orange appearance is due to -

Accepted Answer

Lymphatic permeation

Answer

Intra-epithelial cancer

Answer

Vascular embolization

Answer

Sub-epidermal cancer

Question 5

Triple assessment for carcinoma breast includes:

Accepted Answer

Clinical examination, Mammography, biopsy/cytology

Answer

Observation, Ultrasonography, biopsy/cytology

Answer

History, clinical examination, biopsy/cytology

Answer

History, clinical examination, Ultrasonography

Question 6

Using a small fine probe, a single lactiferous duct is excised. What is the name of the procedure:

Accepted Answer

Microdochectomy

Answer

Hadfield operation

Answer

Webster operation

Answer

Macrodochectomy

Question 7

Which of the following is not true about breast cancer?

Accepted Answer

Lobular carcinoma is most common

Answer

Family history is a risk factor

Answer

Paget’s disease affects the nipple

Answer

Estrogen exposure increases risk

Question 8

What factors should be considered when choosing between implant-based and autologous breast reconstruction options for a patient after mastectomy?

Accepted Answer

Patient's body image concerns, availability of donor tissue, recovery time, and medical comorbidities.

Answer

Patient's aesthetic preferences and desired breast size.

Answer

Financial implications and insurance coverage.

Answer

Oncological factors and timing of adjuvant therapy.

Question 9

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?

Accepted Answer

SLNB is associated with lower lymphedema rates compared to ALND.

Answer

SLNB is less effective in controlling cancer compared to ALND.

Answer

ALND is associated with lower lymphedema rates than SLNB.

Answer

SLNB and ALND have similar rates of lymphedema.

Question 10

A 45-year-old female presents with a lump in the breast and axillary lymphadenopathy. What is the most likely diagnosis?

Accepted Answer

Breast cancer

Answer

Fibroadenoma

Answer

Mastitis

Answer

Breast cyst

Breast Surgery — MCQs

Breast Surgery — MCQs

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