Breast Surgery — MCQs

Breast Surgery Indian Medical PG Practice Questions and MCQs

Question 421: Which of the following is a contraindication to breast conservation surgery?

A. Presence of multicentric tumors (Correct Answer)
B. Involvement of axillary lymph nodes
C. Tumor size greater than 4 cm
D. Presence of diffuse microcalcifications

Explanation: ***Presence of multicentric tumors*** - **Multicentric tumors** are defined as two or more discrete tumors in different quadrants of the breast, which cannot be removed with a single lumpectomy. - This condition is a contraindication for breast conservation surgery (BCS) because complete removal of all tumor foci while maintaining an acceptable cosmetic outcome is highly unlikely. *Involvement of axillary lymph nodes* - **Axillary lymph node involvement** is an important prognostic factor in breast cancer and influences adjuvant therapy decisions, but it is not a direct contraindication to BCS. - Patients with positive nodes often undergo axillary dissection or sentinel lymph node biopsy, followed by radiation and/or systemic therapy, which can be combined with BCS. *Tumor size greater than 4 cm* - While larger tumor size (e.g., >4-5 cm) can make achieving negative surgical margins and a good cosmetic outcome more challenging with BCS, it is not an absolute contraindication. - **Neoadjuvant chemotherapy** can often downstage larger tumors, making BCS a viable option for many patients. *Presence of diffuse microcalcifications* - **Diffuse microcalcifications** can sometimes indicate extensive ductal carcinoma in situ (**DCIS**) or invasive lobular carcinoma with a widespread component. - However, if the microcalcifications represent a single focus of disease that can be entirely excised with negative margins, BCS may still be an option, especially if guided by stereotactic biopsy and imaging.

Question 422: What does the acronym NSABP represent in the context of cancer research?

A. National surgical adjuvant for brain and breast
B. National surgical adjuvant for bowel and brain
C. National surgical adjuvant for breast project
D. National Surgical Adjuvant Breast and Bowel Project (Correct Answer)

Explanation: ***National surgical adjuvant for breast and bowel project*** - **NSABP** stands for **National Surgical Adjuvant Breast and Bowel Project**. - It is a prominent research organization focused on conducting clinical trials for the prevention and treatment of breast and colorectal cancer. *National surgical adjuvant for breast project* - This option is incomplete as it omits the "bowel" component of the organization's focus. - The NSABP's research scope extends beyond just breast cancer to include **colorectal cancer**. *National surgical adjuvant for brain and breast* - This option incorrectly includes "brain" and omits "bowel" from the acronym. - The NSABP's primary research areas are **breast and bowel (colorectal) cancers**, not brain cancer. *National surgical adjuvant for bowel and brain* - This option incorrectly includes "brain" and omits "breast" from the acronym. - The NSABP is known for its extensive work in both **breast and colorectal cancer research**.

Question 423: Which condition typically presents with irregular, hard palpable masses in the breast?

A. Non comedo DCIS
B. Fibroadenoma
C. Invasive ductal carcinoma (Correct Answer)
D. Comedocarcinoma

Explanation: ***Paget's disease*** - Paget's disease of the breast leads to **palpable abnormalities** such as skin changes and underlying mass formation [1]. - Often presents with **nipple discharge** and alterations in the areola, indicating an underlying malignancy [2]. *Non comedo DCIS* - Non comedo ductal carcinoma in situ (DCIS) typically presents with **microscopic changes** and lacks palpable masses. - Frequently asymptomatic and may not cause any **significant clinical findings** or changes in the breast. *None* - This option suggests the absence of a related condition, which does not address the query about a type of DCIS causing a **palpable abnormality**. - In the context of DCIS, there are sure conditions (like Paget's) that **do cause palpable changes**. *Comedocarcinoma* - This type of DCIS is characterized by **necrosis and calcifications**, rather than a palpable mass. - While potentially aggressive, it usually does not present with noticeable **palpable abnormalities** like Paget's disease. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1061-1062. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 456-457.

Question 424: Which of the following is NOT a standard component of the triple test for breast cancer detection?

A. USG/ mammography
B. Breast self examination (Correct Answer)
C. Clinical examination
D. FNAC/ trucut biopsy

Explanation: ***Breast self examination*** - While **breast self-examination (BSE)** is important for **personal awareness** and **early detection**, it is not considered a standard component of the diagnostic "triple test" for breast cancer, which aims for definitive diagnosis. - The traditional triple test comprises **clinical examination**, **imaging** (mammography/ultrasound), and **pathological assessment** (FNAC/biopsy). *USG/ mammography* - **Mammography** and **ultrasonography (USG)** are crucial imaging modalities and an integral part of the **triple test**, providing detailed anatomical information about breast lesions. - They help characterize masses detected clinically and guide biopsy procedures, contributing significantly to diagnosis. *FNAC/ trucut biopsy* - **Fine needle aspiration cytology (FNAC)** and **tru-cut biopsy** are essential for **histopathological diagnosis**, confirming malignancy and determining tumor characteristics. - This is the third component of the triple test, providing a definitive cellular or tissue diagnosis. *Clinical examination* - A **thorough clinical breast examination** by a healthcare professional is the first step in the triple test, identifying palpable masses or other suspicious signs. - It involves **inspection** and **palpation** to assess breast tissue and lymph nodes.

Question 425: In the context of inflammatory breast cancer, what is the TNM stage associated with the peau d'orange appearance?

A. T4b (Correct Answer)
B. T4a
C. T3
D. T2

Explanation: ***T4b*** * The **TNM staging system** classifies T4b specifically for inflammatory breast cancer, which is characterized by the presence of **peau d'orange** (edema) of the skin of the breast. * This T stage also encompasses **ulceration of the skin** of the breast or satellite nodules confined to the same breast. *T4a* * T4a describes an **extension to the chest wall**, which includes the ribs, intercostal muscles, and serratus anterior muscle, but **not** the pectoralis muscle, which is generally not considered part of the chest wall for this classification. * This stage does **not** include the characteristic skin changes associated with inflammatory breast cancer. *T3* * T3 describes a tumor with a **size greater than 5 cm** in its greatest dimension, without direct extension to the chest wall or skin involvement. * This stage is based solely on tumor size and **does not account for the skin changes** like peau d'orange. *T2* * T2 describes a tumor with a **size greater than 2 cm but not more than 5 cm** in its greatest dimension. * Similar to T3, this stage is also based on tumor size and **does not include any skin involvement** or inflammatory features.

Question 426: A 25-year-old female complains of discharge of blood from a single duct in her breast. The most appropriate treatment is:

A. Radical excision
B. Microdochectomy (Correct Answer)
C. Radical mastectomy
D. Biopsy to rule out carcinoma

Explanation: **Microdochectomy** - **Microdochectomy** involves the surgical excision of a single lactiferous duct identified as the source of discharge, which is the most appropriate treatment for persistent or bloody solitary duct discharge. - This procedure aims to remove the **etiologic duct** and any underlying benign lesion (e.g., papilloma) while preserving the remaining breast tissue. *Radical excision* - This term is broad and doesn't specify the extent or nature of the excision in the context of a single duct discharge. **Radical excision** usually implies removal of a larger tissue volume and is typically reserved for malignancies or extensive benign disease, which is not indicated here. - Simply calling it radical excision without further specification makes it inappropriate as an initial treatment given the localized nature of the problem. *Radical mastectomy* - **Radical mastectomy** involves removal of the entire breast, overlying skin, and axillary lymph nodes. This is an extensive and disfiguring procedure indicated only for large or aggressive breast cancers, not for isolated single-duct discharge unless malignancy is strongly suspected and proven. - It is **overtreatment** for this presentation, as the vast majority of single-duct bloody discharges are due to benign causes like intraductal papillomas. *Biopsy to rule out carcinoma* - While ruling out carcinoma is important, a **biopsy** (e.g., core needle biopsy) of a duct for discharge is often technically challenging and may not yield representative tissue. - The definitive diagnosis and treatment for a persistent or bloody single-duct discharge is typically **surgical excision (microdochectomy)**, which serves both diagnostic and therapeutic purposes by removing the entire duct and allowing for pathological analysis.

Question 427: Nipple retraction in Ca breast is due to infiltration of:

A. Suspensory ligaments (Correct Answer)
B. Lymphatics
C. Pectoralis fascia
D. Lactiferous ducts

Explanation: ***Suspensory ligaments*** - **Malignant cells** infiltrate and shorten the **suspensory ligaments (of Cooper)**, which extend from the deep fascia to the skin. - This shortening pulls the skin inward, causing characteristic **nipple retraction** or **peau d'orange** appearance. *Lactiferous ducts* - While cancer can involve and obstruct lactiferous ducts, its primary role in causing **nipple retraction** is less direct. - Obstruction of lactiferous ducts might lead to **nipple discharge** or a mass, but not typically retraction as a primary mechanism. *Lymphatics* - Infiltration of lymphatics can lead to **lymphedema** and **peau d'orange** (skin thickening) due to fluid accumulation. - However, direct **nipple retraction** is more specifically attributed to the shortening of the connective tissue framework rather than lymphatic involvement itself. *Pectoralis fascia* - Infiltration of the **pectoralis fascia** would indicate deep tumor invasion and can cause fixation of the breast to the chest wall. - This might restrict breast movement but does not directly cause **nipple retraction**; rather, it indicates a more advanced stage of disease.

Question 428: Treatment of choice for phyllodes tumor is:

A. Wide local excision (Correct Answer)
B. Radical mastectomy
C. Radiotherapy
D. Chemotherapy

Explanation: ***Wide local excision*** - The primary treatment for phyllodes tumors is **surgical excision with wide clear margins (at least 1 cm)** to prevent recurrence. - The goal is to remove the tumor completely with adequate margins, as these tumors have a high local recurrence rate (up to 20-30%) if inadequately excised. - Most phyllodes tumors are benign (60-75%), but even benign variants require wide excision due to their infiltrative growth pattern. *Radical mastectomy* - This is an **overly aggressive procedure** for most phyllodes tumors, which are typically benign or borderline and do not require such extensive surgery. - Radical mastectomy may only be considered for very large malignant phyllodes tumors where breast conservation is not feasible. *Radiotherapy* - **Adjuvant radiotherapy** may be considered in cases of malignant phyllodes tumors with close or positive surgical margins or recurrent disease. - However, it is not the primary treatment of choice and is not effective as a standalone treatment for these tumors. *Chemotherapy* - Chemotherapy is **generally not effective** and not routinely indicated for phyllodes tumors, as they are largely resistant to systemic therapy. - It might be considered only in cases of **distant metastatic disease** from a malignant phyllodes tumor, which occurs in less than 5% of cases.

Question 429: A 25-year-old lady presents with spontaneous nipple discharge of 3 months duration. On examination, the discharge is bloody and from a single duct. The following statements about management of this patient are true EXCEPT:

A. Ultrasound can be a useful investigation.
B. Galactogram, though useful, is not essential.
C. Radical duct excision is the operation of choice. (Correct Answer)
D. Majority of blood-stained nipple discharges are due to papilloma or other benign conditions.

Explanation: ***Radical duct excision is the operation of choice.*** - **Radical duct excision** (also known as a Hadfield procedure) involves the removal of all major ducts and is an older, more extensive procedure generally reserved for cases of **multiple recurrent duct ectasia** or if symptoms persist after prior targeted excision. - For **single-duct bloody discharge**, the standard surgical approach is a **microdochectomy** (single duct excision), which targets the affected duct from which the discharge originates, thereby being less invasive and preserving more breast tissue. *Ultrasound can be a useful investigation.* - **Ultrasound** is a valuable initial imaging modality for nipple discharge, particularly in younger women with dense breasts, as it can help identify **intraductal masses**, cysts, or other abnormalities. - It can guide further investigation and often localize the cause of the discharge, especially if a mass is palpable or visible within the ducts. *Galactogram, though useful, is not essential.* - A **galactogram (ductogram)** is a specialized mammogram where contrast is injected into the discharging duct, allowing visualization of intraductal lesions like **papillomas** or ductal carcinoma in situ (DCIS). - While it can provide precise localization and characterization of intraductal pathology, it is not always performed as other imaging (like ultrasound or MRI) and clinical evaluation often provides sufficient information for management, particularly with **single-duct bloody discharge**. *Majority of blood-stained nipple discharges are due to papilloma or other benign conditions.* - In cases of **pathological nipple discharge**, particularly spontaneous and bloody discharge from a single duct, **intraductal papilloma** is the most common benign cause, accounting for a large percentage of such presentations. - Other benign conditions, such as **duct ectasia** or **fibrocystic changes**, can also cause nipple discharge, although bloody discharge often raises a higher suspicion for papilloma or malignancy.

Question 430: A woman noticed a mass in her left breast with bloody discharge. Histopathology revealed duct ectasia. What is the treatment?

A. Lobectomy
B. Hadfield operation (Correct Answer)
C. Simple mastectomy
D. Microdochectomy

Explanation: ***Hadfield operation*** - The Hadfield operation, also known as **total duct excision** or **microdochectomy**, is indicated for **benign duct ectasia** with pathological nipple discharge, especially if persistent, bloody, or associated with a discrete mass. - This procedure removes the affected duct system, preventing recurrence of the discharge and addressing the mass. *Simple mastectomy* - This involves the removal of the entire breast and is typically reserved for **malignant conditions** (breast cancer). - It is an **overly aggressive** treatment for a benign condition like duct ectasia. *Microdochectomy* - This term usually refers to the **excision of a single duct** and is a type of duct excision, often used interchangeably with total duct excision. - While it addresses the issue, the Hadfield operation generally implies a more comprehensive removal of the major duct system via a circumareolar incision. *Lobectomy* - Lobectomy is typically associated with **lung surgery** (removal of a lung lobe) and is not a breast surgical procedure. - It describes the removal of an entire lobe of an organ, which is not applicable to breast duct disease in this context.

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

Practice Questions

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