Breast Surgery — MCQs

Breast Surgery Indian Medical PG Practice Questions and MCQs

Question 431: What is the most reliable investigation to confirm carcinoma of the breast?

A. FNAC
B. USG
C. Mammography
D. Biopsy (Histopathological examination) (Correct Answer)

Explanation: ***Biopsy (Histopathological examination)*** - A **biopsy** remains the gold standard for diagnosing breast carcinoma as it allows for direct visualization of tissue architecture and cellular characteristics by a pathologist. - This method provides definitive confirmation of malignancy, tumor type, grade, and receptor status, which are crucial for treatment planning. *FNAC* - **Fine-needle aspiration cytology (FNAC)** can suggest malignancy by analyzing individual cells, but it doesn't provide tissue architecture. - It has a risk of **false negatives** and cannot differentiate between in situ and invasive carcinoma, or assess tumor grade as reliably as a biopsy. *USG* - **Ultrasonography (USG)** is an imaging technique that helps characterize breast lesions (solid vs. cystic, benign vs. suspicious). - It is often used to guide biopsies but cannot definitively diagnose cancer on its own; it requires further histological confirmation. *Mammography* - **Mammography** is a screening tool used to detect breast abnormalities, such as masses, calcifications, and architectural distortion. - While it can identify suspicious lesions, it is an imaging technique and cannot provide a definitive diagnosis of carcinoma, requiring biopsy for confirmation.

Question 432: A 47-year-old female patient's right breast exhibits peau d'orange characteristics. This condition is primarily a result of which of the following occurrences?

A. Blockage of cutaneous lymphatic vessels (Correct Answer)
B. Invasion of the pectoralis major by cancer, leading to breast changes
C. Shortening of the suspensory ligaments due to cancer in the axillary tail of the breast
D. Contraction of the retinacula cutis of the areola and nipple

Explanation: ***Blockage of cutaneous lymphatic vessels*** - **Peau d'orange** (orange peel skin) appearance in breast cancer is caused by the **obstruction of superficial lymphatic drainage** by tumor cells. - This blockage leads to **edema** and swelling of the skin, causing the hair follicles to become prominent and resulting in the characteristic dimpled appearance. *Invasion of the pectoralis major by cancer, leading to breast changes* - Invasion of the **pectoralis major muscle** can cause breast fixation to the chest wall, but it does not directly produce the **cutaneous edema and dimpling** characteristic of peau d'orange. - This type of invasion is more associated with **immobility of the breast** and palpable mass rather than skin texture changes. *Shortening of the suspensory ligaments due to cancer in the axillary tail of the breast* - Shortening of the **suspensory ligaments (of Cooper)** due to tumor infiltration can cause skin dimpling or retraction, but it typically results in a **localized depression** rather than widespread **edema and pores** seen in peau d'orange. - While cancer in the axillary tail can affect lymph nodes, this specific mechanism does not cause the diffuse skin appearance. *Contraction of the retinacula cutis of the areola and nipple* - Contraction of the **retinacula cutis** in the nipple and areola region would primarily cause **nipple retraction** or inversion. - This mechanism does not account for the **diffuse swelling and pitting** of the skin surface observed in **peau d'orange**.

Question 433: What is the cardiac risk associated with breast surgery?

A. > 10 %
B. 1 - 5 %
C. 5 - 10 %
D. < 1% (Correct Answer)

Explanation: ***< 1%*** - Breast surgery is generally considered a **low-risk procedure** regarding cardiac complications. - The incidence of major adverse cardiac events (MACE) is typically very low, often reported as **less than 1%**. *1 - 5 %* - This risk range is usually associated with **intermediate-risk surgical procedures**, such as carotid endarterectomy or peripheral vascular surgery, which involve higher cardiac stress. - Breast surgery does not typically fall into this category due to its less extensive physiological impact. *5 - 10 %* - This elevated risk percentage is characteristic of **high-risk surgeries**, including major vascular procedures (e.g., aortic aneurysm repair) or organ transplantation. - Such procedures involve significant fluid shifts, blood loss, and prolonged anesthesia, increasing cardiac strain. *> 10 %* - A cardiac risk exceeding 10% is extremely high and would generally be seen only in patients with **severe pre-existing cardiac disease** undergoing emergency major surgery, or in complex, extremely high-risk procedures. - Breast surgery typically does not pose such a profound cardiac risk.

Question 434: Which of the following statements is MOST accurate regarding surgical treatment for breast carcinoma?

A. Mastectomy is not necessarily superior to breast-conserving surgery. (Correct Answer)
B. Paget's disease always presents bilaterally.
C. Radiation therapy is never required after mastectomy.
D. Paget's disease of the breast always requires mastectomy.

Explanation: ***Mastectomy is not necessarily superior to breast-conserving surgery.*** - Studies have shown that for early-stage breast cancer, **breast-conserving surgery (lumpectomy with radiation)** has comparable long-term survival rates to mastectomy. - The choice between these surgical options often depends on factors like tumor size, location, patient preference, and the availability of radiation therapy. *Radiation therapy is never required after mastectomy.* - Radiation therapy **may be required after mastectomy** in cases of large tumors, positive surgical margins, extensive nodal involvement, or specific histologies, to reduce the risk of local recurrence. - This is known as **post-mastectomy radiation therapy (PMRT)** and is an important part of adjuvant treatment for high-risk patients. *Paget's disease always presents bilaterally.* - **Paget's disease of the breast** almost always presents as a **unilateral** eczema-like rash or lesion involving the nipple and areola. - Bilateral presentation is extremely rare and should prompt investigation for other underlying conditions. *Paget's disease of the breast always requires mastectomy.* - While mastectomy was traditionally the standard treatment, **breast-conserving surgery with adjuvant radiation therapy** can be an option for carefully selected patients with Paget's disease, especially when the underlying carcinoma is small and localized. - The decision depends on the extent of the disease and patient factors.

Question 435: In which of the following situations is breast conservation surgery not indicated?

A. SLE
B. Large pendular breast
C. Diffuse microcalcification
D. All of the options (Correct Answer)

Explanation: ***All of the options*** - All listed scenarios—**large pendular breast**, **SLE**, and **diffuse microcalcification**—represent situations where breast conservation surgery is generally contraindicated or challenging. - Their presence often necessitates alternative treatment approaches, such as mastectomy, to achieve optimal oncologic and cosmetic outcomes. *Large pendular breast* - While not an absolute contraindication, a **very large or pendulous breast** can make it difficult to achieve a satisfactory cosmetic outcome after breast conservation surgery. - The disproportionate breast size post-lumpectomy may lead to significant **asymmetry**, requiring further reconstructive procedures. *SLE* - Patients with **Systemic Lupus Erythematosus (SLE)** are at an increased risk of complications from radiation therapy, a mandatory component of breast conservation surgery. - They tend to experience more severe and prolonged **acute and chronic skin reactions** to radiation, which can significantly impair healing and quality of life. *Diffuse microcalcification* - **Diffuse microcalcification** within the breast can indicate widespread in situ carcinoma (e.g., DCIS) or an invasive carcinoma with extensive intraductal component. - In such cases, achieving **clear surgical margins** with breast conservation surgery can be challenging and often leads to multiple re-excisions or an increased risk of local recurrence.

Question 436: Most common complication of mastectomy is:

A. Seroma (Correct Answer)
B. Hemorrhage
C. Infection
D. Lymphedema

Explanation: ***Seroma*** - **Seroma** formation is the most common complication after mastectomy, involving the accumulation of serous fluid in the surgical dead space. - This complication can lead to discomfort, delayed wound healing, and an increased risk of infection. *Hemorrhage* - While a serious complication, **hemorrhage** is less common than seroma formation. - Significant hemorrhage usually occurs intraoperatively or in the immediate postoperative period and is typically managed promptly. *Lymphedema* - **Lymphedema** is a chronic condition characterized by swelling of the arm due to impaired lymphatic drainage, often developing months to years after surgery. - Although highly significant and debilitating, its incidence is lower than acute complications like seroma. *Infection* - Surgical site **infection** is a potential complication but is generally less frequent than seroma due to careful aseptic techniques and prophylactic antibiotics. - Infections can range from superficial wound infections to more serious cellulitis.

Question 437: The most important prognostic factor in carcinoma of the breast is

A. Size of tumour
B. Skin involvement
C. Axillary gland involvement (Correct Answer)
D. Involvement of muscles

Explanation: ***Axillary gland involvement*** - The presence and number of involved **axillary lymph nodes** are the single most significant factor in determining prognosis and guiding adjuvant therapy in breast cancer. - Lymphatic spread to the axillary nodes indicates a higher likelihood of distant metastasis, directly impacting survival rates. *Size of tumour* - While **tumor size** is an important prognostic factor and is part of the TNM staging system (T for tumor size), it is less significant than nodal status. - A small tumor with nodal involvement has a worse prognosis than a larger tumor without nodal involvement. *Skin involvement* - **Skin involvement** (T4b in TNM staging) indicates locally advanced disease and is a poor prognostic sign, but it is not as universally important as axillary nodal status in predicting overall survival. - It often reflects aggressive local tumor growth rather than systemic spread as directly as nodal metastasis. *Involvement of muscles* - **Muscle involvement** (specifically the pectoralis major muscle, T4a in TNM staging) signifies locally advanced disease and is associated with a poor prognosis. - Similar to skin involvement, it suggests extensive local spread but is not as strong a predictor of distant metastasis and overall survival as axillary nodal involvement.

Question 438: In which of the following types of breast carcinoma would you consider a biopsy of the opposite breast?

A. Lobular carcinoma (Correct Answer)
B. Comedo carcinoma
C. Medullary carcinoma
D. Adenocarcinoma-poorly differentiated

Explanation: ***Lobular carcinoma*** - **Invasive lobular carcinoma (ILC)** is known for its **multicentricity** (multiple foci within the same breast) and a higher incidence of **bilateral involvement** compared to other breast cancer types. - Due to its infiltrating growth pattern without significant desmoplasia, ILC can be **clinically subtle** and difficult to detect by imaging, thus biopsy of the contralateral breast may be considered if there are any suspicious findings. *Comedo carcinoma* - This is a subtype of **ductal carcinoma in situ (DCIS)** characterized by central necrosis, calcifications, and high-grade nuclei confined to the ducts. - While DCIS can recur or progress, its primary concern is typically within the affected breast, and it does not inherently carry a significantly increased risk of contralateral involvement requiring routine biopsy. *Medullary carcinoma* - **Medullary carcinoma** is a rare subtype of invasive ductal carcinoma known for its distinct histological features, including a pushing border, prominent lymphocytic infiltrate, and high-grade nuclei. - It generally has a **better prognosis** than other invasive ductal carcinomas and does not have a characteristically high incidence of bilateral involvement that would routinely warrant a contralateral breast biopsy. *Adenocarcinoma-poorly differentiated* - This term describes an **invasive ductal carcinoma** with a high histologic grade, indicating aggressive features and poor differentiation. - While any invasive breast cancer carries some risk of bilateral disease, poorly differentiated adenocarcinoma does not have the uniquely high predisposition for **contralateral synchronous or metachronous disease** that is characteristic of lobular carcinoma.

Question 439: A 30-year-old woman presents with blood-stained nipple discharge. What is the most likely diagnosis?

A. Breast abscess
B. Ductal papilloma (Correct Answer)
C. Fat necrosis of breast
D. Fibroadenoma

Explanation: ***Ductal papilloma*** - **Ductal papillomas** are benign lesions that commonly present with spontaneous, unilateral, bloody, or serosanguineous **nipple discharge**. - They arise from the epithelial lining of the mammary ducts and are the most frequent cause of **blood-stained nipple discharge** in women. *Breast abscess* - A breast abscess typically presents with a painful, tender, and **fluctuant breast mass**, often accompanied by signs of infection like **fever** and **erythema**. - Nipple discharge, if present, is usually purulent (pus-like) rather than blood-stained. *Fat necrosis of breast* - Fat necrosis usually follows **trauma or surgery** to the breast and presents as a **firm, often tender mass** with possible skin retraction or bruising. - It does not typically cause nipple discharge, especially not blood-stained discharge. *Fibroadenoma* - A **fibroadenoma** is a common benign breast tumor characterized by a **firm, movable, well-circumscribed, non-tender lump**. - It does not characteristically cause nipple discharge; blood-stained discharge is not a typical symptom.

Question 440: Breast cancer: What is the most important prognostic factor?

A. Lymph node status (Correct Answer)
B. Size of tumor
C. Skin involvement
D. Peau d'orange

Explanation: ***Lymph node status*** - The presence and number of **axillary lymph node metastases** are the most significant predictors of breast cancer recurrence and overall survival. - Involvement of lymph nodes indicates a higher likelihood of **systemic disease** and distant metastasis. *Size of tumor* - While tumor size is an important prognostic factor, particularly for **smaller tumors**, its impact on prognosis is generally considered secondary to lymph node involvement. - Large tumors tend to have a worse prognosis than small ones, but even a small tumor with **positive lymph nodes** carries a higher risk than a larger tumor without nodal involvement. *Skin involvement* - **Skin involvement** (e.g., **ulceration, edema, or nodularity**) is a sign of locally advanced breast cancer. - It indicates a more aggressive tumor and a worse prognosis than tumors without skin involvement, but it is less critical than lymph node status in predicting overall survival. *Peau d'orange* - **Peau d'orange** (orange peel skin) is a clinical sign of **inflammatory breast cancer** or extensive lymphatic invasion. - It signifies a poor prognosis due to widespread lymphatic obstruction, but it is a manifestation of disease extent rather than an independent prognostic factor surpassing lymph node status.

Practice by Chapter

Breast Anatomy and Physiology

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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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