Sentinel Lymph Node Biopsy — MCQs
The surgical registrar successfully performs a testicular biopsy and hands over the specimen to the attending nurse. The sister asks you how to send the specimen to the pathologist. What fluid will you tell the sister to put the specimen in?
Which of the following stages of Breast Cancer corresponds to the following features: a breast mass of 6 x 3 cm, ipsilateral supraclavicular lymph node involvement, and distant metastasis that cannot be assessed?
A 45-year-old woman with early-stage breast cancer is discussing treatment options with her surgeon. Which of the following statements regarding breast conservation surgery is NOT true?
Gold standard investigation for breast carcinoma screening in a patient with silicone breast implants
Sentinel lymph node biopsy is most useful for:
Most common complication of mastectomy is:
Sentinel lymph node biopsy in carcinoma breast is done if -
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?
Indication for sentinel node biopsy is:
Sentinel Lymph Node Biopsy Indian Medical PG Practice Questions and MCQs
Question 1: The surgical registrar successfully performs a testicular biopsy and hands over the specimen to the attending nurse. The sister asks you how to send the specimen to the pathologist. What fluid will you tell the sister to put the specimen in?
- A. 95% ethanol
- B. Zenker's solution
- C. 10% formalin
- D. Bouin's solution (Correct Answer)
Explanation: ***Bouin's solution*** - **Bouin's solution is the preferred fixative for testicular biopsies**, particularly for infertility evaluation and detailed assessment of spermatogenesis. - It provides **superior preservation of testicular architecture** and excellent nuclear detail, which is critical for evaluating seminiferous tubule morphology and germ cell maturation. - While it may cause some tissue shrinkage, the **enhanced nuclear detail and better preservation of seminiferous epithelium** make it the gold standard for testicular tissue. - Bouin's is specifically recommended in standard pathology protocols for reproductive tissue. *10% formalin* - While 10% neutral buffered formalin is the most common fixative for general surgical pathology specimens, it is **not optimal for testicular biopsies**. - Formalin provides adequate preservation but **does not give the superior nuclear and cytoplasmic detail** needed for detailed evaluation of spermatogenesis. - For routine testicular tumor specimens, formalin may be acceptable, but for **diagnostic testicular biopsies (especially for infertility)**, Bouin's solution is preferred. *95% ethanol* - Ethanol is primarily a **dehydrating agent**, not a suitable primary fixative for histology specimens. - It causes significant **tissue shrinkage and distortion**, making histological interpretation challenging. - Not appropriate for testicular tissue preservation. *Zenker's solution* - Zenker's solution is a **mercuric chloride-based fixative** with significant drawbacks. - Contains **toxic mercury** requiring special handling and disposal. - Can interfere with certain special stains and cause **chromatin clumping**. - Largely obsolete in modern pathology practice due to mercury content.
Question 2: Which of the following stages of Breast Cancer corresponds to the following features: a breast mass of 6 x 3 cm, ipsilateral supraclavicular lymph node involvement, and distant metastasis that cannot be assessed?
- A. T4 N3 MX
- B. T4 N1 M1
- C. T4 N0 M0
- D. T3 N3c MX (Correct Answer)
Explanation: ***T3 N3c MX*** - A **breast mass of 6 x 3 cm** indicates a T3 tumor (tumor size > 5 cm). - **Ipsilateral supraclavicular lymph node involvement** is classified as N3c disease. **Distant metastasis that cannot be assessed** is denoted by MX. *T4 N3 MX* - A **T4 classification** is reserved for tumors with direct extension to the chest wall or skin, or inflammatory breast cancer, which is not mentioned here. - While N3c and MX are correct for the nodal and metastatic status, the T stage is inaccurate based on the provided tumor size. *T4 N1 M1* - A **T4 classification** is incorrect as the mass size alone (6 x 3 cm) does not meet T4 criteria. - **N1** denotes involvement of 1-3 axillary lymph nodes, which is less extensive than supraclavicular involvement (N3c). **M1** indicates confirmed distant metastasis, but the question states it "cannot be assessed" (MX). *T4 N0 M0* - **T4** is incorrect, as this stage is for direct chest wall/skin involvement or inflammatory breast cancer. - **N0** signifies no regional lymph node metastasis, contradicting the presence of supraclavicular lymph node involvement. **M0** indicates no distant metastasis, whereas the question specifies it cannot be assessed (MX).
Question 3: A 45-year-old woman with early-stage breast cancer is discussing treatment options with her surgeon. Which of the following statements regarding breast conservation surgery is NOT true?
- A. Post-operative radiotherapy
- B. Axillary dissection (Correct Answer)
- C. Wide local excision
- D. Sentinel lymph node biopsy
Explanation: ***Axillary dissection*** - **Axillary dissection is NOT a routine component of breast conservation surgery** for early-stage breast cancer. - In early-stage disease, **sentinel lymph node biopsy (SLNB)** has largely replaced routine axillary dissection as it provides accurate staging with significantly less morbidity. - Axillary dissection is only performed when there is **proven extensive lymph node involvement** or when SLNB shows metastatic disease requiring further assessment. - Therefore, this statement is **NOT true** regarding routine breast conservation surgery. *Wide local excision* - **Wide local excision (lumpectomy)** is the primary surgical component of breast conservation therapy. - It involves removing the cancerous tumor along with a margin of healthy breast tissue to achieve clear margins while preserving the breast. *Sentinel lymph node biopsy* - **SLNB** is a standard procedure performed with breast conservation surgery to assess for regional lymph node metastasis. - It identifies and removes the first few lymph nodes draining the tumor, allowing accurate staging with minimal morbidity. *Post-operative radiotherapy* - **Post-operative radiotherapy** to the preserved breast is a critical and essential component of breast conservation therapy. - It significantly reduces the risk of local recurrence by treating any microscopic tumor cells that may remain after surgery.
Question 4: Gold standard investigation for breast carcinoma screening in a patient with silicone breast implants
- A. Mammography
- B. CT scan
- C. USG
- D. MRI (Correct Answer)
Explanation: ***MRI*** - **MRI** is considered the **gold standard** for breast cancer screening in patients with silicone breast implants due to its superior ability to visualize breast tissue through the implant and detect subtle lesions. - It offers **high sensitivity** in detecting both implant rupture and early malignancies, often providing better clarity than mammography in augmented breasts where implants can obscure tissue. *Mammography* - While a standard screening tool, **mammography** can be limited in patients with silicone implants because the implants can **obscure adjacent breast tissue**, making detection of small masses challenging. - Special views (e.g., **Eklund views**) can be used, but sensitivity is still reduced compared to MRI in augmented breasts. *CT scan* - **CT scans** are not routinely used for primary breast cancer screening due to their use of **ionizing radiation** and lower sensitivity for detecting early breast lesions compared to MRI. - CT is more commonly used for **staging** advanced cancers or evaluating complex masses detected by other modalities. *USG* - **Ultrasound (USG)** is a valuable complementary tool, especially for evaluating palpable lumps or clarifying findings from mammography, but it is **operator-dependent** and has a lower overall sensitivity for general screening compared to MRI. - It is particularly useful for differentiating between **cystic and solid masses** and detecting implant ruptures but is not the gold standard for comprehensive screening in augmented breasts.
Question 5: Sentinel lymph node biopsy is most useful for:
- A. Carcinoma vulva (Correct Answer)
- B. Carcinoma endometrium
- C. Carcinoma vagina
- D. Carcinoma cervix
Explanation: ***Carcinoma vulva*** - **Sentinel lymph node biopsy (SLNB)** is a standard procedure for early-stage vulvar carcinoma to assess nodal involvement with less morbidity than full inguinofemoral lymphadenectomy. - The procedure helps identify metastases in regional lymph nodes, guiding further treatment decisions while minimizing complications like **lymphedema**. *Carcinoma endometrium* - While SLNB can be used in endometrial cancer, its primary utility is in tailoring **lymphadenectomy** rather than being the "most useful" or universally preferred primary staging tool compared to vulvar cancer. - The anatomical spread often involves different lymphatic basins, and **comprehensive pelvic and para-aortic lymphadenectomy** or systematic nodal dissection remains a common approach, though SLNB is gaining traction. *Carcinoma vagina* - The lymphatic drainage of the vagina is complex and variable, making SLNB challenging and less standardized compared to vulvar cancer. - **Radical surgical excision** with **regional lymphadenectomy** remains the mainstay for staging and treatment of invasive vaginal carcinoma. *Carcinoma cervix* - For cervical cancer, SLNB is primarily used in **early-stage disease** to detect micrometastases and guide the extent of lymph node dissection. - However, **imaging** and comprehensive **pelvic lymphadenectomy** are often still crucial components for complete staging and treatment, depending on tumor characteristics.
Question 6: 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 7: Sentinel lymph node biopsy in carcinoma breast is done if -
- A. LN palpable
- B. Breast lump with palpable axillary node
- C. Metastatic CA breast
- D. Breast mass but no lymph node palpable (Correct Answer)
Explanation: ***Breast mass but no lymph node palpable*** - Sentinel lymph node biopsy is primarily performed in patients with **clinically negative axillae** (no palpable lymph nodes) to assess for microscopic metastatic disease. - The goal is to avoid full axillary lymph node dissection if the sentinel nodes are negative, thus reducing the risk of **lymphedema** and other complications. *LN palpable* - If a lymph node is palpable, it is often considered **clinically suspicious** and may warrant a direct fine-needle aspiration (FNA) or core biopsy rather than a sentinel node biopsy. - A positive biopsy from a palpable node would typically lead directly to an **axillary lymph node dissection** or neoadjuvant therapy, as the sentinel node procedure offers less benefit in this scenario. *Breast lump with palpable axillary node* - Similar to a palpable LN, a **palpable axillary node** in the presence of a breast lump suggests established nodal involvement. - In such cases, **sentinel lymph node biopsy** is often not the initial step; rather, direct biopsy of the palpable node or upfront axillary dissection (sometimes after neoadjuvant treatment) is considered. *Metastatic CA breast* - In **metastatic breast cancer** (stage IV disease), the focus shifts to systemic treatment, and axillary lymph node dissection, including sentinel node biopsy, is generally not indicated for staging purposes. - The primary goal is palliative care or controlling systemic disease, not regional lymph node staging.
Question 8: 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 9: 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 10: Indication for sentinel node biopsy is:
- A. Palpable axillary lymph node
- B. Metastasis
- C. Mass > 5 cm
- D. Non-palpable axillary lymph node (Correct Answer)
Explanation: ***Non-palpable axillary lymph node*** - **Sentinel lymph node biopsy (SLNB)** is indicated when there is no clinical evidence of axillary lymph node involvement, meaning the nodes are **non-palpable**. - Its purpose is to identify micrometastases that would not be detectable by physical examination, staging the cancer more accurately and guiding further treatment. *Palpable axillary lymph node* - A **palpable axillary lymph node** suggests macroscopic nodal involvement, usually requiring a fine needle aspiration (FNA) or core needle biopsy for diagnosis. - If positive, these patients typically proceed directly to **axillary lymph node dissection (ALND)** rather than SLNB. *Mass > 5 cm* - The size of the primary tumor (e.g., > 5 cm) is a factor in staging but does not, in itself, preclude or indicate SLNB. - While larger tumors have a higher risk of nodal involvement, the decision for SLNB still hinges on the clinical status of the axilla (palpable vs. non-palpable nodes). *Metastasis* - If **distant metastasis** is confirmed, the focus shifts to palliative care and systemic treatment, making a regional staging procedure like SLNB less relevant or unnecessary. - SLNB is used for staging early-stage cancer to detect regional spread, not when widespread disease is already established.
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