Breast Surgery Practice Questions

Q: Which of the following is a complication of mastectomy?

All of the above. **Explanation:** Mastectomy is a major surgical procedure associated with several early and late complications. The correct answer is **All of the above** because each option represents a recognized clinical outcome following the procedure. 1. **Seroma (Option A):** This is the **most common** early complication of mastectomy. It involves a collection of serous fluid in the dead space under the skin flaps or in the axilla. It occurs due to the disruption of lymphatics and capillaries during dissection. 2. **Long Thoracic Nerve Palsy (Option B):** During axillary lymph node dissection (ALND), the long thoracic nerve (Nerve of Bell) is at risk. Injury leads to paralysis of the **Serratus Anterior** muscle, clinically presenting as **"Winging of the Scapula."** 3. **Angiosarcoma (Option C):** This is a rare but dreaded late complication known as **Stewart-Treves Syndrome**. It refers to lymphangiosarcoma arising in a limb affected by chronic lymphedema (usually 10+ years post-mastectomy). **Clinical Pearls for NEET-PG:** * **Nerve Injuries:** * *Intercostobrachial nerve:* Most commonly injured nerve; leads to numbness of the inner aspect of the upper arm. * *Thoracodorsal nerve:* Injury leads to weakness in internal rotation and adduction (Latissimus dorsi). * **Lymphedema:** Occurs in about 10-25% of patients post-ALND; risk is significantly reduced with Sentinel Lymph Node Biopsy (SLNB). * **Flap Necrosis:** Usually occurs at the edges of the skin flaps if they are tensioned or too thin.

Q: Which is a distressing complication after modified radical mastectomy?

Lymphedema. **Explanation:** **1. Why Lymphedema is the Correct Answer:** Lymphedema is considered the most **distressing and dreaded** long-term complication of Modified Radical Mastectomy (MRM). It occurs due to the disruption of lymphatic drainage following Axillary Lymph Node Dissection (ALND). The resulting chronic swelling of the arm leads to functional impairment, psychological distress, recurrent cellulitis, and, in rare cases, lymphangiosarcoma (Stewart-Treves Syndrome). While not immediately life-threatening, its chronic, progressive nature and impact on the quality of life make it the most "distressing" clinical outcome. **2. Analysis of Incorrect Options:** * **Axillary Vein Thrombosis:** This is a rare acute complication. While serious, it is far less common than lymphedema and usually manageable with anticoagulation. * **Seroma:** This is the **most common** early complication after MRM. While annoying and requiring frequent aspirations, it is usually self-limiting and does not cause the long-term morbidity associated with lymphedema. * **Death:** Mortality following MRM is extremely low (<0.1%) as it is a major but non-cavitary surgery. It is not a characteristic complication of the procedure itself. **Clinical Pearls for NEET-PG:** * **Most common complication:** Seroma formation. * **Most distressing/dreaded complication:** Lymphedema. * **Incidence of Lymphedema:** Approximately 10–30% after ALND; significantly reduced (<5%) with Sentinel Lymph Node Biopsy (SLNB). * **Nerve Injuries during MRM:** * **Long Thoracic Nerve (Bell’s):** Leads to Winging of Scapula. * **Thoracodorsal Nerve:** Leads to weakness in adduction/internal rotation (Latissimus dorsi). * **Intercostobrachial Nerve:** Most commonly injured nerve; leads to numbness of the inner aspect of the upper arm.

Q: What is the LEAST diagnostic test for breast tumours?

Chest X-ray. ### Explanation The diagnosis of a breast lump follows the **Triple Assessment** protocol, which includes clinical examination, imaging, and pathology. **Why Chest X-ray is the Correct Answer:** A Chest X-ray (CXR) is **not a diagnostic tool** for the primary breast tumor itself. It cannot differentiate between benign and malignant breast tissue, nor can it visualize the internal architecture of the breast. In the context of breast cancer, a CXR is used only as a **staging investigation** to look for distant pulmonary metastases or pleural effusion, rather than for diagnosing the primary lesion. **Why the other options are incorrect:** * **Mammography (D):** This is the gold standard screening and diagnostic imaging modality for women over 35–40 years. It identifies microcalcifications and architectural distortions. * **USG (C):** The investigation of choice for women under 30, pregnant women, and for differentiating between cystic and solid lesions. It also guides interventional procedures. * **Biopsy (B):** Specifically, **Core Needle Biopsy (CNB)** is the definitive diagnostic test. It provides histological details, including tumor grade and receptor status (ER/PR/HER2), which are essential for planning treatment. **Clinical Pearls for NEET-PG:** * **Triple Assessment:** Clinical Examination + Imaging (USG/Mammography) + Pathology (FNAC/Core Biopsy). It has a diagnostic accuracy of >99%. * **Gold Standard for Diagnosis:** Core Needle Biopsy (preferred over FNAC as it preserves tissue architecture). * **BIRADS Scoring:** Used in Mammography to communicate the risk of malignancy (BIRADS 1: Normal; BIRADS 5: Highly suggestive of malignancy). * **MRI Breast:** The most sensitive imaging for detecting breast cancer, especially in patients with BRCA mutations or breast implants.

Q: What is the best chemotherapy regimen for carcinoma of the breast?

Cyclophosphamide, adriamycin, 5-fluorouracil. **Explanation:** The treatment of breast cancer frequently utilizes polychemotherapy to improve survival rates. The combination of **Cyclophosphamide, Adriamycin (Doxorubicin), and 5-Fluorouracil (CAF)** is a classic, highly effective anthracycline-based regimen. 1. **Why Option A is correct:** * **Cyclophosphamide:** An alkylating agent that cross-links DNA. * **Adriamycin (Doxorubicin):** An anthracycline that inhibits topoisomerase II and generates free radicals. Anthracyclines are considered the "backbone" of breast cancer chemotherapy due to their superior efficacy in reducing recurrence. * **5-Fluorouracil:** An antimetabolite that inhibits thymidylate synthase. The CAF (or FAC) regimen has historically been the standard of care before the widespread introduction of taxanes (Paclitaxel/Docetaxel). 2. **Why other options are incorrect:** * **Option B & C:** Cisplatin is primarily used in triple-negative breast cancer (TNBC) or germline BRCA mutations, but it is not part of the standard first-line regimen for general breast carcinoma. * **Option D:** Methotrexate was part of the older CMF regimen (Cyclophosphamide, Methotrexate, 5-FU), but it is generally less effective than anthracycline-based regimens like CAF. Steroids are supportive (anti-emetics) but not primary chemotherapeutic agents. **High-Yield Clinical Pearls for NEET-PG:** * **Cardiotoxicity:** Adriamycin is notorious for dose-dependent irreversible dilated cardiomyopathy. Monitor with ECHO (LVEF). * **Hemorrhagic Cystitis:** Associated with Cyclophosphamide; prevented by hydration and **MESNA**. * **Taxanes:** Modern regimens often add Taxanes (e.g., AC → T) for node-positive or high-risk disease. * **Trastuzumab (Herceptin):** Specifically used for **HER2/neu positive** patients; note that it also carries a risk of reversible cardiotoxicity.

Q: A patient presents 1 month after a benign right breast biopsy with a lateral subcutaneous cord felt just under the skin and causing pain. What is the etiology of this condition?

Superficial thrombophlebitis. **Explanation:** The clinical presentation of a palpable, tender, subcutaneous "cord-like" structure following breast surgery or trauma is classic for **Mondor’s Disease**, which is **superficial thrombophlebitis** of the veins of the breast and anterior chest wall. It most commonly involves the lateral thoracic vein, superior epigastric vein, or thoracoepigastric vein. **Why the correct answer is right:** * **Superficial Thrombophlebitis (Mondor’s Disease):** This is a benign, self-limiting condition. The "cord" represents a thrombosed vein. It typically presents 2–6 weeks after surgery (like biopsy or augmentation), trauma, or even extreme physical activity. The pain is usually acute but subsides as the cord becomes more fibrous. **Why the incorrect options are wrong:** * **Fat Necrosis:** Usually presents as a firm, irregular, painless mass following trauma. While it can mimic carcinoma clinically, it does not present as a longitudinal subcutaneous cord. * **Infection:** Post-operative infections (abscess or mastitis) present with systemic symptoms (fever), localized warmth, erythema, and fluctuance, rather than a distinct, non-erythematous cord. * **Suture Granuloma:** This is a localized inflammatory response to suture material, presenting as a small, firm nodule at the site of the incision, not a linear cord extending across the breast. **NEET-PG High-Yield Pearls:** * **Management:** Mondor’s disease is **self-limiting**. Treatment is conservative with NSAIDs and warm compresses. Anticoagulants are NOT indicated. * **Physical Sign:** The "Iron Wire" sign—the cord may become more prominent when the patient raises their arm. * **Association:** While usually benign/traumatic, in rare cases, it can be a marker for underlying breast malignancy; hence, a follow-up mammogram is often advised if not recently performed.

Q: Pathological nipple discharge is most commonly associated with which of the following?

Duct papilloma. **Explanation:** Nipple discharge is classified as **pathological** if it is spontaneous, unilateral, and arises from a single duct. The most common cause of such discharge (especially if bloody or serosanguinous) is an **Intraductal Papilloma**. 1. **Why Duct Papilloma is Correct:** Intraductal papillomas are benign, finger-like epithelial proliferations within the lactiferous ducts. Because these growths are fragile and highly vascular, they tend to bleed easily into the ductal lumen, leading to the classic presentation of a **spontaneous, bloody nipple discharge** in women aged 30–50. It is typically non-palpable and located in the subareolar region. 2. **Why the Other Options are Incorrect:** * **Fibroadenoma:** This is the most common benign breast tumor ("breast mouse"), but it arises from the terminal duct lobular unit (TDLU) and presents as a firm, mobile mass, not with nipple discharge. * **Adenocarcinoma (Invasive Ductal Carcinoma):** While malignancy is the second most common cause of pathological discharge (approx. 5-15% of cases), it is less frequent than papilloma. Malignant discharge is more likely to be associated with a palpable mass or skin changes. * **Lobular Carcinoma:** This often presents as an occult, multifocal, or bilateral thickening rather than a discrete mass or nipple discharge. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of bloody nipple discharge:** Intraductal Papilloma. * **Most common cause of milky discharge (Galactorrhea):** Prolactinoma (Pituitary adenoma). * **Investigation of choice:** Triple assessment (Clinical exam + Imaging + Cytology/Biopsy). For single-duct discharge, **Microdochectomy** (removal of the involved duct) is both diagnostic and therapeutic. * **Amniotic fluid-like/Greenish discharge:** Usually associated with **Mammary Duct Ectasia**.

Q: A 51-year-old female with ductal carcinoma in situ of the breast is best managed by:

Simple mastectomy. **Explanation:** The management of **Ductal Carcinoma in Situ (DCIS)** is based on the fact that it is a non-invasive, pre-malignant condition confined within the basement membrane. Because the cancer cells have not invaded the stroma, there is no risk of lymphatic spread. **1. Why Simple Mastectomy is Correct:** A **Simple (Total) Mastectomy** involves the removal of the entire breast tissue including the nipple-areola complex, but **without axillary lymph node dissection**. This is considered the "gold standard" for extensive DCIS or when the patient prefers to avoid radiotherapy, as it provides a near 100% cure rate by removing all potential sites of disease. **2. Why other options are incorrect:** * **Breast Conservative Surgery (BCS):** While BCS (Wide Local Excision) is an option for small, localized DCIS, it must always be followed by **Radiotherapy** to reduce the risk of local recurrence. Since the option only mentions BCS alone, Simple Mastectomy is the more definitive and "best" surgical answer in a general context. * **Modified Radical Mastectomy (MRM):** MRM includes axillary lymph node dissection (Level I, II). Since DCIS is non-invasive, the risk of nodal metastasis is <1%, making MRM an unnecessary over-treatment. * **Radical Mastectomy:** This involves removing the pectoralis muscles and is obsolete for almost all breast cancers, especially a non-invasive one like DCIS. **Clinical Pearls for NEET-PG:** * **Van Nuys Prognostic Index:** Used to decide between BCS and Mastectomy in DCIS based on size, margin width, grade, and age. * **Comedo Necrosis:** A high-grade subtype of DCIS with a higher risk of progression to invasive cancer. * **Sentinel Lymph Node Biopsy (SLNB):** Not routine for DCIS, but recommended if a mastectomy is planned (as a later SLNB is impossible once breast tissue is removed) or if there is high suspicion of occult invasion.

Q: All of the following are poor prognostic markers of CA Breast except?

ER positivity. ### Explanation The prognosis of breast cancer is determined by a combination of clinical, histological, and molecular markers. This question tests the ability to distinguish between **favorable** and **unfavorable** prognostic factors. **Why ER Positivity is the Correct Answer:** Estrogen Receptor (ER) and Progesterone Receptor (PR) positivity are **favorable prognostic markers**. Tumors expressing these receptors are generally well-differentiated, grow more slowly, and, most importantly, are responsive to **hormonal therapy** (e.g., Tamoxifen or Aromatase Inhibitors). Patients with ER+ tumors typically have a better disease-free survival rate compared to those with ER-negative tumors. **Analysis of Incorrect Options (Poor Prognostic Markers):** * **DNA Aneuploidy:** An abnormal amount of DNA within tumor cells (aneuploidy) indicates high genetic instability and is associated with aggressive tumor behavior and a higher risk of recurrence. * **Her2/neu Positivity:** Overexpression of the human epidermal growth factor receptor 2 (HER2) is associated with rapid cell proliferation, increased risk of metastasis, and historically poorer outcomes (though targeted therapy like Trastuzumab has improved this). * **p53 Overexpression:** Mutations in the *TP53* tumor suppressor gene lead to the accumulation of defective p53 protein. This is a marker of high-grade tumors, poor differentiation, and resistance to certain chemotherapies. **NEET-PG High-Yield Pearls:** * **Most Important Prognostic Factor:** Number of axillary lymph nodes involved. * **Most Important Predictive Factor:** ER/PR status (predicts response to hormone therapy). * **Triple Negative Breast Cancer (TNBC):** ER-, PR-, and Her2-negative; carries the worst prognosis due to lack of targeted therapy options. * **Other Poor Markers:** High S-phase fraction, Cathepsin D overexpression, and high Ki-67 index (marker of proliferation).

Question 1

Which of the following is a complication of mastectomy?

Accepted Answer

All of the above

Answer

Seroma

Answer

Long thoracic nerve palsy

Answer

Angiosarcoma

Question 2

Which is a distressing complication after modified radical mastectomy?

Accepted Answer

Lymphedema

Answer

Axillary vein thrombosis

Answer

Seroma

Answer

Death

Question 3

What is the LEAST diagnostic test for breast tumours?

Accepted Answer

Chest X-ray

Answer

Biopsy

Answer

USG

Answer

Mammography

Question 4

What is the best chemotherapy regimen for carcinoma of the breast?

Accepted Answer

Cyclophosphamide, adriamycin, 5-fluorouracil

Answer

Methotrexate, cisplatin

Answer

Cisplatin, adriamycin, steroid

Answer

Methotrexate, adriamycin, steroid

Question 5

What is the commonest carcinoma of the breast with multifocal origin?

Accepted Answer

Ductal carcinoma

Answer

Schirrhous carcinoma

Answer

Adenocystic carcinoma

Answer

Lobular carcinoma

Question 6

A patient presents 1 month after a benign right breast biopsy with a lateral subcutaneous cord felt just under the skin and causing pain. What is the etiology of this condition?

Accepted Answer

Superficial thrombophlebitis

Answer

Fat necrosis

Answer

Infection

Answer

Suture granuloma

Question 7

Pathological nipple discharge is most commonly associated with which of the following?

Accepted Answer

Duct papilloma

Answer

Fibroadenoma

Answer

Adenocarcinoma

Answer

Lobular carcinoma

Question 8

A 17-year-old male develops a painless, firm mass beneath the nipple of his left breast. The mass is mobile, and no fluid can be expressed from the breast. The right breast is normal to examination. Which of the following conditions does this mass most likely represent?

Accepted Answer

Gynecomastia

Answer

Fibrocystic changes

Answer

Intraductal papilloma

Answer

Invasive duct carcinoma

Question 9

A 51-year-old female with ductal carcinoma in situ of the breast is best managed by:

Accepted Answer

Simple mastectomy

Answer

Breast conservative surgery

Answer

Modified radical mastectomy

Answer

Radical mastectomy

Question 10

All of the following are poor prognostic markers of CA Breast except?

Accepted Answer

ER positivity

Answer

DNA aneuploidy

Answer

Her 2 neu positivity

Answer

p53 over expression

Breast Surgery — MCQs

Breast Surgery — MCQs

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