Breast Surgery Practice Questions

Q: A female presents with a breast lump of size 6 cm. On examination, ipsilateral axillary lymph nodes are found to be enlarged and fixed. What is the TNM staging?

T3 N2. ### Explanation The TNM staging system for breast cancer is a cornerstone of surgical oncology. To solve this question, we must break down the clinical findings based on the AJCC 8th Edition criteria. **1. Tumor (T) Staging:** The size of the lump is **6 cm**. * T1: ≤ 2 cm * T2: > 2 cm but ≤ 5 cm * **T3: > 5 cm** * T4: Any size with extension to the chest wall or skin (edema/ulceration). Since the lump is 6 cm, it is classified as **T3**. **2. Node (N) Staging:** The examination reveals **ipsilateral axillary lymph nodes** that are **fixed** to one another or to other structures. * N1: Movable ipsilateral axillary lymph nodes. * **N2: Ipsilateral axillary lymph nodes that are fixed** or matted. * N3: Metastasis in ipsilateral infraclavicular, internal mammary, or supraclavicular nodes. The presence of fixed nodes confirms **N2**. **Conclusion:** Combining these gives **T3 N2**. --- ### Why Other Options are Incorrect: * **B (T2 N2):** Incorrect because T2 is limited to tumors ≤ 5 cm. * **C (T4 N2):** Incorrect because T4 requires involvement of the chest wall (Serratus anterior/Ribs) or skin (Peau d'orange/Ulceration). Size alone does not make a tumor T4. * **D (T1 N1):** Incorrect as T1 is ≤ 2 cm and N1 implies movable (not fixed) nodes. --- ### NEET-PG High-Yield Pearls: * **T4 Classification:** Note that involvement of the Pectoralis major muscle alone does **not** constitute T4; it must involve the chest wall (ribs, intercostals, or serratus anterior). * **Inflammatory Carcinoma:** This is clinically diagnosed and automatically staged as **T4d**. * **Dimpling vs. Peau d'orange:** Skin dimpling (tethering) is due to Cooper’s ligament involvement and does not change the T stage, whereas Peau d'orange (dermal lymphatic edema) signifies T4.

Q: Winging of the scapula is typically seen after mastectomy due to injury to which nerve?

Long thoracic nerve. **Explanation:** **1. Why the Long Thoracic Nerve is Correct:** The **Long Thoracic Nerve (Nerve of Bell)** originates from the nerve roots C5, C6, and C7. It runs along the lateral chest wall on the superficial surface of the **Serratus Anterior** muscle. During an Axillary Lymph Node Dissection (ALND) as part of a Modified Radical Mastectomy (MRM), this nerve is vulnerable to injury. The Serratus Anterior is responsible for protracting the scapula and holding its medial border against the thoracic wall. Denervation leads to paralysis of this muscle, causing the medial border of the scapula to protrude posteriorly—a clinical sign known as **"Winging of the Scapula."** Patients often complain of difficulty in lifting the arm above the shoulder level. **2. Why the Other Options are Incorrect:** * **Musculocutaneous Nerve:** This nerve (C5-C7) supplies the coracobrachialis, biceps brachii, and brachialis. It is not encountered during routine breast surgery. * **Intercostobrachial Nerve:** This is the most commonly injured nerve during mastectomy/ALND. Injury results in **numbness or paresthesia** of the skin on the upper inner aspect of the arm, but it does not cause motor deficits like winging. * **Thoracodorsal Nerve:** This nerve supplies the **Latissimus Dorsi** muscle. Injury leads to weakness in internal rotation, adduction, and extension of the arm (difficulty in "climbing" or "scratching the back"), but not winging of the scapula. **3. Clinical Pearls for NEET-PG:** * **Nerve of Bell:** Long Thoracic Nerve (Supplies Serratus Anterior $\rightarrow$ Winging). * **Nerve to Latissimus Dorsi:** Thoracodorsal Nerve (Injury $\rightarrow$ Weak adduction/extension). * **Most commonly injured nerve in MRM:** Intercostobrachial nerve (Sensory loss only). * **Halsted’s Sign:** If the medial pectoral nerve is injured, it leads to atrophy of the Pectoralis major muscle.

Q: Hadfield operation is done for which condition?

Duct Ectasia. **Explanation:** **Hadfield’s Operation (Total Duct Excision)** is the definitive surgical treatment for **Duct Ectasia** (also known as periductal mastitis). This condition involves the dilation of the major subareolar ducts, leading to chronic inflammation and symptoms such as cheesy/colored nipple discharge, nipple retraction, or recurrent subareolar abscesses. * **Why Option A is correct:** When medical management fails or when there is multi-duct discharge/recurrent fistula formation, Hadfield’s operation is performed. It involves a circumareolar incision to excise the entire major duct system (cone excision) from the base of the nipple. This removes the diseased tissue and prevents recurrence. **Why other options are incorrect:** * **B. Fibroadenoma:** These are benign "breast mice" typically managed by observation or simple **enucleation** if they are large or symptomatic. * **C. Mondor’s Disease:** This is a self-limiting thrombophlebitis of the superficial veins of the breast/chest wall. It is managed conservatively with **NSAIDs** and warm compresses; surgery is not indicated. * **D. Breast Cancer:** Management involves Wide Local Excision (Breast Conservation Surgery) or Modified Radical Mastectomy (MRM), depending on the stage. Hadfield’s is a benign duct procedure, not an oncological resection. **High-Yield Clinical Pearls for NEET-PG:** * **Microdochectomy:** If the discharge is from a **single duct** (e.g., Intraductal Papilloma), only that specific duct is excised (Urban’s procedure). * **Hadfield’s:** Indicated for **multiple ducts** or recurrent periductal mastitis. * **Zuska’s Disease:** Another name for recurrent retroareolar abscess associated with squamous metaplasia of lactiferous ducts, often requiring Hadfield’s operation. * **Smoking:** The strongest risk factor for the development of Duct Ectasia/Periductal mastitis.

Q: Which of the following statements regarding fibroadenoma is FALSE?

Responds well to hormone. **Explanation:** Fibroadenoma is the most common benign tumor of the female breast, typically occurring in women aged 15–35 years. It is a fibroepithelial tumor characterized by the proliferation of both glandular and stromal elements. **Why Option C is the Correct (False) Statement:** While fibroadenomas are hormonally sensitive—meaning they may enlarge during pregnancy or fluctuate slightly during the menstrual cycle—they **do not "respond well" to hormonal therapy** in a clinical or therapeutic sense. There is no standard medical treatment involving hormones (like OCPs or SERMs) that reliably shrinks or eliminates a fibroadenoma. Management is typically conservative (observation) or surgical excision. **Analysis of Other Options:** * **A. Painless:** Most fibroadenomas are characteristically painless, smooth, and discrete. * **B. Unilateral:** Although they can be bilateral in 10–15% of cases, the vast majority present as a single, unilateral lump. * **D. Firm:** On palpation, they have a classic firm, rubbery consistency. **NEET-PG High-Yield Pearls:** * **"Breast Mouse":** Due to high mobility within the breast tissue (not fixed to skin or chest wall). * **Mammography:** May show a well-defined mass with "Popcorn calcification" (seen in older, involuted fibroadenomas). * **Histology:** Two patterns are described—**Intracanalicular** (stroma compresses ducts into slits) and **Pericanalicular** (ducts remain patent). * **Giant Fibroadenoma:** Defined as a fibroadenoma >5 cm in size or >500g in weight. * **Phyllodes Tumor:** The most important differential diagnosis; it grows rapidly and has higher stromal cellularity.

Q: Stage T1N0M0 in breast cancer indicates:

Tumor 2 cm or less without axillary nodes and no metastasis. ### Explanation The staging of breast cancer follows the **AJCC TNM Classification** (Tumor, Node, Metastasis), which is a critical high-yield topic for NEET-PG. **1. Why the Correct Answer is Right:** * **T1:** Refers to a tumor that is **2 cm or less** in its greatest dimension. * **N0:** Indicates that there is **no regional lymph node metastasis** (clinically or pathologically). * **M0:** Indicates that there is **no distant metastasis**. Therefore, T1N0M0 represents an early-stage breast cancer (Stage IA) where the primary lesion is small and localized. **2. Analysis of Incorrect Options:** * **Option A:** A tumor **more than 2 cm** would be classified as **T2** (if 2–5 cm) or **T3** (if >5 cm). * **Option C:** Fixation to the **chest wall** (ribs, intercostals, or serratus anterior) automatically classifies the tumor as **T4a**, regardless of size. * **Option D:** Fixation to the underlying muscle (Pectoralis) does not change the T-stage unless it involves the chest wall, but the presence of **distant metastasis** makes it **M1 (Stage IV)**, regardless of T or N status. **3. Clinical Pearls for NEET-PG:** * **T1 Subdivisions:** T1mi (≤0.1 cm), T1a (>0.1 to 0.5 cm), T1b (>0.5 to 1 cm), and T1c (>1 to 2 cm). * **T4 Categories:** T4a (Chest wall), T4b (Skin edema/Peau d'orange/Ulceration), T4c (Both 4a & 4b), T4d (Inflammatory carcinoma). * **Stage IA vs. IB:** Stage IA is T1N0M0. Stage IB involves micrometastasis in lymph nodes (T0/T1, N1mi, M0). * **Management:** T1N0M0 is typically managed with Breast Conservation Surgery (BCS) or Modified Radical Mastectomy (MRM) followed by appropriate adjuvant therapy.

Q: Which myocutaneous flap is considered the best for reconstruction surgery in breast carcinoma?

Transverse rectus abdominis. **Explanation:** The **Transverse Rectus Abdominis Myocutaneous (TRAM) flap** is considered the "gold standard" for autologous breast reconstruction. **Why TRAM is the best choice:** The primary goal of breast reconstruction is to provide adequate volume, natural contour, and skin coverage. The TRAM flap utilizes the skin and subcutaneous fat from the lower abdomen (the "tummy tuck" area), which closely mimics the consistency and volume of natural breast tissue. It can be performed as a **pedicled flap** (based on the superior epigastric artery) or a **free flap** (based on the deep inferior epigastric artery). Its ability to provide a large amount of tissue without the need for synthetic implants makes it the preferred choice for most surgeons. **Analysis of Incorrect Options:** * **Pectoralis major/minor:** These are muscles of the chest wall. While the Pectoralis major is often used to provide muscular coverage for a breast *implant* (subpectoral placement), it does not provide the bulk or skin required for a complete autologous reconstruction. * **Latissimus dorsi (LD) flap:** This was historically common but is now generally considered second-line. The LD muscle is thin and often requires an additional silicone implant to achieve sufficient breast volume, unlike the TRAM flap which is usually "implant-independent." **High-Yield Clinical Pearls for NEET-PG:** * **Blood Supply:** The pedicled TRAM flap is based on the **Superior Epigastric Artery**, while the free TRAM/DIEP flap is based on the **Deep Inferior Epigastric Artery**. * **DIEP Flap:** The Deep Inferior Epigastric Perforator (DIEP) flap is a refinement of the TRAM that spares the rectus muscle, reducing the risk of abdominal wall hernia. * **Contraindication:** TRAM flaps are generally avoided in patients with significant prior abdominal surgeries (e.g., extensive abdominoplasty) or heavy smokers due to compromised microvasculature.

Question 1

A woman is diagnosed to have breast carcinoma. What is the recommended investigation for the contralateral breast?

Accepted Answer

Mammography

Answer

Random Fine Needle Aspiration Cytology (FNAC)

Answer

No investigation needed

Answer

Clinical breast examination

Question 2

A 60-year-old lady presents with blood-stained nipple discharge and a family history of breast cancer. What is the next best step in her management?

Accepted Answer

MRI

Answer

Ductoscopy

Answer

Nipple discharge cytology

Answer

Sono-mammogram

Question 3

A female presents with a breast lump of size 6 cm. On examination, ipsilateral axillary lymph nodes are found to be enlarged and fixed. What is the TNM staging?

Accepted Answer

T3 N2

Answer

T2 N2

Answer

T4 N2

Answer

T1 N1

Question 4

A 45-year-old female presented to the OPD with a 4 cm breast lump in the left breast. On examination, left axillary lymph nodes were fixed and matted. Which of the following is the preferred treatment option?

Accepted Answer

Neoadjuvant chemotherapy + Modified radical mastectomy + Radiotherapy

Answer

Breast conservation surgery + Axillary LN sampling + Radiotherapy

Answer

Simple mastectomy + Axillary LN sampling

Answer

Halsted radical mastectomy followed by Radiotherapy

Question 5

Winging of the scapula is typically seen after mastectomy due to injury to which nerve?

Accepted Answer

Long thoracic nerve

Answer

Musculocutaneous nerve

Answer

Intercostobrachial nerve

Answer

Thoracodorsal nerve

Question 6

Hadfield operation is done for which condition?

Accepted Answer

Duct Ectasia

Answer

Fibroadenoma

Answer

Mondor's disease

Answer

Breast cancer

Question 7

Which of the following statements regarding fibroadenoma is FALSE?

Accepted Answer

Responds well to hormone

Answer

Painless

Answer

Unilateral

Answer

Firm

Question 8

A 55-year-old female patient presents with a 3 cm fungating breast mass and palpable ipsilateral axillary lymph nodes. There is no evidence of distant metastases. What is the most appropriate surgical management?

Accepted Answer

Modified radical mastectomy with axillary lymph node dissection

Answer

Radical mastectomy

Answer

Hormonal therapy

Answer

Palliative therapy

Question 9

Stage T1N0M0 in breast cancer indicates:

Accepted Answer

Tumor 2 cm or less without axillary nodes and no metastasis

Answer

Tumor more than 2 cm in diameter without axillary nodes and absent metastasis

Answer

Tumor fixed to the chest wall without axillary nodes or distant metastasis

Answer

Tumor fixed to the underlying muscle with no nodes in axilla but with distant metastasis

Question 10

Which myocutaneous flap is considered the best for reconstruction surgery in breast carcinoma?

Accepted Answer

Transverse rectus abdominis

Answer

Pectoralis minor

Answer

Pectoralis major

Answer

Latissimus dorsi

Breast Surgery — MCQs

Breast Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?