Breast Surgery Practice Questions

Q: A 48-year-old post-menopausal lady presents with an 8 cm breast lump that is adherent to the skin, with one firm apical lymph node in the axilla and one more in the supraclavicular region, with no distant metastases clinically. What is the TNM staging?

T3N3M0. ### **Explanation** To determine the TNM staging for this patient, we must break down the clinical findings based on the **AJCC 8th Edition** criteria: **1. Tumor (T) Stage:** * The lump is **8 cm** in size. * **T3** is defined as a tumor **>5 cm** in greatest dimension. * *Note:* Although the lump is "adherent to the skin," it does not qualify as T4 unless there is skin ulceration, satellite nodules, or peau d'orange (T4b), or involvement of the chest wall (T4a). Simple adherence/tethering remains T3. **2. Node (N) Stage:** * **Apical lymph node (Level III axillary):** This signifies **N3a**. * **Supraclavicular lymph node:** This signifies **N3c**. * According to TNM rules, the highest N category is used. Therefore, the presence of a supraclavicular node classifies the patient as **N3**. **3. Metastasis (M) Stage:** * No distant metastases clinically = **M0**. **Conclusion:** The staging is **T3N3M0 (Stage IIIC).** --- ### **Why other options are incorrect:** * **Option A (T3N2M0):** Incorrect because N2 refers to fixed/matted axillary nodes (N2a) or internal mammary nodes (N2b). Supraclavicular nodes are always N3. * **Option B & C (T4...):** Incorrect because T4 requires specific skin changes (ulceration/edema) or chest wall fixation (serratus anterior/intercostals). Simple skin adherence is insufficient for T4. --- ### **High-Yield Clinical Pearls for NEET-PG:** * **T4a:** Extension to the chest wall (ribs, intercostals, serratus anterior). *Note: Pectoralis muscle involvement is NOT T4.* * **T4b:** Edema (peau d'orange), ulceration, or satellite skin nodules. * **N3 Categories:** * **N3a:** Infraclavicular (Level III). * **N3b:** Internal mammary + Axillary. * **N3c:** Supraclavicular. * **Stage IIIC:** Any T, N3, M0. This is considered **Locally Advanced Breast Cancer (LABC)** and usually requires Neoadjuvant Chemotherapy (NACT).

Q: A 45-year-old woman presents with a hard and mobile lump in the breast. What is the next investigation?

Mammography. ### Explanation The correct approach to any breast lump is the **Triple Assessment**, which consists of clinical examination, imaging, and pathology. **1. Why Mammography is the correct answer:** In a woman aged **45 years**, the breast tissue is less dense and contains more fat, making **Mammography** the gold standard primary imaging modality. It helps characterize the lesion (looking for microcalcifications or spiculation) and screens the contralateral breast for occult lesions. In the diagnostic algorithm for a breast lump, imaging always precedes pathological intervention. **2. Why other options are incorrect:** * **Ultrasonography (USG):** This is the initial investigation of choice for women **<35 years** (due to dense breast tissue) or to differentiate between cystic and solid lesions. At age 45, it is used as an adjunct to mammography, not the primary tool. * **FNAC:** While part of the triple assessment, it has been largely replaced by **Core Needle Biopsy (CNB)** because FNAC cannot distinguish between *in situ* and invasive carcinoma. Furthermore, imaging must be performed before any needle intervention to avoid hematomas that obscure radiological findings. * **Excision Biopsy:** This is a surgical procedure and is never the "next" step. It is only indicated if the triple assessment is inconclusive or if the lesion is small and requires removal for definitive diagnosis. **Clinical Pearls for NEET-PG:** * **Triple Assessment Accuracy:** If all three components (Clinical, Imaging, Pathology) are concordant, the diagnostic accuracy is **>99%**. * **Age Cut-off:** Use **35 years** as the threshold. Below 35, start with USG; above 35, start with Mammography. * **BIRADS:** Mammography findings are reported using the BIRADS (Breast Imaging-Reporting and Data System) score (0–6). * **Gold Standard for Pathology:** Core Needle Biopsy (CNB) is preferred over FNAC for suspicious solid lumps.

Q: Which of the following best describes the location of Level II axillary lymph nodes?

Posterior to pectoralis minor. The classification of axillary lymph nodes into three levels is based on their anatomical relationship with the **Pectoralis minor muscle**. This is known as **Berg’s classification**, which is crucial for staging and surgical management of breast cancer. ### **Explanation of the Correct Answer** * **Level II (Middle Group):** These nodes are located **posterior (deep)** to the pectoralis minor muscle. This group also includes the **Rotter’s nodes** (interpectoral nodes), which lie between the pectoralis major and minor muscles. ### **Analysis of Incorrect Options** * **Option A (Lateral to pectoralis minor):** This describes **Level I (Lower Group)** nodes. They are located lateral and inferior to the lower border of the pectoralis minor. This group includes the anterior (pectoral), posterior (subscapular), and lateral (humeral) groups. * **Option C (Medial to pectoralis minor):** This describes **Level III (Upper Group)** nodes. They are located medial and superior to the upper border of the pectoralis minor, extending up to the lower border of the clavicle (Halsted’s ligament). * **Option D (Superomedial to pectoralis major):** This is anatomically incorrect regarding Berg’s levels; the landmark is strictly the pectoralis **minor**, not major. ### **High-Yield Clinical Pearls for NEET-PG** * **Surgical Boundary:** The pectoralis minor acts as the "key" to the axilla. * **Rotter’s Nodes:** Specifically located in Level II; their involvement can change the surgical approach. * **Axillary Vein:** Forms the superior boundary of the axillary dissection. * **Nerves to preserve:** During axillary clearance, the **Long thoracic nerve** (supplying Serratus anterior; injury causes Winging of Scapula) and the **Thoracodorsal nerve** (supplying Latissimus dorsi) must be protected. * **Sentinel Lymph Node (SLN):** Usually found in Level I; it is the first node to receive lymphatic drainage from the primary tumor.

Q: Which type of ductal carcinoma in situ (DCIS) typically results in a palpable abnormality?

Paget's disease. **Explanation:** **Paget’s Disease of the Breast** is the correct answer because it is a unique clinical presentation of DCIS where malignant cells (Paget cells) migrate from the underlying lactiferous ducts into the epidermis of the nipple-areola complex. Unlike most forms of DCIS, which are typically subclinical and detected only via microcalcifications on screening mammography, Paget’s disease presents with **palpable skin changes** (eczematous crusting, scaling, or ulceration) and is associated with an underlying palpable mass in approximately 50% of cases. **Analysis of Incorrect Options:** * **Comedocarcinoma:** This is the most aggressive subtype of DCIS characterized by high-grade nuclei and central "comedo" necrosis. While it is more likely to form larger areas of involvement, it typically presents as **microcalcifications** on mammography rather than a palpable lump. * **Non-comedo DCIS:** This includes subtypes like cribriform, papillary, and solid. These are generally lower-grade lesions that are almost exclusively detected radiologically and rarely, if ever, produce a palpable abnormality. **High-Yield Clinical Pearls for NEET-PG:** * **Pathognomonic Feature:** Presence of **Paget cells** (large cells with clear/pale cytoplasm and prominent nucleoli) within the squamous epithelium. * **Underlying Malignancy:** Nearly 100% of Paget’s disease cases have an underlying DCIS or invasive carcinoma. * **Differential Diagnosis:** Always differentiate from nipple eczema; Paget’s involves the **nipple first** and then spreads to the areola, whereas eczema usually involves the areola first. * **Staining:** Paget cells are typically **PAS positive** (mucin-producing) and **HER2/neu positive**.

Q: Which one of the following is the most sensitive and specific screening test to detect breast cancer?

Mammography. **Explanation:** **Mammography** is the gold standard and the most sensitive and specific screening tool for breast cancer. Its primary strength lies in its ability to detect **non-palpable lesions** and **microcalcifications** (specifically pleomorphic or linear branching types), which are often the earliest signs of Ductal Carcinoma In Situ (DCIS) or early invasive cancer, long before a lump can be felt. **Analysis of Options:** * **Self-Breast Examination (SBE):** While useful for breast awareness, SBE has a high false-positive rate and has not been shown to reduce mortality in large-scale trials. It often detects cancers at a later stage compared to imaging. * **Regular X-ray:** A standard chest or general X-ray lacks the soft-tissue resolution required to differentiate breast parenchyma from neoplastic masses. Mammography is a specialized low-dose X-ray technique designed specifically for this purpose. * **Regular Biopsy:** Biopsy (FNAC or Core Needle Biopsy) is a **diagnostic** tool, not a screening tool. It is invasive and performed only after a suspicious lesion is identified via clinical exam or imaging. **High-Yield Clinical Pearls for NEET-PG:** * **Screening Guidelines:** Most international guidelines (like ACS) recommend annual mammography starting at age 40–45. * **BI-RADS Classification:** Mammogram results are reported using the BI-RADS scale (0-6); BI-RADS 4 and 5 require biopsy. * **Young Patients:** In women under 35, **Ultrasonography (USG)** is the preferred initial investigation because young breast tissue is too dense for mammography to be effective. * **MRI:** This is the most sensitive imaging modality overall but is reserved for high-risk screening (e.g., BRCA mutations) due to lower specificity and high cost.

Q: An elderly female presented with 'Peau de orange appearance' of the breast. What is it likely to be associated with?

Obstruction of cutaneous lymphatics. **Explanation:** **Peau d’orange** (French for "orange peel skin") is a classic clinical sign of advanced breast malignancy, specifically inflammatory breast cancer. **1. Why the Correct Answer is Right:** The appearance is caused by the **obstruction of cutaneous lymphatics** by tumor emboli. When the superficial lymphatic drainage is blocked, it leads to localized lymphedema of the skin. However, the skin remains tethered to the underlying subcutaneous tissue by the **suspensory ligaments of Cooper**. As the skin swells (edema), these tethered points create characteristic "pits" or dimples, resembling the texture of an orange peel. **2. Why the Incorrect Options are Wrong:** * **A. Drug reaction:** While drug reactions can cause skin rashes or generalized edema (angioedema), they do not typically cause the localized, pitted "orange peel" texture associated with lymphatic obstruction. * **C. Postoperative scarring:** Scarring usually results in skin retraction or puckering due to fibrosis, but it lacks the diffuse edematous, pitted appearance of peau d'orange. * **D. Tumor necrosis:** Necrosis within a tumor may lead to skin ulceration or discharge, but it does not directly cause the specific lymphatic-mediated edema seen in this condition. **3. Clinical Pearls for NEET-PG:** * **Significance:** Peau d’orange is a hallmark of **Inflammatory Breast Cancer** (T4d in TNM staging). * **Differential Diagnosis:** It can also be seen in severe cases of mastitis or breast abscess, though the clinical context (fever, pain) usually differs. * **Histology:** If a skin biopsy is performed, it often shows **lymphatic invasion** by malignant cells in the dermal lymphatics. * **Staging:** The presence of peau d'orange automatically classifies the breast cancer as **Stage T4**, regardless of the size of the underlying tumor.

Question 1

A 48-year-old post-menopausal lady presents with an 8 cm breast lump that is adherent to the skin, with one firm apical lymph node in the axilla and one more in the supraclavicular region, with no distant metastases clinically. What is the TNM staging?

Accepted Answer

T3N3M0

Answer

T3N2M0

Answer

T4N3CM0

Answer

T4N2CM0

Question 2

A 45-year-old woman presents with a hard and mobile lump in the breast. What is the next investigation?

Accepted Answer

Mammography

Answer

Fine Needle Aspiration Cytology (FNAC)

Answer

Ultrasonography (USG)

Answer

Excision biopsy

Question 3

A 24-year-old woman presents two weeks after delivering a 3.5-kg baby, during which she has been breastfeeding. She has a fever of 38

C (101

F). Physical examination reveals redness on the lower side of the left breast, but no abnormal vaginal discharge or evidence of pelvic pain. Despite temporarily stopping nursing the infant, her symptoms persist, and the entire breast becomes swollen and painful. What is the most likely diagnosis?

Accepted Answer

Acute mastitis

Answer

Chronic mastitis

Answer

Duct ectasia

Answer

Granulomatous mastitis

Question 4

Postoperative radiotherapy in breast cancer is indicated for which of the following reasons?

Accepted Answer

Prevention of local recurrence

Answer

Prevention of metastasis

Answer

Ablation of remnant cancer tissue

Answer

Prevention of distant metastasis

Question 5

Which of the following best describes the location of Level II axillary lymph nodes?

Accepted Answer

Posterior to pectoralis minor

Answer

Lateral to pectoralis major and minor

Answer

Medial to pectoralis minor

Answer

Superomedial to pectoralis major

Question 6

Clinical stage II of carcinoma breast means?

Accepted Answer

Tumor is present in the breast and axillary lymph nodes are involved

Answer

Tumor is limited to the breast

Answer

Tumor with evidence of distant metastasis

Answer

Tumor has involved breast, pectoral muscles, and a wide area of skin

Question 7

Which type of ductal carcinoma in situ (DCIS) typically results in a palpable abnormality?

Accepted Answer

Paget's disease

Answer

Comedocarcinoma

Answer

Non-comedo DCIS

Answer

None of the above

Question 8

Which one of the following is the most sensitive and specific screening test to detect breast cancer?

Accepted Answer

Mammography

Answer

Regular X-ray

Answer

Self breast examination

Answer

Regular biopsy

Question 9

An elderly female presented with 'Peau de orange appearance' of the breast. What is it likely to be associated with?

Accepted Answer

Obstruction of cutaneous lymphatics

Answer

Drug reaction

Answer

Postoperative scarring

Answer

Tumor necrosis

Question 10

A 75-year-old hypertensive lady has a 2 x 2 cm infiltrating duct cell carcinoma in the subareolar region. There are no palpable lymph nodes and no distant metastases. However, she had been treated for pulmonary tuberculosis 20 years ago. What is the best course of management?

Accepted Answer

Modified radical mastectomy followed by hormone therapy

Answer

Modified radical mastectomy followed by radiotherapy

Answer

Modified radical mastectomy followed by 6 cycles of chemotherapy

Answer

Breast conservation surgery followed by radiotherapy

Breast Surgery — MCQs

Breast Surgery — MCQs

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