Breast Surgery Practice Questions

Q: Regarding cystic disease of the breast, which one of the following statements is true?

Aspiration is the treatment. **Explanation:** Cystic disease of the breast, often part of **Fibrocystic Change (ANDI - Aberrations of Normal Development and Involution)**, is a benign condition characterized by fluid-filled sacs resulting from the involution of breast lobules. **Why Option D is correct:** **Fine Needle Aspiration (FNA)** is both diagnostic and therapeutic. If the aspirated fluid is non-bloody and the lump disappears completely without recurrence, no further treatment is required. This makes aspiration the primary management strategy for symptomatic or large cysts. **Why other options are incorrect:** * **Option A:** Cystic disease is most common in the **perimenopausal age group (35–50 years)**, not 25. It is rare after menopause unless the patient is on Hormone Replacement Therapy (HRT). * **Option B:** Excision is not the first-line treatment. Surgery is only indicated if the cyst recurs repeatedly after aspiration, contains blood-stained fluid, or shows a residual solid mass (intracystic papilloma/carcinoma). * **Option C:** Simple cysts are **benign** and do not carry an increased risk of malignancy. Only complex cysts with solid components or proliferative changes with atypia (found on biopsy) increase the risk of future breast cancer. **NEET-PG High-Yield Pearls:** * **Triple Assessment:** Clinical examination, Imaging (Ultrasound is preferred for cysts), and Pathology (FNA/Core Biopsy). * **Blue-Domed Cysts of Bloodgood:** A classic pathological description of large, tense cysts containing brownish-blue fluid. * **Management Rule:** If the fluid is bloody or the mass persists after aspiration, a core needle biopsy is mandatory to rule out malignancy.

Q: Which of the following statements regarding Paget's disease of the breast is true, except?

None of the above. **Explanation:** Paget’s disease of the breast is a rare manifestation of breast cancer characterized by the infiltration of the epidermis by malignant cells (Paget cells). The question asks for the "false" statement, but since all options (A, B, and C) are clinically accurate, the correct answer is **"None of the above."** **1. Why the options are correct:** * **Option B (Represents underlying malignancy):** This is a hallmark of the disease. In over 95% of cases, Paget’s disease is associated with an underlying **Ductal Carcinoma In Situ (DCIS)** or invasive carcinoma. The Paget cells migrate from the underlying lactiferous ducts to the nipple skin. * **Option C (Presents as eczema):** The classic clinical presentation is a chronic, crusting, scaling, or eroding lesion of the nipple-areola complex that mimics **eczema**. A key differentiating factor is that Paget’s typically involves the **nipple first** and may spread to the areola, whereas cutaneous eczema usually involves the areola and spares the nipple. * **Option A (Treated by simple mastectomy):** While Breast Conserving Surgery (BCS) followed by radiotherapy is an option for localized disease, **Simple Mastectomy** (with or without axillary evaluation) remains a standard and definitive surgical treatment, especially when the underlying malignancy is multicentric. **High-Yield Clinical Pearls for NEET-PG:** * **Pathology:** Paget cells are large, pale cells with granular cytoplasm and pleomorphic nuclei. They are **PAS positive** (diastase resistant) and stain positive for **Her2/neu** and **CK7**. * **Diagnosis:** The gold standard for diagnosis is a **full-thickness punch biopsy** of the nipple-areola complex. * **Prognosis:** The prognosis depends entirely on the stage and characteristics of the underlying breast cancer, not the skin changes themselves.

Q: Unilateral breast involvement with scaly skin around the nipple and intermittent bleeding is suggestive of:

Paget's disease. **Explanation:** The clinical presentation of unilateral, scaly, or eczematous lesions of the nipple-areola complex, especially when associated with intermittent bleeding or ulceration, is a classic hallmark of **Paget’s disease of the breast**. **1. Why Paget’s Disease is Correct:** Paget’s disease is an intraepidermal manifestation of an underlying breast malignancy (usually Ductal Carcinoma In Situ or invasive ductal carcinoma). Malignant "Paget cells" migrate from the lactiferous ducts into the epidermis of the nipple. Key diagnostic features include: * **Unilateral involvement** (unlike constitutional eczema). * **Destruction of the nipple-areola complex** (starts at the nipple and spreads to the areola). * **Palpable mass** present in approximately 50% of cases. **2. Why Other Options are Incorrect:** * **Eczema:** Typically **bilateral**, involves the areola first (sparing the nipple), and presents with intense pruritus without destruction of the nipple architecture. It responds to topical steroids, whereas Paget’s does not. * **Galactocoele:** A milk-containing cyst occurring in lactating women. It presents as a painless, fluctuant mass rather than a surface skin lesion. * **Sebaceous Cysts:** These are common cutaneous lumps that may occur on the breast skin but do not cause diffuse scaling or bleeding of the nipple-areola complex. **Clinical Pearls for NEET-PG:** * **Pathology:** Look for **Paget cells** (large, PAS-positive, pale-staining cells with prominent nucleoli) on skin biopsy. * **Management:** Mammography is mandatory to locate the underlying malignancy. * **Rule of Thumb:** Any "eczema" of the nipple that does not heal with topical treatment within 2–3 weeks must be biopsied to rule out Paget’s disease.

Q: What is the most common site of metastasis for breast carcinoma?

Lumbar vertebra. **Explanation:** Breast carcinoma is known for its predilection for hematogenous spread to the skeletal system. Bone is the most common site of distant metastasis, occurring in approximately 70% of patients with advanced disease. **Why Lumbar Vertebra is Correct:** The primary route for spinal metastasis in breast cancer is the **Batson’s venous plexus** (a valveless vertebral venous system). This plexus connects the deep pelvic veins and thoracic veins directly to the internal vertebral venous plexus without passing through the lungs or the portal system. Due to the effects of gravity and intra-abdominal pressure, the **Lumbar vertebrae** are the most frequently involved segment of the spine, followed by the thoracic vertebrae. **Analysis of Incorrect Options:** * **Thoracic vertebra (A):** While the thoracic spine is the second most common site of spinal metastasis, it is statistically less frequent than the lumbar region. * **Pelvis (B):** The pelvis is a common site for bony metastasis, but it ranks lower in frequency compared to the axial skeleton (spine). * **Femur (C):** The femur is the most common site for metastasis in the **appendicular skeleton**, but overall, it is less common than spinal involvement. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of distant metastasis:** Bone (specifically the Lumbar spine). * **Most common organ for metastasis:** Lungs (followed by Liver). * **Nature of lesions:** Breast cancer bone metastases are typically **osteolytic**, though they can be osteoblastic (especially in certain subtypes). * **Batson’s Plexus:** This is the key anatomical structure explaining why breast, prostate, and thyroid cancers frequently metastasize to the spine while bypassing the caval system.

Question 1

Regarding cystic disease of the breast, which one of the following statements is true?

Accepted Answer

Aspiration is the treatment

Answer

Common in 25 years of age

Answer

Excision is the treatment

Answer

May turn into malignant

Question 2

A 40-year-old female presents with a 2 cm breast nodule and a proven metastatic axillary lymph node. What is the recommended treatment?

Accepted Answer

Patey's mastectomy with adjuvant chemotherapy

Answer

Quadrantectomy

Answer

Mastectomy with local radiotherapy

Answer

Halsted's radical mastectomy with tamoxifen

Question 3

Which of the following pathologic findings is the strongest contraindication to breast preservation (lumpectomy with breast radiation) as primary treatment for a newly diagnosed breast cancer?

Accepted Answer

Positive surgical margin for invasive cancer

Answer

Grade 3, poorly differentiated, infiltrating ductal carcinoma

Answer

Extensive intraductal cancer around the invasive lesion

Answer

Tumor size less than 3 cm

Question 4

Which of the following statements regarding Paget's disease of the breast is true, except?

Accepted Answer

None of the above

Answer

Treated by simple mastectomy

Answer

Represents underlying malignancy

Answer

Presents as eczema

Question 5

Unilateral breast involvement with scaly skin around the nipple and intermittent bleeding is suggestive of:

Accepted Answer

Paget's disease

Answer

Galactocoele

Answer

Eczema

Answer

Sebaceous cysts

Question 6

Which of the following statements is FALSE regarding breast cancer during pregnancy?

Accepted Answer

Mammography has reduced sensitivity during pregnancy.

Answer

Axillary lymph node metastases are present in 75% of affected women.

Answer

Radiation therapy cannot be considered for treatment during pregnancy.

Answer

Less than 25% of breast nodules discovered are cancerous.

Question 7

Fibrocystic disease of the breast has been associated with elevated blood levels of which hormone?

Accepted Answer

Estrogen

Answer

Testosterone

Answer

Progesterone

Answer

Luteinizing hormone

Question 8

Self breast examination by females is advisable to be done at which of the following times?

Accepted Answer

7-10 days after menses

Answer

Premenstrual period

Answer

During menses

Answer

Ovulatory period

Question 9

A 45-year-old lady presents with a lump in her right breast. The lump is 4 cm in diameter with evidence of cutaneous edema (peau d'orange), not fixed to the pectoralis major muscle. The axillary lymph nodes are not enlarged. What is the status of T in the TNM classification?

Accepted Answer

T4: tumor of any size with direct extension to chest wall or skin

Answer

T1: tumor ≤ 2 cm in greatest dimension

Answer

T2: tumor > 2 cm but ≤ 5 cm in greatest dimension

Answer

T3: tumor > 5 cm in greatest dimension

Question 10

What is the most common site of metastasis for breast carcinoma?

Accepted Answer

Lumbar vertebra

Answer

Thoracic vertebra

Answer

Pelvis

Answer

Femur

Breast Surgery — MCQs

Breast Surgery — MCQs

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