Breast Surgery Practice Questions

Q: Prognostic stage groups in carcinoma breast include all except?

Age. The **AJCC Cancer Staging Manual (8th Edition)** introduced a paradigm shift in breast cancer staging by moving from a purely **Anatomic Stage** (TNM) to a **Prognostic Stage**. ### Why "Age" is the Correct Answer While age is a significant risk factor for developing breast cancer and can influence treatment decisions (e.g., choosing breast-conserving surgery vs. mastectomy), it is **not** a component of the AJCC 8th Edition Prognostic Staging system. Staging is designed to reflect the biological behavior and outcome of the tumor itself, rather than patient demographics. ### Explanation of Other Options (Included in Prognostic Staging) The AJCC 8th Edition integrates biological markers with traditional TNM to provide a more accurate prognosis: * **Tumor Size (T):** Remains a fundamental part of the anatomic staging component. * **Grade (G):** Histological grade (Nottingham Grade) is now mandatory for prognostic grouping as it reflects tumor aggressiveness. * **HER-2 Status:** Along with **ER (Estrogen Receptor)** and **PR (Progesterone Receptor)** status, this molecular marker is essential for determining the Clinical and Pathological Prognostic Groups. ### High-Yield Clinical Pearls for NEET-PG * **The "Big 5" of Prognostic Staging:** To determine the Prognostic Stage Group, you need: **T** (Tumor size), **N** (Node status), **M** (Metastasis), **Grade**, and **Biomarker status** (ER, PR, and HER2). * **Oncotype DX:** In the US/specific settings, multigene assays (like the 21-gene recurrence score) are also integrated into staging for T1-T2, N0, ER+ tumors. * **Triple Negative Breast Cancer (TNBC):** Usually carries a worse prognostic stage compared to Luminal A types, even if the anatomic TNM is the same. * **Most Important Prognostic Factor:** Overall, the number of **axillary lymph nodes** involved remains the most significant prognostic factor for recurrence and survival.

Q: A 50-year-old lady presented with a lump in the left breast that developed suddenly over weeks. Perimenopausal symptoms are present. There is no associated family history. On examination, the lump is well-circumscribed, fluctuant, and measures 1.5 cm with an oval shape. What is the most likely diagnosis?

Breast cyst. **Explanation:** The clinical presentation is classic for a **Breast Cyst**, which is the most common cause of a discrete breast lump in women aged 35–50 years (perimenopausal age group). **Why Option A is correct:** 1. **Age & Hormonal Status:** Breast cysts are most prevalent in perimenopausal women due to hormonal fluctuations. 2. **Rapid Onset:** Cysts often appear "suddenly" or enlarge rapidly, sometimes causing mild discomfort. 3. **Physical Findings:** A **fluctuant** (fluid-filled), well-circumscribed, and oval mass is the hallmark of a cyst. Solid tumors like cancer or fibroadenomas are typically firm or hard, not fluctuant. **Why other options are incorrect:** * **B. Galactocele:** These are milk-containing cysts that occur exclusively during or shortly after **lactation**. A 50-year-old perimenopausal woman is outside this clinical window. * **C. Fibroadenoma:** Known as the "breast mouse," these are typically found in younger women (15–35 years). While well-circumscribed, they are firm and rubbery, not fluctuant. * **D. Breast Cancer:** While a priority to rule out, malignancy usually presents as a hard, painless, irregular, and non-mobile mass that develops over months rather than weeks. It would not be fluctuant. **NEET-PG High-Yield Pearls:** * **Investigation of Choice:** Ultrasound (USG) is the best initial modality to differentiate a solid mass from a cystic one. * **Management:** Simple asymptomatic cysts require no treatment. If symptomatic or tense, **Fine Needle Aspiration (FNA)** is performed. * **Red Flags:** If the aspirated fluid is blood-stained or the lump recurs immediately, a biopsy is mandatory to rule out intracystic carcinoma.

Q: Mondor's disease is characterized by which of the following?

Thrombophlebitis of superficial veins of the breast. **Explanation:** **Mondor’s disease** is a rare, benign condition characterized by **superficial thrombophlebitis** of the veins of the breast and anterior chest wall. It most commonly involves the **lateral thoracic vein**, **thoracoepigastric vein**, or the **superior epigastric vein**. 1. **Why Option D is correct:** The underlying pathology is the inflammation and subsequent thrombosis of these superficial veins. Clinically, it presents as a sudden onset of a painful, palpable, "cord-like" structure under the skin of the breast. When the arm is elevated, a skin groove or tethering may become visible over the cord. It is usually self-limiting and managed with NSAIDs and warm compresses. 2. **Why other options are incorrect:** * **Option A:** Migratory thrombophlebitis associated with visceral malignancy (especially pancreatic cancer) is known as **Trousseau sign of malignancy**. * **Option B:** **Thromboangiitis obliterans (Buerger’s disease)** is an inflammatory occlusive disease of small and medium-sized arteries and veins, strongly associated with smoking and typically affecting the extremities. * **Option C:** Thrombosis of deep veins of the leg refers to **Deep Vein Thrombosis (DVT)**, which carries a high risk of pulmonary embolism, unlike the superficial involvement in Mondor’s. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Often idiopathic, but can be triggered by local trauma, vigorous exercise, breast surgery, or tight-fitting brassieres. * **Association with Malignancy:** While usually benign, in rare cases, it can mask an underlying breast cancer (approx. 5% association). Therefore, a mammogram is often recommended to rule out occult malignancy. * **Management:** Reassurance is key. It typically resolves spontaneously within 4 to 6 weeks.

Q: A 35-year-old woman, 10 years after mastectomy, notices gradual swelling and heaviness in her right upper limb without pain. On examination, bluish nodules on the skin with no infections are noted. What is the most likely cause of her symptoms?

Lymphangiosarcoma. ***Lymphangiosarcoma*** - The appearance of **bluish-purple cutaneous nodules** in a limb affected by long-standing **chronic lymphedema** (secondary to mastectomy and likely axillary dissection) is the classic presentation of **Stewart-Treves syndrome**, or post-mastectomy lymphangiosarcoma. - This is a rare, highly aggressive form of **angiosarcoma** arising from lymphatic endothelial cells in chronically static fluid, which aligns perfectly with the patient's history (10 years post-mastectomy). *Thoracic outlet syndrome* - This condition typically results from compression of the neurovascular bundle, causing symptoms like pain, paresthesias, weakness, or vascular changes (e.g., *Raynaud phenomenon*). - While mild edema can occur, it does not explain the significant history of chronic post-operative lymphedema or the development of highly specific **bluish cutaneous tumor nodules**. *Chronic venous insufficiency* - CVI typically affects the **lower limbs** and is characterized by edema, **skin hyperpigmentation**, and potential venous ulceration or stasis dermatitis, rather than post-mastectomy lymphedema. - The primary pathology here is lymphatic blockage following surgery, not incompetence of the venous valves, and CVI does not lead to the formation of sarcomatous skin nodules. *Recurrent breast cancer* - While recurrence can cause new lymphedema through **lymphatic obstruction**, the appearance of aggressive, rapidly growing **bluish vascular nodules** is highly suggestive of a secondary sarcoma (lymphangiosarcoma) rather than typical epithelial recurrence. - Recurrence often presents as a firm, ill-defined mass or local inflammatory changes, unlike the descriptive appearance of an **angiomatous tumor**.

Q: A 51-year-old lady presents with complaints of a mass in the right breast. On examination, the mass was larger than 5 cm and ipsilateral mobile axillary lymph nodes were present. What is the staging, considering the mass is malignant?

cT3N1M0. ***cT3N1M0*** **Correct answer based on TNM staging for breast cancer:** **T (Tumor) - T3:** - Tumor **>5 cm** in greatest dimension = T3 - The patient has a mass **larger than 5 cm**, meeting T3 criteria **N (Nodes) - N1:** - **Ipsilateral mobile axillary lymph nodes** = N1 - Mobile nodes without fixation to surrounding structures **M (Metastasis) - M0:** - **No mention of distant metastasis** = M0 **Clinical vs Pathological Staging:** - **"c" prefix** = clinical staging (based on physical examination, imaging) - **"p" prefix** = pathological staging (after surgery, histopathological examination) - This case uses **clinical examination findings**, so "c" prefix is appropriate *pT4N1M0* - Incorrect because: - Uses pathological prefix "p" without surgical specimen - T4 indicates chest wall/skin involvement, not present here *cT4N1M0* - Incorrect because: - T4 requires tumor extension to chest wall or skin ulceration/nodules - This tumor is only >5 cm without local extension *pT3N1M0* - Incorrect because: - Uses pathological staging prefix "p" when only clinical examination performed - Correct T and N staging but wrong staging type

Q: A 43-year-old female presents to OPD due to changes in breast and a lump in breast as given below. What is the diagnosis?

T4d. ### ***T4d*** - The image displays characteristic findings of **Inflammatory Breast Cancer** (IBC), including **erythema** (redness), **edema**, and **peau d'orange** (orange peel appearance) involving more than one-third of the skin of the breast. - According to the **AJCC TNM Staging** system (8th edition), T4d specifically denotes a tumor size equivalent to Inflammatory Breast Cancer, regardless of the actual tumor dimension or nodal status. ### *T4a* - T4a describes a tumor of any size with direct extension to the **chest wall** (ribs, intercostal muscles, or serratus anterior muscle) but **not** including the pectoralis muscle. - The primary feature in the image is **skin involvement** (**edema** and **erythema**), **not** direct extension to the underlying chest wall structures, which is why this is not T4a. ### *T1c* - T1c describes an invasive carcinoma where the maximum tumor dimension is **greater than 10 mm but less than or equal to 20 mm**. - This staging category is based on the size of the primary tumor mass and does not account for the extensive skin changes (**inflammatory signs**) visible in the image, which immediately mandate a T4 classification. ### *T3* - T3 describes an invasive carcinoma where the maximum tumor dimension is **greater than 50 mm**. - While the tumor size might be large, the presence of **Inflammatory breast symptoms** (**erythema**, **edema**, **peau d'orange**) overrides tumor size for T staging, escalating the stage to **T4d**.

Q: All are true about the condition shown except?

Surgical excision. ***Surgical excision*** - Mondor's disease, or **thrombophlebitis** of the **superficial veins** of the breast or chest wall, is a **self-limiting condition** that typically resolves with conservative management and does not require surgical excision. - Treatment usually involves **warm compresses**, **analgesics**, and **anti-inflammatory medication**, with symptoms resolving within weeks to months. *Thrombophlebitis* - The image shows a **reddened**, **indurated** chord-like structure on the breast, consistent with **Mondor's disease**, which is a **superficial thrombophlebitis**. - This condition involves inflammation and **thrombosis** of subcutaneous veins, leading to the characteristic palpable cord. *Thoracoepigastric vein involved* - Mondor's disease most commonly affects the **lateral thoracic**, **thoracoepigastric**, or **superior epigastric veins**. - The palpable cord seen in the image corresponds to one of these superficial veins that has become thrombosed. *Thrombosed subcutaneous cord* - A hallmark of Mondor's disease is the presence of a **palpable**, **tender**, **cord-like structure** beneath the skin. - This cord represents a thrombosed and inflamed superficial vein, which is clearly depicted in the provided image.

Question 1

Prognostic stage groups in carcinoma breast include all except?

Accepted Answer

Age

Answer

Tumour size

Answer

Grade

Answer

HER-2 status

Question 2

A 50-year-old lady presented with a lump in the left breast that developed suddenly over weeks. Perimenopausal symptoms are present. There is no associated family history. On examination, the lump is well-circumscribed, fluctuant, and measures 1.5 cm with an oval shape. What is the most likely diagnosis?

Accepted Answer

Breast cyst

Answer

Galactocele

Answer

Fibroadenoma

Answer

Breast cancer

Question 3

Mondor's disease is characterized by which of the following?

Accepted Answer

Thrombophlebitis of superficial veins of the breast

Answer

Migratory thrombophlebitis seen in pancreatic carcinoma

Answer

Thromboangiitis obliterans

Answer

Thrombosis of deep veins of the leg

Question 4

A 35-year-old woman, 10 years after mastectomy, notices gradual swelling and heaviness in her right upper limb without pain. On examination, bluish nodules on the skin with no infections are noted. What is the most likely cause of her symptoms?

Accepted Answer

Lymphangiosarcoma

Answer

Recurrent breast cancer

Answer

Thoracic outlet syndrome

Answer

Chronic venous insufficiency

Question 5

Genetic testing for BRCA 1/BRCA 2 is indicated for all of the following except:

Accepted Answer

Breast cancer diagnosed in a postmenopausal female >50 years of age

Answer

Breast and ovarian cancer

Answer

Male breast cancer

Answer

Bilateral breast cancer

Question 6

A 51-year-old lady presents with complaints of a mass in the right breast. On examination, the mass was larger than 5 cm and ipsilateral mobile axillary lymph nodes were present. What is the staging, considering the mass is malignant?

Accepted Answer

cT3N1M0

Answer

pT4N1M0

Answer

cT4N1M0

Answer

pT3N1M0

Question 7

Which of the following is not included in T4b classification of breast cancer?

Accepted Answer

Cellulitis/erythema over one-third of the breast (inflammatory breast cancer)

Answer

Satellite nodule

Answer

Ulceration

Answer

Peau d'orange

Question 8

Which of the following is not a contraindication for breast conservation surgery?

Accepted Answer

Multiple cancer in one quadrant

Answer

Scleroderma

Answer

History of radiation

Answer

Persistent positive margin

Question 9

A 43-year-old female presents to OPD due to changes in breast and a lump in breast as given below. What is the diagnosis?

Accepted Answer

T4d

Answer

T3

Answer

T1c

Answer

T4a

Question 10

All are true about the condition shown except?

Accepted Answer

Surgical excision

Answer

Thrombophlebitis

Answer

Thoracoepigastric vein involved

Answer

Thrombosed subcutaneous cord

Breast Surgery — MCQs

Breast Surgery — MCQs

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