Breast Surgery Practice Questions

Q: All of the following are true regarding this picture except: (Recent NEET Pattern 2016-17)

Usually bilateral. ***Usually bilateral*** - Paget's disease of the nipple, as depicted in the image (lesions on the nipple with surrounding dermatitis-like changes), is almost always an **unilateral condition**. - Its bilateral occurrence is exceedingly rare and would suggest a different or coincidental pathology. - **This is the FALSE statement** - Paget's disease is typically unilateral, not bilateral. *Associated with underlying invasive carcinoma of breast* - **Paget's disease of the nipple** is histologically characterized by the presence of **Paget cells** (adenocarcinoma cells) in the epidermis of the nipple and areola [2]. - In a vast majority of cases (90-95%), it is associated with an underlying **ductal carcinoma in situ (DCIS)** or an **invasive ductal carcinoma** originating from the lactiferous ducts [1], [2]. *Itching is a common symptom* - **Itching (pruritus)** is a **prominent and common symptom** of Paget's disease of the nipple, along with burning, pain, and crusting. - The eczematous changes often lead to significant discomfort and itching. *Treatment is simple mastectomy with axillary lymph node dissection* - The standard treatment for Paget's disease of the nipple, especially when associated with an underlying invasive carcinoma, is **surgical excision**. - A **simple mastectomy** removes the entire breast and is often combined with **axillary lymph node dissection** or sentinel lymph node biopsy to assess for nodal involvement [1]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 456-457. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1061-1062.

Q: What is the most possible diagnosis?

Mondor's disease. ***Mondor's disease*** - The image shows a **palpable, tender cord-like structure** with skin retraction, characteristic of **thrombophlebitis of superficial veins** in the breast or chest wall, which is Mondor's disease. - This condition is often **self-limiting** and can be associated with trauma, surgery, or inflammation, leading to a firm, subcutaneous cord. *Poland syndrome* - This is a **congenital anomaly** characterized by **underdevelopment or absence of the pectoralis muscle** and often involves syndactyly or brachydactyly. - It would present as a **missing or underdeveloped chest muscle**, not a palpable cord-like lesion. *Tietze disease* - Involves **inflammation of the costochondral junctions**, typically presenting as localized pain and swelling in the chest wall, usually at the second or third rib. - It is an inflammation of cartilage and does not involve a **visible, cord-like structure** on the breast surface. *Duct ectasia* - This condition involves the **dilation of breast ducts**, often leading to nipple discharge, periareolar inflammation, or a palpable mass beneath the nipple. - It does not typically present as a **superficial, firm cord** with skin retraction, as seen in the image.

Q: What is true regarding the condition shown in this USG breast? (Recent NEET Pattern 2016-17)

Excision is the treatment. ***Excision is the treatment*** - The ultrasound image shows a **well-defined, hypoechoic solid mass** with smooth margins, characteristic of a **fibroadenoma**. - While small, asymptomatic fibroadenomas can be observed, **excision is a common treatment** option, especially for larger lesions, those causing symptoms, or for definitive diagnosis. *Common aged between 10-20 years* - While fibroadenomas are most common in **younger women**, typically between **20 and 30 years old**, they can occur at any age. - They are less common in the 10-20 year range compared to the 20-30 year range, though still possible. *Pre-malignant condition* - Fibroadenomas are generally considered **benign breast lesions** and are not typically pre-malignant. - The risk of a fibroadenoma transforming into malignancy is very low, except for complex fibroadenomas, which have a slightly increased risk. *Aspiration is the treatment* - **Aspiration** is primarily used for **cystic lesions** (fluid-filled) or for **fine-needle aspiration cytology (FNAC)** for diagnostic purposes of solid masses. - Since this appears to be a solid mass, aspiration alone would not remove the lesion, and while FNAC can be diagnostic, it's not the definitive treatment for a symptomatic or growing fibroadenoma.

Q: The following image is suggestive of diagnosis of:

Duct ectasia. ***Duct ectasia*** - The image suggests **nipple retraction**, indicated by the arrow pointing towards the inverted nipple, which is a classic clinical sign of duct ectasia. - **Duct ectasia** can also cause nipple discharge, an inflamed nipple, or a lump behind the nipple, though these are not directly visible in the image. *Duct papilloma* - **Duct papillomas** are benign growths within the breast ducts, typically presenting with spontaneous nipple discharge, often bloody or serous. - They usually do not cause nipple retraction unless they are large and located close to the nipple. *Carcinoma breast* - While **nipple retraction** can be a sign of breast carcinoma, especially **invasive ductal carcinoma**, other clinical features like a palpable mass, skin dimpling, or changes in breast contour are often present. - The image alone, without other clinical context, does not definitively point to carcinoma over a benign condition like duct ectasia. *Galactocele* - A **galactocele** is a milk-filled cyst that typically occurs during or after lactation. - It usually presents as a discrete, mobile, non-tender lump and does not cause nipple retraction.

Q: What technique has been depicted in the image shown below?

Sentinel lymph node biopsy. ***Sentinel lymph node biopsy*** - The image shows a **skin incision in the axilla**, which is the typical site for accessing **axillary lymph nodes for biopsy**. - A surgical instrument is poised to enter the incision, consistent with the procedure for **identifying and removing the sentinel lymph node**. *Brachytherapy* - This involves placing **radioactive sources** inside or next to the area requiring treatment, usually for cancer. - The image does not depict any radioactive sources or the specialized equipment used for brachytherapy. *USG* - **Ultrasonography (USG)** uses sound waves to create images of internal body structures. - The image shows a surgical incision and instrument, not an ultrasound transducer or screen. *Lateral pectoral nerve block* - A **nerve block** involves injecting an anesthetic close to a nerve to relieve pain or numb an area. - While it involves an injection, the image shows an incision in the axillary region, which is typically for surgical access, not solely for nerve block administration.

Q: A 45-year-old lady presents with history of a painless lump in the right breast since 1 month. On examination, the lump is hard, 3 x 4 cm in size in the upper outer quadrant and is not fixed to the skin or the underlying structures. The axilla reveals firm mobile lymph nodes (level I). Rest of systemic examination is normal. The clinical stage of this disease is :

cT₂ N₁ Mₓ. **cT₂ N₁ Mₓ** - The tumor size of **3 x 4 cm** falls within the T2 classification (>2 cm but ≤5 cm). The description of the lump being "not fixed to the skin or the underlying structures" further supports a T2 (or lower) classification, as fixation would suggest a more advanced T stage (T4). - The presence of "firm mobile lymph nodes (level I)" indicates involvement of regional lymph nodes, which is classified as **N1** in breast cancer staging. An "Mx" designation means that distant metastasis cannot be assessed clinically without further investigation. *cT₃ N₁ Mₓ* - A **T3 classification** would apply if the tumor measured **greater than 5 cm** in its largest dimension, which is not the case here, as the lump is 3 x 4 cm. - While the **N1 and Mx** components are consistent with the findings, the T component is incorrect for the given tumor size. *cT₁ N₁ Mₓ* - A **T1 classification** is used for tumors that are **2 cm or less in greatest dimension**. The given tumor size of 3 x 4 cm clearly exceeds this limit. - The **N1 and Mx** components are consistent, but the T component is inappropriate for the described tumor size. *cT₃ N₂ Mₓ* - This option is incorrect on two counts: the **T3 classification** is wrong for a 3 x 4 cm tumor (should be >5 cm), and the **N2 classification** is also incorrect. - **N2** would indicate metastases to **ipsilateral axillary lymph nodes that are fixed or matted**, or in ipsilateral internal mammary lymph nodes in the absence of clinically apparent axillary lymph node metastases. The description states "firm mobile lymph nodes (level I)," which corresponds to N1, not N2.

Q: The best cosmetic result following breast reconstruction is achieved with :

Transverse rectus abdominis myocutaneous flap. ***Transverse rectus abdominis myocutaneous flap*** - The **TRAM flap** offers excellent aesthetic outcomes by utilizing the patient's own **abdominal tissue**, providing a natural look and feel that mimics breast tissue. - This method results in a soft, pliable breast mound with good long-term stability and can provide a **simultaneous abdominoplasty** effect. *Latissimus dorsi flap* - While a viable option, the **latissimus dorsi flap** is typically smaller and may require an **implant** to achieve adequate breast volume, potentially leading to a less natural result than a TRAM flap. - It uses tissue from the back, which can leave a noticeable scar and may cause **weakness in the shoulder** or back. *Silicone gel implant with reconstruction* - Implants can provide good cosmetic results but carry risks such as **capsular contracture**, rupture, and the need for future revisions, which can affect long-term satisfaction. - They do not offer the same **natural feel or warmth** as autologous tissue reconstruction, as the reconstructed breast is not made of living tissue. *Acellular dermal matrix flap* - **Acellular dermal matrix (ADM)** is often used as an adjunct in implant-based reconstruction to support and reinforce the breast tissue, rather than as a primary reconstructive flap for optimal cosmetic results. - While it aids in tissue expansion and support, it does not provide the **volume or natural contour** that an autologous flap like the TRAM can achieve on its own.

Q: Which of the following is the FIRST step in triple assessment of breast lumps? 1. Clinical assessment 2. Radiological assessment 3. Histopathological assessment 4. Sentinel lymph node biopsy

Clinical assessment. ***Clinical assessment*** - The **first step** in triple assessment involves taking a thorough history and performing a physical examination to identify concerning features of a breast lump. - This step helps to guide the subsequent radiological and histopathological investigations. *Radiological assessment* - This is the **second step** of triple assessment and typically involves mammography, ultrasound, or MRI to characterize the lump's features and extent. - It provides imaging information but does not precede the initial clinical evaluation. *Histopathological assessment* - This is the **third step**, involving a biopsy (fine needle aspiration, core needle biopsy) to obtain tissue for microscopic examination and definitive diagnosis. - While crucial for diagnosis, it follows both clinical and radiological assessments in the triple assessment pathway. *Sentinel lymph node biopsy* - This procedure is performed to determine if **cancer cells have spread** to the regional lymph nodes, typically after a confirmed diagnosis of breast cancer. - It is not part of the initial diagnostic triple assessment for a breast lump but rather a staging procedure.

Question 1

All of the following are true regarding this picture except: (Recent NEET Pattern 2016-17)

Accepted Answer

Usually bilateral

Answer

Associated with underlying invasive carcinoma of breast

Answer

Itching is a common symptom

Answer

Treatment is simple mastectomy with axillary lymph node dissection

Question 2

What is the most possible diagnosis?

Accepted Answer

Mondor's disease

Answer

Poland syndrome

Answer

Tietze disease

Answer

Duct ectasia

Question 3

What is true regarding the condition shown in this USG breast? (Recent NEET Pattern 2016-17)

Accepted Answer

Excision is the treatment

Answer

Common aged between 10-20 years

Answer

Pre-malignant condition

Answer

Aspiration is the treatment

Question 4

The following image is suggestive of diagnosis of:

Accepted Answer

Duct ectasia

Answer

Duct papilloma

Answer

Carcinoma breast

Answer

Galactocele

Question 5

All are true about the condition shown in the image except:

Accepted Answer

Overexpression of HER 2/neu shows poor response to adriamycin

Answer

Occurs due to lymphatics destruction

Answer

Peau d'orange

Answer

Van Nuys prognostic index

Question 6

What technique has been depicted in the image shown below?

Accepted Answer

Sentinel lymph node biopsy

Answer

Brachytherapy

Answer

USG

Answer

Lateral pectoral nerve block

Question 7

A 45-year-old lady presents with history of a painless lump in the right breast since 1 month. On examination, the lump is hard, 3 x 4 cm in size in the upper outer quadrant and is not fixed to the skin or the underlying structures. The axilla reveals firm mobile lymph nodes (level I). Rest of systemic examination is normal. The clinical stage of this disease is :

Accepted Answer

cT₂ N₁ Mₓ

Answer

cT₃ N₁ Mₓ

Answer

cT₁ N₁ Mₓ

Answer

cT₃ N₂ Mₓ

Question 8

The best cosmetic result following breast reconstruction is achieved with :

Accepted Answer

Transverse rectus abdominis myocutaneous flap

Answer

Latissimus dorsi flap

Answer

Silicone gel implant with reconstruction

Answer

Acellular dermal matrix flap

Question 9

Which of the following is the FIRST step in triple assessment of breast lumps?

1. Clinical assessment
2. Radiological assessment
3. Histopathological assessment
4. Sentinel lymph node biopsy

Accepted Answer

Clinical assessment

Answer

Radiological assessment

Answer

Sentinel lymph node biopsy

Answer

Histopathological assessment

Question 10

Which of the following vital structures in the axilla should always be preserved in modified radical mastectomy?

Accepted Answer

Axillary vein

Answer

Intercostobrachial nerves

Answer

Nerve to serratus anterior

Answer

Nerve to latissimus dorsi

Breast Surgery — MCQs

Breast Surgery — MCQs

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