Breast Surgery Practice Questions

Q: Which one of the following is not a correct statement with reference to locally advanced carcinoma breast ?

Radical Mastectomy is the treatment of choice. *Patients are staged as T3 or T4 with any N, without distant metastasis (M0)* - **Locally advanced breast cancer (LABC)** is correctly defined as tumors that are **T3 or T4** or involve regional lymph nodes (**any N**) without distant metastasis (**M0**). - This statement is **correct** regarding LABC staging criteria. *It constitutes the bulk of patients of carcinoma breast in India* - This statement is **correct**. In India, approximately **50-60% of breast cancer patients present with locally advanced disease** at the time of diagnosis. - This is in stark contrast to Western countries where LABC represents less than 10% of cases. - The high prevalence is attributed to lack of screening programs, delayed presentation, limited awareness, and socioeconomic factors. *Neoadjuvant chemotherapy downgrades the disease* - This statement is **correct**. **Neoadjuvant chemotherapy (NACT)** is a cornerstone of LABC management. - NACT aims to **downstage** the tumor, making it more amenable to surgical resection and increasing the feasibility of breast-conserving surgery. - It also provides early treatment of micrometastases and serves as an in vivo test of tumor chemosensitivity. ***Radical Mastectomy is the treatment of choice*** - This statement is **INCORRECT** and is the correct answer to this negation question. - **Radical mastectomy (Halsted mastectomy)** involving removal of breast, pectoral muscles, and axillary nodes is **no longer the standard treatment** for LABC. - Modern treatment involves a **multimodal approach**: neoadjuvant chemotherapy followed by **modified radical mastectomy (MRM)** or breast-conserving surgery with radiation therapy. - MRM preserves the pectoral muscles, providing better functional and cosmetic outcomes while maintaining oncological safety.

Q: The inflammatory breast carcinoma is staged as

T4d. ***T4d*** - **Inflammatory breast carcinoma** is by definition a **T4d tumor** in the TNM staging system, regardless of tumor size. - This designation reflects the aggressive nature and characteristic features of erythema and edema involving a substantial portion of the breast. *T4c* - **T4c** refers to either **T4a** (chest wall invasion) and **T4b** (ulceration, edema, or skin nodules) combined. - While these can be features of advanced breast cancer, they do not specifically define inflammatory breast carcinoma. *T1a* - **T1a** describes a tumor size of **greater than 0.5 cm but not more than 1 cm** in greatest dimension. - Inflammatory breast carcinoma is not staged based on tumor size in this manner due to its diffuse nature. *T1b* - **T1b** describes a tumor size of **greater than 1 cm but not more than 2 cm** in greatest dimension. - Inflammatory breast carcinoma is characterized by diffuse involvement of the breast skin and does not fit into typical size-based T categories like T1b.

Q: Following radical surgery for the carcinoma of breast, reconstruction of the breast can be performed by using the following procedures except

Deltopectoral flap. ***Deltopectoral flap*** - The **deltopectoral flap**, also known as the Bakamjian flap, is primarily used for **head and neck reconstruction**, particularly for defects in the pharynx, esophagus, or oral cavity. - It involves tissue from the shoulder and chest wall, but its design and vascular supply make it unsuitable for **breast reconstruction** after radical mastectomy, which requires significantly more volume and different tissue characteristics. *Silicone implants* - **Silicone implants** are a common method for breast reconstruction, offering a less invasive option than flap procedures. - They are placed either beneath the pectoral muscle or subcutaneously to restore breast volume and shape. *Transversus abdominis muscle flap (TRAM flap)* - The **TRAM flap** is a widely used and versatile autologous tissue reconstruction method, utilizing tissue from the lower abdomen to create a new breast mound. - It can be either pedicled (retaining its original blood supply) or free (requiring microvascular anastomosis), providing a natural-feeling and long-lasting reconstruction. *Latissimus dorsi flap (LD flap)* - The **latissimus dorsi (LD) flap** involves transferring muscle, fat, and skin from the back to the chest to reconstruct the breast. - It is particularly useful for smaller breasts or when combined with an implant, and it can provide good aesthetic results with reliable blood supply.

Q: The most common site of skeletal metastases in carcinoma of the breast is

Thoracic vertebrae. ***Thoracic vertebrae*** - The **thoracic spine** accounts for **68-80%** of all spinal metastases in breast cancer due to direct venous drainage via **Batson's venous plexus** through the **azygos vein** and **intercostal veins**. - The **valveless nature** of Batson's plexus allows **retrograde seeding** of tumor cells, making thoracic vertebrae the primary target for skeletal metastases. *Skull* - While skull metastases can occur in breast cancer, they represent a **less frequent site** compared to the axial skeleton, particularly thoracic vertebrae. - Skull involvement typically presents as **lytic lesions** and may cause neurological symptoms, but occurs in a minority of cases. *Pelvis* - The pelvis is indeed a common site for bone metastases in breast cancer, but it is **secondary** to thoracic vertebral involvement. - Pelvic metastases can cause **pathological fractures** and hip pain, but represent a smaller percentage of initial skeletal spread. *Lumbar vertebrae* - Lumbar spine involvement occurs in only **16-22%** of spinal metastases, significantly **less frequent** than thoracic vertebrae. - This distinction is crucial for exam purposes as lumbar involvement is often confused with thoracic, but the **anatomical drainage pattern** clearly favors thoracic spread.

Q: A patient has a 6-cm breast tumor with mobile, clinically positive, ipsilateral axillary lymph nodes and no evidence of distant metastasis. The stage of the breast cancer is

Stage IIIa. ***Stage IIIa*** - A **6-cm tumor (T3)** with **mobile, clinically positive ipsilateral axillary lymph nodes (N1)** and **no distant metastasis (M0)** classifies as **T3N1M0 = Stage IIIA** according to AJCC TNM staging. - Stage IIIA includes **T3N1M0** among other combinations, representing locally advanced breast cancer with significant tumor burden and regional nodal involvement. *Stage IIb* - Stage IIB is classified as **T2N1M0** (2-5 cm tumor with mobile axillary nodes) or **T3N0M0** (>5 cm tumor with no nodal involvement). - This patient has **T3N1M0**, which exceeds Stage IIB criteria due to the combination of large tumor size and positive lymph nodes. *Stage I* - Stage I involves **small tumors (T1, ≤2 cm)** with **no lymph node involvement (N0)** or only micrometastases. - The **6-cm tumor size** and **clinically evident axillary lymph node involvement** far exceed Stage I parameters. *Stage IIIb* - Stage IIIB requires **T4 disease** with chest wall invasion, skin involvement (ulceration, satellite nodules), or inflammatory breast cancer features. - This case shows **T3 disease** without signs of **locally advanced features** like chest wall fixation or skin changes.

Q: Which of the following does not alter the T stage in breast cancer?

Nipple retraction. ***Nipple retraction*** - Nipple retraction, while a significant clinical sign that can indicate an underlying malignancy, does **not alter the T stage** (tumor size and extent) of breast cancer. - It is considered a local sign of tumor proximity or involvement but does not classify the tumor into a T4 category according to AJCC TNM staging. - Nipple retraction may be seen with various T stages and is **not a criterion for upstaging**. *Pectoral muscle involvement* - **Important note**: Involvement of the **pectoralis muscle alone does NOT alter T stage** according to current AJCC TNM classification. - Only **chest wall involvement** (ribs, intercostal muscles, serratus anterior) qualifies as **T4b**. - This is a common point of confusion, but pectoralis muscle is **not considered chest wall** for staging purposes. *Skin ulceration* - **Skin ulceration** directly reflects tumor invasion through the skin of the breast. - This finding is a criterion for classifying the tumor as **T4b**, indicating advanced local disease. - Clearly **alters the T stage** regardless of tumor size. *Peau d'orange* - **Peau d'orange** (orange peel appearance) is caused by obstruction of dermal lymphatics by tumor cells, leading to **skin edema**. - This sign is a criterion for classifying the tumor as **T4b** (edema of the skin including peau d'orange). - Clearly **alters the T stage** and indicates advanced local disease.

Q: Which of the following is NOT correct for breast abscess?

A counterincision is made in the dependant part. ***A counterincision is made in the dependant part*** - **Counterincisions** are generally *not* required for breast abscesses as a single **radial incision** is usually sufficient for adequate drainage. - Making additional incisions can damage the **ductal architecture** and increase the risk of **fistula formation** and poor cosmetic outcomes. *Dressings are changed frequently* - **Frequent dressing changes** are essential after abscess drainage to remove **exudate** and monitor healing progress. - This prevents secondary infection and allows the cavity to heal from the **inside out** properly. *Antibiotic is given if pus is already present* - **Antibiotics** are indicated even when pus is present, as they treat the underlying **bacterial infection** and prevent spread. - They work synergistically with surgical drainage to ensure complete resolution and prevent **recurrence**. *Drainage of abscess by a radial incision* - **Radial incisions** are the gold standard as they follow the natural **ductal pattern** of the breast tissue. - This approach minimizes damage to **milk ducts** and provides better cosmetic results compared to circumferential incisions.

Q: Mondor’s disease is

Thrombophlebitis of superficial veins of breast. ***Thrombophlebitis of superficial veins of breast*** - Mondor's disease is characterized by **thrombophlebitis**, which is inflammation and clotting, of the **superficial veins of the breast** and sometimes the chest wall. - It often manifests as a **palpable, tender cord-like structure** under the skin. *Multiple breast cysts* - This condition involves the presence of **fluid-filled sacs** within the breast tissue, which can be palpable but do not present as a classic cord-like structure. - Cysts are typically smooth, mobile, and can fluctuate in size with the **menstrual cycle**, unlike Mondor's disease. *Eczema by nipple and areola* - This refers to an **inflammatory skin condition** affecting the **nipple and areola**, characterized by redness, itching, scaling, and sometimes oozing. - It is a **dermatological issue** and does not involve vascular clotting or a palpable cord. *Lymphangitis of mammary lymphatics* - **Lymphangitis** is the inflammation of **lymphatic vessels**, often presenting as red streaks and tenderness. - While it can affect the breast, it involves the **lymphatic system** rather than the superficial venous system and would not typically present as a thrombosed vessel.

Question 1

Which one of the following is not a correct statement with reference to locally advanced carcinoma breast ?

Accepted Answer

Radical Mastectomy is the treatment of choice

Answer

Patients are staged as T3 or T4 with any N, without distant metastasis (M0)

Answer

It constitutes the bulk of patients of carcinoma breast in India

Answer

Neoadjuvant chemotherapy downgrades the disease

Question 2

The inflammatory breast carcinoma is staged as

Accepted Answer

T4d

Answer

T4c

Answer

T1a

Answer

T1b

Question 3

Following radical surgery for the carcinoma of breast, reconstruction of the breast can be performed by using the following procedures except

Accepted Answer

Deltopectoral flap

Answer

Silicone implants

Answer

Transversus abdominis muscle flap (TRAM flap)

Answer

Latissimus dorsi flap (LD flap)

Question 4

The most common site of skeletal metastases in carcinoma of the breast is

Accepted Answer

Thoracic vertebrae

Answer

Skull

Answer

Pelvis

Answer

Lumbar vertebrae

Question 5

A patient has a 6-cm breast tumor with mobile, clinically positive, ipsilateral axillary lymph nodes and no evidence of distant metastasis. The stage of the breast cancer is

Accepted Answer

Stage IIIa

Answer

Stage IIIb

Answer

Stage I

Answer

Stage IIb

Question 6

Which of the following does not alter the T stage in breast cancer?

Accepted Answer

Nipple retraction

Answer

Pectoral muscle involvement

Answer

Skin ulceration

Answer

Peau d'orange

Question 7

In carcinoma breast, adjuvant radiotherapy is indicated after modified radical mastectomy in all of the following, except

Accepted Answer

ER, PR hormone receptor negative tumour

Answer

more than four positive axillary lymph nodes

Answer

positive margins

Answer

tumour size more than 5 cm

Question 8

Which of the following is NOT correct for breast abscess?

Accepted Answer

A counterincision is made in the dependant part

Answer

Antibiotic is given if pus is already present

Answer

Drainage of abscess by a radial incision

Answer

Dressings are changed frequently

Question 9

Mondor’s disease is

Accepted Answer

Thrombophlebitis of superficial veins of breast

Answer

Multiple breast cysts

Answer

Eczema of nipple and areola

Answer

Lymphangitis of mammary lymphatics

Question 10

Regarding breast conservative therapy and issue of post operative local recurrence, all are true except:

Accepted Answer

Margins should be clear for lobular carcinoma in situ (LCIS)

Answer

Margins should be clear for ductal carcinoma in situ (DCIS)

Answer

Margins should be clear for invasive cancer

Answer

Lumpectomy can be considered in any size provided the tumour can be excised with clear margins and acceptable cosmetic results

Breast Surgery — MCQs

Breast Surgery — MCQs

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