Breast Surgery — MCQs

Breast Surgery Indian Medical PG Practice Questions and MCQs

Question 411: Which of the following represents the most definitive guideline-based indication for adjuvant therapy in early breast carcinoma?

A. In premenopausal women, multidrug chemotherapy is given based on tumor characteristics and risk factors.
B. Post mastectomy radiation therapy is indicated when 4 or more lymph nodes are positive. (Correct Answer)
C. Aromatase inhibitors are used in premenopausal women only with ovarian suppression.
D. Tamoxifen is useful in postmenopausal women, but aromatase inhibitors are generally preferred.

Explanation: **Post mastectomy radiation therapy is indicated when 4 or more lymph nodes are positive.** - **Post-mastectomy radiation therapy (PMRT)** is strongly recommended for early breast cancer patients with **four or more positive axillary lymph nodes** due to a significantly increased risk of locoregional recurrence. - This indication is largely driven by numerous clinical trials and meta-analyses showing a **survival benefit** and reduced recurrence rates in this high-risk group. *Aromatase inhibitors are used in premenopausal women only with ovarian suppression.* - **Aromatase inhibitors (AIs)** convert androgens to estrogens, a process that occurs primarily in peripheral tissues. Thus, AIs are only effective in **postmenopausal women** (due to their low ovarian estrogen production) or **premenopausal women who have undergone ovarian suppression** (e.g., with GnRH agonists). - AIs are not generally given to premenopausal women without **concomitant ovarian suppression** because their ovaries would continue producing estrogen, negating the AI's effect. *In premenopausal women, multidrug chemotherapy is given based on tumor characteristics and risk factors.* - **Multidrug chemotherapy** in premenopausal women is an important adjuvant treatment. Its use is guided by a comprehensive assessment of **tumor characteristics** (e.g., tumor size, grade, hormone receptor status, HER2 status) and **individual patient risk factors**. - This approach aims to reduce recurrence risk, but does not represent the *most definitive guideline-based indication* when compared to the established threshold for PMRT based on nodal involvement, which has a very high level of evidence. *Tamoxifen is useful in postmenopausal women, but aromatase inhibitors are generally preferred.* - **Tamoxifen** is a selective estrogen receptor modulator (SERM) that blocks estrogen action. It is effective in both **premenopausal and postmenopausal estrogen receptor-positive (ER+) breast cancer**. - While aromatase inhibitors (AIs) are often preferred in **postmenopausal women** with ER+ breast cancer due to their superior efficacy and different side effect profile, tamoxifen remains a viable and often necessary option, especially in cases where AIs are contraindicated or poorly tolerated.

Question 412: Which of the following factors is NOT a component of the Van Nuys prognostic index?

A. Age
B. Tumor size
C. Estrogen receptor (ER) status (Correct Answer)
D. Margin width

Explanation: ***Estrogen receptor (ER) status*** - The **Van Nuys prognostic index** (VNPI) for **ductal carcinoma in situ (DCIS)** assesses factors related to local recurrence risk after breast-conserving therapy. - The VNPI includes: **tumor size, margin width, pathologic classification (nuclear grade and necrosis), and age**. - While ER status is an important prognostic factor in **invasive breast cancer**, it is **not included** in the VNPI scoring system for DCIS. *Age* - **Age** is a key component of the VNPI, with younger patients having higher risk of local recurrence. - Patients **under 40 years** receive score 3, **40-60 years** receive score 2, and **over 60 years** receive score 1. *Tumor size* - The **size of the DCIS lesion** is a critical component of the VNPI. - Lesions **≥41 mm** receive score 3, **16-40 mm** receive score 2, and **≤15 mm** receive score 1. *Margin width* - **Surgical margin width** is an essential component of the VNPI. - Margins **<1 mm** receive score 3, **1-9 mm** receive score 2, and **≥10 mm** receive score 1.

Question 413: A 45-year-old female underwent a modified radical mastectomy with axillary clearance for breast cancer. Post-surgery, she is unable to lift her arm above her head. Which nerve is most likely to be injured?

A. Intercostobrachial nerve
B. Nerve to latissimus Dorsi
C. Lateral Pectoral nerve
D. Long thoracic nerve of Bell (Correct Answer)

Explanation: ***Long thoracic nerve of Bell*** - Injury to the **long thoracic nerve** (nerve to the serratus anterior) leads to **paralysis of the serratus anterior muscle**. - This muscle is crucial for **upward rotation and protraction of the scapula**, which is essential for arm elevation above the head and preventing **'winging' of the scapula**. *Intercostobrachial nerve* - Injury to the **intercostobrachial nerve** typically causes **sensory loss** or numbness in the medial upper arm. - It does not primarily affect motor function or the ability to lift the arm. *Nerve to latissimus Dorsi* - The **thoracodorsal nerve** innervates the **latissimus dorsi muscle**, which is involved in adduction, extension, and internal rotation of the arm. - Injury to this nerve would impair these movements but not directly prevent arm elevation above the head. *Lateral Pectoral nerve* - The **lateral pectoral nerve** supplies the **pectoralis major muscle**, primarily its clavicular head. - Injury would weaken adduction and flexion of the arm, but the inability to lift the arm above the head strongly points to serratus anterior dysfunction.

Question 414: A 22 year old woman comes with a non progressive mass in the left breast since 6 months. There are no associated symptoms. Examination shows a mobile mass not attached to the overlying skin or underlying tissue. The possible diagnosis is

A. Fibroadenoma (Correct Answer)
B. Cystasarcoma Phylloides
C. Scirrhous Carcinoma
D. Fibroadenosis

Explanation: ***Fibroadenoma*** - This is the most common benign breast tumor in young women, typically presenting as a **mobile, non-tender, firm mass** with no attachment to surrounding tissues. - The history of a **non-progressive mass** over six months in a 22-year-old woman is highly characteristic of a fibroadenoma. *Cystasarcoma Phylloides* - While it can present as a mobile mass, phyllodes tumors tend to grow **rapidly** and can reach a large size, which contradicts the "non-progressive" nature of the mass described. - Phyllodes tumors often have a **leaf-like architectural pattern** histologically and can be benign, borderline, or malignant. *Scirrhous Carcinoma* - This is a type of invasive ductal carcinoma that typically presents as a **hard, irregular, fixed mass** that is often attached to the skin or underlying tissue, unlike the mobile mass described here. - It is common in older women and often associated with **skin dimpling** or nipple retraction. *Fibroadenosis* - This refers to a group of benign breast changes, often presenting with generalized **lumpiness, pain, or tenderness** that fluctuates with the menstrual cycle, rather than a discrete, solitary mass. - It usually presents as **multiple, diffuse nodules** rather than a single, well-defined mass.

Question 415: CA Breast may locally spread to all of the following muscles except

A. Latissimus Dorsi (Correct Answer)
B. Pectoralis Minor
C. Serratus Anterior
D. Pectoralis Major

Explanation: ***Latissimus Dorsi*** - The **latissimus dorsi** muscle is located on the posterior aspect of the trunk and arm, significantly deeper and further away from the breast tissue compared to other surrounding muscles. - Direct local invasion of breast cancer to the latissimus dorsi is rare and typically requires extensive tumor growth or metastasis to more distant sites before affecting this muscle. *Pectoralis Minor* - The **pectoralis minor** muscle lies directly beneath the pectoralis major and is in close proximity to the deeper aspects of the breast tissue. - Tumors that invade the **deep fascia** of the breast can directly extend into this muscle. *Serratus Anterior* - The **serratus anterior** muscle is located on the lateral wall of the thorax, forming part of the chest wall beneath the breast. - **Aggressive breast cancers**, particularly those in the outer quadrants, can invade the fascial planes covering this muscle. *Pectoralis Major* - The **pectoralis major** forms the anterior wall of the axilla and lies directly beneath the majority of the breast tissue. - It is one of the most common muscles to be affected by **direct local invasion** from breast cancer due to its anatomical proximity.

Question 416: Sentinel lymph node biopsy in carcinoma breast is done if -

A. LN palpable
B. Breast lump with palpable axillary node
C. Metastatic CA breast
D. Breast mass but no lymph node palpable (Correct Answer)

Explanation: ***Breast mass but no lymph node palpable*** - Sentinel lymph node biopsy is primarily performed in patients with **clinically negative axillae** (no palpable lymph nodes) to assess for microscopic metastatic disease. - The goal is to avoid full axillary lymph node dissection if the sentinel nodes are negative, thus reducing the risk of **lymphedema** and other complications. *LN palpable* - If a lymph node is palpable, it is often considered **clinically suspicious** and may warrant a direct fine-needle aspiration (FNA) or core biopsy rather than a sentinel node biopsy. - A positive biopsy from a palpable node would typically lead directly to an **axillary lymph node dissection** or neoadjuvant therapy, as the sentinel node procedure offers less benefit in this scenario. *Breast lump with palpable axillary node* - Similar to a palpable LN, a **palpable axillary node** in the presence of a breast lump suggests established nodal involvement. - In such cases, **sentinel lymph node biopsy** is often not the initial step; rather, direct biopsy of the palpable node or upfront axillary dissection (sometimes after neoadjuvant treatment) is considered. *Metastatic CA breast* - In **metastatic breast cancer** (stage IV disease), the focus shifts to systemic treatment, and axillary lymph node dissection, including sentinel node biopsy, is generally not indicated for staging purposes. - The primary goal is palliative care or controlling systemic disease, not regional lymph node staging.

Question 417: Indication for sentinel node biopsy is:

A. Palpable axillary lymph node
B. Metastasis
C. Mass > 5 cm
D. Non-palpable axillary lymph node (Correct Answer)

Explanation: ***Non-palpable axillary lymph node*** - **Sentinel lymph node biopsy (SLNB)** is indicated when there is no clinical evidence of axillary lymph node involvement, meaning the nodes are **non-palpable**. - Its purpose is to identify micrometastases that would not be detectable by physical examination, staging the cancer more accurately and guiding further treatment. *Palpable axillary lymph node* - A **palpable axillary lymph node** suggests macroscopic nodal involvement, usually requiring a fine needle aspiration (FNA) or core needle biopsy for diagnosis. - If positive, these patients typically proceed directly to **axillary lymph node dissection (ALND)** rather than SLNB. *Mass > 5 cm* - The size of the primary tumor (e.g., > 5 cm) is a factor in staging but does not, in itself, preclude or indicate SLNB. - While larger tumors have a higher risk of nodal involvement, the decision for SLNB still hinges on the clinical status of the axilla (palpable vs. non-palpable nodes). *Metastasis* - If **distant metastasis** is confirmed, the focus shifts to palliative care and systemic treatment, making a regional staging procedure like SLNB less relevant or unnecessary. - SLNB is used for staging early-stage cancer to detect regional spread, not when widespread disease is already established.

Question 418: Which of the following is a contraindication to breast conservation surgery?

A. Presence of multicentric tumors (Correct Answer)
B. Involvement of axillary lymph nodes
C. Tumor size greater than 4 cm
D. Presence of diffuse microcalcifications

Explanation: ***Presence of multicentric tumors*** - **Multicentric tumors** are defined as two or more discrete tumors in different quadrants of the breast, which cannot be removed with a single lumpectomy. - This condition is a contraindication for breast conservation surgery (BCS) because complete removal of all tumor foci while maintaining an acceptable cosmetic outcome is highly unlikely. *Involvement of axillary lymph nodes* - **Axillary lymph node involvement** is an important prognostic factor in breast cancer and influences adjuvant therapy decisions, but it is not a direct contraindication to BCS. - Patients with positive nodes often undergo axillary dissection or sentinel lymph node biopsy, followed by radiation and/or systemic therapy, which can be combined with BCS. *Tumor size greater than 4 cm* - While larger tumor size (e.g., >4-5 cm) can make achieving negative surgical margins and a good cosmetic outcome more challenging with BCS, it is not an absolute contraindication. - **Neoadjuvant chemotherapy** can often downstage larger tumors, making BCS a viable option for many patients. *Presence of diffuse microcalcifications* - **Diffuse microcalcifications** can sometimes indicate extensive ductal carcinoma in situ (**DCIS**) or invasive lobular carcinoma with a widespread component. - However, if the microcalcifications represent a single focus of disease that can be entirely excised with negative margins, BCS may still be an option, especially if guided by stereotactic biopsy and imaging.

Question 419: Among the following, intraoperative sentinel lymph node detection in axilla can be done using

A. Mammography
B. Isosulfan blue dye (Correct Answer)
C. MRI
D. CT

Explanation: ***Correct Option: Isosulfan blue dye*** - **Isosulfan blue dye** is a vital dye used for **intraoperative visual identification** of sentinel lymph nodes in the axilla during breast cancer surgery - The dye is injected near the tumor site and **preferentially concentrates in lymphatic channels**, allowing the surgeon to visually trace the lymphatic drainage to the **first lymph node(s)** (sentinel nodes) receiving lymph flow - The sentinel nodes appear **blue-stained** and can be identified and excised for biopsy to determine lymph node status - **Alternative methods** include radioactive tracers like **Technetium-99m** or a combination of both (dual mapping technique) *Incorrect Option: Mammography* - Mammography is an **X-ray imaging technique** used for breast cancer screening and diagnosis to detect tumors and calcifications - It is a **pre-operative diagnostic tool**, not used for intraoperative sentinel lymph node detection - Cannot visualize or track lymphatic flow during surgery *Incorrect Option: MRI* - MRI (Magnetic Resonance Imaging) provides detailed anatomical assessment and staging of breast cancer pre-operatively - It is a **static imaging modality** that cannot be used for real-time intraoperative sentinel lymph node detection - Does not visualize lymphatic drainage or dye uptake during surgery *Incorrect Option: CT* - CT scans (Computed Tomography) provide cross-sectional images useful for assessing tumor size and metastatic spread - Not employed for **intraoperative sentinel lymph node detection** - Cannot track real-time lymphatic flow with dyes during surgery

Question 420: Which of the following stages of Breast Cancer corresponds to the following features: a breast mass of 6 x 3 cm, ipsilateral supraclavicular lymph node involvement, and distant metastasis that cannot be assessed?

A. T4 N3 MX
B. T4 N1 M1
C. T4 N0 M0
D. T3 N3c MX (Correct Answer)

Explanation: ***T3 N3c MX*** - A **breast mass of 6 x 3 cm** indicates a T3 tumor (tumor size > 5 cm). - **Ipsilateral supraclavicular lymph node involvement** is classified as N3c disease. **Distant metastasis that cannot be assessed** is denoted by MX. *T4 N3 MX* - A **T4 classification** is reserved for tumors with direct extension to the chest wall or skin, or inflammatory breast cancer, which is not mentioned here. - While N3c and MX are correct for the nodal and metastatic status, the T stage is inaccurate based on the provided tumor size. *T4 N1 M1* - A **T4 classification** is incorrect as the mass size alone (6 x 3 cm) does not meet T4 criteria. - **N1** denotes involvement of 1-3 axillary lymph nodes, which is less extensive than supraclavicular involvement (N3c). **M1** indicates confirmed distant metastasis, but the question states it "cannot be assessed" (MX). *T4 N0 M0* - **T4** is incorrect, as this stage is for direct chest wall/skin involvement or inflammatory breast cancer. - **N0** signifies no regional lymph node metastasis, contradicting the presence of supraclavicular lymph node involvement. **M0** indicates no distant metastasis, whereas the question specifies it cannot be assessed (MX).

Practice by Chapter

Breast Anatomy and Physiology

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Benign Breast Diseases

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Breast Cancer Screening

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Breast Cancer: Diagnosis and Staging

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Surgical Management of Breast Cancer

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Oncoplastic Breast Surgery

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Sentinel Lymph Node Biopsy

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Axillary Surgery

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Breast Reconstruction Techniques

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Male Breast Disorders

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Phyllodes Tumors

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Management of Ductal Carcinoma In Situ

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