Breast Surgery MCQs

Explanation: When mammography shows a suspicious malignant lump (BI-RADS 4 or 5) but the fine needle aspiration cytology (FNAC) is unremarkable (e.g., benign or non-diagnostic), there is a discordance between imaging and cytology. In such cases, a more definitive tissue diagnosis is needed to rule out malignancy, as FNAC can have limitations in sensitivity and may not sample the most representative area of the lesion.

• a) True cut biopsy (Core biopsy) (Correct): True cut biopsy, also known as core needle biopsy, is the next best investigation. It uses a larger needle to obtain a core of breast tissue, providing histological information about the lesion’s architecture, which is more informative than the cellular sample obtained by FNAC. This helps in accurately diagnosing malignancy, its type, and grade.
• b) Excision biopsy (Consider): Excision biopsy, the surgical removal of the entire lump for pathological examination, would also provide a definitive diagnosis. However, it is a more invasive procedure than core biopsy. Core biopsy is usually preferred as the next step to confirm malignancy before proceeding with a potentially more extensive surgical treatment.
• c) Wide local excision (Incorrect): Wide local excision is a surgical treatment for breast cancer (lumpectomy) aimed at removing the tumour with a margin of normal tissue. It is not the appropriate next step for diagnosis when malignancy has not yet been confirmed histologically.
• d) Repeat FNAC (Less likely to be helpful): If the initial FNAC was truly unremarkable despite suspicious imaging, repeating it is unlikely to yield a different result unless there was a clear issue with the initial sampling technique or targeting. A core biopsy, providing histological information, is more likely to resolve the diagnostic uncertainty.
• e) USS (Ultrasound) (Already done as part of evaluation): Ultrasound is often used in conjunction with mammography to evaluate breast lumps. If the question implies that the suspicious lump was identified on mammogram and further evaluated with ultrasound (which might have guided the FNAC), then additional ultrasound without a better tissue sampling method is unlikely to provide a diagnosis.

Therefore, given a suspicious malignant lump on mammogram and an unremarkable FNAC, a true cut biopsy (core biopsy) is the most appropriate next investigation to obtain a more definitive tissue diagnosis.

Explanation: The standard initial diagnostic approach for a palpable breast lump in a woman over the age of 30 typically involves a combination of imaging and tissue sampling.

• a) cytology, mammogram, ultrasound (Incorrect): Cytology (e.g., FNAC) is a tissue sampling technique and is usually guided by findings on imaging. Performing it before imaging might not target the most appropriate area or provide sufficient context.
• b) mammogram, ultrasound, cytology (Correct): For women over 30 with a breast lump, the usual first steps are mammography and ultrasound. Mammography can detect calcifications and architectural distortions, while ultrasound can characterize the lump as solid or cystic and evaluate surrounding tissue. Based on the findings from these imaging modalities (BIRADS assessment), a decision is made regarding the need for tissue sampling, which can be cytology (FNAC) or histology (core biopsy).
• c) mammogram, cytology, ultrasound (Incorrect): Ultrasound often provides additional information to mammography, especially in characterizing palpable lumps. Performing cytology before ultrasound might miss crucial information about the lesion’s characteristics.
• d) ultrasound, mammogram, cytology (Consider): Some guidelines might suggest ultrasound first, especially if the lump is highly palpable and the woman has dense breasts where ultrasound might be more informative. Mammography would still be performed to screen the rest of the breast and look for calcifications. Cytology would follow if imaging findings are suspicious. This order is also plausible.
• e) ultrasound, cytology, mammogram (Incorrect): Mammography is an important initial step, especially in women over 30, for detecting calcifications and providing an overview of the breast tissue. Delaying it until after cytology might miss important mammographic features.

The most common and generally accepted order is mammogram followed by ultrasound for initial imaging of a breast lump in a woman over 30, with cytology (or preferably core biopsy for solid lesions) performed if imaging findings are suspicious (BIRADS 3, 4, or 5). Option b reflects this sequence. Option d is also a reasonable approach in some settings, where ultrasound might be prioritized based on clinical presentation or breast density. However, given the options, b) mammogram, ultrasound, cytology aligns best with general guidelines.

Explanation: The patient has T4N1Mx breast cancer, which indicates locally advanced or inflammatory breast cancer (T4), with regional lymph node involvement (N1), and distant metastasis (Mx – indicating the presence of distant spread, although ‘M1’ is the standard notation for confirmed metastasis). The presence of distant metastasis significantly alters the treatment approach, making local therapies like surgery the primary initial focus.

• a) Breast conservative surgery (Incorrect): Breast-conserving surgery is typically indicated for early-stage breast cancer (T1 or T2) without extensive local involvement or distant metastasis. In T4 disease, especially with metastasis, local control is usually achieved through other means, and systemic therapy takes precedence.
• b) Neoadjuvant therapy (Often the initial step): For locally advanced breast cancer (T4) with regional nodal involvement (N1) and distant metastasis (Mx/likely M1), the initial management often involves systemic therapy, such as chemotherapy (neoadjuvant if given before surgery in non-metastatic settings, but here it’s primary systemic therapy). This aims to treat the distant disease and can also help downstage the local disease, potentially making local control (like surgery or radiation) more feasible later. Hormonal therapy might be considered if the cancer is hormone receptor-positive. The term neoadjuvant” is traditionally used for treatment before definitive local therapy in the absence of metastasis but the principle of initial systemic treatment applies here.
• c) Salvage mastectomy (Incorrect): Salvage mastectomy is considered for local recurrence after prior breast cancer treatment. It is not the initial treatment for metastatic T4 breast cancer.
• d) Tamoxifen therapy (Consider): Tamoxifen is a hormonal therapy used for oestrogen receptor-positive breast cancer. If the patient’s cancer is ER+ tamoxifen (or another endocrine agent) might be part of the systemic treatment but it is unlikely to be the sole initial step especially in the presence of aggressive local disease (T4) and metastasis. Chemotherapy is often needed for more rapid control.
• e) Total mastectomy (Consider): Mastectomy might be considered for local control in T4 disease after a response to systemic therapy particularly if it helps manage local symptoms like pain or fungating wounds. However it is not usually the initial step when distant metastasis is present. Systemic therapy to address the metastatic disease takes priority.

Explanation: Simple mastectomy involves the removal of the entire breast, and axillary clearance (axillary lymph node dissection) involves the removal of lymph nodes in the axilla. These procedures can lead to several complications.

• a) Bleeding (Haematoma) (Common but usually not the *most* common): Postoperative bleeding can occur, leading to haematoma formation (a collection of blood at the surgical site). While it is a recognized complication, it is usually managed with pressure or drainage and may not be the most frequent.
• b) Thoracodorsal nerve damage (Less common): The thoracodorsal nerve supplies the latissimus dorsi muscle. Damage to this nerve during axillary dissection can lead to weakness in shoulder extension, adduction, and internal rotation. While it can occur, it is not typically the most common complication of a standard axillary clearance.
• c) Seroma (Most common): A seroma is a collection of serous fluid (a clear, straw-coloured fluid) in the surgical site, typically in the space where tissue has been removed. Seroma formation is very common after mastectomy and axillary lymph node dissection. It usually occurs within a few days to weeks after surgery and may require aspiration for symptomatic relief.
• d) Surgical site infection (Common but usually less frequent than seroma): Surgical site infections can occur after any surgery, including mastectomy and axillary clearance. They are characterized by redness, warmth, pain, swelling, and sometimes purulent drainage. While a significant complication, the incidence is generally lower than seroma formation.
• e) Flap necrosis (Less common): Flap necrosis refers to the death of skin flaps created during the mastectomy, usually due to insufficient blood supply. This is a more severe complication and is less common in simple mastectomies compared to procedures involving larger skin flaps or in patients with risk factors like smoking or poor circulation.

Based on the frequency of occurrence, seroma formation is the most common complication following simple mastectomy and axillary clearance.

Explanation: When a woman over 30 presents with a new breast lump that is suspicious for malignancy, the standard initial workup involves a combination of imaging to evaluate the lump and surrounding breast tissue, followed by tissue sampling if the imaging is suspicious or inconclusive.

• a) Cytology>Mammography>USS of breast (Incorrect): Cytology (e.g., FNAC) is a method of tissue sampling and is usually guided by imaging findings. Performing it before imaging may not target the most appropriate area or provide sufficient context about the lesion’s characteristics and the rest of the breast.
• b) Cytology>USS of breast>Mammography (Incorrect): Similar to option a, performing cytology before comprehensive imaging is not the standard approach. Ultrasound is valuable for characterizing the lump, but mammography is also crucial in women over 30 to screen for other lesions and microcalcifications.
• c) Mammography>USS of breast>Cytology (Correct): This sequence is generally considered the most appropriate. Mammography is often the first imaging modality for women over 30 as it can detect calcifications and architectural distortions. Ultrasound is then used to further evaluate palpable lumps, differentiate solid from cystic lesions, and assess the surrounding tissue. If the findings on mammography and ultrasound are suspicious (BIRADS 3, 4, or 5), tissue sampling (cytology or, preferably, core biopsy) is performed for a definitive diagnosis.
• d) USS of breast>Cytology>Mammography (Consider): In some cases, particularly if the lump is very palpable or if the patient has dense breasts, ultrasound might be performed first to characterize the lesion. Mammography would still be important to screen the rest of the breast. Cytology would follow if imaging is suspicious. This sequence is also reasonable.
• e) USS of breast>Mammography>Cytology (Similar to d, also a reasonable sequence): This is essentially the same as option d and can be a valid approach, especially if ultrasound provides a clear target for biopsy.

Both options c) and e) (which is the same as d) present a reasonable sequence. However, mammography first is often preferred in women over 30 to screen for calcifications and provide an overview before targeted ultrasound of the lump. Therefore, option c) is often cited as the classic initial sequence.

Explanation: Several factors can increase a woman’s risk of developing breast cancer.

• a. b/l oophorectomy at 35 years (Generally protective if before menopause): Bilateral oophorectomy (removal of both ovaries) before menopause reduces the levels of oestrogen and progesterone, which can lower the risk of hormone receptor-positive breast cancers, especially if done at a younger age. However, if done for certain genetic conditions that increase cancer risk (like BRCA mutations), the overall risk might still be elevated, but the oophorectomy itself is risk-reducing.
• b. Nulliparity (Risk factor): Women who have never given birth (nulliparous) have a slightly higher risk of breast cancer compared to women who have had children. This is thought to be related to lifetime exposure to oestrogen and the hormonal changes associated with pregnancy.
• c. Post menopausal drug therapy (Hormone replacement therapy – Risk factor): Hormone replacement therapy (HRT) used after menopause, particularly combination therapy with oestrogen and progestin, has been associated with an increased risk of breast cancer. Oestrogen-only HRT may also carry some risk, although generally lower than combination therapy.
• d. Positive family history (Risk factor): A family history of breast cancer, especially in first-degree relatives (mother, sister, daughter) or at a young age, significantly increases a woman’s risk. This may be due to inherited genetic mutations or shared environmental factors.
• e. Breast feeding (Generally protective): As mentioned before, breastfeeding has generally been shown to have a protective effect against breast cancer.

Therefore, nulliparity, postmenopausal hormone therapy, and a positive family history are established risk factors for breast cancer. Bilateral oophorectomy before menopause is generally protective, and breastfeeding is also associated with a reduced risk.

Explanation: ANDI stands for Aberrations of Normal Development and Involution. It is a classification system for benign breast disorders, categorizing them as variations of normal breast tissue development and aging processes.

• a) Fibroadenoma (True): Fibroadenomas are benign breast tumours that are considered part of the spectrum of ANDI, representing an aberration of normal lobular development.
• b) Breast CA (False): Breast carcinoma is a malignant condition and is not included in the ANDI classification, which specifically deals with benign breast disorders.
• c) Breast cyst (True): Breast cysts are fluid-filled sacs that are common benign findings, particularly in women of reproductive age, and are considered part of the involutional changes in ANDI.
• d) Fibroadenosis (True): Fibroadenosis (also known as fibrocystic changes or benign mammary dysplasia) encompasses a range of benign changes in the breast tissue, including fibrosis, cyst formation, and ductal hyperplasia, and is a major component of the ANDI classification.
• e) Duct-ectasia (True): Duct ectasia, the widening of milk ducts, is another benign breast condition often seen with aging and is included under the ANDI classification as an involutional change.

Reference: Breast pathology resources on benign breast disease and ANDI classification.

Explanation: Predisposing factors for breast cancer are conditions or characteristics that increase a person’s risk of developing the disease.

• a) Breast feeding (Generally protective): Breastfeeding has generally been shown to have a protective effect against breast cancer, especially if done for a longer duration. It is associated with a reduced lifetime exposure to oestrogen and can promote differentiation of breast cells.
• b) FHx (Family History) (Risk factor): A family history of breast cancer, especially in first-degree relatives (mother, sister, daughter) or at a young age, significantly increases a woman’s risk of developing the disease. This may be due to inherited genetic mutations (like BRCA1 and BRCA2) or shared environmental or lifestyle factors.

Therefore, a family history (FHx) of breast cancer is a well-established predisposing factor for the disease, while breastfeeding is generally considered protective.

Explanation: The patient has Stage 1 (T1N0M0 equivalent based on complete excision and negative sentinel node) invasive ductal carcinoma with negative oestrogen receptors (ER-). Adjuvant therapy aims to reduce the risk of recurrence after local treatment (surgery and likely radiotherapy).

• a) Aromatase inhibitors (AAdorol) (Incorrect): Aromatase inhibitors are a form of hormonal therapy that works by reducing oestrogen levels. They are effective in oestrogen receptor-positive breast cancers but have no benefit in ER-negative cancers.
• b) Chemotherapy (Correct): For early-stage invasive breast cancer, especially with high-risk features such as ER-negative status, adjuvant chemotherapy is often recommended. Chemotherapy targets rapidly dividing cells and can help eradicate any microscopic disease that may remain after surgery. The decision to use chemotherapy depends on various factors, including tumour size, grade, lymphovascular invasion, and patient characteristics. Given the ER-negative status, hormonal therapy is not an option, making chemotherapy a more likely recommendation.
• c) Radiotherapy to whole breast (Likely indicated): After breast-conserving surgery (wide local excision) for invasive ductal carcinoma, radiotherapy to the whole breast is a standard component of local treatment to reduce the risk of local recurrence. This should be part of the management, but the question asks for the *most* appropriate *management option*, implying a choice between systemic and local therapy. Given the ER-negative status, systemic therapy (chemotherapy) to address distant recurrence risk is often prioritized alongside local control with radiotherapy.
• d) Systemic therapy (Vague): Systemic therapy” is a broad term that includes hormonal therapy chemotherapy and targeted therapy. Since the tumour is ER-negative hormonal therapy is not appropriate. Chemotherapy is a likely systemic option. This choice is less specific than option b.
• e) Mastectomy (Incorrect): The patient has already undergone wide local excision with clear margins. Mastectomy (removal of the entire breast) is not indicated for local control in this setting unless there was a local recurrence or persistent disease.

Given the ER-negative status of the invasive ductal carcinoma adjuvant chemotherapy is a critical component of systemic therapy to reduce the risk of distant recurrence. Radiotherapy to the breast is also essential for local control after breast-conserving surgery. The question asks for the *most* appropriate *management option* and in early-stage ER-negative disease Common Post-Mastectomy Complication the systemic risk addressed by chemotherapy is often a primary concern alongside local control. Therefore chemotherapy is a strong contender for the most appropriate management option.

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Explanation: Bilateral breast pain (mastalgia) is common in premenopausal women and can be related to hormonal fluctuations, including those caused by oral contraceptive pills (OCPs). If the clinical examination and ultrasound (USS) are normal, and there are no suspicious findings, the management should focus on addressing potential hormonal factors and providing reassurance.

• a) Explain and ensure (Correct): If the examination and USS are normal, and the pain is likely hormonal or related to OCP use, explaining the possible causes of the breast pain and providing reassurance about the absence of any concerning findings is often the most appropriate initial step. Symptomatic relief with mild analgesics (like paracetamol or ibuprofen) or supportive measures (like a well-fitting bra) can also be recommended.
• b) Stop OCP and review (Consider): Oral contraceptives can sometimes be associated with breast tenderness or pain in some women. Stopping the OCP might alleviate the symptoms. Reviewing the patient after stopping the OCP to see if the pain has improved is a reasonable step if the pain is bothersome and no other cause is identified. However, if the patient is otherwise well and the pain is mild, explanation and reassurance might be tried first.
• c) Mammogram (Not indicated): Mammography is primarily a screening and diagnostic tool for breast lesions, especially in women over 30 or those with suspicious findings on examination or other imaging. In a 30-year-old woman with bilateral breast pain and normal clinical examination and USS, a mammogram is not indicated as the initial step.
• d) Vitamin E (Not routinely recommended): While some women report improvement in breast pain with vitamin E supplementation, the evidence for its effectiveness is limited and not consistently supported by medical guidelines. It is not a standard recommendation for initial management of breast pain with normal findings.
• e) CT scan (Not indicated): CT scan of the breast is not a standard imaging modality for breast pain and is typically used for staging advanced cancers or evaluating other chest conditions. It is not appropriate for the initial evaluation of bilateral breast pain with normal clinical and USS findings.

Given the normal examination and USS, and the potential link to OCP use, explaining the likely hormonal causes and providing reassurance is the most appropriate initial management. Stopping OCP and reviewing could be considered if the pain is persistent or bothersome. Further imaging is not indicated at this stage.