Surgery of the Breasts- Questions for Surgery Residents

Q1 Which of the following is a contraindication for breast conserving surgery (BCT)?

A) Small lump to breast ratio

b) Central breast tumor mass

c) Breast Tumor size less than 5 cm

d) Young age

Q2. Which is not true regarding BRCA mutations in breast cancer?

a) BRCA 1 tumors are high grade as compared to BRCA 2

b) BRCA 1 breast cancer are hormone receptor positive

c) BRCA 1 breast tumor are aneuploid

d) BRCA 1 breast cancer have an incraesed S phase fraction

Q3 ) Which of the following muscles do not form the posterior relation of breast?

a) Pectoralis major

b) Serratus Anterior

c) Rectus Abdominis

d) Lattismus Dorsi

Q4 Minimum number of lymph nodes to be dissected in Axillary sampling in brest conservation surgery is

a) 2

b) 3

c) 4

d) 5

Q5) In Breast Reconstructive surgery after mastectomy which of the following is not true regarding TRAM flap

a) TRAM flap may be based on a pedicled Superior Epigastric artery

b) TRAM flap can be transferred as a free flap

c) It is a type of myocutaneous flap

d) It uses supraumbilical fat

Q6) Not a true statement regarding breast implants

a) They are made of silicone shell filled with either saline or silicone gel

b) Silicone gels filled implants provide a more natural shape

c) Silicone gel filled implants became controversial becasue of risk of associated malignancy

d) In case of rupture of implants silicone gel may get absorbed in axillary lymph nodes

Answers

1) b

Breast conservation involves resection of the primary breast cancer with atleast 2 mm margin of normal-appearing breast tissue, adjuvant radiation therapy, and assessment of axillary lymph node status.

Breast conservation surgery is contraindicated when

-- the tumor is multicentric and multifocal

-- the tumor is central, the advantages of preserving the breast are lost as nipple areola complex is sacrificed

-- tumor is to breast ratio is large ie the form of breast is not preserved

-- Patient is not a candidate for radiation exposure, eg pregnancy, previous history of radiation SLE etc

Age is no criteria.

2) b . BRCA1- associated breast tumors have a worse prognosis than BRCA2- associated breast cancers.

They are high grade, associated with negative ER- PR receptors, increased S phase fraction and aneuploid.

3. d

The deep or posterior surface of the breast rests on the fascia of the pectoralis major, serratus anterior, and external oblique abdominal muscles, and the upper extent of the rectus sheath.

Schwartz Surgery

4. c

Minimum number of lymphnodes to be removed in Axillary sampling is 4 and in Sentinel Lymph node biopsy is 2

In Breast conservation surgery the axilla can be dealt in three separate ways;

1. Sentinel Lymph Node Biopsy

2. Axillary sampling

3. Axillary Dissection

Sentinel Lymphnode biopsy axillary sampling is done for clinically node negative axilla.

5) d

After MRM, breast mound can be created using a TRAm flap which is a myocutaneous flap. It uses infraumbilical suprapubic fat and not supraumbilical fat. It may be pedicled based on superior epigastric artery or free flap based on deep inferior epigastric or perforator veseels.

Drawbacks to the TRAM flap include a longer operative time, a visible scar on the lower abdomen, and a slight weakening of the abdominal wall.

Sabiston 18th edition

6) c

Silicone filled implants became controversial not because of their association with malignancy but because of the associated risk of systemic diseases like autoimmune disorders, arthritis and collagen vascular disorders.