MCQ bank · 36 questions · free
Breast surgery MCQs with answers
36 single-best-answer questions on breast lumps, breast cancer, mastitis and nipple discharge. Try each one, then open the answer to see the explanation, why the other options are wrong, and the guideline or trial behind it.
A 29-year-old woman, 6 weeks after delivery and breastfeeding, has 3 days of fever and a painful, red, swollen left breast. Ultrasound shows a 3-cm fluid collection beneath the area of redness. What is the best next step?
- Antibiotics alone and review in 6 weeks
- Incision and drainage under general anaesthesia as first-line treatment
- Stop breastfeeding on that side and start cabergoline
- Ultrasound-guided needle aspiration, oral antibiotics, and continue breastfeeding or expressing
- Core needle biopsy to exclude inflammatory breast cancer
Show the answer and explanation
Answer: D. Ultrasound-guided needle aspiration, oral antibiotics, and continue breastfeeding or expressing. A lactational breast abscess is treated first with ultrasound-guided aspiration (repeated if needed) and antibiotics active against Staphylococcus aureus. Milk drainage should continue, as stopping feeding worsens engorgement. Incision and drainage is kept for large or multiloculated collections, failed aspiration or skin necrosis.
Why not the others? Biopsy is needed only if the picture does not settle with treatment. Antibiotics alone do not treat an established collection.
References
A 58-year-old woman has clustered fine pleomorphic calcifications on a screening mammogram. Stereotactic core biopsy shows high-grade ductal carcinoma in situ (DCIS) spanning 15 mm. Which statement about breast-conserving treatment is correct?
- Adjuvant chemotherapy is standard for high-grade DCIS
- A margin of at least 1 cm is required in every case
- Observation is the standard of care because DCIS is not invasive
- Axillary lymph node dissection is routinely required
- Wide local excision with a margin of at least 2 mm, followed by whole-breast radiotherapy, is standard
Show the answer and explanation
Answer: E. Wide local excision with a margin of at least 2 mm, followed by whole-breast radiotherapy, is standard. For DCIS treated with breast-conserving surgery and whole-breast radiotherapy, a 2-mm margin minimises local recurrence; wider margins add no benefit. DCIS does not spread to the nodes, so axillary dissection is not done; sentinel node biopsy is considered only with mastectomy or when invasion is suspected.
Why not the others? Chemotherapy has no role in pure DCIS. Active surveillance of low-risk DCIS is being studied in trials but is not standard for high-grade disease.
References
A 34-year-old woman has a painless, mobile 2-cm lump. Ultrasound shows an oval, well-circumscribed, wider-than-tall solid lesion, and core biopsy confirms a fibroadenoma, concordant with the imaging. What is the most appropriate management?
- Excision of every fibroadenoma
- Mammography every 6 months
- Reassurance, with clinical follow-up and excision only if it grows or causes symptoms
- Breast MRI
- Tamoxifen for 6 months
Show the answer and explanation
Answer: C. Reassurance, with clinical follow-up and excision only if it grows or causes symptoms. A fibroadenoma diagnosed by core biopsy that is concordant with the imaging does not need excision. Excision is offered for growth, size over about 3 cm, symptoms, patient preference, or discordant findings (where a phyllodes tumour must be excluded).
Why not the others? Routine imaging surveillance, MRI and hormonal treatment add nothing for a concordant benign lesion.
References
A 62-year-old woman has had a red, warm, swollen right breast with peau d’orange for 4 weeks. It has not improved after 10 days of antibiotics. She is not breastfeeding. What is the next step?
- Mastectomy without a tissue diagnosis
- A further 2 weeks of a different antibiotic
- Mammography and ultrasound with core biopsy of the breast and a punch biopsy of the skin
- Incision and drainage
- Review in 3 months
Show the answer and explanation
Answer: C. Mammography and ultrasound with core biopsy of the breast and a punch biopsy of the skin. Erythema and oedema involving much of the breast that do not respond to antibiotics in a non-lactating woman must be treated as inflammatory breast cancer until proven otherwise. Diagnosis needs imaging plus tissue: a core biopsy, and a skin punch biopsy to look for dermal lymphatic invasion.
Why not the others? Repeated antibiotic courses delay diagnosis. Inflammatory breast cancer is treated first with systemic therapy, never with immediate surgery.
References
A 36-year-old woman carries a pathogenic BRCA1 variant. She has two children and does not plan more. She asks what will most reduce her risk of dying from a BRCA-related cancer. What do you advise?
- Hysterectomy alone
- Risk-reducing bilateral salpingo-oophorectomy now, between 35 and 40, with breast MRI surveillance or risk-reducing mastectomy discussed
- No action until age 50
- Annual CA-125 and pelvic ultrasound instead of surgery
- Tamoxifen alone
Show the answer and explanation
Answer: B. Risk-reducing bilateral salpingo-oophorectomy now, between 35 and 40, with breast MRI surveillance or risk-reducing mastectomy discussed. Ovarian cancer cannot be detected early by screening, so risk-reducing salpingo-oophorectomy is advised for BRCA1 carriers at 35–40 once childbearing is complete. It lowers ovarian cancer risk by about 80% and reduces all-cause mortality. For the breasts, the choice is annual MRI surveillance or risk-reducing mastectomy.
Why not the others? CA-125 and ultrasound screening do not reduce ovarian cancer deaths. Waiting until 50 misses the years of highest ovarian risk in BRCA1 carriers.
References
A 55-year-old woman with a 2-cm invasive ductal carcinoma and a clinically and radiologically normal axilla has a wide local excision and sentinel node biopsy. Two of three sentinel nodes contain macrometastases. She will have whole-breast radiotherapy. What about the axilla?
- No axillary dissection; adjuvant treatment and radiotherapy as planned
- PET-CT and then axillary dissection
- Repeat sentinel node biopsy
- Completion axillary lymph node dissection in all cases
- Convert to mastectomy with axillary dissection
Show the answer and explanation
Answer: A. No axillary dissection; adjuvant treatment and radiotherapy as planned. In women with T1–2 clinically node-negative cancer treated by breast-conserving surgery and whole-breast radiotherapy, one or two positive sentinel nodes do not need completion dissection: the ACOSOG Z0011 trial showed no difference in 10-year survival or regional recurrence, with less lymphoedema.
Why not the others? These results do not apply to mastectomy without radiotherapy, three or more positive nodes, or clinically positive nodes before surgery.
References
A 45-year-old woman has spontaneous, blood-stained discharge from a single duct of the left nipple. There is no lump. What is the most likely cause?
- Galactorrhoea from a prolactinoma
- Intraductal papilloma
- Paget’s disease of the nipple
- Fibroadenoma
- Duct ectasia
Show the answer and explanation
Answer: B. Intraductal papilloma. Spontaneous, single-duct, bloody discharge is pathological discharge. The commonest cause is an intraductal papilloma; carcinoma is found in a minority. She needs mammography and ultrasound, and if these are normal, further assessment (MRI or ductography) or excision of the duct.
Why not the others? Duct ectasia usually causes multi-duct, green or cream discharge. Galactorrhoea is milky and from both breasts. Paget’s disease presents with eczema-like change of the nipple.
References
An 88-year-old woman with severe heart failure and dementia has a 3-cm ER-positive, HER2-negative breast cancer. She is not fit for general anaesthesia. What is the best treatment?
- Primary endocrine therapy with an aromatase inhibitor
- No treatment, because she is too old
- Mastectomy under general anaesthesia
- Adjuvant chemotherapy
- Trastuzumab
Show the answer and explanation
Answer: A. Primary endocrine therapy with an aromatase inhibitor. For older women with ER-positive cancer who are unfit for or decline surgery, primary endocrine therapy, usually an aromatase inhibitor, controls the disease for years in most patients. Treatment decisions should be based on fitness and frailty, not age alone.
Why not the others? Trastuzumab is for HER2-positive disease. Chemotherapy is not appropriate here.
References
Core biopsy of a 4-cm rapidly growing breast mass in a 42-year-old woman shows a fibroepithelial lesion; excision confirms a borderline phyllodes tumour with a positive margin. What is the next step?
- Observation
- Re-excision to achieve a clear margin (often about 1 cm), with no axillary surgery
- Axillary lymph node dissection
- Tamoxifen
- Adjuvant chemotherapy
Show the answer and explanation
Answer: B. Re-excision to achieve a clear margin (often about 1 cm), with no axillary surgery. Borderline and malignant phyllodes tumours recur locally if the margin is involved, so they are re-excised to a clear margin. They rarely spread to lymph nodes, so axillary staging is not needed. Hormone therapy and chemotherapy have no routine role.
Why not the others? Unlike carcinoma, phyllodes tumours spread by the blood, not the lymphatics.
References
A healthy 14-year-old boy has a tender, 2-cm disc of tissue under both nipples. Testicular examination is normal. What is the most appropriate management?
- Subcutaneous mastectomy now
- Tamoxifen for every case
- Mammography
- Core biopsy
- Reassurance; pubertal gynaecomastia usually resolves within 1–2 years
Show the answer and explanation
Answer: E. Reassurance; pubertal gynaecomastia usually resolves within 1–2 years. Gynaecomastia affects many boys during puberty because of a temporary imbalance between oestrogen and testosterone, and most cases settle within 1–2 years. Examine the testes and look for medicines or drugs (for example anabolic steroids or cannabis). Surgery is considered only if it persists after puberty.
Why not the others? Mammography and biopsy are not indicated for typical pubertal gynaecomastia.
References
A 52-year-old woman has a new, firm 2-cm lump in the right breast. What is the standard approach to diagnosis?
- Mammography alone; biopsy only if it shows calcification
- Fine-needle aspiration only
- Triple assessment: clinical examination, imaging (mammography and ultrasound) and image-guided core biopsy
- MRI only
- Excision of every lump before any imaging
Show the answer and explanation
Answer: C. Triple assessment: clinical examination, imaging (mammography and ultrasound) and image-guided core biopsy. Triple assessment combines examination, imaging and tissue diagnosis. Core biopsy is preferred to fine-needle aspiration because it distinguishes invasive from in-situ disease and provides receptor status. If any element is suspicious or discordant, further assessment is needed.
Why not the others? A normal mammogram does not exclude cancer in a palpable lump.
References
A 47-year-old woman has a 2.5-cm invasive ductal carcinoma that is HER2-positive. The axilla is clinically and radiologically normal. What is the usual first treatment?
- Radiotherapy alone
- Endocrine therapy alone
- Mastectomy and axillary clearance, then observation
- Surgery only; HER2 status does not change treatment
- Neoadjuvant chemotherapy with anti-HER2 therapy (trastuzumab, often with pertuzumab), then surgery
Show the answer and explanation
Answer: E. Neoadjuvant chemotherapy with anti-HER2 therapy (trastuzumab, often with pertuzumab), then surgery. For HER2-positive cancers larger than about 2 cm or node-positive, systemic treatment before surgery is standard. It can shrink the tumour to allow breast conservation, and the response guides further treatment: patients with residual disease benefit from switching to T-DM1 (trastuzumab emtansine).
Why not the others? Treatment for HER2-positive cancer always includes anti-HER2 therapy.
References
Stereotactic core biopsy of calcifications in a 55-year-old woman shows atypical ductal hyperplasia (ADH). What is the next step?
- Surgical excision of the area, because a significant proportion are upgraded to DCIS or invasive cancer
- Mastectomy
- Chemotherapy
- Routine screening only
- Axillary dissection
Show the answer and explanation
Answer: A. Surgical excision of the area, because a significant proportion are upgraded to DCIS or invasive cancer. ADH found on core biopsy is upgraded to DCIS or invasive cancer at excision in a significant proportion of cases, so diagnostic surgical excision is generally recommended. After excision, women with ADH have a higher long-term risk and are offered risk-reducing medication and enhanced surveillance.
Why not the others? ADH is not cancer, so mastectomy and axillary surgery are not indicated.
References
A 61-year-old woman has a red, scaly, itchy rash on one nipple that has not improved with 4 weeks of steroid cream. The areola is spared at first and the nipple is slowly being eroded. What is the next step?
- Antifungal cream
- A stronger steroid cream for 3 months
- Incision and drainage
- Urgent referral for mammography, ultrasound and a punch biopsy of the nipple
- Reassure, as it is eczema
Show the answer and explanation
Answer: D. Urgent referral for mammography, ultrasound and a punch biopsy of the nipple. A one-sided nipple rash that starts on the nipple and does not respond to treatment is Paget’s disease of the nipple until proven otherwise. It is usually associated with underlying DCIS or invasive cancer, so imaging and a skin biopsy are needed.
Why not the others? Eczema usually affects the areola first, is often on both sides and responds to steroid cream.
References
A 66-year-old man has a firm, painless 2-cm lump under the left areola with skin tethering. What is correct about male breast cancer?
- Radiotherapy alone is the standard
- Aromatase inhibitor alone is the standard adjuvant therapy
- It is always HER2-positive
- It is always gynaecomastia and needs no biopsy
- It needs triple assessment; most are ER-positive, usually treated by mastectomy with sentinel node biopsy and then tamoxifen
Show the answer and explanation
Answer: E. It needs triple assessment; most are ER-positive, usually treated by mastectomy with sentinel node biopsy and then tamoxifen. Male breast cancer is uncommon but is diagnosed with triple assessment, just as in women. Over 90% are ER-positive. Tamoxifen is the preferred adjuvant endocrine therapy; an aromatase inhibitor alone is less effective in men unless combined with testosterone suppression. Genetic testing (especially BRCA2) is offered to all men with breast cancer.
Why not the others? Hard, eccentric or tethered lumps are not typical of gynaecomastia.
References
A 38-year-old woman who smokes, and is not breastfeeding, has a painful red swelling next to the areola. Ultrasound shows a small collection. This is her third episode. Which statement is correct?
- Mastectomy is the treatment
- Antibiotics against Staphylococcus only are enough
- This is periductal mastitis: aspirate and give antibiotics covering anaerobes (e.g. co-amoxiclav), advise stopping smoking, and consider total duct excision for recurrent disease
- Smoking is unrelated
- This is lactational mastitis: continue breastfeeding
Show the answer and explanation
Answer: C. This is periductal mastitis: aspirate and give antibiotics covering anaerobes (e.g. co-amoxiclav), advise stopping smoking, and consider total duct excision for recurrent disease. Periductal mastitis and non-lactational subareolar abscesses are strongly linked with smoking and often involve anaerobes. Recurrent episodes and mammary duct fistulas are common, so definitive treatment is excision of the major ducts together with stopping smoking.
Why not the others? Antibiotics without anaerobic cover often fail in this setting.
References
A 50-year-old woman has a mastectomy and axillary clearance. Pathology shows a 3-cm cancer with 5 of 14 lymph nodes involved. Which adjuvant treatment reduces both recurrence and breast cancer death?
- Radiotherapy to the opposite breast
- Repeat axillary surgery
- Post-mastectomy radiotherapy to the chest wall and regional nodes, along with systemic therapy
- Radiotherapy only if margins are involved
- No radiotherapy after mastectomy
Show the answer and explanation
Answer: C. Post-mastectomy radiotherapy to the chest wall and regional nodes, along with systemic therapy. Post-mastectomy radiotherapy reduces locoregional recurrence and breast cancer mortality in women with involved axillary nodes; the benefit is clearest with 4 or more positive nodes and is also seen with 1–3 positive nodes.
Why not the others? Mastectomy does not remove the need for radiotherapy when nodes are involved.
References
A 64-year-old postmenopausal woman has had breast-conserving surgery for an ER-positive, HER2-negative cancer. What is the standard adjuvant endocrine therapy?
- Trastuzumab
- Tamoxifen for 6 months
- Oestrogen replacement therapy
- No endocrine therapy after radiotherapy
- An aromatase inhibitor for at least 5 years, with bone density assessment and bone protection as needed
Show the answer and explanation
Answer: E. An aromatase inhibitor for at least 5 years, with bone density assessment and bone protection as needed. In postmenopausal women with hormone receptor-positive cancer, aromatase inhibitors give a modest improvement over tamoxifen. They cause bone loss, so bone density is measured and bisphosphonates are used when indicated. Extended therapy beyond 5 years is considered for higher-risk disease.
Why not the others? Trastuzumab is only for HER2-positive disease. Oestrogen would stimulate the tumour.
References
A 32-year-old woman has bilateral breast pain that is worse in the week before her period. Examination is normal. What is the best management?
- Surgical excision of the painful area
- Breast MRI
- Reassurance, a well-fitting supportive bra and simple analgesia such as topical NSAIDs
- Danazol as first-line treatment
- Mammography
Show the answer and explanation
Answer: C. Reassurance, a well-fitting supportive bra and simple analgesia such as topical NSAIDs. Cyclical mastalgia is common and benign. When examination is normal, imaging is not needed for pain alone, and reassurance with simple measures helps most women. Hormonal drugs have significant side effects and are used rarely, for severe persistent pain under specialist care.
Why not the others? A focal lump, skin change or nipple discharge would change the plan.
References
A 41-year-old woman has just been diagnosed with triple-negative breast cancer. Her family history is unknown. What should be offered?
- Genetic testing only if two relatives are affected
- Testing only after age 60
- No genetic testing in triple-negative cancer
- Germline genetic testing (including BRCA1 and BRCA2), because the result can change surgery, systemic treatment and family risk
- Testing of her children instead
Show the answer and explanation
Answer: D. Germline genetic testing (including BRCA1 and BRCA2), because the result can change surgery, systemic treatment and family risk. Germline testing is recommended for all patients diagnosed with breast cancer at age 65 or younger, and for those with triple-negative disease. A pathogenic variant may change surgical choices (for example bilateral mastectomy), allows PARP inhibitor therapy, and identifies relatives at risk.
Why not the others? Waiting for a strong family history misses many carriers.
References
Two years after mastectomy and axillary clearance, a woman notices that her arm on the operated side is swollen and heavy. There is no recurrence on examination. What is the first-line management?
- Immediate surgery for every patient
- Antibiotics for 6 months
- Referral to a lymphoedema service for complex decongestive therapy: compression, manual lymphatic drainage, exercise and skin care
- Restricting all use of the arm
- Diuretics
Show the answer and explanation
Answer: C. Referral to a lymphoedema service for complex decongestive therapy: compression, manual lymphatic drainage, exercise and skin care. Lymphoedema after axillary surgery and radiotherapy is managed first with conservative decongestive therapy and lifelong compression and skin care, because cellulitis worsens it. Surgical options (lymphovenous anastomosis, lymph node transfer, liposuction) are for selected patients.
Why not the others? Diuretics do not remove protein-rich lymph. Gentle exercise helps rather than harms.
References
A woman who is 18 weeks pregnant has a 2.5-cm invasive breast cancer with no spread. Which statement is correct?
- No treatment until after delivery
- Surgery can be performed during pregnancy, and chemotherapy can be given after the first trimester; radiotherapy, tamoxifen and trastuzumab are delayed until after delivery
- Chemotherapy is safe in the first trimester
- Tamoxifen is the treatment of choice during pregnancy
- Termination of pregnancy is required before any treatment
Show the answer and explanation
Answer: B. Surgery can be performed during pregnancy, and chemotherapy can be given after the first trimester; radiotherapy, tamoxifen and trastuzumab are delayed until after delivery. Breast cancer in pregnancy is treated with curative intent, much as outside pregnancy. Surgery is safe in any trimester, and many chemotherapy regimens can be given in the second and third trimesters. Tamoxifen and trastuzumab are harmful to the fetus, and radiotherapy is postponed.
Why not the others? Termination does not improve the mother’s prognosis.
References
A woman with a biopsy-proven positive axillary lymph node receives neoadjuvant chemotherapy. Afterwards the axilla is clinically and radiologically normal. Which axillary surgery is acceptable?
- Fine-needle aspiration of the axilla only
- No axillary surgery
- Axillary dissection is always required
- Radiotherapy alone without surgery
- Sentinel node biopsy, using dual tracer and removing at least 3 nodes including the clipped (originally positive) node
Show the answer and explanation
Answer: E. Sentinel node biopsy, using dual tracer and removing at least 3 nodes including the clipped (originally positive) node. After neoadjuvant chemotherapy, sentinel node biopsy is accurate in patients who were node-positive and became clinically node-negative, provided techniques reduce false negatives: dual tracer, at least three nodes, and retrieval of the clipped node. Residual disease usually leads to axillary dissection.
Why not the others? Omitting axillary surgery entirely is not standard after initially node-positive disease.
References
Pathology after wide local excision of a 1.8-cm invasive ductal carcinoma shows the closest margin is 0.5 mm, with no tumour at the inked edge. Whole-breast radiotherapy is planned. What do you do?
- Re-excise to a 5-mm margin
- Re-excise to obtain a 1-cm margin
- Mastectomy
- Add axillary dissection
- No re-excision; “no ink on tumour” is an adequate margin for invasive cancer
Show the answer and explanation
Answer: E. No re-excision; “no ink on tumour” is an adequate margin for invasive cancer. For invasive cancer treated with breast-conserving surgery and radiotherapy, wider margins than no ink on tumour do not reduce local recurrence. This consensus has lowered re-excision rates. DCIS is different: a 2-mm margin is preferred.
Why not the others? Unnecessary re-excision delays treatment and worsens the cosmetic result.
References
A 50-year-old woman with no family history or genetic mutation has a left breast cancer and asks for removal of the healthy right breast as well, believing it will improve her survival. What is correct?
- It is recommended for all women under 60
- It removes the need for treatment of the cancer
- Contralateral prophylactic mastectomy does not improve survival in average-risk women; it can be discussed, but should be discouraged on that basis
- It is mandatory for every breast cancer
- It doubles survival
Show the answer and explanation
Answer: C. Contralateral prophylactic mastectomy does not improve survival in average-risk women; it can be discussed, but should be discouraged on that basis. The risk of a new cancer in the other breast is low in average-risk women and does not drive survival, which depends on the original cancer. Contralateral mastectomy adds complications and recovery time. It is reasonable for BRCA carriers and selected high-risk women.
Why not the others? Fear is understandable; the decision should be informed, not prohibited.
References
A 74-year-old woman has had breast-conserving surgery for a 1.5-cm, node-negative, ER-positive, HER2-negative, grade 2 cancer with clear margins. She will take endocrine therapy. What is true about radiotherapy?
- Chemotherapy replaces radiotherapy
- Radiotherapy is mandatory for everyone
- Radiotherapy improves survival by 30%
- She needs mastectomy instead
- Omitting radiotherapy is a reasonable option: it slightly increases local recurrence but does not change overall survival
Show the answer and explanation
Answer: E. Omitting radiotherapy is a reasonable option: it slightly increases local recurrence but does not change overall survival. In older women with low-risk, hormone receptor-positive cancer who take endocrine therapy, trials such as PRIME II show that omitting radiotherapy increases local recurrence modestly with no difference in overall survival. The choice is shared with the patient.
Why not the others? The decision depends on endocrine adherence; stopping endocrine therapy changes the balance.
References
A 26-year-old woman has a new palpable lump in her breast. What is the first imaging test?
- Mammography
- MRI
- CT
- PET-CT
- Targeted ultrasound
Show the answer and explanation
Answer: E. Targeted ultrasound. In women under about 30–35, breast tissue is dense and benign lesions are common, so ultrasound is the first-line test. Mammography is added if ultrasound is suspicious. A solid lesion still needs biopsy if imaging or the clinical findings are not clearly benign.
Why not the others? MRI is not a first-line test for a palpable lump.
References
A 45-year-old woman has a painful, smooth lump. Ultrasound shows a simple cyst. It is aspirated to dryness, the fluid is straw-coloured, and the lump disappears. What is next?
- Mammography every 3 months
- MRI
- Discard the fluid and reassure; no further follow-up for this cyst unless it recurs
- Send the fluid for cytology in every case
- Excision of the cyst
Show the answer and explanation
Answer: C. Discard the fluid and reassure; no further follow-up for this cyst unless it recurs. Simple cysts are benign. Symptomatic cysts are aspirated. Cytology is needed only if the fluid is bloody. Biopsy is needed if a lump remains after aspiration, the cyst is complex, or it recurs repeatedly.
Why not the others? Routine cytology of clear fluid adds nothing.
References
A healthy 45-year-old woman at average risk asks when she should start screening mammography. What does the 2024 USPSTF recommendation say?
- No screening until 60
- Ultrasound every 6 months
- Mammography only if a lump is found
- Annual MRI from age 25
- Mammography every 2 years from age 40 to 74
Show the answer and explanation
Answer: E. Mammography every 2 years from age 40 to 74. In 2024 the USPSTF lowered the starting age for biennial screening mammography to 40 for average-risk women, continuing to 74. Programmes differ between countries (for example, the UK screens 50–71 every 3 years). Women at high risk follow separate pathways, often including MRI.
Why not the others? MRI screening is for high-risk women, such as BRCA carriers.
References
A screen-detected area of distortion is biopsied and shows a radial scar (complex sclerosing lesion) without atypia (B3). What is the usual next step?
- Chemotherapy
- Discharge to routine screening without further tissue
- Axillary surgery
- Further sampling by vacuum-assisted excision, discussed at the multidisciplinary meeting
- Mastectomy
Show the answer and explanation
Answer: D. Further sampling by vacuum-assisted excision, discussed at the multidisciplinary meeting. B3 lesions have uncertain malignant potential. For many B3 lesions without atypia, such as radial scars, vacuum-assisted excision provides enough tissue to exclude cancer while avoiding a surgical excision. Lesions with atypia may need surgical excision.
Why not the others? Radial scars are not cancer, so mastectomy is never the answer.
References
A 33-year-old woman who had a baby 2 years ago has a painful inflammatory breast mass with sterile abscesses. Core biopsy shows non-caseating granulomas centred on lobules; cultures and TB tests are negative. What is the usual first-line treatment?
- Medical treatment, such as oral steroids (or methotrexate), with drainage of abscesses if needed; avoid early wide excision
- Anti-tuberculous therapy for 6 months without testing
- Radiotherapy
- Repeated wide excisions
- Immediate mastectomy
Show the answer and explanation
Answer: A. Medical treatment, such as oral steroids (or methotrexate), with drainage of abscesses if needed; avoid early wide excision. Idiopathic granulomatous mastitis is a benign inflammatory condition mainly affecting young parous women. It often responds to steroids or methotrexate, or resolves with time. Wide excision of inflamed tissue causes poor healing and fistulas. TB and cancer must be excluded first.
Why not the others? Granulomatous mastitis can mimic cancer clinically, which is why biopsy is essential.
References
After breast-conserving surgery for early breast cancer, which whole-breast radiotherapy schedule was shown to be non-inferior to 3 weeks of treatment?
- 26 Gy in 5 fractions over 1 week (FAST-Forward)
- 10 fractions twice a day
- 70 Gy in 35 fractions
- A single dose of 50 Gy
- No radiotherapy for anyone
Show the answer and explanation
Answer: A. 26 Gy in 5 fractions over 1 week (FAST-Forward). The FAST-Forward trial showed that 26 Gy in five fractions over 1 week was as effective as 40 Gy in 15 fractions, with similar side effects. Shorter schedules are more convenient for patients and reduce pressure on radiotherapy services.
Why not the others? Very high doses in many fractions are used for other cancers, not breast.
References
Four years after breast-conserving surgery and radiotherapy, a woman has a new cancer in the same breast near the scar. Restaging shows no distant spread. What is the usual surgical treatment?
- Mastectomy (because the breast has already been irradiated), with systemic therapy guided by the tumour biology
- Radiotherapy alone
- Observation
- Another wide local excision and a second full course of whole-breast radiotherapy
- Chemotherapy alone
Show the answer and explanation
Answer: A. Mastectomy (because the breast has already been irradiated), with systemic therapy guided by the tumour biology. In-breast recurrence after breast-conserving therapy is usually treated by mastectomy, because repeat whole-breast radiotherapy is generally not possible. Restaging and receptor testing of the recurrence guide systemic therapy. Repeat breast conservation is possible only in selected cases.
Why not the others? Staging is essential because recurrence may be the first sign of distant disease.
References
A 58-year-old woman has newly diagnosed ER-positive, HER2-negative breast cancer with bone metastases only. She is well. What is the standard first-line treatment?
- Mastectomy and axillary clearance
- No treatment
- Trastuzumab
- Endocrine therapy (an aromatase inhibitor) combined with a CDK4/6 inhibitor, plus bone-protecting treatment
- Chemotherapy alone in every case
Show the answer and explanation
Answer: D. Endocrine therapy (an aromatase inhibitor) combined with a CDK4/6 inhibitor, plus bone-protecting treatment. In hormone receptor-positive, HER2-negative metastatic breast cancer, endocrine therapy combined with a CDK4/6 inhibitor (palbociclib, ribociclib or abemaciclib) improves progression-free and, for some agents, overall survival. Chemotherapy is reserved for visceral crisis or endocrine resistance. Bisphosphonates or denosumab reduce skeletal events.
Why not the others? Trastuzumab is only for HER2-positive disease.
References
A 28-year-old woman has milky discharge from both nipples and irregular periods. She is not pregnant or breastfeeding. What is the next step?
- Core biopsy of both breasts
- Check pregnancy test, prolactin and thyroid function, and review medications (for example antipsychotics, metoclopramide)
- Antibiotics
- Reassure without tests
- Mammography and duct excision
Show the answer and explanation
Answer: B. Check pregnancy test, prolactin and thyroid function, and review medications (for example antipsychotics, metoclopramide). Bilateral milky discharge (galactorrhoea) is usually endocrine or drug-related, not a breast disease. Raised prolactin from a pituitary adenoma, hypothyroidism and dopamine-blocking drugs are common causes. Pituitary MRI is done if prolactin is raised without a drug cause.
Why not the others? Surgical breast investigations are for spontaneous, single-duct or bloody discharge.
References
Two months after a fall onto a car seat belt, a 60-year-old woman has a firm, irregular lump with skin tethering under the bruised area. What is correct?
- Antibiotics
- Fat necrosis is likely, but it can mimic cancer clinically and on imaging, so triple assessment with biopsy is still needed
- Reassure without imaging because of the trauma history
- Mastectomy
- Aspirate and discharge
Show the answer and explanation
Answer: B. Fat necrosis is likely, but it can mimic cancer clinically and on imaging, so triple assessment with biopsy is still needed. Fat necrosis after trauma or surgery often produces a firm, irregular mass with tethering and sometimes calcification, closely resembling carcinoma. A history of trauma should not prevent standard assessment. Typical oil cysts on imaging may be diagnostic; otherwise biopsy is required.
Why not the others? A trauma history can be coincidental.
References