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🔴 NEET PG / INICET RAPID REVISION NOTES

BREAST SURGERY — Complete High-Yield Guide

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📌 SECTION 1: SURGICAL ANATOMY (High-Yield for NEET PG)

Structure of the Breast

TDLU (Terminal Duct Lobular Unit) = FUNCTIONAL UNIT of breast
↓
15–20 lobes → each with lactiferous duct → opens at nipple
↓
Supported by Cooper's ligaments (suspensory ligaments)

• Breast lies between 2nd–6th rib, 2nd–3rd intercostal space
• Axillary tail of Spence = projection into axilla through foramen in deep fascia
• Blood supply: Internal mammary artery (medial 60%) + lateral thoracic artery (lateral 40%)
• Nerve supply: Intercostal nerves T4–T6 (nipple = T4 dermatome) ⭐
• Lymphatic drainage: Axilla (75%) → internal mammary nodes (20%) → supraclavicular nodes

Axillary Lymph Node Levels (VERY HIGH YIELD ⭐⭐⭐)

┌─────────────────────────────────────────────────────┐
│  Level I  = LATERAL to pectoralis minor              │
│  Level II = BEHIND pectoralis minor (includes        │
│             Rotter's nodes between pectoralis major  │
│             and minor)                               │
│  Level III = MEDIAL to pectoralis minor              │
│             (Halsted's ligament = level III)         │
└─────────────────────────────────────────────────────┘

PYQ Memory: "Rotter's nodes" = interpectoral nodes (between pec major & minor) = Level II

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📌 SECTION 2: TRIPLE ASSESSMENT ⭐⭐⭐ (Examiner LOVES this)

        ┌──────────────────────────────────┐
        │       TRIPLE ASSESSMENT          │
        │                                  │
        │  1. Clinical Examination         │
        │  2. Imaging (USG / Mammography)  │
        │  3. Pathology (FNAC / Core Bx)   │
        └──────────────────────────────────┘

• FNAC = cytology (cells), no architecture, cannot distinguish invasive vs in situ
• Core biopsy (Tru-cut) = histology, shows architecture ⭐
• Vacuum-assisted biopsy (8G or 11G needles) = best for microcalcifications

BI-RADS Classification ⭐⭐⭐ (PYQ Guaranteed)

🔴 PYQ Tip: BI-RADS 3 → 6-month follow-up, NOT biopsy. BI-RADS 5 → ≥95% malignancy.

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📌 SECTION 3: BENIGN BREAST DISEASE

ANDI Framework (Cardiff Concept)

MNEMONIC: "DEV-CYC-INV"
Phase 1 (15–25 yrs): DEVelopment → Fibroadenoma (lobule hyperplasia)
Phase 2 (15–50 yrs): CYClic → Cyclical mastalgia, nipple discharge
Phase 3 (35–55 yrs): INVolution → Cysts, sclerosing adenosis

Fibroadenoma ⭐⭐⭐

• Simple fibroadenoma: RR 1.5–1.7
• Fibroadenoma + epithelial hyperplasia: RR 3.4–3.7
• Complex fibroadenoma + family history: RR 3.0–4.0 ⭐

Mnemonic: "SAFISH"

• Size >5 cm
• Atypia on histology
• Family history of breast cancer
• Imaging suspicious (microlobulation)
• Suspect phyllodes
• History - age >30 years (or patient preference)

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Phyllodes Tumor ⭐⭐⭐ (PYQ Favorite)

┌────────────────┬──────────────────────────┐
│ Benign         │ <4 mitoses/10 HPF         │
│ Borderline     │ 4–9 mitoses/10 HPF        │
│ Malignant      │ >10 mitoses/10 HPF  ⭐    │
└────────────────┴──────────────────────────┘

⚠️ PYQ Trap: Phyllodes = surgery with WIDE margin (NOT simple enucleation). High recurrence if inadequate margin.

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Breast Cysts

• Age: perimenopausal women (35–55 years)
• Aspirate: usually clear/turbid fluid - if bloodstained → send for cytology ⭐
• If cyst disappears completely after aspiration → no further action needed
• If cyst refills or aspirate is bloodstained → surgery

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Nipple Conditions (High-Yield)

🔴 PYQ: Most common cause of blood-stained nipple discharge = Duct papilloma (solitary intraductal papilloma)

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Breast Abscess

🔴 PYQ: Lactational mastitis/abscess = continue breastfeeding ⭐

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Mondor's Disease ⭐

• Thrombophlebitis of superficial veins of breast/anterior chest wall
• Signs: Tender subcutaneous cord, skin groove on arm elevation
• Differential diagnosis: Lymphatic permeation from occult carcinoma ⭐
• Treatment: Rest, restrict arm movements - resolves spontaneously

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Gynaecomastia ⭐⭐

D = Drugs (spironolactone, digoxin, cimetidine, estrogens, cannabis)
E = Estrogen-secreting tumors (adrenal, testicular)
A = Alcoholism/liver cirrhosis
D = Digitalis

C = Castration/Klinefelter's
A = Androgen deficiency
T = Thyrotoxicosis
S = Starvation (refeeding)

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Congenital Breast Anomalies

🔴 PYQ: Poland's syndrome = absent breast + absent pectoralis major + hand anomaly (symbrachydactyly)

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📌 SECTION 4: BREAST CANCER ⭐⭐⭐

Risk Factors for Breast Cancer

Mnemonic: "FEMALE FAN"
F = Female sex (ratio F:M = 100:1)
E = Early menarche (<12 yrs)
M = Menopausal age late (>55 yrs)
A = Age (older)
L = Late first pregnancy (>35 yrs) or nulliparity
E = Estrogen exposure (HRT, OCP)

F = Family history (BRCA1/2)
A = Atypical hyperplasia (ADH/ALH)
N = No breastfeeding history

🔴 PYQ: BRCA1 = chromosome 17, BRCA2 = chromosome 13. BRCA2 associated with male breast cancer.

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Pathological Types ⭐⭐⭐

🔴 PYQ: LCIS = incidental finding, bilateral marker of risk, NOT a direct precursor to invasive cancer. DCIS = true precancer.

Mnemonic: "IDC = I Do Cancer" (Invasive Ductal Carcinoma = MOST COMMON 80%)

Types by frequency:
1. IDC (NOS) = 80% ← MOST COMMON ⭐⭐⭐
2. ILC = 10–15%
3. Medullary = 5% (good prognosis, lymphocytic infiltrate)
4. Mucinous/Colloid = good prognosis
5. Tubular = excellent prognosis
6. Inflammatory = WORST prognosis ⭐⭐⭐

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Molecular Subtypes ⭐⭐⭐ (NEET PG 2023/2024 Trend)

┌─────────────────┬──────────┬──────────┬──────────┬──────────────┐
│ Subtype         │ ER       │ PR       │ HER2     │ Treatment    │
├─────────────────┼──────────┼──────────┼──────────┼──────────────┤
│ Luminal A       │ +        │ +        │ -        │ Hormonal Rx  │
│ Luminal B       │ +        │ +/-      │ +/-      │ Hormonal ±   │
│                 │          │          │          │ chemo        │
│ HER2-enriched   │ -        │ -        │ +        │ Trastuzumab  │
│ Triple Negative │ -        │ -        │ -        │ Chemo ONLY   │
│ (TNBC)         │          │          │          │ Worst prog.  │
└─────────────────┴──────────┴──────────┴──────────┴──────────────┘

🔴 PYQ: Triple Negative Breast Cancer (TNBC) = ER-, PR-, HER2-. Only option = chemotherapy. Poor prognosis.

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TNM Staging (UICC/AJCC 8th Edition) ⭐⭐⭐

• N0 = No nodes
• N1 = Mobile ipsilateral Level I–II axillary nodes
• N2 = Fixed/matted Level I–II OR internal mammary nodes
• N3 = Level III / supraclavicular / infraclavicular nodes

Stage I   = T1N0M0 (Early, <2 cm, no nodes)
Stage II  = T2N0 or T1-2N1 (Operable)
Stage III = T3-4 or N2-3 (Locally advanced)
Stage IV  = M1 (Distant mets = incurable)

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Clinical Features of Breast Cancer ⭐⭐⭐

Mnemonic: "HISSFIT"
H = Hard consistency
I = Irregular surface
S = Skin changes (peau d'orange, dimpling)
S = Skirrhous (infiltrates surrounding tissue)
F = Fixed to skin or chest wall
I = Increased vascularity
T = Tethering of Cooper's ligaments

• French = "skin of orange"
• Mechanism: Dermal lymphatic obstruction → skin dimpling + edema
• Seen in inflammatory carcinoma ⭐

• Unilateral eczematous change of nipple
• Does NOT heal with topical steroids (unlike eczema)
• Paget cells = large cells with pale cytoplasm + prominent nucleolus
• Always has underlying DCIS or invasive Ca ⭐
• Treatment: Mastectomy if invasive; BCS + radiation if DCIS only

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📌 SECTION 5: INVESTIGATIONS

Mammography ⭐⭐⭐

MAMMOGRAPHY preferred when:
  • Age >30–35 years
  • Screening (>40 years - annual screening)
  • Suspicious microcalcifications
  • Assessment of entire breast

USG preferred when:
  • Age <30 years (dense breasts)
  • Pregnant / lactating
  • Differentiate cyst vs solid
  • Guided biopsy
  • Dense breast tissue

• Spiculated mass with ill-defined margins
• Pleomorphic microcalcifications (clustered) ⭐
• Architectural distortion
• Asymmetric density

• Dense breasts with discordant mammogram/USG
• Distinguish scar vs recurrence
• Screening for BRCA mutation carriers ⭐
• Extent assessment before BCS
• Occult primary with axillary nodal metastasis

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📌 SECTION 6: SURGICAL TREATMENT ⭐⭐⭐

Types of Mastectomy (NEET PG Loves This)

┌──────────────────────────────────────────────────────────────────┐
│ RADICAL MASTECTOMY (Halsted)                                     │
│ Removal of: breast + skin + pectoralis major + minor +           │
│             ALL axillary LN levels I, II, III                    │
│ Complication: Arm edema, frozen shoulder, ugly scar              │
│ Status: HISTORICAL, rarely done today ⭐                         │
├──────────────────────────────────────────────────────────────────┤
│ MODIFIED RADICAL MASTECTOMY (MRM) = Patey's Op ⭐⭐⭐            │
│ Removal of: breast + skin + pectoralis minor +                   │
│             axillary LN levels I, II, III                        │
│ Pectoralis MAJOR is PRESERVED ⭐                                 │
│ This is the STANDARD surgery for operable breast cancer          │
├──────────────────────────────────────────────────────────────────┤
│ AUCHINCLOSS-MADDEN MRM                                           │
│ Removal of: breast + skin + axillary LN levels I, II            │
│ BOTH pectoralis muscles PRESERVED                                │
├──────────────────────────────────────────────────────────────────┤
│ SIMPLE MASTECTOMY (Total Mastectomy)                             │
│ Removal of breast + skin only, NO axillary dissection            │
│ Used for: DCIS, prophylactic mastectomy                          │
├──────────────────────────────────────────────────────────────────┤
│ BREAST CONSERVING SURGERY (BCS) = Lumpectomy/WLE                │
│ Removes tumor with 1-cm margin + SLNB/ALND                      │
│ MUST be followed by radiotherapy ⭐⭐⭐                           │
└──────────────────────────────────────────────────────────────────┘

🔴 KEY PYQ: In Patey's MRM → Pectoralis MINOR removed, Major PRESERVED. 🔴 KEY PYQ: BCS = equivalent survival to mastectomy (proven by NSABP B-06 trial) ⭐

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Nerve Injuries During Axillary Dissection ⭐⭐⭐ (NEET PG FAVORITE)

┌──────────────────┬────────────────────────────────────────────┐
│ Nerve            │ Injury Result                              │
├──────────────────┼────────────────────────────────────────────┤
│ Long thoracic N. │ "Winging of scapula" (serratus anterior)  │
│ (of Bell)        │ MOST COMMON NERVE INJURED ⭐               │
├──────────────────┼────────────────────────────────────────────┤
│ Thoracodorsal N. │ Paralysis of latissimus dorsi              │
│                  │ (weak shoulder adduction/extension)        │
├──────────────────┼────────────────────────────────────────────┤
│ Medial pectoral N│ Paralysis of pectoralis minor              │
├──────────────────┼────────────────────────────────────────────┤
│ Intercostobrachial│ Numbness/paraesthesia of medial arm ⭐    │
│ nerve (T2)       │ (routinely divided in axillary dissection) │
└──────────────────┴────────────────────────────────────────────┘

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Breast Conserving Surgery (BCS) ⭐⭐⭐

CRITERIA (Mnemonic: "SLIM"):
S = Single focus tumor
L = Lump ≤4 cm
I = Intact breast (adequate residual breast)
M = Margins clear (>1 mm)

Mnemonic: "PRIME":
P = Pregnancy (1st/2nd trimester)
R = Radiotherapy previously to same breast
I = Inflammatory carcinoma (T4d)
M = Multicentric disease
E = Extensive DCIS (involving >2 quadrants)

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Sentinel Lymph Node Biopsy (SLNB) ⭐⭐⭐

• Dual tracer: Blue dye (Patent blue/isosulfan blue) + radioactive isotope (Tc-99m labeled sulfur colloid) ⭐
• Hot (blue) node = sentinel node
• False negative rate: 5–10% (reduced if ≥3 nodes removed)

• Clinically node-negative (cN0) early breast cancer
• Before neoadjuvant chemotherapy

• Clinically node-positive (cN+)
• Inflammatory carcinoma

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Radiotherapy in Breast Cancer ⭐⭐

1. After BCS (mandatory) ⭐
2. After mastectomy if:
   • Tumor size ≥5 cm
   • Skin/chest wall involvement
   • Lymphovascular invasion (LVI)
   • Grade 3 with axillary node positivity
3. Locally advanced breast cancer (T3, T4, N1–N3)

⚠️ Axilla should NOT be irradiated after axillary dissection (increases lymphedema risk) ⭐

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Systemic Therapy ⭐⭐⭐

┌─────────────────────────────────────────────────────────┐
│ HORMONE THERAPY                                          │
│  • ER/PR+ premenopausal → TAMOXIFEN (SERM) 20mg × 5 yrs│
│  • ER/PR+ postmenopausal → AROMATASE INHIBITORS         │
│    (Anastrozole, Letrozole, Exemestane) × 5 yrs         │
├─────────────────────────────────────────────────────────┤
│ HER2-TARGETED THERAPY                                    │
│  • TRASTUZUMAB (Herceptin) = monoclonal Ab vs HER2 ⭐   │
│  • PERTUZUMAB = neoadjuvant for HER2+ tumors >5 mm      │
├─────────────────────────────────────────────────────────┤
│ CHEMOTHERAPY                                             │
│  • Anthracyclines (doxorubicin, epirubicin)             │
│  • Taxanes (paclitaxel, docetaxel)                      │
│  • Used for: TNBC, HER2+, node-positive, aggressive Ca  │
└─────────────────────────────────────────────────────────┘

• HER2/neu-positive tumors
• Triple-negative breast cancer (TNBC)
• Premenopausal women (<50 yrs)
• Axillary node metastasis
• To downstage for BCS (tumor >4–5 cm wanting BCS)

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📌 SECTION 7: SPECIAL SCENARIOS

Carcinoma of Male Breast ⭐⭐

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Breast Cancer in Pregnancy (Gestational Breast Cancer) ⭐

TRIMESTER-BASED MANAGEMENT:
1st/2nd Trimester → MASTECTOMY preferred (delay of RT unacceptable)
                  → SLNB with low-dose Tc-99m = SAFE for fetus ⭐
                  → NO chemotherapy in 1st trimester (organogenesis)
                  → Chemo in 2nd/3rd trimester (until 34 weeks) = SAFE
                     (Anthracyclines + Taxanes preferred)

AVOID:
  • 5-Fluorouracil in pregnancy ⭐
  • Anti-HER2 therapy (trastuzumab) during pregnancy ⭐
  • Endocrine therapy (tamoxifen) during pregnancy ⭐

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Locally Advanced Breast Cancer (LABC) ⭐

• Definition: Stage III (T3/T4 or N2/N3)
• Includes: Inflammatory carcinoma (T4d)
• Treatment: Neoadjuvant chemotherapy FIRST → reassess → surgery → adjuvant therapy

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📌 SECTION 8: HIGH-YIELD MNEMONICS SUMMARY

🔑 Master Mnemonic: "BREAST CANCER"

B = BRCA1 (chr 17), BRCA2 (chr 13)
R = Risk factors: FEMALE FAN
E = Early detection: triple assessment
A = All types: IDC most common (80%)
S = Staging: TNM AJCC 8th ed
T = Treatment: BCS = MRM (survival equal)

C = Contraindications to BCS: PRIME
A = Axillary nodes: 3 levels (lateral/behind/medial to pec minor)
N = Nerve injury: long thoracic → winging
C = Chemo: anthracyclines + taxanes
E = Endocrine: tamoxifen (pre) / AI (post)
R = Reconstruction: TRAM flap, DIEP flap, implants

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📌 SECTION 9: PREVIOUS YEAR QUESTIONS (PYQs) + PUTS

⭐ PYQs - NEET PG / INICET

✅ Duct papilloma (Intraductal papilloma) Ref: Bailey & Love 28e, p.944

✅ Pectoralis major (pectoralis minor is removed) Ref: Bailey & Love 28e

✅ Long thoracic nerve of Bell → serratus anterior paralysis → winging of scapula Ref: Bailey & Love 28e

✅ ≥95%

✅ Intercostobrachial nerve (T2)

✅ Chromosome 17q

✅ Chemotherapy only (no hormonal/HER2-targeted therapy applicable)

✅ Dermal lymphatic obstruction (NOT subcutaneous edema)

✅ T4d - any N, any M

✅ Wide local excision with 2-cm margin (high local recurrence risk without adequate margins)

✅ Patent blue (isosulfan blue) + Tc-99m labeled sulfur colloid

✅ Absent breast, absent pectoralis major sternal head, symbrachydactyly of ipsilateral hand

✅ Axilla (along milk line)

✅ Thrombophlebitis of superficial veins of breast - self-limiting

✅ Atypical Ductal Hyperplasia (ADH) when fulfills criteria → reclassified as DCIS

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🔮 PUTS (Probable Upcoming Topics - Examiner Prediction)

Know BI-RADS 3 (6-month follow-up, <2% malignancy) vs BI-RADS 4 (biopsy) vs BI-RADS 5 (≥95% malignancy)

BRCA1 = Chr 17q = Breast + Ovarian cancer BRCA2 = Chr 13q = Breast + Ovarian + Male breast + Pancreatic cancer

Triple negative → chemo only. HER2+ → trastuzumab. ER+ → tamoxifen/AI.

Malignant = >10 mitoses/10 HPF (most NEET PG variant)

FNAC = cytology (cannot distinguish invasive vs in situ) → Core biopsy = histology (gold standard)

Long thoracic N (winging) + Thoracodorsal N (lat. dorsi) + Intercostobrachial N (arm numbness)

Premenopausal = Tamoxifen; Postmenopausal = Aromatase Inhibitors Tamoxifen SE: Endometrial cancer, DVT, hot flashes

TNBC + HER2+ + Node positive + Premenopausal + To achieve BCS

Chemotherapy safe in 2nd/3rd trimester. Avoid 5-FU, anti-HER2, tamoxifen in pregnancy.

LCIS = bilateral marker, not precancer per se. DCIS = true precancer, unifocal, associated with calcification on mammography.

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📌 SECTION 10: QUICK-LOOK FLOWCHARTS

Flowchart 1: Approach to a Breast Lump

Breast Lump
    ↓
Age?
├── <30 yrs → USG first → FNAC/Core Bx (BI-RADS)
│       ↓
│   Fibroadenoma (most common) → observe if <30, excise if >30
└── >30 yrs → Mammogram first → USG + Core Bx
        ↓
    BI-RADS score
    ├── 1-2 → Routine follow-up
    ├── 3 → 6-month short interval follow-up
    ├── 4-5 → Core biopsy
    └── Malignant → Triple assessment → Staging → Surgery

Flowchart 2: Treatment of Operable Breast Cancer

Operable Breast Cancer
    ↓
Staging (clinical + imaging)
    ↓
Early (Stage I-II) ←──────── Locally Advanced (Stage III)
    ↓                                  ↓
BCS vs MRM                    NACT first → Reassess
    ↓                                  ↓
Both = equivalent survival    → MRM or BCS
    ↓
After BCS → Radiotherapy (MANDATORY)
After MRM → Radiotherapy if T3/T4/N+
    ↓
Systemic Therapy based on receptor status:
ER+ → Tamoxifen/AI
HER2+ → Trastuzumab
TNBC → Chemo alone

Flowchart 3: Nipple Discharge - Type-Based Approach

Nipple Discharge
    ↓
Milky, bilateral → Galactorrhea → Check prolactin
    ↓
Non-milky, spontaneous
    ├── Bloodstained, single duct, unilateral → DUCT PAPILLOMA ⭐
    ├── Green/brown, multiple ducts, bilateral → DUCT ECTASIA
    ├── Clear/serous, perimenopausal → FIBROCYSTIC CHANGE
    └── Associated nipple change (eczema) → PAGET'S DISEASE ⭐

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📌 SECTION 11: KEY IMAGES (Bailey & Love 28e)

Image Reference - Fibroadenoma USG (Bailey & Love Fig 58.14): Well-defined, oval, homogeneous hypoechoic mass with smooth margins on USG. BI-RADS 3.

Image Reference - Mammogram of DCIS (Bailey & Love): Clustered pleomorphic microcalcifications on mammogram = classic DCIS appearance ⭐

Image Reference - BI-RADS 5 on USG (Bailey & Love Fig 58.6): Solid, irregular-shaped mass, taller than wide, angular irregular margins.

Image Reference - Phyllodes tumor (Bailey & Love Fig 58.15): Large, bosselated, mobile tumor with unevenly lobulated surface.

Image Reference - Paget's disease: Eczematous change confined to nipple-areola (unlike eczema which spares nipple typically).

Image Reference - PET scan (Bailey & Love Fig 58.10): Hot spots in breast and axillary lymph nodes on PET = staging investigation for breast cancer.

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📌 FINAL REVISION SNAPSHOT (Read 5 minutes before exam)

★ MOST COMMON breast lump in 15–25 yr old = FIBROADENOMA
★ Most common breast cancer = IDC (NOS) - 80%
★ Most common cause of bloodstained nipple discharge = DUCT PAPILLOMA
★ WORST prognosis = Inflammatory carcinoma (T4d)
★ BEST prognosis = Tubular > Mucinous > Medullary > IDC
★ Patey's MRM = pec minor REMOVED, pec major PRESERVED
★ Halsted = both pec muscles removed (historical)
★ BCS = equal survival to mastectomy (NSABP B-06) + MANDATORY RT after
★ Most common nerve injury in axillary dissection = Long thoracic N (winging)
★ BRCA1 = Chr 17q | BRCA2 = Chr 13q
★ BI-RADS 5 = ≥95% malignancy, biopsy/surgery
★ DCIS = true precancer; LCIS = bilateral marker only
★ Inflammatory Ca = T4d = NACT first (NOT surgery first)
★ Paget's nipple = always underlying DCIS/Ca
★ Poland's = no pec major sternal + no breast + symbrachydactyly
★ Polymazia most common site = axilla (milk line)
★ Mondor's = thrombophlebitis superficial veins - resolves spontaneously
★ Phyllodes = WLE 2 cm margin; malignant = >10 mitoses/10 HPF
★ SLNB: Blue dye + Tc-99m sulfur colloid (dual tracer)
★ TNBC = chemo only; HER2+ = trastuzumab; ER+ = tamoxifen/AI
★ Tamoxifen = premenopausal; AI = postmenopausal
★ Chemo in pregnancy: 2nd/3rd trimester safe; AVOID 1st trimester, 5-FU, trastuzumab

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📋 What's Included:

🔴 Top 3 Examiner-Favorites (based on PYQ pattern):

1. BI-RADS classification (asked almost every exam)
2. Patey's MRM vs Halsted (pec major preserved in Patey's)
3. Long thoracic nerve injury → winging of scapula (most common nerve injured)