Example FRCS Plast questions

Breast: FRCS(Plast) example questions

Our breast coverage spans the whole JCST oncoplastic curriculum, from triple assessment and axillary staging through to implant based and autologous reconstruction and the management of their complications, with illustrated questions and referenced explanations throughout.

Breast assessment

Breast cancer

Benign breast disease

Implant based reconstruction

Autologous reconstruction

Back to Overview

Question 1

Breast

A 71-year-old woman is referred to the regional sarcoma MDT with multiple violaceous papules, nodules and ill-defined coalescent plaques on her right arm and forearm, evolving over the past 4 months. She has had longstanding non-pitting oedema of the right upper limb since undergoing a right radical mastectomy with axillary clearance and adjuvant radiotherapy for breast carcinoma 14 years previously. There are no lesions on the chest wall or remaining breast skin. She is otherwise well, takes no immunosuppressive medication, and has no constitutional symptoms. Incisional biopsy has been performed.

What is the most likely diagnosis?

AI-generated image

CORRECT ANSWER

The most likely diagnosis is Stewart–Treves syndrome (STS) - cutaneous angiosarcoma arising in a chronically lymphoedematous limb. Long-standing post-mastectomy arm lymphoedema with ~14-year latency, multifocal violaceous lesions confined to the affected arm, and progressive coalescence over months is classical.

Each distractor has a discriminating feature:

Radiation-induced angiosarcoma (B) is the closest histological mimic - both are MYC-amplified angiosarcomas, but anatomically arises within the irradiated field (chest wall or residual breast skin), not in the lymphoedematous arm. Mean latency is also shorter (~5–10 years).
Kaposi sarcoma (A) produces violaceous lesions but is HHV-8-driven, occurring in immunosuppressed/HIV-positive patients - not chronic post-mastectomy lymphoedema.
Atypical vascular lesion (C) is a benign post-radiation reactive lesion: typically small, static, MYC-negative, and lacks the progressive, multifocal, coalescent behaviour described.
Cutaneous breast metastases (E) typically present on the chest wall, not as multifocal violaceous lesions in the lymphoedematous arm.

Diagnosis is confirmed by incisional biopsy: CD31, CD34 and ERG positivity with MYC amplification on FISH.

Management is via the sarcoma MDT - wide local excision with clear margins, with amputation reserved for extensive proximal disease. Prognosis is poor: median survival ~19–31 months, 5-year survival ~10–15%.

REFERENCES

Sharma A, Schwartz RA. Stewart-Treves syndrome: pathogenesis and management. Journal of the American Academy of Dermatology. 2012;67(6):1342-8.Hao K, Sun Y, Zhu Y, Xin J, Zhang L, Li B, et al. A retrospective analysis of Stewart-Treves syndrome in the context of chronic lymphedema. Anais brasileiros de dermatologia. 2023;98(3):287-295.Chopra S, Ors F, Bergin D. MRI of angiosarcoma associated with chronic lymphoedema: Stewart Treves syndrome. The British journal of radiology. 2007;80(960):e310-3.

Question 2

Breast

A 34-year-old woman is seen in clinic 12 days after bilateral Wise-pattern breast reduction. She has a 1.5 cm dehiscence at the left T-junction with a clean granulating base and no undermining. She is afebrile and systemically well, with no surrounding cellulitis, purulence or breast tenderness. She has no implants. A wound swab taken at her previous dressing clinic has grown MRSA sensitive to doxycycline, rifampicin and vancomycin. She is a nursery nurse, keen to return to work.

Which is the most appropriate management?

AI-generated image

CORRECT ANSWER

There are no clinical signs of infection - no cellulitis, no purulence, systemically well; therefore MRSA on the swab represents colonisation of an open wound, not a surgical site infection.

NICE is clear that microbiology results alone should not drive antibiotic prescribing; treat the patient, not the swab. Systemic anti-MRSA agents (doxycycline, teicoplanin) are reserved for clinical infection.

T-junction breakdown is the commonest wound complication of Wise-pattern reduction, arising from tension and relative ischaemia where three flaps meet. These are usually minor problems that heal by secondary intention with simple dressings and rarely need surgical revision; early re-excision and closure recreates the same tension and typically breaks down again.

Decolonisation remains worthwhile. Standard UK regimens are nasal mupirocin 2% three times daily for 5 days plus a daily chlorhexidine 4% (or octenidine) body wash, arranged with infection prevention and the GP. The CLEAR trial showed post-discharge decolonisation reduced subsequent MRSA infection by around 30%.

Mupirocin should not be applied to the wound bed - that drives mupirocin resistance and is not a decolonisation regimen. Document MRSA status for any future implant-based or revision surgery, and advise on occupational health review before returning to work.

REFERENCES

Huang SS, Singh R, McKinnell JA, Park S, Gombosev A, Eells SJ, et al. Decolonization to Reduce Postdischarge Infection Risk among MRSA Carriers. The New England journal of medicine. 2019;380(7):638-650.Hall JD, Schwartz E. Solving "T" Junction Wound Breakdown With a Single Tension-reducing Device. Plastic and reconstructive surgery. Global open. 2025;13(8):e6882.MRSA decolonisation regime for adults, children and neonates | Right Decisions [Internet]. rightdecisions.scot.nhs.uk.

frcs(plast) part 1 question bank

Better questions.
Better preparation.

Give yourself the months that matter. Start revising with a question bank built for the exam.

Start revising

Breast: FRCS(Plast) example questions

Better questions. Better preparation.

Better questions.
Better preparation.