Oncological Surgery

Oncological Surgery Indian Medical PG Question 1: The commando operation is:

• A. Abdomino-perineal resection of the rectum for carcinoma
• B. Extended radical mastectomy
• C. Disarticulation of the hip for gas gangrene of the leg
• D. Excision of carcinoma of the tongue, the floor of the mouth, part of the jaw and lymph nodes en bloc (Correct Answer)

Oncological Surgery Explanation: ***Excision of carcinoma of the tongue, the floor of the mouth, part of the jaw and lymph nodes en bloc*** - The **Commando operation** specifically refers to a radical surgical procedure for advanced head and neck cancers, typically involving the **tongue**, **floor of the mouth**, and often requiring removal of a portion of the **mandible (jaw)** and a **neck dissection (lymph nodes en bloc)**. - This extensive, single-block resection aims to provide wide margins for large or invasive tumors in the oral cavity. *Abdomino-perineal resection of the rectum for carcinoma* - This procedure, known as **APR**, is a common surgery for low rectal cancers but is not referred to as a "Commando operation." - It involves the removal of the rectum and anus through both abdominal and perineal incisions, usually resulting in a permanent colostomy. *Extended radical mastectomy* - **Extended radical mastectomy** involves the removal of the breast, axillary lymph nodes, and potentially some chest wall muscles, but it is a procedure for breast cancer and not related to head and neck surgery, nor is it termed a "Commando operation." - This operation is a historically significant, though less common, approach to breast cancer management. *Disarticulation of the hip for gas gangrene of the leg* - **Hip disarticulation** is an amputation procedure at the hip joint for severe conditions like gas gangrene or extensive trauma and is not known as a "Commando operation." - This is an emergency or salvage procedure aimed at preventing further spread of infection or disease.

Oncological Surgery Indian Medical PG Question 2: Indication for sentinel node biopsy is:

• A. Palpable axillary lymph node
• B. Metastasis
• C. Mass > 5 cm
• D. Non-palpable axillary lymph node (Correct Answer)

Oncological Surgery Explanation: ***Non-palpable axillary lymph node*** - **Sentinel lymph node biopsy (SLNB)** is indicated when there is no clinical evidence of axillary lymph node involvement, meaning the nodes are **non-palpable**. - Its purpose is to identify micrometastases that would not be detectable by physical examination, staging the cancer more accurately and guiding further treatment. *Palpable axillary lymph node* - A **palpable axillary lymph node** suggests macroscopic nodal involvement, usually requiring a fine needle aspiration (FNA) or core needle biopsy for diagnosis. - If positive, these patients typically proceed directly to **axillary lymph node dissection (ALND)** rather than SLNB. *Mass > 5 cm* - The size of the primary tumor (e.g., > 5 cm) is a factor in staging but does not, in itself, preclude or indicate SLNB. - While larger tumors have a higher risk of nodal involvement, the decision for SLNB still hinges on the clinical status of the axilla (palpable vs. non-palpable nodes). *Metastasis* - If **distant metastasis** is confirmed, the focus shifts to palliative care and systemic treatment, making a regional staging procedure like SLNB less relevant or unnecessary. - SLNB is used for staging early-stage cancer to detect regional spread, not when widespread disease is already established.

Oncological Surgery Indian Medical PG Question 3: The most important prognostic factor in carcinoma of the breast is

• A. Size of tumour
• B. Skin involvement
• C. Axillary gland involvement (Correct Answer)
• D. Involvement of muscles

Oncological Surgery Explanation: ***Axillary gland involvement*** - The presence and number of involved **axillary lymph nodes** are the single most significant factor in determining prognosis and guiding adjuvant therapy in breast cancer. - Lymphatic spread to the axillary nodes indicates a higher likelihood of distant metastasis, directly impacting survival rates. *Size of tumour* - While **tumor size** is an important prognostic factor and is part of the TNM staging system (T for tumor size), it is less significant than nodal status. - A small tumor with nodal involvement has a worse prognosis than a larger tumor without nodal involvement. *Skin involvement* - **Skin involvement** (T4b in TNM staging) indicates locally advanced disease and is a poor prognostic sign, but it is not as universally important as axillary nodal status in predicting overall survival. - It often reflects aggressive local tumor growth rather than systemic spread as directly as nodal metastasis. *Involvement of muscles* - **Muscle involvement** (specifically the pectoralis major muscle, T4a in TNM staging) signifies locally advanced disease and is associated with a poor prognosis. - Similar to skin involvement, it suggests extensive local spread but is not as strong a predictor of distant metastasis and overall survival as axillary nodal involvement.

Oncological Surgery Indian Medical PG Question 4: What is the documented mortality rate for healthy liver donors undergoing donor hepatectomy?

• A. Mortality for donor is 0.6 to 0.8 %
• B. Mortality for donor is 0.5 %
• C. Mortality for donor is 0.2 to 0.4 % (Correct Answer)
• D. Mortality for donor is 1%

Oncological Surgery Explanation: ***Correct: Mortality for donor is 0.2 to 0.4%*** - Studies indicate that the **mortality rate** for healthy liver donors undergoing **donor hepatectomy** is very low, typically ranging from **0.2% to 0.4%**. - This rate reflects the extensive **pre-operative screening** and careful surgical techniques used to ensure donor safety. - Current data from major transplant centers worldwide support this range as the most accurate representation of donor risk. *Incorrect: Mortality for donor is 0.6 to 0.8%* - This range is **higher** than the generally accepted and documented mortality rates for healthy liver donors. - While complications can occur, fatal outcomes are rare, making this percentage an **overestimation** of actual risk. *Incorrect: Mortality for donor is 0.5%* - This mortality rate is also **higher** than the current reported rates for living liver donation in well-established centers. - Continuous advancements in surgical safety and donor selection have driven the mortality rate **below 0.5%** in most high-volume centers. *Incorrect: Mortality for donor is 1%* - A 1% mortality rate for healthy liver donors would be considered **unacceptably high** given the current standards of care. - This percentage severely **overestimates** the actual risks associated with living related liver donation and does not reflect modern surgical outcomes.

Oncological Surgery Indian Medical PG Question 5: Which statement is incorrect about the pathology of the bone tumor?

• A. Tumor has distinct margin
• B. Tumor arises from epiphyseal to metaphyseal region
• C. Eccentric lesion
• D. Chemotherapy is the treatment of choice for all bone tumors. (Correct Answer)

Oncological Surgery Explanation: ***Tumor has distinct margin*** - A **distinct margin** often indicates a benign tumor, while malignant tumors typically show **infiltrative margins**. - In bone tumors, particularly malignant ones, the lack of clear demarcation is a key pathological feature. *Chemotherapy is the treatment of choice* - While chemotherapy may be used for certain **malignant bone tumors**, it is not the first-line treatment for most bone tumors [1]. - The primary treatment is often **surgical excision**, especially for localized lesions [1]. *Tumor arise from epiphyseal to metaphyseal region* - While some tumors can originate in these areas, many actually arise from the **diaphyseal** region in bone tumors like osteosarcoma. - This option misrepresents the common locations where various tumors develop, as osteochondromas tend to develop near the epiphyses of limb bones [2]. *Eccentric lesion* - Many bone tumors do indeed present as **eccentric lesions**, especially benign ones like **osteochondromas**. - However, this feature does not apply universally, as some malignant tumors can also be **central or infiltrative** in nature. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 673-674. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 672-673.

Oncological Surgery Indian Medical PG Question 6: Which of the following statements are correct regarding iron deficiency? 1. More common in older age group 2. More common in females of reproductive age 3. Associated with heavy menstrual bleeding 4. Commonly caused by chronic blood loss Select the correct answer using the code given below.

• A. 1, 2 and 3
• B. 1, 2 and 4 (Correct Answer)
• C. 2, 3 and 4
• D. 1, 3 and 4

Oncological Surgery Explanation: ***1, 2 and 4*** * **Iron deficiency** is indeed more common in **older age groups**, often due to decreased dietary intake, malabsorption, or chronic diseases [1], [3]. * It is also frequently observed in **females of reproductive age**, primarily due to physiological iron loss through menstruation [2]. * **Chronic blood loss** from various sources, such as gastrointestinal bleeding [1] or heavy menstruation [2], is a very common cause of iron deficiency [3]. *1, 2 and 3* * While iron deficiency is common in older age groups and females of reproductive age, the statement that it is *only* associated with heavy menstrual bleeding isn't comprehensive enough, as chronic blood loss is a broader and more common cause [1]. * Though heavy menstrual bleeding is a significant cause of iron deficiency in women, this option omits chronic blood loss as a more general and equally important cause. *2, 3 and 4* * This option incorrectly implies that iron deficiency is *not* more common in older age groups, which is a known demographic at risk [3]. * While **heavy menstrual bleeding** and **chronic blood loss** are major causes, excluding the increased prevalence in older populations makes this option incomplete. *1, 3 and 4* * This option inaccurately suggests that iron deficiency is *not* more common in females of reproductive age, which is a key demographic for iron deficiency due to menstrual blood loss [2]. * It correctly identifies chronic blood loss and heavy menstrual bleeding as causes but misses a significant demographic for prevalence.

Oncological Surgery Indian Medical PG Question 7: Which of the following is a scoring system for severity of wound infection, and is particularly useful for surveillance and research ?

• A. Southampton grading system (Correct Answer)
• B. Apgar score
• C. Glasgow scoring system
• D. ASA classification

Oncological Surgery Explanation: ***Southampton grading system*** - The **Southampton grading system** is specifically designed for the **severity of wound infection**, offering a clear framework for classification based on clinical signs. - Its utility in **surveillance and research** stems from its structured and reproducible assessment, allowing for consistent data collection on wound healing and infection rates. *Apgar score* - The **Apgar score** is a rapid assessment of a **newborn's health** immediately after birth, evaluating heart rate, respiratory effort, muscle tone, reflex irritability, and color. - It is not used for assessing wound infection severity. *Glasgow scoring system* - The **Glasgow Coma Scale (GCS)** is used to assess the **level of consciousness** in a person following a brain injury, comprising eye opening, verbal, and motor responses. - It is not relevant to wound infection assessment. *ASA classification* - The **American Society of Anesthesiologists (ASA) Physical Status Classification System** is used to assess a patient's **overall health before surgery**, providing an indication of anesthetic risk. - It is not used for evaluating wound infection.

Oncological Surgery Indian Medical PG Question 8: Match List-I with List-II and select the correct answer using the code given below the Lists:

• A. A→4 B→1 C→2 D→3 (Correct Answer)
• B. A→3 B→2 C→1 D→4
• C. A→3 B→1 C→2 D→4
• D. A→4 B→2 C→1 D→3

Oncological Surgery Explanation: ***A→4 B→1 C→2 D→3*** - This option correctly matches each carcinoma with its characteristic feature. **Seminoma testis** is **highly radiosensitive** (A→4), making radiation therapy an effective treatment modality with excellent cure rates. **Carcinoma of the prostate** is **hormone-dependent** (B→1), relying on androgens for growth, which is why androgen deprivation therapy is a key treatment [1]. **Basal cell carcinoma** is a locally invasive tumor that **does not significantly spread by lymphatics** (C→2), which contributes to its excellent prognosis despite being the most common skin cancer [2, 4]. **Malignant melanoma** has a prognosis that depends on **Breslow thickness** (D→3), which measures the depth of invasion and is the most important prognostic factor. *A→4 B→2 C→1 D→3* - This option incorrectly states that **carcinoma of the prostate does not spread by lymphatics** (B→2) and that **basal cell carcinoma is hormone-dependent** (C→1). Prostate cancer commonly metastasizes to pelvic lymph nodes via lymphatic spread [1], and BCC is not influenced by hormones. *A→3 B→2 C→1 D→4* - This option incorrectly matches **seminoma testis** with prognosis depending on thickness (A→3) and **malignant melanoma** with being highly radiosensitive (D→4). Seminoma is radiosensitive (not melanoma), and melanoma's prognosis depends on Breslow thickness (not seminoma). *A→3 B→1 C→2 D→4* - This option correctly identifies that **prostate cancer is hormone-dependent** (B→1) and **basal cell carcinoma has limited lymphatic spread** (C→2), but incorrectly associates **seminoma testis** with prognosis depending on thickness (A→3) and **malignant melanoma** with being highly radiosensitive (D→4). These last two matches are reversed. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lower Urinary Tract and Male Genital System, pp. 993-994. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Skin, pp. 1157-1160. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Disorders Involving Inflammatory And Haemopoietic Cells, pp. 643-644.

Oncological Surgery Indian Medical PG Question 9: A patient has carcinoid tumour of appendix of size more than 2.5 cm. The management of choice is:

• A. Appendectomy
• B. Right hemicolectomy (Correct Answer)
• C. Appendectomy and 24 hour urinary HIAA
• D. Appendectomy and abdominal CT scan

Oncological Surgery Explanation: **Right hemicolectomy** - For **carcinoid tumors of the appendix** larger than **2.0 cm (or 2.5 cm by some guidelines)**, a right hemicolectomy is the recommended management due to the increased risk of **lymph node metastasis** and distant spread. - This procedure ensures adequate tumor clearance and regional lymphadenectomy, which is crucial for staging and preventing recurrence in larger tumors. *Appendectomy* - An appendectomy alone is usually sufficient for **small carcinoid tumors (<1-2 cm)** that are **confined to the appendix**, without evidence of mesoappendiceal invasion or lymph node involvement. - For tumors exceeding 2.5 cm, the risk of metastasis is considerably higher, making appendectomy alone inadequate for complete oncological control. *Appendectomy and 24 hour urinary HIAA* - While a **24-hour urinary 5-hydroxyindoleacetic acid (5-HIAA)** measurement is useful for diagnosing and monitoring **carcinoid syndrome**, it does not influence the primary surgical management decision for an appendiceal tumor of this size. - The surgical approach is dictated by **tumor size** and the risk of metastasis, not by biochemical markers alone, unless the patient presents with symptoms of carcinoid syndrome. *Appendectomy and abdominal CT scan* - An abdominal **CT scan** is valuable for **staging** and detecting distant metastases or nodal involvement, especially in larger tumors, but it is a diagnostic tool, not a treatment itself. - While a CT scan would likely be performed as part of the work-up, an appendectomy alone is insufficient as the definitive surgical management for a tumor of this size without addressing the high risk of regional spread.

Oncological Surgery Indian Medical PG Question 10: The best treatment of tension pneumothorax is -

• A. Underwater drainage
• B. Immediate letting out of air (Correct Answer)
• C. Rib resection
• D. Wait and watch

Oncological Surgery Explanation: ***Immediate letting out of air*** - The primary goal in a tension pneumothorax is to **relieve the life-threatening intrathoracic pressure** caused by trapped air. - This is achieved urgently by either **needle decompression** (inserting a large-bore needle into the pleural space) or a **finger thoracostomy**, allowing air to escape before a formal chest tube can be inserted. *Underwater drainage* - This refers to the standard procedure for a chest tube insertion to remove air or fluid from the pleural space, but it's a **definitive treatment** rather than the immediate life-saving maneuver for tension pneumothorax. - While a chest tube is ultimately necessary, **delaying decompression** to set up a full underwater drainage system can be fatal in a tension pneumothorax. *Rib resection* - **Rib resection** is a major surgical procedure that is not indicated for the acute management of a tension pneumothorax. - This procedure might be considered in some complex, chronic chest wall deformities or tumors, but it's entirely **irrelevant for emergent pneumothorax treatment**. *Wait and watch* - **Tension pneumothorax** is a medical emergency that can rapidly lead to cardiovascular collapse and death due to severe compromise of heart and lung function. - A "wait and watch" approach is **contraindicated** and would be lethal, as the condition progressively worsens without immediate intervention.

Oncological Surgery Flashcard 1 of 9

Question: 50% of patients with _____ metastases can be sucessfully treated with resection of the hepatoblastoma

Answer: pulmonary

Oncological Surgery Flashcard 2 of 9

Question: The D1 gastrectomy involves the removal of lymph node stations _____

Answer: 1-6

Oncological Surgery Flashcard 3 of 9

Question: The D1 gastrectomy involves the removal of lymph node stations _____

Answer: 1-6

Oncological Surgery Flashcard 4 of 9

Question: Gastric carcinoma may spread and involve the _____ node, also known as Virchow's node

Answer: left supraclavicular

Oncological Surgery Flashcard 5 of 9

Question: _____ cell carcinomas of the lung usually do not respond well to chemotherapy and are thus treated upfront with surgical resection

Answer: Non-small

Oncological Surgery Flashcard 6 of 9

Question: _____ was the inventor of radiosurgery

Answer: Lars Leksell

Oncological Surgery Flashcard 7 of 9

Question: What is the first line treatment of periocular BCC?_____

Answer: Mohs micrographic surgery or wide surgical excision with frozen section margin control

Oncological Surgery Flashcard 8 of 9

Question: A desmoid tumor generally arises from musculoaponeurotic structures usually _____ the umbilicus

Answer: below

Oncological Surgery Flashcard 9 of 9

Question: Gastric cancer may metastasize to the _____ lymph node, also called as irish node

Answer: left axillary