NEET-PG 2015 Practice Questions

Q: All of the following may lead to gall bladder carcinoma except which of the following?

Echinococcus Granulosus Infection. ***Echinococcus Granulosus Infection*** - Echinococcus granulosus is primarily associated with **hydatid cyst formation**, not directly linked to gallbladder carcinoma. - This infection typically affects the **liver** rather than inducing malignant transformation in the gallbladder. *Typhoid carriers* - Chronic infection with **Salmonella typhi** in carriers can cause **gallbladder inflammation** and is a risk factor for gallbladder cancer. - Typhoid carriers retain the bacteria in the gallbladder, leading to chronic irritation and potentially malignant changes. *Gall Bladder Polyps* - Certain types of gallbladder polyps, especially those larger than **1 cm**, have a significant risk of undergoing malignant transformation. - They are associated with **chronic inflammation** and may progress to cancer if not monitored. *Exposure to carcinogens like nitrosamine* - Nitrosamines are known **carcinogens** that can induce protein modifications leading to DNA damage, contributing to gallbladder cancer. - Long-term exposure to such chemicals can result in **cellular mutations** in the gallbladder epithelial lining.

Q: A 65 year old male presents with CA prostate. The tumour is limited to the capsule and it is palpable on PR examination. The patient is diagnosed as stage T2a. What is the most appropriate treatment option?

Surgical removal of the prostate (Radical prostatectomy). ***Surgical removal of the prostate (Radical prostatectomy)*** - **Radical prostatectomy** is the **definitive treatment of choice** for **localized prostate cancer (T2a)** in patients with **good life expectancy (>10 years)**. - For a **65-year-old patient** with tumor confined to the prostate, **surgical removal offers excellent disease control** and potential cure. - This is the **preferred option** when the patient is **medically fit for surgery** and has adequate life expectancy. *External beam radiation therapy* - **External beam radiation therapy (EBRT)** is also an effective treatment for **localized T2a prostate cancer** with comparable long-term survival outcomes. - However, **radical prostatectomy is generally preferred** in younger, healthier patients as it: - Provides definitive pathological staging - Allows for immediate assessment of surgical margins - Preserves radiation as a salvage option if needed - EBRT is better suited for patients who are **not surgical candidates** due to comorbidities or patient preference. *Active surveillance* - **Active surveillance** is appropriate for **very low-risk prostate cancer** (T1c, PSA <10, Gleason ≤6). - For **T2a disease** (palpable tumor), the risk of progression is significant, making active surveillance **not the most appropriate first-line option**. - Would be considered only in patients with limited life expectancy or significant comorbidities. *Androgen deprivation therapy (ADT)* - **ADT** is used for **advanced, locally advanced, or metastatic prostate cancer** to reduce testosterone and slow tumor growth. - It is **not curative** and not appropriate as **monotherapy for localized T2a disease**. - May be used as adjuvant therapy with radiation in higher-risk cases, but not as primary treatment alone.

Q: What is the appropriate management for a patient with a carcinoid tumor of the appendix larger than 2 cm?

Right hemicolectomy. ***Right hemicolectomy*** - Carcinoid tumors of the appendix larger than **2 cm** are considered at high risk for **lymph node metastasis** and recurrence. - A **right hemicolectomy** provides adequate margins and allows for lymph node dissection, which is essential for staging and definitive treatment in such cases. *Appendicectomy* - An **appendicectomy** alone is typically sufficient for carcinoid tumors of the appendix that are **less than 1 cm** and localized to the tip. - For larger tumors, appendicectomy carries an unacceptably high risk of **incomplete resection** and metastatic disease. *Appendicectomy + abdominal CT scan* - While an **abdominal CT scan** is useful for assessing local spread and distant metastases, it does not address the need for a more extensive surgical resection for a **large primary tumor**. - A simple **appendicectomy** in this scenario would be inadequate as definitive treatment. *Appendicectomy + 24 hrs urinary HIAA* - **24-hour urinary 5-hydroxyindoleacetic acid (5-HIAA)** is a biomarker used to detect and monitor **carcinoid syndrome**, which occurs in a minority of patients with carcinoid tumors. - Measuring 5-HIAA is primarily for assessing systemic symptoms rather than determining the primary surgical management of the **tumor size**.

Q: A 25 year old male is receiving conservative management for an appendicular mass since 3 days now presents with a rising pulse rate, tachycardia and fever. The mode of management must be -

Proceed to laparotomy and appendicectomy. ***Proceed to laparotomy and appendicectomy*** - A **rising pulse rate, tachycardia, and fever** indicate **worsening sepsis** or **perforation** of the appendicular mass, necessitating urgent surgical intervention. - Continuing conservative management in the face of these signs carries a high risk of **morbidity and mortality** from peritonitis or widespread sepsis. *Continue Ochsner Sherren regimen with close monitoring* - The Ochsner Sherren regimen is a **conservative approach** for a stable appendicular mass, which is no longer the case with signs of deterioration. - **Clinical worsening** (tachycardia, rising fever, increased pulse) signifies failure of conservative management and requires a shift to surgical intervention. *Continue conservative management* - Continuing conservative management despite **signs of deterioration** (rising pulse, tachycardia, fever) would lead to further progression of the disease and potential life-threatening complications. - These symptoms suggest that the infection is **not contained** and is likely spreading, indicating the need for immediate surgical treatment. *Intravenous antibiotics* - While intravenous antibiotics are part of the initial conservative management, they are **insufficient** alone for an appendicular mass showing signs of deterioration. - The worsening clinical picture suggests a **failed antibiotic response** or a more severe underlying issue (e.g., abscess rupture) that requires surgical drainage or removal.

Q: Under what guidelines is treatment started for a patient presenting with appendicular mass on a CT scan?

Ochsner Sherren Regimen. ***Ochsner Sherren Regimen*** - The **Ochsner Sherren regimen** is a conservative management approach specifically used for patients presenting with an **appendicular mass** (a palpable mass formed by the inflamed appendix, omentum, and small bowel loops). - This regimen involves **nil by mouth**, **intravenous fluids**, **antibiotics**, and **analgesia**, with close observation to allow the inflammation to subside before potential interval appendectomy. *Conservative management and discharge* - While the Ochsner Sherren regimen is a form of conservative management, simply stating "conservative management and discharge" is incomplete and potentially dangerous for a patient with an **appendicular mass**. - **Discharge** is not appropriate without a period of observation and specific medical interventions like antibiotics, as there's a risk of abscess formation or perforation. *Kocher's Regimen* - **Kocher's regimen** is not a recognized treatment protocol for an appendicular mass. - The term "Kocher" is more commonly associated with a **surgical incision** (Kocher incision for cholecystectomy) or a **maneuver** (Kocher maneuver for duodenal mobilization). *Immediate Laparotomy* - **Immediate laparotomy** is generally contraindicated in the presence of a well-formed **appendicular mass**. - Operating on a friable, inflamed mass can disrupt the natural containment, leading to widespread peritonitis and increased morbidity. The Ochsner Sherren regimen aims to cool down the inflammation first.

Q: Treatment of choice for mucinous carcinoma of the gall bladder in the early stage is -

Simple cholecystectomy. ***Simple cholecystectomy*** - For **early-stage (T1a) mucinous carcinoma of the gallbladder**, **simple cholecystectomy** is the treatment of choice - T1a disease (tumor confined to mucosa) has an excellent prognosis with **5-year survival >90%** after simple cholecystectomy alone - Extended resection offers **no survival benefit** for T1a disease and increases surgical morbidity - If incidentally discovered post-cholecystectomy with negative margins, no further surgery is needed *Extended cholecystectomy* - **Extended cholecystectomy** (cholecystectomy + liver segments IVb/V resection + portal lymphadenectomy) is indicated for **T2 or higher stage** disease (tumor invading muscularis propria or beyond) - This is **not** the treatment for early-stage disease as it increases morbidity without survival benefit - Reserved for more advanced tumors with deeper invasion *Cholecystectomy with wedge resection of liver* - This describes a component of extended cholecystectomy and is similarly indicated for **T2+ disease**, not early-stage - Wedge resection aims to achieve negative margins when tumor extends beyond the gallbladder wall - Not appropriate for early-stage mucinous carcinoma confined to mucosa *Chemotherapy only* - **Chemotherapy alone** is not curative for early-stage gallbladder carcinoma - Surgery remains the primary curative treatment for resectable disease - Chemotherapy is reserved for advanced, metastatic, or unresectable disease as palliative treatment

Q: What is the primary indication for the Nigro Regimen?

Anal Carcinoma. ***Anal Carcinoma*** - The **Nigro Regimen** is a standard treatment protocol involving concurrent **chemotherapy** (5-fluorouracil and mitomycin C) and **radiation therapy** for anal carcinoma. - Its primary goal is to achieve **organ preservation** and avoid the need for abdominoperineal resection, which would result in a permanent colostomy. *Rectal Carcinoma* - Treatment for **rectal carcinoma** often involves surgery (e.g., low anterior resection), radiation, and chemotherapy, but the specific **Nigro Regimen** is not the primary protocol. - While some chemotherapy drugs might overlap, the combined regimen and indications are distinct. *Sigmoid Colon Carcinoma* - **Sigmoid colon carcinoma** is typically treated primarily with **surgical resection**, often followed by adjuvant chemotherapy based on staging. - The Nigro Regimen is specifically designed for tumors in the **anal canal**, not the more proximal colon. *Duodenal Carcinoma* - **Duodenal carcinoma** is a rare gastrointestinal cancer usually managed with surgical resection, such as a **Whipple procedure**, and sometimes adjuvant chemotherapy. - This type of cancer is anatomically and etiologically distinct from anal carcinoma, making the Nigro Regimen irrelevant.

Q: A 60-year-old male presented with jaundice, pale stools, dark urine, and a mass in the epigastric region. Which of the following diagnoses is least likely to be the cause of these symptoms?

Chronic Cholecystitis. ***Chronic Cholecystitis*** - While chronic cholecystitis can cause epigastric pain, it rarely presents with **jaundice**, **pale stools**, and **dark urine** because it typically does not obstruct the common bile duct. - The presence of a palpable **epigastric mass** is also not a common feature of chronic cholecystitis. *Biliary Cancer* - **Biliary cancer**, particularly choledochal cancer, can cause **obstructive jaundice**, leading to **pale stools** (lack of bilirubin) and **dark urine** (conjugated bilirubin in urine). - A mass in the **epigastric region** could represent an enlarged gallbladder due to distal obstruction (Courvoisier's sign) or the tumor itself. *Periampullary Cancer* - **Periampullary cancers**, which arise near the ampulla of Vater, characteristically cause **obstructive jaundice**, presenting with **pale stools** and **dark urine**. - A mass in the **epigastric region** might be the tumor or a dilated gallbladder due to bile duct obstruction. *Pancreatic cancer* - **Pancreatic head cancer** frequently obstructs the common bile duct, resulting in **jaundice**, **pale stools**, and **dark urine**. - An **epigastric mass** can be the palpable tumor itself or an enlarged, distended gallbladder.

Q: Which of the following statements about Gallbladder carcinoma is true?

Gallstones may be a predisposing factor. ***Gallstones may be a predisposing factor*** - The chronic inflammation and irritation caused by **gallstones (cholelithiasis)** are considered major risk factors for the development of gallbladder carcinoma. - Approximately 70-90% of patients with gallbladder carcinoma also have **cholelithiasis**, suggesting a strong association. *Carries a good prognosis* - Gallbladder carcinoma generally has a **poor prognosis** due to its asymptomatic nature in early stages and aggressive local invasion. - Most cases are diagnosed at an advanced stage, leading to a **low 5-year survival rate**. *Commonly squamous cell carcinoma* - The vast majority of gallbladder carcinomas are **adenocarcinomas** (around 90%), arising from the glandular epithelium. - **Squamous cell carcinoma** is rare, accounting for only a small percentage of cases. *Jaundice is rare* - **Jaundice** is a common symptom in advanced gallbladder carcinoma, often indicating obstruction of the biliary ducts. - It arises when the tumor invades or compresses the **common bile duct**, leading to bilirubin backup.

Question 1

All of the following may lead to gall bladder carcinoma except which of the following?

Accepted Answer

Echinococcus Granulosus Infection

Answer

Gall Bladder Polyps

Answer

Typhoid carriers

Answer

Exposure to carcinogens like nitrosamine

Question 2

A 65 year old male presents with CA prostate. The tumour is limited to the capsule and it is palpable on PR examination. The patient is diagnosed as stage T2a. What is the most appropriate treatment option?

Accepted Answer

Surgical removal of the prostate (Radical prostatectomy)

Answer

External beam radiation therapy

Answer

Androgen deprivation therapy (ADT)

Answer

Active surveillance

Question 3

What is the appropriate management for a patient with a carcinoid tumor of the appendix larger than 2 cm?

Accepted Answer

Right hemicolectomy

Answer

Appendicectomy

Answer

Appendicectomy + abdominal CT scan

Answer

Appendicectomy + 24 hrs urinary HIAA

Question 4

A 25 year old male is receiving conservative management for an appendicular mass since 3 days now presents with a rising pulse rate, tachycardia and fever. The mode of management must be -

Accepted Answer

Proceed to laparotomy and appendicectomy

Answer

Intravenous antibiotics

Answer

Continue Ochsner Sherren regimen with close monitoring

Answer

Continue conservative management

Question 5

Under what guidelines is treatment started for a patient presenting with appendicular mass on a CT scan?

Accepted Answer

Ochsner Sherren Regimen

Answer

Conservative management and discharge

Answer

Kocher's Regimen

Answer

Immediate Laparotomy

Question 6

Treatment of choice for mucinous carcinoma of the gall bladder in the early stage is -

Accepted Answer

Simple cholecystectomy

Answer

Extended cholecystectomy

Answer

Cholecystectomy with wedge resection of liver

Answer

Chemotherapy only

Question 7

What is the primary indication for the Nigro Regimen?

Accepted Answer

Anal Carcinoma

Answer

Rectal Carcinoma

Answer

Sigmoid Colon Carcinoma

Answer

Duodenal Carcinoma

Question 8

A 35 year old male came with jaundice, palpable mass in the right hypochondrium not associated with pain. The probable diagnosis is -

Accepted Answer

Pancreatic head carcinoma

Answer

Hepatocellular carcinoma

Answer

Choledochal cyst

Answer

Acute cholecystitis

Question 9

A 60-year-old male presented with jaundice, pale stools, dark urine, and a mass in the epigastric region. Which of the following diagnoses is least likely to be the cause of these symptoms?

Accepted Answer

Chronic Cholecystitis

Answer

Biliary Cancer

Answer

Periampullary Cancer

Answer

Pancreatic Cancer

Question 10

Which of the following statements about Gallbladder carcinoma is true?

Accepted Answer

Gallstones may be a predisposing factor

Answer

Carries a good prognosis

Answer

Commonly squamous cell carcinoma

Answer

Jaundice is rare

NEET-PG 2015

Internal Medicine

Surgery