Merkel Cell Carcinoma — MCQs
Nivolumab is used as checkpoint inhibitor in
Which of the following stages of Breast Cancer corresponds to the following features: a breast mass of 6 x 3 cm, ipsilateral supraclavicular lymph node involvement, and distant metastasis that cannot be assessed?
A patient's skin biopsy shows a box-shaped or square-shaped pattern of inflammatory infiltrate, as shown in the image. What is the most likely diagnosis?
Which HPV oncoprotein initiates cervical carcinogenesis primarily by inactivating the p53 tumor suppressor?
Carcinoma tongue less than 2 cm is treated by -
Classification system of bone tumors is -
For the treatment of basal cell carcinoma, what is the popular surgery that is carried out?
Rodent ulcer is
A male patient presented with a 0.3 cm nodule on the left nasolabial fold. A pathological examination revealed a basaloid appearance with peripheral palisading. What is the most likely diagnosis?
A 70-year-old male presents with a red, scaling plaque on the lower lip that has not healed over the past few months. What is the most likely diagnosis?
Merkel Cell Carcinoma Indian Medical PG Practice Questions and MCQs
Question 1: Nivolumab is used as checkpoint inhibitor in
- A. Hodgkin's lymphoma (Correct Answer)
- B. Medulloblastoma
- C. Retinoblastoma
- D. Pleuropulmonary blastoma
Explanation: ***Hodgkin's lymphoma*** - **Nivolumab** is an **immune checkpoint inhibitor** targeting **PD-1**. It has shown significant efficacy in treating relapsed or refractory Hodgkin's lymphoma, particularly in patients who have failed prior therapies. - Hodgkin's lymphoma cells, specifically **Reed-Sternberg cells**, often overexpress PD-L1, which allows them to evade the immune system, making PD-1 blockade a rational therapeutic strategy. *Medulloblastoma* - **Medulloblastoma** is a common malignant brain tumor in children, and while immunotherapy research is ongoing, Nivolumab is **not a standard treatment** for this condition. - Treatment typically involves **surgery, radiation, and chemotherapy**, with targeted therapies under investigation. *Retinoblastoma* - **Retinoblastoma** is a malignant tumor of the retina, most commonly affecting young children. Treatment usually involves **chemotherapy, laser therapy, cryotherapy, or enucleation**. - There is **no established role for Nivolumab** or PD-1 inhibitors in the routine management of retinoblastoma. *Pleuropulmonary blastoma* - **Pleuropulmonary blastoma** is a rare, malignant lung tumor of childhood. Treatment primarily consists of **surgery and chemotherapy**. - While experimental, there is **no current evidence** supporting the use of Nivolumab as a standard treatment for pleuropulmonary blastoma.
Question 2: Which of the following stages of Breast Cancer corresponds to the following features: a breast mass of 6 x 3 cm, ipsilateral supraclavicular lymph node involvement, and distant metastasis that cannot be assessed?
- A. T4 N3 MX
- B. T4 N1 M1
- C. T4 N0 M0
- D. T3 N3c MX (Correct Answer)
Explanation: ***T3 N3c MX*** - A **breast mass of 6 x 3 cm** indicates a T3 tumor (tumor size > 5 cm). - **Ipsilateral supraclavicular lymph node involvement** is classified as N3c disease. **Distant metastasis that cannot be assessed** is denoted by MX. *T4 N3 MX* - A **T4 classification** is reserved for tumors with direct extension to the chest wall or skin, or inflammatory breast cancer, which is not mentioned here. - While N3c and MX are correct for the nodal and metastatic status, the T stage is inaccurate based on the provided tumor size. *T4 N1 M1* - A **T4 classification** is incorrect as the mass size alone (6 x 3 cm) does not meet T4 criteria. - **N1** denotes involvement of 1-3 axillary lymph nodes, which is less extensive than supraclavicular involvement (N3c). **M1** indicates confirmed distant metastasis, but the question states it "cannot be assessed" (MX). *T4 N0 M0* - **T4** is incorrect, as this stage is for direct chest wall/skin involvement or inflammatory breast cancer. - **N0** signifies no regional lymph node metastasis, contradicting the presence of supraclavicular lymph node involvement. **M0** indicates no distant metastasis, whereas the question specifies it cannot be assessed (MX).
Question 3: A patient's skin biopsy shows a box-shaped or square-shaped pattern of inflammatory infiltrate, as shown in the image. What is the most likely diagnosis?
- A. Lichen planus (Correct Answer)
- B. Lichen amyloidosis
- C. Morphea
- D. Lichen nitidus
Explanation: ***Lichen planus*** - The image shows a characteristic **"box-shaped" or "square-shaped" infiltrate** of lymphocytes at the dermal-epidermal junction, obscuring the basal layer. - Other features consistent with lichen planus include **hypergranulosis**, **sawtooth rete ridges**, and **Civatte bodies** (apoptotic keratinocytes) in the basal layer. *Lichen amyloidosis* - This condition is characterized by deposition of **amyloid material** in the papillary dermis, often associated with keratinocyte necrosis. - While it can present with pruritic papules similar to lichen planus, the histology specifically shows **amyloid deposits**, not the typical basal cell damage or band-like infiltrate seen in the image. *Morphea* - Morphea is a form of localized scleroderma, characterized by **thickening of collagen bundles** in the dermis and subcutaneous tissue, leading to hardened skin plaques. - Histologically, it involves **sclerosis** and homogenization of collagen, with a sparse inflammatory infiltrate, which is distinct from the dense band-like infiltrate and epidermal changes shown. *Lichen nitidus* - Lichen nitidus is characterized by **small, discrete granulomas** within the papillary dermis (the "ball-and-claw" appearance), with epithelial extensions embracing the inflammatory infiltrate. - It involves a more **localized inflammatory process** and distinct granulomatous appearance, rather than the broad, band-like infiltrate seen across the dermal-epidermal junction in this image.
Question 4: Which HPV oncoprotein initiates cervical carcinogenesis primarily by inactivating the p53 tumor suppressor?
- A. E3
- B. E5
- C. E6 (Correct Answer)
- D. E7
Explanation: ***E6*** - **E6 oncoprotein is the HPV protein that specifically targets and degrades p53** through ubiquitin-mediated proteolysis [2]. - **p53 degradation** prevents apoptosis and allows cells with damaged DNA to survive and proliferate, a critical early step in malignant transformation [3]. - E6 works synergistically with E7 in cervical carcinogenesis, but **E6 is uniquely responsible for p53 inactivation** [1]. *E3* - HPV does not have a clinically significant E3 oncoprotein in the context of cervical cancer pathogenesis. - This is not a major viral oncoprotein involved in malignant transformation. *E5* - **E5 oncoprotein** plays a minor role in early infection by enhancing growth factor receptor signaling. - It does **not target p53** and is often lost during viral integration, making it less critical for malignant progression. *E7* - **E7 oncoprotein targets the retinoblastoma protein (Rb)**, not p53 [1]. - Rb inactivation releases E2F transcription factors, driving cell cycle progression [1]. - E7 and E6 work together, but **E7's specific target is Rb, not p53** [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, pp. 334-335. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1006-1007. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, pp. 303-304.
Question 5: Carcinoma tongue less than 2 cm is treated by -
- A. Excision and Radiotherapy
- B. Excision (Correct Answer)
- C. Chemotherapy
- D. Radiotherapy
Explanation: ***Excision*** - **Early-stage oral tongue carcinoma** (T1, less than 2 cm) is primarily treated with **surgical excision** due to its high cure rates. - The goal is complete removal with **clear margins**, which is often curative for small lesions. *Excision and Radiotherapy* - While excision is appropriate, **adjuvant radiotherapy** is typically reserved for larger tumors, those with **positive margins**, **lymph node involvement**, or **perineural/vascular invasion**. - For very small tumors (<2 cm) with clear margins and no high-risk features, radiotherapy is often **overtreatment** and adds unnecessary side effects. *Chemotherapy* - **Chemotherapy** is generally used in more advanced stages of oral tongue carcinoma, either as neoadjuvant therapy, concurrent with radiotherapy, or for metastatic disease. - It is **not a primary treatment** for early-stage localized disease due to its systemic toxicity and limited role in local control compared to surgery. *Radiotherapy* - **Radiotherapy alone** can be used as a primary treatment for oral tongue carcinoma, especially in patients who are **unfit for surgery** or refuse surgery. - However, for small lesions, **surgery typically offers better local control** and avoids the long-term side effects of radiation, such as xerostomia and osteoradionecrosis.
Question 6: Classification system of bone tumors is -
- A. Enneking (Correct Answer)
- B. Edmonton
- C. TNM
- D. Manchester
Explanation: ***Enneking*** - The **Enneking staging system** is widely used for primary **bone tumors**, particularly sarcomas. - It classifies tumors based on their histological grade, local extension, and presence of metastases, which guides surgical planning and prognosis. *Edmonton* - The **Edmonton classification** is primarily used for **periprosthetic fractures** around hip and knee replacements. - It does not classify primary bone tumors but rather describes fracture patterns related to prosthetic implants. *TNM* - The **TNM (Tumor, Node, Metastasis)** classification is a general staging system used for many types of cancer, but it's not the primary system for bone tumors. - While applicable for some bone cancers, the **Enneking system** provides a more specific functional and anatomical assessment for limb-sparing surgery in bone sarcomas. *Manchester* - The **Manchester staging system** is primarily used for **lymphoma**, particularly Hodgkin lymphoma. - It describes the extent of lymph node involvement and extralymphatic disease, completely unrelated to bone tumors.
Question 7: For the treatment of basal cell carcinoma, what is the popular surgery that is carried out?
- A. Mohs surgery (Correct Answer)
- B. Superficial laser surgery
- C. Curettage and electrodesiccation
- D. Wide local excision
Explanation: ***Mohs surgery*** - **Mohs micrographic surgery** is the most popular and highly effective procedure specifically designed for **basal cell carcinoma (BCC)**, especially on the face and other cosmetically sensitive areas. - It involves the **progressive removal** of thin layers of skin, which are immediately examined under a microscope, allowing for complete tumor removal while preserving maximum healthy tissue. - Mohs surgery has the **highest cure rate** (95-99%) for BCC and is particularly preferred for high-risk locations, recurrent tumors, and poorly defined borders. *Superficial laser surgery* - While lasers can sometimes be used for very superficial skin lesions, **superficial laser surgery** is generally not the primary treatment for established **BCC** due to the risk of incomplete removal and recurrence. - It lacks the **histological margin control** provided by Mohs surgery, which is crucial for ensuring complete eradication of BCC. *Curettage and electrodesiccation* - **Curettage and electrodesiccation** is an alternative surgical treatment for small, low-risk BCCs in non-critical areas. - However, it has **lower cure rates** (85-95%) compared to Mohs surgery and does not provide histological margin assessment. - It is less preferred for facial BCCs where cosmetic outcome and complete removal are critical. *Wide local excision* - **Wide local excision** is a standard surgical approach that removes the tumor with predetermined margins (typically 4-5 mm for BCC). - While effective, it requires **larger tissue removal** compared to Mohs surgery and lacks the real-time microscopic margin control. - Mohs surgery remains more popular due to its tissue-sparing nature and higher cure rates, especially in cosmetically sensitive areas.
Question 8: Rodent ulcer is
- A. Squamous cell carcinoma
- B. Basal cell carcinoma (Correct Answer)
- C. Rhinophyma
- D. Adenocarcinoma (glandular cancer)
Explanation: ***Basal cell carcinoma*** - The term **"rodent ulcer"** is a historical and descriptive term for a specific type of **basal cell carcinoma (BCC)**, characterized by a **pearly raised border** and a central ulceration. - This appearance, with its rolled edges and sometimes visible telangiectasias, gives the impression of a lesion gnawing away at the tissue, hence the "rodent" description. *Squamous cell carcinoma* - While also a common skin cancer, **squamous cell carcinoma (SCC)** typically presents as a **scaly, crusted nodule or plaque** with irregular borders, or a non-healing ulcer that does not have the classic rolled border of a rodent ulcer. - It is more prone to **metastasis** than BCC. *Rhinophyma* - **Rhinophyma** is a severe form of **rosacea** that causes a bulbous, red, and swollen nose due to hyperplasia of sebaceous glands and connective tissue. - It is a **benign condition** and not a form of skin cancer or ulcer. *Adenocarcinoma (glandular cancer)* - **Adenocarcinoma** is a type of cancer that originates in **glandular tissue**, such as in the breast, prostate, colon, or lung. - It is **not a primary skin cancer** and does not typically present as a "rodent ulcer" on the skin surface.
Question 9: A male patient presented with a 0.3 cm nodule on the left nasolabial fold. A pathological examination revealed a basaloid appearance with peripheral palisading. What is the most likely diagnosis?
- A. Basal cell carcinoma (Correct Answer)
- B. Melanoma
- C. Squamous cell carcinoma
- D. Nevus
Explanation: ***Basal cell carcinoma*** - The description of a **basaloid appearance with peripheral palisading** on pathological examination is a classic histological feature of basal cell carcinoma (BCC). - BCC commonly presents as a nodule on sun-exposed areas like the **nasolabial fold** and is the most common skin cancer. *Melanoma* - Melanoma is characterized by the **malignant proliferation of melanocytes** and histologically shows atypical melanocytes with pagetoid spread or nest formation. - While it can appear as a nodule, the described **basaloid appearance with peripheral palisading** is not characteristic of melanoma. *Squamous cell carcinoma* - Squamous cell carcinoma typically shows **atypical keratinocytes** with keratinization, intercellular bridges, and sometimes desmoplasia. - It usually presents as an **erythematous, scaly patch** or nodule, often with ulceration, and the described histology does not match. *Nevus* - A nevus (mole) is a benign proliferation of melanocytes, showing **uniform nests of melanocytes** with maturation as they descend into the dermis. - The term **basaloid appearance** refers to cells resembling basal keratinocytes, which is not typical for a nevus.
Question 10: A 70-year-old male presents with a red, scaling plaque on the lower lip that has not healed over the past few months. What is the most likely diagnosis?
- A. Squamous cell carcinoma (Correct Answer)
- B. Basal cell carcinoma
- C. Actinic keratosis
- D. Lichen planus
Explanation: ***Squamous cell carcinoma*** - Presents as a **red, scaling plaque** on the lower lip, which is the **most common site for oral SCC** (90-95% of lip cancers) due to **chronic UV exposure**. - The history of **non-healing over several months** is highly suspicious for malignancy, particularly SCC in this location. - Lower lip SCC is common in elderly males with chronic sun exposure history. *Basal cell carcinoma* - Typically presents as a **pearly nodule with telangiectasias** or an ulcer, commonly found on sun-exposed skin but **rarely involves the lip**. - While BCC is the most common skin cancer overall, it is uncommon on the lips compared to SCC. *Actinic keratosis* - Characterized by **rough, scaling patches** on sun-exposed areas and is a **premalignant lesion** that can progress to SCC. - However, the description of a **non-healing lesion over months** points more strongly towards an already established malignancy (SCC) rather than a premalignant lesion. *Lichen planus* - An **inflammatory condition** that can affect the skin and mucous membranes, including the lips. - Oral lichen planus presents as **white lace-like patterns (Wickham's striae)** or erosions, not typically a persistent, red, scaling plaque that fails to heal.
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