Oncology Practice Questions

Q: A 45-year-old man presents with splenomegaly and weight loss. Peripheral smear shows leukocytosis with a left shift. Bone marrow is hypercellular. Cytogenetic analysis reveals t(9;22). What is the treatment of choice?

Imatinib. ***Imatinib*** - This drug acts as a **tyrosine kinase inhibitor** that specifically targets the **BCR-ABL fusion protein** created by the **t(9;22)** chromosomal translocation. - It is the **first-line therapy** for chronic phase Chronic Myeloid Leukemia (CML) due to its high efficacy and minimal side-effect profile compared to older treatments. *Rituximab* - A monoclonal antibody directed against **CD20**, used primarily in the treatment of **B-cell non-Hodgkin lymphomas** and certain autoimmune conditions. - It is not indicated for CML treatment because the malignant cells in CML do not typically express the CD20 surface antigen. *IFN alpha* - Historically used as the treatment of choice for CML before the development of targeted therapies like tyrosine kinase inhibitors. - It is now mostly relegated to a second-line role or used when target-specific therapy is contraindicated, as it is associated with significant **flu-like side effects**. *Hydroxyurea* - A non-specific **myelosuppressive agent** used to provide temporary control of leukocyte counts in CML. - While it helps in reducing cytoreduction, it does not induce **molecular remission** or address the underlying BCR-ABL molecular driver, so it is not the curative treatment of choice.

Q: Which of the following hormones is elevated in small cell carcinoma of the lung?

Atrial natriuretic factor (ANF). Small cell lung carcinoma (SCLC) is a neuroendocrine tumor known for its strong association with paraneoplastic syndromes due to the ectopic secretion of hormones [1]. **Why Option B is Correct:** SCLC is the most common cause of the **Syndrome of Inappropriate Antidiuretic Hormone (SIADH)** [1], [2]. While SIADH is primarily caused by ectopic ADH (vasopressin) production, studies have shown that SCLC cells can also secrete **Atrial Natriuretic Factor (ANF)** or Brain Natriuretic Peptide (BNP). Both ADH and ANF contribute to the characteristic hyponatremia seen in these patients—ADH by increasing water reabsorption and ANF by promoting natriuresis (sodium excretion). **Analysis of Incorrect Options:** * **Option A (PTH):** Ectopic production of **PTHrP** (Parathyroid Hormone-related Protein) is classically associated with **Squamous Cell Carcinoma** of the lung, leading to hypercalcemia [1]. * **Option C (Growth Hormone):** Ectopic GH is rare in lung cancer; however, Growth Hormone-Releasing Hormone (GHRH) can occasionally be secreted by bronchial carcinoids. * **Option D (VIP):** VIP secretion is typically associated with **VIPomas** (pancreatic islet cell tumors) or neuroblastomas, causing watery diarrhea, hypokalemia, and achlorhydria (WDHA syndrome). **High-Yield Clinical Pearls for NEET-PG:** * **SCLC Associations:** SIADH (most common), Ectopic ACTH (Cushing’s Syndrome) [1], [3], and Lambert-Eaton Myasthenic Syndrome (LEMS). * **Rule of "S":** **S**quamous cell carcinoma and **S**mall cell carcinoma are both **S**moking-related and **S**entrally (centrally) located. * **Hypercalcemia in Lung Cancer:** If it's Squamous cell, think **PTHrP** [1]. If it's Small cell, hypercalcemia is rare and usually due to bone metastasis, not hormones.

Q: A 65-year-old man with a 45-pack-per-year history of smoking presents with hematuria, flank pain, and unintentional weight loss. He has no fever, chills, or dysuria. Physical examination reveals no abdominal mass or flank tenderness. Laboratory findings show a hemoglobin of 18.5 g/dL and normal liver enzymes. An abdominal CT scan demonstrates a left kidney mass involving the renal vein. What is the most likely diagnosis?

Renal cell carcinoma. **Explanation:** The clinical presentation of **Renal Cell Carcinoma (RCC)** is classically described by the "triad" of hematuria, flank pain, and a palpable abdominal mass [1]. However, this triad is seen in only about 10% of cases and often signifies advanced disease. **Why Renal Cell Carcinoma is correct:** 1. **Risk Factors:** The patient’s age (65) and significant smoking history (45 pack-years) are major risk factors [1]. 2. **Paraneoplastic Syndrome:** The hemoglobin of 18.5 g/dL indicates **polycythemia**, a classic paraneoplastic manifestation of RCC caused by the ectopic production of **Erythropoietin (EPO)**. 3. **Imaging:** A solid mass involving the renal vein is highly characteristic of RCC, as it has a notorious propensity for **vascular invasion** (extending into the renal vein and potentially the inferior vena cava). **Why other options are incorrect:** * **Renal cyst:** Typically asymptomatic and incidentally found; simple cysts do not cause weight loss, polycythemia, or vascular invasion. * **Renal metastases:** While possible, primary renal tumors are more common than metastases to the kidney [1]. Furthermore, polycythemia specifically points toward a primary EPO-secreting renal tumor. * **Renal abscess:** Usually presents with systemic signs of infection such as high-grade fever, chills, and leukocytosis, which are absent here. **NEET-PG High-Yield Pearls:** * **Most common histological type:** Clear cell carcinoma (derived from proximal convoluted tubule) [1]. * **Genetic association:** Deletion of the **VHL gene** on chromosome 3p. * **Stauffer Syndrome:** Reversible hepatic dysfunction (elevated LFTs) in the absence of liver metastases, another classic paraneoplastic syndrome of RCC. * **Left-sided varicocele:** May occur if the tumor obstructs the left renal vein, preventing drainage of the left gonadal vein.

Q: All of the following are associated with paraneoplastic syndromes except?

Progressive multifocal leukoencephalopathy. **Explanation:** The core concept in this question is distinguishing between a **Paraneoplastic Syndrome (PNS)** and an **Opportunistic Infection** occurring in a malignancy-associated immunocompromised state. **Why Option B is the correct answer:** **Progressive Multifocal Leukoencephalopathy (PML)** is not a paraneoplastic syndrome. It is a demyelinating disease of the CNS caused by the reactivation of the **JC virus** (a polyomavirus). While it occurs frequently in patients with hematological malignancies (like CLL or Lymphoma) due to profound immunosuppression, it is an **infectious process**, not an immune-mediated response to the tumor itself. **Analysis of Incorrect Options:** * **A. Cerebellar Degeneration:** A classic PNS (Subacute Cerebellar Degeneration) often associated with **anti-Yo** (Breast/Ovarian cancer), **anti-Hu** (SCLC), or **anti-Tr** (Hodgkin’s) antibodies. * **C. Amyotrophic Lateral Sclerosis (ALS):** While most ALS is idiopathic, a "motor neuron disease" phenotype can occur as a paraneoplastic manifestation, particularly in patients with **Lymphoma** or **Renal Cell Carcinoma**. * **D. Opsoclonus Myoclonus:** Known as "dancing eyes, dancing feet" syndrome. In children, it is highly suggestive of **Neuroblastoma**; in adults, it is often associated with **Small Cell Lung Cancer (SCLC)** (anti-Ri antibodies). **High-Yield Clinical Pearls for NEET-PG:** 1. **Lambert-Eaton Myasthenic Syndrome (LEMS):** Most common paraneoplastic neuromuscular junction disorder (associated with SCLC; anti-VGCC antibodies). 2. **Anti-NMDA Receptor Encephalitis:** Classically associated with **Ovarian Teratoma** in young females. 3. **Syndrome of Inappropriate Antidiuretic Hormone (SIADH):** The most common endocrine PNS, typically seen in **SCLC**. 4. **Hypercalcemia:** Most commonly caused by **PTHrP** production in **Squamous Cell Carcinoma** (Lung).

Q: What is the most common anterior mediastinal tumor?

Thymoma. **Explanation:** The mediastinum is anatomically divided into compartments, each associated with specific pathologies. The **anterior mediastinum** (the space between the sternum and the pericardium) is the most common site for mediastinal masses [1]. **1. Why Thymoma is Correct:** Thymoma is the most common primary tumor of the anterior mediastinum in adults (typically aged 40–60). It originates from the epithelial cells of the thymus. A classic clinical association high-yield for exams is that approximately 30–50% of patients with thymoma have **Myasthenia Gravis**, while about 15% of patients with Myasthenia Gravis are found to have a thymoma. **2. Analysis of Incorrect Options:** * **Neurogenic Tumors (Option B):** These are the most common tumors of the **posterior mediastinum**, usually arising from nerve sheaths (e.g., Schwannomas) or sympathetic ganglia [1]. * **Lymphoma (Option C):** While common in the anterior mediastinum (especially Hodgkin Lymphoma in younger patients), it is statistically less frequent as a primary isolated mass compared to thymoma. * **Teratoma (Option D):** These are the most common **germ cell tumors** of the anterior mediastinum but are less common overall than thymomas. **Clinical Pearls for NEET-PG:** * **The "4 Ts" of Anterior Mediastinal Masses:** **T**hymoma (most common), **T**errible Lymphoma, **T**eratoma (and other Germ Cell Tumors), and **T**hyroid (Retrosternal Goiter) [1]. * **Imaging:** Contrast-Enhanced CT (CECT) is the gold standard for localization [1]. * **Red Flag:** If a patient presents with an anterior mass and elevated **AFP or beta-hCG**, think Non-Seminomatous Germ Cell Tumor.

Q: A 72-year-old man with a significant smoking history presents with dyspnea and one week of truncal, arm, and facial swelling. Physical examination reveals facial erythema, facial, truncal, and arm edema, with prominence of thoracic and neck veins. Chest x-ray shows a right mediastinal mass with adenopathy. What is the most likely diagnosis?

Small cell carcinoma. **Explanation:** The clinical presentation of facial, truncal, and arm edema, coupled with venous prominence and a mediastinal mass, is classic for **Superior Vena Cava (SVC) Syndrome**. This occurs due to extrinsic compression or invasion of the SVC, most commonly by malignant tumors. **Why Small Cell Carcinoma (SCLC) is correct:** While non-small cell lung cancer (NSCLC) is numerically the most common cause of SVC syndrome due to its higher overall incidence, **Small Cell Carcinoma** has the strongest association with this condition. SCLC is typically **centrally located** and grows rapidly, leading to early compression of mediastinal structures [2]. In a 72-year-old smoker with a right-sided mediastinal mass, SCLC is the most likely histological diagnosis causing SVC obstruction [1]. **Why other options are incorrect:** * **Adenocarcinoma:** This is the most common type of lung cancer overall, but it is typically **peripherally located**, making it a less frequent cause of SVC syndrome compared to central tumors [2]. * **Hodgkin’s Lymphoma:** While it can cause SVC syndrome (especially in younger patients), the patient’s age (72) and significant smoking history point strongly toward primary lung malignancy [2]. * **Large Cell Carcinoma:** This is a less common subtype of NSCLC and, while it can cause SVC syndrome, it is statistically less likely than SCLC in the context of a central mediastinal mass. **Clinical Pearls for NEET-PG:** * **Most common cause of SVC Syndrome:** Malignancy (Lung cancer > Lymphoma). * **Pemberton’s Sign:** Facial flushing and respiratory distress upon elevating both arms (indicates thoracic outlet obstruction). * **Management:** Immediate management includes head elevation and oxygen. Definitive treatment for SCLC-induced SVC syndrome is **Chemotherapy**, as SCLC is highly chemo-sensitive [3]. Radiation is used for NSCLC.

Q: Which of the following is NOT a characteristic of tumor lysis syndrome?

Hypercalcemia. Enriched Explanation: Tumor Lysis Syndrome (TLS) is an oncologic emergency caused by the massive, rapid breakdown of malignant cells (most commonly in high-grade lymphomas and leukemias) following chemotherapy. This release of intracellular contents into the bloodstream leads to specific metabolic derangements. **Why Hypercalcemia is the Correct Answer:** TLS is characterized by **Hypocalcemia**, not hypercalcemia [1]. As intracellular phosphorus is released, it binds to serum calcium to form calcium phosphate crystals. This "precipitation" leads to a rapid decline in ionized calcium levels, which can cause tetany or seizures. **Analysis of Incorrect Options:** * **Hyperkalemia (A):** Potassium is the primary intracellular cation. Rapid cell lysis floods the extracellular space with potassium, posing a risk for lethal cardiac arrhythmias. This is often the most immediate life-threatening complication. * **Hyperuricemia (C):** The breakdown of nucleic acids releases purines, which are metabolized by xanthine oxidase into uric acid. This can lead to acute uric acid nephropathy and renal failure. * **Hyperphosphatemia (D):** Malignant cells contain significantly higher concentrations of phosphorus than normal cells. Their destruction leads to a surge in serum phosphate, which subsequently drives the secondary hypocalcemia mentioned above. **High-Yield Clinical Pearls for NEET-PG:** * **Cairo-Bishop Criteria:** Used for the diagnosis of laboratory and clinical TLS. * **Prophylaxis/Treatment:** Aggressive hydration is the mainstay. **Allopurinol** (prevents new uric acid formation) or **Rasburicase** (recombinant urate oxidase that breaks down existing uric acid) are used to manage hyperuricemia. * **ECG Changes:** Watch for peaked T-waves (hyperkalemia) and prolonged QT intervals (hypocalcemia).

Q: Which of the following tumors is most likely associated with either hyponatremia or diffuse pigmentation of the skin?

Small cell carcinoma of the lung. The correct answer is **Small cell carcinoma of the lung (SCLC)**. This tumor is a neuroendocrine malignancy derived from Kulchitsky cells, which possess the metabolic machinery to produce various ectopic hormones, leading to **Paraneoplastic Syndromes (PNS)**. [1] 1. **Hyponatremia:** SCLC is the most common cause of the **Syndrome of Inappropriate Antidiuretic Hormone (SIADH)** [1]. The tumor secretes ectopic ADH (Arginine Vasopressin), leading to water retention and dilutional hyponatremia [2]. 2. **Diffuse Pigmentation:** SCLC can secrete ectopic **ACTH (Adrenocorticotropic Hormone)** [2]. High levels of ACTH (or its precursor POMC) stimulate melanocytes directly or via MSH-like activity, resulting in generalized hyperpigmentation. This is often seen in "Ectopic ACTH Syndrome" rather than Cushing’s Disease [1]. **Analysis of Incorrect Options:** * **Renal Adenocarcinoma (RCC):** Classically associated with polycythemia (Erythropoietin) [1], hypercalcemia (PTHrP), and Stauffer’s syndrome, but not typically SIADH or ACTH secretion. * **Hepatocellular Carcinoma:** Associated with hypoglycemia (IGF-II) and erythrocytosis [1], but rarely causes these specific electrolyte or pigmentary changes. * **Squamous Cell Carcinoma (SCC) of the Lung:** This is the classic lung cancer associated with **Hypercalcemia** due to the secretion of Parathyroid Hormone-related Protein (PTHrP) [1]. It does not typically cause SIADH or ectopic ACTH. **High-Yield Clinical Pearls for NEET-PG:** * **SCLC (Small Cell):** Think "S" for **S**IADH, **S**eizures (due to hyponatremia), and **S**ubacute cerebellar degeneration [3]. It is also associated with Lambert-Eaton Myasthenic Syndrome [3]. * **SCC (Squamous Cell):** Think "C" for **C**alcium (Hypercalcemia) and **C**entral location. * **Adenocarcinoma:** Most common lung cancer in non-smokers; associated with hypertrophic osteoarthropathy (clubbing) [2].

Question 1

A 45-year-old man presents with splenomegaly and weight loss. Peripheral smear shows leukocytosis with a left shift. Bone marrow is hypercellular. Cytogenetic analysis reveals t(9;22). What is the treatment of choice?

Accepted Answer

Imatinib

Answer

Rituximab

Answer

IFN alpha

Answer

Hydroxyurea

Question 2

A patient was detected to have a medullary carcinoma of thyroid and has a family history of endocrine tumors, and genetic counseling is advised. The clinician plans further evaluation to identify associated inherited syndromes and guide family screening. Which of the following statements regarding this condition is correct?

Accepted Answer

Patients should be screened for RET gene mutations associated with MEN 2A and MEN 2B

Answer

Menin proto-oncogene mutation is associated with MEN 1

Answer

Medullary thyroid carcinoma arises from follicular cells and is associated with BRAF mutation

Answer

Prophylactic thyroidectomy is not indicated in asymptomatic family members

Question 3

Which of the following hormones is elevated in small cell carcinoma of the lung?

Accepted Answer

Atrial natriuretic factor (ANF)

Answer

Parathyroid hormone (PTH)

Answer

Growth hormone

Answer

Vasoactive intestinal peptide (VIP)

Question 4

A 65-year-old man with a 45-pack-per-year history of smoking presents with hematuria, flank pain, and unintentional weight loss. He has no fever, chills, or dysuria. Physical examination reveals no abdominal mass or flank tenderness. Laboratory findings show a hemoglobin of 18.5 g/dL and normal liver enzymes. An abdominal CT scan demonstrates a left kidney mass involving the renal vein. What is the most likely diagnosis?

Accepted Answer

Renal cell carcinoma

Answer

Renal cyst

Answer

Renal metastases

Answer

Renal abscess

Question 5

All of the following are associated with paraneoplastic syndromes except?

Accepted Answer

Progressive multifocal leukoencephalopathy

Answer

Cerebellar degeneration

Answer

Amyotrophic lateral sclerosis

Answer

Opsoclonus myoclonus

Question 6

What is the most common anterior mediastinal tumor?

Accepted Answer

Thymoma

Answer

Neurogenic tumor

Answer

Lymphoma

Answer

Teratoma

Question 7

A 72-year-old man with a significant smoking history presents with dyspnea and one week of truncal, arm, and facial swelling. Physical examination reveals facial erythema, facial, truncal, and arm edema, with prominence of thoracic and neck veins. Chest x-ray shows a right mediastinal mass with adenopathy. What is the most likely diagnosis?

Accepted Answer

Small cell carcinoma

Answer

Adenocarcinoma

Answer

Hodgkin's lymphoma

Answer

Large cell carcinoma

Question 8

Which of the following is NOT a characteristic of tumor lysis syndrome?

Accepted Answer

Hypercalcemia

Answer

Hyperkalemia

Answer

Hyperuricemia

Answer

Hyperphosphatemia

Question 9

Which of the following tumors is most likely associated with either hyponatremia or diffuse pigmentation of the skin?

Accepted Answer

Small cell carcinoma of the lung

Answer

Renal adenocarcinoma

Answer

Hepatocellular carcinoma

Answer

Primary squamous cell carcinoma of the lung

Question 10

A 69-year-old man, whose friend died of prostate cancer, wishes to be evaluated for the disease. He has no urinary symptoms. Which of the following tests is most likely indicated to screen him for prostate cancer?

Accepted Answer

DRE and prostate specific antigen (PSA)

Answer

prostate ultrasound

Answer

digital rectal examination (DRE)

Answer

PSA

Oncology — MCQs

Oncology — MCQs

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