Oncology — MCQs

A 69-year-old woman presents with left flank pain and hematuria. Physical examination reveals a blood pressure of 165/96 mmHg, heart rate of 104/min, and left costovertebral angle tenderness. An abdominal CT scan shows a 5-cm left kidney mass. Which of the following laboratory abnormalities might also be present?

Q94Medium

All of the following are good prognostic factors for seminoma testis except?

Q95Easy

Beta-2-microglobulin is a tumor marker for which of the following conditions?

Q96Easy

In tumor lysis syndrome, all of the following are seen except:

Q97Medium

A 44-year-old woman presents with symptoms of muscle weakness and fatigue. Her laboratory findings include serum potassium of 2.5 mEq/L, bicarbonate of 18 mEq/L, and a normal anion gap. Urine potassium is 40 mEq/L. What is the most likely diagnosis for this patient's hypokalemia?

Q98Medium

A 60-year-old man with a 20-year smoking history presents with altered behavior over the past week, personality changes, and a productive cough for the past month. He is not a known drug addict, diabetic, or hypertensive. Physical examination reveals multiple bruises, hyper-pigmented spots on the buccal mucosa and the back of his neck. His blood pressure is 160/90 mmHg, and pulse is 70/mm. Laboratory studies show random blood sugar of 224 mg/dL, serum sodium of 140 mEq/L, serum potassium of 2.0 mEq/L, and serum bicarbonate of 27 mEq/L. Which of the following tests is most likely to be abnormal in this patient?

Q99Easy

Which of the following is not a characteristic of Tumor Lysis Syndrome?

Q100Medium

In the case of CNS relapse in AML, what chemotherapy agent(s) would be administered intrathecally?

Oncology Indian Medical PG Practice Questions and MCQs

Question 91: Which feature is common to carcinoma of the pancreas, lungs, and stomach?

A. Retinoblastoma
B. Migratory thrombophlebitis (Correct Answer)
C. Ascites
D. Disseminated intravascular coagulation (DIC)

Explanation: **Explanation:** The correct answer is **Migratory thrombophlebitis**, also known as **Trousseau’s Syndrome**. **1. Why Migratory Thrombophlebitis is Correct:** Trousseau’s syndrome is a paraneoplastic manifestation characterized by recurrent episodes of superficial venous thrombosis that appear at different sites (migratory). It is most classically associated with **adenocarcinomas**, particularly of the **pancreas** (most common), **lungs**, and **stomach** [1]. The underlying mechanism involves the secretion of procoagulants (like tissue factor and mucins) by the tumor cells, which interact with platelets and the coagulation cascade, leading to a hypercoagulable state [1]. **2. Analysis of Incorrect Options:** * **A. Retinoblastoma:** This is a primary malignant intraocular tumor of childhood, usually linked to the *RB1* gene mutation. It is not a clinical feature or complication of adult adenocarcinomas. * **C. Ascites:** While common in advanced pancreatic and stomach cancers (due to peritoneal carcinomatosis or portal hypertension), it is rarely a feature of lung cancer unless there is extensive liver metastasis. It is not a unifying paraneoplastic feature. * **D. Disseminated Intravascular Coagulation (DIC):** While DIC can occur in advanced malignancies (especially Acute Promyelocytic Leukemia), it is an acute, systemic consumption coagulopathy. Migratory thrombophlebitis is a more specific, localized, and recurrent paraneoplastic sign shared by these specific solid tumors. **Clinical Pearls for NEET-PG:** * **Trousseau’s Sign of Malignancy:** Do not confuse this with Trousseau’s sign of Latent Tetany (carpopedal spasm during BP cuff inflation in hypocalcemia). * **Pancreatic Cancer:** Migratory thrombophlebitis is most frequently associated with the **tail and body** of the pancreas rather than the head. * **Management:** The treatment of choice for cancer-associated thrombosis is **Low Molecular Weight Heparin (LMWH)**, not Warfarin.

Question 92: What is the most common type of bronchogenic carcinoma?

A. Adenocarcinoma (Correct Answer)
B. Oat cell carcinoma
C. Squamous cell carcinoma
D. Large cell carcinoma

Explanation: **Explanation:** **Adenocarcinoma** is currently the most common histological type of bronchogenic carcinoma worldwide [1], accounting for approximately 40% of all lung cancer cases. Historically, squamous cell carcinoma was the most frequent; however, due to changes in cigarette composition and smoking patterns, adenocarcinoma has surpassed it [1]. It is the most common type found in **non-smokers, women, and younger adults** [1]. It typically presents as a **peripheral lesion** and is associated with scarring (scar carcinoma) [1]. **Analysis of Incorrect Options:** * **Oat cell carcinoma (Small Cell Lung Cancer):** This is the most aggressive form of lung cancer, strongly associated with smoking [2]. It usually presents as a central mass and is notorious for causing various paraneoplastic syndromes (e.g., SIADH, ectopic ACTH). * **Squamous cell carcinoma:** Formerly the most common type, it is now the second most frequent. It is strongly linked to smoking and typically presents as a **central/hilar mass** [1] with a tendency for **cavitary lesions** and hypercalcemia (due to PTHrP secretion). * **Large cell carcinoma:** A diagnosis of exclusion, these are undifferentiated malignant epithelial tumors. They represent a smaller percentage of cases and typically present as large peripheral masses with a poor prognosis. **High-Yield Clinical Pearls for NEET-PG:** * **Location Mnemonic:** **S**quamous and **S**mall cell are **S**entral; Adenocarcinoma and Large cell are Peripheral [1]. * **Most common lung cancer in smokers:** Adenocarcinoma (though Squamous has a stronger *relative* association with smoking, Adenocarcinoma is more common in absolute numbers). * **Driver Mutations:** EGFR mutations and ALK rearrangements are most frequently seen in Adenocarcinomas, especially in non-smokers. * **Pancoast Tumor:** Most commonly caused by Squamous cell carcinoma or Adenocarcinoma.

Question 93: A 69-year-old woman presents with left flank pain and hematuria. Physical examination reveals a blood pressure of 165/96 mmHg, heart rate of 104/min, and left costovertebral angle tenderness. An abdominal CT scan shows a 5-cm left kidney mass. Which of the following laboratory abnormalities might also be present?

A. polycythemia (Correct Answer)
B. thrombocytopenia
C. hypocalcemia
D. leukocytosis

Explanation: The clinical presentation of a flank mass, hematuria, and hypertension in an elderly patient is highly suggestive of **Renal Cell Carcinoma (RCC)** [1]. ### **Explanation of the Correct Answer** **Polycythemia (Option A)** is a classic paraneoplastic syndrome associated with RCC. It occurs due to the ectopic production of **Erythropoietin (EPO)** by the tumor cells, which stimulates the bone marrow to increase red blood cell production. While anemia is actually more common in RCC (due to chronic disease), polycythemia is a high-yield diagnostic clue. ### **Analysis of Incorrect Options** * **Thrombocytopenia (B):** RCC is more likely to cause thrombocytosis (as an acute phase reactant) rather than a low platelet count. * **Hypocalcemia (C):** RCC is famously associated with **Hypercalcemia**, not hypocalcemia. This occurs either due to bone metastasis or the secretion of **Parathyroid Hormone-related Protein (PTHrP)**. * **Leukocytosis (D):** While non-specific inflammation can occur, it is not a classic paraneoplastic hallmark of RCC compared to erythrocytosis. ### **NEET-PG High-Yield Pearls: RCC Paraneoplastic Syndromes** * **The "Internist's Tumor":** RCC is known by this name because it presents with diverse systemic symptoms. * **Stauffer Syndrome:** Reversible hepatic dysfunction (elevated LFTs, alkaline phosphatase) in the absence of liver metastases. * **Hypertension:** Caused by increased **Renin** production or direct compression of the renal artery by the tumor. * **Classic Triad:** Flank pain, hematuria, and palpable abdominal mass (seen in only 10% of cases, usually indicating advanced disease) [1]. * **Most Common Histology:** Clear cell carcinoma (originates from the proximal convoluted tubule) [1].

Question 94: All of the following are good prognostic factors for seminoma testis except?

A. Primarily gonadal
B. Primarily retroperitoneal
C. Nonpulmonary visceral metastases (Correct Answer)
D. AFP more than 10,000 ng/Ml

Explanation: This question is based on the **IGCCCG (International Germ Cell Cancer Collaborative Group) Classification**, which is the gold standard for prognosticating germ cell tumors (GCTs). ### **Explanation of the Correct Answer** For **Seminomas**, the IGCCCG classification only recognizes two categories: **Good Prognosis** and **Intermediate Prognosis**. There is no "Poor Prognosis" category for seminoma. * **Non-pulmonary visceral metastases** (e.g., liver, bone, or brain) automatically upgrade a seminoma from "Good" to **"Intermediate" prognosis**. Therefore, it is not a good prognostic factor. ### **Analysis of Incorrect Options** * **A & B (Primarily Gonadal/Retroperitoneal):** For a seminoma, the primary site can be either the testis (gonadal) or the retroperitoneum to be classified as **Good Prognosis**. This differs from Non-Seminomatous Germ Cell Tumors (NSGCT), where a mediastinal primary indicates a poor prognosis. * **D (AFP more than 10,000 ng/mL):** This is a "trick" option. By definition, **pure seminomas do not produce AFP**. If AFP is elevated, the tumor is treated as a Non-Seminoma. Therefore, an elevated AFP is not a prognostic factor for seminoma; it changes the diagnosis itself. ### **NEET-PG High-Yield Pearls** 1. **Seminoma IGCCCG Criteria:** * **Good Prognosis:** Any primary site (Testis/Retroperitoneum) AND No non-pulmonary visceral metastases. (Normal AFP, any hCG/LDH). * **Intermediate Prognosis:** Any primary site AND **Presence of non-pulmonary visceral metastases**. 2. **Markers:** LDH is the most common marker elevated in seminoma; hCG may be elevated in 10-15% (due to syncytiotrophoblasts), but **AFP is never elevated in pure seminoma**. 3. **Radiosensitivity:** Seminomas are highly radiosensitive and chemosensitive (Cisplatin-based therapy).

Question 95: Beta-2-microglobulin is a tumor marker for which of the following conditions?

A. Multiple myeloma (Correct Answer)
B. Lung cancer
C. Colonic neoplasm
D. Choriocarcinoma

Explanation: **Beta-2-microglobulin (B2M)** is a low-molecular-weight protein that forms the light chain subunit of the **MHC Class I molecule**, found on the surface of almost all nucleated cells. 1. **Why Multiple Myeloma is correct:** In plasma cell dyscrasias like Multiple Myeloma, there is a high turnover of lymphoid cells, leading to increased shedding of B2M into the serum [1]. In clinical practice, B2M is the **most important prognostic marker** for Multiple Myeloma and is a core component of the **International Staging System (ISS)**. Higher levels correlate with a higher tumor burden and renal impairment. 2. **Why other options are incorrect:** * **Lung Cancer:** While non-specific markers like CEA or NSE may be elevated, B2M is not used for diagnosis or staging [2]. * **Colonic Neoplasm:** The primary tumor marker is **Carcinoembryonic Antigen (CEA)**, used mainly for monitoring recurrence [2]. * **Choriocarcinoma:** The definitive tumor marker is the **beta subunit of Human Chorionic Gonadotropin (β-hCG)** [2]. **High-Yield Clinical Pearls for NEET-PG:** * **B2M in Renal Failure:** Since B2M is excreted by the kidneys, its levels rise in renal failure. It is the precursor protein for **Dialysis-related Amyloidosis** (presents as Carpal Tunnel Syndrome in long-term dialysis patients). * **Other B2M associations:** It is also elevated in Chronic Lymphocytic Leukemia (CLL) and B-cell Lymphomas. * **ISS Staging for Myeloma:** * Stage I: B2M < 3.5 mg/L and Albumin ≥ 3.5 g/dL. * Stage III: B2M ≥ 5.5 mg/L.

Question 96: In tumor lysis syndrome, all of the following are seen except:

A. Hyperuricemia
B. Hypercalcemia (Correct Answer)
C. Hyperkalemia
D. Hyperphosphatemia

Explanation: **Explanation:** Tumor Lysis Syndrome (TLS) is an oncologic emergency caused by the rapid destruction of a large number of tumor cells, typically following chemotherapy in high-grade malignancies (e.g., Burkitt lymphoma, ALL). When these cells rupture, they release their intracellular contents into the systemic circulation, leading to a specific constellation of metabolic derangements. **Why Hypercalcemia is the Correct Answer:** In TLS, **Hypocalcemia** (low calcium) is seen, not hypercalcemia. This occurs because the massive release of intracellular phosphorus leads to **Hyperphosphatemia**. The excess phosphate binds to circulating ionized calcium, forming calcium phosphate crystals that precipitate in soft tissues and the kidneys (metastatic calcification). This "precipitation effect" rapidly depletes serum calcium levels. **Analysis of Incorrect Options:** * **Hyperuricemia (A):** Nucleic acids from the destroyed cell nuclei are catabolized into purines and then into uric acid by xanthine oxidase. * **Hyperkalemia (C):** Potassium is the primary intracellular cation. Rapid cell lysis dumps massive amounts of potassium into the blood, posing a risk for fatal arrhythmias. * **Hyperphosphatemia (D):** Malignant cells contain significantly higher concentrations of intracellular phosphorus than normal cells; their rupture leads to a profound rise in serum phosphate. **NEET-PG High-Yield Pearls:** * **Cairo-Bishop Criteria:** Used for the diagnosis of laboratory and clinical TLS. * **Renal Failure:** Caused by the precipitation of uric acid and calcium phosphate crystals in the renal tubules. * **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.

Question 97: A 44-year-old woman presents with symptoms of muscle weakness and fatigue. Her laboratory findings include serum potassium of 2.5 mEq/L, bicarbonate of 18 mEq/L, and a normal anion gap. Urine potassium is 40 mEq/L. What is the most likely diagnosis for this patient's hypokalemia?

A. Lower gastrointestinal losses
B. Prior use of diuretics
C. Renal tubular acidosis (RTA) (Correct Answer)
D. Current use of diuretics

Explanation: ### Explanation The patient presents with a triad of **hypokalemia**, **metabolic acidosis** (low bicarbonate), and a **normal anion gap**. The key to differentiating the cause lies in the urinary potassium excretion. **1. Why Renal Tubular Acidosis (RTA) is Correct:** In a patient with metabolic acidosis, the kidneys should ideally conserve potassium. However, in RTA (specifically Type 1 and Type 2), there is significant **renal potassium wasting**. A urine potassium level >20 mEq/L in the presence of hypokalemia indicates a renal cause of loss. The combination of a normal anion gap metabolic acidosis (NAGMA) and high urinary potassium (40 mEq/L) is classic for RTA. **2. Why the other options are incorrect:** * **Lower GI losses (e.g., Diarrhea):** While diarrhea causes NAGMA and hypokalemia [1], the kidneys would respond by conserving potassium. Therefore, urine potassium would typically be **<20 mEq/L** [1]. * **Prior use of diuretics:** While diuretics cause hypokalemia, they typically result in metabolic **alkalosis** (contraction alkalosis), not acidosis. * **Current use of diuretics:** Similar to prior use, this would present with metabolic alkalosis. Additionally, while urine potassium would be high, the acid-base status does not fit the NAGMA seen in this patient. **Clinical Pearls for NEET-PG:** * **NAGMA + Hypokalemia:** Think RTA or Diarrhea. Check Urine Potassium [1]. * **Urine Anion Gap (UAG):** In RTA, the UAG is usually **positive** (reflecting decreased NH4+ excretion), whereas in diarrhea, it is **negative**. * **Type 1 RTA (Distal):** Associated with high urine pH (>5.5) and hypokalemia. * **Type 2 RTA (Proximal):** Associated with Fanconi syndrome and hypokalemia. * **Type 4 RTA:** The only RTA associated with **hyperkalemia**.

Question 98: A 60-year-old man with a 20-year smoking history presents with altered behavior over the past week, personality changes, and a productive cough for the past month. He is not a known drug addict, diabetic, or hypertensive. Physical examination reveals multiple bruises, hyper-pigmented spots on the buccal mucosa and the back of his neck. His blood pressure is 160/90 mmHg, and pulse is 70/mm. Laboratory studies show random blood sugar of 224 mg/dL, serum sodium of 140 mEq/L, serum potassium of 2.0 mEq/L, and serum bicarbonate of 27 mEq/L. Which of the following tests is most likely to be abnormal in this patient?

A. CT chest (Correct Answer)
B. MRI brain
C. Plasma metanephrine levels
D. Renal Doppler

Explanation: This clinical scenario describes a classic presentation of **Ectopic ACTH Syndrome**, most commonly associated with **Small Cell Lung Cancer (SCLC)** [1]. ### **Clinical Reasoning** The patient presents with a triad of: 1. **Cushingoid Features:** Hyperglycemia (224 mg/dL), hypertension (160/90 mmHg), and hyperpigmentation (due to ACTH-induced stimulation of melanocytes). 2. **Metabolic Derangements:** Severe hypokalemia (2.0 mEq/L) is a hallmark of ectopic ACTH production, as high cortisol levels overwhelm the 11β-HSD2 enzyme in the kidney, acting on mineralocorticoid receptors [1]. 3. **Pulmonary Symptoms:** A 20-year smoking history and productive cough strongly suggest an underlying lung malignancy. In a smoker with sudden-onset Cushing syndrome and severe hypokalemia, the most likely diagnosis is **Small Cell Lung Cancer** producing ectopic ACTH [1]. Therefore, a **CT Chest** is the most appropriate next step to identify the primary tumor [1]. ### **Analysis of Incorrect Options** * **B. MRI Brain:** While personality changes occur, they are likely due to metabolic encephalopathy (hypokalemia/hypercortisolism) rather than metastases. Pituitary MRI is used for Cushing Disease, but the rapid onset and pulmonary symptoms point toward an ectopic source [2]. * **C. Plasma Metanephrine:** Used to diagnose Pheochromocytoma. While it causes hypertension, it does not explain the hyperpigmentation or severe hypokalemia. * **D. Renal Doppler:** Used for renal artery stenosis. It causes hypertension and hypokalemia but not hyperglycemia or hyperpigmentation. ### **NEET-PG High-Yield Pearls** * **Small Cell Lung Cancer (SCLC):** Most common cause of Ectopic ACTH [1]. * **Ectopic ACTH vs. Cushing Disease:** Ectopic ACTH presents with **severe hypokalemia**, rapid onset, and hyperpigmentation; Cushing Disease (pituitary) usually lacks these. * **Paraneoplastic Syndromes of SCLC:** 1. SIADH (Hyponatremia) 2. Ectopic ACTH (Hypokalemic Alkalosis) [1] 3. Lambert-Eaton Myasthenic Syndrome (LEMS)

Question 99: Which of the following is not a characteristic of Tumor Lysis Syndrome?

A. Hyperkalemia
B. Hyperuricemia
C. Hyperphosphatemia
D. Hypercalcemia (Correct Answer)

Explanation: Tumor Lysis Syndrome (TLS) is an oncologic emergency caused by the rapid destruction of a large number of tumor cells (most commonly in high-grade lymphomas and leukemias). When these cells rupture, they release their intracellular contents into the bloodstream, leading to specific metabolic derangements. ### Explanation of the Correct Answer **D. Hypercalcemia** is the correct answer because TLS is characterized by **Hypocalcemia**, not hypercalcemia [1]. As intracellular phosphorus is released into the blood (Hyperphosphatemia), it binds to circulating calcium to form calcium phosphate crystals. This precipitation leads to a rapid decline in serum ionized calcium levels. ### Analysis of Incorrect Options * **A. Hyperkalemia:** This is the most dangerous component of TLS. Potassium is the primary intracellular cation; its massive release can lead to life-threatening cardiac arrhythmias. * **B. Hyperuricemia:** Nucleic acids from the cell nuclei are catabolized into purines and then into uric acid by xanthine oxidase. This can lead to acute uric acid nephropathy and renal failure. * **C. Hyperphosphatemia:** Malignant cells contain significantly higher concentrations of phosphorus than normal cells. Their lysis leads to a surge in serum phosphate. ### High-Yield Clinical Pearls for NEET-PG * **Cairo-Bishop Definition:** TLS is defined by the presence of two or more metabolic abnormalities (Hyperuricemia, Hyperkalemia, Hyperphosphatemia, or Hypocalcemia) occurring within 3 days before or 7 days after chemotherapy. * **Prevention/Treatment:** Aggressive hydration is the mainstay. **Allopurinol** is used for prophylaxis (prevents new uric acid formation), while **Rasburicase** (recombinant urate oxidase) is used for established hyperuricemia to break down existing uric acid into allantoin. * **Renal Failure:** The primary cause of acute kidney injury in TLS is the deposition of calcium phosphate and uric acid crystals in the renal tubules.

Question 100: In the case of CNS relapse in AML, what chemotherapy agent(s) would be administered intrathecally?

A. Methotrexate
B. Methotrexate + Cytosine Arabinoside
C. Prednisolone
D. None of the above (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. None of the above** **1. Why the correct answer is right:** In the management of CNS relapse in Acute Myeloid Leukemia (AML), the standard of care for intrathecal (IT) chemotherapy is the **"Triple Intrathecal Therapy"** regimen. This combination consists of **Methotrexate, Cytosine Arabinoside (Cytarabine), AND a corticosteroid (usually Hydrocortisone or Dexamethasone)**. The question provides options that are incomplete: Option A and B lack the steroid component, and Option C (Prednisolone) is not the steroid typically used in IT formulations. Because the standard protocol requires the synergistic combination of all three agents to effectively clear leukemic blasts from the cerebrospinal fluid, "None of the above" is the most accurate choice among the provided options. **2. Analysis of Incorrect Options:** * **Option A (Methotrexate):** Used as monotherapy for CNS prophylaxis in some lymphomas, but insufficient for active CNS relapse in AML. * **Option B (Methotrexate + Cytosine Arabinoside):** While these are the two primary cytotoxic agents, the omission of a corticosteroid (which reduces chemical arachnoiditis and enhances efficacy) makes this an incomplete regimen. * **Option C (Prednisolone):** Prednisolone is an oral/IV steroid. For intrathecal administration, **Hydrocortisone** is the preferred steroid component of the triple therapy. **3. High-Yield Clinical Pearls for NEET-PG:** * **CNS Involvement in AML:** Much rarer than in ALL (<5% at diagnosis), but more common in M4 (Myelomonocytic) and M5 (Monocytic) FAB subtypes. * **Triple IT Regimen:** Methotrexate (12.5–15 mg) + Cytarabine (40–50 mg) + Hydrocortisone (25–50 mg). * **Alternative:** Liposomal Cytarabine is sometimes used due to its longer half-life, allowing for less frequent dosing. * **Prophylaxis:** Unlike ALL, routine CNS prophylaxis is not standard for all AML patients; it is reserved for high-risk features like hyperleukocytosis (>1 lakh count) or specific monocytic lineages.

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Oncology — MCQs

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