Oncology — MCQs

A 23-year-old man undergoing chemotherapy for acute lymphoblastic leukemia has developed a fever and abdominal pain within the past week. He now has a severe cough. On physical examination, his temperature is 38.4°C. On auscultation, crackles are heard over all lung fields. Laboratory studies show hemoglobin, 12.8 g/dL; hematocrit, 39%; MCV, 90 mm³; platelet count, 221,000/mm³; and WBC count, 16,475/mm³ with 51% segmented neutrophils, 5% bands, 18% lymphocytes, 8% monocytes, and 18% eosinophils. Infection with which of the following organisms is most likely to be complicating the course of this patient's disease?

Q137Medium

A 43-year-old man had a subarachnoid hemorrhage from an intracranial aneurysm 8 years ago. He has also had progressive renal impairment associated with hematuria. What is the most likely diagnosis?

Q138Medium

Which type of lung cancer is known to exhibit lung-to-lung metastasis?

Q139Medium

Which is the most common metastatic disease causing Superior Vena Cava (SVC) syndrome?

Q140Medium

A 14-year-old girl presents with a rash, abdominal pain, arthralgias, nausea, vomiting, and bloody stools. Physical examination reveals a palpable purpuric rash on her buttocks and lower legs, a tender abdomen, and no active joint inflammation. Urinalysis shows RBCs and RBC casts, and her renal function deteriorates rapidly. A renal biopsy is performed. Considering the clinical presentation and biopsy, what is the most likely diagnosis on renal biopsy for this patient with glomerulonephritis (GN)?

Oncology Indian Medical PG Practice Questions and MCQs

Question 131: Radiation can cause which of the following conditions?

A. Non Hodgkin lymphoma
B. Hodgkin lymphoma
C. Acute leukemia (Correct Answer)
D. Papillary carcinoma thyroid

Explanation: **Explanation:** Ionizing radiation is a well-established carcinogen that induces DNA damage through direct ionization or the production of free radicals [1]. Among the malignancies associated with radiation exposure, **Acute Leukemia** (specifically Acute Myeloid Leukemia, AML) is the most characteristic and frequently tested association. **Why Acute Leukemia is the correct answer:** The bone marrow is highly radiosensitive due to its rapid cell turnover. Exposure to ionizing radiation (e.g., survivors of atomic bombs, therapeutic radiation) significantly increases the risk of leukemias. Typically, there is a lot of risk associated with hematopoietic failure and anemia following exposure [2]. While AML is most common, Chronic Myeloid Leukemia (CML) and Acute Lymphoblastic Leukemia (ALL) are also linked [3]; however, Chronic Lymphocytic Leukemia (CLL) is notably **not** associated with radiation. **Analysis of Incorrect Options:** * **A & B (Lymphomas):** While radiation can slightly increase the risk of Non-Hodgkin Lymphoma (NHL), the association is significantly weaker than that of leukemia. Hodgkin Lymphoma has no established causal link to radiation exposure. * **D (Papillary Carcinoma Thyroid):** This is a classic "distractor." Radiation *is* a major risk factor for Papillary Carcinoma of the thyroid (especially in children). However, in the context of standard medical examinations, if both are listed, **Leukemia** is traditionally considered the most "classic" and systemic hematological consequence of ionizing radiation. **High-Yield Clinical Pearls for NEET-PG:** * **Most common radiation-induced cancer:** Leukemia (excluding CLL). * **Most common radiation-induced solid tumor:** Thyroid cancer (specifically Papillary type). * **Radiosensitive tissues:** Bone marrow, GI epithelium, and gonads [2]. * **Radioresistant tissues:** Nerve cells and mature bone. * **Latent Period:** Leukemia has a shorter latent period (5–10 years) compared to solid tumors (20+ years).

Question 132: Which of the following cancers is the most common cause of cancer-related death?

A. Lung cancer (Correct Answer)
B. Oral cancer
C. Skin cancer
D. Prostate cancer

Explanation: **Explanation:** **Lung cancer** is the leading cause of cancer-related mortality worldwide and in most developed countries [1], [2]. The high mortality rate is primarily due to the fact that lung cancer is often asymptomatic in its early stages, leading to a majority of cases being diagnosed at an advanced or metastatic stage (Stage III or IV) when curative treatment is no longer possible [3]. Additionally, the aggressive biological nature of small cell lung cancer and the resistance of many non-small cell lung cancers to conventional therapies contribute to its high lethality [3]. **Analysis of Incorrect Options:** * **Oral Cancer:** While highly prevalent in India due to tobacco and betel nut use, it is more easily detectable during physical exams and has a lower overall global mortality rate compared to lung cancer. * **Skin Cancer:** Basal cell carcinoma is the most common cancer overall, but it is rarely fatal [2]. Even malignant melanoma, though dangerous, accounts for far fewer deaths than lung cancer. * **Prostate Cancer:** This is the most common cancer in men in many regions, but it often follows an indolent course. Many patients die *with* prostate cancer rather than *of* it, resulting in a much higher survival rate. **High-Yield Clinical Pearls for NEET-PG:** * **Global & India Trend:** Globally, Lung cancer is the #1 cause of cancer death [1]. In India, **Breast cancer** is the most common cancer in women, while **Lung/Oral cancer** leads in men. * **Risk Factor:** Tobacco smoking is the most significant risk factor, linked to ~85% of lung cancer deaths [2]. * **Screening:** Low-dose CT (LDCT) is the recommended screening tool for high-risk smokers (50–80 years old with a 20 pack-year history).

Question 133: Which of the following is the most serious late side effect of treatment of Hodgkin's disease?

A. Cardiac injury (Correct Answer)
B. Infertility
C. Hair loss
D. Osteoporosis

Explanation: The treatment of Hodgkin’s Lymphoma (HL) has a high cure rate, making the management of long-term survivorship and **late toxicities** a critical clinical focus. [1] **Cardiac injury** is considered the most serious late side effect because it is a leading cause of non-malignant morbidity and mortality in HL survivors. It typically manifests 10–20 years after treatment. The injury is multifactorial: 1. **Radiation Therapy (Mediastinal):** Causes accelerated coronary artery disease (CAD), valvular dysfunction, and pericarditis. [1] 2. **Chemotherapy (Anthracyclines like Doxorubicin):** Leads to dose-dependent, irreversible dilated cardiomyopathy and congestive heart failure. **Analysis of Incorrect Options:** * **B. Infertility:** While common (especially with alkylating agents like Procarbazine in the older MOPP regimen), it is not considered as "serious" or life-threatening as cardiac failure or secondary malignancies. Modern ABVD regimens have a much lower risk of permanent infertility. * **C. Hair Loss (Alopecia):** This is an **acute** side effect that occurs during treatment and is reversible. It is not a "late" side effect. * **D. Osteoporosis:** Can occur due to prolonged steroid use (Prednisone), but it is rarely the most life-limiting complication compared to cardiotoxicity. **NEET-PG High-Yield Pearls:** * The **most common** late cause of death in HL survivors is **Secondary Malignancies** (most commonly Breast Cancer and Lung Cancer). * If "Secondary Malignancy" is not an option, **Cardiac Injury** is the next most significant life-threatening late complication. * **Lhermitte’s sign** (electric shock sensation down the spine) is a transient late effect of neck radiation in HL patients. * Survivors require lifelong screening, including annual mammograms (starting 8-10 years post-radiation) and aggressive lipid management.

Question 134: Which of the following is NOT true regarding Superior Vena Cava (SVC) syndrome?

A. Malignant lymphoma is the leading cause of SVC syndrome in elderly patients. (Correct Answer)
B. Widening of the superior mediastinum is seen on chest radiograph.
C. Patients present with dilated neck veins and an increased number of collateral veins covering the anterior chest wall.
D. None of the above

Explanation: ### Explanation **1. Why Option A is the Correct Answer (The False Statement):** While malignant lymphoma is a significant cause of Superior Vena Cava (SVC) syndrome, it is **not** the leading cause in elderly patients. **Bronchogenic carcinoma (Lung Cancer)**, specifically Small Cell Lung Cancer (SCLC) and Squamous Cell Carcinoma, is the most common cause of SVC syndrome overall, accounting for approximately 70-80% of cases [1]. Lymphoma is a more frequent cause in younger patients/children. **2. Analysis of Incorrect Options (True Statements):** * **Option B:** SVC syndrome typically results from extrinsic compression or invasion of the SVC by a mediastinal mass. This mass effect, along with associated lymphadenopathy, characteristically manifests as **widening of the superior mediastinum** on a chest X-ray. * **Option C:** Obstruction of the SVC leads to increased venous pressure. To bypass the blockage, blood is diverted through collateral pathways (e.g., azygos, internal mammary, and lateral thoracic veins). This results in the classic clinical triad: **facial/neck edema, dilated neck veins (non-pulsatile), and prominent collateral veins** on the anterior chest wall. **3. Clinical Pearls for NEET-PG:** * **Most Common Cause:** Bronchogenic Carcinoma (Lung Cancer). * **Most Common Benign Cause:** Iatrogenic (Indwelling central venous catheters or pacemaker leads) – this is increasing in frequency. * **Pemberton’s Sign:** Facial flushing and cyanosis when the patient raises both arms above the head; indicates thoracic inlet obstruction. * **Management:** SVC syndrome is a clinical diagnosis. While it was once considered a surgical emergency, the current approach is to **obtain a tissue diagnosis first** (unless there is airway compromise or cerebral edema) to tailor therapy (e.g., radiation for NSCLC [2] vs. chemotherapy for SCLC/Lymphoma [2]).

Question 135: Hyperglycemia is seen in which of the following types of lung cancer?

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

Explanation: The correct answer is **Small Cell Carcinoma (SCLC)**. This association is primarily due to the **Ectopic ACTH Syndrome**, a classic paraneoplastic manifestation of SCLC. **1. Why Small Cell Carcinoma is correct:** Small cell carcinoma is a neuroendocrine tumor capable of secreting various hormones [1], [4]. In roughly 1–5% of cases, it secretes ectopic Adrenocorticotropic Hormone (ACTH) [3]. This leads to excessive cortisol production (Cushing Syndrome), which promotes gluconeogenesis and insulin resistance, resulting in **hyperglycemia** and hypokalemia [1]. SCLC is also famously associated with SIADH (hyponatremia) and Lambert-Eaton Myasthenic Syndrome [4]. **2. Why the other options are incorrect:** * **Squamous Cell Carcinoma (SCC):** SCC is most commonly associated with the secretion of **PTHrP** (Parathyroid Hormone-related Protein), which leads to **hypercalcemia**, not hyperglycemia [1]. * **Adenocarcinoma:** This is the most common lung cancer in non-smokers and females. Its paraneoplastic associations include hypertrophic osteoarthropathy (clubbing) and Trousseau syndrome (thrombophlebitis), but not typically endocrine-induced hyperglycemia [2]. * **Large Cell Carcinoma:** This is associated with gynecomastia due to beta-hCG production, but it is not a classic cause of hyperglycemia. **High-Yield Clinical Pearls for NEET-PG:** * **SCLC (The "S" rules):** **S**moking related, **S**entral location, **S**IADH, and ACTH (**S**ugar elevation). * **SCC (The "C" rules):** **S**moking related, **C**entral location, **C**avitary lesions, and **C**alcium elevation (PTHrP). * **Most common paraneoplastic syndrome in SCLC:** SIADH. * **Most common lung cancer overall:** Adenocarcinoma.

Question 136: A 23-year-old man undergoing chemotherapy for acute lymphoblastic leukemia has developed a fever and abdominal pain within the past week. He now has a severe cough. On physical examination, his temperature is 38.4°C. On auscultation, crackles are heard over all lung fields. Laboratory studies show hemoglobin, 12.8 g/dL; hematocrit, 39%; MCV, 90 mm³; platelet count, 221,000/mm³; and WBC count, 16,475/mm³ with 51% segmented neutrophils, 5% bands, 18% lymphocytes, 8% monocytes, and 18% eosinophils. Infection with which of the following organisms is most likely to be complicating the course of this patient's disease?

A. Cryptococcus neoformans
B. Cytomegalovirus
C. Pseudomonas aeruginosa
D. Strongyloides stercoralis (Correct Answer)

Explanation: ### Explanation The correct answer is **Strongyloides stercoralis**. **1. Why it is correct:** The patient is immunocompromised due to chemotherapy for leukemia [1]. The clinical presentation of fever, abdominal pain, cough, and diffuse pulmonary crackles, combined with a significant **peripheral eosinophilia (18%)**, is classic for **Strongyloides Hyperinfection Syndrome** [2]. * *Strongyloides stercoralis* is unique because it can undergo an **autoinfective cycle**. In immunocompromised hosts (especially those on steroids or chemotherapy), the larvae rapidly multiply and migrate from the GI tract to the lungs (causing cough/crackles) and other organs [2]. * The abdominal pain reflects the intestinal phase, while the cough reflects the pulmonary migration (Löffler-like syndrome) [2]. Eosinophilia is a hallmark finding in helminthic infections, which helps differentiate this from viral or bacterial causes [2]. **2. Why incorrect options are wrong:** * **A. Cryptococcus neoformans:** Typically presents as meningitis or subacute pneumonia in immunocompromised patients, but it does not cause significant peripheral eosinophilia or acute abdominal pain. * **B. Cytomegalovirus (CMV):** Can cause interstitial pneumonitis in transplant or leukemia patients, but it is associated with lymphocytosis or leukopenia, not eosinophilia. * **C. Pseudomonas aeruginosa:** A common cause of neutropenic fever and necrotizing pneumonia. However, this patient is **not neutropenic** (WBC 16,475/mm³), and *Pseudomonas* causes a shift to the left (neutrophilia), not eosinophilia. **3. NEET-PG High-Yield Pearls:** * **Hyperinfection Syndrome:** Triggered by immunosuppression (Steroids are the biggest risk factor) [2]. * **Diagnosis:** Identification of **rhabditiform larvae** in stool or sputum. * **Drug of Choice:** Ivermectin (Albendazole is an alternative). * **Rule of Thumb:** In an immunocompromised patient with pulmonary symptoms + GI symptoms + **Eosinophilia**, always think of *Strongyloides* [2].

Question 137: A 43-year-old man had a subarachnoid hemorrhage from an intracranial aneurysm 8 years ago. He has also had progressive renal impairment associated with hematuria. What is the most likely diagnosis?

A. polycystic kidney disease (Correct Answer)
B. medullary sponge kidney
C. medullary cystic disease
D. Bartter syndrome

Explanation: **Explanation:** The clinical presentation of a middle-aged patient with a history of **intracranial aneurysm (Subarachnoid Hemorrhage)** and progressive **renal impairment with hematuria** is a classic description of **Autosomal Dominant Polycystic Kidney Disease (ADPKD)**. **1. Why ADPKD is correct:** ADPKD is the most common inherited kidney disease. It is characterized by the growth of numerous cysts in the kidneys, which eventually lead to renal failure and hematuria (due to cyst rupture) [1]. A key extra-renal manifestation of ADPKD is **berry aneurysms** in the Circle of Willis; rupture of these aneurysms leads to subarachnoid hemorrhage (SAH). Approximately 5-10% of ADPKD patients develop intracranial aneurysms. **2. Why other options are incorrect:** * **Medullary Sponge Kidney:** This is a congenital dilation of collecting ducts [2]. While it can cause hematuria and stones, it is typically a benign condition that does not lead to progressive renal failure or intracranial aneurysms. * **Medullary Cystic Disease (Nephronophthisis):** This presents with small kidneys and tubulointerstitial fibrosis leading to polyuria and salt wasting [2]. It does not typically present with hematuria or berry aneurysms. * **Bartter Syndrome:** This is a renal tubular defect (thick ascending limb) presenting as hypokalemic metabolic alkalosis with normal blood pressure. It does not cause renal cysts or aneurysms. **Clinical Pearls for NEET-PG:** * **Genetics:** Most cases are due to mutations in **PKD1** (Chromosome 16 - more severe) or **PKD2** (Chromosome 4) [1]. * **Extra-renal manifestations:** Hepatic cysts (most common), Berry aneurysms, Mitral Valve Prolapse (MVP), and Diverticulosis. * **Diagnosis:** Ultrasonography is the initial screening modality of choice. * **Management:** Tolvaptan (Vasopressin V2 receptor antagonist) is used to slow disease progression.

Question 138: Which type of lung cancer is known to exhibit lung-to-lung metastasis?

A. Adenocarcinoma of lung (Correct Answer)
B. Squamous cell carcinoma
C. Small cell carcinoma
D. Neuroendocrine tumor of lung

Explanation: Explanation: Adenocarcinoma of the lung is the correct answer because it is the most common histological subtype to exhibit intrapulmonary (lung-to-lung) metastasis. This occurs via two primary mechanisms: hematogenous spread and aerogenous (lepidic) spread, where malignant cells travel through the airways to seed other lobes. Specifically, the bronchioloalveolar pattern (now classified under adenocarcinoma in situ or minimally invasive adenocarcinoma) is notorious for presenting as multinodular disease or diffuse consolidations mimicking pneumonia, representing multicentricity or intrapulmonary spread. Analysis of Incorrect Options: * Squamous Cell Carcinoma: Typically presents as a central, endobronchial mass. It is more likely to spread via local invasion into the mediastinum or cavitate rather than seeding the contralateral lung. [1] * Small Cell Carcinoma: Known for rapid doubling time and early hematogenous spread to distant organs (brain, liver, bones, and adrenals) rather than localized lung-to-lung seeding. [1] * Neuroendocrine Tumors (e.g., Carcinoid): These are generally slow-growing and tend to remain localized or spread to regional lymph nodes rather than exhibiting diffuse intrapulmonary metastasis. High-Yield Clinical Pearls for NEET-PG: * Adenocarcinoma: Most common lung cancer in non-smokers and women [1]; usually peripheral in location [1]; associated with hypertrophic osteoarthropathy (clubbing) [1]. * Squamous Cell Carcinoma: Strongly associated with smoking; central location; associated with Paraneoplastic Hypercalcemia (due to PTHrP) [1]. * Small Cell Carcinoma: Strongest association with smoking; central location; associated with SIADH and ACTH (Cushing’s syndrome) [1]. * Pancoast Tumor: Most commonly an Adenocarcinoma (historically Squamous) involving the superior sulcus, leading to Horner’s Syndrome.

Question 139: Which is the most common metastatic disease causing Superior Vena Cava (SVC) syndrome?

A. Bronchogenic carcinoma
B. Metastatic breast carcinoma (Correct Answer)
C. Metastatic vertebral carcinoma
D. Gastric carcinoma

Explanation: **Explanation:** Superior Vena Cava (SVC) syndrome results from the external compression or internal thrombosis of the SVC, leading to venous congestion in the head, neck, and upper extremities. **1. Why Metastatic Breast Carcinoma is correct:** While **Bronchogenic carcinoma** is the most common *overall* cause of SVC syndrome (accounting for ~75% of cases), the question specifically asks for the most common **metastatic** disease. In the context of secondary spread from a distant primary site (excluding direct extension from the lung), **Breast carcinoma** is the most frequent metastatic malignancy to cause SVC syndrome [1]. This typically occurs via mediastinal lymph node metastasis or direct compression from metastatic masses. **2. Analysis of Incorrect Options:** * **A. Bronchogenic carcinoma:** This is the most common **primary** malignancy causing SVC syndrome. It is categorized as a primary intrathoracic tumor rather than a "metastatic disease" in this context [2]. * **C. Metastatic vertebral carcinoma:** While vertebral metastases are common in many cancers, they rarely involve the anterior mediastinal space or the SVC directly [3]. * **D. Gastric carcinoma:** Though it can metastasize to Virchow’s node (supraclavicular), it rarely involves the mediastinal nodes to a degree that causes SVC obstruction. **3. NEET-PG High-Yield Pearls:** * **Most common cause overall:** Bronchogenic carcinoma (Small Cell Lung Cancer > Non-Small Cell). * **Second most common cause:** Lymphoma (especially Non-Hodgkin Lymphoma). * **Most common benign cause:** Iatrogenic (indwelling central venous catheters or pacemakers). * **Clinical Sign:** Pemberton’s sign (facial flushing/cyanosis when arms are raised). * **Management:** Emergency radiotherapy is indicated if there is airway compromise or cerebral edema; otherwise, stenting and treating the underlying malignancy is the mainstay.

Question 140: A 14-year-old girl presents with a rash, abdominal pain, arthralgias, nausea, vomiting, and bloody stools. Physical examination reveals a palpable purpuric rash on her buttocks and lower legs, a tender abdomen, and no active joint inflammation. Urinalysis shows RBCs and RBC casts, and her renal function deteriorates rapidly. A renal biopsy is performed. Considering the clinical presentation and biopsy, what is the most likely diagnosis on renal biopsy for this patient with glomerulonephritis (GN)?

A. Diffuse proliferative GN (Correct Answer)
B. Crescentic GN
C. Focal proliferative GN
D. Membranoproliferative GN

Explanation: **Explanation:** The clinical presentation of a palpable purpuric rash (buttocks/legs), abdominal pain, arthralgia, and hematuria in a young patient is classic for **Henoch-Schönlein Purpura (HSP)**, also known as IgA Vasculitis. When HSP involves the kidneys, it is termed HSP nephritis. **Why Option A is Correct:** The renal manifestations of HSP are histologically identical to IgA Nephropathy [1]. The severity of the biopsy findings correlates with the clinical presentation. While HSP can show a spectrum of changes, in cases where there is **rapidly deteriorating renal function** and significant hematuria (RBC casts), the most common underlying histological pattern is **Diffuse Proliferative Glomerulonephritis (DPGN)**. This involves global involvement of more than 50% of glomeruli with significant mesangial and endocapillary proliferation. **Why other options are incorrect:** * **B. Crescentic GN:** While this represents the most severe form (Type VI) and can cause rapid deterioration [2], DPGN is the broader pathological category often associated with the initial aggressive proliferative phase in systemic vasculitis. * **C. Focal Proliferative GN:** This is seen in milder clinical cases of HSP where renal function is usually preserved. * **D. Membranoproliferative GN (MPGN):** This is characterized by "tram-track" basement membrane splitting and is typically associated with Hepatitis C or complement dysregulation, not classic HSP. **High-Yield Clinical Pearls for NEET-PG:** * **HSP Tetrad:** Purpura (non-thrombocytopenic), Arthralgia, Abdominal pain, and Renal disease. * **Pathogenesis:** Systemic deposition of **IgA1-containing immune complexes**. * **Biopsy Gold Standard:** Immunofluorescence showing **mesangial IgA deposits** [1]. * **Prognosis:** Generally excellent in children, but the presence of RBC casts and nephritic/nephrotic range proteinuria indicates a higher risk of chronic kidney disease.

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Oncology — MCQs

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