Oncology — MCQs
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A 65-year-old woman is admitted to the hospital after a stroke resulting in left hemiparesis. She has no trouble swallowing and is on a full diet. One week later, on routine biochemistry, her sodium is 128 mEq/L and osmolality is 270 mOsm/kg. She has no symptoms and is euvolemic on clinical examination. Urine sodium is 40 mEq/L and urine osmolality is 450 mOsm/kg. For the above patient with hyponatremia, select the most likely diagnosis?
Which of the following is NOT recommended for the management of Tumour lysis syndrome?
What is the diagnostic tumor marker for medullary thyroid cancer?
Which of the following conditions can present with recurrent episodes of upper limb thrombosis?
What is the commonest carcinoma in elderly males?
Which of the following is NOT a paraneoplastic manifestation of bronchogenic carcinoma?
Migratory thrombophlebitis is associated with all of the following malignancies, except:
Which of the following is the only form of Hodgkin disease (HD) more common in women?
In tumor lysis syndrome, all of the following are seen except?
Central nervous system involvement in diffuse large B-cell lymphoma (DLBCL) is not typically seen with involvement of which of the following organs?
Oncology Indian Medical PG Practice Questions and MCQs
Question 151: A 65-year-old woman is admitted to the hospital after a stroke resulting in left hemiparesis. She has no trouble swallowing and is on a full diet. One week later, on routine biochemistry, her sodium is 128 mEq/L and osmolality is 270 mOsm/kg. She has no symptoms and is euvolemic on clinical examination. Urine sodium is 40 mEq/L and urine osmolality is 450 mOsm/kg. For the above patient with hyponatremia, select the most likely diagnosis?
- A. Congestive heart failure (CHF)
- B. Extrarenal sodium and fluid losses
- C. SIADH (Correct Answer)
- D. Polydipsia
Explanation: ### Explanation The patient presents with **hypotonic hyponatremia** (Serum Na+ 128 mEq/L, Osmolality 270 mOsm/kg) in a **clinically euvolemic** state [1]. The diagnosis is **SIADH (Syndrome of Inappropriate Antidiuretic Hormone)**, likely secondary to her recent stroke (CNS insult). **1. Why SIADH is correct:** The diagnosis of SIADH is based on the following criteria: * **Hypotonic Hyponatremia:** Serum osmolality <280 mOsm/kg. * **Euvolemia:** No signs of edema (CHF/Cirrhosis) or dehydration [1]. * **Inappropriate Urine Concentration:** Urine osmolality >100 mOsm/kg (here 450 mOsm/kg) despite low serum osmolality [2]. * **Elevated Urine Sodium:** >40 mEq/L (due to pressure natriuresis and suppressed aldosterone), which confirms the kidneys are not trying to conserve sodium as they would in hypovolemia. **2. Why other options are wrong:** * **CHF:** Patients with CHF present with **hypervolemia** (edema, JVP elevation). While they have hyponatremia, their urine sodium is typically **low (<20 mEq/L)** due to RAAS activation [1]. * **Extrarenal losses:** This leads to **hypovolemic** hyponatremia. Clinical signs of dehydration would be present, and urine sodium would be **low (<20 mEq/L)** as the kidneys attempt to conserve salt. * **Polydipsia:** In primary polydipsia, the kidneys function normally to excrete excess water. Therefore, the urine would be **maximally dilute** (Urine Osmolality <100 mOsm/kg), unlike this patient’s concentrated urine [1]. **3. NEET-PG High-Yield Pearls:** * **Common Causes of SIADH:** Small cell lung cancer (ectopic ADH), CNS disorders (stroke, trauma, meningitis), and drugs (SSRIs, Carbamazepine, Cyclophosphamide). * **Treatment:** Fluid restriction is the first-line treatment for asymptomatic SIADH [3]. For severe symptomatic hyponatremia, use 3% hypertonic saline. * **Complication:** Rapid correction of chronic hyponatremia (>8-10 mEq/L in 24h) can lead to **Osmotic Demyelination Syndrome (Central Pontine Myelinolysis) [3].**
Question 152: Which of the following is NOT recommended for the management of Tumour lysis syndrome?
- A. Allopurinol
- B. Febuxostat
- C. Urinary alkalinisation using soda bicarbonate (Correct Answer)
- D. Rasburicase
Explanation: **Explanation:** Tumor Lysis Syndrome (TLS) is an oncologic emergency characterized by hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. While historically recommended, **Urinary Alkalinisation (Option C)** is no longer recommended in modern management guidelines [2]. **Why Urinary Alkalinisation is NOT recommended:** 1. **Risk of Calcium-Phosphate Precipitation:** While alkalization increases the solubility of uric acid, it significantly decreases the solubility of calcium phosphate [2]. In TLS, phosphate levels are high; raising urinary pH promotes calcium phosphate deposition in the renal tubules, worsening acute kidney injury (nephrocalcinosis). 2. **Metabolic Alkalosis:** It can exacerbate the clinical effects of hypocalcemia. 3. **Efficacy:** With the availability of potent urate-lowering agents like Rasburicase, the benefit of alkalization is minimal compared to its risks. **Analysis of other options:** * **Allopurinol (Option A):** A xanthine oxidase inhibitor used for **prophylaxis** in low-to-intermediate risk patients. It prevents the formation of new uric acid but does not reduce existing levels. * **Febuxostat (Option B):** A potent, selective xanthine oxidase inhibitor [1]. Recent trials (e.g., FLORENCE trial) show it is an effective alternative to allopurinol for TLS prophylaxis, especially in patients with renal impairment [1]. * **Rasburicase (Option D):** A recombinant urate oxidase that converts existing uric acid into highly soluble allantoin. It is the **treatment of choice** for established TLS or high-risk patients. **High-Yield Clinical Pearls for NEET-PG:** * **Cairo-Bishop Definition:** Used for laboratory vs. clinical TLS. * **Hydration:** Aggressive IV hydration is the cornerstone of TLS management. * **Rasburicase Contraindication:** Absolutely contraindicated in **G6PD deficiency** due to the risk of hemolysis. * **Electrolyte Hallmark:** Hyperuricemia, Hyperkalemia, Hyperphosphatemia, and **Hypocalcemia** (the only "low" electrolyte) [3].
Question 153: What is the diagnostic tumor marker for medullary thyroid cancer?
- A. BRAF
- B. VMA
- C. Calcitonin (Correct Answer)
- D. Melatonin
Explanation: **Explanation:** **Medullary Thyroid Carcinoma (MTC)** originates from the **parafollicular C-cells** of the thyroid gland. These neuroendocrine cells are embryologically derived from the neural crest and are responsible for the secretion of **Calcitonin**, a hormone involved in calcium homeostasis. Because MTC cells retain this secretory function, serum Calcitonin levels serve as a highly sensitive and specific tumor marker for diagnosis, monitoring treatment response, and detecting recurrence. **Analysis of Options:** * **A. BRAF:** This is a genetic mutation (specifically BRAF V600E) commonly associated with **Papillary Thyroid Cancer**, not Medullary. It is used for prognosis rather than as a primary diagnostic serum marker. * **B. VMA (Vanillylmandelic Acid):** This is a urinary metabolite of catecholamines used to diagnose **Pheochromocytoma**. While Pheochromocytoma is associated with MTC in MEN 2A and 2B syndromes, VMA is not a marker for the thyroid cancer itself. * **D. Melatonin:** This is a hormone secreted by the pineal gland to regulate sleep-wake cycles and has no diagnostic relevance to thyroid oncology. **High-Yield Clinical Pearls for NEET-PG:** * **Carcinoembryonic Antigen (CEA):** Also elevated in MTC and used alongside Calcitonin for prognosis. * **Genetic Screening:** All patients with MTC must be screened for **RET proto-oncogene** mutations to rule out Multiple Endocrine Neoplasia (MEN) type 2. * **Amyloid Stroma:** Histologically, MTC is characterized by nests of cells separated by amyloid deposits (formed by altered calcitonin). * **Screening:** In families with known RET mutations, prophylactic thyroidectomy is often indicated.
Question 154: Which of the following conditions can present with recurrent episodes of upper limb thrombosis?
- A. Prostatic carcinoma
- B. Pancreatic carcinoma
- C. Osteosarcoma
- D. All of the above (Correct Answer)
Explanation: This question tests your understanding of **Trousseau Syndrome** (Migratory Thrombophlebitis), a classic paraneoplastic manifestation of underlying malignancy. ### **Explanation** The underlying medical concept is **Cancer-Associated Thrombosis (CAT)**. Malignant cells produce procoagulant factors (like tissue factor and cysteine proteases) and inflammatory cytokines that activate the coagulation cascade. **Trousseau Syndrome** is characterized by recurrent, migratory episodes of venous thrombosis at unusual sites, such as the upper limbs or superficial veins [1]. While it is most classically associated with **mucin-secreting adenocarcinomas**, any advanced malignancy can trigger a hypercoagulable state [2]. * **Pancreatic Carcinoma (Option B):** This is the most common association [2]. Mucin produced by the tumor cells directly interacts with selectins, leading to microthrombi formation. * **Prostatic Carcinoma (Option A):** As an adenocarcinoma, it is a well-documented cause of systemic hypercoagulability and recurrent venous thromboembolism (VTE). * **Osteosarcoma (Option C):** While less common than adenocarcinomas, sarcomas are highly prothrombotic due to the release of membrane-bound tissue factor and tumor-derived microvesicles. ### **Clinical Pearls for NEET-PG** * **Trousseau Sign of Malignancy:** Migratory thrombophlebitis (not to be confused with Trousseau sign of latent tetany/hypocalcemia). * **Most common site:** Pancreas (tail and body > head) [2]. * **Management:** Low Molecular Weight Heparin (LMWH) is generally preferred over Warfarin for cancer-associated thrombosis, as Warfarin is often ineffective in these patients. * **High-Yield Association:** If a patient presents with "spontaneous" or "migratory" clots without obvious risk factors, the first step is to screen for an occult malignancy.
Question 155: What is the commonest carcinoma in elderly males?
- A. Stomach
- B. Lung
- C. Esophagus
- D. Prostate (Correct Answer)
Explanation: **Explanation:** The correct answer is **Prostate (Option D)**. In the elderly male population (typically defined as >65 years), **Prostate Carcinoma** is the most frequently diagnosed malignancy. The incidence of prostate cancer is strongly age-dependent; it is rare before age 40 but increases exponentially thereafter. Autopsy studies have shown that nearly 50-60% of men over the age of 80 have histological evidence of prostatic adenocarcinoma, often referred to as "latent carcinoma." **Analysis of Incorrect Options:** * **Stomach (Option A):** While historically common in India and East Asia, its incidence is declining globally. It is not the most common cancer in the elderly compared to prostate or lung. * **Lung (Option B):** Lung cancer is the leading cause of **cancer-related mortality** (deaths) in men worldwide [2], but in terms of **incidence** (new cases) in the elderly, prostate cancer ranks higher. * **Esophagus (Option C):** This is common in specific geographical belts (like the "Asian Esophageal Cancer Belt") and is associated with smoking and alcohol, but it does not surpass the prevalence of prostate cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Global vs. India:** Globally, Prostate is the commonest cancer in males. However, in **India**, according to recent ICMR data, **Lung cancer** or **Oral cavity cancer** often tops the list for males, but for the specific demographic of "elderly males" in a general medical context, Prostate remains the classic textbook answer. * **Screening:** PSA (Prostate Specific Antigen) is the screening marker, though its routine use is controversial due to overdiagnosis. * **Metastasis:** Prostate cancer characteristically spreads to the bone, causing **osteoblastic (sclerotic) lesions**, commonly involving the lumbar spine [1].
Question 156: Which of the following is NOT a paraneoplastic manifestation of bronchogenic carcinoma?
- A. Dermatomyositis
- B. Acanthosis nigricans (Correct Answer)
- C. Cerebellar degeneration
- D. Hyperkeratosis of palm and soles
Explanation: **Explanation:** Paraneoplastic syndromes are clinical syndromes involving non-metastatic systemic effects that accompany malignant disease [3]. While many cancers share similar paraneoplastic manifestations, certain signs are classically associated with specific primary tumors. **Why Acanthosis Nigricans is the correct answer:** Acanthosis nigricans (specifically the malignant type) is most strongly associated with **intra-abdominal adenocarcinomas**, with **gastric carcinoma** being the most common (approx. 55-60% of cases). While it can rarely occur with other cancers, it is not a classic paraneoplastic manifestation of bronchogenic carcinoma. **Analysis of other options:** * **Dermatomyositis (A):** This inflammatory myopathy has a strong association with several malignancies, particularly **Small Cell Lung Cancer (SCLC)** and non-small cell lung cancer, as well as ovarian and breast cancers [1]. * **Cerebellar degeneration (C):** Paraneoplastic cerebellar degeneration is a well-documented neurological manifestation of **Small Cell Lung Cancer**, often mediated by anti-Hu or anti-VGCC antibodies [3]. * **Hyperkeratosis of palms and soles (D):** Also known as **Tylosis**, this is a recognized paraneoplastic feature of **Squamous Cell Carcinoma of the Lung** (and esophagus). **NEET-PG High-Yield Pearls:** * **Small Cell Lung Cancer (SCLC):** Most common cause of SIADH, Ectopic ACTH (Cushing’s), and Lambert-Eaton Myasthenic Syndrome [1], [3]. * **Squamous Cell Carcinoma:** Most common cause of Hypercalcemia (due to PTHrP) [1]. * **Hypertrophic Osteoarthropathy (HOA):** Classically associated with Adenocarcinoma of the lung [2]. * **Leser-Trélat sign:** Sudden onset of multiple seborrheic keratoses; like malignant acanthosis nigricans, it points toward **Gastric Adenocarcinoma**.
Question 157: Migratory thrombophlebitis is associated with all of the following malignancies, except:
- A. Testis (Correct Answer)
- B. Lung
- C. Colon
- D. Pancreas
Explanation: **Explanation:** **Migratory Thrombophlebitis (Trousseau’s Syndrome)** is a paraneoplastic syndrome characterized by recurrent, spontaneous episodes of venous thrombosis that appear in different locations over time. It is classically associated with **mucin-secreting adenocarcinomas**. **1. Why Testis is the Correct Answer:** Testicular cancers (such as seminomas or non-seminomatous germ cell tumors) [1] are not typically mucin-secreting. While they can cause a hypercoagulable state due to tumor bulk or chemotherapy, they are not classically associated with the "migratory" pattern of thrombophlebitis seen in Trousseau’s Syndrome. **2. Analysis of Other Options:** * **Pancreas (Option D):** This is the **most common** association [2]. Carcinoma of the body and tail of the pancreas is the classic "textbook" cause of Trousseau’s Syndrome. * **Lung (Option B) and Colon (Option C):** Both are common sites for adenocarcinomas. These tumors produce procoagulants like **tissue factor** and **cancer procoagulant**, as well as mucins that interact with P-selectin and L-selectin, triggering the formation of microthrombi [2]. **Clinical Pearls for NEET-PG:** * **Pathophysiology:** The syndrome is driven by the interaction of circulating mucins with selectins and the release of tissue factor, leading to chronic disseminated intravascular coagulation (DIC). * **Trousseau’s Sign vs. Syndrome:** Do not confuse *Trousseau’s Syndrome* (migratory thrombophlebitis) with *Trousseau’s Sign of Latent Tetany* (carpopedal spasm induced by BP cuff inflation in hypocalcemia). * **Management:** The treatment of choice for malignancy-associated thrombosis is **Low Molecular Weight Heparin (LMWH)**, as these patients are often resistant to Warfarin.
Question 158: Which of the following is the only form of Hodgkin disease (HD) more common in women?
- A. Lymphocyte-predominant Hodgkin disease
- B. Nodular-sclerosing Hodgkin disease (Correct Answer)
- C. Mixed-cellularity Hodgkin disease
- D. Lymphocyte-depleted Hodgkin disease, reticular type
Explanation: **Explanation:** In Hodgkin Lymphoma (HL), there is a distinct gender distribution pattern. While the overall incidence of Hodgkin Lymphoma is higher in males, **Nodular Sclerosis Hodgkin Lymphoma (NSHL)** is the notable exception. It is the only subtype that shows a **female preponderance** (or an equal gender distribution depending on the study population) and is the most common subtype overall, accounting for approximately 60–80% of cases [1]. It typically affects adolescents and young adults and frequently presents with a mediastinal mass [2]. **Analysis of Options:** * **Nodular Sclerosis (Correct):** Characterized by broad bands of collagen fibrosis surrounding nodules of tumor cells and the presence of **Lacunar cells** (a variant of Reed-Sternberg cells). It is the most common subtype in females and young adults [1]. * **Lymphocyte-Predominant (Incorrect):** This subtype has a strong male predominance (approx. 3:1). It is characterized by "Popcorn cells" (L&H cells) and generally carries the best prognosis. * **Mixed-Cellularity (Incorrect):** More common in males and older patients. It is strongly associated with EBV infection and presents with a diverse inflammatory background. * **Lymphocyte-Depleted (Incorrect):** The rarest subtype, seen most often in elderly or HIV-positive males. It carries the worst prognosis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common subtype:** Nodular Sclerosis. * **Best prognosis:** Lymphocyte-Predominant. * **Worst prognosis:** Lymphocyte-Depleted. * **EBV Association:** Highest in Mixed-Cellularity and Lymphocyte-Depleted subtypes. * **Bimodal Age Distribution:** HL peaks at 15–35 years and again after 50 years. * **Reed-Sternberg (RS) Cells:** The hallmark of HL; they are CD15+ and CD30+ (except in the Nodular Lymphocyte Predominant type, which is CD20+).
Question 159: In tumor lysis syndrome, all of the following are seen except?
- A. Hypernatremia
- B. Hypercalcemia (Correct Answer)
- C. Hyperkalemia
- D. Hyperphosphatemia
Explanation: **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 the initiation of chemotherapy [1]. When these cells rupture, they release their intracellular contents into the systemic circulation, leading to specific metabolic derangements. **Why Hypercalcemia is the correct answer (The "Except"):** 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 ionized calcium, forming calcium-phosphate crystals that precipitate in soft tissues and the kidneys. This "precipitation effect" secondary to high phosphate levels results in a rapid drop in serum calcium. **Analysis of Incorrect Options:** * **Hyperkalemia (C):** Potassium is the primary intracellular cation. Rapid cell lysis releases massive amounts of potassium into the blood, which can lead to life-threatening cardiac arrhythmias. * **Hyperphosphatemia (D):** Malignant cells contain significantly higher concentrations of phosphorus than normal cells. Their destruction leads to a surge in serum phosphate. * **Hypernatremia (A):** While not a primary diagnostic hallmark like the others, hypernatremia can occur due to osmotic diuresis or aggressive treatment strategies. However, it is not the "classic" metabolic contraindication that hypercalcemia is in this context. **NEET-PG High-Yield Pearls:** * **The Metabolic Quartet of TLS:** Hyperuricemia, Hyperkalemia, Hyperphosphatemia, and **Hypocalcemia**. * **Hyperuricemia:** Caused by the breakdown of nucleic acids into purines, then into uric acid via xanthine oxidase. * **Prophylaxis/Treatment:** Aggressive hydration is first-line. **Allopurinol** (prevents new uric acid formation) or **Rasburicase** (recombinant urate oxidase that breaks down existing uric acid) are used to manage hyperuricemia. * **Renal Failure:** Acute Kidney Injury (AKI) in TLS is primarily due to the precipitation of uric acid crystals and calcium-phosphate crystals in the renal tubules.
Question 160: Central nervous system involvement in diffuse large B-cell lymphoma (DLBCL) is not typically seen with involvement of which of the following organs?
- A. Ovary (Correct Answer)
- B. Testis
- C. Kidney
- D. Adrenal gland
Explanation: In Diffuse Large B-cell Lymphoma (DLBCL), certain extranodal sites are associated with a significantly higher risk of secondary Central Nervous System (CNS) relapse. This is often due to the biological behavior of the tumor or the presence of "sanctuary sites" where systemic chemotherapy penetration is poor. [1] **Explanation of the Correct Option:** * **A. Ovary:** While DLBCL can involve the ovaries, it is **not** classically associated with an increased risk of CNS dissemination. In contrast to the male gonads, ovarian involvement does not mandate routine CNS prophylaxis in the same high-risk category as the other options listed. **Explanation of Incorrect Options:** * **B. Testis:** The testis is a classic "sanctuary site" due to the blood-testis barrier. Primary or secondary testicular DLBCL has a very high propensity (up to 15-30%) for CNS relapse. [1] * **C & D. Kidney and Adrenal Gland:** Involvement of the retroperitoneal organs, specifically the kidneys and adrenal glands, is a well-recognized independent risk factor for CNS involvement. [3] The **CNS-IPI (International Prognostic Index)** specifically includes "kidney or adrenal involvement" as a high-risk criterion. **High-Yield Clinical Pearls for NEET-PG:** * **CNS-IPI Score:** Used to predict CNS relapse. It includes the 5 standard IPI factors (Age >60, LDH >normal, Performance Status ≥2, Stage III/IV, >1 Extranodal site) **PLUS** kidney/adrenal involvement. [3] * **High-Risk Sites:** The "Rule of T's and R's" for CNS risk: **T**estis, **R**etroperitoneum (Kidney/Adrenal), and sometimes **B**one Marrow or **B**reast. * **Prophylaxis:** Patients with involvement of the testis, kidney, or adrenal glands often require CNS-directed therapy (e.g., Intrathecal Methotrexate or high-dose systemic Methotrexate) alongside R-CHOP. [2]
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