Oncology — MCQs
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A 56-year-old man is evaluated for a recent onset painful skin lesion involving his abdominal wall. The lesion started 3 days ago as a small erythematous macule which has gradually increased in size to a large purpuric lesion with bulla formation. He is afebrile and does not recall any trauma. His medical history is significant for atrial fibrillation; he was recently switched from rivaroxaban to warfarin due to the high cost of rivaroxaban. What is the most probable cause of the condition?
Brain metastasis are common among which of the following malignancies?
Which of the following is the most likely type of thyroid cancer with the best prognosis of all thyroid malignancies?
Tumor lysis syndrome is characterized by:
Which of the following are characteristic biochemical features of tumor lysis syndrome?
Which of the following is NOT part of the ABVD regimen for chemotherapeutic treatment of Non-Hodgkin's Lymphoma?
A patient with leukemia on chemotherapy develops acute right lower abdominal pain associated with anemia, thrombocytopenia, and leukopenia. What is the clinical diagnosis?
A 28-year-old man presents with a new onset rash on both legs for 1 week. He has no past medical history and is not taking any medications. He denies recent fever but reports occasional gum bleeding and one episode of epistaxis 4 days ago. He is a non-smoker, drinks alcohol socially, and denies recreational drug use. Physical examination reveals no lymphadenopathy or hepatosplenomegaly. Laboratory studies show hemoglobin 14.8 gm/dL, hematocrit 42%, MCV 86 fL, leukocyte count 6,000/mL, and platelet count 22,000/mL. Liver and renal function tests are normal. Peripheral smear shows decreased platelet count with no red cell abnormalities. What is the most probable diagnosis?
A 53-year-old woman presents with a 1-cm invasive carcinoma of the breast, detected on mammography. She feels well and has no other symptoms. On examination the lump is palpable, and there are no axillary lymph nodes. Which of the following is the most appropriate local therapy for her tumor?
Stauffer syndrome is associated with which of the following malignancies?
Oncology Indian Medical PG Practice Questions and MCQs
Question 161: A 56-year-old man is evaluated for a recent onset painful skin lesion involving his abdominal wall. The lesion started 3 days ago as a small erythematous macule which has gradually increased in size to a large purpuric lesion with bulla formation. He is afebrile and does not recall any trauma. His medical history is significant for atrial fibrillation; he was recently switched from rivaroxaban to warfarin due to the high cost of rivaroxaban. What is the most probable cause of the condition?
- A. Rivaroxaban
- B. Low-molecular-weight heparin
- C. Warfarin (Correct Answer)
- D. Low dose aspirin (81 mg/d)
Explanation: ### Explanation The clinical presentation describes **Warfarin-induced Skin Necrosis (WISN)**, a rare but serious complication of oral anticoagulant therapy. **1. Why Warfarin is Correct:** Warfarin inhibits Vitamin K epoxide reductase, leading to a decrease in Vitamin K-dependent clotting factors (II, VII, IX, X) and anticoagulant proteins (Protein C and Protein S). Protein C has a significantly shorter half-life (~6 hours) compared to procoagulant factors like Factor II (~60 hours) and Factor X (~40 hours). During the initial phase of warfarin therapy, Protein C levels drop rapidly, creating a transient **prothrombotic state**. This leads to microvascular thrombosis, skin ischemia, and subsequent necrosis. It typically occurs 3–10 days after starting therapy, often in areas with high subcutaneous fat (breasts, thighs, abdomen). **2. Why Incorrect Options are Wrong:** * **Rivaroxaban (A):** As a direct Factor Xa inhibitor, it does not affect Protein C/S levels and is not associated with skin necrosis. In fact, switching *from* rivaroxaban *to* warfarin triggered this event. * **Low-molecular-weight heparin (B):** LMWH is actually used to *prevent* WISN by providing "bridging" anticoagulation until a stable INR is reached. * **Low dose aspirin (D):** Aspirin is an antiplatelet agent. While it can cause bruising, it does not cause the characteristic purpuric bullae and necrosis seen in this patient. **3. High-Yield Pearls for NEET-PG:** * **Risk Factor:** Underlying **Protein C deficiency** is the most common predisposing factor. * **Prevention:** Always "bridge" with Heparin/LMWH when starting Warfarin in high-risk patients. * **Management:** Immediate cessation of Warfarin, administration of Vitamin K, and giving **Protein C concentrate** or Fresh Frozen Plasma (FFP). * **Differential:** Do not confuse with *Calciphylaxis* (seen in ESRD) or *Heparin-induced Thrombocytopenia (HIT)*.
Question 162: Brain metastasis are common among which of the following malignancies?
- A. Breast (Correct Answer)
- B. Testis
- C. Thyroid
- D. Tongue
Explanation: ### Explanation Brain metastases are the most common intracranial tumors in adults, occurring in approximately 20–40% of all cancer patients. The correct answer is **Breast** because it is one of the top three primary sources of brain metastases. **1. Why Breast Cancer is Correct:** The incidence of brain metastasis depends on the primary site. The most common primaries, in order of frequency, are: * **Lung Cancer (40–50%):** The most common overall [1]. * **Breast Cancer (15–25%):** The second most common. It is particularly prevalent in HER2-positive and Triple-Negative subtypes. * **Melanoma (5–20%):** Has the highest *propensity* (likelihood per case) to spread to the brain. * **Renal Cell Carcinoma and Colon Cancer.** **2. Why Other Options are Incorrect:** * **Testis:** While germ cell tumors can spread to the brain (especially choriocarcinoma), they are far less common statistically than breast cancer. * **Thyroid:** Brain metastasis from thyroid cancer is rare (approx. 1%), usually occurring only in advanced papillary or follicular stages. * **Tongue:** Squamous cell carcinomas of the head and neck typically spread via local invasion or to regional lymph nodes; distant metastasis to the brain is highly unusual. **Clinical Pearls for NEET-PG:** * **Location:** 80% of brain metastases occur in the **cerebral hemispheres**, 15% in the cerebellum, and 5% in the brainstem (proportional to blood flow). * **The "Water-Shed" Zone:** Metastases often lodge at the junction of the gray and white matter where blood vessel caliber narrows. * **Multiplicity:** Metastatic lesions are typically multiple and well-circumscribed with significant peritumoral edema. * **Highest Propensity:** If the question asks which cancer has the *highest percentage* of its patients developing brain mets, the answer is **Melanoma**. If it asks for the *most common* source, it is **Lung** [1].
Question 163: Which of the following is the most likely type of thyroid cancer with the best prognosis of all thyroid malignancies?
- A. Anaplastic thyroid cancer
- B. Follicular cancer of the thyroid
- C. Lymphoma of the thyroid
- D. Papillary cancer of the thyroid (Correct Answer)
Explanation: **Explanation:** **1. Why Papillary Thyroid Cancer (PTC) is the correct answer:** Papillary thyroid cancer is the most common type of thyroid malignancy (accounting for approximately 80–85% of cases). It is characterized by an **excellent prognosis**, with a 10-year survival rate exceeding 90–95%. The favorable outcome is due to its slow-growing nature, high responsiveness to radioactive iodine (RAI) therapy [1], and tendency to remain localized or spread only to regional lymph nodes rather than distant organs. **2. Why the other options are incorrect:** * **Anaplastic Thyroid Cancer:** This is the most aggressive thyroid malignancy with the **worst prognosis**. It is rapidly enlarging, often fatal within months, and shows poor response to treatment. * **Follicular Thyroid Cancer:** While it has a good prognosis, it is generally considered more aggressive than PTC because it tends to spread **hematogenously** (via blood) to distant sites like bone and lungs. * **Lymphoma of the Thyroid:** Usually associated with Hashimoto’s thyroiditis, its prognosis depends on the histological subtype (e.g., MALT vs. DLBCL) [2], but it does not surpass the survival rates of PTC. **3. High-Yield Clinical Pearls for NEET-PG:** * **Psammoma bodies:** Concentric calcifications seen on histology (pathognomonic for PTC). * **Orphan Annie Eye Nuclei:** Large, pale, clear nuclei seen in PTC. * **Risk Factor:** Prior exposure to ionizing radiation is the most significant risk factor for PTC. * **Genetic Association:** *BRAF* mutations (most common) and *RET/PTC* rearrangements. * **Staging:** In patients <55 years, the TNM staging system only uses Stage I and II, reflecting the excellent prognosis in younger individuals.
Question 164: Tumor lysis syndrome is characterized by:
- A. Hyperkalemia
- B. Hyperphosphatemia
- C. Hyperuricemia
- D. All of the above (Correct Answer)
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 for high-grade hematologic 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 "All of the above" is correct: * Hyperkalemia (Option A): Potassium is the primary intracellular cation. Rapid cell lysis floods the bloodstream with potassium, which is the most immediate life-threatening complication due to the risk of cardiac arrhythmias. * Hyperphosphatemia (Option B): Malignant cells contain significantly higher concentrations of phosphorus than normal cells. Their destruction leads to hyperphosphatemia, which can cause secondary hypocalcemia (as phosphate binds to calcium, forming crystals). * Hyperuricemia (Option C): The breakdown of nucleic acids (purines) from the tumor's DNA is metabolized by the liver into uric acid [1]. Excessive levels lead to the precipitation of uric acid crystals in the renal tubules, causing acute kidney injury (AKI). In conditions like leukemia, uric acid production is increased because of the increased breakdown of uric acid-rich white blood cells [1]. Clinical Pearls for NEET-PG: 1. 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 starting chemotherapy. 2. The "Low" Exception: Remember that while most electrolytes go "Up," Calcium goes "Down" (Hypocalcemia). 3. Prophylaxis/Treatment: Aggressive IV hydration is the mainstay. Rasburicase (recombinant urate oxidase) is the drug of choice for high-risk patients as it converts uric acid to soluble allantoin. Allopurinol is used for prophylaxis but does not reduce pre-existing uric acid.
Question 165: Which of the following are characteristic biochemical features of tumor lysis syndrome?
- A. Hyperuricemia, Hyperkalemia, Hypernatremia
- B. Hypercalcemia, Hyperkalemia, Hypernatremia
- C. Hyperuricemia, Hyperkalemia, Hyperphosphatemia (Correct Answer)
- D. Hyperuricemia, Hyperkalemia, Hypercalcemia
Explanation: **Explanation:** Tumor Lysis Syndrome (TLS) is an oncologic emergency caused by the rapid destruction of a large number of neoplastic cells, typically following chemotherapy for high-grade hematologic 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 [1]. **Why Option C is Correct:** The hallmark biochemical features of TLS are: 1. **Hyperuricemia:** Catabolism of nucleic acids (purines) into uric acid [1], [2]. 2. **Hyperkalemia:** Release of intracellular potassium. 3. **Hyperphosphatemia:** Release of intracellular organic phosphates. 4. **Hypocalcemia (Secondary):** Elevated phosphate binds to calcium, causing calcium phosphate precipitation in the kidneys. **Why Other Options are Incorrect:** * **Options A & B (Hypernatremia):** Sodium is the primary extracellular cation. Cell lysis does not significantly increase serum sodium levels; in fact, renal failure associated with TLS may lead to fluid retention and dilutional hyponatremia. * **Options B & D (Hypercalcemia):** TLS is characterized by **hypocalcemia**, not hypercalcemia. Hypercalcemia is a separate paraneoplastic syndrome (often associated with PTHrP production in solid tumors). **NEET-PG High-Yield Pearls:** * **Cairo-Bishop Definition:** The standard clinical and laboratory criteria used to diagnose TLS. * **Renal Impact:** Uric acid and calcium phosphate crystals precipitate in the renal tubules, leading to **Acute Kidney Injury (AKI)**. * **Prophylaxis/Treatment:** Aggressive hydration is the most important step. **Allopurinol** prevents new uric acid formation, while **Rasburicase** (recombinant urate oxidase) breaks down existing uric acid into the more soluble allantoin. * **ECG Changes:** Monitor for peaked T-waves due to hyperkalemia and prolonged QT interval due to hypocalcemia.
Question 166: Which of the following is NOT part of the ABVD regimen for chemotherapeutic treatment of Non-Hodgkin's Lymphoma?
- A. Doxorubicin
- B. Dacarbazine
- C. Bleomycin
- D. Vincristine (Correct Answer)
Explanation: The **ABVD regimen** is the gold standard first-line chemotherapy for **Hodgkin Lymphoma (HL)** [1]. The question asks which drug is NOT part of this regimen in the context of Non-Hodgkin's Lymphoma (NHL). ### **Explanation of the Correct Answer** **D. Vincristine** is the correct answer because it is not a component of the ABVD regimen. Vincristine is, however, a key component of the **CHOP** or **R-CHOP** regimens, which are the standard treatments for **Non-Hodgkin Lymphoma (NHL)** [1]. It is also part of the older MOPP regimen for Hodgkin Lymphoma. ### **Analysis of Incorrect Options** The acronym **ABVD** stands for: * **A: Adriamycin (Doxorubicin):** An anthracycline that inhibits topoisomerase II. (Option A) * **B: Bleomycin:** A glycopeptide antibiotic that causes DNA strand breaks. (Option C) * **V: Vinblastine:** A microtubule inhibitor (vinca alkaloid). Note that while Vincristine and Vinblastine are in the same class, they are not interchangeable in this regimen. * **D: Dacarbazine:** An alkylating agent. (Option B) ### **Clinical Pearls for NEET-PG** * **Regimen Distinction:** Remember **ABVD for Hodgkin Lymphoma** and **CHOP for Non-Hodgkin Lymphoma**. * **Specific Toxicities (High Yield):** * **Doxorubicin:** Dilated Cardiomyopathy (monitor with ECHO/MUGA scan). * **Bleomycin:** Pulmonary Fibrosis (monitor with Pulmonary Function Tests/DLCO). * **Vinblastine:** Bone marrow suppression (unlike Vincristine, which is more neurotoxic). * **Vincristine:** Peripheral neuropathy and paralytic ileus. * **Historical Note:** ABVD replaced the MOPP regimen because it has a lower risk of causing secondary leukemia and sterility.
Question 167: A patient with leukemia on chemotherapy develops acute right lower abdominal pain associated with anemia, thrombocytopenia, and leukopenia. What is the clinical diagnosis?
- A. Appendicitis
- B. Leukemic colitis
- C. Perforation peritonitis
- D. Neutropenic colitis (Correct Answer)
Explanation: ### Explanation **Neutropenic colitis** (also known as **Typhlitis**) is the correct diagnosis. It is a life-threatening necrotizing inflammation of the cecum and ascending colon occurring in immunocompromised patients, typically those with profound neutropenia (Absolute Neutrophil Count < 500/mm³) following chemotherapy for hematologic malignancies like leukemia. **Why it is the correct answer:** The clinical triad of **fever, neutropenia, and right lower quadrant (RLQ) pain** in a patient undergoing chemotherapy is classic for typhlitis. The pathogenesis involves mucosal injury by chemotherapy, which, in the setting of neutropenia, allows for bacterial or fungal invasion of the bowel wall (most commonly the cecum), leading to transmural inflammation and potential necrosis. **Analysis of Incorrect Options:** * **A. Appendicitis:** While it presents with RLQ pain, it is less common than typhlitis in neutropenic patients. Surgery for suspected appendicitis in a neutropenic patient can be easily mistaken as the primary diagnosis [1]. Surgery in a neutropenic patient can be fatal; hence, typhlitis must be ruled out first via CT scan (showing cecal wall thickening >4mm). * **B. Leukemic colitis:** This refers to direct infiltration of the colon by leukemic cells, which usually occurs at the time of diagnosis or relapse, not typically as an acute complication during chemotherapy-induced cytopenia. * **C. Perforation peritonitis:** While this can be a *complication* of neutropenic colitis, the primary clinical diagnosis based on the initial presentation of pain and cytopenia is the underlying colitis itself. **Clinical Pearls for NEET-PG:** * **Most common site:** Cecum (due to its distensibility and limited vascularity). * **Investigation of Choice:** **CT Scan of the abdomen** (shows bowel wall thickening and pericolic fat stranding). * **Management:** Primarily medical (bowel rest, IV fluids, and broad-spectrum antibiotics). Surgery is reserved for perforation or uncontrolled hemorrhage. * **Common organisms:** *Clostridium septicum*, *Pseudomonas aeruginosa*, and *E. coli*.
Question 168: A 28-year-old man presents with a new onset rash on both legs for 1 week. He has no past medical history and is not taking any medications. He denies recent fever but reports occasional gum bleeding and one episode of epistaxis 4 days ago. He is a non-smoker, drinks alcohol socially, and denies recreational drug use. Physical examination reveals no lymphadenopathy or hepatosplenomegaly. Laboratory studies show hemoglobin 14.8 gm/dL, hematocrit 42%, MCV 86 fL, leukocyte count 6,000/mL, and platelet count 22,000/mL. Liver and renal function tests are normal. Peripheral smear shows decreased platelet count with no red cell abnormalities. What is the most probable diagnosis?
- A. Acute lymphoblastic leukemia
- B. Immune thrombocytopenic purpura (Correct Answer)
- C. Leukemoid reaction
- D. Chronic lymphocytic leukemia
Explanation: **Explanation:** The patient presents with **isolated thrombocytopenia** (platelets 22,000/mL) in the absence of anemia, leukopenia, or systemic symptoms like fever, lymphadenopathy, or hepatosplenomegaly. This clinical picture is classic for **Immune Thrombocytopenic Purpura (ITP)**. **Why ITP is the correct answer:** ITP is an acquired autoimmune disorder characterized by the immune-mediated destruction of platelets [1]. In adults, it often presents as a diagnosis of exclusion. Key diagnostic features seen here include: * **Isolated thrombocytopenia:** Normal Hb and WBC counts. * **Normal peripheral smear:** No schistocytes (ruling out TTP/HUS) or blasts (ruling out leukemia). * **Clinical presentation:** Mucocutaneous bleeding (epistaxis, gum bleeding) and petechiae/purpura (the "rash" on the legs) without systemic illness [2], [3]. **Why the other options are incorrect:** * **Acute Lymphoblastic Leukemia (ALL):** Typically presents with "B-symptoms" (fever, weight loss), lymphadenopathy, hepatosplenomegaly, and significant abnormalities in other cell lines (anemia, high/low WBC) with blasts on the smear. * **Leukemoid Reaction:** This is an exaggerated WBC response (>50,000/mL) to infection or stress. This patient has a normal leukocyte count (6,000/mL). * **Chronic Lymphocytic Leukemia (CLL):** Usually seen in older adults (>60 years) and presents with significant lymphocytosis and lymphadenopathy. **High-Yield Pearls for NEET-PG:** * **ITP Treatment:** Start steroids if platelets <30,000/mL or if significant bleeding occurs. IVIG is used for rapid platelet elevation. * **Bone Marrow:** In ITP, bone marrow shows **increased megakaryocytes** (compensatory response). * **Secondary ITP:** Always screen for underlying HIV, Hepatitis C, or SLE in adults diagnosed with ITP [1].
Question 169: A 53-year-old woman presents with a 1-cm invasive carcinoma of the breast, detected on mammography. She feels well and has no other symptoms. On examination the lump is palpable, and there are no axillary lymph nodes. Which of the following is the most appropriate local therapy for her tumor?
- A. Simple mastectomy with axillary dissection
- B. Radiation therapy to breast and axilla
- C. Local excision plus radiation therapy
- D. Local excision and axillary dissection followed by radiation therapy (Correct Answer)
Explanation: ### Explanation The management of early-stage breast cancer (Stage I and II) focuses on **Breast Conservation Therapy (BCT)**, which is equivalent in survival outcomes to a modified radical mastectomy. **1. Why Option D is Correct:** For a 1-cm invasive carcinoma (T1) with clinically negative nodes (N0), the standard of care is **Local Excision (Lumpectomy)** combined with **Axillary Lymph Node Evaluation** (either dissection or sentinel lymph node biopsy) and **Post-operative Radiation Therapy**. * **Local Excision:** Removes the primary tumor with clear margins. * **Axillary Dissection/Evaluation:** Essential for staging and determining the need for adjuvant systemic therapy, even if nodes are not palpable. * **Radiation:** Mandatory after breast-conserving surgery to reduce the risk of local recurrence. **2. Why Other Options are Incorrect:** * **Option A:** Simple mastectomy removes the breast but ignores the axilla. While mastectomy is an option, BCT (Option D) is preferred for a small 1-cm tumor as it preserves the breast with equal survival. * **Option B:** Radiation alone is not a primary treatment for invasive carcinoma; surgical excision of the primary tumor is required. * **Option C:** This omits axillary dissection/evaluation. In invasive carcinoma, staging the axilla is mandatory to guide further management. **3. Clinical Pearls for NEET-PG:** * **BCT Criteria:** Tumor size <5 cm, favorable tumor-to-breast ratio, and no contraindications to radiation (e.g., pregnancy, prior chest wall radiation, or multicentric disease). * **Sentinel Lymph Node Biopsy (SLNB):** Currently the preferred method for axillary staging in clinically N0 patients to avoid the morbidity of full axillary dissection. * **Survival:** Large trials (like the NSABP B-06) proved that Lumpectomy + Radiation has the **same long-term survival** as Mastectomy.
Question 170: Stauffer syndrome is associated with which of the following malignancies?
- A. Renal cell carcinoma (Correct Answer)
- B. Neuroblastoma
- C. Prostate cancer
- D. Small cell carcinoma of the lung
Explanation: ### Explanation **Stauffer syndrome** is a rare paraneoplastic syndrome characterized by **non-metastatic hepatic dysfunction** in the presence of **Renal Cell Carcinoma (RCC)** [1]. **1. Why Renal Cell Carcinoma (RCC) is correct:** The underlying pathophysiology involves the systemic release of cytokines, specifically **Interleukin-6 (IL-6)**, by the tumor cells. This leads to cholestasis and liver enzyme derangements (elevated alkaline phosphatase, bilirubin, and prolonged prothrombin time) without any evidence of direct liver metastases or primary biliary disease [1]. A classic clinical feature is that the hepatic dysfunction typically **resolves following a nephrectomy** (removal of the primary tumor). **2. Why the other options are incorrect:** * **Small cell carcinoma of the lung:** Known for various paraneoplastic syndromes (SIADH, ACTH production, Lambert-Eaton syndrome), but hepatic dysfunction without metastasis is not its hallmark [2]. **3. NEET-PG High-Yield Pearls:** * **Triad of RCC:** Hematuria, flank pain, and palpable mass (seen in only 10% of cases) [1]. * **Other RCC Paraneoplastic Syndromes:** Polycythemia (due to Erythropoietin), Hypercalcemia (due to PTHrP), and Hypertension (due to Renin).
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