Which is the most commonly used chemotherapy regimen in the adjuvant treatment following modified radical mastectomy in the estrogen receptor negative 35 year old female with breast cancer?
Q222
Consider the following statements: Poor prognostic indicators in advanced germ cell tumours show
1. primary sites in mediastinum
2. non-pulmonary metastasis
3. lactate dehydrogenase more than 10 times of normal value Which of the statements given above are correct?
Q223
A 50 year old male presented with pain along the left arm and ptosis. His chest X-ray showed soft tissue opacity at the apex of the left lung along with the erosion of the adjacent rib. The probable diagnosis is:
Q224
First line hormone therapy for post-menopausal woman with metastatic carcinoma breast is:
Q225
An 85-year-old male with prostate cancer, Gleason score of 6 , and PSA <8 ng/mL. What is the best management approach?
Q226
A 60-year-old male patient has an antral carcinoma spreading to the head of the pancreas with multiple small metastases to the right lobe of the liver. What is the best treatment approach?
Q227
A patient presents with a mediastinal mass and is diagnosed with pure red cell aplasia. What is the most probable underlying cause?
Q228
KEYNOTE-189 trial for pembrolizumab is done for?
Q229
A 55-year-old female smoker presents with a breast lump and is seeking medical evaluation. On examination, a palpable mass is detected in the breast. The patient's smoking history is significant, with a 30-year smoking habit. Which of the following conditions is strongly associated with smoking in relation to breast health?
Q230
A 62-year-old man presents with “yellowing” of the skin. He says he has been having intermittent upper abdominal pain, which is relieved by Tylenol. He also recalls that he has lost some weight over the past several months but can not quantify the amount. His past medical history is significant for type 2 diabetes mellitus. He reports a 40-pack-year smoking history. The patient is afebrile and vital signs are within normal limits. Physical examination reveals mild jaundice and a palpable gallbladder. Laboratory findings are significant for the following:
Total bilirubin 13 mg/dL
Direct bilirubin: 10 mg/dL
Alkaline phosphatase (ALP): 560 IU/L
An ultrasound of the abdomen reveals a hypoechoic mass in the epigastric region. The patient is scheduled for a CT abdomen and pelvis with specific organ protocol for further evaluation. Which of the following best describes this patient’s most likely diagnosis?
Oncology Indian Medical PG Practice Questions and MCQs
Question 221: Which is the most commonly used chemotherapy regimen in the adjuvant treatment following modified radical mastectomy in the estrogen receptor negative 35 year old female with breast cancer?
A. Adriamycin + 5-Fluorouracil
B. Cyclophosphamide + Adriamycin + 5-Fluorouracil (Correct Answer)
C. Cyclophosphamide + 5-Fluorouracil
D. Cyclophosphamide + Methotrexate + 5-Fluorouracil
Explanation: ***Cyclophosphamide + Adriamycin + 5-Fluorouracil***
- The **CAF** (Cyclophosphamide, Adriamycin, 5-Fluorouracil) or **FAC** regimen is a widely used and effective **combination chemotherapy** for adjuvant treatment in **ER-negative breast cancer**, offering a robust approach to systemic control.
- This regimen addresses the aggressive nature of **ER-negative tumors**, for which **endocrine therapy** is not an option, and aims to eradicate micrometastases reducing recurrence risk.
*Adriamycin + 5-Fluorouracil*
- While both **Adriamycin** and **5-Fluorouracil** are active agents in breast cancer, this two-drug combination in isolation is generally considered less potent than multi-agent regimens, particularly for **ER-negative disease**.
- It lacks the additional mechanism of action and efficacy provided by **cyclophosphamide**, which is a key component in many standard regimens for this aggressive tumor subtype.
*Cyclophosphamide + 5-Fluorouracil*
- This two-drug regimen is not a standard frontline or the most common adjuvant chemotherapy for ER-negative breast cancer due to its relatively lower efficacy compared to regimens that include an **anthracycline** like Adriamycin.
- The absence of an **anthracycline** like Adriamycin, which is a powerful agent against breast cancer, limits its overall effectiveness in a setting where aggressive systemic treatment is crucial.
*Cyclophosphamide + Methotrexate + 5-Fluorouracil*
- The **CMF** (Cyclophosphamide, Methotrexate, 5-Fluorouracil) regimen was historically a foundational adjuvant therapy; however, for **ER-negative breast cancer**, regimens containing an **anthracycline** like Adriamycin are generally preferred due to their superior efficacy.
- While effective, **CMF** is often considered less potent than anthracycline-containing regimens like **CAF/FAC** in treating aggressive, **ER-negative tumors**, which typically benefit from the broader cytotoxic activity of an anthracycline.
Question 222: Consider the following statements: Poor prognostic indicators in advanced germ cell tumours show
1. primary sites in mediastinum
2. non-pulmonary metastasis
3. lactate dehydrogenase more than 10 times of normal value Which of the statements given above are correct?
A. 1 and 2 only
B. 2 and 3 only
C. 1, 2 and 3 (Correct Answer)
D. 1 and 3 only
Explanation: ***1, 2 and 3***
- **All three statements** represent poor prognostic indicators in advanced germ cell tumors, as defined by the **International Germ Cell Cancer Collaborative Group (IGCCCG)** classification.
- A primary site in the **mediastinum**, the presence of **non-pulmonary visceral metastases**, and **LDH levels >10 times the upper limit of normal** are all independent factors associated with a worse prognosis.
*1 and 2 only*
- This option is incorrect because it excludes a critically important poor prognostic indicator: **markedly elevated lactate dehydrogenase (LDH)**.
- While mediastinal primary and non-pulmonary metastases are poor prognostic factors, high LDH further defines the **poor risk group**. [1]
*2 and 3 only*
- This option is incorrect as it omits the significance of a **mediastinal primary site** as a poor prognostic factor in advanced germ cell tumors.
- **Mediastinal germ cell tumors** are known to have a worse prognosis compared to testicular primaries, even in the absence of other poor risk factors.
*1 and 3 only*
- This option is incorrect because it fails to include **non-pulmonary metastases** as a distinct poor prognostic factor for advanced germ cell tumors.
- The presence of metastases to sites like the **liver, brain, or bone** significantly worsens the prognosis compared to lung-only metastases.
Question 223: A 50 year old male presented with pain along the left arm and ptosis. His chest X-ray showed soft tissue opacity at the apex of the left lung along with the erosion of the adjacent rib. The probable diagnosis is:
A. Pancoast lung (Correct Answer)
B. Bronchial carcinoma
C. Lung abscess
D. Adenocarcinoma of lung
Explanation: ***Pancoast lung***
- A **Pancoast tumor** (superior sulcus tumor) is a **non-small cell lung cancer** located at the apex of the lung, typically invading adjacent structures.
- This invasion can lead to **Pancoast syndrome**, characterized by **shoulder and arm pain** (due to brachial plexus involvement) and **Horner's syndrome** (ptosis, miosis, anhidrosis due to sympathetic chain involvement), often accompanied by rib erosion [1].
*Bronchial carcinoma*
- While a Pancoast tumor is a type of **bronchial carcinoma** (lung cancer), this option is too general and doesn't specify the unique apical location and associated neurological symptoms [1].
- Bronchial carcinomas can present with a wide range of symptoms, including cough, hemoptysis, and weight loss, but the specific triad of symptoms described points to a particular subtype.
*Lung abscess*
- A **lung abscess** is a pus-filled cavity in the lung, usually caused by bacterial infection, and typically presents with fever, cough with purulent sputum, and sometimes pleuritic chest pain.
- It does not typically cause **arm pain**, **ptosis**, or **rib erosion** unless there is direct extension from the abscess, which is uncommon and not the primary presentation.
*Adenocarcinoma of lung*
- **Adenocarcinoma** is a subtype of **non-small cell lung cancer**, but it is generally located in the periphery of the lung and is less likely to present with the classic **Pancoast syndrome** symptoms [1].
- While it can be found in the apex, the specific clinical presentation (arm pain, ptosis, rib erosion) points more strongly to the syndrome that results from apical tumor location rather than just the histological type.
Question 224: First line hormone therapy for post-menopausal woman with metastatic carcinoma breast is:
A. Ovarian suppression by surgery
B. Antiprogestins
C. Tamoxifen
D. Anastrazole (Correct Answer)
Explanation: ***Anastrazole***
- **Aromatase inhibitors** like anastrozole are the preferred first-line hormone therapy for **post-menopausal women** with **hormone-receptor-positive metastatic breast cancer**.
- They work by **blocking the aromatase enzyme**, which is responsible for estrogen production in peripheral tissues in post-menopausal women.
*Ovarian suppression by surgery*
- Ovarian suppression is primarily used in **pre-menopausal women** to reduce estrogen production by the ovaries.
- Since the patient is **post-menopausal**, her ovaries are no longer the primary source of estrogen production.
*Antiprogestins*
- **Antiprogestins** are not standard first-line hormone therapy for metastatic breast cancer.
- While some progestational agents have been used in breast cancer treatment, **antiprogestins** are not established as a primary treatment.
*Tamoxifen*
- **Tamoxifen** is a **selective estrogen receptor modulator (SERM)** that has been widely used in breast cancer treatment.
- While effective, **aromatase inhibitors** are generally preferred over tamoxifen as first-line therapy for **post-menopausal metastatic breast cancer** due to superior efficacy and tolerability profiles in this demographic.
Question 225: An 85-year-old male with prostate cancer, Gleason score of 6 , and PSA <8 ng/mL. What is the best management approach?
A. Active surveillance/Watchful waiting (Correct Answer)
B. Radical prostatectomy
C. External beam radiation therapy
D. Androgen deprivation therapy
Explanation: Androgen deprivation therapy
- **Hormonal therapy** is primarily used for advanced, metastatic, or high-risk localized prostate cancer [1], or as an adjunct to radiation therapy.
- It is not indicated as a primary first-line treatment for **low-risk, localized prostate cancer** in an elderly patient, as its side effects (e.g., hot flashes, fatigue, bone loss, cardiovascular effects) can significantly impact quality of life without offering a survival advantage in this specific scenario.
Question 226: A 60-year-old male patient has an antral carcinoma spreading to the head of the pancreas with multiple small metastases to the right lobe of the liver. What is the best treatment approach?
A. Surgical resection with adjuvant chemotherapy
B. Radiation therapy alone
C. Palliative chemotherapy (Correct Answer)
D. Supportive care only
Explanation: Palliative chemotherapy
- The presence of **multiple small metastases** in the liver indicates **metastatic disease**, which is generally considered incurable with surgery [2].
- **Palliative chemotherapy** aims to control disease progression, alleviate symptoms, and improve quality of life in patients with advanced metastatic cancer.
Surgical resection with adjuvant chemotherapy
- **Surgical resection** is not indicated due to the presence of **distant metastases** (to the liver), classifying the disease as Stage IV [1].
- **Adjuvant chemotherapy** is given after curative surgery to reduce recurrence risk, which is not the goal here as the disease is already metastatic.
Radiation therapy alone
- **Radiation therapy alone** is typically reserved for localized disease or for palliative symptom management (e.g., pain from bone metastases), not for widespread metastatic disease.
- It would not adequately address the systemic nature of **multiple liver metastases** from a pancreatic primary.
Supportive care only
- While supportive care is crucial, **palliative chemotherapy** offers a chance to prolong survival and manage symptoms more effectively than supportive care alone in suitable patients with advanced pancreatic cancer.
- Skipping chemotherapy entirely would mean foregoing potential benefits in terms of disease control and quality of life, especially for patients with a good performance status.
Question 227: A patient presents with a mediastinal mass and is diagnosed with pure red cell aplasia. What is the most probable underlying cause?
A. Bronchogenic carcinoma
B. T-cell Acute Lymphoblastic Leukemia
C. Non-Hodgkin Lymphoma
D. Thymic neoplasia (Correct Answer)
Explanation: ***Thymic neoplasia***
- **Thymoma** is strongly associated with **pure red cell aplasia (PRCA)**, where the body's immune system, influenced by the abnormal thymus, attacks and destroys red blood cell precursors in the bone marrow.
- A mediastinal mass, particularly in an adult presenting with PRCA, should raise strong suspicion for a **thymic tumor**.
*Bronchogenic carcinoma*
- While bronchogenic carcinoma can present as a **mediastinal mass**, it is not typically associated with **pure red cell aplasia**.
- Its paraneoplastic syndromes usually involve endocrine or neurological manifestations rather than direct hematopoietic suppression of red cell precursors.
*T-cell Acute Lymphoblastic Leukemia*
- **T-cell ALL** can present with a **mediastinal mass** due to thymic involvement, but it causes **pancytopenia** or **anemia** due to bone marrow infiltration by leukemic cells, not a selective aplasia of red cell precursors.
- In T-cell ALL, there would be a proliferation of immature lymphoid cells, differentiating it from PRCA.
*Non-Hodgkin Lymphoma*
- Certain types of **non-Hodgkin lymphoma** (e.g., lymphoblastic lymphoma) can present with a **mediastinal mass**.
- However, lymphoma would typically cause **bone marrow infiltration** leading to cytopenias, not specifically **pure red cell aplasia**, where only erythroid precursors are targeted.
Question 228: KEYNOTE-189 trial for pembrolizumab is done for?
A. Nivolumab with chemo given for NSCLC
B. Only Pembrolizumab for NSCLC
C. Pembrolizumab with chemo given for NSCLC (Correct Answer)
D. Only nivolumab for NSCLC
Explanation: ***Pembrolizumab with chemo given for NSCLC***
- The **KEYNOTE-189 trial** investigated the efficacy of **pembrolizumab** in combination with chemotherapy as first-line treatment for **metastatic nonsquamous non-small cell lung cancer (NSCLC)**.
- This trial demonstrated significant improvements in overall survival and progression-free survival, leading to the approval of pembrolizumab in this setting.
*Nivolumab with chemo given for NSCLC*
- **Nivolumab** is another PD-1 inhibitor, but studies specifically combining nivolumab with chemotherapy for NSCLC (e.g., CheckMate 227) are distinct from KEYNOTE-189.
- While both drugs are used in NSCLC, their pivotal trials and specific combination regimens differ.
*Only Pembrolizumab for NSCLC*
- Although pembrolizumab monotherapy is approved for certain NSCLC patients with high PD-L1 expression, the **KEYNOTE-189 trial specifically focused on a combination approach** with chemotherapy.
- Other KEYNOTE trials, like KEYNOTE-024, evaluated pembrolizumab monotherapy in NSCLC.
*Only nivolumab for NSCLC*
- **Nivolumab monotherapy** has been studied and approved for NSCLC, particularly in the second-line setting or for patients with high PD-L1 expression, but this was not the focus of the KEYNOTE-189 trial.
- Trials like CheckMate 017 and 057 investigated nivolumab as a single agent in NSCLC.
Question 229: A 55-year-old female smoker presents with a breast lump and is seeking medical evaluation. On examination, a palpable mass is detected in the breast. The patient's smoking history is significant, with a 30-year smoking habit. Which of the following conditions is strongly associated with smoking in relation to breast health?
A. Duct ectasia
B. Fibroadenoma
C. Mondor disease
D. Breast cancer (Correct Answer)
Explanation: ***Breast cancer*** -
**Smoking** is a well-established risk factor for various cancers, including **breast cancer**, due to the presence of carcinogens in tobacco smoke [1].
- The patient's age and palpable lump further raise suspicion for malignancy, prompting thorough investigation. [1]
*Duct ectasia*
- Characterized by widening and inflammation of the **milk ducts**, which can cause nipple discharge, tenderness, and a palpable mass.
- While smoking can be a risk factor, the more significant association in this age group and with a palpable lump leans towards malignancy.
*Fibroadenoma*
- These are **benign breast tumors** composed of glandular and stromal tissue, most common in younger women.
- They are typically rubbery, mobile masses and are not strongly linked to smoking.
*Mondor disease*
- This is a rare, **benign condition** characterized by thrombophlebitis of the superficial veins of the breast or chest wall.
- It typically presents as a painful, cord-like structure and is not directly associated with smoking.
Question 230: A 62-year-old man presents with “yellowing” of the skin. He says he has been having intermittent upper abdominal pain, which is relieved by Tylenol. He also recalls that he has lost some weight over the past several months but can not quantify the amount. His past medical history is significant for type 2 diabetes mellitus. He reports a 40-pack-year smoking history. The patient is afebrile and vital signs are within normal limits. Physical examination reveals mild jaundice and a palpable gallbladder. Laboratory findings are significant for the following:
Total bilirubin 13 mg/dL
Direct bilirubin: 10 mg/dL
Alkaline phosphatase (ALP): 560 IU/L
An ultrasound of the abdomen reveals a hypoechoic mass in the epigastric region. The patient is scheduled for a CT abdomen and pelvis with specific organ protocol for further evaluation. Which of the following best describes this patient’s most likely diagnosis?
A. Caffeine consumption is an established risk factor for this condition.
B. Patients with this condition often rapidly develop glucose intolerance and severe diabetes.
C. This condition is most common in Caucasians.
D. The majority of cases occur in the body of the pancreas.
E. CA 19-9 is a marker for this condition. (Correct Answer)
Explanation: ***CA 19-9 is a marker for this condition.***
- The patient's presentation with **painless jaundice**, **weight loss**, **palpable gallbladder (Courvoisier's sign)**, and markedly elevated **direct bilirubin** and **ALP** strongly suggests **pancreatic head adenocarcinoma**, which obstructs the common bile duct [1].
- **CA 19-9** is a widely used and clinically relevant tumor marker for **pancreatic cancer**, though its utility is primarily for monitoring treatment response and recurrence rather than initial diagnosis.
*Caffeine consumption is an established risk factor for this condition.*
- **Smoking**, not caffeine consumption, is a significant and well-established **risk factor for pancreatic cancer**, aligning with the patient's 40-pack-year history.
- Other risk factors include **chronic pancreatitis**, **obesity**, **diabetes**, and certain **hereditary syndromes** [1].
*Patients with this condition often rapidly develop glucose intolerance and severe diabetes.*
- While pancreatic cancer can cause **new-onset diabetes** or worsen pre-existing diabetes, this is typically a **consequence of the tumor** affecting pancreatic islet cells, not a characteristic of its development [1].
- The patient already has a history of **type 2 diabetes mellitus**, which is a *risk factor* for pancreatic cancer.
*This condition is most common in Caucasians.*
- **Pancreatic cancer** shows a slightly higher incidence in **African Americans** compared to Caucasians.
- The incidence generally **increases with age** and is more common in males.
*The majority of cases occur in the body of the pancreas.*
- Approximately **60-70% of pancreatic adenocarcinomas** occur in the **head of the pancreas**, consistent with the patient's presentation of obstructive jaundice and a palpable gallbladder [1].
- Tumors in the body or tail are less likely to present with jaundice early as they do not obstruct the bile duct.
