A 65-year-old man comes to the clinic complaining of abdominal pain for the past 2 months. He describes the pain as a dull, aching, 6/10 pain that is diffuse but worse in the right upper quadrant (RUQ). His past medical history is significant for diabetes controlled with metformin and a cholecystectomy 10 years ago. He reports fatigue and a 10-lb weight loss over the past month that he attributes to poor appetite; he denies fever, nausea/vomiting, palpitations, chest pain, or bowel changes. Physical examination is significant for mild scleral icterus and tenderness at the RUQ. Further workup reveals a high-grade malignant vascular neoplasm of the liver. What relevant detail would you expect to find in this patient’s history?
Q232
A 63-year-old man comes to the physician because of a 3-month history of fatigue and constipation. He reports having dull pain in the left portion of the midback for 2 weeks that has persisted despite taking ibuprofen. His father died of prostate cancer at 70 years of age. The patient has smoked one pack of cigarettes daily for 45 years. Vital signs are within normal limits. Physical examination shows a left-sided varicocele both in supine and in standing position. Rectal examination shows a symmetrically enlarged prostate with no masses. Laboratory studies show:
Hemoglobin 11.2 g/dL
Serum
Creatinine 1.0 mg/dL
Calcium 11.8 mg/dL
Urine
Protein 1+
Blood 2+
Which of the following is the most appropriate next step in management?
Q233
A 58-year-old woman comes to the physician because of constipation, loss of appetite, and increased urinary frequency for the past 8 weeks. She has a history of hypertension and underwent mastectomy for breast cancer 9 months ago. Her sister has hyperthyroidism and her mother died of complications from breast cancer at the age of 52 years. She does not smoke or drink alcohol. Current medications include chlorthalidone. Her temperature is 36.2°C (97.2°F), pulse is 102/min, and blood pressure is 142/88 mm Hg. Physical examination shows dry mucous membranes. Abdominal examination shows mild, diffuse abdominal tenderness to palpation with decreased bowel sounds. Her serum creatinine concentration is 1.2 mg/dL and serum calcium concentration is 12 mg/dL. Serum parathyroid hormone levels are decreased. Which of the following is the most appropriate long-term pharmacotherapy?
Q234
A 70-year-old man comes to the physician because of a 4-month history of epigastric pain, nausea, and weakness. He has smoked one pack of cigarettes daily for 50 years and drinks one alcoholic beverage daily. He appears emaciated. He is 175 cm (5 ft 9 in) tall and weighs 47 kg (103 lb); BMI is 15 kg/m2. He is diagnosed with gastric cancer. Which of the following cytokines is the most likely direct cause of this patient’s examination findings?
Q235
All are risk factors of esophageal squamous cell carcinoma except:
Q236
Which of the following is true about carcinoid tumor?
Q237
Which is not seen in Tumour lysis Syndrome?
Q238
Prostatic cancer mostly seen in
Q239
Route of administration of BCG for bladder cancer is
Q240
A 65-year-old woman presents with a 5-week history of yellow skin and sclera, anorexia, and epigastric pain. Her past medical history is significant for insulin-dependent diabetes mellitus. She smoked one pack of cigarettes a day for the past 20 years. Physical examination reveals jaundice and a palpable gallbladder. Laboratory studies show a serum bilirubin level of 10 mg/dL, mostly in the conjugated form, and an elevated alkaline phosphatase (260 U/L). A CT scan of the abdomen discloses a mass in the head of the pancreas and multiple nodules in the liver measuring up to 3 cm. Which of the following is the most important risk factor for the neoplasm arising in the patient?
Oncology Indian Medical PG Practice Questions and MCQs
Question 231: A 65-year-old man comes to the clinic complaining of abdominal pain for the past 2 months. He describes the pain as a dull, aching, 6/10 pain that is diffuse but worse in the right upper quadrant (RUQ). His past medical history is significant for diabetes controlled with metformin and a cholecystectomy 10 years ago. He reports fatigue and a 10-lb weight loss over the past month that he attributes to poor appetite; he denies fever, nausea/vomiting, palpitations, chest pain, or bowel changes. Physical examination is significant for mild scleral icterus and tenderness at the RUQ. Further workup reveals a high-grade malignant vascular neoplasm of the liver. What relevant detail would you expect to find in this patient’s history?
A. Chronic alcohol abuse
B. Heavy ingestion of acetaminophen
C. Infection with the hepatitis B virus
D. Obesity
E. Prior occupation in a chemical plastics manufacturing facility (Correct Answer)
Explanation: ***Prior occupation in a chemical plastics manufacturing facility***
- This history suggests exposure to **vinyl chloride**, a known carcinogen associated with hepatic angiosarcoma, a rare but aggressive **vascular neoplasm of the liver**.
- **Hepatic angiosarcoma** often presents with vague symptoms like abdominal pain, weight loss, and fatigue, as seen in this patient, and can lead to liver failure and jaundice [1].
*Chronic alcohol abuse*
- While chronic alcohol abuse can lead to various liver diseases, including **alcoholic hepatitis**, **cirrhosis**, and **hepatocellular carcinoma (HCC)**, it is not typically associated with angiosarcomas.
- The patient's symptoms are more consistent with a rapidly progressing malignancy, and HCC typically presents in patients with underlying cirrhosis or hepatitis.
*Heavy ingestion of acetaminophen*
- Acute or chronic overdose of **acetaminophen** primarily causes **centrilobular necrosis** and liver failure, but it is not linked to the development of hepatic vascular neoplasms like angiosarcoma.
- The patient's presentation of a high-grade malignant vascular neoplasm points away from drug-induced liver injury as the primary cause.
*Infection with the hepatitis B virus*
- **Hepatitis B virus (HBV)** infection is a major risk factor for **hepatocellular carcinoma (HCC)**, a common primary liver cancer, but not for hepatic angiosarcoma.
- The patient's clinical picture of a "high-grade malignant vascular neoplasm" is less typical for HCC, which originates from hepatocytes, not vascular endothelial cells.
*Obesity*
- Obesity is a risk factor for **non-alcoholic fatty liver disease (NAFLD)**, which can progress to **non-alcoholic steatohepatitis (NASH)**, cirrhosis, and **hepatocellular carcinoma (HCC)** [2].
- However, obesity is not directly linked to the development of primary hepatic vascular neoplasms like angiosarcoma.
Question 232: A 63-year-old man comes to the physician because of a 3-month history of fatigue and constipation. He reports having dull pain in the left portion of the midback for 2 weeks that has persisted despite taking ibuprofen. His father died of prostate cancer at 70 years of age. The patient has smoked one pack of cigarettes daily for 45 years. Vital signs are within normal limits. Physical examination shows a left-sided varicocele both in supine and in standing position. Rectal examination shows a symmetrically enlarged prostate with no masses. Laboratory studies show:
Hemoglobin 11.2 g/dL
Serum
Creatinine 1.0 mg/dL
Calcium 11.8 mg/dL
Urine
Protein 1+
Blood 2+
Which of the following is the most appropriate next step in management?
A. Urine cytology
B. CT scan of the abdomen (Correct Answer)
C. Chest x-ray
D. Serum protein electrophoresis
E. Prostate biopsy
Explanation: ***CT scan of the abdomen***
- The patient's symptoms, including **fatigue**, **constipation**, **dull midback pain**, **anemia**, **hypercalcemia**, and **new-onset left-sided varicocele**, are highly concerning for a retroperitoneal malignancy, most likely **renal cell carcinoma** [1].
- A **CT scan of the abdomen** is the most appropriate next step to evaluate the kidneys and retroperitoneum for a mass, as it can characterize the varicocele etiology (tumor compressing the **left renal vein**) [1].
*Urine cytology*
- **Urine cytology** is primarily used to detect malignant cells in the urine, typically for suspected bladder or upper urinary tract transitional cell carcinoma.
- While there is hematuria, the overall clinical picture with **hypercalcemia**, **anemia**, and **varicocele** points to a broader retroperitoneal process rather than solely a urinary tract epithelial malignancy.
*Chest x-ray*
- A **chest x-ray** evaluates the lungs and mediastinum and would be useful for assessing for metastatic disease, particularly in the context of cancer.
- However, given the strong localizing signs (left-sided varicocele, midback pain), the priority is to identify the primary tumor in the abdomen before scanning for distant metastases.
*Serum protein electrophoresis*
- **Serum protein electrophoresis** is used to detect and characterize monoclonal gammopathies, such as those seen in **multiple myeloma**.
- While hypercalcemia can be associated with multiple myeloma, the presence of a **new-onset left-sided varicocele** is highly suggestive of a mass compressing the left renal vein, which is not typically seen in multiple myeloma.
*Prostate biopsy*
- A **prostate biopsy** would be indicated if there were suspicious findings on rectal exam (e.g., prostatic nodule) or an elevated PSA, suggesting prostate cancer.
- The rectal exam showed a **symmetrically enlarged prostate with no masses**, and while the father had prostate cancer, hypercalcemia and a new varicocele are not typical primary manifestations of prostate cancer.
Question 233: A 58-year-old woman comes to the physician because of constipation, loss of appetite, and increased urinary frequency for the past 8 weeks. She has a history of hypertension and underwent mastectomy for breast cancer 9 months ago. Her sister has hyperthyroidism and her mother died of complications from breast cancer at the age of 52 years. She does not smoke or drink alcohol. Current medications include chlorthalidone. Her temperature is 36.2°C (97.2°F), pulse is 102/min, and blood pressure is 142/88 mm Hg. Physical examination shows dry mucous membranes. Abdominal examination shows mild, diffuse abdominal tenderness to palpation with decreased bowel sounds. Her serum creatinine concentration is 1.2 mg/dL and serum calcium concentration is 12 mg/dL. Serum parathyroid hormone levels are decreased. Which of the following is the most appropriate long-term pharmacotherapy?
A. Denosumab
B. Furosemide
C. Zoledronic acid (Correct Answer)
D. Magnesium oxide
E. Prednisone
Explanation: **Zoledronic acid**
- The patient presents with **hypercalcemia** (12 mg/dL) and a history of **breast cancer with mastectomy**, strongly suggesting **humoral hypercalcemia of malignancy** or **bone metastases**. **Zoledronic acid**, a potent bisphosphonate, is the most appropriate long-term treatment as it inhibits osteoclast activity and reduces calcium release from bone [1].
- Her **decreased parathyroid hormone (PTH)** level further supports a non-PTH mediated cause of hypercalcemia, such as malignancy [2].
*Denosumab*
- While denosumab is effective for **hypercalcemia of malignancy**, it is generally reserved for patients who are **refractory to bisphosphonates** or have **renal impairment**, as it carries a risk of osteonecrosis of the jaw and severe hypocalcemia.
- Given the patient's creatinine of 1.2 mg/dL, **bisphosphonates like zoledronic acid** are typically first-line and generally safe for renal function until it falls below 30 mL/min.
*Furosemide*
- **Loop diuretics** like furosemide can be used in the **acute management of severe hypercalcemia** to promote calcium excretion in the urine.
- However, furosemide is insufficient as **long-term monotherapy** for malignancy-associated hypercalcemia; it does not address the underlying bone resorption and can lead to electrolyte imbalances.
*Magnesium oxide*
- **Magnesium oxide** is primarily used as a **laxative** or to treat **magnesium deficiency**.
- It has **no role in the management of hypercalcemia** and would not address the patient's elevated calcium levels, which are likely due to malignancy.
*Prednisone*
- **Corticosteroids like prednisone** are effective in treating hypercalcemia caused by **hematologic malignancies** (e.g., multiple myeloma, lymphoma) or **granulomatous diseases** (e.g., sarcoidosis).
- They are generally **not effective nor first-line** for hypercalcemia associated with **solid tumors** like breast cancer.
Question 234: A 70-year-old man comes to the physician because of a 4-month history of epigastric pain, nausea, and weakness. He has smoked one pack of cigarettes daily for 50 years and drinks one alcoholic beverage daily. He appears emaciated. He is 175 cm (5 ft 9 in) tall and weighs 47 kg (103 lb); BMI is 15 kg/m2. He is diagnosed with gastric cancer. Which of the following cytokines is the most likely direct cause of this patient’s examination findings?
A. IL-2
B. TGF-β
C. IL-6 (Correct Answer)
D. TNF-β
E. IFN-α
Explanation: **IL-6**
- **Interleukin-6 (IL-6)** plays a significant role in **cachexia** associated with cancer, leading to features like **anorexia**, muscle wasting, and fatigue.
- Its elevated levels in cancer patients contribute to systemic inflammation and metabolic changes that result in the patient's **emaciated appearance** and weight loss.
*IL-2*
- **Interleukin-2 (IL-2)** is primarily involved in the **proliferation and differentiation of T cells** and natural killer cells, often used in cancer immunotherapy. [1]
- It is not directly implicated as a primary cause of **cancer-associated cachexia** or the systemic symptoms described.
*TGF-β*
- **Transforming Growth Factor-beta (TGF-β)** is a cytokine that generally **inhibits immune responses** and regulates cell growth, differentiation, and apoptosis.
- While it can be involved in tumor progression and metastasis, it is not recognized as a direct cause of the **cachectic syndrome** seen in this patient.
*TNF-β*
- **Tumor Necrosis Factor-beta (TNF-β)**, also known as **lymphotoxin-alpha (LT-α)**, shares some functions with TNF-α, but its role in **cancer cachexia** is less direct and prominent than TNF-α or IL-6. [2]
- It is primarily involved in immune surveillance and inflammation, but not the leading cause of the patient's systemic wasting.
*IFN-α*
- **Interferon-alpha (IFN-α)** is a cytokine primarily known for its **antiviral and anti-proliferative effects** and its role in immune modulation. [1]
- It is used in the treatment of certain cancers but is **not a primary mediator** of cancer-related cachexia or the specific constitutional symptoms of weight loss and emaciation.
Question 235: All are risk factors of esophageal squamous cell carcinoma except:
A. Smoking
B. Achalasia cardia
C. GERD (Correct Answer)
D. Alcohol
Explanation: ***GERD***
- **Gastroesophageal reflux disease (GERD)** is strongly associated with **esophageal adenocarcinoma**, not esophageal squamous cell carcinoma.
- Chronic acid reflux can lead to **Barrett's esophagus**, which is a precursor to adenocarcinoma [1].
*Smoking*
- **Smoking** is a significant and well-documented risk factor for **esophageal squamous cell carcinoma**, increasing the risk in a dose-dependent manner.
- Carcinogens in tobacco smoke directly damage esophageal epithelial cells, promoting malignant transformation.
*Achalasia cardia*
- **Achalasia cardia** involves impaired relaxation of the lower esophageal sphincter and loss of peristalsis, leading to food stasis and chronic inflammation [2].
- This chronic irritation and inflammation significantly increase the risk of developing **esophageal squamous cell carcinoma**.
*Alcohol*
- **Alcohol consumption**, especially heavy drinking, is a major risk factor for **esophageal squamous cell carcinoma**.
- Alcohol metabolizes into acetaldehyde, a known carcinogen, which directly damages DNA in esophageal cells.
Question 236: Which of the following is true about carcinoid tumor?
A. Presentation is hypotension and diaphoresis
B. Intestinal carcinoids are of high malignant potential
C. Best diagnosed by elevated urinary vanillymandelic acid levels
D. Can occur throughout the gastrointestinal tract (Correct Answer)
Explanation: ***Can occur throughout the gastrointestinal tract***
- Carcinoid tumors (neuroendocrine tumors) are most commonly found in the **gastrointestinal tract**, particularly in the small intestine, appendix, rectum, and stomach [2].
- They arise from **enterochromaffin cells** and can secrete various vasoactive substances.
*Presentation is hypotension and diaphoresis*
- The classic presentation of **carcinoid syndrome** includes episodes of **flushing**, **diarrhea**, and **bronchospasm**, often accompanied by **hypertension** rather than hypotension due to the release of serotonin and other vasoactive peptides [1].
- While diaphoresis can occur, **hypotension** is not a primary or characteristic feature.
*Intestinal carcinoids are of high malignant potential*
- The malignant potential of carcinoid tumors varies depending on their primary site and size but is generally considered to be of **low-to-moderate malignant potential**, particularly for appendiceal and rectal carcinoids [2].
- Liver metastases significantly increase morbidity and mortality, but many small intestinal carcinoids may grow slowly or remain localized for extended periods [1].
*Best diagnosed by elevated urinary vanillymandelic acid levels*
- Elevated **urinary vanillymandellic acid (VMA)** levels are primarily used to diagnose **pheochromocytoma**, a tumor of the adrenal medulla that secretes catecholamines.
- Carcinoid tumors are best diagnosed by measuring **urinary 5-hydroxyindoleacetic acid (5-HIAA)**, a breakdown product of serotonin.
Question 237: Which is not seen in Tumour lysis Syndrome?
A. Hyperkalemia
B. Hypophosphatemia (Correct Answer)
C. Hyperuricemia
D. Hypocalcemia
Explanation: ***Hypophosphatemia***
- **Tumor lysis syndrome (TLS)** is characterized by the rapid breakdown of tumor cells, leading to the release of intracellular components into the bloodstream.
- This process typically results in **acute hyperphosphatemia**, not hypophosphatemia, due to the high phosphate content within tumor cells.
*Hyperkalemia*
- **Hyperkalemia** is a hallmark of TLS because potassium, a major intracellular cation, is released in large quantities as tumor cells lyse.
- Excess potassium can lead to potentially life-threatening cardiac arrhythmias.
*Hyperuricemia*
- **Hyperuricemia** occurs in TLS because nucleic acids (DNA and RNA) released from dying tumor cells are metabolized into purines, which are then converted to uric acid [1].
- High uric acid levels can precipitate in the renal tubules, leading to **acute kidney injury** [1].
*Hypocalcemia*
- **Hypocalcemia** develops in TLS secondary to the acute hyperphosphatemia.
- The excess phosphate binds with serum calcium to form **calcium-phosphate precipitates**, effectively lowering the concentration of free ionized calcium.
Question 238: Prostatic cancer mostly seen in
A. Posterior (Correct Answer)
B. Lateral
C. Anterior
D. Medial
Explanation: ***Posterior***
- The **peripheral zone** of the prostate, which is located posteriorly, is the most common site for the development of **prostatic adenocarcinoma**.
- This anatomical location is why a **digital rectal exam (DRE)** is an important screening tool, as palpable nodules can be detected [1].
*Lateral*
- While prostatic tissue extends laterally, this region is not the predominant site for cancer development.
- Cancers originating here are less common than those in the posterior peripheral zone.
*Anterior*
- The **anterior fibromuscular stroma** and the anterior portion of the prostate are rarely the primary sites for prostate cancer.
- Tumors found here are often extensions from more posteriorly located cancers.
*Medial*
- The **transition zone**, which is located medially and surrounds the urethra, is the most common site for **benign prostatic hyperplasia (BPH)**, not prostate cancer.
- While cancer can occur in this zone, it is less frequent than in the peripheral zone.
Question 239: Route of administration of BCG for bladder cancer is
A. Oral
B. Subcutaneous
C. Intravenous
D. Intravesical (Correct Answer)
Explanation: ***Intravesical***
- **Bacillus Calmette-Guérin (BCG)** is directly instilled into the bladder via a catheter for the treatment of **non-muscle invasive bladder cancer**.
- This **intravesical** route ensures high local concentrations of the immunotherapeutic agent, stimulating an anti-tumor immune response within the bladder.
*Oral*
- The **oral route** is not used for BCG in bladder cancer due to poor absorption and degradation of the vaccine in the gastrointestinal tract.
- It would not achieve therapeutic concentrations at the target site (the bladder) and would carry a risk of systemic side effects without localized benefit.
*Subcutaneous*
- **Subcutaneous administration** is typically used for systemic vaccination against tuberculosis,
- However, for bladder cancer, it would not deliver the therapeutic agent directly to the cancerous tissue in the bladder lumen, limiting its efficacy.
*Intravenous*
- **Intravenous administration** would lead to systemic distribution of BCG, which is not desired for localized bladder cancer treatment.
- It could result in significant systemic side effects, including disseminated BCG infection, without providing adequate local concentration in the bladder.
Question 240: A 65-year-old woman presents with a 5-week history of yellow skin and sclera, anorexia, and epigastric pain. Her past medical history is significant for insulin-dependent diabetes mellitus. She smoked one pack of cigarettes a day for the past 20 years. Physical examination reveals jaundice and a palpable gallbladder. Laboratory studies show a serum bilirubin level of 10 mg/dL, mostly in the conjugated form, and an elevated alkaline phosphatase (260 U/L). A CT scan of the abdomen discloses a mass in the head of the pancreas and multiple nodules in the liver measuring up to 3 cm. Which of the following is the most important risk factor for the neoplasm arising in the patient?
A. Cholelithiasis
B. Cigarette smoking (Correct Answer)
C. Alcohol abuse
D. Diabetes mellitus type 1
Explanation: ***Cigarette smoking***
- **Smoking** is a well-established and significant risk factor for adenocarcinoma of the **pancreas**, which aligns with the patient's presentation of a pancreatic head mass, obstructive jaundice (yellow skin/sclera, high conjugated bilirubin, elevated alkaline phosphatase), and palpable gallbladder [3].
- The 20-year history of smoking significantly increases her individual risk for this particular type of cancer.
*Cholelithiasis*
- While **gallstones** can cause obstructive jaundice (e.g., choledocholithiasis), they are not a primary risk factor for **pancreatic adenocarcinoma**.
- The patient's CT scan indicates a **pancreatic head mass** and liver nodules, pointing away from primary gallstone disease as the etiology of the neoplasm.
*Alcohol abuse*
- Chronic **alcohol abuse** is a major risk factor for chronic pancreatitis, which can, in turn, increase the risk of pancreatic cancer [1].
- However, direct causation between alcohol abuse and pancreatic cancer is less strong than with smoking, and there is no mention of alcohol abuse in the patient's history [2].
*Diabetes mellitus type 1*
- While a proportion of patients with newly diagnosed **pancreatic cancer** may develop diabetes (often type 2 or an unusual type of diabetes), **insulin-dependent diabetes mellitus type 1** itself is considered a minor or even non-existent risk factor for pancreatic cancer.
- The presence of diabetes in this patient is more likely a concurrent condition or a consequence of the pancreatic tumor rather than a primary risk factor for its development.
