Oncology Practice Questions

Q: Which of the following tumors is radio-resistant? a) Melanoma b) Hodgkin's Disease (HD) c) Seminoma d) Ewing's Sarcoma e) Chondrosarcoma

Chondrosarcoma. ***Chondrosarcoma*** - **Chondrosarcomas** are notoriously **radio-resistant** due to their low metabolic activity and the presence of a cartilaginous matrix that impairs oxygen delivery and DNA damage by radiation. - Due to their radio-resistance, **surgical resection** is the primary treatment for chondrosarcomas. *Hodgkin's Disease (HD)* - **Hodgkin's Disease** is known to be **highly radio-sensitive**, and radiation therapy is a cornerstone of its treatment, often used in conjunction with chemotherapy. - The excellent response to radiation is one of the reasons for the high cure rates associated with early-stage Hodgkin's lymphoma. *Ewing's sarcoma* - **Ewing's sarcoma** is a **highly radio-sensitive** tumor, and radiation therapy plays a crucial role in its local control, often used after or with chemotherapy. - It is frequently treated with a combination of chemotherapy, surgery, and radiation to achieve optimal outcomes. *Seminoma* - **Seminomas** are among the most **radio-sensitive** solid tumors, making radiation therapy a very effective treatment modality, particularly for localized disease. - Even at low doses, radiation can induce a significant response and achieve high cure rates in seminoma. *Melanoma* - While traditionally considered radio-resistant, **melanoma** can sometimes respond to high-dose or fractionated radiation therapy, particularly in palliative settings or for specific subtypes. - However, compared to the other options, its general sensitivity to conventional radiation doses is lower, and immunotherapy and targeted therapy are often preferred.

Q: A 45-year-old woman with metastatic melanoma on pembrolizumab develops symmetrical vitiligo-like depigmentation. Most appropriate management is:

Continue therapy with monitoring. ***Continue therapy with monitoring*** - **Vitiligo-like depigmentation** on pembrolizumab (a PD-1 inhibitor) is a common, often benign, and sometimes even a **favorable prognostic sign** associated with treatment response in melanoma. - As long as the depigmentation is not causing significant distress or rapid progression, continuing therapy with close monitoring is the appropriate initial approach. *Discontinue pembrolizumab* - Discontinuing pembrolizumab would be premature given that **vitiligo** in this context is often a mild immune-related adverse event (irAE) and may correlate with a better treatment outcome. - Early cessation of an effective immunotherapy without compelling reason could negatively impact the patient's cancer control. *Start topical tacrolimus* - **Topical tacrolimus** can be used for localized vitiligo, but its primary role is to **promote repigmentation** or halt progression. - In the context of immunotherapy-induced vitiligo, the depigmentation is often widespread and may be an indicator of a systemic anti-tumor immune response, making repigmentation a secondary concern compared to oncology treatment. *Add systemic steroids* - **Systemic steroids** are typically reserved for more severe or symptomatic immune-related adverse events (irAEs), such as severe colitis, pneumonitis, or hepatitis. - Mild or moderate vitiligo is generally not an indication for systemic immunosuppression, which could also potentially **attenuate the anti-tumor effects** of pembrolizumab.

Q: A 40-year-old man has hemoptysis. CXR shows a coin lesion. Biopsy reveals nests of neuroendocrine cells with salt-and-pepper chromatin. What is the most likely diagnosis?

Carcinoid tumor. ***Carcinoid tumor*** - **Nests of neuroendocrine cells** with **salt-and-pepper chromatin** are classic histological features of a carcinoid tumor. - While presented as a **coin lesion** (solitary pulmonary nodule) [2], this type of neuroendocrine tumor typically has a more indolent course compared to other lung malignancies. *Squamous cell carcinoma* - Characterized by **keratinization** and **intercellular bridges**, not neuroendocrine differentiation. - Often presents as a **central mass** with cavitation and is strongly associated with smoking [1]. *Adenocarcinoma* - Grows in glandular patterns and produces **mucin**, usually found in the periphery of the lung. - Lacks the neuroendocrine features of salt-and-pepper chromatin or rosette formation. *Small cell carcinoma* - Consists of small, undifferentiated cells with **scant cytoplasm** and **absent nucleoli**, known for rapid growth. - Although also neuroendocrine, it presents with a much more aggressive clinical course and characteristic **oat cell morphology**, distinct from the well-differentiated nests seen in carcinoid.

Q: A 60-year-old male with a long history of smoking presents with weight loss and hemoptysis. Chest X-ray shows a hilar mass. Biopsy reveals small blue cells with scant cytoplasm. What is the most likely diagnosis?

Small cell lung cancer. ***Small cell lung cancer*** - The patient's presentation with a **hilar mass**, rapid weight loss, and **hemoptysis** in a heavy smoker are classic symptoms [1]. - **Biopsy findings** of "small blue cells with scant cytoplasm" are highly characteristic of **small cell lung carcinoma**, which is known for its neuroendocrine features and aggressive nature [1]. *Squamous cell carcinoma* - This typically presents as a **hilar mass** in smokers and can cause hemoptysis, but its histology would show **keratinization** or **intercellular bridges**, not small blue cells [1]. - It arises from the **bronchial epithelium**, and frequently causes central airway obstruction [1]. *Adenocarcinoma* - This type of lung cancer is often found **peripherally** and is not as strongly linked to smoking as small cell or squamous cell carcinoma [1]. - Histology would reveal glandular differentiation or **mucin production**, which is not consistent with the "small blue cells" description. *Mesothelioma* - Primarily associated with **asbestos exposure** and typically presents as a **pleural effusion** or diffuse pleural thickening, not a hilar mass. - Histologically, it is characterized by **spindle cells** (sarcomatoid type), epithelial cells (epithelioid type), or a mixture (biphasic type), which are distinct from small blue cells.

Q: A 70-year-old smoker presents with dyspnea and weight loss. CXR shows a mass in the right lung. What is the next step?

CT-guided biopsy. ***CT-guided biopsy*** - A definitive diagnosis of a suspected lung mass, especially in a patient with a history of smoking and weight loss, requires **histological confirmation**. [1] - **CT-guided biopsy** is often the most direct and least invasive method to obtain tissue from a peripheral lung mass for pathological examination. [2] *Bronchoscopy* - While useful for diagnosing central airway lesions, **bronchoscopy** may not reach a peripheral lung mass, making tissue sampling difficult or impossible. [3] - It could be considered if the mass were closer to the main bronchi or if the patient had symptoms suggesting endobronchial involvement. [4] *MRI* - **MRI** is not the primary imaging modality for initial evaluation of a lung mass; **CT scans** provide better anatomical detail of the lungs and chest wall. [2] - It might be used for staging purposes, especially for evaluating brain metastases or chest wall invasion, but not for initial diagnosis of the lung mass itself. *Sputum cytology* - **Sputum cytology** has low sensitivity for diagnosing lung cancer, especially for peripheral lesions, as cancer cells may not be exfoliated into the sputum. - A negative result from sputum cytology does not rule out lung cancer, and a more invasive procedure would still be needed for diagnosis.

Q: Which one of the following is not true about hepatocellular carcinoma?

Metastasis occurs late. Metastasis occurs late - This statement is **false** because **hepatocellular carcinoma (HCC)** is known to **metastasize early**, often disseminating through the **portal vein** to the lung, bone, and brain [1]. - Early metastasis is a significant factor contributing to the **poor prognosis** of HCC even when the primary tumor is relatively small. *AFP is a marker* - **Alpha-fetoprotein (AFP)** is a widely used **tumor marker** for HCC, particularly in surveillance and diagnosis [1]. - While elevated AFP levels can indicate HCC, they are **not always present** and can also be elevated in other conditions such as hepatitis or cirrhosis. *HBV is a risk factor* - **Hepatitis B virus (HBV)** infection is a **major global risk factor** for developing HCC, especially in endemic regions. - Chronic HBV infection leads to **chronic inflammation** and **fibrosis** in the liver, significantly increasing the risk of malignant transformation. *Common in cirrhosis* - HCC is overwhelmingly common in patients with **cirrhosis**, regardless of its etiology (e.g., chronic hepatitis, alcohol abuse, non-alcoholic fatty liver disease) [1]. - The **regenerative nodules** and chronic inflammation associated with cirrhosis create a fertile ground for the development of **dysplastic foci** and ultimately HCC [1].

Q: All of the following are associated with increased risk of gastric adenocarcinoma except which of the following?

Celiac disease. ***Celiac disease*** - While celiac disease increases the risk of certain cancers like **T-cell lymphoma** (e.g., **enteropathy-associated T-cell lymphoma, EATL**) and **small intestinal adenocarcinoma**, it is not a significant risk factor for **gastric adenocarcinoma**. - The primary site of neoplastic transformation in celiac disease is the **small intestine**, not the stomach. *Smoking* - **Smoking** is a well-established risk factor for various cancers, including gastric adenocarcinoma, with a dose-dependent relationship. - It contributes to **chronic inflammation** and **mucosal damage** in the stomach, promoting oncogenesis. *H. pylori* - **_Helicobacter pylori_ infection** is a major causative agent for **gastric adenocarcinoma**, particularly the **intestinal type** [1]. - It induces chronic gastritis, leading to atrophy, intestinal metaplasia, and dysplasia, which are precursors to cancer [1], [2]. *Dietary nitrosamines* - **Dietary nitrosamines**, commonly found in highly processed and preserved foods (smoked meats, pickled vegetables), are potent **carcinogens** [1]. - They are directly linked to an increased risk of **gastric adenocarcinoma**, especially in populations with high consumption of such foods [1].

Q: A 55-year-old woman with non-small cell lung cancer is found to have an ALK gene rearrangement. How should this finding influence her treatment?

Switch to crizotinib, a targeted ALK inhibitor. ***Switch to crizotinib, a targeted ALK inhibitor*** - The presence of an **ALK gene rearrangement** in **non-small cell lung cancer (NSCLC)** is a strong indicator for **targeted therapy** with an **ALK inhibitor** like crizotinib. - These drugs specifically block the aberrant activity of the ALK fusion protein, leading to **superior response rates** and **progression-free survival** compared to standard chemotherapy in ALK-positive patients. *Refer for surgical resection, if appropriate* - **Surgical resection** is primarily considered for **early-stage NSCLC** without evidence of metastatic disease [1]. - While surgery can be curative, the presence of specific gene rearrangements like ALK typically prompts consideration of **neoadjuvant or adjuvant targeted therapy** or systemic therapy for advanced disease. *Consider radiation therapy, if indicated* - **Radiation therapy** for NSCLC is usually employed for **local control**, either in curative intent for early stages or for **palliative management** of symptoms in advanced disease [2]. - It does not directly address the underlying **genetic driver** (ALK rearrangement) and would not be the primary systemic treatment. *Continue standard chemotherapy, if appropriate for the patient's condition* - While **standard chemotherapy** is a treatment option for NSCLC, the identification of a **driver mutation** like an ALK rearrangement makes **targeted therapy** a significantly more effective and preferred first-line approach. - Continuing chemotherapy without considering targeted therapy would be **suboptimal** for a patient with an ALK rearrangement due to the availability of more effective treatments.

Q: Which of the following is not a risk factor for cholangiocarcinoma?

Hepatitis B. ***Hepatitis B*** - While **Hepatitis B** is a major risk factor for **hepatocellular carcinoma (HCC)**, its direct association with cholangiocarcinoma is less clear and not as established as other risk factors. - The primary connection between Hepatitis B and liver cancer is through chronic inflammation leading to **cirrhosis** and subsequent HCC. *Opisthorchis viverrini* - This **liver fluke** is a well-established and significant risk factor for cholangiocarcinoma, particularly in Southeast Asia, by inducing chronic inflammation and epithelial damage in bile ducts. - The parasite's presence leads to **biliary stasis**, chronic irritation, and genetic alterations that promote malignant transformation. *PCS* - **Primary Sclerosing Cholangitis (PSC)** is a strong risk factor for cholangiocarcinoma, with a lifetime risk of approximately 5-10% [1]. - The chronic inflammation and fibrosis of the bile ducts in PSC create an environment highly conducive to malignant transformation [1]. *Caroli's disease* - **Caroli's disease**, a congenital disorder characterized by multifocal segmental dilation of intrahepatic bile ducts, is strongly associated with an increased risk of cholangiocarcinoma [1]. - The **biliary stasis** and recurrent cholangitis caused by the dilations promote chronic inflammation, a key driver of malignancy [1].

Question 1

Which of the following tumors is radio-resistant? a) Melanoma b) Hodgkin's Disease (HD) c) Seminoma d) Ewing's Sarcoma e) Chondrosarcoma

Accepted Answer

Chondrosarcoma

Answer

Hodgkin's Disease (HD)

Answer

Ewing's sarcoma

Answer

Seminoma

Answer

Melanoma

Question 2

Radioresistant tumour is

Accepted Answer

Malignant melanoma

Answer

Osteosarcoma

Answer

Multiple myeloma

Answer

Glioblastoma

Answer

Chondrosarcoma

Answer

Ewing's sarcoma

Answer

Wilms tumour

Answer

Seminoma

Answer

Lymphoma

Question 3

A 45-year-old woman with metastatic melanoma on pembrolizumab develops symmetrical vitiligo-like depigmentation. Most appropriate management is:

Accepted Answer

Continue therapy with monitoring

Answer

Discontinue pembrolizumab

Answer

Start topical tacrolimus

Answer

Add systemic steroids

Question 4

A 40-year-old man has hemoptysis. CXR shows a coin lesion. Biopsy reveals nests of neuroendocrine cells with salt-and-pepper chromatin. What is the most likely diagnosis?

Accepted Answer

Carcinoid tumor

Answer

Squamous cell carcinoma

Answer

Adenocarcinoma

Answer

Small cell carcinoma

Question 5

A 60-year-old male with a long history of smoking presents with weight loss and hemoptysis. Chest X-ray shows a hilar mass. Biopsy reveals small blue cells with scant cytoplasm. What is the most likely diagnosis?

Accepted Answer

Small cell lung cancer

Answer

Squamous cell carcinoma

Answer

Adenocarcinoma

Answer

Mesothelioma

Question 6

A 70-year-old smoker presents with dyspnea and weight loss. CXR shows a mass in the right lung. What is the next step?

Accepted Answer

CT-guided biopsy

Answer

Bronchoscopy

Answer

MRI

Answer

Sputum cytology

Question 7

Which one of the following is not true about hepatocellular carcinoma?

Accepted Answer

Metastasis occurs late

Answer

AFP is a marker

Answer

HBV is a risk factor

Answer

Common in cirrhosis

Question 8

All of the following are associated with increased risk of gastric adenocarcinoma except which of the following?

Accepted Answer

Celiac disease

Answer

Smoking

Answer

H. pylori

Answer

Dietary nitrosamines

Question 9

A 55-year-old woman with non-small cell lung cancer is found to have an ALK gene rearrangement. How should this finding influence her treatment?

Accepted Answer

Switch to crizotinib, a targeted ALK inhibitor

Answer

Refer for surgical resection, if appropriate

Answer

Consider radiation therapy, if indicated

Answer

Continue standard chemotherapy, if appropriate for the patient's condition

Question 10

Which of the following is not a risk factor for cholangiocarcinoma?

Accepted Answer

Hepatitis B

Answer

Opisthorchis viverrini

Answer

PCS

Answer

Caroli's disease

Oncology — MCQs

Oncology — MCQs

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