Principles of Cancer Diagnosis and Staging — MCQs

10 questions

What is the T stage of a 2.5cm lung carcinoma, not involving the pleura?

Which of the following stages of Breast Cancer corresponds to the following features: a breast mass of 6 x 3 cm, ipsilateral supraclavicular lymph node involvement, and distant metastasis that cannot be assessed?

All are clinical signs of malignant hyperthermia except-

The most appropriate first-line imaging modality to detect adrenal metastasis due to bronchogenic carcinoma is:

Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?

Laparoscopy is the diagnostic procedure of choice for:

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 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?

Metastases from follicular carcinoma should be treated by:

Q10

International prognostic index for lymphomas includes the following prognostic factors, EXCEPT:

Principles of Cancer Diagnosis and Staging Indian Medical PG Practice Questions and MCQs

Question 1: What is the T stage of a 2.5cm lung carcinoma, not involving the pleura?

A. T1a
B. T2
C. T1b
D. T1c (Correct Answer)

Explanation: ***T1c*** - A **2.5 cm lung carcinoma** without pleural involvement falls into the T1 category [1]. - According to the **TNM staging system (8th edition)** for lung cancer, a tumor between **2-3 cm is classified as T1c** [1]. *T1a* - This classification is reserved for tumors that are **1 cm or less** in greatest dimension. - The given tumor size of **2.5 cm is larger** than the T1a criteria. *T2* - A T2 tumor is generally defined by a size greater than **3 cm but less than or equal to 5 cm**, or has specific features like visceral pleural invasion or involvement of the main bronchus regardless of distance from the carina [1]. - Our tumor is **only 2.5 cm** and does not involve the pleura, excluding T2. *T1b* - This category applies to tumors that are **greater than 1 cm but equal to or less than 2 cm** in greatest dimension. - The 2.5 cm tumor size exceeds the criteria for **T1b**. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 721-725.

Question 2: Which of the following stages of Breast Cancer corresponds to the following features: a breast mass of 6 x 3 cm, ipsilateral supraclavicular lymph node involvement, and distant metastasis that cannot be assessed?

A. T4 N3 MX
B. T4 N1 M1
C. T4 N0 M0
D. T3 N3c MX (Correct Answer)

Explanation: ***T3 N3c MX*** - A **breast mass of 6 x 3 cm** indicates a T3 tumor (tumor size > 5 cm). - **Ipsilateral supraclavicular lymph node involvement** is classified as N3c disease. **Distant metastasis that cannot be assessed** is denoted by MX. *T4 N3 MX* - A **T4 classification** is reserved for tumors with direct extension to the chest wall or skin, or inflammatory breast cancer, which is not mentioned here. - While N3c and MX are correct for the nodal and metastatic status, the T stage is inaccurate based on the provided tumor size. *T4 N1 M1* - A **T4 classification** is incorrect as the mass size alone (6 x 3 cm) does not meet T4 criteria. - **N1** denotes involvement of 1-3 axillary lymph nodes, which is less extensive than supraclavicular involvement (N3c). **M1** indicates confirmed distant metastasis, but the question states it "cannot be assessed" (MX). *T4 N0 M0* - **T4** is incorrect, as this stage is for direct chest wall/skin involvement or inflammatory breast cancer. - **N0** signifies no regional lymph node metastasis, contradicting the presence of supraclavicular lymph node involvement. **M0** indicates no distant metastasis, whereas the question specifies it cannot be assessed (MX).

Question 3: All are clinical signs of malignant hyperthermia except-

A. Hypercarbia
B. Hypothermia (Correct Answer)
C. Hypertension
D. Metabolic acidosis

Explanation: ***Hypothermia*** - Malignant hyperthermia is characterized by a rapid and uncontrolled increase in **body temperature (hyperthermia)**, not hypothermia. - Reduced body temperature would imply a different physiological process and is not characteristic of this condition. *Hypercarbia* - **Hypercarbia**, or an increase in blood CO2 levels, is an early and prominent sign due to increased cellular metabolism and muscle rigidity. - The rapid rise in end-tidal CO2 despite adequate ventilation is often the first indicator of malignant hyperthermia. *Hypertension* - **Hypertension** is a common clinical sign, resulting from the massive release of catecholamines and intense sympathetic stimulation during the hypermetabolic state. - The elevated blood pressure is part of the body's generalized stress response to the crisis. *Metabolic acidosis* - **Metabolic acidosis** is a key feature due to the excessive production of lactic acid from anaerobic metabolism in hyperactive muscles. - This accumulation of acid contributes significantly to the overall physiological derangement observed in malignant hyperthermia.

Question 4: The most appropriate first-line imaging modality to detect adrenal metastasis due to bronchogenic carcinoma is:

A. PET scan
B. MRI of the abdomen
C. Adrenal radionuclide scan
D. Contrast Enhanced CT abdomen (Correct Answer)

Explanation: **Contrast Enhanced CT abdomen** - **Contrast-enhanced CT abdomen** is generally considered the most sensitive and cost-effective imaging modality for detecting **adrenal metastases**. - It allows for detailed visualization of adrenal gland morphology, including size, shape, and enhancement patterns, which can help differentiate benign from malignant lesions. *PET scan* - While **PET (Positron Emission Tomography) scans** are highly sensitive for detecting metabolically active metastatic disease, they are often used as a secondary imaging modality to characterize indeterminate lesions found on CT or MRI. - **PET scans** can have false positives in benign adrenal tumors (e.g., adenomas rich in fat) and are less readily available or higher in cost for initial screening compared to CT. *MRI of the abdomen* - **MRI of the abdomen** can be very useful for further characterization of adrenal masses, especially for distinguishing between lipid-rich adenomas and metastases. - However, for initial detection, especially in the context of screening for distant metastases from bronchogenic carcinoma, **CT is generally preferred due to its wider availability, speed, and lower cost**. *Adrenal radionuclide scan* - **Adrenal radionuclide scans** (e.g., using MIBG or iodocholesterol) are primarily used for functional imaging of adrenal glands, typically to detect specific types of tumors like pheochromocytomas or aldosteronomas. - These scans are **not sensitive for detecting adrenal metastases** from bronchogenic carcinoma, as the metastatic lesions do not typically exhibit the specific uptake patterns targeted by these radiotracers.

Question 5: Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?

A. Anaplastic carcinoma of thyroid
B. Medullary carcinoma of thyroid
C. Follicular carcinoma of thyroid (Correct Answer)
D. Papillary carcinoma of thyroid

Explanation: ***Follicular carcinoma of thyroid*** - The definitive diagnosis of **follicular carcinoma** requires the presence of **capsular or vascular invasion**, which cannot be assessed through **fine needle aspiration cytology (FNAC)** alone [1], [5]. - FNA may show features suggestive of follicular neoplasm (e.g., hypercellularity with microfollicles), but differentiation from **follicular adenoma** requires histological examination of the excised specimen [1], [4]. *Anaplastic carcinoma of thyroid* - **Anaplastic carcinoma** is highly aggressive and characterized by **pleomorphic, bizarre cells** that are easily identifiable on FNAC [2], [5]. - The distinctive cytological features, including **spindle cells, giant cells, and rapid cellular atypia**, allow for a relatively straightforward diagnosis via FNAC [2]. *Medullary carcinoma of thyroid* - **Medullary carcinoma** cells have characteristic cytological features, such as **plasmacytoid appearance**, **amyloid deposition**, and **neuroendocrine granules**, which can be identified on FNAC [5]. - Confirmation can be made by **immunohistochemical staining for calcitonin** on the FNA sample [5]. *Papillary carcinoma of thyroid* - **Papillary carcinoma** has distinct cytological features, including **orphan Annie eye nuclei**, **intranuclear grooves**, **pseudoinclusions**, and **papillary structures**, readily identified by FNAC [3]. - These features are highly specific and often allow for a definitive diagnosis of papillary thyroid carcinoma [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1100-1101. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1101-1102. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 429-430. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 428-429. [5] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 430-431.

Question 6: Laparoscopy is the diagnostic procedure of choice for:

A. Ca rectum
B. Endometriosis (Correct Answer)
C. Ca cervix
D. Ca uterus

Explanation: ***Endometriosis*** - Laparoscopy allows for direct visualization of **endometrial implants** outside the uterus, which is crucial for diagnosis and staging. - It also allows for **biopsy confirmation** and potential treatment (excision or ablation) of endometriotic lesions during the same procedure. *Ca rectum* - The primary diagnostic procedure for **rectal cancer** is usually **colonoscopy** with biopsy. - **Laparoscopy** may be used for staging **rectal cancer** but it is not the initial diagnostic procedure of choice. *Ca cervix* - The primary diagnostic procedure for **cervical cancer** is a **colposcopy** with directed biopsy of suspicious lesions. - **Laparoscopy** is not typically used for the initial diagnosis of **cervical cancer** but may be used for staging in advanced cases. *Ca uterus* - The primary diagnostic procedure for **uterine cancer** (endometrial cancer) is an **endometrial biopsy** or **dilation and curettage (D&C)**. - **Laparoscopy** may be used for surgical staging of **uterine cancer** but is not the initial diagnostic procedure.

Question 7: 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 8: 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 9: Metastases from follicular carcinoma should be treated by:

A. Radioiodine (Correct Answer)
B. Surgery
C. Thyroxine
D. Observation

Explanation: ***Radioiodine*** - **Differentiated thyroid cancers**, including **follicular carcinoma**, retain the ability to uptake iodine, making **radioiodine (I-131) therapy** highly effective for treating metastases [1]. - This therapy targets and destroys thyroid cancer cells wherever they are located in the body, including distant metastatic sites. *Surgery* - While surgery (e.g., **thyroidectomy**) is the primary treatment for localized thyroid cancer and can be used to resect some metastases, it is **not always feasible** for all metastatic sites, especially widely disseminated disease. - Surgery for widespread metastases carries significant risks and may not be curative if all tumor burden cannot be removed. *Thyroxine* - **Thyroxine (T4)** replacement therapy is crucial after thyroidectomy to replace missing hormones and to **suppress TSH** production, which can stimulate residual cancer growth [1]. - However, thyroxine itself does **not directly destroy** existing metastases; it's a supportive and suppressive therapy, not a primary treatment for metastases. *Observation* - **Observation** is generally not appropriate for treating metastases from **follicular carcinoma**, as these metastases have the potential to grow and lead to significant morbidity and mortality if left untreated. - Active treatment is usually indicated to improve prognosis and quality of life.

Question 10: International prognostic index for lymphomas includes the following prognostic factors, EXCEPT:

A. LDH
B. Number of extralymphatic sites involved
C. Hemoglobin and albumin (Correct Answer)
D. Stage of disease

Explanation: ***Hemoglobin and albumin*** - While hemoglobin and albumin can be indicators of overall health and nutritional status, they are **not part of the standard International Prognostic Index (IPI)** for lymphomas. - The IPI specifically focuses on factors directly related to tumor burden and patient vitality, not general systemic markers like these. *LDH* - **Lactate dehydrogenase (LDH)** is a crucial component of the IPI, reflecting tumor burden and aggressiveness [1]. - Elevated LDH levels indicate a higher risk and are associated with a poorer prognosis [1]. *Number of extralymphatic sites involved* - The **number of extralymphatic sites involved** is a key prognostic factor in the IPI. - Involvement of more than one extralymphatic site indicates more widespread disease and a worse prognosis. *Stage of disease* - The **stage of disease**, as defined by the Ann Arbor staging system, is an essential element of the IPI [1]. - Advanced stages (III or IV) are associated with a poorer prognosis compared to early stages [1].

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