Neoplasia — MCQs

Neoplasia Indian Medical PG Practice Questions and MCQs

Question 851: In a histopathological examination, a tumor shows a hobnail appearance. Which of the following tumors is most likely associated with this finding?

A. Clear cell carcinoma (Correct Answer)
B. Endodermal sinus tumor
C. HCC
D. Choriocarcinoma

Explanation: ***Clear cell carcinoma*** - The **hobnail appearance** describes tumor cells that protrude into the lumen, resembling a hobnail, which is a characteristic feature of **clear cell carcinoma** in various organs like the kidney, ovary, and uterus. - These cells often have **clear cytoplasm** and prominent apical nuclei, contributing to their distinct appearance. *Endodermal sinus tumor* - This tumor is known for forming **Schiller-Duval bodies**, which are pathognomonic glomeruloid structures, not a hobnail appearance. - It typically contains regions of a reticular pattern and often stains positive for **alpha-fetoprotein (AFP)**. *HCC* - **Hepatocellular carcinoma (HCC)** is characterized by cells resembling hepatocytes, forming trabecular, solid, or pseudoglandular patterns. - It does not typically exhibit the **hobnail cell morphology** described. *Choriocarcinoma* - **Choriocarcinoma** is composed of cytotrophoblasts and syncytiotrophoblasts, which are often arranged in a haphazard fashion without distinct hobnail features. - This tumor is characterized by high levels of **human chorionic gonadotropin (hCG)**.

Question 852: Commonest malignancy that can cause splenic metastasis is which of the following?

A. Ca. Melanoma (Correct Answer)
B. Ca. Stomach
C. Ca. Cervix
D. Ca. Pancreas

Explanation: ***Correct: Ca. Melanoma*** - **Melanoma** is the **most common primary malignancy** to metastasize to the spleen in autopsy series [1] - Despite splenic metastases being rare overall (2-9% of cancer patients), melanoma has the **highest propensity** for splenic involvement due to its aggressive hematogenous spread pattern [1] - Melanoma can metastasize to virtually any organ, and the spleen is a recognized site with melanoma being the leading primary source - Other common primaries include breast, lung, ovarian, and colorectal cancers *Incorrect: Ca. Pancreas* - While pancreatic cancer can involve the spleen, this typically occurs through **direct extension** due to anatomical proximity rather than true hematogenous metastasis - Pancreatic cancer more commonly spreads to liver, peritoneum, and regional lymph nodes - It is not the most common source of splenic metastases overall *Incorrect: Ca. Stomach* - Gastric cancer can rarely metastasize to the spleen, but this is uncommon - More typical sites of gastric cancer metastasis include liver, peritoneum, lungs, and lymph nodes - Splenic involvement is much less frequent than with melanoma *Incorrect: Ca. Cervix* - Cervical cancer typically spreads by **local extension** and via lymphatics to pelvic and para-aortic nodes - It may involve bladder, rectum, and vagina through direct spread - **Splenic metastases** from cervical cancer are extremely rare and not a characteristic pattern of spread **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Disorders Involving Inflammatory And Haemopoietic Cells, pp. 650-651.

Question 853: Inhibin is a tumor marker associated with which of the following tumors?

A. Krukenberg tumor
B. Dysgerminoma
C. Granulosa cell tumor (Correct Answer)
D. Serous cystadenoma

Explanation: ***Granulosa cell tumor (a type of ovarian tumor)*** - **Inhibin** is a polypeptide hormone primarily produced by the **granulosa cells** of the ovary and Sertoli cells of the testis [1]. - Granulosa cell tumors, being composed of granulosa cells, often **overproduce inhibin**, making it a valuable tumor marker for diagnosis, monitoring recurrence, and treatment response [1]. *Serous cystadenoma (a type of ovarian epithelial tumor)* - While serous cystadenomas are common ovarian tumors, they are of **epithelial origin** and typically do not produce inhibin. - Markers like **CA-125** are more commonly associated with epithelial ovarian cancers, though not typically with benign serous cystadenomas. *Krukenberg tumor (a metastatic ovarian tumor)* - Krukenberg tumors are **metastatic neoplasms to the ovary**, most commonly originating from the gastrointestinal tract (especially the stomach). - Their marker profile reflects the primary tumor, and **inhibin is not a typical marker** for these metastatic lesions. *Dysgerminoma (a type of ovarian germ cell tumor)* - Dysgerminomas are **germ cell tumors** of the ovary, analogous to seminomas in males. - Tumor markers associated with dysgerminomas include **lactate dehydrogenase (LDH)**, and sometimes **beta-hCG**, but not inhibin. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1036-1037.

Question 854: What is the most common type of anal canal carcinoma?

A. Squamous cell carcinoma (Correct Answer)
B. Adenocarcinoma
C. Adenoacanthoma
D. Papillary carcinoma

Explanation: ***Squamous cell carcinoma*** - This is the most prevalent type of anal canal carcinoma, accounting for over **80% of all anal cancers**. - It arises from the **squamous epithelial cells** lining the anal canal, often linked to **HPV infection**. *Adenocarcinoma* - This type of cancer originates from the **glandular cells** in the upper part of the anal canal or from **anal glands**. - It is a much rarer form of anal cancer compared to squamous cell carcinoma. *Adenoacanthoma* - This is a rare variant of **adenocarcinoma** that also contains foci of benign or malignant squamous differentiation. - It is not the most common type and represents a specific histological subtype. *Papillary carcinoma* - This term describes a **growth pattern** of various carcinomas characterized by finger-like projections or papillae. - It is not a distinct primary type of anal canal carcinoma, but rather a descriptive feature that can be found in some adeno- or squamous cell carcinomas.

Question 855: What is the best assessment for the tendency of colonic carcinoma to metastasize?

A. Size of tumor
B. Carcinoembryonic antigen (CEA) levels
C. Depth of penetration of bowel wall (T stage) (Correct Answer)
D. Histological grade of the tumor

Explanation: ***Depth of penetration of bowel wall (T stage)*** - The **depth of tumor invasion** through the bowel wall is the most critical factor reflecting the likelihood of metastasis in colorectal cancer [1]. - Deeper invasion (higher T stage) directly correlates with increased risk of involvement of lymphatics, blood vessels, and adjacent organs, leading to **distant metastasis** [2]. *Size of tumor* - While larger tumor size can sometimes correlate with advanced disease, it is not as reliable a predictor of metastatic potential as the **depth of invasion**. - A small tumor deeply invading the bowel wall can be more aggressive than a large, superficial one. *Carcinoembryonic antigen (CEA) levels* - **CEA levels** are primarily used for monitoring treatment response and detecting recurrence, not for initially assessing the metastatic potential of the primary tumor. - Elevated pre-operative CEA can indicate more advanced disease, but it's not the primary determinant of metastatic risk itself. *Proportion of bowel circumference involved* - The **circumferential involvement** can indicate a more advanced local tumor and greater risk of obstruction, but it is not the most direct predictor of distant metastatic potential [2]. - Lateral spread along the circumference is distinct from the depth of penetration through the wall. *Histological grade of the tumor* - The **histological grade** (differentiation) of the tumor is an important prognostic factor, with poorly differentiated tumors generally having a worse prognosis and higher metastatic risk. - However, the depth of invasion (T stage) is generally considered a more dominant predictor of metastatic tendency in colorectal cancer. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 236-237. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 374-375.

Question 856: Which type of breast cancer is most commonly associated with bilateral breast carcinoma?

A. Invasive lobular carcinoma (Correct Answer)
B. Ductal carcinoma in situ
C. Invasive ductal carcinoma
D. None of the options

Explanation: ***Invasive lobular carcinoma*** - **Invasive lobular carcinoma (ILC)** is the type of breast cancer most frequently associated with **bilateral disease**. [1], [2] This is due to its growth pattern, which often involves the widespread infiltration of cells that can occur in both breasts. [2] - ILC cells tend to grow in single-file strands, making them less likely to form a palpable mass or be detected by mammography, leading to a higher chance of multifocal or bilateral involvement. [1] *Ductal carcinoma in situ* - **Ductal carcinoma in situ (DCIS)** is a non-invasive lesion, meaning the cancerous cells are confined to the breast ducts and have not spread into surrounding breast tissue. - While DCIS can be multifocal within the same breast, it is less commonly associated with bilateral synchronous or metachronous disease compared to invasive lobular carcinoma. *Invasive ductal carcinoma* - **Invasive ductal carcinoma (IDC)** is the most common type of invasive breast cancer overall, accounting for 70-80% of all invasive breast cancers. - While IDC can be bilateral, it is less frequently associated with bilateral presentation than invasive lobular carcinoma. Its growth pattern typically forms a distinct mass that is more readily detected. *None of the options* - This option is incorrect because **invasive lobular carcinoma** is indeed a type of breast cancer with a well-established association with bilateral disease. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 454-455. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1068-1069.

Question 857: In breast carcinoma, prognosis depends best upon -

A. Size of tumour
B. Site of tumour
C. Estrogen receptor status
D. Axillary lymph node status (Correct Answer)

Explanation: ***Axillary lymphnode status*** - The presence and number of **positive axillary lymph nodes** are the **most significant prognostic factor** in breast carcinoma, as they directly indicate the extent of regional spread [1]. - Involvement of axillary lymph nodes is strongly predictive of a **higher risk of distant metastasis** and generally a poorer prognosis [2]. *Estrogen receptor status* - **Estrogen receptor (ER) status** is an important **predictive marker** for response to hormonal therapy, but it is not the best single indicator of overall prognosis in metastatic disease [2]. - While ER-positive tumors generally have a better prognosis and respond to endocrine therapy, the presence of metastasis itself dictates much of the prognosis. *Size of tumour* - **Tumor size** is a significant prognostic factor for **primary breast cancer**, with larger tumors generally having a worse prognosis [1]. - However, in the context of **metastasis**, the spread to lymph nodes or distant sites becomes a more critical determinant of overall prognosis than the original tumor size. *Site of tumour* - The **site of the primary tumor within the breast** generally has **little independent prognostic value** once metastasis has occurred or is being evaluated. - While certain locations might be associated with variations in lymph node drainage, the actual **lymph node status** is what directly reflects metastatic spread and prognosis. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1070-1072. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 458-459.

Question 858: In which type of cancer is K-ras mutation most commonly observed?

A. Prostate cancer
B. Gastric cancer
C. Liver cancer
D. Pancreatic cancer (Correct Answer)

Explanation: ***Pancreatic carcinoma*** - K-ras mutations are found in **over 90%** of pancreatic adenocarcinomas, making it a hallmark of this cancer type [1]. - These mutations are involved in the **initiation and progression** of pancreatic tumors [1]. *Hepatic carcinoma* - Hepatic carcinoma is more associated with mutations in **TP53** and **CTNNB1**, rather than K-ras mutations. - K-ras mutations are not a primary driver in the context of liver cancer development. *Prostate carcinoma* - Prostate carcinoma typically involves mutations in **PTEN** and **TMPRSS2-ERG** fusion genes, not K-ras. - K-ras mutations are not a significant feature in the pathogenesis of prostate cancer. *Gastric carcinoma* - Gastric carcinoma can have mutation involvement often related to **CDH1** and **TP53**, with variable K-ras mutation presence. - K-ras mutations are less frequent when compared to other mutations seen in gastric tumorigenesis. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Pancreas, pp. 897-898.

Question 859: Paraneoplastic syndrome Hypercalcemia of malignancy is produced due to ectopic production of which hormone by solid tumors like squamous cell carcinoma?

A. Calcitonin
B. PGE2
C. PTHrP (Correct Answer)
D. Parathormone

Explanation: ***PTHrP*** - **Parathyroid hormone-related protein (PTHrP)** is the most common cause of **humoral hypercalcemia of malignancy**, particularly in **solid tumors** such as squamous cell carcinoma (lung, head and neck), renal cell carcinoma, and breast cancer. - It mimics the actions of parathyroid hormone (PTH), leading to increased **bone resorption** and **renal calcium reabsorption**. - PTHrP binds to the same PTH receptor and activates similar signaling pathways, resulting in elevated serum calcium levels. *Calcitonin* - **Calcitonin** is a hormone that **lowers blood calcium levels** by inhibiting osteoclast activity and increasing renal calcium excretion. - Ectopic production of calcitonin (seen in medullary thyroid carcinoma) would cause **hypocalcemia**, not hypercalcemia. *PGE2* - **Prostaglandin E2 (PGE2)** can contribute to **local bone resorption** in some malignancies through stimulation of osteoclast activity. - However, its role is less prominent and typically involves **local osteolytic** mechanisms rather than systemic humoral effects like PTHrP. *Parathormone* - **Parathormone (PTH)** is produced by the parathyroid glands; true ectopic PTH production by tumors is **extremely rare**. - The primary mechanism of humoral hypercalcemia of malignancy in solid tumors is almost exclusively due to **PTHrP**, not PTH itself.

Question 860: Which of the following is included in the Modified Bloom Richardson criteria for Carcinoma Breast?

A. Desmoplasia
B. Lymphovascular invasion
C. Mitotic rate (Correct Answer)
D. Nuclear pleomorphism

Explanation: ***Mitotic rate*** - The **Modified Bloom-Richardson (Nottingham) criteria** for breast carcinoma grading includes three components: **tubular/glandular formation**, **nuclear pleomorphism**, and **mitotic rate**. - **Mitotic rate** assesses the frequency of cell division and is scored based on the number of mitoses per 10 high-power fields. - A higher mitotic rate indicates more aggressive tumor growth and contributes to a higher histological grade. *Desmoplasia* - **Desmoplasia** refers to the fibrous stromal reaction surrounding a tumor and is a common feature of invasive carcinomas. - While it is associated with tumor invasion, it is **not one of the three specific criteria** used in the Modified Bloom-Richardson grading system. - The MBR system focuses on cellular morphology and proliferative activity, not stromal response. *Lymphovascular invasion* - **Lymphovascular invasion** (LVI) indicates the presence of tumor cells within lymphatic or blood vessels, signifying higher metastatic potential. - While LVI is an important **prognostic factor** in breast cancer staging and treatment planning, it is **not part of the MBR histological grading criteria**. - The MBR system evaluates only tubular formation, nuclear features, and mitotic activity. *Nuclear pleomorphism* - **Nuclear pleomorphism** (nuclear grade/nuclear atypia) is actually **one of the three components** of the Modified Bloom-Richardson criteria. - It assesses variation in nuclear size, shape, and chromatin pattern within tumor cells. - Both mitotic rate and nuclear pleomorphism are correct components of the MBR system; however, if forced to choose one answer, mitotic rate is more distinctly quantifiable and is often emphasized in teaching contexts.

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