Tumor Progression and Metastasis — MCQs
What is the investigation of choice for whole body imaging in metastatic breast cancer?
Which of the following is not a part of extracellular matrix (ECM)?
Which of the following is the platinum-based chemotherapeutic agent used as first-line treatment for ovarian carcinoma?
In prostatic metastasis, the site most commonly involved is which one?
Through which route does prostate cancer primarily spread to the vertebral column?
The most common site of metastasis in neuroblastoma is?
Lymph node metastasis in neck is almost never seen with:
Which of the following is the most critical factor in the tumor metastasis cascade?
Which of the following statements regarding Wilms tumor is false?
All of the following are growth promoting proto-oncogenes except?
Tumor Progression and Metastasis Indian Medical PG Practice Questions and MCQs
Question 1: What is the investigation of choice for whole body imaging in metastatic breast cancer?
- A. Angiography
- B. Venography
- C. Magnetic Resonance Imaging
- D. CT Scan (Correct Answer)
Explanation: ***CT Scan (Correct answer for NEET 2013)*** - **Contrast-enhanced CT scan** was the standard imaging modality for **whole-body staging** in metastatic breast cancer at the time of this exam (2013). - CT offers **excellent spatial resolution** for detecting metastases in **bone, lung, liver, and lymph nodes**. - It is widely available, relatively quick, and provides comprehensive anatomical information. - **Modern Update:** While CT was the standard in 2013, **PET-CT (FDG-PET/CT) is now considered the gold standard** for whole-body staging in metastatic breast cancer due to its combined metabolic and anatomical imaging capabilities. However, PET-CT was not among the options in this historical question. *Magnetic Resonance Imaging* - **MRI** is highly sensitive for specific sites, particularly for **brain metastases** and **bone metastases (especially spine and bone marrow)**. - **Whole-body MRI** protocols are emerging but require longer acquisition times and specialized equipment. - Not ideal as a single first-line modality for comprehensive whole-body staging compared to CT (or modern PET-CT). *Angiography* - **Angiography** is an invasive vascular imaging procedure used to visualize **arterial blood flow**. - It has **no role in routine metastatic screening or staging** of breast cancer. - Reserved for specific indications like preoperative vascular mapping or interventional procedures. *Venography* - **Venography** specifically visualizes **venous structures** and is used to detect venous thrombosis or venous obstructions. - It is **not applicable** for detecting solid organ metastases, bone lesions, or lymph node involvement in cancer staging.
Question 2: Which of the following is not a part of extracellular matrix (ECM)?
- A. Lectins (Correct Answer)
- B. Fibronectin
- C. Laminin
- D. Proteoglycans
Explanation: ***Lectins*** - **Lectins** are carbohydrate-binding proteins involved in various cellular processes but are typically found **on cell surfaces** or within cells, not as a major structural component of the ECM. - While they can interact with ECM components, they are not considered a direct structural element of the extracellular matrix itself. *Fibronectin* - **Fibronectin** is a critical **glycoprotein** in the ECM, playing a vital role in cell adhesion, growth, migration, and differentiation. - It links cells to collagen fibers and other ECM components, forming an essential scaffold. *Laminin* - **Laminin** is a major **glycoprotein** component of the **basal lamina**, a specialized layer of the ECM found beneath epithelial cells. - It helps in cell attachment, differentiation, and migration. *Proteoglycans* - **Proteoglycans** are macromolecules consisting of a **core protein** covalently linked to one or more **glycosaminoglycan (GAG) chains**. - They are abundant in the ECM, where they contribute to its structural integrity, hydration, and can regulate the diffusion of molecules.
Question 3: Which of the following is the platinum-based chemotherapeutic agent used as first-line treatment for ovarian carcinoma?
- A. Cyclophosphamide
- B. Methotrexate
- C. Cisplatin (Correct Answer)
- D. Dacarbazine
Explanation: ***Cisplatin*** - **Cisplatin** is a platinum-based chemotherapy drug that forms **DNA cross-links**, inhibiting DNA synthesis and leading to the death of rapidly dividing cells, making it highly effective against **ovarian carcinoma**. - It is a cornerstone of chemotherapy regimens for ovarian cancer, often used in combination with other agents such as paclitaxel. *Methotrexate* - **Methotrexate** is an **antimetabolite** that inhibits dihydrofolate reductase, thereby interfering with DNA synthesis. - While it is used in various cancers like leukemia, lymphoma, and some solid tumors (e.g., breast cancer, gestational trophoblastic disease), it is **not a primary recommended drug for ovarian carcinoma**. *Cyclophosphamide* - **Cyclophosphamide** is an **alkylating agent** that causes DNA damage, leading to cell death. - It is used in many cancers, including lymphoma, breast cancer, and some leukemias, but it is **not a first-line or primary agent for ovarian carcinoma** in contemporary treatment guidelines. *Dacarbazine* - **Dacarbazine** is an **alkylating agent** primarily used in the treatment of **malignant melanoma** and Hodgkin lymphoma. - It is **not indicated for the treatment of ovarian carcinoma**.
Question 4: In prostatic metastasis, the site most commonly involved is which one?
- A. Perivesical nodes
- B. Obturator nodes (Correct Answer)
- C. Pre-sacral nodes
- D. Para-aortic nodes
Explanation: ***Obturator nodes*** - The **obturator nodes** are a primary site for metastatic spread from the prostate due to their close proximity and direct lymphatic drainage pathways. - Prostate cancer cells often spread via the **lymphatic system** to regional lymph nodes before disseminating to distant sites. **Perivesical nodes** * While also regional, perivesical nodes are less frequently the _initial_ or most common site of metastasis compared to the obturator and internal iliac nodes. * Lymphatic drainage from the prostate primarily follows pathways that lead to obturator and internal iliac nodes first. **Pre-sacral nodes** * Pre-sacral nodes are considered more distant regional nodes compared to the obturator nodes and are typically involved later in the metastatic process. * Their involvement often indicates a more advanced stage of nodal metastasis. **Para-aortic nodes** * Para-aortic nodes are considered distant metastases for prostate cancer, indicating widespread disease. * Metastasis to para-aortic nodes usually occurs after involvement of more proximal regional nodes like the obturator and internal iliac nodes.
Question 5: Through which route does prostate cancer primarily spread to the vertebral column?
- A. None of the options
- B. Batson plexus (Correct Answer)
- C. Inferior hypogastric plexus
- D. Superior hypogastric plexus
Explanation: Batson plexus - The Batson plexus is a valveless network of veins that connects the deep pelvic veins (including those draining the prostate) to the internal vertebral venous plexuses. - The absence of valves in this plexus allows for the retrograde flow of tumor cells, facilitating the direct spread of prostate cancer to the vertebral column and other bones without passing through the pulmonary circulation. Inferior hypogastric plexus - The inferior hypogastric plexus is a nerve plexus containing sympathetic and parasympathetic fibers, primarily involved in innervating pelvic organs. - It is a neural structure, not a vascular pathway, and therefore does not play a direct role in the hematogenous spread of cancer cells. Superior hypogastric plexus - The superior hypogastric plexus is also a nerve plexus, located anterior to the sacral promontory, involved in autonomic innervation of pelvic organs. - Like the inferior hypogastric plexus, it is a neural structure and not a venous pathway for metastatic spread of cancer. None of the options - This option is incorrect because the Batson plexus is a well-established and critically important route for the metastatic spread of prostate cancer to the vertebral column. - The involvement of this valveless venous system is a hallmark in understanding the predilection of prostate cancer for bone metastases.
Question 6: The most common site of metastasis in neuroblastoma is?
- A. Lung
- B. Liver
- C. Lymph nodes
- D. Bone marrow (Correct Answer)
Explanation: ***Bone marrow*** - **Bone marrow** is the most common site of metastasis in neuroblastoma, occurring in more than half of all patients and being a primary determinant of prognosis. - Metastasis to the bone marrow often leads to **anemia**, **thrombocytopenia**, and sometimes **bone pain**. *Lung* - While possible, lung metastases are relatively **uncommon** in neuroblastoma, especially when compared to bone marrow involvement. - Lung metastases tend to occur in **later stages** or with specific genetic subtypes. *Liver* - Liver metastases, though seen, are more prevalent in **infants** with **Stage 4S neuroblastoma**, where the liver can be massively enlarged [1]. - This specific stage often has a **better prognosis** than other metastatic forms [1]. *Lymph nodes* - **Regional lymph node** involvement is common at diagnosis, but distant lymph node metastasis is less frequent than bone marrow involvement. - Involvement of regional lymph nodes does contribute to staging but is not the most frequent site of **distant metastasis**. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, p. 486.
Question 7: Lymph node metastasis in neck is almost never seen with:
- A. Carcinoma vocal cords (Correct Answer)
- B. Supraglottic carcinoma
- C. Carcinoma of tonsil
- D. Papillary carcinoma thyroid
Explanation: ***Carcinoma vocal cords*** - The **vocal cords** are relatively poor in lymphatic drainage, which significantly reduces the likelihood of regional lymph node metastasis. - Due to this sparse lymphatic network, spread to cervical lymph nodes is rare, especially in early-stage disease. *Supraglottic carcinoma* - **Supraglottic** regions have a rich lymphatic network, leading to a high incidence of cervical lymph node metastasis, even in early stages. - Bilateral lymphatic drainage further increases the risk of nodal involvement. *Carcinoma of tonsil* - The **tonsils** are richly supplied with lymphatic vessels, making them prone to early and frequent metastasis to cervical lymph nodes. - Metastasis is often seen in levels II, III, and IV of the neck. *Papillary carcinoma thyroid* - **Papillary thyroid carcinoma** commonly metastasizes to regional lymph nodes, with documented rates as high as 30-80%. - Nodal metastasis can occur in the central compartment (level VI) and lateral neck (levels II-V).
Question 8: Which of the following is the most critical factor in the tumor metastasis cascade?
- A. E-Cadherin (Correct Answer)
- B. Type IV collagenase
- C. Tyrosine kinase
- D. Fibronectin
Explanation: ***E-Cadherin*** - E-Cadherin plays a crucial role in **cell-cell adhesion**, maintaining the integrity of epithelial tissues, and is notably downregulated during epithelial-mesenchymal transition (EMT) in tumor metastasis [1][3]. - Loss of E-Cadherin promotes **invasiveness** and the ability of cancer cells to enter the bloodstream for metastasis [1][3]. *Fibronectin* - While involved in the **extracellular matrix**, it mainly supports cell adhesion and migration but is not specifically tied to the cascade of tumor metastasis [2]. - It does not directly influence the **cellular changes** needed for metastasis like EMT does. *Type IV collagenase* - Type IV collagenase is important for **degrading basement membranes**, but is not as directly involved in the initial stages of **tumor cell dissemination** as E-Cadherin [2][3]. - Its role is more supportive in the context of **tissue remodeling** rather than in the metastatic cascade itself [2]. *Tyrosine kinase* - Tyrosine kinases are involved in **signal transduction** and cellular communication but are not a structural component in the metastasis cascade [2]. - While they may modulate pathways that affect metastasis, they do not directly facilitate cell adhesion or detachment processes essential for initial metastasis [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, pp. 317-318. [2] 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. 233-234. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, pp. 314-316.
Question 9: Which of the following statements regarding Wilms tumor is false?
- A. Most commonly seen < 5 years of age
- B. Most patients recover well with chemotherapy and radiotherapy.
- C. Presents as a renal mass.
- D. Lung metastasis is rare and occurs late (Correct Answer)
Explanation: ***Lung metastasis is rare and occurs late*** - This statement is **false** primarily because when lung metastases occur, they often present **early (at initial diagnosis)** rather than late. - Approximately **10-15% of patients** have pulmonary metastases at presentation, making the "occurs late" portion incorrect. - While lungs are the **most common site** for distant metastases when they do occur, the overall incidence is relatively low, so calling it "rare" is debatable but the "late" timing is definitively wrong. - The statement's claim about late occurrence contradicts clinical reality where metastatic disease, when present, is typically identified at diagnosis or within the first 2 years. *Most commonly seen < 5 years of age* - This statement is **true** as Wilms tumor has **peak incidence at ages 2-3 years**, with the majority of cases diagnosed before age **5 years**. - It is the most common primary **renal malignancy in children**, predominantly affecting young children. *Most patients recover well with chemotherapy and radiotherapy.* - This statement is **true** as Wilms tumor has an **excellent prognosis** with **overall survival rates exceeding 90%** using multimodal therapy. - Treatment includes **surgery (nephrectomy), chemotherapy**, and **radiotherapy** (in selected cases), resulting in high cure rates even in advanced stages. *Presents as a renal mass.* - This statement is **true** as the typical presentation is an **asymptomatic abdominal mass** discovered incidentally by parents or during routine examination. - The mass is usually **firm, smooth, and non-tender**, representing an **intrarenal tumor** that may cause abdominal distension.
Question 10: All of the following are growth promoting proto-oncogenes except?
- A. Fibroblast Growth Factor (FGF)
- B. TGF alpha
- C. TGF beta (Correct Answer)
- D. Platelet-Derived Growth Factor (PDGF)
Explanation: ***TGF beta*** - **TGF-β (Transforming Growth Factor-beta)** is primarily a **growth inhibitory cytokine** and a **tumor suppressor**, rather than a growth-promoting proto-oncogene [3]. - While it can have complex roles, its main function in the context of cancer is to **inhibit cell proliferation** and promote differentiation or apoptosis, unless its signaling pathway is disrupted. *Fibroblast Growth Factor (FGF)* - **FGFs** are a family of **growth factors** that play crucial roles in cell proliferation, differentiation, and tissue repair [1]. - **Overexpression** or aberrant signaling of FGF receptors can lead to uncontrolled cell growth and is associated with various cancers, making them **growth-promoting proto-oncogenes** [1]. *TGF alpha* - **TGF-α (Transforming Growth Factor-alpha)** is a **growth factor** that binds to the **epidermal growth factor receptor (EGFR)**, stimulating cell proliferation and differentiation [1]. - Its mechanism of action is distinctly different from TGF-β, and its involvement in **promoting cell growth** classifies it as a growth-promoting proto-oncogene [1]. *Platelet-Derived Growth Factor (PDGF)* - **PDGF** is a potent **mitogen** that stimulates cell division in various cell types, particularly fibroblasts and smooth muscle cells [2]. - **Dysregulation** of PDGF signaling can contribute to tumor growth and angiogenesis, confirming its role as a **growth-promoting proto-oncogene** [1], [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, p. 292. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. With Illustrations By, pp. 31-32. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 706-707.
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