Cystic Lesions of Pancreas — MCQs
Term "Pseudo" used in "Pseudocyst" is due to its -
The highest life time risk of pancreatic malignancy is seen with:
Marker for pancreatic non-functional neuro-endocrine tumor is
A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?
Which is the best investigation for carcinoma of the head of pancreas?
In cystic fibrosis, which of the following structures is affected in the pancreas?
In cystic fibrosis, which of the following structures is affected in the pancreas?
A 45 year old female presented with a cystic lesion in the lesser sac on CT scan. Endoscopic ultrasound guided aspiration showed amylase to be 500 IU and carcinoembryonic antigen as 500ng/ml. What was she suffering from?
Which of the following exocrine glandular ducts are not obstructed in cystic fibrosis?
What anatomical regions does the transpyloric plane separate?
Cystic Lesions of Pancreas Indian Medical PG Practice Questions and MCQs
Question 1: Term "Pseudo" used in "Pseudocyst" is due to its -
- A. Lining (Correct Answer)
- B. Site
- C. Course
- D. Contents
Explanation: ***Lining*** - A **pseudocyst** lacks an **epithelial or endothelial lining**, which is characteristic of true cysts [1]. - Instead, its wall is formed by **fibrous tissue** and **granulation tissue** surrounding fluid collections [1]. *Site* - The term "pseudo" does not refer to the **location** of the cyst. - Pseudocysts commonly occur in specific organs like the **pancreas**, but their site is not what defines them as "pseudo" [1]. *Course* - The **clinical course** or progression of a pseudocyst, whether it resolves spontaneously or requires intervention, is not the basis for the "pseudo" designation [1]. - Its behavior, while clinically important, does not define its fundamental nature. *Contents* - The contents of a pseudocyst, which often include **necrotic debris**, **inflammatory fluid**, or **pancreatic enzymes**, do not define the "pseudo" aspect. - The fluid composition is a result of the underlying condition, not the reason for the term "pseudo." **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Pancreas, p. 895.
Question 2: The highest life time risk of pancreatic malignancy is seen with:
- A. Familial adenomatous polyposis
- B. Peutz-Jeghers syndrome (Correct Answer)
- C. Hereditary nonpolyposis colorectal cancer
- D. Li-Fraumeni syndrome
Explanation: ***Peutz-Jeghers syndrome*** - **Peutz-Jeghers syndrome** is an autosomal dominant disorder characterized by **hamartomatous polyps** in the gastrointestinal tract and mucocutaneous pigmentation. - It significantly increases the lifetime risk of various cancers, including **pancreatic cancer**, with estimates as high as 11-36% by age 70 [1]. *Familial adenomatous polyposis* - **Familial adenomatous polyposis (FAP)** is primarily associated with a very high lifetime risk of **colorectal cancer** [2]. - While there is a slightly increased risk of pancreatic cancer in FAP patients, it is considerably lower than the risk seen in Peutz-Jeghers syndrome. *Hereditary nonpolyposis colorectal cancer* - **Hereditary nonpolyposis colorectal cancer (HNPCC)**, also known as **Lynch syndrome**, is mainly associated with a high risk of **colorectal** and **endometrial cancers**. - While it does increase the risk of other extra-colonic cancers like gastric, ovarian, and urinary tract cancers, the lifetime risk of pancreatic cancer is lower compared to Peutz-Jeghers syndrome. *Li-Fraumeni syndrome* - **Li-Fraumeni syndrome** is caused by a germline mutation in the **TP53 tumor suppressor gene**, leading to a high predisposition to a wide variety of cancers at a young age. - Common cancers include soft tissue sarcomas, osteosarcomas, breast cancer, brain tumors, and adrenocortical carcinomas; however, the lifetime risk for **pancreatic cancer** is not as prominently high as in Peutz-Jeghers syndrome.
Question 3: Marker for pancreatic non-functional neuro-endocrine tumor is
- A. CEA
- B. PSA
- C. CD100
- D. Chromogranin-A (Correct Answer)
Explanation: ***Chromogranin-A*** - **Chromogranin-A** is a glycoprotein found in the neurosecretory granules of various neuroendocrine cells, making it a reliable **general neuroendocrine tumor marker** [1]. - Elevated levels are particularly useful for detecting and monitoring **pancreatic non-functional neuroendocrine tumors**, which often lack specific hormonal symptoms. *CEA* - **Carcinoembryonic antigen (CEA)** is primarily used as a tumor marker for **colorectal cancer**, and less commonly for other adenocarcinomas like pancreatic adenocarcinoma. - It is generally **not a specific marker** for neuroendocrine tumors. *PSA* - **Prostate-specific antigen (PSA)** is a specific marker for **prostate cancer**, used for screening, diagnosis, and monitoring of this particular malignancy. - It has **no relevance** in the diagnosis or monitoring of pancreatic neuroendocrine tumors. *CD100* - **CD100** (also known as semaphorin-4D) is a membrane glycoprotein involved in immune cell regulation and has been implicated in certain cancers, such as those of **hematopoietic origin**. - It is **not used as a marker** for pancreatic non-functional neuroendocrine tumors. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 780-781.
Question 4: A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?
- A. 48%
- B. 12%
- C. 24%
- D. 3% (Correct Answer)
Explanation: ***3%*** - **Purely cystic thyroid nodules** (as described in this case with "isolated cystic swelling") have a **very low risk of malignancy**, typically **2-3%** or less. - According to **ATA guidelines** and **TIRADS classification**, purely cystic nodules are considered **low suspicion** lesions. - The cystic nature suggests a **benign process** such as a degenerated adenoma, colloid cyst, or simple cyst. - **Fine needle aspiration (FNA)** may still be considered if the nodule is >2 cm or has any suspicious solid components, but is often not required for purely cystic lesions. *48%* - This percentage is **significantly higher** than the actual malignancy risk for a purely cystic thyroid swelling. - Such a **high risk** would typically be associated with **solid nodules** exhibiting highly suspicious ultrasound features such as: - Microcalcifications - Irregular or spiculated margins - Taller-than-wide shape - Marked hypoechogenicity - Extrathyroidal extension *24%* - This percentage represents a **moderate to high risk** of malignancy, which is **not characteristic** of an isolated purely cystic thyroid swelling. - A risk in this range might be seen with: - **Mixed solid-cystic nodules** with predominantly solid components - Solid nodules with **intermediate suspicious features** on ultrasound *12%* - While lower than 24% or 48%, 12% is still **considerably higher** than the generally accepted malignancy risk for purely cystic thyroid nodules. - This risk level could be plausible for: - **Predominantly cystic nodules** with some eccentric solid components - Solid nodules with **mildly suspicious** features on ultrasound
Question 5: Which is the best investigation for carcinoma of the head of pancreas?
- A. Transduodenal/transperitoneal sampling
- B. Guided biopsy
- C. ERCP
- D. EUS (Correct Answer)
Explanation: ***EUS*** - **Endoscopic ultrasound (EUS)** provides the highest resolution imaging of the pancreas and allows for **fine-needle aspiration (FNA)** of suspicious lesions, offering definitive tissue diagnosis. - Its ability to visualize small, early-stage tumors and regional lymph nodes makes it the **most accurate method for diagnosis and staging** of pancreatic head carcinoma. *Guided biopsy* - While a biopsy is necessary for definitive diagnosis, 'guided biopsy' is a broad term that doesn't specify the highly effective EUS guidance. - Other biopsy methods that are not guided by EUS may be less accurate and carry higher risks for pancreatic lesions. *ERCP* - **Endoscopic retrograde cholangiopancreatography (ERCP)** is primarily a therapeutic procedure used for **biliary drainage** in cases of obstruction caused by pancreatic head tumors. - Although it can visualize ductal abnormalities and allow brush cytology, it is **less sensitive for direct tumor visualization** and tissue acquisition compared to EUS-FNA. *Transduodenal/transperitoneal sampling* - These are **invasive surgical approaches** for obtaining tissue samples, typically reserved when less invasive methods like EUS-FNA are unsuccessful or when intraoperative confirmation is needed. - They carry **higher risks** and are not considered the "best investigation" for initial diagnosis due to their invasiveness and potential for complications.
Question 6: In cystic fibrosis, which of the following structures is affected in the pancreas?
- A. Acinar cells
- B. Islets of Langerhans
- C. Pancreatic ducts (Correct Answer)
- D. Stromal tissue
Explanation: ***Pancreatic ducts*** - In cystic fibrosis, the **CFTR protein** dysfunction leads to thick, viscous secretions that obstruct the **pancreatic ducts** [2]. - This obstruction prevents digestive enzymes from reaching the intestine, causing **malabsorption** and progressive pancreatic damage [2]. *Acinar cells* - While pancreatic acinar cells are responsible for producing digestive enzymes, they are not directly dysfunctional in cystic fibrosis. - Their function is secondarily impaired due to the **blockage of the ducts** that carry their secretions [2]. *Islets of Langerhans* - The **islets of Langerhans** contain endocrine cells (e.g., insulin-producing beta cells) and are generally unaffected early in cystic fibrosis [1]. - Long-standing inflammation and fibrosis in severe cases can eventually impair islet function, leading to **CF-related diabetes** [1]. *Stromal tissue* - Stromal tissue (supporting connective tissue) is not the primary site of pathology in cystic fibrosis. - While chronic inflammation may lead to **fibrosis** of stromal tissue over time, the initial and primary defect is in the **ductal obstruction**, not in the stroma itself. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Pancreas, pp. 893-895. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, p. 789.
Question 7: In cystic fibrosis, which of the following structures is affected in the pancreas?
- A. Pancreatic capsule
- B. Ducts (Correct Answer)
- C. Acinar cells
- D. Islets of Langerhans
Explanation: ***Ducts*** - In **cystic fibrosis**, mutations in the **CFTR gene** lead to defective chloride transport, resulting in thick, viscous secretions [1]. - These thick secretions obstruct the **pancreatic ducts**, leading to autodigestion, inflammation, and fibrosis of the pancreas [2]. *Pancreatic capsule* - The pancreatic capsule is the **outer connective tissue layer** of the pancreas. - While the entire organ is eventually affected, the **primary pathology** in cystic fibrosis begins within the glandular structures, not the capsule itself. *Acinar cells* - **Acinar cells** are responsible for producing **digestive enzymes**. - While they are damaged secondary to ductal obstruction and inflammation, the **initial defect** is in the transport of fluid and electrolytes, leading to ductal blockage [2]. *Islets of Langerhans* - The **Islets of Langerhans** contain **endocrine cells** that produce hormones like **insulin and glucagon**. - While long-standing pancreatic damage can eventually affect islet function and lead to **cystic fibrosis-related diabetes**, the primary and initial structural involvement is with the exocrine ducts [2]. **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. 120-122. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 476-478.
Question 8: A 45 year old female presented with a cystic lesion in the lesser sac on CT scan. Endoscopic ultrasound guided aspiration showed amylase to be 500 IU and carcinoembryonic antigen as 500ng/ml. What was she suffering from?
- A. Pancreatic adenocarcinoma
- B. Pseudocyst pancreas with ductal communication
- C. Chronic pseudocyst
- D. Mucinous neoplasm of pancreas (Correct Answer)
Explanation: ***Mucinous neoplasm of pancreas*** - **Markedly elevated CEA** (500 ng/ml, well above the threshold of 192 ng/ml) is highly specific for **mucinous cystic neoplasms** (MCN or IPMN). - The presence of **elevated amylase** (500 IU) indicates communication with the pancreatic ductal system, which can occur with **intraductal papillary mucinous neoplasms (IPMN)** or MCN with ductal involvement. - **CEA >192 ng/ml has >90% specificity** for distinguishing mucinous from non-mucinous lesions. - This patient likely has either an **MCN** (mucinous cystadenoma/cystadenocarcinoma) or **IPMN** with malignant potential requiring surgical evaluation. *Pseudocyst pancreas with ductal communication* - Pseudocysts typically have **high amylase** but **low CEA (<5 ng/ml)**. - A CEA of 500 ng/ml essentially **rules out a simple pseudocyst**. - Pseudocysts lack epithelial lining and do not produce CEA. *Chronic pseudocyst* - Similar to acute pseudocyst, chronic pseudocysts have **high amylase but low CEA**. - The markedly elevated CEA (500 ng/ml) makes this diagnosis incorrect. - Would expect CEA <5 ng/ml in pseudocyst fluid. *Pancreatic adenocarcinoma* - Solid pancreatic adenocarcinoma can have elevated CEA, but typically presents as a **solid mass**, not a cystic lesion. - Cyst fluid analysis would show **malignant cells on cytology** and typically **low amylase**. - Does not present as a pure cystic lesion in the lesser sac.
Question 9: Which of the following exocrine glandular ducts are not obstructed in cystic fibrosis?
- A. Pancreas
- B. Lung
- C. Sweat gland (Correct Answer)
- D. None of the options
Explanation: ***Sweat gland*** - In cystic fibrosis, the **CFTR protein** in sweat glands is defective, leading to **impaired chloride reabsorption** and excessively salty sweat [1]. - This defect causes dysfunctional sweat production but **does not result in obstruction** of the sweat gland ducts, which continue to secrete. *Pancreas* - The **exocrine pancreatic ducts** are frequently obstructed in cystic fibrosis due to the production of **thick, sticky mucus**. - This obstruction leads to maldigestion and **pancreatic insufficiency**, requiring enzyme replacement therapy. *Lung* - **Bronchial ducts** and airways in the lungs are severely affected by the accumulation of **viscous mucus**, leading to chronic obstruction [1]. - This obstruction impairs mucociliary clearance, making patients susceptible to recurrent **pulmonary infections** and progressive lung damage [1], [2]. *None of the options* - This option is incorrect because sweat glands are indeed not obstructed, making option C the appropriate answer.
Question 10: What anatomical regions does the transpyloric plane separate?
- A. Hypogastrium from hypochondrium
- B. Hypochondrium from lumbar region (Correct Answer)
- C. Iliac fossa from lumbar region
- D. Umbilical region from lumbar region
Explanation: ***Hypochondrium from lumbar region*** - The **transpyloric plane** is an imaginary horizontal line that passes through the **pylorus of the stomach** and the tips of the ninth costal cartilages. - This plane separates the **upper lateral abdominal regions** (hypochondria) from the **middle lateral abdominal regions** (lumbar regions) on each side. *Hypogastrium from hypochondrium* - The **hypogastrium** is inferior to the umbilical region, while the **hypochondria** are located in the upper lateral parts of the abdomen. - These regions are separated by the **subcostal plane**, not the transpyloric plane. *Iliac fossa from lumbar region* - The **iliac fossa** is located in the lower lateral part of the abdomen, while the **lumbar region** is in the middle lateral part. - These specific regions are primarily divided by the **intertubercular plane**, which is inferior to the transpyloric plane. *Umbilical region from lumbar region* - The **umbilical region** is the central area of the abdomen around the umbilicus, and the **lumbar regions** are lateral to it. - The transpyloric plane transverses the upper part of the umbilical region but does not primarily serve to separate the umbilical from the lumbar regions.
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