Pancreatic Neoplasms — MCQs
A 38-year-old female presents to the physician with complaints of excessive thirst and urination for the past 4 weeks. Her appetite has been normal and she has not had diarrhea. Blood chemistry showed mildly elevated glucose and glucagon. Physical examination reveals tenderness in the left upper quadrant and an erythematous necrotizing skin eruption on her legs. Radiographic studies show a tumor in the pancreas. Which of the following cells is responsible for this lesion?
A 68-year-old man with jaundice. CT reveals a pancreatic mass. Biopsy shows glandular cells with desmoplastic stroma. What is the most likely diagnosis?
True about pancreatic pseudocysts is:
Most common complication of a pseudocyst of the pancreas is
Most frequently altered oncogene in pancreatic cancer is:
A 65-year-old woman presents with a 5-week history of yellow skin and sclera, anorexia, and epigastric pain. Her past medical history is significant for insulin-dependent diabetes mellitus. She smoked one pack of cigarettes a day for the past 20 years. Physical examination reveals jaundice and a palpable gallbladder. Laboratory studies show a serum bilirubin level of 10 mg/dL, mostly in the conjugated form, and an elevated alkaline phosphatase (260 U/L). A CT scan of the abdomen discloses a mass in the head of the pancreas and multiple nodules in the liver measuring up to 3 cm. Which of the following is the most important risk factor for the neoplasm arising in the patient?
The triad of diabetes, gallstones, and steatorrhea is associated with which of the following?
Carcinoma of pancreas attains largest size when it is sited in -
Type of necrosis in pancreatitis-
A young boy presents with failure to thrive. Biochemical analysis of an aspirate after a meal reveals a deficiency of enteropeptidase (enterokinase). The levels of which digestive enzymes would be affected?
Pancreatic Neoplasms Indian Medical PG Practice Questions and MCQs
Question 1: A 38-year-old female presents to the physician with complaints of excessive thirst and urination for the past 4 weeks. Her appetite has been normal and she has not had diarrhea. Blood chemistry showed mildly elevated glucose and glucagon. Physical examination reveals tenderness in the left upper quadrant and an erythematous necrotizing skin eruption on her legs. Radiographic studies show a tumor in the pancreas. Which of the following cells is responsible for this lesion?
- A. Beta cell
- B. Acinar cell
- C. Delta cell
- D. Alpha cell (Correct Answer)
Explanation: ### Alpha cell - The constellation of **excessive thirst and urination (polyuria/polydipsia)**, **mildly elevated glucose**, **elevated glucagon**, **necrolytic migratory erythema (NME)**, and a **pancreatic tumor** is highly characteristic of a **glucagonoma**. [1] - Glucagonomas originate from **pancreatic alpha cells**, which are responsible for glucagon production. [2] ### Beta cell - **Beta cell tumors** (insulinomas) primarily cause **hypoglycemia** due to excessive insulin secretion, which is antithetical to the patient's symptoms of elevated glucose. [2] - While beta cell tumors can be found in the pancreas, they are not associated with necrolytic migratory erythema or glucagon excess. [1] ### Acinar cell - **Acinar cell carcinomas** are exocrine pancreatic tumors that can cause symptoms related to their size and local invasion (e.g., pain, weight loss, jaundice) but are not typically associated with specific hormonal syndromes such as glucagon excess. - They do not cause the characteristic skin rash or metabolic disturbances seen in this patient. ### Delta cell - **Delta cells** produce **somatostatin**, and tumors originating from these cells (somatostatinomas) can cause symptoms like diabetes, steatorrhea, and gallstones. - However, they do not typically present with elevated glucagon or the characteristic necrolytic migratory erythema.
Question 2: A 68-year-old man with jaundice. CT reveals a pancreatic mass. Biopsy shows glandular cells with desmoplastic stroma. What is the most likely diagnosis?
- A. Cholangiocarcinoma
- B. Hepatocellular carcinoma
- C. Neuroendocrine tumor
- D. Pancreatic adenocarcinoma (Correct Answer)
Explanation: ***Pancreatic adenocarcinoma*** - The combination of **jaundice**, a **pancreatic mass** on CT, and a biopsy showing **glandular cells with desmoplastic stroma** is highly characteristic of pancreatic adenocarcinoma [1], [2]. - **Desmoplastic stroma** (dense fibrous tissue reaction) is a hallmark feature of pancreatic adenocarcinoma, supporting its diagnosis [1], [2]. *Cholangiocarcinoma* - While it can present with **jaundice** and a mass, cholangiocarcinoma arises from the **bile ducts**, not typically presenting as a primary pancreatic mass. - The biopsy demonstrating glandular cells with desmoplastic stroma is more specific to pancreatic adenocarcinoma than cholangiocarcinoma. *Hepatocellular carcinoma* - **Hepatocellular carcinoma** arises from the **liver parenchyma** and is usually associated with underlying liver disease (e.g., cirrhosis), not a pancreatic mass. - The biopsy findings of glandular cells are inconsistent with hepatocellular carcinoma, which typically shows hepatocytes. *Neuroendocrine tumor* - **Pancreatic neuroendocrine tumors** can present as a pancreatic mass but often have distinct histological features, including uniform cells with salt-and-pepper chromatin and less prominent desmoplastic stroma. - While some can secrete hormones, making them functional, the descriptive histology of "glandular cells with desmoplastic stroma" points away from a typical neuroendocrine tumor. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 408-409. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Pancreas, pp. 898-900.
Question 3: True about pancreatic pseudocysts is:
- A. No epithelial lining (Correct Answer)
- B. Develops after 4 weeks
- C. Contains solid components
- D. Always needs surgery
Explanation: ***No epithelial lining*** - A pancreatic pseudocyst is defined by its lack of a true **epithelial lining**, distinguishing it from other cystic lesions of the pancreas. - Instead, its wall is formed by **fibrous and granulation tissue** surrounding a collection of pancreatic enzymes, inflammatory exudates, and necrotic debris. *Develops after 4 weeks* - While many pseudocysts do develop after an acute pancreatitis episode, the 4-week timeline is more specifically associated with the definition of a **pancreatic collection becoming a mature pseudocyst**. - However, pseudocysts can sometimes be observed earlier, and the defining characteristic is the absence of epithelium, not the time of formation. *Contains solid components* - Pancreatic pseudocysts are typically **fluid-filled collections** with a relatively uniform, anechoic appearance on imaging studies. - The presence of significant **solid components** would suggest a different lesion, such as a cystic tumor or a walled-off necrosis, rather than a simple pseudocyst. *Always needs surgery* - Many pancreatic pseudocysts, particularly smaller ones, can **resolve spontaneously** and thus do not always require surgical intervention. - Treatment often depends on size, symptoms, complications, and the duration of the pseudocyst, with conservative management or endoscopic drainage being viable options in many cases.
Question 4: Most common complication of a pseudocyst of the pancreas is
- A. Rupture into peritoneum
- B. Haemorrhage
- C. Infection (Correct Answer)
- D. Rupture into colon
Explanation: ***Infection*** - **Infection** is the most common and clinically significant complication of a pancreatic pseudocyst, often leading to sepsis and increased mortality. - While other complications can occur, **secondary infection** transforms a sterile pseudocyst into an abscess, requiring urgent intervention. *Rupture into peritoneum* - While possible, **rupture into the peritoneum** (free rupture) is a less frequent complication compared to infection. - This leads to acute peritonitis and is a highly morbid event, but statistically less common than infection. *Haemorrhage* - **Hemorrhage** (bleeding) into a pseudocyst is a serious and potentially life-threatening complication, but it is less common than infection. - It usually results from erosion into adjacent blood vessels, such as the splenic or gastroduodenal arteries. *Rupture into colon* - **Rupture into the colon** or other adjacent organs (like the stomach or duodenum) can occur, but these are less frequent compared to infection. - Such ruptures can lead to internal fistula formation, but infection remains the predominant complication.
Question 5: Most frequently altered oncogene in pancreatic cancer is:
- A. K-RAS (Correct Answer)
- B. CDKN2A
- C. SMAD4
- D. TP53
Explanation: ***K-RAS*** - **K-RAS** mutations are present in approximately **90%** of pancreatic adenocarcinomas, making it the most frequently altered oncogene in this cancer type [1]. - It plays a major role in the **Ras signaling pathway**, which is crucial for cell proliferation and survival. *TP53* - While **TP53** mutations are also common in various cancers, they are not the most prevalent in pancreatic cancer, where K-RAS is more frequently mutated [1]. - Typically associated with **tumor progression**, rather than initiating changes seen in pancreatic carcinogenesis [1]. *SMAD4* - **SMAD4** mutations occur in about **55%** of pancreatic cancers but are generally involved in the later stages of tumor progression, rather than being an initiating oncogenic event [1]. - Primarily functions in the **TGF-beta signaling pathway**, which is different from the K-RAS pathway. *CDKN2A* - Although **CDKN2A** deletions are implicated in pancreatic cancer, they are not as frequently altered as K-RAS mutations [1]. - This gene is related to the regulation of the **cell cycle**, but its alterations are secondary in the context of pancreatic oncogenesis [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Pancreas, pp. 897-898.
Question 6: A 65-year-old woman presents with a 5-week history of yellow skin and sclera, anorexia, and epigastric pain. Her past medical history is significant for insulin-dependent diabetes mellitus. She smoked one pack of cigarettes a day for the past 20 years. Physical examination reveals jaundice and a palpable gallbladder. Laboratory studies show a serum bilirubin level of 10 mg/dL, mostly in the conjugated form, and an elevated alkaline phosphatase (260 U/L). A CT scan of the abdomen discloses a mass in the head of the pancreas and multiple nodules in the liver measuring up to 3 cm. Which of the following is the most important risk factor for the neoplasm arising in the patient?
- A. Cholelithiasis
- B. Cigarette smoking (Correct Answer)
- C. Alcohol abuse
- D. Diabetes mellitus type 1
Explanation: ***Cigarette smoking*** - **Smoking** is a well-established and significant risk factor for adenocarcinoma of the **pancreas**, which aligns with the patient's presentation of a pancreatic head mass, obstructive jaundice (yellow skin/sclera, high conjugated bilirubin, elevated alkaline phosphatase), and palpable gallbladder [3]. - The 20-year history of smoking significantly increases her individual risk for this particular type of cancer. *Cholelithiasis* - While **gallstones** can cause obstructive jaundice (e.g., choledocholithiasis), they are not a primary risk factor for **pancreatic adenocarcinoma**. - The patient's CT scan indicates a **pancreatic head mass** and liver nodules, pointing away from primary gallstone disease as the etiology of the neoplasm. *Alcohol abuse* - Chronic **alcohol abuse** is a major risk factor for chronic pancreatitis, which can, in turn, increase the risk of pancreatic cancer [1]. - However, direct causation between alcohol abuse and pancreatic cancer is less strong than with smoking, and there is no mention of alcohol abuse in the patient's history [2]. *Diabetes mellitus type 1* - While a proportion of patients with newly diagnosed **pancreatic cancer** may develop diabetes (often type 2 or an unusual type of diabetes), **insulin-dependent diabetes mellitus type 1** itself is considered a minor or even non-existent risk factor for pancreatic cancer. - The presence of diabetes in this patient is more likely a concurrent condition or a consequence of the pancreatic tumor rather than a primary risk factor for its development.
Question 7: The triad of diabetes, gallstones, and steatorrhea is associated with which of the following?
- A. Somatostatinomas (Correct Answer)
- B. VIPomas
- C. Gastrinomas
- D. Glucagonomas
Explanation: ***Somatostatinomas*** - This **triad** is characteristic of a somatostatinoma, as somatostatin inhibits insulin release, gallbladder contraction, and pancreatic enzyme secretion. - The inhibition of **insulin release** leads to diabetes [1], blocked **cholecystokinin (CCK)** release causes gallstones, and reduced **pancreatic enzyme** secretion results in steatorrhea. *Gastrinomas* - Gastrinomas typically cause **Zollinger-Ellison syndrome**, characterized by severe peptic ulcers and diarrhea due to excessive acid production. - They are not directly associated with the specific triad of diabetes, gallstones, and steatorrhea. *VIPomas* - VIPomas are known for causing **Verner-Morrison syndrome** or pancreatic cholera, leading to severe watery diarrhea, hypokalemia, and achlorhydria. - Diabetes and gallstones are not prominent features of VIPomas. *Glucagonomas* - Glucagonomas primarily manifest with **diabetes** (due to elevated glucagon), a characteristic skin rash called **necrolytic migratory erythema**, and weight loss [1]. - While diabetes is present, gallstones and steatorrhea are not typical associations.
Question 8: Carcinoma of pancreas attains largest size when it is sited in -
- A. Head
- B. Periampullary
- C. Body & tail (Correct Answer)
- D. Ampulla
Explanation: ***Body & tail*** - Carcinomas in the **body and tail of the pancreas** are often diagnosed at a later stage because they typically do not cause symptoms as early as those in the head of the pancreas. - This delayed diagnosis allows the tumor to grow larger before detection, resulting in a **larger tumor size** at presentation compared to other locations. *Head* - Pancreatic cancers in the **head of the pancreas** often present early with symptoms like **jaundice** (due to biliary obstruction) or weight loss. - Due to these early warning signs, they are usually detected when they are **smaller in size**. *Periampullary* - **Periampullary tumors** are located near the ampulla of Vater and often cause **biliary obstruction** early in their development. - This obstruction leads to symptoms such as **jaundice**, prompting earlier investigation and diagnosis when the tumor is still relatively small. *Ampulla* - Tumors originating directly from the **ampulla of Vater** are often diagnosed at a very early stage because they cause prominent and early symptoms, particularly **obstructive jaundice**. - This early symptomatic presentation leads to their discovery when they are generally the **smallest** among pancreatic or periampullary cancers.
Question 9: Type of necrosis in pancreatitis-
- A. Coagulative
- B. Caseous
- C. Fibrinoid
- D. Fat (Correct Answer)
Explanation: ***Fat*** - In pancreatitis, the release of **lipases** from damaged pancreatic cells leads to the breakdown of fat cells, resulting in the formation of **fatty acids** and **glycerol** [1]. - These fatty acids then combine with calcium to form **calcium soaps**, which appear as white, chalky deposits and signify **fat necrosis** [1]. *Coagulative* - This type of necrosis typically occurs due to **ischemia** (lack of blood supply) in solid organs, preserving the outline of the cells for a period [1]. - While ischemia can play a role in severe pancreatitis, the primary and distinctive type of necrosis in this condition is not coagulative. *Caseous* - **Caseous necrosis** is characteristic of **tuberculosis** and certain fungal infections, where the tissue has a crumbly, cheese-like appearance [1]. - It involves a combination of liquefactive and coagulative necrosis, but it is not seen in pancreatitis. *Fibrinoid* - **Fibrinoid necrosis** is often associated with **immune-mediated vascular damage**, such as in cases of **vasculitis** or **malignant hypertension** [2]. - It involves the deposition of immune complexes and fibrin in arterial walls, which is not the primary necrotic process in pancreatitis. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Cellular Responses to Stress and Toxic Insults: Adaptation, Injury, and Death, pp. 53-55. [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. 103-104.
Question 10: A young boy presents with failure to thrive. Biochemical analysis of an aspirate after a meal reveals a deficiency of enteropeptidase (enterokinase). The levels of which digestive enzymes would be affected?
- A. Trypsin (Correct Answer)
- B. Colipase
- C. Lactase
- D. Amylase
Explanation: ***Trypsin*** - **Enteropeptidase** (also known as enterokinase) is crucial for activating **trypsinogen** into its active form, **trypsin**. - A deficiency in enteropeptidase would lead to a lack of active trypsin, impairing subsequent protein digestion as trypsin activates other proteases. *Colipase* - **Colipase** is required for optimal activity of pancreatic lipase in fat digestion. - Its activation is not directly dependent on **enteropeptidase**, and therefore, its levels or function would not be primarily affected by this deficiency. *Lactase* - **Lactase** is a brush border enzyme responsible for the digestion of lactose into glucose and galactose. - Its activity is independent of **enteropeptidase** and protein digestion pathways. *Amylase* - **Amylase** (both salivary and pancreatic) is responsible for carbohydrate digestion (starch). - Its function and levels are not directly affected by **enteropeptidase**, which primarily initiates protein digestion.
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