Oncology — MCQs

Oncology Indian Medical PG Practice Questions and MCQs

Question 101: A family of a child just diagnosed with acute lymphoblastic leukemia asks about the child's prognosis. Which of the following is a poor prognostic indicator?

A. Presence of mediastinal mass (Correct Answer)
B. Age between 1 and 10 years
C. Hyperploidy with more than 50 chromosomes
D. WBC count less than 50,000/mm3 at diagnosis

Explanation: In Pediatric Acute Lymphoblastic Leukemia (ALL), prognosis is determined by age, initial white blood cell (WBC) count, and cytogenetic markers. ### **Explanation of the Correct Answer** **A. Presence of mediastinal mass:** This is a poor prognostic indicator. A mediastinal mass is classically associated with **T-cell ALL**, which typically presents in older children (adolescents) with very high WBC counts. T-cell ALL is generally considered higher risk compared to the more common precursor B-cell ALL, requiring more intensive chemotherapy. ### **Explanation of Incorrect Options** * **B. Age between 1 and 10 years:** This is the **optimal age group** for a good prognosis. Children younger than 1 year (infants) or older than 10 years have a significantly worse prognosis. * **C. Hyperploidy (>50 chromosomes):** This is a **favorable** cytogenetic marker. Other favorable markers include the presence of the **t(12;21)** [ETV6-RUNX1] translocation. Conversely, hypodiploidy (<44 chromosomes) and the Philadelphia chromosome [t(9;22)] are poor prognostic markers. * **D. WBC count <50,000/mm³:** A lower initial tumor burden (WBC <50,000) is a **favorable** prognostic sign. A WBC count >50,000/mm³ at diagnosis is a major criteria for "High Risk" stratification. ### **NEET-PG High-Yield Pearls** * **Most Common Childhood Cancer:** ALL (Peak age: 2–5 years). * **Best Prognostic Factors:** Age 1–10 years, WBC <50,000, Hyperploidy, t(12;21), and rapid response to initial induction therapy (minimal residual disease negative). * **Worst Prognostic Factors:** Age <1 or >10, WBC >50,000, Hypodiploidy, t(9;22) [BCR-ABL], and CNS involvement at diagnosis. * **L-asparaginase:** A key drug in ALL treatment; watch for side effects like pancreatitis and thrombosis.

Question 102: What is the most common tumor of the face in children?

A. Rhabdomyosarcoma (Correct Answer)
B. Squamous cell carcinoma
C. Basal cell carcinoma
D. Mixed parotid tumor

Explanation: **Explanation:** **Rhabdomyosarcoma (RMS)** is the correct answer because it is the most common soft tissue sarcoma in children, accounting for approximately 50% of all pediatric soft tissue sarcomas. The **head and neck** are the most frequent primary sites (approx. 35-40%), with the orbit, nasopharynx, and facial soft tissues being common locations. Unlike adults, where epithelial tumors (carcinomas) are common, pediatric malignancies are predominantly mesenchymal or embryonal in origin. **Analysis of Incorrect Options:** * **B & C (Squamous Cell and Basal Cell Carcinoma):** These are the most common skin cancers in **adults**, typically resulting from cumulative UV damage over decades. They are extremely rare in children unless there is a predisposing genetic condition like Xeroderma Pigmentosum. * **D (Mixed Parotid Tumor/Pleomorphic Adenoma):** While this is the most common benign salivary gland tumor, it is significantly less frequent in the pediatric population compared to RMS and typically presents as a localized parotid swelling rather than a general facial tumor. **Clinical Pearls for NEET-PG:** * **Subtypes:** The **Embryonal** variant is the most common overall (better prognosis), while the **Alveolar** variant is more aggressive and often found in the extremities. * **Common Sites:** Orbit is the most common head and neck site; it presents with rapid-onset proptosis. * **Staging:** RMS is unique as it uses both a "Stage" (TNM) and a "Group" (based on the extent of surgical resection). * **Histology:** Look for **"Rhabdomyoblasts"** or "Strap cells" and immunohistochemistry markers like **Desmin, Myogenin, and Myo-D1**.

Question 103: Which of the following is NOT a characteristic feature of neuroblastoma in children?

A. Proptosis
B. Hypertension
C. Hepatomegaly
D. Cafe-au-lait spots (Correct Answer)

Explanation: **Explanation:** Neuroblastoma is a common extracranial solid tumor in children, arising from primordial neural crest cells of the sympathetic nervous system. **Why Cafe-au-lait spots is the correct answer:** Cafe-au-lait spots are hyperpigmented macules typically associated with **Neurofibromatosis Type 1 (NF-1)**, McCune-Albright syndrome, or Tuberous Sclerosis. While NF-1 increases the risk of certain tumors (like optic gliomas or pheochromocytomas), it is not a characteristic clinical feature of neuroblastoma. **Analysis of other options:** * **Proptosis:** This is a classic sign of metastatic neuroblastoma. Retro-orbital metastasis leads to periorbital ecchymosis and proptosis, famously known as **"Raccoon Eyes."** * **Hypertension:** Neuroblastomas are embryonal tumors of the sympathetic chain/adrenal medulla. They often produce catecholamines (VMA/HVA). While not as common as in pheochromocytoma, hypertension can occur due to catecholamine excess or renal artery compression (Goldblatt kidney). * **Hepatomegaly:** Massive liver involvement is a hallmark of **Stage 4S neuroblastoma** (Pepper Syndrome), seen in infants, where the liver is a primary site of metastatic spread. **High-Yield Clinical Pearls for NEET-PG:** * **Opsoclonus-Myoclonus Syndrome:** A paraneoplastic syndrome ("Dancing eyes, dancing feet") highly specific to neuroblastoma. * **Homer-Wright Rosettes:** The characteristic histopathological finding (pseudorosettes). * **N-myc Amplification:** The most important prognostic factor; its presence indicates a poor prognosis. * **Differentiating from Wilms Tumor:** Neuroblastoma often **crosses the midline**, is irregular/nodular, and may show **calcifications** on X-ray/CT, unlike Wilms tumor which is usually smooth and confined to one side.

Question 104: Which of the following is a poor prognostic factor for acute lymphoblastic leukemia (ALL)?

A. Female sex
B. Leukocyte count < 50,000
C. Age greater than 1 year
D. Hypodiploidy (Correct Answer)

Explanation: **Explanation:** Prognostic factors in Acute Lymphoblastic Leukemia (ALL) are critical for risk stratification and determining treatment intensity. **Why Hypodiploidy is correct:** Cytogenetics play a major role in prognosis. **Hypodiploidy** (defined as <44 chromosomes) is a well-established **poor prognostic factor**. It is associated with a higher risk of treatment failure and relapse. In contrast, hyperdiploidy (>50 chromosomes) and the presence of the t(12;21) translocation (TEL-AML1) are associated with a favorable prognosis. **Analysis of Incorrect Options:** * **Female sex:** Male sex is actually considered a relatively poorer prognostic factor compared to females, partly due to the risk of sanctuary site relapses (e.g., testicular relapse). * **Leukocyte count < 50,000/µL:** A low initial White Blood Cell (WBC) count (<50,000/µL) is a **favorable** prognostic factor. A high WBC count (≥50,000/µL) at presentation indicates a high tumor burden and poor prognosis. * **Age greater than 1 year:** The "age peak" for a favorable prognosis is between **1 and 10 years**. Infants (<1 year) and adolescents/adults (>10 years) have a significantly poorer prognosis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common childhood cancer:** ALL (specifically B-cell ALL). * **Best Prognosis:** Age 1–10 years, WBC <50,000, Female, Hyperdiploidy, t(12;21). * **Worst Prognosis:** Age <1 or >10 years, WBC >50,000, Male, **Hypodiploidy**, t(9;22) [Philadelphia chromosome], and t(4;11). * **Minimal Residual Disease (MRD):** Currently the most important independent predictor of treatment outcome. Presence of MRD at the end of induction therapy signifies a poor prognosis.

Question 105: Neuroblastoma originates from which of the following locations?

A. Adrenals, Peripheral Nerve, Paraveebral retroperitoneum are true; Posterior mediastinum, Lymph node are false
B. Adrenals, Peripheral Nerve, Paraveebral retroperitoneum are false; Posterior mediastinum, Lymph node are true
C. Adrenals, Paraveebral retroperitoneum, Posterior mediastinum are true; Peripheral Nerve, Lymph node are false
D. Adrenals, Peripheral Nerve, Posterior mediastinum are true; Paraveebral retroperitoneum, Lymph node are false (Correct Answer)

Explanation: **Explanation:** Neuroblastoma is the most common extracranial solid tumor of childhood. It originates from **primordial neural crest cells** that normally give rise to the **sympathetic ganglia** and the **adrenal medulla**. **1. Why Option D is Correct:** The distribution of neuroblastoma follows the sympathetic chain. The most common primary sites are: * **Adrenal Medulla (approx. 40%):** The most frequent site of origin. * **Paraspinal Sympathetic Ganglia:** This includes the **posterior mediastinum** (the most common site in the thorax) and the **peripheral sympathetic nerves**. * **Note on Terminology:** While neuroblastoma occurs in the retroperitoneum, it specifically arises from the sympathetic chain or adrenal gland. **Lymph nodes** are common sites for *metastasis*, but they are not the site of *origin*. **2. Analysis of Incorrect Options:** * **Option A & B:** These incorrectly categorize the posterior mediastinum or adrenal glands as false sites of origin. The posterior mediastinum is a classic location for thoracic neuroblastomas. * **Option C:** This option labels lymph nodes as false (correct) but incorrectly groups the paraveebral retroperitoneum as a primary site of origin in a way that contradicts the specific sympathetic nerve origin highlighted in the standard NEET-PG curriculum. **High-Yield Clinical Pearls for NEET-PG:** * **Median Age:** 2 years (90% diagnosed before age 5). * **Biomarkers:** Elevated urinary catecholamines (**VMA and HVA**) are found in 90% of cases. * **Genetic Marker:** **N-myc (MYCN) amplification** is the most important poor prognostic factor. * **Clinical Sign:** "Dancing eyes, dancing feet" (**Opsoclonus-myoclonus syndrome**) is a classic paraneoplastic presentation. * **Staging:** **Stage 4S** is a unique category in infants with a high rate of spontaneous regression.

Question 106: A child presents with hemihypertrophy (left arm and leg appear larger than the right) and aniridia. There is no family history of aniridia or hemihypertrophy. Which of the following is the most likely associated major abnormality in this patient?

A. Deafness
B. Seizures
C. Wilms tumor (Correct Answer)
D. Congestive heart failure

Explanation: **Explanation:** The clinical presentation of **hemihypertrophy** (asymmetric overgrowth) and **aniridia** (absence of the iris) in a child strongly suggests **WAGR Syndrome**. This is a microdeletion syndrome involving chromosome **11p13**, affecting the *WT1* (Wilms tumor suppressor) and *PAX6* (ocular development) genes. 1. **Why Wilms Tumor is correct:** The acronym **WAGR** stands for **W**ilms tumor, **A**niridia, **G**enitourinary anomalies, and **R**ange of developmental delays (Intellectual disability). Hemihypertrophy is a classic phenotypic association with Wilms tumor, often seen in WAGR or Beckwith-Wiedemann Syndrome. Due to the deletion of the *WT1* gene, these children have a 40–50% lifetime risk of developing Wilms tumor. 2. **Why other options are incorrect:** * **Deafness:** Not a component of WAGR or common Wilms-associated syndromes. (Associated with syndromes like Alport or Waardenburg). * **Seizures:** While intellectual disability is part of WAGR, epilepsy is not a primary or defining feature. * **Congestive Heart Failure:** Not typically associated with Wilms tumor unless as a rare complication of chemotherapy (e.g., Doxorubicin) or severe hypertension. **High-Yield Clinical Pearls for NEET-PG:** * **WAGR Syndrome:** Deletion of **11p13** (*WT1* and *PAX6*). * **Beckwith-Wiedemann Syndrome (BWS):** Characterized by macroglossia, omphalocele, and hemihypertrophy; involves **11p15** (*IGF-2*). * **Denys-Drash Syndrome:** Triad of Wilms tumor, pseudohermaphroditism, and early-onset renal failure (nephropathy). * **Screening:** Children with hemihypertrophy or WAGR require abdominal ultrasounds every 3 months until age 7–8 to screen for Wilms tumor.

Question 107: Opsoclonus is associated with which of the following conditions?

A. Neuroblastoma (Correct Answer)
B. Nephroblastoma
C. Retinoblastoma
D. Hypernephroma

Explanation: **Explanation:** **Neuroblastoma** is the correct answer because it is classically associated with **Opsoclonus-Myoclonus-Ataxia Syndrome (OMS)**, also known as "Dancing Eyes, Dancing Feet" syndrome. This is a **paraneoplastic syndrome** caused by an autoimmune cross-reactivity where antibodies directed against the tumor cells mistakenly attack the cerebellum and brainstem. * **Opsoclonus:** Rapid, involuntary, multivectorial (horizontal and vertical), unpredictable eye movements. * **Myoclonus:** Brief, shock-like muscle jerks. * **Ataxia:** Lack of voluntary coordination of muscle movements. **Analysis of Incorrect Options:** * **B. Nephroblastoma (Wilms Tumor):** This is the most common renal tumor in children. It is associated with syndromes like WAGR, Denys-Drash, and Beckwith-Wiedemann, but not with opsoclonus. * **C. Retinoblastoma:** This is a primary intraocular tumor. While it affects the eyes (leukocoria or strabismus), it does not cause the neurological paraneoplastic phenomenon of opsoclonus. * **D. Hypernephroma (Renal Cell Carcinoma):** This is primarily an adult renal malignancy. While it has many paraneoplastic manifestations (e.g., erythrocytosis, hypercalcemia), opsoclonus is not one of them. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Adrenal medulla (derived from neural crest cells). * **Biomarkers:** Elevated urinary catecholamines (VMA and HVA). * **Staging:** N-myc amplification is the most important poor prognostic factor. * **Homer-Wright Rosettes:** Characteristic histopathology finding. * **OMS Prognosis:** Interestingly, neuroblastomas associated with Opsoclonus-Myoclonus often have a **better prognosis** and are usually low-stage (favorable) tumors.

Question 108: Which testicular tumor is rare in childhood?

A. Seminoma (Correct Answer)
B. Teratoma
C. Interstitial cell tumor
D. None of the above

Explanation: **Explanation:** Testicular tumors in children differ significantly from those in adults regarding histopathology and clinical behavior. **Why Seminoma is the correct answer:** Seminomas are the most common type of testicular germ cell tumor (GCT) in **adults**, typically occurring between the ages of 15 and 35. However, they are **extremely rare in the prepubertal pediatric population**. In children, germ cell tumors are usually non-seminomatous. **Analysis of Incorrect Options:** * **Teratoma:** This is one of the most common testicular tumors in infants and young children. Unlike adult teratomas, prepubertal teratomas usually follow a **benign** clinical course. * **Interstitial Cell Tumor (Leydig Cell Tumor):** While rare overall, these are the most common sex cord-stromal tumors in children. They often present with **precocious puberty** due to androgen production, making them a classic pediatric board topic. **High-Yield Clinical Pearls for NEET-PG:** * **Most common testicular tumor in children:** Yolk Sac Tumor (Endodermal Sinus Tumor). It is associated with elevated **Alpha-Fetoprotein (AFP)** levels and the presence of **Schiller-Duval bodies** on histology. * **Most common benign testicular tumor in children:** Teratoma. * **Bimodal distribution:** Testicular tumors show peaks in infancy (mostly Yolk Sac and Teratoma) and post-puberty (mostly Seminomas and Mixed GCTs). * **Key distinction:** Prepubertal germ cell tumors are generally not associated with *Testicular Carcinoma in Situ* (GCNIS), whereas adult tumors are.

Question 109: A 1.5-year-old female presents with excessive head enlargement, feeding intolerance, and severe malnutrition. MRI suggests a medulloblastoma causing obstructive hydrocephalus. Which of the following represents an irrational management approach for this patient?

A. Craniotomy with subtotal tumor excision, leaving the layer of tumor adherent to the colliculus.
B. Ventriculoperitoneal shunt placement.
C. Administration of CCNU and vincristine as chemotherapy.
D. Radiotherapy of 35-40 Gy to the whole craniospinal axis. (Correct Answer)

Explanation: **Explanation:** The core concept in pediatric neuro-oncology is the **avoidance of craniospinal irradiation (CSI) in children under 3 years of age.** **Why Option D is the Correct (Irrational) Choice:** In a 1.5-year-old child, the developing brain is highly sensitive to radiation. Radiotherapy to the craniospinal axis at this age leads to devastating long-term sequelae, including severe neurocognitive deficits, endocrine dysfunction (growth hormone deficiency), and secondary malignancies. Therefore, the standard of care for medulloblastoma in infants is maximal safe resection followed by intensive chemotherapy to delay or eliminate the need for radiotherapy. **Analysis of Incorrect Options:** * **Option A:** Subtotal excision is often preferred over gross total resection if the tumor is adherent to vital structures like the brainstem (colliculus) to prevent permanent neurological deficits. * **Option B:** Obstructive hydrocephalus is a common complication of posterior fossa tumors. A VP shunt or an External Ventricular Drain (EVD) is a standard palliative or preoperative measure to stabilize intracranial pressure. * **Option C:** Chemotherapy (using agents like Vincristine, Cisplatin, or CCNU) is the primary adjuvant treatment modality for medulloblastoma in children <3 years to avoid the toxic effects of radiation. **High-Yield Clinical Pearls for NEET-PG:** * **Medulloblastoma:** Most common malignant brain tumor in children; arises from the roof of the 4th ventricle (vermis). * **Homer-Wright Rosettes:** Classic histopathological finding. * **Drop Metastasis:** Medulloblastoma has a high propensity for CSF seeding; hence, the entire neuraxis must be imaged (MRI Spine). * **Age Cut-off:** Always look for the age in the stem. If the patient is **<3 years old**, radiotherapy is generally contraindicated.

Question 110: A 3-year-old child presented with a hypoechoic lesion on USG abdomen. What is the most probable diagnosis?

A. Neuroblastoma
B. Teratoma
C. Wilms tumor (Correct Answer)
D. Renal cell carcinoma

Explanation: **Explanation:** **Wilms Tumor (Nephroblastoma)** is the most common primary renal malignancy in children, typically peaking between 2–5 years of age. On ultrasonography (USG), it characteristically appears as a large, well-circumscribed, solid **hypoechoic** or heterogeneously echogenic mass arising from the renal parenchyma. The presence of a "claw sign" (normal kidney tissue stretched around the tumor) often confirms its intra-renal origin. **Analysis of Options:** * **Neuroblastoma (Option A):** While also a common pediatric abdominal mass, it is typically **suprarenal** (adrenal origin). On USG, it is often more heterogeneous with irregular borders and frequently shows **stippled calcifications**, which are less common in Wilms tumor. * **Teratoma (Option B):** These are germ cell tumors that typically present as complex masses with mixed echogenicity, containing fat, fluid, and dense calcifications (bone/teeth), rather than a uniform hypoechoic solid appearance. * **Renal Cell Carcinoma (Option D):** Extremely rare in the 3-year-old age group; it typically occurs in adolescents or adults. **High-Yield Clinical Pearls for NEET-PG:** * **Presentation:** Usually an asymptomatic, smooth, firm abdominal mass that **does not cross the midline** (unlike Neuroblastoma, which often crosses the midline). * **WAGR Syndrome:** Wilms tumor, Aniridia, Genitourinary anomalies, and intellectual disability (formerly Retardation). * **Beckwith-Wiedemann Syndrome:** Associated with Wilms tumor, macroglossia, and hemihypertrophy. * **Staging:** Unlike many cancers, Wilms tumor staging is primarily **surgical** (based on findings during nephrectomy). * **Metastasis:** The most common site for distant spread is the **Lungs** (cannonball metastasis).

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Bone Tumors

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Retinoblastoma

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Oncology — MCQs

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