Principles of Pediatric Chemotherapy — MCQs
Which of the following medications is a first-line antitubercular drug used routinely in children of all age groups without significant monitoring limitations?
Which of the following antineoplastic drugs SHOULD NOT be given by rapid IV infusion?
All of the following are true about long-term sequelae of craniospinal radiotherapy for children with CNS tumors except:
Many drugs are used as rescue therapy for preventing the adverse effects of anticancer drugs. Folinic acid is used in:-
Bleomycin toxicity affects which organ predominantly?
Which of the following is an alkylating agent used in cancer treatment?
American Heart Association standard pediatric dose of amoxicillin for antibiotic prophylaxis, in cases of endocarditis is
Prophylaxis with cotrimoxazole is recommended in all situations except for which of the following?
A 2 year old child is seen on a routine visit in the pediatric clinic. Abdominal examination demonstrates a palpable, non-tender mass on the left side of the abdomen. The mother had no idea the mass was present and the pediatrician did not note the presence of the mass at the child's 18-month's visit for immunisation. Physical examination is otherwise unremarkable. If a CT guided biopsy of the mass were performed, which of the following histological patterns would be most suggestive of the likely diagnosis?
Cancer management in which of the following malignancies has dramatically increased the survival?
Principles of Pediatric Chemotherapy Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following medications is a first-line antitubercular drug used routinely in children of all age groups without significant monitoring limitations?
- A. Ethambutol
- B. Streptomycin
- C. Pyrazinamide (Correct Answer)
- D. Combination of all first-line ATT agents
Explanation: ***Pyrazinamide*** - **Pyrazinamide** is one of the four core first-line antitubercular drugs (along with isoniazid, rifampicin, and ethambutol) [2, 4] and is used **routinely in children of all age groups** without significant monitoring limitations. - It is highly effective against **intracellular mycobacteria** in acidic environments, which are abundant in the early inflammatory stages of tuberculosis [1]. - Its inclusion is crucial for shortening the duration of treatment to 6 months and preventing the development of drug-resistant strains, especially in the initial intensive phase [3, 4]. *Ethambutol* - **Ethambutol** is indeed a first-line antitubercular drug, but its use in **children under 5 years** is often avoided or given with caution due to difficulty in monitoring for **optic neuritis** [1]. - Young children may not be able to reliably report visual changes (color vision defects, decreased visual acuity), making its safe administration challenging [1]. - WHO guidelines recommend avoiding ethambutol in children who cannot reliably report visual symptoms. *Streptomycin* - **Streptomycin** is an **aminoglycoside antibiotic** and is classified as a **second-line** (or alternative first-line) injectable antitubercular drug [3]. - It is primarily used for drug-resistant tuberculosis or in special circumstances where oral first-line regimens cannot be used. - It requires intramuscular injection and is associated with significant toxicities including **ototoxicity** (vestibular and auditory damage) and **nephrotoxicity**, making it unsuitable as a routine first-line option in children. *Combination of all first-line ATT agents* - While the standard treatment involves a **combination of four first-line drugs** (isoniazid, rifampicin, pyrazinamide, and ethambutol), this option describes a treatment regimen rather than answering which individual medication is a first-line drug [3]. - The question specifically asks for "which medication" (singular), making this option inappropriate as an answer.
Question 2: Which of the following antineoplastic drugs SHOULD NOT be given by rapid IV infusion?
- A. Cyclophosphamide
- B. Cytosine arabinoside
- C. Cisplatin (Correct Answer)
- D. Bleomycin
Explanation: ***Cisplatin*** - **Cisplatin** is highly nephrotoxic and emetogenic; rapid IV infusion can exacerbate these adverse effects, leading to severe renal damage and intractable nausea/vomiting. - It typically requires **prolonged infusion times** (e.g., 6-8 hours) with extensive pre- and post-hydration to reduce kidney toxicity and ensure patient tolerance. *Cyclophosphamide* - While cyclophosphamide can cause **hemorrhagic cystitis**, this is managed by adequate hydration and mesna, and its infusion rate is generally not as critically prolonged as cisplatin's. - It is often administered as a **relatively quick IV infusion** over 30-60 minutes, emphasizing hydration. *Bleomycin* - **Bleomycin** is known for pulmonary toxicity and hypersensitivity reactions, but these are not primarily linked to its infusion rate. - It is commonly given via **slow IV push or short infusion**, sometimes with a test dose to assess for hypersensitivity. *Cytosine arabinoside* - **Cytosine arabinoside** can cause myelosuppression and cerebellar toxicity, but these toxicities are not typically exacerbated by a rapid infusion rate. - It is often administered via a **continuous infusion** over several days or as a rapid IV bolus.
Question 3: All of the following are true about long-term sequelae of craniospinal radiotherapy for children with CNS tumors except:
- A. Musculoskeletal hypoplasia
- B. Neurocognitive dysfunction
- C. Endocrinologic dysfunction
- D. Neuropsychological sequelae are independent of radiation dose (Correct Answer)
Explanation: ***Neuropsychological sequelae are independent of radiation dose*** - This statement is incorrect; **neuropsychological sequelae** are **highly dependent on the radiation dose** received by the brain, with higher doses generally leading to more severe and frequent cognitive impairments. - The impact of radiation on developing neural tissue is dose-related, affecting **myelination**, **synaptogenesis**, and **neurogenesis**, leading to dose-dependent cognitive deficits. *Musculoskeletal hypoplasia* - **Craniospinal irradiation (CSI)** can lead to musculoskeletal hypoplasia, particularly affecting the **vertebrae** and **long bones**, resulting in **short stature** and **scoliosis**. - Radiation can damage growth plates and bone-forming cells, impairing normal bone development and leading to growth deficiencies. *Neurocognitive dysfunction* - **Radiation to the brain** in children, especially at a young age, can cause significant **neurocognitive dysfunction**, including deficits in **memory**, **attention**, **processing speed**, and **executive functions**. - Damage to **white matter**, particularly secondary to demyelination and vasculopathy, plays a significant role in these cognitive impairments. *Endocrinologic dysfunction* - **CSI** frequently affects the **hypothalamic-pituitary axis**, leading to various **endocrinologic dysfunctions** such as **growth hormone deficiency**, **thyroid dysfunction**, and **gonadal dysfunction**. - The developing endocrine glands and their regulatory centers are particularly sensitive to radiation, impacting hormonal production and regulation.
Question 4: Many drugs are used as rescue therapy for preventing the adverse effects of anticancer drugs. Folinic acid is used in:-
- A. Cyclophosphamide toxicity
- B. Doxorubicin toxicity
- C. Methotrexate toxicity (Correct Answer)
- D. Cisplatin toxicity
Explanation: ***Methotrexate toxicity*** - **Folinic acid (leucovorin)** is a reduced folate that bypasses the metabolic block caused by **methotrexate** on dihydrofolate reductase. - It replenishes the body's **folate stores** and protects healthy cells from methotrexate's cytotoxic effects, particularly in the bone marrow and gastrointestinal tract. *Cyclophosphamide toxicity* - **Cyclophosphamide** toxicity, primarily hemorrhagic cystitis, is prevented by **mesna** (2-mercaptoethane sulfonate). - Mesna inactivates the urotoxic metabolite **acrolein** in the urine, preventing bladder damage. *Doxorubicin toxicity* - **Doxorubicin** causes cardiotoxicity, which can be mitigated by the iron-chelating agent **dexrazoxane**. - Dexrazoxane reduces the formation of **free radicals** that contribute to doxorubicin-induced myocardial damage. *Cisplatin toxicity* - **Cisplatin** toxicity, especially nephrotoxicity, is largely prevented by **aggressive hydration** and administration of **diuretics**. - **Amifostine** is another agent that can reduce cisplatin-induced nephrotoxicity, neurotoxicity, and ototoxicity by acting as a cytoprotectant.
Question 5: Bleomycin toxicity affects which organ predominantly?
- A. Bone marrow
- B. Lungs (Correct Answer)
- C. Liver
- D. RBC
Explanation: ***Lungs*** - **Bleomycin** is well-known for causing **pulmonary fibrosis**, an irreversible scarring of the lungs, as its most significant and dose-limiting toxicity. - This toxicity is thought to be due to an inability of the lungs to adequately inactivate bleomycin, leading to oxidative damage. *Bone marrow* - While many chemotherapeutic agents cause **bone marrow suppression**, bleomycin is notable for causing **minimal myelosuppression** compared to other cytotoxic drugs. - Therefore, bone marrow is not the predominantly affected organ for toxicity with bleomycin. *Liver* - **Hepatotoxicity** (liver damage) can occur with some chemotherapy agents, but it is **not a primary or prominent toxicity associated with bleomycin**. - Other drugs are much more frequently associated with liver damage. *RBC* - Bleomycin does not directly target **red blood cells (RBCs)** for toxicity. - While severe bone marrow suppression from other drugs can lead to anemia, bleomycin's effect on RBCs is indirect and not its predominant toxicity profile.
Question 6: Which of the following is an alkylating agent used in cancer treatment?
- A. Actinomycin-D
- B. 5-Fluorouracil
- C. Chlorambucil (Correct Answer)
- D. Vincristine
Explanation: ***Chlorambucil*** - **Chlorambucil** is a classic example of an **alkylating agent** used in chemotherapy. - Alkylating agents work by forming **covalent bonds** with DNA, leading to DNA damage and ultimately cell death. - It is particularly used in chronic lymphocytic leukemia and lymphomas. *Actinomycin-D* - **Actinomycin-D** is an **antibiotic** that functions as an **intercalating agent**, inhibiting RNA synthesis. - It works by inserting itself between DNA base pairs, distorting the DNA structure and preventing transcription. *5-Fluorouracil* - **5-Fluorouracil (5-FU)** is an **antimetabolite**, specifically a pyrimidine analog. - It interferes with DNA synthesis by mimicking **uracil** and inhibiting **thymidylate synthase**. *Vincristine* - **Vincristine** is a **vinca alkaloid**, a type of **microtubule inhibitor**. - It prevents the formation of the **mitotic spindle**, thereby arresting cells in metaphase and inhibiting cell division.
Question 7: American Heart Association standard pediatric dose of amoxicillin for antibiotic prophylaxis, in cases of endocarditis is
- A. 20mg/kg
- B. 125mg/kg
- C. 100mg/kg
- D. 50mg/kg (Correct Answer)
Explanation: ***50mg/kg*** - The **American Heart Association (AHA)** guidelines recommend **50 mg/kg** of amoxicillin as the standard pediatric dose for antibiotic prophylaxis against infective endocarditis before certain dental procedures. - This dose is typically given orally, as a single dose, 30-60 minutes before the procedure. *20mg/kg* - This dose is lower than the recommended **AHA guideline** for infective endocarditis prophylaxis in children. - Administering this dose could result in **subtherapeutic levels**, failing to adequately prevent bacterial colonization and infection. *125mg/kg* - This dosage is significantly higher than the standard **AHA recommendation** for endocarditis prophylaxis. - Such a high dose could increase the risk of **adverse effects** without providing additional prophylactic benefit. *100mg/kg* - While higher than the standard 50mg/kg, this dose also exceeds the **AHA guidelines** for pediatric endocarditis prophylaxis. - Overdosing can lead to increased **gastrointestinal side effects** and other unwanted drug reactions.
Question 8: Prophylaxis with cotrimoxazole is recommended in all situations except for which of the following?
- A. All symptomatic HIV infected children > 5 years of age irrespective of CD4 (Correct Answer)
- B. All HIV infected infants less than 1 year age irrespective of symptoms or CD4 counts
- C. All HIV exposed infants till HIV infection can be ruled out
- D. As secondary prophylaxis after initial treatment for Pneumocystis jirovecii pneumonia
Explanation: ***All symptomatic HIV infected children > 5 years of age irrespective of CD4*** - Cotrimoxazole prophylaxis is generally recommended for HIV-infected children with **CD4 counts below certain thresholds** or **specific clinical scenarios**, not just based on age and symptoms alone for those > 5 years. - The guidelines often focus on preventing **Pneumocystis jirovecii pneumonia (PJP)** and other opportunistic infections in pediatric HIV, with a nuanced approach to older children based on immune status. *All HIV exposed infants till HIV infection can be ruled out* - **Cotrimoxazole prophylaxis** is strongly recommended for **all HIV-exposed infants** from 4-6 weeks of age until HIV infection is definitively ruled out. - This prevents **P. jirovecii pneumonia**, which has a high mortality rate in this vulnerable population. *All HIV infected infants less than 1 year age irrespective of symptoms or CD4 counts* - **Cotrimoxazole prophylaxis** is indicated for **all HIV-infected infants younger than 1 year of age**, regardless of their clinical symptoms or CD4 counts. - This is due to their **immature immune system** and high risk of **opportunistic infections**, especially PJP. *As secondary prophylaxis after initial treatment for pneumocystis carini pneumonia* - **Cotrimoxazole** is the **standard drug** used for **secondary prophylaxis** following successful treatment of **Pneumocystis jirovecii pneumonia (PJP)**. - This prevents recurrence of PJP, which can be life-threatening in immunocompromised individuals.
Question 9: A 2 year old child is seen on a routine visit in the pediatric clinic. Abdominal examination demonstrates a palpable, non-tender mass on the left side of the abdomen. The mother had no idea the mass was present and the pediatrician did not note the presence of the mass at the child's 18-month's visit for immunisation. Physical examination is otherwise unremarkable. If a CT guided biopsy of the mass were performed, which of the following histological patterns would be most suggestive of the likely diagnosis?
- A. Triphasic pattern with tubule formation, spindle cells, and blastemal elements (Correct Answer)
- B. Invasive papillary lesions with delicate connective tissue stalk covered with epithelium resembling that lining the bladder.
- C. Cords of clear cells with rounded or polygonal shape and abundant clear cytoplasm
- D. Small dark cells embedded in a finely fibrillar matrix with formation of numerous rosettes
Explanation: ***Triphasic pattern with tubule formation, spindle cells, and blastemal elements*** - The presence of a **palpable, non-tender abdominal mass** in a 2-year-old, previously undetected, is highly suggestive of **Wilms tumor (nephroblastoma)**. - Wilms tumor characteristically exhibits a **triphasic histological pattern** consisting of **blastemal**, **stromal (spindle cells)**, and **epithelial (tubule formation)** elements. *Invasive papillary lesions with delicate connective tissue stalk covered with epithelium resembling that lining the bladder.* - This description typically refers to **papillary urothelial carcinoma**, a tumor of the **bladder or urinary tract**, which is rarely seen in young children and presents with hematuria, not primarily an abdominal mass. - The absence of urinary symptoms and the age of the patient make this an unlikely diagnosis for an abdominal mass. *Cords of clear cells with rounded or polygonal shape and abundant clear cytoplasm* - This histological pattern is characteristic of **clear cell renal carcinoma**, an adult kidney malignancy, not a common pediatric abdominal tumor. - While clear cell renal cell carcinoma can present as an abdominal mass, it is exceptionally rare in a 2-year-old child. *Small dark cells embedded in a finely fibrillar matrix with formation of numerous rosettes* - This description is highly suggestive of **neuroblastoma**, a small round blue cell tumor that arises from neural crest cells (e.g., adrenal gland or sympathetic chain). - While **neuroblastoma** is the second most common abdominal mass in children after Wilms tumor, it typically presents with different histological features and may be associated with systemic symptoms like weight loss, fever, or bone pain. - The **triphasic pattern** described in option A is more specific for Wilms tumor.
Question 10: Cancer management in which of the following malignancies has dramatically increased the survival?
- A. Cholangiocarcinoma
- B. ALL in children (Correct Answer)
- C. Esophagus carcinoma
- D. Glioblastoma multiforme
Explanation: ***ALL in children*** - Significant advancements in chemotherapy regimens, supportive care, and **risk stratification** have led to dramatically improved survival rates, with over 90% cure rates in many cases. - Recognition of distinct **genetic subtypes** and targeted therapies has further refined treatment approaches. *Cholangiocarcinoma* - This is an **aggressive cancer** with a generally poor prognosis, often diagnosed at advanced stages. - While there have been some therapeutic developments, the overall survival rate remains low. *Esophagus carcinoma* - Despite advances in surgery, radiation, and chemotherapy, **esophageal cancer** still carries a high mortality rate. - It is often diagnosed late, and effective systemic treatments for advanced disease are limited. *Glioblastoma multiforme* - This is the most common and most aggressive type of **brain tumor** in adults, with a very poor prognosis. - Despite intensive treatment with surgery, radiation, and chemotherapy, survival rates remain low, and recurrence is common.
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