Anticancer Drugs Practice Questions

Q: Which of the following drugs are used in the treatment of multiple myeloma?

Bortezomib, Melphalan, Cyclophosphamide. Multiple myeloma is a plasma cell dyscrasia characterized by the malignant proliferation of plasma cells in the bone marrow. The management involves a combination of proteasome inhibitors, alkylating agents, immunomodulators, and steroids. **Why Option B is Correct:** * **Bortezomib:** A reversible inhibitor of the **26S proteasome**. It prevents the degradation of pro-apoptotic proteins, leading to apoptosis of malignant plasma cells. It is a cornerstone of modern myeloma therapy. * **Melphalan:** A nitrogen mustard **alkylating agent**. It has been a standard treatment for myeloma for decades, often used in high doses prior to autologous stem cell transplantation. * **Cyclophosphamide:** Another **alkylating agent** frequently used in combination regimens (e.g., CyBorD: Cyclophosphamide, Bortezomib, Dexamethasone) for patients who may not tolerate melphalan or as part of salvage therapy. **Why Other Options are Incorrect:** * **Hydroxyurea:** Primarily used in myeloproliferative neoplasms (like Polycythemia Vera) and Sickle Cell Anemia (to increase HbF). It is not a standard treatment for multiple myeloma. * **Ketoconazole:** An antifungal that also inhibits steroidogenesis. While used in Cushing’s syndrome or advanced prostate cancer (to reduce androgens), it has no role in treating multiple myeloma. **High-Yield Clinical Pearls for NEET-PG:** * **Bortezomib Side Effect:** Peripheral neuropathy is a major dose-limiting toxicity. * **Thalidomide/Lenalidomide:** These immunomodulators (IMiDs) are also first-line agents for myeloma. Remember: Thalidomide causes **phocomelia** (teratogenicity). * **Mnemonic for Myeloma Clinical Features:** **CRAB** (Calcium elevation, Renal insufficiency, Anemia, Bone lesions). * **Drug of Choice for Hypercalcemia in Myeloma:** IV Bisphosphonates (e.g., Zoledronic acid).

Q: Venoocclusive disease of the liver is caused by which of the following agents?

Both Cyclophosphamide and Melphalan. **Explanation:** **Sinusoidal Obstruction Syndrome (SOS)**, formerly known as **Veno-occlusive Disease (VOD)** of the liver, is a clinical syndrome characterized by hepatomegaly, jaundice, and fluid retention. It occurs due to toxic injury to the sinusoidal endothelial cells, leading to the occlusion of terminal hepatic venules. **Why the correct answer is C:** Both **Cyclophosphamide** and **Melphalan** are potent alkylating agents commonly used in high-dose conditioning regimens prior to Hematopoietic Stem Cell Transplantation (HSCT). * **Cyclophosphamide:** Its metabolite, acrolein, is primarily associated with hemorrhagic cystitis, but the drug is also a well-documented cause of hepatic VOD, especially when used in combination with total body irradiation. * **Melphalan:** High-dose melphalan is a standard treatment for Multiple Myeloma and is a recognized independent risk factor for the development of VOD. Since both drugs are implicated in the pathogenesis of this condition, Option C is the most accurate choice. **Analysis of incorrect options:** * **Option A & B:** While both are correct individually, they are incomplete. In the context of NEET-PG, when two drugs in the options are known to cause a specific side effect, the "Both" or "All of the above" option is the preferred answer. **High-Yield Clinical Pearls for NEET-PG:** 1. **Antidote for VOD:** **Defibrotide** is the drug of choice for treating severe hepatic veno-occlusive disease. 2. **Busulfan:** This is another high-yield alkylating agent frequently associated with VOD (often more so than cyclophosphamide). 3. **Acrolein Toxicity:** Remember that while acrolein causes VOD in the liver, it causes **hemorrhagic cystitis** in the bladder (prevented by **MESNA**). 4. **Other drugs causing VOD:** Azathioprine and 6-Thioguanine.

Q: Axicabtagene ciloleucel is indicated for which of the following conditions?

Diffuse large B cell lymphoma. **Explanation:** **Axicabtagene ciloleucel (Yescarta)** is a pioneering **Chimeric Antigen Receptor (CAR) T-cell therapy**. It involves genetically engineering a patient’s own T-cells to express a receptor that targets the **CD19 antigen**, which is characteristically found on the surface of B-cells. 1. **Why Option C is Correct:** Axicabtagene ciloleucel is FDA-approved for the treatment of adult patients with **relapsed or refractory large B-cell lymphoma**, including **Diffuse Large B-Cell Lymphoma (DLBCL)**, primary mediastinal B-cell lymphoma, and high-grade B-cell lymphoma after two or more lines of systemic therapy. By targeting CD19, the engineered T-cells directly identify and eliminate the malignant B-cells. 2. **Why Other Options are Incorrect:** * **Relapsed Myeloma:** While CAR-T therapies exist for Multiple Myeloma (e.g., **Idecabtagene vicleucel**), they typically target **BCMA** (B-cell maturation antigen), not CD19. * **T-cell Lymphoma:** Axicabtagene targets CD19, which is a B-cell marker. It is ineffective against T-cell malignancies. * **Small Cell Lung Cancer:** This is a solid tumor of epithelial origin; CAR-T therapies are currently primarily utilized for hematological malignancies. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Adoptive immunotherapy (CD19-directed CAR-T). * **Major Side Effects:** * **Cytokine Release Syndrome (CRS):** Managed with **Tocilizumab** (IL-6 inhibitor). * **ICANS:** Immune Effector Cell-Associated Neurotoxicity Syndrome. * **Other CAR-T drugs:** **Tisagenlecleucel** (indicated for DLBCL and B-cell ALL).

Q: Alkalinization of urine is done during the administration of which of the following chemotherapeutic drugs?

Methotrexate. **Explanation:** **Methotrexate (MTX)** is the correct answer because it is a weak acid that is primarily excreted by the kidneys. At high doses, MTX and its metabolite (7-OH-methotrexate) are poorly soluble in acidic urine, leading to the formation of crystals in the renal tubules (**crystalluria**). This can cause acute kidney injury (AKI) due to obstructive nephropathy. **Alkalinization of urine** (using Sodium Bicarbonate) increases the ionization of Methotrexate, significantly enhancing its solubility and renal clearance, thereby preventing nephrotoxicity. **Analysis of Incorrect Options:** * **Ara-C (Cytarabine):** Its dose-limiting toxicity is bone marrow suppression and cerebellar ataxia (at high doses). It does not require urinary alkalinization. * **Cisplatin:** It is highly nephrotoxic (causing ATN), but the prevention strategy involves **aggressive hydration** and the use of **Amifostine** (a cytoprotective agent) or osmotic diuresis (Mannitol), not alkalinization. * **Ifosfamide:** Along with Cyclophosphamide, it causes **hemorrhagic cystitis** due to the metabolite **Acrolein**. This is prevented by vigorous hydration and the administration of **MESNA**, which neutralizes acrolein in the bladder. **High-Yield Clinical Pearls for NEET-PG:** * **Leucovorin Rescue:** Folinic acid (Leucovorin) is used to "rescue" normal cells from MTX toxicity by bypassing the inhibited Dihydrofolate Reductase (DHFR) enzyme. * **Glucarpidase:** An enzyme used as an antidote for MTX toxicity in patients with renal failure. * **Drug Interactions:** NSAIDs, Penicillins, and Probenecid decrease MTX excretion by competing for organic anion transporters (OAT), increasing toxicity.

Q: Which of the following statements is true regarding methotrexate?

Causes thrombocytopenia.. Methotrexate (MTX) is a folate antimetabolite that acts as a competitive inhibitor of the enzyme dihydrofolate reductase (DHFR) [1]. This inhibition prevents the conversion of dihydrofolate to tetrahydrofolate, halting DNA synthesis and cell proliferation [1]. 1. Why Option C is Correct: Methotrexate is a potent myelosuppressant. It inhibits the rapidly dividing cells of the bone marrow, leading to a decrease in all cell lines (pancytopenia) [2]. Thrombocytopenia (low platelet count) is a common and dose-limiting adverse effect of MTX therapy [3]. 2. Why Other Options are Incorrect: * Option A: At low doses (used in RA or psoriasis), MTX has high oral bioavailability (>70%). Bioavailability only decreases at higher doses due to saturation of intestinal transporters. * Option B: MTX has potent anti-inflammatory effects. It increases extracellular adenosine levels, which interferes with the action of IL-1 and other pro-inflammatory cytokines (TNF-α, IL-6). * Option D: MTX is an established second-line therapy for Crohn’s disease, particularly for maintaining remission in patients who are steroid-dependent or resistant to thiopurines. High-Yield Clinical Pearls for NEET-PG: * Rescue Therapy: Leucovorin (Folinic acid) is used to "rescue" normal cells from MTX toxicity by bypassing the inhibited DHFR enzyme [1]. * Antidote for Toxicity: Glucarpidase can be used to rapidly reduce toxic plasma concentrations of MTX. * Monitoring: Always monitor Liver Function Tests (LFTs) as MTX can cause hepatic fibrosis/cirrhosis with long-term use. * Contraindication: It is highly teratogenic (Category X) and must be avoided in pregnancy.

Q: Ofatumumab is a monoclonal antibody against:

CD20. **Explanation:** **Ofatumumab** is a fully humanized monoclonal antibody that targets the **CD20** antigen. CD20 is a transmembrane protein expressed on the surface of B-lymphocytes, from the pre-B cell stage through mature B cells (but not on plasma cells). **Why Option C is Correct:** Ofatumumab binds to a unique epitope on the CD20 molecule (distinct from the binding site of Rituximab), encompassing both the small and large extracellular loops. This binding triggers B-cell lysis primarily through **Complement-Dependent Cytotoxicity (CDC)** and Antibody-Dependent Cellular Cytotoxicity (ADCC). It is clinically used in the treatment of Chronic Lymphocytic Leukemia (CLL) and Relapsing Multiple Sclerosis (RMS). **Why Other Options are Incorrect:** * **CD19 (Option A):** Targeted by drugs like **Blinatumomab** (a BiTE) and CAR-T cell therapies (e.g., Tisagenlecleucel). CD19 is a biomarker for B-cell lineage but is not the target for Ofatumumab. * **CD79a (Option B):** Part of the B-cell receptor complex. While used in immunohistochemistry to identify B-cell neoplasms, it is not a common target for current monoclonal antibody therapy in this context. * **CD25 (Option C):** This is the alpha chain of the IL-2 receptor. It is targeted by **Basiliximab** and **Daclizumab**, primarily used to prevent transplant rejection. **High-Yield Clinical Pearls for NEET-PG:** * **Anti-CD20 Trio:** Remember **Rituximab** (chimeric), **Ofatumumab** (fully human), and **Obinutuzumab** (type II, glycoengineered). * **Ofatumumab Advantage:** Being a fully human antibody, it has a lower risk of infusion-related reactions compared to the chimeric Rituximab. * **Key Indication:** It is a first-line subcutaneous B-cell depleting therapy for **Multiple Sclerosis**.

Q: A patient on treatment for leukemia develops chest pain, pulmonary infiltrates, and pleural effusion. What is the likely cause?

Tretinoin. ### **Explanation** The clinical presentation of chest pain, pulmonary infiltrates, and pleural effusion in a patient being treated for leukemia (specifically Acute Promyelocytic Leukemia - APL) describes **Differentiation Syndrome** (formerly known as Retinoic Acid Syndrome). **1. Why Tretinoin is Correct:** Tretinoin (All-Trans Retinoic Acid or ATRA) induces the maturation of malignant promyelocytes. During this process, these cells release inflammatory cytokines and express adhesion molecules, leading to massive pulmonary infiltration and capillary leak. This manifests clinically as fever, dyspnea, weight gain, pleural/pericardial effusions, and pulmonary infiltrates. * **Management:** High-dose intravenous **Dexamethasone** is the treatment of choice. **2. Why Other Options are Incorrect:** * **Daunorubicin:** An anthracycline primarily associated with **cardiotoxicity** (dilated cardiomyopathy and congestive heart failure) rather than acute pulmonary infiltrates. * **Hydroxyurea:** Primarily causes myelosuppression and cutaneous side effects (hyperpigmentation, leg ulcers). While it can cause rare interstitial pneumonitis, it is not the classic cause of this acute triad in leukemia treatment. * **Cytarabine:** Known for causing **"Ara-C Syndrome"** (fever, rash, conjunctivitis) and cerebellar toxicity at high doses. While it can cause non-cardiogenic pulmonary edema, the context of APL treatment strongly points toward Tretinoin. **3. High-Yield Clinical Pearls for NEET-PG:** * **APL Marker:** Associated with **t(15;17)** translocation, involving the PML-RARα gene. * **Differentiation Syndrome:** Can also be caused by **Arsenic Trioxide**, another first-line agent for APL. * **Emergency Management:** Do not wait for radiological confirmation; if Differentiation Syndrome is suspected, start steroids immediately to prevent mortality.

Q: Thalidomide was reintroduced for certain indications like multiple myeloma after being withdrawn due to side effects. Which of the following is NOT a side effect of thalidomide?

Diarrhea. **Explanation:** Thalidomide is an immunomodulatory drug (IMiD) used primarily in the treatment of Multiple Myeloma and Erythema Nodosum Leprosum (ENL). **Why Diarrhea is the correct answer:** Thalidomide is characteristically associated with **constipation**, not diarrhea. It has significant neurotoxic and sedative properties that slow down gastrointestinal motility. In contrast, its newer analogue, Lenalidomide, is more frequently associated with diarrhea. **Analysis of incorrect options:** * **Hypothyroidism:** Thalidomide can cause primary hypothyroidism. Patients on long-term therapy require regular monitoring of Thyroid Stimulating Hormone (TSH) levels. * **Teratogenicity:** This is the most infamous side effect of thalidomide. If taken during the first trimester of pregnancy, it causes **Phocomelia** (seal-like limbs) due to its anti-angiogenic properties. This led to its withdrawal in the 1960s (the "Thalidomide Tragedy"). * **Deep Vein Thrombosis (DVT):** Thalidomide significantly increases the risk of venous thromboembolism, especially when used in combination with high-dose dexamethasone or chemotherapy in myeloma patients. Prophylactic anticoagulation is often required. **High-Yield Clinical Pearls for NEET-PG:** 1. **Mechanism of Action:** It binds to a protein called **Cereblon**, part of the E3 ubiquitin ligase complex, leading to the degradation of transcription factors (IKZF1/3). 2. **Peripheral Neuropathy:** A common dose-limiting toxicity; it is usually a symmetrical, painful sensory neuropathy. 3. **STEPS Program:** Due to its teratogenic potential, it is distributed under a restricted program (System for Thalidomide Education and Prescribing Safety). 4. **Drug of Choice:** Thalidomide is the drug of choice for Type 2 Lepra Reaction (ENL).

Question 1

Which of the following drugs are used in the treatment of multiple myeloma?

Accepted Answer

Bortezomib, Melphalan, Cyclophosphamide

Answer

Bortezomib, Melphalan, Hydroxyurea

Answer

Hydroxyurea, Ketoconazole, Cyclophosphamide

Answer

Bortezomib, Hydroxyurea, Ketoconazole

Question 2

What is true about Azathioprine?

Accepted Answer

It selectively affects the differentiation of T cells

Answer

It has more antitumor effect than immunosuppressant effect

Answer

It is not a prodrug

Answer

It is a pyrimidine antimetabolite

Question 3

Venoocclusive disease of the liver is caused by which of the following agents?

Accepted Answer

Both Cyclophosphamide and Melphalan

Answer

Cyclophosphamide

Answer

Melphalan

Answer

None of the above

Question 4

Axicabtagene ciloleucel is indicated for which of the following conditions?

Accepted Answer

Diffuse large B cell lymphoma

Answer

Relapsed myeloma

Answer

T cell lymphoma

Answer

Small cell lung cancer

Question 5

A 25-year-old female presents with palpable lumps in the axilla and supra-clavicular region. Following clinical examination and diagnostic procedures including X-ray, USG-guided biopsy, and HPE, a diagnosis was established. Flow cytometry revealed CD15 and CD30 positivity. The patient was initiated on chemotherapy and subsequently developed skin lesions. Which of the following chemotherapeutic agents is most likely responsible for these skin manifestations?

Accepted Answer

Bleomycin

Answer

Daunorubicin

Answer

Capecitabine

Answer

Cyclophosphamide

Question 6

Alkalinization of urine is done during the administration of which of the following chemotherapeutic drugs?

Accepted Answer

Methotrexate

Answer

Ara-C

Answer

Cisplatin

Answer

Ifosfamide

Question 7

Which of the following statements is true regarding methotrexate?

Accepted Answer

Causes thrombocytopenia.

Answer

Oral bioavailability is 30-40%.

Answer

Does not interfere with the action of IL-1.

Answer

Not useful in Crohn's disease.

Question 8

Ofatumumab is a monoclonal antibody against:

Accepted Answer

CD20

Answer

CD19

Answer

CD79a

Answer

CD25

Question 9

A patient on treatment for leukemia develops chest pain, pulmonary infiltrates, and pleural effusion. What is the likely cause?

Accepted Answer

Tretinoin

Answer

Daunorubicin

Answer

Hydroxyurea

Answer

Cytarabine

Question 10

Thalidomide was reintroduced for certain indications like multiple myeloma after being withdrawn due to side effects. Which of the following is NOT a side effect of thalidomide?

Accepted Answer

Diarrhea

Answer

Hypothyroidism

Answer

Teratogenicity

Answer

Deep Vein Thrombosis

Anticancer Drugs — MCQs

Anticancer Drugs — MCQs

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