Pulmonary Neoplasms — MCQs
Popcorn calcification is seen in:
A 57-year-old man presents with hemoptysis and generalized weakness. His symptoms began with small-volume hemoptysis 4 weeks ago, followed by progressive weakness, fatigue, and weight loss over the past 2 weeks. He has a 45-pack-year history of cigarette smoking. Physical examination is unremarkable, and laboratory studies reveal mild anemia and hyponatremia. Chest x-ray shows a 5-cm left, mid-lung field mass with mediastinal lymphadenopathy. MR scan of the brain is normal. What is the most likely cause of his symptoms?
Which condition is characterized by a specific appearance on CT scans that resembles small centrilobular nodules with branching linear structures?
What is the most appropriate initial investigation for a solitary thyroid nodule (STN)?
Which type of lung cancer is most commonly found in non-smokers?
Which of the following stages of lip carcinoma does not have nodal involvement?
Which of the following is a characteristic of bronchoalveolar carcinoma?
Most common lung cancer in non-smokers is:
Calcified pulmonary metastasis is seen in which carcinoma?
Match the following: A) Caplan syndrome- 1) Found first in coal worker B) Asbestosis- 2) Upper lobe predominance C) Mesothelioma- 3) Involves lower lobe D) Sarcoidosis- 4) Pleural effusion is seen
Pulmonary Neoplasms Indian Medical PG Practice Questions and MCQs
Question 1: Popcorn calcification is seen in:
- A. Pulmonary hamartoma (Correct Answer)
- B. Bronchogenic carcinoma
- C. Tuberculosis
- D. Pulmonary metastases
Explanation: ***Pulmonary hamartoma*** - **Popcorn calcification** is a pathognomonic radiographic finding highly suggestive of **pulmonary hamartoma**, a **benign tumor** composed of cartilage, fat, and connective tissue - This characteristic calcification pattern is due to the presence of **chondroid (cartilaginous) tissue** within the lesion - Appears as coarse, irregular calcifications resembling popcorn on chest X-ray or CT scan *Bronchogenic carcinoma* - Malignant lung lesions typically show **irregular, spiculated, or ill-defined margins** and tend to grow rapidly - While calcification can occur in some lung malignancies, it usually appears as **eccentric, stippled, or amorphous** rather than the distinctive popcorn pattern - Popcorn calcification is not a feature of primary lung cancers *Tuberculosis* - **Granulomatous infections** such as tuberculosis often lead to calcification, but it usually presents as **laminated, clustered, or target-like patterns** in lymph nodes or within granulomas (Ghon lesion, Ranke complex) - **Popcorn calcification** is not a typical feature of active or healed tuberculous lesions *Pulmonary metastases* - **Metastatic lesions** are generally not calcified, although a few primary tumors (e.g., mucinous adenocarcinoma, osteosarcoma, chondrosarcoma) can metastasize as calcified nodules - When calcification is present in metastases, it is rarely in the specific **popcorn pattern** and is usually diffuse, punctate, or amorphous
Question 2: A 57-year-old man presents with hemoptysis and generalized weakness. His symptoms began with small-volume hemoptysis 4 weeks ago, followed by progressive weakness, fatigue, and weight loss over the past 2 weeks. He has a 45-pack-year history of cigarette smoking. Physical examination is unremarkable, and laboratory studies reveal mild anemia and hyponatremia. Chest x-ray shows a 5-cm left, mid-lung field mass with mediastinal lymphadenopathy. MR scan of the brain is normal. What is the most likely cause of his symptoms?
- A. Bronchial carcinoid tumor
- B. Lung adenocarcinoma
- C. Small cell lung carcinoma (Correct Answer)
- D. Lung abscess
Explanation: ***Small cell lung carcinoma*** - This presentation, including **hemoptysis** [1], **progressive weakness**, **fatigue**, **weight loss** [2], and a **large lung mass with mediastinal lymphadenopathy** in a heavy smoker [3], is highly characteristic of **small cell lung carcinoma (SCLC)**. - The presence of **hyponatremia** suggests **syndrome of inappropriate antidiuretic hormone (SIADH)**, a common paraneoplastic syndrome associated with SCLC due to ectopic ADH production [2]. *Bronchial carcinoid tumor* - While carcinoid tumors can cause hemoptysis, they typically grow slowly and are characterized by **neuroendocrine symptoms** (e.g., flushing, diarrhea, wheezing) that are not mentioned here. - Malignant carcinoid tumors are less common and rarely present with such rapid progressive systemic symptoms and extensive lymphadenopathy. *Lung adenocarcinoma* - Adenocarcinoma often presents with a mass and can cause hemoptysis and systemic symptoms, but it is **less strongly associated with SIADH** and mediastinal lymphadenopathy in the initial presentation compared to SCLC. - While adenocarcinoma is common in smokers, the rapid progression and specific paraneoplastic finding point more towards SCLC. *Lung abscess* - A lung abscess typically presents with **fever**, **productive cough of purulent sputum**, and often pleuritic chest pain, which are absent in this case [4]. - While an abscess can cause hemoptysis and general malaise, the presence of **lymphadenopathy** and the rapid progression with hyponatremia are not typical features [4].
Question 3: Which condition is characterized by a specific appearance on CT scans that resembles small centrilobular nodules with branching linear structures?
- A. Pulmonary tuberculosis (Correct Answer)
- B. Silicosis
- C. Pulmonary hydatid cyst
- D. Small cell carcinoma
Explanation: ***Pulmonary tuberculosis*** - This description ("small centrilobular nodules with **branching linear structures**") is characteristic of the **tree-in-bud pattern** seen on CT scans, which is a hallmark finding in active **endobronchial spread of tuberculosis**. - The tree-in-bud pattern results from the impaction of tuberculous **granulomas** and caseous material in the terminal and respiratory bronchioles. *Silicosis* - Characterized by multiple small, well-defined **nodules** (often in the upper lobes) that tend to calcify, but typically lacks the fine **branching linear structures**. - It’s associated with occupational exposure to **silica dust** and may progress to **massive progressive fibrosis**. *Pulmonary hydatid cyst* - Presents as a well-defined, usually **single, large cystic lesion** on CT, often with internal membranes if ruptured (water lily sign or crumpled membrane sign). - It does not typically manifest with small centrilobular nodules or branching linear structures. *Small cell carcinoma* - Usually appears as a **large central mass**, often with mediastinal lymphadenopathy, and sometimes associated with obstructive pneumonitis. - It does not typically present as diffuse small centrilobular nodules with branching patterns.
Question 4: What is the most appropriate initial investigation for a solitary thyroid nodule (STN)?
- A. I-123 scan
- B. Ultrasound (Correct Answer)
- C. Fine-needle aspiration (FNA) biopsy
- D. Thyroid function tests (TFTs)
- E. CT scan of the neck
Explanation: ***Ultrasound*** - **Ultrasound** is the initial investigation of choice for a solitary thyroid nodule (STN) because it can differentiate between **solid, cystic, or mixed lesions**, assess nodule size, and identify suspicious features (e.g., microcalcifications, irregular margins, internal vascularity). - It also helps to determine if there are other nodules not palpable on physical examination, allowing for a more complete assessment of the **thyroid gland**. *Fine-needle aspiration (FNA) biopsy* - **FNA biopsy** is the most accurate diagnostic tool for evaluating the malignant potential of a thyroid nodule, but it is typically performed *after* an initial ultrasound has characterized the nodule. - It requires guidance (often by ultrasound) to obtain an adequate sample for cytological analysis, making ultrasound a prerequisite for optimal FNA performance. *Thyroid function tests (TFTs)* - **TFTs (TSH, T3, T4)** are important for assessing the functional status of the thyroid gland (e.g., hyperthyroidism or hypothyroidism) and can provide context for the nodule. - However, TFTs do not directly evaluate the **morphology or malignant potential** of the nodule itself, making them less appropriate as an initial, stand-alone investigation for an STN. *I-123 scan* - An **I-123 scan** (radioactive iodine uptake and scan) is used to determine if a nodule is "hot" (hyperfunctioning/benign) or "cold" (non-functioning/potentially malignant). - It is typically reserved for cases where **TSH levels are suppressed**, suggesting a hyperfunctioning nodule, and is not the first-line imaging modality for initial characterization of all STNs. *CT scan of the neck* - **CT scan** can visualize thyroid nodules and assess for extrathyroidal extension or lymphadenopathy, but it is **not recommended as an initial investigation** for STN. - It involves **radiation exposure**, is more expensive than ultrasound, and provides **less detailed characterization** of nodule morphology compared to ultrasound, making it a less appropriate first-line modality.
Question 5: Which type of lung cancer is most commonly found in non-smokers?
- A. Adenocarcinoma (Correct Answer)
- B. Squamous cell carcinoma (associated with smoking)
- C. Oat cell carcinoma (small cell lung cancer)
- D. None of the options
Explanation: ***Adenocarcinoma*** - It is the most common type of lung cancer among **non-smokers**, often associated with **lung scarring** and **asbestos exposure**. - Typically presents in the **peripheral** regions of the lungs and has a **glandular** pattern on histology. *Squamous cell carcinoma* - More commonly associated with **smoking** [1] and usually arises in the **central parts** of the lungs. - Known for cavitary lesions and often linked to chronic **lung disease** rather than non-smokers. *None of the above* - This oes not provide a definitive lung cancer type, which is **not relevant** when adenocarcinoma is the correct answer. - Fails to recognize the significant evidence linking adenocarcinoma as the predominant type in non-smokers. *Oat cell carcinoma* - This represents **small cell lung cancer**, which is strongly linked to **smoking** rather than being common in non-smokers [1]. - Often presents with **metastatic lesions** and is more aggressive, unlike adenocarcinoma.
Question 6: Which of the following stages of lip carcinoma does not have nodal involvement?
- A. T2N1
- B. T3N0 (Correct Answer)
- C. T2N2
- D. T1N1
Explanation: ***T3N0*** - The **'N' classification** in the TNM staging system refers to **nodal involvement**. A stage with **'N0' indicates no regional lymph node metastasis**. - A **T3 lesion** signifies a large primary tumor, but if it's accompanied by **N0**, it means there's no evidence of spread to the lymph nodes. *T2N1* - The **'N1' classification** indicates the presence of **regional lymph node metastasis**, specifically in a **single ipsilateral lymph node** that is 3 cm or less in its greatest dimension. - This stage therefore **does have nodal involvement**, contradicting the premise of the question. *T2N2* - The **'N2' classification** signifies more advanced regional lymph node metastasis, such as a **single ipsilateral lymph node** greater than 3 cm but not more than 6 cm. - It could also refer to **multiple ipsilateral lymph nodes**, none greater than 6 cm, or bilateral/contralateral lymph nodes, none greater than 6 cm. In all these cases, **nodal involvement is present**. *T1N1* - Similar to T2N1, the **'N1' component** in T1N1 indicates the presence of **regional lymph node metastasis** in a single ipsilateral lymph node of 3 cm or less. - Therefore, this stage **does involve nodal spread**, despite having a smaller primary tumor (T1).
Question 7: Which of the following is a characteristic of bronchoalveolar carcinoma?
- A. Stromal invasion with desmoplasia
- B. Grows along existing anatomical structures
- C. Adenocarcinoma
- D. Lepidic growth with preservation of alveolar structure (Correct Answer)
Explanation: ***Adenocarcinoma*** - Bronchoalveolar carcinoma is classified as a subtype of **adenocarcinoma**, specifically presenting as non-small cell lung cancer (NSCLC) [1]. - It is characterized by **lepidic growth pattern** in the alveolar structures, which preserves the architecture of the lung parenchyma. *Stromal invasion with desmoplasia* - Typically, bronchoalveolar carcinoma shows **minimal invasion**, contrasting with the extensive desmoplastic reaction seen in other types of lung cancer. - This type is more about growth patterns than typical invasive features associated with stromal changes. *Grows along pre-existing anatomical structures* - While some lung tumors may grow along bronchi, bronchoalveolar carcinoma primarily **grows along alveolar surfaces** rather than conforming to anatomical structures. - This growth pattern leads to its distinct histological features, differing from the infiltrative patterns of other cancers. *Preservation of Alveolar structure* - Although bronchoalveolar carcinoma does preserve some architecture, stating it relies solely on this aspect is misleading as this does not comprehensively define the tumor. - Its distinction lies in its subtype classification as an **adenocarcinoma** rather than merely structural preservation [1]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 335-336.
Question 8: Most common lung cancer in non-smokers is:
- A. Adenocarcinoma (Correct Answer)
- B. Squamous cell carcinoma
- C. Oat cell carcinoma
- D. Large cell carcinoma
Explanation: ***Adenocarcinoma*** - **Adenocarcinoma** is the most common type of lung cancer found in non-smokers, often associated with peripheral lung nodules. - This subtype has a rising incidence rate, particularly among women and younger individuals, often linked to factors like **environmental exposures** or **genetics**. *None of the above* - This option is incorrect since adenocarcinoma is a recognized **primary lung cancer** type in non-smokers. - The statement does not address the specific cancer types and neglects to acknowledge the commonality of adenocarcinoma. *Squamous cell carcinoma* - Generally associated with smoking [1,2] and presents centrally in the lungs, making it less common among non-smokers. - Often linked to **cavitary lesions** [1] and associated with **hypercalcemia** due to parathyroid hormone-related peptide secretion. *Oat cell carcinoma* - Also known as small cell lung cancer (SCLC), is primarily linked to smoking and has a **very aggressive** nature. - Typically arises in the central airways and is associated with **paraneoplastic syndromes**, which are not relevant to the non-smoker context. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 336-337. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, pp. 720-721.
Question 9: Calcified pulmonary metastasis is seen in which carcinoma?
- A. Pancreatic carcinoma
- B. Thyroid carcinoma (Correct Answer)
- C. Endometrial carcinoma
- D. None of the options
Explanation: ***Thyroid carcinoma*** - **Papillary** and **medullary thyroid carcinomas** can produce **calcified pulmonary metastases**. - In **papillary thyroid cancer**, calcification occurs due to **psammoma bodies** (concentrically laminated calcified structures). - In **medullary thyroid cancer**, calcification can occur through **dystrophic calcification** within the tumor tissue. - Other common causes of calcified lung metastases include **osteosarcoma** and **chondrosarcoma**. *Pancreatic carcinoma* - Pancreatic carcinoma rarely causes **calcified pulmonary metastases**; metastatic lesions are typically **non-calcified**. - Metastases are more commonly found in the **liver** and **peritoneum**. - Primary pancreatic tumors may show calcification, but metastases usually do not. *Endometrial carcinoma* - Endometrial carcinoma metastases to the lungs are usually **non-calcified** and appear as **soft tissue nodules**. - While it can metastasize to the lungs, **calcification** is not a typical feature of its pulmonary spread. *None of the options* - This option is incorrect because **thyroid carcinoma** (particularly papillary type) is a well-recognized cause of **calcified pulmonary metastases**. - Among epithelial malignancies, thyroid carcinoma is one of the classic causes of this finding.
Question 10: Match the following: A) Caplan syndrome- 1) Found first in coal worker B) Asbestosis- 2) Upper lobe predominance C) Mesothelioma- 3) Involves lower lobe D) Sarcoidosis- 4) Pleural effusion is seen
- A. A-3, B-4, C-2, D-1
- B. A-1, B-4, C-3, D-2 (Correct Answer)
- C. A-4, B-2, C-3, D-1
- D. A-2, B-4, C-3, D-1
Explanation: **A-1, B-4, C-3, D-2** - **Caplan syndrome** was first described in **coal workers** with **rheumatoid arthritis** and progressive massive fibrosis. - **Asbestosis** is often associated with **pleural effusion**, which can be benign or malignant. - **Mesothelioma** typically involves the **lower lobes** of the lungs, specifically the pleura, and is strongly linked to asbestos exposure. - **Sarcoidosis** is characterized by **non-caseating granulomas**, which have a predilection for the **upper lobes** of the lungs. *A-3, B-4, C-2, D-1* - This option incorrectly states that Caplan syndrome involves the lower lobe; **Caplan syndrome** is defined by the presence of large nodules in the lungs of coal workers with rheumatoid arthritis, and their specific lobar distribution is not a defining characteristic. - This option incorrectly states that Mesothelioma has an upper lobe predominance; **Mesothelioma** is a pleural malignancy and typically involves the **lower lobes**, extending along the pleura. *A-4, B-2, C-3, D-1* - This option incorrectly associates Caplan syndrome with pleural effusion; **Caplan syndrome** manifests as rheumatoid nodules in the lungs, not primarily pleural effusion. - This option incorrectly states that Asbestosis has an upper lobe predominance; **Asbestosis** predominantly affects the **lower lobes** of the lungs, causing interstitial fibrosis. *A-2, B-4, C-3, D-1* - This option incorrectly states that Caplan syndrome has an upper lobe predominance; the defining feature of **Caplan syndrome** is the combination of rheumatoid arthritis and pneumoconiosis, not specific lobar involvement. - This option correctly identifies pleural effusion with asbestosis and lower lobe involvement with mesothelioma, but **Caplan syndrome** is not characterized by upper lobe predominance.
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