Cancer Staging — MCQs
Staging of ovarian cancer when the rectum is involved.
International prognostic index for lymphomas includes the following prognostic factors, EXCEPT:
Which malignancy is characterized by a stepwise progression through lymph nodes, making staging an important prognostic factor?
Classification system of bone tumors is -
Which of the following stages of lip carcinoma does not have nodal involvement?
Radiotherapy has the most significant therapeutic role in:
Which of the following treatment options best represents the standard management approach for stage IB cervical cancer?
A colonic carcinoma involving muscularis propria, with one or two nodes involved with a solitary metastasis in the liver, the TNM stage would be:
A patient has carcinoid tumour of appendix of size more than 2.5 cm. The management of choice is:
Which of the following requires the maximum margin of excision?
Cancer Staging Indian Medical PG Practice Questions and MCQs
Question 1: Staging of ovarian cancer when the rectum is involved.
- A. Stage I
- B. Stage 2 (Correct Answer)
- C. Stage 4
- D. Stage 3
Explanation: ***Stage 2*** - **Rectal involvement** in ovarian cancer represents direct extension to other **pelvic structures**, which defines **Stage II disease** according to FIGO staging. - **Stage IIB** specifically includes extension to other pelvic intraperitoneal tissues, including the rectum, sigmoid colon, bladder, and uterus. - The rectum is a **pelvic organ**, and its involvement represents local spread within the pelvis, not distant metastasis. *Stage I* - **Stage I** ovarian cancer is confined to the **ovaries or fallopian tubes** only. - There is no extension beyond the ovaries or fallopian tubes, making rectal involvement inconsistent with this stage. *Stage 3* - **Stage III** involves tumor **outside the pelvis** with peritoneal implants beyond the pelvis or positive retroperitoneal lymph nodes. - This represents intra-abdominal spread but still within the peritoneal cavity, not limited to pelvic organ involvement like the rectum. *Stage 4* - **Stage IV** is defined by **distant metastasis outside the peritoneal cavity**, including parenchymal liver or spleen metastasis, pleural effusion with positive cytology, or metastasis to extra-abdominal organs. - Direct rectal involvement does not constitute distant metastasis and therefore is not Stage IV.
Question 2: International prognostic index for lymphomas includes the following prognostic factors, EXCEPT:
- A. LDH
- B. Number of extralymphatic sites involved
- C. Hemoglobin and albumin (Correct Answer)
- D. Stage of disease
Explanation: ***Hemoglobin and albumin*** - While hemoglobin and albumin can be indicators of overall health and nutritional status, they are **not part of the standard International Prognostic Index (IPI)** for lymphomas. - The IPI specifically focuses on factors directly related to tumor burden and patient vitality, not general systemic markers like these. *LDH* - **Lactate dehydrogenase (LDH)** is a crucial component of the IPI, reflecting tumor burden and aggressiveness [1]. - Elevated LDH levels indicate a higher risk and are associated with a poorer prognosis [1]. *Number of extralymphatic sites involved* - The **number of extralymphatic sites involved** is a key prognostic factor in the IPI. - Involvement of more than one extralymphatic site indicates more widespread disease and a worse prognosis. *Stage of disease* - The **stage of disease**, as defined by the Ann Arbor staging system, is an essential element of the IPI [1]. - Advanced stages (III or IV) are associated with a poorer prognosis compared to early stages [1].
Question 3: Which malignancy is characterized by a stepwise progression through lymph nodes, making staging an important prognostic factor?
- A. Hodgkin's lymphoma (Correct Answer)
- B. Multiple myeloma
- C. Mature T cell NHL
- D. Mature B cell NHL
Explanation: ***Hodgkin's lymphoma*** - Characteristically spreads in a **stepwise fashion** through lymphatic pathways [1], making **staging critical** for prognosis [1]. - Its localized dissemination and the presence of **Reed-Sternberg cells** help define its distinct clinical behavior [1]. *Multiple myeloma* - Primarily characterized by **disseminated plasma cell proliferation** and typically does not follow a stepwise spread pattern. - Staging is based on **serum markers** rather than anatomical spread, focusing more on paraproteins and organ damage. *Mature T cell NHL* - Often exhibits an **aggressive** nature with various patterns of spread, but not characteristically in a stepwise manner [2]. - Staging relevance is less focused compared to Hodgkin's lymphoma, as many subtypes present differently. *Mature B cell NHL* - More variable in behavior and can disseminate **discontinuously** [2], lacking a uniform stepwise progression. - Staging exists but is often less straightforward compared to **Hodgkin's lymphoma**, which has a more predictable pattern [1][2].
Question 4: Classification system of bone tumors is -
- A. Enneking (Correct Answer)
- B. Edmonton
- C. TNM
- D. Manchester
Explanation: ***Enneking*** - The **Enneking staging system** is widely used for primary **bone tumors**, particularly sarcomas. - It classifies tumors based on their histological grade, local extension, and presence of metastases, which guides surgical planning and prognosis. *Edmonton* - The **Edmonton classification** is primarily used for **periprosthetic fractures** around hip and knee replacements. - It does not classify primary bone tumors but rather describes fracture patterns related to prosthetic implants. *TNM* - The **TNM (Tumor, Node, Metastasis)** classification is a general staging system used for many types of cancer, but it's not the primary system for bone tumors. - While applicable for some bone cancers, the **Enneking system** provides a more specific functional and anatomical assessment for limb-sparing surgery in bone sarcomas. *Manchester* - The **Manchester staging system** is primarily used for **lymphoma**, particularly Hodgkin lymphoma. - It describes the extent of lymph node involvement and extralymphatic disease, completely unrelated to bone tumors.
Question 5: 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 6: Radiotherapy has the most significant therapeutic role in:
- A. Monoclonal gammopathy
- B. Tuberculosis
- C. Sarcomas (Correct Answer)
- D. Sarcoidosis
Explanation: ***Sarcomas*** - **Radiotherapy** plays a crucial therapeutic role in **sarcomas**, though typically as **adjuvant therapy** combined with surgical resection - Used for **local control** in soft tissue sarcomas, particularly when wide margins cannot be achieved - **Primary radiotherapy** is the treatment of choice for certain radiation-sensitive sarcomas like **Ewing's sarcoma** and in cases of **inoperable tumors** - Essential for reducing **local recurrence rates** in high-grade soft tissue sarcomas - Among the options listed, sarcomas have the **strongest and most established indication** for radiotherapy *Monoclonal gammopathy* - Generally **observation only** for MGUS (Monoclonal Gammopathy of Undetermined Significance) - Radiotherapy used only for **solitary plasmacytoma**, which is a specific localized manifestation - Multiple myeloma (if it progresses) is treated with **chemotherapy** and targeted agents, not radiotherapy as primary treatment *Tuberculosis* - An **infectious disease** caused by *Mycobacterium tuberculosis* - Treated exclusively with **anti-tubercular drug regimens** (RIPE: Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) - Radiotherapy has **no role** in treating infections *Sarcoidosis* - A **systemic inflammatory condition** with non-caseating granulomas - Primary treatment is **corticosteroids** for symptomatic cases - Immunosuppressants used for refractory cases - Radiotherapy has **no role** in inflammatory/granulomatous diseases
Question 7: Which of the following treatment options best represents the standard management approach for stage IB cervical cancer?
- A. Surgery and Radiotherapy
- B. Surgery (Correct Answer)
- C. Chemotherapy and Radiotherapy
- D. Surgery and Chemotherapy
Explanation: ***Surgery*** - For **stage IB cervical cancer**, **radical hysterectomy with pelvic lymphadenectomy** is the primary standard surgical treatment option. - Surgery alone is appropriate for cases without high-risk features on final pathology. - This represents the cornerstone primary management approach for early-stage cervical cancer. - Alternative primary treatment is definitive **concurrent chemoradiation**, which is considered equivalent to surgery. *Surgery and Radiotherapy* - **Adjuvant radiotherapy** (or chemoradiation) is added only if **high-risk pathologic features** are found post-surgery, such as positive margins, parametrial involvement, or positive lymph nodes. - This is not the standard primary approach but rather selective adjuvant therapy based on surgical pathology findings. - Not all stage IB cases require adjuvant radiotherapy. *Surgery and Chemotherapy* - **Adjuvant chemotherapy alone** is NOT standard management for cervical cancer. - When adjuvant therapy is needed, it is **concurrent chemoradiation** (radiation with chemotherapy as a radiosensitizer), not chemotherapy alone. - Chemotherapy alone does not provide adequate locoregional control for cervical cancer. *Chemotherapy and Radiotherapy* - **Concurrent chemoradiation** is the primary treatment for **locally advanced cervical cancer** (stages IB3 with certain features, IIB-IVA). - It is also an alternative to surgery for primary treatment of stage IB, but the question asks for standard management, which traditionally refers to the surgical approach for early-stage disease. - This is definitive treatment without surgery for larger or locally advanced tumors.
Question 8: A colonic carcinoma involving muscularis propria, with one or two nodes involved with a solitary metastasis in the liver, the TNM stage would be:
- A. T2 N1 M1 (Correct Answer)
- B. T1 N2 M1
- C. T1 N1 M1
- D. T2 N2 M1
Explanation: ***T2 N1 M1*** **(Correct Answer)** - **T2** indicates the tumor invades the **muscularis propria** in the TNM classification for colorectal cancer. - **N1** signifies involvement of **one to three regional lymph nodes**, which corresponds to "one or two nodes involved" in the question. - **M1** denotes the presence of **distant metastasis**, specifically a "solitary metastasis in the liver" as described. *T1 N2 M1* - **T1** describes a tumor that invades the **submucosa** but not the muscularis propria, which is less advanced than the scenario described. - **N2** would imply involvement of **four or more regional lymph nodes**, contradicting the "one or two nodes involved" stated in the question. *T1 N1 M1* - **T1** indicates invasion into the **submucosa**, not reaching the muscularis propria as specified in the case description. - The **N1** and **M1** components are consistent with the nodal involvement and distant metastasis, but the **T stage** is incorrect. *T2 N2 M1* - While **T2** is correct for invasion into the muscularis propria, **N2** incorrectly implies involvement of **four or more regional lymph nodes**. - The question states "one or two nodes involved," making **N1** the appropriate nodal classification.
Question 9: A patient has carcinoid tumour of appendix of size more than 2.5 cm. The management of choice is:
- A. Appendectomy
- B. Right hemicolectomy (Correct Answer)
- C. Appendectomy and 24 hour urinary HIAA
- D. Appendectomy and abdominal CT scan
Explanation: **Right hemicolectomy** - For **carcinoid tumors of the appendix** larger than **2.0 cm (or 2.5 cm by some guidelines)**, a right hemicolectomy is the recommended management due to the increased risk of **lymph node metastasis** and distant spread. - This procedure ensures adequate tumor clearance and regional lymphadenectomy, which is crucial for staging and preventing recurrence in larger tumors. *Appendectomy* - An appendectomy alone is usually sufficient for **small carcinoid tumors (<1-2 cm)** that are **confined to the appendix**, without evidence of mesoappendiceal invasion or lymph node involvement. - For tumors exceeding 2.5 cm, the risk of metastasis is considerably higher, making appendectomy alone inadequate for complete oncological control. *Appendectomy and 24 hour urinary HIAA* - While a **24-hour urinary 5-hydroxyindoleacetic acid (5-HIAA)** measurement is useful for diagnosing and monitoring **carcinoid syndrome**, it does not influence the primary surgical management decision for an appendiceal tumor of this size. - The surgical approach is dictated by **tumor size** and the risk of metastasis, not by biochemical markers alone, unless the patient presents with symptoms of carcinoid syndrome. *Appendectomy and abdominal CT scan* - An abdominal **CT scan** is valuable for **staging** and detecting distant metastases or nodal involvement, especially in larger tumors, but it is a diagnostic tool, not a treatment itself. - While a CT scan would likely be performed as part of the work-up, an appendectomy alone is insufficient as the definitive surgical management for a tumor of this size without addressing the high risk of regional spread.
Question 10: Which of the following requires the maximum margin of excision?
- A. Malignant melanoma
- B. Basal cell carcinoma (BCC)
- C. Squamous cell carcinoma (SCC)
- D. Dermatofibrosarcoma protuberans (Correct Answer)
Explanation: **Explanation:** The correct answer is **Dermatofibrosarcoma Protuberans (DFSP)**. The primary factor determining excision margins is the biological behavior and local invasiveness of the tumor. DFSP is a low-to-intermediate grade cutaneous sarcoma characterized by extensive, subclinical **tentacle-like lateral extensions** (microscopic projections) into the surrounding dermis and subcutaneous fat. Because these extensions often go beyond the clinically visible tumor, standard narrow margins lead to extremely high recurrence rates. Current guidelines recommend a wide local excision with a margin of **2 to 4 cm**, or ideally, Mohs Micrographic Surgery (MMS). **Analysis of Incorrect Options:** * **Malignant Melanoma:** Margins are determined by the **Breslow thickness**. Even for the thickest tumors (>2 mm), the maximum recommended margin is **2 cm**. * **Squamous Cell Carcinoma (SCC):** Standard margins for high-risk SCC are typically **6 mm to 10 mm**. * **Basal Cell Carcinoma (BCC):** This is the least aggressive of the group. Standard excision margins are usually **4 mm to 5 mm** for low-risk lesions. **High-Yield Clinical Pearls for NEET-PG:** * **DFSP Pathognomonic Feature:** Histology shows a characteristic **"storiform" (cartwheel) pattern** of spindle cells and a **"honeycomb" appearance** when invading subcutaneous fat. * **Cytogenetics:** Associated with a translocation **t(17;22)**, leading to overexpression of PDGFB. * **Treatment of Choice:** Mohs Micrographic Surgery (MMS) is preferred over wide local excision to minimize tissue loss while ensuring clear margins. * **Medical Management:** **Imatinib** (a tyrosine kinase inhibitor) is used for metastatic or unresectable DFSP.
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