Cytoreductive Surgery — MCQs
Which classification system is currently used in North America for Wilms' tumor based on surgical and pathological findings?
The commando operation is:
Which of the following factors is not included in the MACIS score used for the prognosis of papillary thyroid cancer?
Which of the following antineoplastic drugs SHOULD NOT be given by rapid IV infusion?
Drug used in treatment of malignant hyperthermia is
A patient presents with bilateral ovarian carcinoma, capsule involvement, ascites, and paraaortic lymphadenopathy. What is the appropriate stage of the disease?
Local excision in rectal cancer is done in all, except:
Which of the following cancers are correctly matched with the criteria for the minimum number of lymph nodes required for pathological staging? A. CA stomach -10 B. CA colon -12 C. CA gall bladder -6 D. CA breast -15
Which of the following is the most characteristic symptom of a peritonsillar abscess?
A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?
Cytoreductive Surgery Indian Medical PG Practice Questions and MCQs
Question 1: Which classification system is currently used in North America for Wilms' tumor based on surgical and pathological findings?
- A. COG (Children's Oncology Group) classification (Correct Answer)
- B. SIOP (International Society of Pediatric Oncology Classification)
- C. UICC (Union for International Cancer Control Classification)
- D. NWTS V (National Wilms Tumor Study V)
Explanation: ***COG (Children's Oncology Group) classification*** - The **Children's Oncology Group (COG) classification system** is the primary system used in **North America** for staging Wilms' tumor. - This system relies on **surgical and pathological findings post-nephrectomy** to determine the stage, which then guides subsequent treatment [1]. - COG typically involves **upfront nephrectomy** followed by staging based on operative and histopathological findings, making it the correct answer to this question's specific criteria [1]. *SIOP (International Society of Pediatric Oncology Classification)* - The **SIOP staging system** is predominantly used in **Europe** and other parts of the world. - A key difference is that **SIOP advocates for preoperative chemotherapy** followed by surgery, unlike the COG approach which typically involves immediate surgery. - Because SIOP stages after chemotherapy rather than based on initial surgical findings, it doesn't fit the question's criteria as well as COG. *UICC (Union for International Cancer Control Classification)* - The **UICC classification** is a widely recognized general cancer staging system (TNM system) but is **not specifically tailored** or the primary system used for Wilms' tumor in North America. - While it includes pediatric cancers, specialized systems like COG or SIOP are preferred for their detailed, disease-specific staging of Wilms' tumor. *NWTS V (National Wilms Tumor Study V)* - The **National Wilms Tumor Study (NWTS)** was a series of pivotal clinical trials that significantly advanced the understanding and treatment of Wilms' tumor. - While **NWTS V** was the fifth iteration of these studies and contributed to the current COG staging system, it represented a **clinical trial protocol** and not a standalone classification system for ongoing clinical practice. - The legacy of NWTS lives on through the COG system, which evolved from these important studies. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 488-490.
Question 2: The commando operation is:
- A. Abdomino-perineal resection of the rectum for carcinoma
- B. Extended radical mastectomy
- C. Disarticulation of the hip for gas gangrene of the leg
- D. Excision of carcinoma of the tongue, the floor of the mouth, part of the jaw and lymph nodes en bloc (Correct Answer)
Explanation: ***Excision of carcinoma of the tongue, the floor of the mouth, part of the jaw and lymph nodes en bloc*** - The **Commando operation** specifically refers to a radical surgical procedure for advanced head and neck cancers, typically involving the **tongue**, **floor of the mouth**, and often requiring removal of a portion of the **mandible (jaw)** and a **neck dissection (lymph nodes en bloc)**. - This extensive, single-block resection aims to provide wide margins for large or invasive tumors in the oral cavity. *Abdomino-perineal resection of the rectum for carcinoma* - This procedure, known as **APR**, is a common surgery for low rectal cancers but is not referred to as a "Commando operation." - It involves the removal of the rectum and anus through both abdominal and perineal incisions, usually resulting in a permanent colostomy. *Extended radical mastectomy* - **Extended radical mastectomy** involves the removal of the breast, axillary lymph nodes, and potentially some chest wall muscles, but it is a procedure for breast cancer and not related to head and neck surgery, nor is it termed a "Commando operation." - This operation is a historically significant, though less common, approach to breast cancer management. *Disarticulation of the hip for gas gangrene of the leg* - **Hip disarticulation** is an amputation procedure at the hip joint for severe conditions like gas gangrene or extensive trauma and is not known as a "Commando operation." - This is an emergency or salvage procedure aimed at preventing further spread of infection or disease.
Question 3: Which of the following factors is not included in the MACIS score used for the prognosis of papillary thyroid cancer?
- A. Age
- B. Size
- C. Excision completion in surgery
- D. Mitotic index (Correct Answer)
Explanation: ***Mitotic index*** - The MACIS score is a **prognostic scoring system** for papillary thyroid carcinoma, and the mitotic index is **not a component** of this score. - The MACIS score considers factors such as **Metastasis**, **Age**, **Completeness of excision**, **Invasion**, and **Size** of the tumor. *Age* - **Age** is a crucial factor in the MACIS score, with patients older than 40 years typically having a **worse prognosis**. - It differentiates between patients <40 years and ≥40 years, assigning different points based on age. *Size* - The **size** of the primary tumor is an important component of the MACIS score. - Tumors larger than 4 cm (or 40 mm) are associated with a **higher score** and a less favorable prognosis. *Excision completion in surgery* - The **completeness of surgical excision** is a critical factor in the MACIS score. - **Incomplete tumor removal** or gross residual tumor after surgery indicates a worse prognosis and adds points to the score.
Question 4: 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 5: Drug used in treatment of malignant hyperthermia is
- A. Phenobarbitone
- B. Dantrolene (Correct Answer)
- C. Paracetamol
- D. Diazepam
Explanation: ***Dantrolene*** - **Dantrolene** is a direct-acting **skeletal muscle relaxant** that works by preventing calcium release from the sarcoplasmic reticulum. - This mechanism effectively counteracts the excessive calcium efflux responsible for the sustained muscle contraction and hypermetabolic state in **malignant hyperthermia**. *Phenobarbitone* - **Phenobarbitone** is a barbiturate primarily used as an **anticonvulsant** and sedative-hypnotic. - It has no direct muscle relaxant properties or specific action to address the underlying pathophysiology of **malignant hyperthermia**. *Paracetamol* - **Paracetamol** (acetaminophen) is an **analgesic** and **antipyretic**. - While it can help manage fever, it does not address the fundamental muscle rigidity, metabolic acidosis, or **calcium dysregulation** characteristic of malignant hyperthermia. *Diazepam* - **Diazepam** is a benzodiazepine primarily used for its **anxiolytic**, sedative, and **anticonvulsant** properties, acting on GABA receptors. - It would not treat the underlying **muscle rigidity** and hypermetabolism of malignant hyperthermia, though it might reduce anxiety.
Question 6: A patient presents with bilateral ovarian carcinoma, capsule involvement, ascites, and paraaortic lymphadenopathy. What is the appropriate stage of the disease?
- A. Stage 1C
- B. Stage 3C (Correct Answer)
- C. Stage 2C
- D. Stage 4C
Explanation: ***Stage 3C*** - **Bilateral ovarian carcinoma** with **capsule involvement**, **ascites**, and especially **paraaortic lymph node metastases** are defining features of Stage IIIC ovarian cancer. - Involvement of **retroperitoneal lymph nodes**, including paraaortic nodes, automatically upstages the disease to Stage III, irrespective of other abdominal spread. *Stage 1C* - This stage refers to ovarian cancer confined to **one or both ovaries**, with evidence of rupture, capsule involvement, or malignant cells in ascites/peritoneal washings, but **without lymph node involvement**. - The presence of **paraaortic lymphadenopathy** in this patient immediately excludes Stage 1C. *Stage 2C* - Stage 2 ovarian cancer involves one or both ovaries with **pelvic extension** beyond the ovaries, but still **without lymph node involvement**. - The patient's involvement of **paraaortic lymph nodes** goes beyond pelvic extension and therefore excludes Stage 2C. *Stage 4C* - Stage 4 ovarian carcinoma involves **distant metastasis** beyond the peritoneal cavity or distant lymph nodes (e.g., pleural effusion with positive cytology, parenchymal liver/spleen metastasis). - While paraaortic lymphadenopathy indicates advanced disease, it falls within the criteria for Stage 3 due to its location, not Stage 4.
Question 7: Local excision in rectal cancer is done in all, except:
- A. Involvement of <40% circumference
- B. Lesion <4 cm
- C. Within 6 cm of anal verge
- D. T2 cancer or any lymph node involvement (Correct Answer)
Explanation: ***T2 cancer or any lymph node involvement*** - Local excision is typically reserved for **early-stage rectal cancers (T1 tumors)** where the risk of lymph node metastasis is very low and there is **no lymph node involvement**. - **T2 tumors** (invasion into muscularis propria) carry a significantly higher risk of lymph node metastasis (10-20%) and are generally **not suitable for local excision**, requiring radical resection instead. - **Any lymph node involvement** (even in T1 disease) is an **absolute contraindication** to local excision, as it indicates metastatic spread requiring comprehensive lymphadenectomy through radical resection. *Within 6 cm of anal verge* - This refers to the **location within the rectum** and accessibility for transanal approaches. - Rectal tumors within 6-8 cm of the anal verge are **suitable for local excision** techniques like transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS) if they meet other criteria (T1, N0, favorable histology). *Lesion <4 cm* - **Tumor size <3-4 cm** is one of the favorable criteria for local excision. - Smaller tumors are more amenable to complete excision with adequate margins and are associated with lower risk of lymph node metastasis. *Involvement of <40% circumference* - The **circumferential involvement** of the rectal wall is an important factor for technical feasibility. - Tumors involving **<30-40% of the circumference** are suitable for local excision, allowing adequate margin resection and primary closure without compromising rectal function or causing stenosis.
Question 8: Which of the following cancers are correctly matched with the criteria for the minimum number of lymph nodes required for pathological staging? A. CA stomach -10 B. CA colon -12 C. CA gall bladder -6 D. CA breast -15
- A. A,B,C
- B. A,B,C,D
- C. B,C (Correct Answer)
- D. A,C,D
Explanation: ***B,C (Correct Answer)*** - **Colorectal cancer (B)** requires a minimum of **12 lymph nodes** for adequate pathological staging - **correctly matched** ✅ - **Gallbladder cancer (C)** requires at least **6 lymph nodes** for proper staging - **correctly matched** ✅ - These are the only two correctly matched pairs in the question - Adequate lymph node retrieval is essential to prevent **understaging** and ensure accurate prognostic assessment *A,B,C (Incorrect)* - While B and C are correct, **gastric cancer (A)** requires a minimum of **15 lymph nodes**, not 10 - The inclusion of A makes this combination incorrect *A,B,C,D (Incorrect)* - **Gastric cancer (A)** requires **15 lymph nodes**, not 10 - **incorrectly matched** - **Breast cancer (D)** requires a minimum of **10 lymph nodes**, not 15 - **incorrectly matched** - Only B and C are correctly matched *A,C,D (Incorrect)* - **Gastric cancer (A)** requires **15 lymph nodes**, not 10 - **incorrectly matched** - **Breast cancer (D)** requires **10 lymph nodes**, not 15 - **incorrectly matched** - C is correct, but A and D are both incorrectly matched
Question 9: Which of the following is the most characteristic symptom of a peritonsillar abscess?
- A. Trismus (difficulty opening the mouth) (Correct Answer)
- B. Difficulty swallowing (dysphagia)
- C. Muffled or 'hot potato' voice
- D. Severe sore throat
Explanation: ***Trismus (difficulty opening the mouth)*** - **Trismus** is a hallmark symptom of a peritonsillar abscess, resulting from irritation and spasm of the **pterygoid muscles** due to inflammation and pus accumulation. - Its presence is a strong indicator, often more specific than generalized symptoms, aiding in the differentiation from simple tonsillitis. *Difficulty swallowing (dysphagia)* - While **dysphagia** is common with a peritonsillar abscess due to pain and swelling, it is also a feature of severe tonsillitis or pharyngitis, making it less specific than trismus. - The pain associated with swallowing is typically **odynophagia**, though both are related to inflammation. *Muffled or 'hot potato' voice* - A **muffled** or "hot potato" voice is characteristic of a peritonsillar abscess due to swelling in the oral pharynx, affecting vocal resonance. - However, this symptom can also be present in other conditions causing significant pharyngeal swelling, making it less unique than trismus. *Severe sore throat* - A **severe sore throat** is a common and prominent symptom, often unilateral, but it is present in many other throat infections such as **strep throat** or severe tonsillitis. - Its presence, though significant, does not specifically point to a peritonsillar abscess over other inflammatory conditions of the throat.
Question 10: A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?
- A. 48%
- B. 12%
- C. 24%
- D. 3% (Correct Answer)
Explanation: ***3%*** - **Purely cystic thyroid nodules** (as described in this case with "isolated cystic swelling") have a **very low risk of malignancy**, typically **2-3%** or less. - According to **ATA guidelines** and **TIRADS classification**, purely cystic nodules are considered **low suspicion** lesions. - The cystic nature suggests a **benign process** such as a degenerated adenoma, colloid cyst, or simple cyst. - **Fine needle aspiration (FNA)** may still be considered if the nodule is >2 cm or has any suspicious solid components, but is often not required for purely cystic lesions. *48%* - This percentage is **significantly higher** than the actual malignancy risk for a purely cystic thyroid swelling. - Such a **high risk** would typically be associated with **solid nodules** exhibiting highly suspicious ultrasound features such as: - Microcalcifications - Irregular or spiculated margins - Taller-than-wide shape - Marked hypoechogenicity - Extrathyroidal extension *24%* - This percentage represents a **moderate to high risk** of malignancy, which is **not characteristic** of an isolated purely cystic thyroid swelling. - A risk in this range might be seen with: - **Mixed solid-cystic nodules** with predominantly solid components - Solid nodules with **intermediate suspicious features** on ultrasound *12%* - While lower than 24% or 48%, 12% is still **considerably higher** than the generally accepted malignancy risk for purely cystic thyroid nodules. - This risk level could be plausible for: - **Predominantly cystic nodules** with some eccentric solid components - Solid nodules with **mildly suspicious** features on ultrasound
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