Follow-up and Surveillance — MCQs
A woman with postmenopausal bleeding has thickened endometrium. Which approach is most suitable for evaluating malignancy risk?
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?
Which is the best investigation for carcinoma of the head of pancreas?
A patient with gastric cancer shows positive CEA. What is its significance?
Screening is not useful in which carcinoma
A 52 year old male patient comes with history of rectal bleeding, alteration in bowel habits and tenesmus. The ideal investigation would be:
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?
The staging system for thymoma was developed by whom?
Follow-up and Surveillance Indian Medical PG Practice Questions and MCQs
Question 1: A woman with postmenopausal bleeding has thickened endometrium. Which approach is most suitable for evaluating malignancy risk?
- A. Endometrial biopsy (Correct Answer)
- B. Transvaginal ultrasound
- C. Pap smear
- D. Hysteroscopy
Explanation: ***Endometrial biopsy*** - An **endometrial biopsy** directly obtains tissue samples from the endometrial lining, allowing for histological examination to definitively diagnose or rule out **endometrial hyperplasia** or **carcinoma**. - This is the **most suitable first-line approach** when postmenopausal bleeding is coupled with a thickened endometrium, as it directly assesses for **malignancy at a cellular level**. - It is **cost-effective, minimally invasive, and can be performed in an office setting** without anesthesia. *Transvaginal ultrasound* - While a **transvaginal ultrasound** can measure endometrial thickness and identify structural abnormalities, it cannot definitively differentiate between benign and malignant changes. - It serves as an initial screening tool but requires further investigation like a **biopsy** for definitive diagnosis in cases of thickened endometrium and postmenopausal bleeding. - An endometrial thickness >4-5 mm in postmenopausal women warrants tissue diagnosis. *Pap smear* - A **Pap smear** (Papanicolaou test) is used to screen for **cervical cancer** by collecting cells from the cervix. - It is not effective for detecting **endometrial pathologies** or cancer of the uterine lining. *Hysteroscopy* - **Hysteroscopy** allows for direct visualization of the uterine cavity and directed biopsies under direct vision, which is highly accurate for identifying focal lesions such as polyps or fibroids. - While it provides excellent diagnostic accuracy, it is **more invasive, expensive, and typically requires anesthesia**. - For initial evaluation of postmenopausal bleeding with diffuse endometrial thickening, **endometrial biopsy is preferred** as the first-line approach due to its accessibility, lower cost, and adequate sensitivity (>90% for detecting endometrial cancer).
Question 2: 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
Question 3: Which is the best investigation for carcinoma of the head of pancreas?
- A. Transduodenal/transperitoneal sampling
- B. Guided biopsy
- C. ERCP
- D. EUS (Correct Answer)
Explanation: ***EUS*** - **Endoscopic ultrasound (EUS)** provides the highest resolution imaging of the pancreas and allows for **fine-needle aspiration (FNA)** of suspicious lesions, offering definitive tissue diagnosis. - Its ability to visualize small, early-stage tumors and regional lymph nodes makes it the **most accurate method for diagnosis and staging** of pancreatic head carcinoma. *Guided biopsy* - While a biopsy is necessary for definitive diagnosis, 'guided biopsy' is a broad term that doesn't specify the highly effective EUS guidance. - Other biopsy methods that are not guided by EUS may be less accurate and carry higher risks for pancreatic lesions. *ERCP* - **Endoscopic retrograde cholangiopancreatography (ERCP)** is primarily a therapeutic procedure used for **biliary drainage** in cases of obstruction caused by pancreatic head tumors. - Although it can visualize ductal abnormalities and allow brush cytology, it is **less sensitive for direct tumor visualization** and tissue acquisition compared to EUS-FNA. *Transduodenal/transperitoneal sampling* - These are **invasive surgical approaches** for obtaining tissue samples, typically reserved when less invasive methods like EUS-FNA are unsuccessful or when intraoperative confirmation is needed. - They carry **higher risks** and are not considered the "best investigation" for initial diagnosis due to their invasiveness and potential for complications.
Question 4: A patient with gastric cancer shows positive CEA. What is its significance?
- A. Prognostic (Correct Answer)
- B. Diagnostic
- C. Therapeutic
- D. Screening
Explanation: ***Prognostic*** - A positive **carcinoembryonic antigen (CEA)** in gastric cancer indicates **larger tumor burden** and more advanced disease [1] - Elevated preoperative CEA levels are associated with **poorer prognosis**, higher risk of recurrence, and decreased survival [1] - CEA levels can be used to **monitor treatment response** and detect early recurrence after curative resection [1] - Higher CEA values correlate with advanced stage, lymph node involvement, and distant metastases *Diagnostic* - CEA is **not specific enough** for diagnosing gastric cancer as it can be elevated in other malignancies (colorectal, pancreatic, lung) and benign conditions (smoking, cirrhosis, inflammatory bowel disease) [2] - Diagnosis of gastric cancer requires **endoscopic biopsy** with histopathological examination - CEA may be normal even in confirmed gastric cancer cases (limited sensitivity) [2] *Therapeutic* - CEA is a **tumor marker**, not a therapeutic agent or treatment modality - While CEA levels help guide treatment decisions and monitor response, the marker itself has no therapeutic role - Treatment decisions are based on staging, histology, and patient factors, not solely on CEA values *Screening* - CEA lacks sufficient **sensitivity and specificity** for population-based screening of gastric cancer [2] - Screening for gastric cancer uses **endoscopy** in high-risk populations, not serum tumor markers - CEA is primarily used for post-treatment surveillance in patients with known cancer, not for detecting occult disease in asymptomatic individuals **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 254-255. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, p. 346.
Question 5: Screening is not useful in which carcinoma
- A. Testicular carcinoma (Correct Answer)
- B. Carcinoma prostate
- C. Carcinoma colon
- D. Carcinoma breast
Explanation: Testicular carcinoma - **Testicular cancer** typically presents as a painless mass, and **self-examination** is often emphasized for early detection rather than formal screening programs due to low incidence and variable benefits. - While early detection is important, population-wide screening for testicular cancer is **not recommended** due to its rarity and lack of evidence for improved outcomes compared to opportunistic detection. *Carcinoma prostate* - **Prostate cancer screening** using **PSA (prostate-specific antigen)** testing and digital rectal examinations is routinely performed, though its benefits and risks are debated [1]. - Early detection aims to identify potentially aggressive cancers, but also leads to **overdiagnosis and overtreatment** of indolent lesions [1]. *Carcinoma colon* - **Colorectal cancer screening** is highly effective and widely recommended through methods like **colonoscopy**, fecal occult blood testing, and sigmoisingoscopy. - Screening aims to detect **polyps** before they become cancerous or find cancer at an early, treatable stage, significantly reducing mortality. *Carcinoma breast* - **Breast cancer screening** using **mammography** is a well-established and highly effective method for early detection in women. - Early detection allows for timely treatment, significantly improving prognosis and reducing breast cancer mortality.
Question 6: A 52 year old male patient comes with history of rectal bleeding, alteration in bowel habits and tenesmus. The ideal investigation would be:
- A. Contrast-enhanced CT scan
- B. Fecal occult blood test
- C. Colonoscopy (Correct Answer)
- D. Ultrasonogram
Explanation: ***Colonoscopy*** - **Colonoscopy** is the gold standard for investigating symptoms like rectal bleeding, altered bowel habits, and tenesmus, as it allows for direct visualization of the entire colon and rectum. - It enables **biopsy of suspicious lesions** for histopathological diagnosis, which is crucial for confirming conditions like colorectal cancer or inflammatory bowel disease. *Contrast-enhanced CT scan* - A **contrast-enhanced CT scan** is primarily used for **staging known malignancies** and assessing for distant metastases, not as a primary diagnostic tool for initial symptoms. - While it can identify large masses, it might miss smaller lesions and does not allow for tissue biopsy. *Fecal occult blood test* - A **fecal occult blood test** screens for blood in the stool, which indicates gastrointestinal bleeding but does not pinpoint the source or cause. - It has **low sensitivity and specificity** for diagnosing underlying conditions like colorectal cancer or inflammatory bowel disease and is mainly a screening tool. *Ultrasonogram* - An **ultrasonogram** is generally not effective for evaluating the colon and rectum due to bowel gas interference. - It is more commonly used for investigating abdominal organs like the liver, gallbladder, and kidneys, or for pelvic pathology, but not the primary investigation for these colorectal symptoms.
Question 7: 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 8: 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 9: 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.
Question 10: The staging system for thymoma was developed by whom?
- A. Masaoka (Correct Answer)
- B. Yokohama
- C. Todani
- D. Kluive
Explanation: The correct answer is **A. Masaoka**. ### Explanation The staging of thymic epithelial tumors (thymomas) is primarily based on the **Masaoka Staging System** (later modified as the Masaoka-Koga system). This system is unique because it is based on the degree of **capsular invasion** and the involvement of adjacent structures rather than just tumor size. * **Stage I:** Macroscopically and microscopically completely encapsulated. * **Stage II:** Microscopic transcapsular invasion (IIa) or macroscopic invasion into surrounding fatty tissue (IIb). * **Stage III:** Macroscopic invasion into neighboring organs (pericardium, great vessels, or lungs). * **Stage IV:** Pleural/pericardial dissemination (IVa) or lymphogenous/hematogenous metastasis (IVb). ### Why the other options are incorrect: * **B. Yokohama:** This is not a recognized surgical staging system. It is likely a distractor. * **C. Todani:** This classification is used for **Choledochal cysts** (Types I-V), a high-yield topic in pediatric and hepatobiliary surgery. * **D. Klatskin (often confused with Kluive):** While "Kluive" is a distractor, **Klatskin tumors** refer to hilar cholangiocarcinoma. If the option meant **Bismuth-Corlette**, that is the staging used for those tumors. ### High-Yield Clinical Pearls for NEET-PG: 1. **Most common association:** 30–45% of patients with thymoma have **Myasthenia Gravis**. Conversely, only 10–15% of patients with Myasthenia Gravis have a thymoma. 2. **Treatment of Choice:** Complete surgical resection (**En-bloc Thymectomy**) is the gold standard for resectable tumors. 3. **WHO Classification:** While Masaoka stages the *extent*, the WHO classification (Types A, AB, B1, B2, B3, and C) categorizes thymomas based on *histology* and cytological atypia. 4. **TNM Staging:** Recently, the AJCC/UICC 8th edition introduced a TNM staging system for thymic tumors, but Masaoka-Koga remains the most widely used in clinical practice.
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