Hyperthermic Intraperitoneal Chemotherapy — MCQs

10 questions

Which does not cause malignant hyperthermia –

After laparoscopic cholecystectomy what should be the urine output of the patient if the renal function of the patient is normal?

Which of the following antineoplastic drugs SHOULD NOT be given by rapid IV infusion?

Among the following conditions, laparoscopy carries the highest risk in patients with:

Which statement is incorrect about the pathology of the bone tumor?

What is the maximum possible score in the APACHE II scoring system?

Which one of the following is not sensitive to chemotherapy in advanced stage?

Management of RCC less than 4 cm in size:

Best treatment strategy for carcinoma of the anal canal:

Q10

Which of the following are indications of splenectomy? 1. Pseudomyxoma peritonei 2. Trauma 3. Idiopathic thrombocytopenic purpura (ITP) 4. Hypersplenism

Hyperthermic Intraperitoneal Chemotherapy Indian Medical PG Practice Questions and MCQs

Question 1: Which does not cause malignant hyperthermia –

A. Enflurane
B. N2O (Correct Answer)
C. Desflurane
D. Isoflurane

Explanation: ***N2O*** - **Nitrous oxide** is a weak inhaled anesthetic and does not trigger **malignant hyperthermia** (MH). - Its mechanism of action does not involve the **ryanodine receptor** or calcium release, which are central to MH pathophysiology. *Enflurane* - **Enflurane** is a volatile inhaled anesthetic that is a known trigger for **malignant hyperthermia**. - It induces uncontrolled **intracellular calcium release** in skeletal muscle, leading to hypermetabolism. *Desflurane* - **Desflurane** is another potent volatile inhaled anesthetic and a classic trigger agent for **malignant hyperthermia**. - Its use can result in a rapid onset of MH symptoms due to its quick pharmacokinetics. *Isoflurane* - **Isoflurane** is also a volatile inhaled anesthetic and is well-established as a trigger for **malignant hyperthermia**. - Like other volatile agents, it can bind to the **ryanodine receptor** (RyR1), causing excessive calcium efflux.

Question 2: After laparoscopic cholecystectomy what should be the urine output of the patient if the renal function of the patient is normal?

A. 0.5 ml/min
B. 0.1 CC/hr
C. 1 ml/kg/hr
D. 0.5-1 ml/kg/hr (Correct Answer)

Explanation: ***0.5-1 ml/kg/hr*** - The standard acceptable urine output for a postoperative patient with normal renal function is **0.5-1 ml/kg/hr** (some sources extend this to 0.5-1.5 ml/kg/hr). - A minimum of **0.5 ml/kg/hr** is considered adequate renal perfusion and function, while outputs up to 1-1.5 ml/kg/hr indicate excellent hydration and renal function. - This weight-adjusted measure is the gold standard for assessing postoperative urine output and renal function. *0.5 ml/min* - This is an absolute rate (not weight-adjusted) and is inadequate as a general measure. - For a 70 kg patient, this would be only 0.43 ml/kg/hr, which is below the minimum acceptable threshold. *0.1 CC/hr* - This rate is **severely low** and indicates **oliguria** or **anuria**. - This suggests **acute kidney injury**, severe dehydration, or inadequate renal perfusion requiring immediate intervention. *1 ml/kg/hr* - While this value falls within the acceptable range, it represents only a single point rather than the **standard range of 0.5-1 ml/kg/hr**. - The range option is more comprehensive and represents the full spectrum of normal postoperative urine output.

Question 3: 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 4: Among the following conditions, laparoscopy carries the highest risk in patients with:

A. COPD (Correct Answer)
B. Diabetes
C. Hypertension
D. Obesity

Explanation: ***COPD*** - **COPD** patients have severely compromised respiratory function, and the **pneumoperitoneum** from CO2 insufflation causes **diaphragmatic splinting** and reduced lung compliance, leading to dangerous **CO2 retention** and respiratory failure. - The increased **intra-abdominal pressure** significantly impairs ventilation in patients who already have limited respiratory reserve, making laparoscopy extremely high-risk. *Diabetes* - While diabetes increases risks of **poor wound healing** and **infection**, these complications are not specifically worse with laparoscopy compared to open surgery. - **Perioperative glucose management** can effectively control diabetes-related risks, and laparoscopy may actually offer benefits like smaller incisions. *Hypertension* - **Hypertension** requires careful **blood pressure monitoring** during surgery but doesn't pose risks unique to laparoscopic procedures. - Well-controlled hypertension with appropriate **antihypertensive medications** allows for safe laparoscopic surgery. *Obesity* - **Obesity** makes laparoscopy technically challenging due to **thick abdominal walls** and need for higher insufflation pressures. - However, laparoscopy is often **preferred over open surgery** in obese patients due to reduced wound complications and faster recovery.

Question 5: Which statement is incorrect about the pathology of the bone tumor?

A. Tumor has distinct margin
B. Tumor arises from epiphyseal to metaphyseal region
C. Eccentric lesion
D. Chemotherapy is the treatment of choice for all bone tumors. (Correct Answer)

Explanation: ***Tumor has distinct margin*** - A **distinct margin** often indicates a benign tumor, while malignant tumors typically show **infiltrative margins**. - In bone tumors, particularly malignant ones, the lack of clear demarcation is a key pathological feature. *Chemotherapy is the treatment of choice* - While chemotherapy may be used for certain **malignant bone tumors**, it is not the first-line treatment for most bone tumors [1]. - The primary treatment is often **surgical excision**, especially for localized lesions [1]. *Tumor arise from epiphyseal to metaphyseal region* - While some tumors can originate in these areas, many actually arise from the **diaphyseal** region in bone tumors like osteosarcoma. - This option misrepresents the common locations where various tumors develop, as osteochondromas tend to develop near the epiphyses of limb bones [2]. *Eccentric lesion* - Many bone tumors do indeed present as **eccentric lesions**, especially benign ones like **osteochondromas**. - However, this feature does not apply universally, as some malignant tumors can also be **central or infiltrative** in nature. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 673-674. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 672-673.

Question 6: What is the maximum possible score in the APACHE II scoring system?

A. 71 (Correct Answer)
B. 61
C. 41
D. 51

Explanation: ***71*** - The **APACHE II (Acute Physiology and Chronic Health Evaluation II)** scoring system includes 12 physiological variables, age, and chronic health status. - Each physiological variable can contribute a maximum of 4 points, age up to 6 points, and chronic health conditions up to 5 points. The sum results in a maximum possible score of **71** (12 × 4 + 6 + 5 = 48 + 6 + 5 = 71). *61* - This score is lower than the actual maximum possible score, which accounts for optimal scoring across all components including physiological variables, age, and chronic health. - A score of 61 would imply lower maximum points for some components or fewer components overall than the APACHE II system utilizes. *41* - This score is significantly less than the maximum possible score for APACHE II and does not reflect the full range of points achievable across its various physiological and non-physiological parameters. - Obtaining a score of 41 would mean that a patient is critically ill, but not at the highest level of severity as defined by the system's maximum score. *51* - While 51 represents a very high and severe score in the APACHE II system, it is not the theoretical maximum. - The calculation considers 12 physiological parameters (each max 4 points), an age component (max 6 points), and a chronic health component (max 5 points), leading to a sum greater than 51.

Question 7: Which one of the following is not sensitive to chemotherapy in advanced stage?

A. Wilm's tumor
B. Ovarian carcinoma
C. Ewing's carcinoma
D. Pancreatic carcinoma (Correct Answer)

Explanation: ***Pancreatic carcinoma*** - **Pancreatic carcinoma** is notoriously difficult to treat with chemotherapy, especially in advanced stages, due to its **aggressive biology**, inherent resistance mechanisms, and late presentation [1]. - The disease often presents with **metastatic spread** before diagnosis, and the response rates to even combination chemotherapy regimens are typically poor, highlighting its poor sensitivity [1]. *Wilm's tumor* - **Wilm's tumor (nephroblastoma)** is a pediatric kidney cancer that is highly sensitive to chemotherapy, even in advanced stages. - Combination chemotherapy regimens are a cornerstone of treatment, often leading to **excellent prognosis** and cure rates. *Ovarian carcinoma* - **Ovarian carcinoma**, particularly epithelial ovarian cancer, is often initially sensitive to **platinum-based chemotherapy**. - While it frequently recurs, the initial response to chemotherapy, even in advanced stages, can be significant, leading to periods of **remission**. *Ewing's sarcoma* - **Ewing's sarcoma** is a highly aggressive bone and soft tissue tumor that is very sensitive to chemotherapy, which is a critical component of its multidisciplinary treatment. - Modern multidisciplinary approaches, including intensive chemotherapy, have significantly improved survival rates for patients with both localized and **metastatic disease**.

Question 8: Management of RCC less than 4 cm in size:

A. Surgery followed by chemotherapy
B. Partial nephrectomy (Correct Answer)
C. Radical nephrectomy
D. Chemotherapy

Explanation: ***Correct: Partial nephrectomy*** - For **renal cell carcinoma (RCC) less than 4 cm (T1a)**, partial nephrectomy is the **gold standard** as it offers equivalent oncological outcomes to radical nephrectomy while preserving renal function. - This approach minimizes the risk of **chronic kidney disease** and its associated complications without compromising cancer control for appropriately selected smaller tumors. - **Nephron-sparing surgery** is now the preferred approach per EAU and AUA guidelines for small renal masses. *Incorrect: Surgery followed by chemotherapy* - While surgery is the primary treatment, **adjuvant chemotherapy** is generally **not effective** for localized RCC and is not routinely recommended for small tumors. - Systemic therapies are typically reserved for **advanced or metastatic RCC**, or in specific clinical trials. *Incorrect: Radical nephrectomy* - This involves removing the entire kidney, which is typically reserved for **larger tumors (T1b and above)**, centrally located tumors, or those with significant renal parenchymal involvement. - For tumors under 4 cm, radical nephrectomy leads to **unnecessary loss of renal function** compared to partial nephrectomy. *Incorrect: Chemotherapy* - **RCC is notoriously chemoresistant**, meaning traditional chemotherapy drugs have very limited efficacy in treating this cancer. - Chemotherapy alone is **not a primary treatment modality** for localized RCC due to its poor response rates in this cancer type.

Question 9: Best treatment strategy for carcinoma of the anal canal:

A. Chemoradiation (Correct Answer)
B. Radiation
C. Surgery
D. Chemotherapy

Explanation: ***Chemoradiation*** - Carcinoma of the anal canal is primarily treated with **chemoradiation** (combinations of chemotherapy and radiation therapy) as the standard of care to achieve **organ preservation**. - This combined approach improves local control and survival rates compared to either modality alone, making it the **primary curative strategy** for most localized anal canal cancers. *Radiation* - While radiation therapy is a crucial component of anal canal cancer treatment, using it alone (**monotherapy**) is generally less effective than chemoradiation. - **Local recurrence rates** are higher with radiation alone compared to combined modality treatment. *Surgery* - Surgery, specifically **abdominoperineal resection (APR)**, is typically reserved for **recurrent disease** or cases where chemoradiation fails. - Initial radical surgery for anal canal cancer leads to significant morbidity (e.g., permanent colostomy) and is generally avoided as a primary treatment due to the success of chemoradiation. *Chemotherapy* - Chemotherapy alone is **not curative** for localized anal canal carcinoma. - It is primarily used in combination with radiation (chemoradiation) to sensitize the tumor to radiation and improve local control, or as treatment for **metastatic disease**.

Question 10: Which of the following are indications of splenectomy? 1. Pseudomyxoma peritonei 2. Trauma 3. Idiopathic thrombocytopenic purpura (ITP) 4. Hypersplenism

A. 1, 2 and 4
B. 2, 3 and 4 (Correct Answer)
C. 1, 2 and 3
D. 1, 3 and 4

Explanation: ***2, 3 and 4*** * **Trauma** is a common indication, particularly for significant splenic injury causing **hemorrhage** that cannot be managed conservatively. * **Idiopathic thrombocytopenic purpura (ITP)** unresponsive to medical therapy is often treated with splenectomy to remove the primary site of **autoantibody production** and platelet destruction. * **Hypersplenism**, characterized by cytopenias affecting one or more blood cell lines due to increased splenic sequestration and destruction, is a clear indication for splenectomy if symptomatic or severe. *1, 2 and 4* * **Pseudomyxoma peritonei** is a rare neoplastic condition involving mucinous ascites and peritoneal implants, for which **cytoreductive surgery** and **hyperthermic intraperitoneal chemotherapy (HIPEC)** are the primary treatments, not splenectomy. * While trauma and hypersplenism are valid indications, including pseudomyxoma peritonei makes this option incorrect. *1, 2 and 3* * **Pseudomyxoma peritonei** is not an indication for splenectomy; its treatment focuses on removing mucinous tumors and affected peritoneal surfaces. * While trauma and ITP are valid indications, the inclusion of pseudomyxoma peritonei makes this option incorrect. *1, 3 and 4* * **Pseudomyxoma peritonei** is not a standard indication for splenectomy, as it requires specialized peritoneal surface malignancy treatment. * While ITP and hypersplenism are valid indications, the inclusion of pseudomyxoma peritonei makes this option incorrect.

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