Metastasectomy — MCQs
Which of the following factors is not included in the MACIS score used for the prognosis of papillary thyroid cancer?
Which of the following is the platinum-based chemotherapeutic agent used as first-line treatment for ovarian carcinoma?
Which nerve is most commonly injured during submandibular gland surgery?
Which statement is incorrect about the pathology of the bone tumor?
In prostatic metastasis, the site most commonly involved is which one?
What is the median survival time for patients with carcinoma of the pancreas after surgery and adjuvant therapy?
Which histological type of lung cancer is most commonly associated with metastasis?
Which of the following requires the maximum margin of excision?
The staging system for thymoma was developed by whom?
What is the recommended treatment for papillary carcinoma of the thyroid with bony metastasis?
Metastasectomy Indian Medical PG Practice Questions and MCQs
Question 1: 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 2: Which of the following is the platinum-based chemotherapeutic agent used as first-line treatment for ovarian carcinoma?
- A. Cyclophosphamide
- B. Methotrexate
- C. Cisplatin (Correct Answer)
- D. Dacarbazine
Explanation: ***Cisplatin*** - **Cisplatin** is a platinum-based chemotherapy drug that forms **DNA cross-links**, inhibiting DNA synthesis and leading to the death of rapidly dividing cells, making it highly effective against **ovarian carcinoma**. - It is a cornerstone of chemotherapy regimens for ovarian cancer, often used in combination with other agents such as paclitaxel. *Methotrexate* - **Methotrexate** is an **antimetabolite** that inhibits dihydrofolate reductase, thereby interfering with DNA synthesis. - While it is used in various cancers like leukemia, lymphoma, and some solid tumors (e.g., breast cancer, gestational trophoblastic disease), it is **not a primary recommended drug for ovarian carcinoma**. *Cyclophosphamide* - **Cyclophosphamide** is an **alkylating agent** that causes DNA damage, leading to cell death. - It is used in many cancers, including lymphoma, breast cancer, and some leukemias, but it is **not a first-line or primary agent for ovarian carcinoma** in contemporary treatment guidelines. *Dacarbazine* - **Dacarbazine** is an **alkylating agent** primarily used in the treatment of **malignant melanoma** and Hodgkin lymphoma. - It is **not indicated for the treatment of ovarian carcinoma**.
Question 3: Which nerve is most commonly injured during submandibular gland surgery?
- A. Lingual nerve
- B. Marginal mandibular branch of facial nerve (Correct Answer)
- C. Mylohyoid nerve
- D. Hypoglossal nerve
Explanation: ***Marginal mandibular branch of facial nerve*** - The **marginal mandibular nerve** courses superficially over and along the superior border of the submandibular gland, making it the **most vulnerable** structure during surgery - It is at highest risk during elevation of the gland, ligation of the facial vessels, and dissection near the gland's superior border - Injury leads to **weakness or paralysis of the depressor muscles of the lower lip** (depressor anguli oris and depressor labii inferioris), causing an asymmetric smile and difficulty with lip movements - This is the **most common nerve injury** in submandibular gland surgery due to its superficial anatomical position *Incorrect: Lingual nerve* - The **lingual nerve** passes medial to the submandibular duct and deep to the gland - While it can be injured during dissection of the submandibular duct or deeper aspects of the gland, it is **less commonly injured** than the marginal mandibular nerve - Damage results in **loss of taste and general sensation** to the anterior two-thirds of the tongue on the ipsilateral side *Incorrect: Mylohyoid nerve* - The **mylohyoid nerve** travels on the inferior surface of the mylohyoid muscle, generally beneath and protected by this muscle - It supplies the mylohyoid and anterior belly of the digastric muscles - Injury is **uncommon** during routine submandibular gland excision due to its protected anatomical position *Incorrect: Hypoglossal nerve* - The **hypoglossal nerve** lies deep and inferior to the submandibular gland - It supplies motor innervation to the intrinsic and extrinsic muscles of the tongue - It is the **least commonly injured** nerve as it is well-protected by its deep position, unless dissection is carried excessively deep or inferiorly
Question 4: 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 5: In prostatic metastasis, the site most commonly involved is which one?
- A. Perivesical nodes
- B. Obturator nodes (Correct Answer)
- C. Pre-sacral nodes
- D. Para-aortic nodes
Explanation: ***Obturator nodes*** - The **obturator nodes** are a primary site for metastatic spread from the prostate due to their close proximity and direct lymphatic drainage pathways. - Prostate cancer cells often spread via the **lymphatic system** to regional lymph nodes before disseminating to distant sites. **Perivesical nodes** * While also regional, perivesical nodes are less frequently the _initial_ or most common site of metastasis compared to the obturator and internal iliac nodes. * Lymphatic drainage from the prostate primarily follows pathways that lead to obturator and internal iliac nodes first. **Pre-sacral nodes** * Pre-sacral nodes are considered more distant regional nodes compared to the obturator nodes and are typically involved later in the metastatic process. * Their involvement often indicates a more advanced stage of nodal metastasis. **Para-aortic nodes** * Para-aortic nodes are considered distant metastases for prostate cancer, indicating widespread disease. * Metastasis to para-aortic nodes usually occurs after involvement of more proximal regional nodes like the obturator and internal iliac nodes.
Question 6: What is the median survival time for patients with carcinoma of the pancreas after surgery and adjuvant therapy?
- A. Approximately 12 months
- B. Approximately 32 months
- C. Approximately 22 months (Correct Answer)
- D. Approximately 44 months
Explanation: ***Approximately 22 months*** - The median survival for patients with **resectable pancreatic adenocarcinoma** treated with surgery (typically pancreaticoduodenectomy) and adjuvant chemotherapy is approximately **22-28 months** based on contemporary studies. - The 22-month figure represents a well-established median from multiple clinical trials including **ESPAC-1 and CONKO-001**, making it the most representative answer among the options provided. - This outcome reflects significant improvement from the pre-adjuvant therapy era but still underscores the aggressive biology of pancreatic cancer. *Approximately 12 months* - This figure represents **historical median survival** prior to the routine use of effective adjuvant chemotherapy, or survival in patients with **unresectable locally advanced disease** treated with palliative chemotherapy alone. - It is **not representative** of outcomes in patients who undergo complete surgical resection followed by modern adjuvant therapy. *Approximately 32 months* - While highly selected patients with **favorable tumor biology** (small tumors, negative margins, low CA 19-9) and optimal response to modern regimens like **FOLFIRINOX** may approach this survival, it exceeds the **median survival** for the general population of resected patients. - This represents the upper quartile rather than the median outcome. *Approximately 44 months* - This exceptionally long survival is **not achieved** as a median in pancreatic ductal adenocarcinoma, even with optimal surgical resection and adjuvant therapy. - Such prolonged survival is occasionally seen in **highly selected patients** or with less aggressive pancreatic neoplasms (e.g., neuroendocrine tumors, intraductal papillary mucinous neoplasms with invasive component), which have substantially better prognoses than typical ductal adenocarcinoma.
Question 7: Which histological type of lung cancer is most commonly associated with metastasis?
- A. Small cell carcinoma (Correct Answer)
- B. Squamous cell carcinoma
- C. Adenocarcinoma
- D. Large cell carcinoma
Explanation: ***Squamous cell CA*** - Known for its **aggressive nature** and propensity to metastasize, particularly in later stages. - Typically arises in the **central part of the lungs**, often associated with smoking and leads to local invasion and distant spread. *Alveolar-carcinoma* - Rarely found and tends to be **less aggressive** compared to squamous cell carcinoma. - Usually has a more localized effect without the same potential for widespread metastasis. *Small cell carcinoma* - Although it is **highly metastatic**, it is less common than squamous cell carcinoma in terms of overall lung cancer incidence. - Characterized by its rapid growth and early metastasis [1], but mostly associated with a specific subtype of lung cancer cases. *Adenocarcinoma* - Generally presents as a **peripheral lung lesion** and has **less propensity for early metastasis** compared to squamous cell carcinoma. - More common in non-smokers and tends to have a less aggressive metastatic pattern. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 337-338.
Question 8: 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 9: 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.
Question 10: What is the recommended treatment for papillary carcinoma of the thyroid with bony metastasis?
- A. Radiotherapy
- B. Radioiodine
- C. Near total thyroidectomy with radiotherapy
- D. Near total thyroidectomy with radioiodine and radiotherapy (Correct Answer)
Explanation: ### Explanation The management of differentiated thyroid cancers (DTC), specifically **Papillary Carcinoma Thyroid (PTC)** with distant metastasis, follows a multimodal approach aimed at both local control and systemic treatment. **Why Option D is Correct:** 1. **Near Total or Total Thyroidectomy:** This is the mandatory first step. Removing all normal thyroid tissue is essential to eliminate the source of thyroglobulin (a tumor marker) and, more importantly, to ensure that subsequent doses of radioactive iodine (RAI) are taken up by the metastatic bone lesions rather than the thyroid gland itself. 2. **Radioiodine (I-131) Therapy:** PTC is typically iodine-avid. RAI is the treatment of choice for distant metastases (lung and bone) after the primary gland is removed. 3. **Radiotherapy (EBRT):** Bone metastases in PTC are often osteolytic and carry a high risk of pathological fractures or spinal cord compression. External Beam Radiation Therapy (EBRT) is added for palliation, pain control, and to stabilize the metastatic site. **Analysis of Incorrect Options:** * **Options A & B:** These are incomplete. Surgery is the cornerstone of management for DTC, even in the presence of metastasis, to facilitate adjuvant therapies. * **Option C:** While it includes surgery and radiotherapy, it misses **Radioiodine**, which is the most specific systemic therapy for thyroid cancer cells. **NEET-PG High-Yield Pearls:** * **Most common site of metastasis in PTC:** Cervical lymph nodes (Level II, III, IV). * **Most common site of distant metastasis:** Lungs (more common than bone). * **Prognostic Scoring:** Use the **AMES** or **MACIS** criteria for PTC. * **Thyroglobulin (Tg):** Used as a postoperative tumor marker to monitor recurrence. * **Treatment of choice for Follicular Carcinoma with bone metastasis:** Also Total Thyroidectomy followed by RAI.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free