Minimally Invasive Approaches in Cancer Surgery — MCQs
Radiotherapy is most useful in:
Discectomy can be performed using:
Local excision in rectal cancer is done in all, except:
Gold standard investigation for breast carcinoma screening in a patient with silicone breast implants
Abbreviated laparotomy done for:
What is the primary aim of performing an abbreviated laparotomy in trauma surgery?
What is the use of the instrument shown in the image?
Treatment of resectable T4N0M0 stage of head and neck carcinoma is?
Best treatment strategy for carcinoma of the anal canal:
Management of RCC less than 4 cm in size:
Minimally Invasive Approaches in Cancer Surgery Indian Medical PG Practice Questions and MCQs
Question 1: Radiotherapy is most useful in:
- A. Melanoma
- B. Pancreatic carcinoma
- C. Osteosarcoma
- D. Seminoma (Correct Answer)
Explanation: ***Seminoma*** - **Seminoma** is a highly **radiosensitive** tumor, making radiotherapy a cornerstone of its treatment, especially for localized disease and in adjuvant settings. - Due to its chemosensitivity and radiosensitivity, even advanced seminoma often responds well to treatment, leading to **high cure rates**. *Melanoma* - **Melanoma** is generally considered **radioresistant**, meaning that it does not respond well to conventional doses of radiation. - Treatment primarily involves **surgical excision**, immunotherapy, and targeted therapies. *Pancreatic carcinoma* - **Pancreatic carcinoma** is notoriously **radioresistant** and has a poor prognosis, with limited effectiveness of standalone radiation therapy. - Treatment often involves a combination of **surgery**, chemotherapy, and sometimes concurrent chemoradiation, though outcomes remain challenging. *Osteosarcoma* - **Osteosarcoma** is primarily managed with **surgical resection** and **neoadjuvant/adjuvant chemotherapy**, as it is relatively radioresistant. - Radiotherapy is typically reserved for unresectable tumors, palliative care, or when surgery is contraindicated.
Question 2: Discectomy can be performed using:
- A. Open surgery
- B. Microdiscectomy
- C. Endoscopic approach
- D. All of the options (Correct Answer)
Explanation: ***All of the options*** - **Discectomy** can be performed through various surgical approaches, including open surgery, minimally invasive techniques using a microscope, and endoscopic procedures. - The choice of method depends on factors such as the **location and size of the disc herniation**, patient anatomy, and surgeon’s preference and expertise. *Open surgery* - This involves a larger incision to directly visualize and access the spinal structures and remove the **herniated disc material**. - While effective, it typically involves more muscle dissection, leading to increased **postoperative pain** and a longer recovery time compared to minimally invasive approaches. *Microscope* - **Microdiscectomy** uses a surgical microscope to provide magnified visualization of the surgical field through a smaller incision. - This minimally invasive approach reduces tissue dissection, leading to less pain, smaller scars, and **faster recovery** than traditional open surgery. *Endoscope* - **Endoscopic discectomy** utilizes a small camera (endoscope) inserted through a tiny incision, allowing the surgeon to view the surgical area on a monitor. - This is a highly minimally invasive technique that typically results in even **less tissue damage** and a quicker return to normal activities compared to microdiscectomy.
Question 3: 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 4: Gold standard investigation for breast carcinoma screening in a patient with silicone breast implants
- A. Mammography
- B. CT scan
- C. USG
- D. MRI (Correct Answer)
Explanation: ***MRI*** - **MRI** is considered the **gold standard** for breast cancer screening in patients with silicone breast implants due to its superior ability to visualize breast tissue through the implant and detect subtle lesions. - It offers **high sensitivity** in detecting both implant rupture and early malignancies, often providing better clarity than mammography in augmented breasts where implants can obscure tissue. *Mammography* - While a standard screening tool, **mammography** can be limited in patients with silicone implants because the implants can **obscure adjacent breast tissue**, making detection of small masses challenging. - Special views (e.g., **Eklund views**) can be used, but sensitivity is still reduced compared to MRI in augmented breasts. *CT scan* - **CT scans** are not routinely used for primary breast cancer screening due to their use of **ionizing radiation** and lower sensitivity for detecting early breast lesions compared to MRI. - CT is more commonly used for **staging** advanced cancers or evaluating complex masses detected by other modalities. *USG* - **Ultrasound (USG)** is a valuable complementary tool, especially for evaluating palpable lumps or clarifying findings from mammography, but it is **operator-dependent** and has a lower overall sensitivity for general screening compared to MRI. - It is particularly useful for differentiating between **cystic and solid masses** and detecting implant ruptures but is not the gold standard for comprehensive screening in augmented breasts.
Question 5: Abbreviated laparotomy done for:
- A. Hemodynamically stable patients with minor trauma
- B. Damage control in hemodynamically unstable trauma patients (Correct Answer)
- C. Elective abdominal surgeries
- D. Early wound healing promotion
Explanation: ***Damage control in hemodynamically unstable trauma patients*** - **Abbreviated laparotomy** is a key component of **damage control surgery**, primarily indicated for hemodynamically unstable trauma patients. - The goal is to rapidly control life-threatening issues like hemorrhage and contamination, then temporarily close the abdomen for physiologic stabilization before definitive repair. *Hemodynamically stable patients with minor trauma* - These patients typically do not require prompt surgical intervention; their injuries can often be managed non-operatively or with standard surgical techniques. - An abbreviated laparotomy is an aggressive approach reserved for severe, life-threatening scenarios, not minor trauma in stable patients. *Elective abdominal surgeries* - Elective surgeries are planned procedures performed on stable patients with no immediate life-threatening conditions. - They allow for complete surgical repair in a single setting, which is the opposite of the staged approach of an abbreviated laparotomy. *Early wound healing promotion* - The focus of an abbreviated laparotomy is on resuscitation and source control, not primarily on wound healing. - The initial closure is temporary, often leaving the wound open, which is not conducive to early, primary wound healing.
Question 6: What is the primary aim of performing an abbreviated laparotomy in trauma surgery?
- A. Definitive repair of all injuries
- B. Reduction of contamination
- C. Rapid stabilization of the patient
- D. Haemostasis (Correct Answer)
Explanation: ***Haemostasis*** - The primary aim of abbreviated laparotomy (damage control surgery) is to achieve **rapid control of life-threatening hemorrhage**. - This involves temporary measures to stop bleeding from major vessels and solid organ injuries, preventing exsanguination and further physiological deterioration. - **Damage control prioritizes hemorrhage control over definitive repair**, using techniques like packing, shunts, and temporary vessel ligation. *Definitive repair of all injuries* - This is specifically **NOT** the goal of abbreviated laparotomy. - Definitive repairs are **delayed** until the patient is physiologically stable (after resuscitation in ICU). - Attempting complete repair in an unstable patient leads to the "lethal triad" (hypothermia, acidosis, coagulopathy). *Reduction of contamination* - While contamination control is an **important component** of damage control surgery, it is typically **secondary to hemorrhage control**. - The sequence prioritizes stopping bleeding first, then controlling contamination from bowel injuries. *Rapid stabilization of the patient* - This is the **overall goal** of damage control surgery but not the specific primary aim of the laparotomy itself. - Stabilization is achieved **through** specific interventions during the abbreviated laparotomy, primarily haemostasis and contamination control.
Question 7: What is the use of the instrument shown in the image?
- A. Laparoscopic sterilization (Correct Answer)
- B. Surgical removal of ectopic pregnancy
- C. Induction of abortion
- D. Creating pneumoperitoneum for laparoscopic procedures
Explanation: ***Laparoscopic sterilization*** - The image depicts a **laparoscopic clip applicator**, specifically designed for placing clips on structures like the **fallopian tubes** during laparoscopic sterilization procedures. - This instrument is used to permanently occlude the fallopian tubes, preventing the passage of eggs and sperm for effective **contraception**. *Surgical removal of ectopic pregnancy* - While an ectopic pregnancy can be removed laparoscopically, the instrument shown is a **clip applicator**, not typically used for dissecting or excising tissue in such a procedure. - Surgical removal of an ectopic pregnancy often involves **laparoscopic salpingostomy** or **salpingectomy**, which require cutting, grasping, and coagulating instruments. *Induction of abortion* - **Abortion induction** is typically performed using medical methods (medications) or surgical procedures like **dilation and curettage (D&C)** or **manual vacuum aspiration (MVA)**, none of which involve the specific instrument shown. - This instrument is designed for **occlusion** rather than tissue removal related to abortion. *Creating pneumoperitoneum for laparoscopic procedures* - **Pneumoperitoneum** is created using a **Veress needle** to insufflate carbon dioxide into the abdominal cavity, providing a working space for laparoscopic instruments. - The instrument shown is a **clip applicator**, not a needle for gas insufflation.
Question 8: Treatment of resectable T4N0M0 stage of head and neck carcinoma is?
- A. Radiotherapy alone
- B. Surgery and Radiotherapy (Correct Answer)
- C. Chemoradiation
- D. Surgery alone
Explanation: ***Surgery and Radiotherapy*** - For **resectable T4N0M0 head and neck carcinoma**, the standard treatment is **surgical resection** of the primary tumor followed by **adjuvant radiotherapy**. - This approach achieves optimal **local control** for advanced primary tumors without nodal involvement. - **Adjuvant radiotherapy** is essential for T4 tumors due to high risk of microscopic residual disease and local recurrence. - Surgery allows for complete tumor removal with negative margins, while radiotherapy addresses subclinical disease. *Radiotherapy alone* - Radiotherapy alone is **insufficient as monotherapy** for T4 tumors due to the large tumor burden and extensive local invasion. - Single modality radiation cannot reliably achieve adequate tumor control for advanced primary lesions. - Generally reserved for early-stage disease or patients unfit for surgery. *Chemoradiation* - **Definitive chemoradiation** is an alternative for **unresectable T4 tumors** or when organ preservation is desired (e.g., laryngeal cancer). - For **resectable** T4N0M0 disease, surgery with adjuvant RT is preferred as it provides better local control and allows pathological staging. - Chemoradiation may be used postoperatively if high-risk features are found (positive margins, perineural invasion, extranodal extension). - In this **N0 case with resectable tumor**, upfront surgery is the preferred initial approach. *Surgery alone* - While surgical resection is crucial for T4 tumors, **surgery alone is inadequate** due to high risk of locoregional recurrence. - T4 classification indicates extensive local invasion, necessitating **adjuvant radiotherapy** to eradicate microscopic disease. - Combined modality treatment (surgery + RT) significantly improves local control and survival compared to surgery alone.
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: 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.
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