Oncological Surgery — MCQs

A 50-year-old male patient presented with progressive dysphagia for 4 months, more pronounced for solids than liquids. He also reported significant weight loss, loss of appetite, odynophagia, a hoarse voice, and cervical lymphadenopathy. Upper GI endoscopy and barium studies were performed, and a biopsy of the lesion was sent for HPE. All of the following are risk factors for the suspected condition, except:

Q97Medium

What is the standard treatment for Hodgkin's disease of the stomach?

Q98Medium

A 50-year-old lady presents with a thyroid swelling diagnosed as papillary carcinoma. The mass measures 4 cm at its greatest diameter and invades strap muscles. Lymph node status is negative. What is the stage of the disease?

Q99Medium

A patient with oral cancer has an ipsilateral lymph node measuring 2 cm, single in number with capsular spread. According to TNM staging, what is this classified as?

Q100Medium

The prognosis of rhabdomyosarcoma is likely to be poor if the site of the tumor is?

Oncological Surgery Indian Medical PG Practice Questions and MCQs

Question 91: What is the most common site for metastasis from carcinoma of the cheek?

A. Brain
B. Regional lymph nodes (Correct Answer)
C. Lung
D. Liver

Explanation: **Explanation:** **1. Why Regional Lymph Nodes is Correct:** Carcinoma of the cheek (most commonly **Squamous Cell Carcinoma**) primarily spreads via the **lymphatic route**. In head and neck cancers, regional lymph node involvement is the most significant prognostic factor and the most common site of initial metastasis. Specifically, for the cheek (buccal mucosa), the primary drainage is to the **Submandibular (Level IB)** and **Upper Deep Cervical (Level II)** lymph nodes. Because the oral cavity is rich in lymphatic plexuses, early micrometastasis to these nodes is frequent, often occurring before any distant hematogenous spread. **2. Why the Other Options are Incorrect:** * **Lung (C):** While the lung is the most common site for *distant* (hematogenous) metastasis in head and neck cancers, it occurs much less frequently and usually much later in the disease progression compared to regional nodal spread. * **Liver (D) & Brain (A):** These are rare sites for metastasis from oral cavity cancers. They typically only occur in advanced, terminal stages of the disease after the cancer has already spread to the lungs. **3. Clinical Pearls for NEET-PG:** * **Most common site of oral cancer in India:** Buccal mucosa (often associated with betel nut/tobacco chewing, known as the "Indian Oral Carcinoma"). * **Staging:** The presence of a single positive regional lymph node (N1) significantly decreases the 5-year survival rate by nearly 50%. * **Skip Metastasis:** Occasionally, buccal carcinoma can skip Level I and present directly in Level II nodes. * **Distant Metastasis:** If a question specifically asks for the most common site of **distant** metastasis, the answer is **Lung**. If it asks for the most common site of **overall** metastasis, the answer is **Regional Lymph Nodes**.

Question 92: Which of the following is NOT a risk factor for gallbladder cancer?

A. Adenomyosis (Correct Answer)
B. Absence of bile duct stones
C. Gallstones
D. Adenomatous polyps

Explanation: **Explanation:** Gallbladder cancer (GBC) is the most common biliary tract malignancy, often associated with chronic inflammation. Understanding the distinction between premalignant conditions and benign variants is crucial for NEET-PG. **Why Adenomyosis is the Correct Answer:** **Adenomyosis** (or Adenomyomatosis) is a benign condition characterized by the overgrowth of the mucosa, thickening of the muscular wall, and the formation of intramural diverticula known as **Rokitansky-Aschoff sinuses**. Current surgical consensus and various longitudinal studies indicate that adenomyosis is **not** a premalignant condition and does not significantly increase the risk of GBC. Therefore, it does not require prophylactic cholecystectomy unless symptomatic. **Analysis of Incorrect Options:** * **Gallstones (Cholelithiasis):** This is the most significant risk factor. Large stones (>3 cm) increase the risk by 10-fold due to chronic mucosal irritation. * **Adenomatous Polyps:** While most GB polyps are cholesterol-based (benign), true adenomatous polyps have a definite malignant potential, especially if they are >10 mm in size. * **Absence of bile duct stones:** This option is technically a distractor in the question's phrasing, but in the context of GBC risk factors, **Anomalous Pancreaticobiliary Duct Junction (APBDJ)**—where the pancreatic duct joins the bile duct outside the duodenal wall—is a major risk factor. This allows pancreatic juice to reflux into the gallbladder, causing chronic inflammation even in the *absence* of stones. **High-Yield Clinical Pearls for NEET-PG:** * **Porcelain Gallbladder:** Intramural calcification of the GB wall; historically cited as high risk, though recent data suggests a lower (but still present) risk of 5-7%. * **Salmonella typhi:** Chronic carrier state in the gallbladder is a strong risk factor for GBC. * **Epidemiology:** GBC is more common in females and shows a high geographic prevalence in North India (Gangetic belt). * **Staging:** Most GBCs are diagnosed at an advanced stage; the most common histological type is **Adenocarcinoma**.

Question 93: Osseous metastasis is most common if the primary tumor is in which organ?

A. Bronchus (Correct Answer)
B. Colon
C. Pancreas
D. Adrenal

Explanation: **Explanation:** The correct answer is **Bronchus (Option A)**. Among the options provided, lung cancer (bronchogenic carcinoma) is the most common primary tumor to metastasize to the bone. **Why Bronchus is Correct:** Bone is the third most common site for cancer metastasis after the lung and liver. In clinical practice, the primary tumors most notorious for osseous metastasis are **Prostate, Breast, Lung (Bronchus), Kidney (RCC), and Thyroid** (Mnemonic: **PB-KLT**). Bronchogenic carcinoma frequently spreads via the systemic circulation to the axial skeleton (vertebrae, ribs, and pelvis). It is a leading cause of osteolytic lesions and is often the most common primary found in males presenting with bone metastasis when the prostate is excluded. **Why Other Options are Incorrect:** * **Colon (Option B):** Colorectal cancers primarily metastasize to the **liver** via the portal venous system. Bone metastasis is rare and usually occurs only in advanced stages after liver involvement. * **Pancreas (Option C):** Pancreatic adenocarcinoma typically spreads to the **liver and peritoneum**. Bone involvement is uncommon. * **Adrenal (Option D):** While Neuroblastoma (an adrenal tumor in children) frequently involves bone, in the general oncological context, primary adrenal cortical carcinomas are rare and do not represent the most common source of osseous spread compared to the bronchus. **High-Yield Clinical Pearls for NEET-PG:** * **Most common source of bone metastasis:** In females, it is **Breast**; in males, it is **Prostate**. * **Nature of lesions:** Prostate cancer typically causes **osteoblastic** (sclerotic) lesions, while Lung and Kidney cancers cause **osteolytic** (destructive) lesions. Breast cancer can be mixed. * **Most common site of bone metastasis:** The **Vertebral column** (specifically the lumbar spine) is the most frequent site due to the Batson venous plexus. * **Batson Venous Plexus:** A valveless communication between the pelvic/thoracic veins and the vertebral venous plexus that allows for retrograde spread of tumor cells without passing through the lungs.

Question 94: What is the most important prognostic factor for cancer of the esophagus?

A. Length of tumor growth
B. Depth of tumor involvement (Correct Answer)
C. Histological grade of the tumor
D. Immunohistochemical markers

Explanation: **Explanation:** The prognosis of esophageal cancer is primarily determined by the **TNM staging system**. Among the options provided, the **depth of tumor involvement (T-stage)** is the most significant prognostic factor. **Why Depth of Involvement is Correct:** The esophagus lacks a serosal layer (except for the intra-abdominal portion), which facilitates early transmural spread. The depth of invasion into the wall (mucosa, submucosa, muscularis propria, or adventitia) directly correlates with the likelihood of lymph node metastasis and distant spread. For instance, while T1a (mucosa) tumors have a low risk of nodal spread (<5%), T1b (submucosa) tumors see a significant jump in risk (approx. 20%), drastically altering the 5-year survival rate. **Analysis of Incorrect Options:** * **Length of tumor growth:** While a tumor length >5 cm often suggests advanced disease and poor resectability, it is not as reliable or standardized a prognostic indicator as the depth of invasion. * **Histological grade:** While high-grade (poorly differentiated) tumors are more aggressive, the anatomical extent (Stage) remains a more powerful predictor of survival than the grade alone. * **Immunohistochemical (IHC) markers:** Markers like HER2 or PD-L1 are vital for guiding targeted therapy and immunotherapy, but they do not supersede anatomical staging in determining overall prognosis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Middle third (Squamous Cell Carcinoma); Lower third (Adenocarcinoma). * **Lymphatic spread:** The esophagus has a rich submucosal lymphatic plexus, leading to "skip metastasis." * **Investigation of choice for T-staging:** Endoscopic Ultrasound (EUS) is the most accurate modality for determining the depth of invasion. * **Most important overall prognostic factor:** While T-stage is crucial, if **Lymph node involvement (N-stage)** is present, it becomes the single most important predictor of poor survival. However, among the given options, depth is the correct choice.

Question 95: What is the primary treatment for Medullary Carcinoma of the thyroid?

A. Surgery and radiotherapy
B. Radiotherapy and chemotherapy
C. Surgery only (Correct Answer)
D. Radioiodine ablation

Explanation: **Explanation:** **Medullary Thyroid Carcinoma (MTC)** arises from the **parafollicular C-cells**, which are neuroendocrine in origin. Unlike follicular cells, C-cells do not concentrate iodine, making MTC fundamentally different from papillary or follicular thyroid cancers. **Why "Surgery Only" is correct:** The primary and only curative treatment for MTC is **Total Thyroidectomy with Central Compartment Neck Dissection (Level VI)**. Because MTC is highly resistant to both radiotherapy and chemotherapy, and does not respond to radioiodine, surgical clearance of the primary tumor and involved lymph nodes is the mainstay of management. **Why other options are incorrect:** * **Radiotherapy and Chemotherapy (A & B):** MTC is notoriously **radioresistant** and **chemoresistant**. These modalities are reserved only for palliative care in advanced, metastatic, or unresectable disease and are never the primary treatment. * **Radioiodine Ablation (D):** Since C-cells do not express the sodium-iodide symporter (NIS), they **do not take up Iodine-131**. Therefore, radioiodine therapy has no role in the management of MTC. **High-Yield Clinical Pearls for NEET-PG:** 1. **Tumor Marker:** Serum **Calcitonin** (used for diagnosis and monitoring recurrence) and CEA. 2. **Genetics:** 25% are familial (MEN 2A/2B syndromes) due to **RET proto-oncogene** mutations. Prophylactic thyroidectomy is indicated in carriers. 3. **Pre-op Screening:** Always rule out **Pheochromocytoma** (by checking urinary metanephrines) before surgery to avoid a hypertensive crisis. 4. **Amyloid Staining:** Histology shows nests of cells with **Congo Red-positive** amyloid stroma.

Question 96: A 50-year-old male patient presented with progressive dysphagia for 4 months, more pronounced for solids than liquids. He also reported significant weight loss, loss of appetite, odynophagia, a hoarse voice, and cervical lymphadenopathy. Upper GI endoscopy and barium studies were performed, and a biopsy of the lesion was sent for HPE. All of the following are risk factors for the suspected condition, except:

A. Smoking
B. Plummer-Vinson syndrome
C. Achalasia cardia
D. Barrett's esophagus (Correct Answer)

Explanation: ### Explanation The clinical presentation—progressive dysphagia (solids > liquids), weight loss, hoarse voice (suggesting recurrent laryngeal nerve involvement), and cervical lymphadenopathy—strongly points toward **Squamous Cell Carcinoma (SCC)** of the esophagus, typically involving the upper or middle third. **1. Why Barrett’s Esophagus is the Correct Answer:** Barrett’s esophagus is a metaplastic change (stratified squamous to columnar epithelium) resulting from chronic GERD. It is the primary precursor for **Adenocarcinoma**, not Squamous Cell Carcinoma. Since the clinical features (hoarseness and cervical nodes) suggest a proximal/mid-esophageal lesion, SCC is the diagnosis, making Barrett’s the "except" option. **2. Analysis of Incorrect Options (Risk Factors for SCC):** * **Smoking:** A major risk factor for SCC. Tobacco contains nitrosamines that are directly carcinogenic to the esophageal squamous lining. * **Plummer-Vinson Syndrome:** Characterized by the triad of iron-deficiency anemia, esophageal webs, and glossitis. It carries a high risk of developing SCC in the post-cricoid region. * **Achalasia Cardia:** Chronic stasis of food leads to esophagitis and mucosal irritation, increasing the risk of SCC (usually after 15–20 years of disease). **3. NEET-PG High-Yield Pearls:** * **Most common site:** Worldwide, SCC is most common in the **middle third**; Adenocarcinoma is most common in the **lower third**. * **Most common histological type:** Globally, SCC is most common; however, in Western countries, Adenocarcinoma is rising. * **Tylosis (Palmar-plantar keratoderma):** An autosomal dominant condition with nearly 100% lifetime risk of esophageal SCC. * **Investigation of choice:** Upper GI Endoscopy + Biopsy. * **Staging:** EUS (Endoscopic Ultrasound) is best for T and N staging; PET-CT is best for distant metastasis (M).

Question 97: What is the standard treatment for Hodgkin's disease of the stomach?

A. Gastric resection
B. Gastric resection and chemotherapy
C. Purely medical treatment
D. None of the above (Correct Answer)

Explanation: ### Explanation The management of primary gastric lymphoma has shifted dramatically from surgical to medical intervention. The correct answer is **None of the above** because the standard of care for Hodgkin’s disease (and most Non-Hodgkin Lymphomas) of the stomach is now **Chemotherapy and/or Radiotherapy**, without routine surgical resection. **1. Why "None of the above" is correct:** Historically, surgery was performed to prevent complications like perforation or bleeding. However, modern clinical trials have proven that Hodgkin’s disease is highly radiosensitive and chemosensitive. The current gold standard is systemic chemotherapy (e.g., ABVD regimen) with or without involved-site radiation. Surgery is reserved only for life-threatening complications (refractory bleeding or perforation). **2. Why the other options are incorrect:** * **Option A & B (Gastric Resection):** Routine resection is no longer recommended. It does not improve survival compared to medical therapy alone and carries significant morbidity (post-gastrectomy syndrome, nutritional deficiencies). * **Option C (Purely medical treatment):** While medical treatment is the mainstay, the term "purely" is often considered absolute in medical exams. Furthermore, the standard management of gastric lymphoma often involves a multidisciplinary approach including staging laparotomy (historically) or specific imaging/endoscopy protocols. **Clinical Pearls for NEET-PG:** * **Most common site** of extranodal lymphoma is the **Stomach**. * **Most common type** of gastric lymphoma is **MALToma** (associated with *H. pylori*) or **DLBCL**. * **Hodgkin’s Disease** of the stomach is extremely rare compared to Non-Hodgkin Lymphoma. * **Treatment of MALToma:** Triple therapy for *H. pylori* eradication is the first-line treatment for low-grade MALT lymphoma. * **Surgery's Role:** Currently limited to "Salvage Surgery" for complications.

Question 98: A 50-year-old lady presents with a thyroid swelling diagnosed as papillary carcinoma. The mass measures 4 cm at its greatest diameter and invades strap muscles. Lymph node status is negative. What is the stage of the disease?

A. Stage I (Correct Answer)
B. Stage II
C. Stage III
D. Stage IV

Explanation: ### **Explanation** The staging of **Differentiated Thyroid Carcinoma (DTC)**, which includes Papillary and Follicular types, is unique because it is heavily dependent on the **age of the patient** at the time of diagnosis. According to the **AJCC 8th Edition** TNM staging system: **1. Why Stage I is Correct:** For patients **younger than 55 years**, the staging is simplified into only two categories: * **Stage I:** Any T, Any N, **M0** (No distant metastasis). * **Stage II:** Any T, Any N, **M1** (Distant metastasis present). In this case, the patient is **50 years old** (under the 55-year cutoff). Although the tumor is 4 cm and invades strap muscles (T3b), and regardless of the lymph node status (N0), the absence of distant metastasis (M0) automatically classifies this as **Stage I**. **2. Why Other Options are Incorrect:** * **Stage II:** In patients <55 years, this is reserved only for cases with distant metastasis (e.g., lung or bone spread). In patients ≥55 years, Stage II involves T1/T2 with N1 or T3 tumors. * **Stage III & IV:** These stages **do not exist** for patients under the age of 55 in the AJCC 8th edition. They are only applicable to patients ≥55 years with advanced local invasion (T4) or distant metastasis. **3. NEET-PG High-Yield Pearls:** * **Age Cutoff:** The AJCC 8th edition increased the prognostic age cutoff from **45 to 55 years**. * **T3b Definition:** Invasion of **strap muscles only** (sternohyoid, sternothyroid, thyrohyoid, or omohyoid) is classified as T3b. * **Prognosis:** Papillary carcinoma has an excellent prognosis; patients <55 years have a near 0% 10-year mortality rate if they are M0. * **Anaplastic Carcinoma:** Always remember that Anaplastic thyroid cancer is considered **Stage IV** regardless of age or size at presentation.

Question 99: A patient with oral cancer has an ipsilateral lymph node measuring 2 cm, single in number with capsular spread. According to TNM staging, what is this classified as?

A. Nx
B. N1
C. N2
D. N3 (Correct Answer)

Explanation: ### Explanation The correct answer is **N3** (specifically **N3a** or **N3b** depending on the presence of Extranodal Extension). #### 1. Why N3 is Correct According to the **AJCC 8th Edition** for Oral Cavity Cancers, the staging of cervical lymph nodes has been updated to include **Extranodal Extension (ENE)**, also known as capsular spread. * **Clinical N3b:** Defined as a single or multiple nodes with **clinically positive ENE**. * **Pathological N3b:** Defined as a single or multiple nodes with **pathologically proven ENE**. Even though the node is single and only 2 cm (which would traditionally be N1), the presence of **capsular spread (ENE)** automatically upgrades the stage to **N3b**. ENE is a significant prognostic factor indicating a higher risk of regional recurrence and distant metastasis. #### 2. Why Other Options are Wrong * **Nx:** This is used when regional lymph nodes cannot be assessed. In this case, the node has been measured and evaluated. * **N1:** This is a single ipsilateral node $\leq$ 3 cm **without** extranodal extension. * **N2:** This category includes nodes between 3–6 cm, or multiple nodes, but specifically **without** extranodal extension. #### 3. High-Yield Clinical Pearls for NEET-PG * **ENE Definition:** Extension of tumor through the lymph node capsule into the surrounding connective tissue. * **AJCC 7th vs 8th Edition:** The most critical change in the 8th edition for Head and Neck cancers is the incorporation of **ENE** into N-staging and **Depth of Invasion (DOI)** into T-staging. * **N3a:** A node > 6 cm without ENE. * **N3b:** Any node (regardless of size or number) with ENE. * **Management:** The presence of ENE is an absolute indication for **adjuvant chemoradiotherapy** post-surgery.

Question 100: The prognosis of rhabdomyosarcoma is likely to be poor if the site of the tumor is?

A. Orbit
B. Paratesticular
C. Extremity (Correct Answer)
D. Urinary bladder

Explanation: **Explanation:** The prognosis of Rhabdomyosarcoma (RMS) is heavily influenced by the primary site of the tumor, which is a key component of the **Intergroup Rhabdomyosarcoma Study (IRS) Grouping System**. **Why Extremity is the Correct Answer:** Tumors located in the **extremities** are classified as **unfavorable sites**. These lesions are often associated with the **Alveolar histological subtype** (which carries a worse prognosis than the Embryonal type) and have a higher propensity for early lymphatic and hematogenous metastasis. Additionally, achieving wide surgical margins in the limbs can be challenging without significant functional loss. **Analysis of Incorrect Options:** * **Orbit (A):** This is considered a **favorable site**. Although it lacks a lymphatic supply (making nodal spread rare), tumors here present early due to proptosis, leading to early diagnosis and excellent cure rates. * **Paratesticular (B):** This is a **favorable site**. These are usually of the Embryonal subtype and are typically detected early as a painless scrotal mass. * **Urinary Bladder (D):** While the bladder/prostate region is generally considered "unfavorable" compared to the orbit, the **extremity** consistently carries a poorer prognosis in clinical staging systems. **High-Yield Clinical Pearls for NEET-PG:** * **Most common soft tissue sarcoma in children:** Rhabdomyosarcoma. * **Favorable Sites:** Orbit, Non-parameningeal Head & Neck, Genitourinary (excluding bladder/prostate), and Biliary tract. * **Unfavorable Sites:** Extremities, Bladder, Prostate, and Parameningeal areas (e.g., nasopharynx, middle ear). * **Histology:** **Embryonal** is the most common and has a better prognosis; **Alveolar** is more common in extremities and has a worse prognosis. * **Genetic Marker:** Alveolar RMS is associated with **t(2;13)** or **t(1;13)** translocations involving the *PAX-FOXO1* gene fusion.

Practice by Chapter

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