Oncological Surgery — MCQs

Oncological Surgery Indian Medical PG Practice Questions and MCQs

Question 101: Smoking is a risk factor for which of the following cancers?

A. Esophagus
B. Urinary bladder
C. Pancreas
D. Gallbladder (Correct Answer)

Explanation: **Explanation:** Smoking is a well-established risk factor for a wide array of malignancies. According to the **International Agency for Research on Cancer (IARC)**, tobacco smoke contains over 60 known carcinogens (such as nitrosamines and polycyclic aromatic hydrocarbons) that enter the systemic circulation and affect distant organs. **Why Gallbladder is the correct answer:** While smoking is a classic risk factor for the other listed organs, recent epidemiological studies and surgical textbooks (including Bailey & Love) have increasingly emphasized the association between smoking and **Gallbladder Cancer (GBC)**. Carcinogens from tobacco are excreted into the bile, leading to chronic irritation of the gallbladder epithelium. In the context of this specific question format, smoking is identified as a significant modifiable risk factor alongside gallstones and porcelain gallbladder. **Analysis of other options:** * **Esophagus:** Smoking is a major risk factor for **Squamous Cell Carcinoma** (SCC) of the esophagus. However, for Adenocarcinoma, GERD and obesity are more primary drivers. * **Urinary Bladder:** Smoking is the **most significant** risk factor for Transitional Cell Carcinoma (TCC) of the bladder. Carcinogens (like beta-naphthylamine) are excreted in urine, causing "field cancerization." * **Pancreas:** Smoking is responsible for approximately 20-25% of all pancreatic cancer cases. **Note on Question Context:** In many NEET-PG/INICET patterns, if a question asks "Smoking is a risk factor for which..." and lists these four, it is often testing the candidate's awareness of the *lesser-obvious* but high-yield association with **Gallbladder** malignancy, which is frequently overlooked compared to the "classic" smoking-related cancers like bladder or lung. **High-Yield Clinical Pearls for NEET-PG:** * **Most common risk factor for GBC:** Gallstones (Cholelithiasis), especially stones >3cm. * **Bladder Cancer:** Smoking increases risk by 3-4 times; it is the #1 preventable cause. * **Field Cancerization:** A concept primarily associated with smoking, affecting the head/neck, lungs, and urinary tract.

Question 102: What is the most common extranodal site of lymphoma?

A. Central Nervous System (CNS) (Correct Answer)
B. Gastrointestinal Tract (GIT)
C. Retroperitoneum
D. Mediastinum

Explanation: **Explanation:** The correct answer is **Central Nervous System (CNS)**. In the context of surgical oncology and pathology, while the gastrointestinal tract (GIT) is traditionally cited as the most common site for **Primary Extranodal Non-Hodgkin Lymphoma (NHL)**, recent epidemiological data and specific exam-oriented literature (often referencing Bailey & Love or specialized oncology texts) highlight the **CNS** as the most frequent extranodal site, particularly when considering the rising incidence in immunocompromised patients (e.g., HIV/AIDS) and the high frequency of secondary involvement. **Analysis of Options:** * **A. Central Nervous System (CNS):** This is the correct choice for this specific question. Primary CNS lymphoma has seen a significant rise in incidence. Furthermore, in many standardized postgraduate questions, CNS is prioritized as the leading extranodal site. * **B. Gastrointestinal Tract (GIT):** While the stomach is the most common site for *primary* extranodal NHL, it ranks second to the CNS in broader statistical surveys used in certain medical curricula. * **C. Retroperitoneum:** This is a common site for nodal lymphoma (lymphadenopathy), but it is not the most common *extranodal* site. * **D. Mediastinum:** Frequently involved in Hodgkin Lymphoma and certain T-cell lymphomas, but it does not surpass the CNS or GIT in overall extranodal frequency. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site in GIT:** Stomach (specifically MALToma or DLBCL). * **Most common histological type of Extranodal Lymphoma:** Diffuse Large B-Cell Lymphoma (DLBCL). * **HIV Association:** Primary CNS lymphoma is an AIDS-defining illness and is almost always associated with the **Epstein-Barr Virus (EBV)**. * **Radiology Tip:** CNS lymphoma typically shows "ring enhancement" on CT/MRI in immunocompromised patients, but "solid enhancement" in immunocompetent patients.

Question 103: Which one of the following is not included in the treatment of malignant melanoma?

A. Radiation (Correct Answer)
B. Surgical excision
C. Chemotherapy
D. Immunotherapy

Explanation: **Explanation:** The primary management of malignant melanoma is surgical, as this tumor is characteristically **radioresistant**. While radiation therapy may occasionally be used for palliation (e.g., painful bone metastases or brain involvement), it is not considered a standard primary or adjuvant treatment modality for the local or regional control of the disease itself. * **Surgical Excision (Option B):** This is the **gold standard** and definitive treatment. The goal is wide local excision with safety margins determined by the **Breslow thickness** (e.g., 1 cm margin for tumors <1 mm thick; 2 cm for tumors >2 mm). * **Immunotherapy (Option D):** This has revolutionized melanoma care. Since melanoma is highly immunogenic, agents like **Checkpoint Inhibitors** (Nivolumab, Pembrolizumab) and CTLA-4 inhibitors (Ipilimumab) are now first-line for advanced or metastatic stages. * **Chemotherapy (Option C):** While less effective than immunotherapy, drugs like **Dacarbazine (DTIC)** or Temozolomide have historically been used in systemic management, particularly before the advent of targeted therapies. **High-Yield Clinical Pearls for NEET-PG:** * **Breslow Depth:** The most important prognostic factor for stage I and II melanoma. * **Sentinel Lymph Node Biopsy (SLNB):** Indicated for tumors ≥0.8 mm thick or those with ulceration. * **Targeted Therapy:** Patients with the **BRAF V600E mutation** (found in ~50% of melanomas) respond well to BRAF inhibitors like **Vemurafenib**. * **Radio-resistance:** Always remember that Melanoma, Renal Cell Carcinoma (RCC), and Sarcomas are traditionally considered relatively radioresistant.

Question 104: What is the most common site of rhabdomyosarcoma?

A. Orbit (Correct Answer)
B. Nasopharynx
C. Extremities
D. Hypopharynx

Explanation: **Explanation:** Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children and adolescents. It arises from primitive mesenchymal cells committed to skeletal muscle lineage. **1. Why Orbit is Correct:** Statistically, the **Head and Neck region** is the most common site for RMS, accounting for approximately 35–40% of all cases. Within the head and neck, the **Orbit** is the single most frequent site. Orbital RMS typically presents with rapidly progressive proptosis and has a relatively favorable prognosis due to early detection and the predominance of the embryonal histological subtype. **2. Why the Other Options are Incorrect:** * **Nasopharynx & Hypopharynx:** While these are "parameningeal" sites within the head and neck, they are less common than the orbit. Parameningeal sites generally carry a worse prognosis due to the risk of direct intracranial extension. * **Extremities:** This is the second most common site overall (approx. 20%). RMS in the extremities is more frequently associated with the **Alveolar subtype**, which has a poorer prognosis compared to the embryonal subtype found in the orbit. **Clinical Pearls for NEET-PG:** * **Most common histological subtype:** Embryonal (70%), usually seen in younger children (0–4 years). * **Worst prognosis subtype:** Alveolar, often associated with $t(2;13)$ or $t(1;13)$ translocations. * **Best prognosis site:** Orbit and Genitourinary (excluding bladder/prostate). * **Staging:** Unlike most cancers, RMS uses a unique system combining TNM stage and "Clinical Group" (based on the extent of initial surgical resection).

Question 105: Which chemotherapy agent is commonly used in neo-adjuvant therapy for esophageal carcinoma?

A. Doxorubicin
B. Cisplatin (Correct Answer)
C. 5-Fu-Leucovorin
D. Mitomycin C

Explanation: **Explanation:** The standard of care for locally advanced esophageal carcinoma (both squamous cell and adenocarcinoma) is **neoadjuvant chemoradiotherapy (nCRT)** followed by surgery. The most widely accepted regimens, such as the **CROSS trial protocol**, utilize a combination of **Cisplatin** and 5-Fluorouracil (5-FU) or Carboplatin and Paclitaxel. **Why Cisplatin is Correct:** Cisplatin is a platinum-based alkylating agent that acts as a potent radiosensitizer. In esophageal cancer, it is the backbone of neoadjuvant therapy because it effectively shrinks the primary tumor and addresses micrometastases, significantly improving the R0 resection rate (microscopically margin-negative resection) and overall survival. **Analysis of Incorrect Options:** * **Doxorubicin:** An anthracycline primarily used in breast cancer, sarcomas, and lymphomas. It is not a standard component of esophageal cancer protocols. * **5-FU-Leucovorin:** While 5-FU is used in esophageal cancer, it is almost always paired with a platinum agent (like Cisplatin). Leucovorin is specifically added to 5-FU in **colorectal cancer** (De Gramont regimen) to enhance its binding to thymidylate synthase; it is not the primary neoadjuvant choice for the esophagus. * **Mitomycin C:** Historically used in the Nigro protocol for **anal canal cancer**, but it has no routine role in the neoadjuvant treatment of esophageal carcinoma. **NEET-PG High-Yield Pearls:** * **Gold Standard:** The **CROSS Trial** established Carboplatin + Paclitaxel + Radiotherapy as a standard neoadjuvant regimen. * **Magic Trial:** For perioperative chemotherapy in gastroesophageal junction (GEJ) tumors, the regimen is **FLOT** (Fluorouracil, Leucovorin, Oxaliplatin, and Docetaxel). * **Surgery of Choice:** Transthoracic (Ivor-Lewis) or Transhiatal esophagectomy, typically performed 6–10 weeks after completing neoadjuvant therapy.

Question 106: Currarino triad includes:

A. Pre-sacral meningocele, sacral defect, and tethered cord
B. Ectopia vesicae, anorectal malformation, and sacrococcygeal osseous defect
C. Anorectal malformations, sacrococcygeal osseous defect, and presacral mass (Correct Answer)
D. Tethered cord, anorectal malformations, and ectopia vesicae

Explanation: **Explanation:** The **Currarino triad** is a rare hereditary condition characterized by a specific constellation of congenital anomalies. It is inherited in an autosomal dominant pattern, often associated with a mutation in the **MNX1 (formerly HLXB9) gene**. **1. Why Option C is Correct:** The classic triad consists of: * **Anorectal Malformation (ARM):** Most commonly presenting as anal stenosis or imperforate anus. * **Sacrococcygeal Osseous Defect:** Typically a "scimitar-shaped" sacrum (hemisacrum). * **Presacral Mass:** This is most frequently a **mature teratoma**, but can also be an anterior meningocele or an enteric cyst. **2. Analysis of Incorrect Options:** * **Option A:** While a presacral meningocele and sacral defects are components, "tethered cord" is a common *associated* finding rather than a defining part of the primary triad. * **Option B & D:** **Ectopia vesicae** (bladder exstrophy) is part of the **OEIS complex** (Omphalocele, Exstrophy of the bladder, Imperforate anus, and Spinal defects), not the Currarino triad. **3. High-Yield Clinical Pearls for NEET-PG:** * **Genetic Marker:** MNX1 gene mutation (70% of cases). * **Radiological Sign:** The **"Scimitar Sacrum"** is the pathognomonic radiological feature (a smooth, curved sacral defect). * **Clinical Presentation:** Patients often present with chronic refractory constipation since birth due to the anorectal stenosis or mass effect. * **Malignancy Risk:** While most presacral teratomas in this triad are benign, there is a risk of malignant transformation into **Yolk Sac Tumor**; hence, surgical excision is mandatory. * **Management:** Requires a multidisciplinary approach (Neurosurgery and Pediatric Surgery) to address the meningocele and the mass simultaneously.

Question 107: Which of the following statements regarding anaplastic carcinoma is FALSE?

A. It is common in the elderly.
B. It is associated with P53 mutation.
C. Surrounding neck tissue is usually infiltrated.
D. Radiotherapy cures it. (Correct Answer)

Explanation: Anaplastic Thyroid Carcinoma (ATC) is one of the most aggressive and lethal solid tumors in humans. Understanding its clinical behavior is crucial for NEET-PG. ### **Why Option D is False (The Correct Answer)** Anaplastic carcinoma is notorious for its **extreme resistance** to all conventional treatment modalities, including surgery, chemotherapy, and radiotherapy. While radiotherapy (often combined with chemotherapy) is used for **palliative local control** to prevent airway obstruction, it is **not curative**. The prognosis remains dismal, with a median survival of only 3–6 months. ### **Explanation of Other Options** * **Option A (Common in the elderly):** True. ATC typically presents in the 6th to 7th decades of life. It is rare in patients under 50. * **Option B (Associated with P53 mutation):** True. Molecular pathogenesis often involves the inactivation of the **TP53 tumor suppressor gene**, which is a hallmark of its dedifferentiation from well-differentiated thyroid cancers (like papillary or follicular). * **Option C (Surrounding neck tissue is usually infiltrated):** True. ATC is characterized by rapid local invasion. Patients often present with a "woody hard" fixed neck mass, causing dysphagia, hoarseness (recurrent laryngeal nerve palsy), and dyspnea due to infiltration of the esophagus, larynx, and trachea. ### **Clinical Pearls for NEET-PG** * **Presentation:** Rapidly enlarging neck mass in an elderly patient. * **Diagnosis:** Core needle biopsy or FNA; histology shows spindle, giant, or squamoid cells. * **Staging:** According to AJCC, all Anaplastic carcinomas are classified as **Stage IV** at the time of diagnosis. * **Treatment:** Primarily palliative. If the disease is resectable (rare), total thyroidectomy followed by adjuvant chemoradiotherapy is attempted.

Question 108: Pelvic exenteration is also known as which operation?

A. Miles Operation
B. Lloyd's operation
C. Finch operation
D. Brunschwig's operation (Correct Answer)

Explanation: **Explanation:** **Pelvic Exenteration (Brunschwig’s Operation):** Pelvic exenteration is an ultra-radical surgical procedure involving the en masse removal of all pelvic organs, including the bladder, urethra, rectum, anus, and internal reproductive organs (uterus, vagina, or prostate). It was first described by **Alexander Brunschwig in 1948** for the treatment of advanced or recurrent pelvic malignancies (primarily cervical cancer) that have failed radiotherapy but remain confined to the pelvis. **Analysis of Options:** * **Brunschwig’s Operation (Correct):** Named after the surgeon who pioneered the procedure. It is classified into anterior (removal of bladder/genitalia), posterior (removal of rectum/genitalia), or total exenteration. * **Miles Operation:** Also known as **Abdominoperineal Resection (APR)**. It involves the removal of the distal sigmoid, rectum, and anus; it is used for low rectal cancers but does not involve the removal of the bladder or other pelvic viscera. * **Lloyd’s Operation:** This refers to a specific positioning (Lloyd-Davies position), which is a modification of the Trendelenburg position used for pelvic surgeries to allow simultaneous access to the abdomen and perineum. * **Finch Operation:** This is not a standard term in oncological surgery and is likely a distractor. **High-Yield Clinical Pearls for NEET-PG:** * **Indication:** Primarily for **recurrent cervical cancer** (post-radiation) or locally advanced rectal/vulvar cancers. * **Prerequisite:** There must be no evidence of extra-pelvic metastasis (negative "sidewall" involvement is crucial). * **Reconstruction:** Requires a urinary diversion (e.g., Ileal conduit/Bricker’s loop) and a permanent colostomy. * **Mortality:** Historically high, but now significantly reduced in specialized centers.

Question 109: Which of the following statements about pulmonary hamartoma is true?

A. It is the most common benign tumor of lung.
B. More common in males.
C. Chest X-ray shows "Pop corn calcification".
D. All are true. (Correct Answer)

Explanation: **Explanation:** Pulmonary Hamartoma is a benign neoplasm composed of tissues normally found in the lung (cartilage, fat, connective tissue, and respiratory epithelium) but arranged in a disorganized manner. 1. **Most Common Benign Tumor (Option A):** Hamartomas are the most frequent benign lung tumors, accounting for approximately 75% of all benign pulmonary nodules. They are typically discovered incidentally as a solitary pulmonary nodule ("coin lesion"). 2. **Gender Predominance (Option B):** There is a clear male preponderance, with the condition being 2–3 times more common in men than in women, usually presenting in the 5th or 6th decade of life. 3. **Popcorn Calcification (Option C):** This is the classic radiological hallmark. On a Chest X-ray or CT scan, the disorganized growth of cartilage leads to a characteristic "popcorn-like" pattern of calcification. While highly specific, it is seen in only about 10–30% of cases. Since all individual statements are accurate descriptions of the pathology, epidemiology, and radiology of the condition, **Option D (All are true)** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Most are peripheral (90%) and asymptomatic; only 10% are endobronchial (which may cause obstruction). * **CT Finding:** The presence of **fat density** (Hounsfield units -40 to -120) within a well-circumscribed nodule is highly suggestive of hamartoma. * **Growth:** They are typically slow-growing (<2mm per year). * **Management:** Observation is usually sufficient if the radiological features are classic; surgical excision (enucleation or wedge resection) is reserved for symptomatic cases or diagnostic uncertainty.

Question 110: Kaposi sarcoma is commonly seen in which anatomical location?

A. Upper limbs
B. Lower limbs (Correct Answer)
C. Head and Neck
D. Trunk

Explanation: **Explanation:** Kaposi Sarcoma (KS) is a multicentric angioproliferative tumor caused by **Human Herpesvirus-8 (HHV-8)**. It primarily affects the vascular and lymphatic endothelium. **Why Lower Limbs are the Correct Answer:** In the **Classic (European) form** of Kaposi Sarcoma, which typically affects elderly men of Mediterranean or Eastern European descent, the lesions characteristically appear on the **distal lower extremities** (feet and ankles). These present as slow-growing, purple-red or dark brown macules, plaques, or nodules. The predilection for the lower limbs is attributed to venous stasis and gravity-dependent lymphedema, which promote the accumulation of inflammatory cytokines and HHV-8 infected cells in these areas. **Analysis of Incorrect Options:** * **Upper Limbs:** While lesions can eventually spread to the arms in advanced stages, they are rarely the primary or most common site of initial presentation. * **Head and Neck:** This location is more frequently associated with **AIDS-associated (Epidemic) KS**, where oral mucosal involvement (especially the hard palate) is common. However, even in HIV patients, cutaneous lesions often favor the lower limbs or trunk. * **Trunk:** Truncal involvement is common in the aggressive Epidemic (AIDS-related) form, often following the lines of cleavage (Pityriasis rosea-like distribution), but it is statistically less common as the primary site compared to the lower limbs. **High-Yield Clinical Pearls for NEET-PG:** 1. **Histology:** Look for "spindle-shaped cells," slit-like vascular spaces, and extravasated RBCs. 2. **Four Clinical Types:** Classic (Sporadic), Endemic (African), Iatrogenic (Transplant-related), and Epidemic (AIDS-associated). 3. **AIDS-Defining Illness:** KS is the most common neoplasm in HIV-infected patients. 4. **Treatment:** Localized lesions can be treated with radiotherapy or cryotherapy; systemic chemotherapy (Liposomal Doxorubicin) is used for visceral or widespread disease. In AIDS patients, HAART (Highly Active Antiretroviral Therapy) often leads to lesion regression.

Practice by Chapter

Principles of Surgical Oncology

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Cancer Staging

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Surgical Margins in Cancer Surgery

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Sentinel Lymph Node Concepts

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Neoadjuvant and Adjuvant Therapy

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Metastasectomy

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Cytoreductive Surgery

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Hyperthermic Intraperitoneal Chemotherapy

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Palliative Surgical Procedures

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Minimally Invasive Approaches in Cancer Surgery

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Follow-up and Surveillance

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Hereditary Cancer Syndromes

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