Oncological Surgery — MCQs

A 35-year-old woman with newly diagnosed metastatic breast cancer (liver and bone metastases) presents with a 6 cm primary tumor, skin involvement, and 4 palpable axillary nodes. Her oncologist recommends neoadjuvant chemotherapy, but she requests immediate surgery. Evaluate the most appropriate recommendation considering oncologic principles, patient preference, and evidence-based care.

Oncological Surgery Indian Medical PG Practice Questions and MCQs

Question 111: Which CNS tumor is typically associated with calcification?

A. Oligodendroglioma (Correct Answer)
B. Astrocytoma
C. Medulloblastoma
D. Pheochromocytoma

Explanation: **Explanation:** **1. Why Oligodendroglioma is Correct:** Oligodendroglioma is the classic CNS tumor associated with **calcification**, occurring in approximately **70–90%** of cases. These are slow-growing tumors typically located in the cortical gray matter of the frontal lobes. On imaging (CT scan), the presence of "clumpy" or "popcorn" calcification is a hallmark feature. Histologically, these tumors exhibit a "fried-egg" appearance (clear cytoplasm with central nuclei) and a "chicken-wire" vascular pattern. **2. Why the Other Options are Incorrect:** * **Astrocytoma:** While some subtypes (like Pilocytic Astrocytoma) can occasionally show calcification, it is much less frequent (approx. 10–20%) compared to oligodendrogliomas. * **Medulloblastoma:** This is a highly malignant primitive neuroectodermal tumor (PNET) found in the posterior fossa of children. It typically presents as a solid, enhancing mass in the cerebellum; calcification is rare. * **Pheochromocytoma:** This is not a CNS tumor. It is a catecholamine-secreting tumor of the adrenal medulla (or extra-adrenal paraganglia). **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common CNS tumor to calcify:** Oligodendroglioma. * **Other CNS tumors with calcification:** Craniopharyngioma (90% in children), Meningioma (Psammoma bodies), and Ependymoma. * **Genetic Marker:** 1p/19q co-deletion is the diagnostic molecular hallmark of oligodendroglioma and predicts a better response to chemotherapy. * **Clinical Presentation:** Seizures are the most common presenting symptom due to the tumor's cortical location.

Question 112: A 60-year-old male was diagnosed with carcinoma of the right lung. CECT chest revealed a 5 x 5 cm tumor in the upper lobe and a 2 x 2 cm tumor nodule in the middle lobe. What is the primary modality of treatment?

A. Radiotherapy
B. Chemotherapy
C. Surgery (Correct Answer)
D. Supportive treatment

Explanation: ### **Explanation** The correct answer is **Surgery (Option C)**. **1. Why Surgery is Correct:** This patient presents with two tumor nodules in different lobes of the same lung (Right Upper Lobe and Right Middle Lobe). According to the **TNM Staging (8th Edition)** for Non-Small Cell Lung Cancer (NSCLC): * Separate tumor nodules in a **different lobe** of the **ipsilateral** lung are classified as **T4**. * In the absence of mediastinal lymphadenopathy (N2/N3) or distant metastasis (M1), a T4 lesion is categorized as **Stage IIIA**. * Current oncological guidelines state that if multiple nodules are present in the same lung (ipsilateral), they are considered **resectable** provided the patient has adequate pulmonary reserve. The primary treatment is surgical resection (e.g., pneumonectomy or bilobectomy) followed by adjuvant chemotherapy. **2. Why Other Options are Incorrect:** * **Radiotherapy (A):** Used primarily for Stage IIIB/IV or as definitive treatment in patients who are medically unfit for surgery. * **Chemotherapy (B):** While used as an adjuvant (after surgery) or neoadjuvant (before surgery) treatment in Stage IIIA, it is not the *primary* modality for resectable tumors. * **Supportive Treatment (D):** Reserved for Stage IV (metastatic) disease where the goal is palliation, not cure. **3. High-Yield Clinical Pearls for NEET-PG:** * **T-Staging for Multiple Nodules:** * Same Lobe: **T3** * Ipsilateral Different Lobe: **T4** * Contralateral Lung: **M1a** * **Resectability vs. Operability:** Resectability depends on the tumor stage (TNM), while operability depends on the patient’s fitness (PFTs/FEV1). * **Standard of Care:** For Stages I, II, and selected IIIA, **Surgery** remains the gold standard for cure.

Question 113: Which of the following types of bronchogenic carcinomas are most likely to develop within a residual area of peripheral scar tissue?

A. Small-cell carcinoma
B. Squamous-cell carcinoma
C. Large-cell carcinoma
D. Adenocarcinoma (Correct Answer)

Explanation: ### Explanation The correct answer is **Adenocarcinoma**. #### 1. Why Adenocarcinoma is Correct Adenocarcinoma is the most common type of bronchogenic carcinoma associated with **"Scar Carcinoma."** This concept refers to the development of malignancy within areas of pre-existing pulmonary fibrosis or localized peripheral scars (resulting from old tuberculosis, infarcts, or chronic inflammation). * **Pathophysiology:** Chronic inflammation and subsequent fibrosis lead to epithelial hyperplasia and dysplasia, eventually progressing to neoplasia. * **Location:** Unlike squamous or small-cell carcinomas, Adenocarcinoma is typically **peripheral** in location, which aligns with the distribution of most pulmonary scars. #### 2. Why Other Options are Incorrect * **Small-cell carcinoma (A):** This is a high-grade neuroendocrine tumor strongly associated with smoking. It is almost exclusively **central** (hilar) in location and arises from the Kulchitsky cells of the bronchial mucosa, not from peripheral scars. * **Squamous-cell carcinoma (B):** While it can occasionally be peripheral, it is predominantly a **central** tumor arising from squamous metaplasia of the large bronchi. It is characterized by cavitation and a strong link to smoking, rather than pre-existing scars. * **Large-cell carcinoma (C):** This is a diagnosis of exclusion (undifferentiated). While it can be peripheral, it is characterized by rapid growth and early metastasis, without a specific predilection for scar tissue. #### 3. NEET-PG High-Yield Pearls * **Most common lung cancer overall:** Adenocarcinoma (especially in non-smokers and women). * **Most common lung cancer in smokers:** Historically Squamous-cell, but currently Adenocarcinoma is increasing in incidence among smokers as well. * **Pancoast Tumor:** Most commonly caused by Adenocarcinoma or Squamous-cell carcinoma. * **Hypercalcemia (PTHrP):** Most commonly associated with **S**quamous-cell carcinoma (**S**-ca**++**mous). * **SIADH/ACTH/Lambert-Eaton:** Most commonly associated with **S**mall-cell carcinoma.

Question 114: Which of the following is NOT a risk factor for melanoma?

A. Exposure to UV radiation
B. Black people (Correct Answer)
C. First-degree relative with melanoma
D. Multiple or dysplastic nevi

Explanation: **Explanation:** The correct answer is **B. Black people**. Melanoma is significantly more common in individuals with fair skin (Fitzpatrick types I and II) who have less melanin. Melanin acts as a natural photoprotectant against DNA damage. While people with darker skin tones can develop melanoma, their risk is substantially lower than that of Caucasians. When it does occur in Black populations, it often presents as **Acral Lentiginous Melanoma** (affecting palms, soles, and nail beds), which is not primarily linked to UV exposure. **Analysis of other options:** * **A. Exposure to UV radiation:** This is the most significant environmental risk factor. Both cumulative sun exposure and episodes of severe, blistering sunburns (especially during childhood) increase risk. * **C. First-degree relative with melanoma:** Approximately 10% of patients have a family history. Mutations in the **CDKN2A** gene are the most common genetic link identified in familial cases. * **D. Multiple or dysplastic nevi:** Having a high total mole count (>50–100) or the presence of atypical (dysplastic) nevi significantly increases the statistical risk of developing melanoma. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** In men, it is the **back**; in women, it is the **lower legs**. * **Prognostic Factor:** The most important prognostic factor for Stage I and II melanoma is **Breslow’s Thickness** (vertical depth in mm). * **ABCDE Criteria:** Used for clinical assessment—**A**symmetry, **B**order irregularity, **C**olor variation, **D**iameter >6mm, and **E**volving/Elevation. * **Biopsy Gold Standard:** Excisional biopsy with a 1–3 mm margin. Never perform a shave biopsy if melanoma is suspected.

Question 115: A 40-year-old smoker presents with soreness of tongue since last 2 months. On examination, it is found that the oral hygiene is poor and there is a white plaque over the lateral border of the tongue. What is the next step in the management of this patient?

A. Edge biopsy of the lesion (Correct Answer)
B. Oral antifungal treatment
C. Local topical cauterization
D. Oral vitamin C supplementation

Explanation: ***Edge biopsy of the lesion*** - The patient's presentation with a **white plaque** on the lateral border of the tongue, coupled with **poor oral hygiene** and a history of **smoking**, raises high suspicion for **oral potentially malignant disorders**, including **leukoplakia** or early **squamous cell carcinoma**. - An **edge biopsy** is the most appropriate next step to obtain a definitive histological diagnosis, which is crucial for determining the correct management strategy and ruling out malignancy. - The lateral border of the tongue is a **high-risk site** for oral cancer, and any persistent lesion in a smoker warrants tissue diagnosis. *Oral antifungal treatment* - This would be indicated if the white plaque were consistent with **oral candidiasis (thrush)**, which typically presents as **scrapable** white patches with a cottage cheese-like appearance. - Given the patient's significant risk factors (smoking, 2-month duration) and the location (lateral tongue border), empirical antifungal treatment without a definitive diagnosis would inappropriately delay management if the lesion is precancerous or cancerous. *Local topical cauterization* - **Cauterization** is contraindicated for undiagnosed oral lesions, especially those suspected of having malignant potential, as it could obscure the true histology and destroy tissue needed for diagnosis. - This method is only suitable for small, confirmed benign lesions or for hemostasis, never as a diagnostic or first-line approach. *Oral vitamin C supplementation* - While **vitamin C** supports overall health and tissue repair, there is no evidence it would resolve a suspicious white plaque on the tongue, especially one with potential malignant transformation. - Delaying proper diagnostic evaluation with supplementation alone could lead to progression of a serious underlying condition such as oral cancer.

Question 116: Which of the following is the best indicator of prognosis of soft tissue sarcoma?

A. Tumour size
B. Nodal metastasis
C. Histological type
D. Tumour grade (Correct Answer)

Explanation: ***Tumour grade*** - **Tumor grade** quantifies the degree of cellular differentiation, mitotic activity, and necrosis within the tumor, reflecting its aggressive potential. - A **higher tumor grade** is directly associated with a poorer prognosis, increased risk of local recurrence, and distant metastasis in soft tissue sarcomas. *Tumour size* - While larger tumor size (e.g., >5 cm) is generally associated with a worse prognosis, it is primarily a factor in **staging**, not the most critical prognostic indicator. - **Tumor grade** provides more fundamental information about the biological aggressiveness of the tumor cells regardless of their current size. *Nodal metastasis* - **Nodal metastasis** in soft tissue sarcomas is relatively uncommon (less than 5% of cases) compared to carcinomas, and its presence is a significant negative prognostic factor. - However, because it is rare, it doesn't serve as the *primary* indicator for the majority of sarcoma patients, where tumor grade is more universally applicable. *Histological type* - The **histological type** (e.g., liposarcoma, leiomyosarcoma) helps classify the sarcoma, but different subtypes can have a wide range of biological behavior. - While certain types may have a generally better or worse prognosis, the **grade** *within* that histological type is a more precise predictor of individual patient outcomes.

Question 117: Which one of the following statements is correct in case of squamous cell carcinoma of the lip?

A. Lymph node metastases occur early
B. Radiotherapy is considered inappropriate treatment for these lesions
C. More than 90 per cent of cases occur on the upper lip
D. Lesion often arises in the areas of persistent hyperkeratosis (Correct Answer)

Explanation: ***Lesion often arises in the areas of persistent hyperkeratosis*** - **Squamous cell carcinoma (SCC) of the lip** frequently originates from areas of **actinic cheilitis**, which presents as persistent hyperkeratosis due to chronic sun exposure. - This chronic irritation and dysplasia in hyperkeratotic lesions are known **precursor conditions** for SCC. *Lymph node metastases occur early* - While metastasis can occur in SCC of the lip, it typically does not occur **early**; the primary concern is **local invasion** before regional nodal involvement becomes significant. - The rate of **lymph node metastasis** is generally lower for SCC of the lip compared to other intraoral cancers and often occurs later in the disease course. *Radiotherapy is considered inappropriate treatment for these lesions* - **Radiotherapy** is a highly effective treatment for SCC of the lip, particularly for **small lesions** and in patients who are not surgical candidates, or as an adjuvant therapy. - It can achieve high cure rates with good cosmetic outcomes, making it a perfectly **appropriate treatment option**. *More than 90 per cent of cases occur on the upper lip* - The vast majority of **squamous cell carcinomas of the lip** (over 90%) occur on the **lower lip**, which is much more exposed to **solar radiation**. - The **upper lip** is less commonly affected due to its lesser exposure to chronic sun damage.

Question 118: Renal carcinoma with solitary lung secondary is best treated by

A. chemotherapy
B. surgery (Correct Answer)
C. immunotherapy
D. radiotherapy

Explanation: ***Surgery*** - For **renal cell carcinoma** with a **solitary lung metastasis**, surgical resection of both the primary tumor (nephrectomy) and the lung metastasis is often the preferred treatment and offers the best chance for long-term survival. - This approach is particularly effective when the patient has a good performance status, the primary tumor is controlled, and the metastasis is truly solitary and resectable. *Chemotherapy* - **Renal cell carcinoma** is classically considered **chemotherapy-resistant**, meaning traditional chemotherapy agents generally have limited efficacy. - While some newer targeted therapies and immunotherapies are used, conventional chemotherapy is not the first-line treatment for metastatic RCC, especially when surgical options are available. *Immunotherapy* - **Immunotherapy** (e.g., nivolumab, pembrolizumab) is a common treatment for advanced or metastatic renal cell carcinoma, particularly when surgery is not feasible or after recurrence. - However, for a **solitary resectable metastasis**, it is typically considered after surgery, or in cases where surgery is contraindicated, rather than as a primary curative approach. *Radiotherapy* - **Radiotherapy** has a limited role in the primary treatment of renal cell carcinoma due to its relative radioresistance, though it can be used for palliative purposes (e.g., pain control, brain metastases). - For a solitary lung metastasis, while **stereotactic body radiation therapy (SBRT)** might be considered in select cases where surgery is not possible, surgical resection remains the gold standard for resectable lesions.

Question 119: Tumours of anterior mediastinum include the following except:

A. Lymphoma
B. Germ cell tumour
C. Thymoma
D. Schwannoma (Correct Answer)

Explanation: ***Schwannoma*** - **Schwannomas** (neurilemmomas) are typically found in the **posterior mediastinum**, arising from **peripheral nerves** or nerve roots. - They are usually benign and grow slowly, presenting with symptoms due to compression of surrounding structures. *Lymphoma* - **Lymphoma** is a common tumor of the **anterior mediastinum**, often presenting as an **anterior mediastinal mass**. - Both Hodgkin and non-Hodgkin lymphomas can involve mediastinal lymph nodes. *Germ cell tumour* - **Germ cell tumors**, including **teratomas** and **seminomas**, frequently occur in the **anterior mediastinum**. - They arise from ectopic germ cell rests that migrate aberrantly during embryonic development. *Thymoma* - **Thymomas** are the most common primary tumor of the **anterior mediastinum**, originating from the **thymus gland**. - They are often associated with **myasthenia gravis** and other paraneoplastic syndromes.

Question 120: A 35-year-old woman with newly diagnosed metastatic breast cancer (liver and bone metastases) presents with a 6 cm primary tumor, skin involvement, and 4 palpable axillary nodes. Her oncologist recommends neoadjuvant chemotherapy, but she requests immediate surgery. Evaluate the most appropriate recommendation considering oncologic principles, patient preference, and evidence-based care.

A. Compromise with lumpectomy and sentinel node biopsy
B. Recommend systemic chemotherapy first and explain that surgery is not indicated initially in metastatic disease (Correct Answer)
C. Proceed with immediate mastectomy and axillary dissection per patient request
D. Refuse surgery and insist on systemic therapy first

Explanation: ***Recommend systemic chemotherapy first and explain that surgery is not indicated initially in metastatic disease*** - For patients with **metastatic (Stage IV) breast cancer**, the disease is incurable and the primary treatment goal is **systemic control** with chemotherapy, targeted therapy, and/or endocrine therapy. - **Surgery to the primary tumor** in asymptomatic metastatic breast cancer is generally **not recommended** as it does not improve survival outcomes, based on evidence from multiple trials. - The best approach is to **educate the patient** about evidence-based care while respecting her autonomy through **shared decision-making**. - The term "neoadjuvant" is reserved for pre-operative therapy given with **curative intent**, which does not apply to Stage IV disease. *Compromise with lumpectomy and sentinel node biopsy* - A **lumpectomy** and **sentinel node biopsy** would be inadequate for a 6 cm primary tumor with skin involvement and 4 palpable axillary nodes, even if there were no metastases. - The presence of **metastatic disease** further dictates a systemic approach as primary treatment, rendering this local compromise medically inappropriate as an initial step. *Proceed with immediate mastectomy and axillary dissection per patient request* - Although this addresses the patient's request for immediate surgery and offers aggressive local control, it is **not indicated** as initial management for **metastatic breast cancer**. - Immediate extensive surgery without prior **systemic treatment** for metastatic disease does not improve survival outcomes and exposes the patient to the risks of major surgery without first addressing the systemic spread of cancer. - Surgery may be considered later for **palliation of local symptoms** if the primary tumor becomes problematic. *Refuse surgery and insist on systemic therapy first* - While this represents the medically appropriate treatment sequence, flatly refusing surgery and "insisting" on systemic therapy fails to acknowledge **patient autonomy** and may damage the physician-patient relationship. - The goal is to educate and guide the patient towards the best evidence-based option while respecting their concerns and preferences through shared decision-making, rather than issuing a directive.

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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