Oncological Surgery Practice Questions

Q: A 45-year-old female is admitted to the hospital after worsening headaches for the past month. She has noticed that the headaches are usually generalized, and frequently occur during sleep. She does not have a history of migraines or other types of headaches. Her past medical history is significant for breast cancer, which was diagnosed a year ago and treated with mastectomy. She recovered fully and returned to work shortly thereafter. CT scan of the brain now shows a solitary cortical 5cm mass surrounded by edema in the left hemisphere of the brain at the grey-white matter junction. She is admitted to the hospital for further management. What is the most appropriate next step in management for this patient?

Surgical resection of the mass. ***Surgical resection of the mass*** - The presence of a **solitary cortical mass** with significant edema [1], [2] in a patient with a history of **breast cancer** [3] strongly suggests a resectable brain metastasis that is causing symptomatic cerebral edema. - **Surgical resection** offers the best chance for immediate symptom relief, pathological diagnosis, and improved prognosis in cases conducive to complete removal [1]. *Seizure prophylaxis and palliative pain therapy* - While seizure prophylaxis might be considered due to the mass effect, it is a **supportive measure** and does not address the underlying cause of the symptoms (the mass) that can be surgically removed. - **Palliative pain therapy** would also be a supportive measure only and would not achieve a definitive diagnosis or treatment of the mass. *Chemotherapy* - **Chemotherapy** for brain metastases often has limited efficacy due to the **blood-brain barrier** and is generally reserved for systemic disease or multiple, unresectable brain lesions. - Prior to initiating chemotherapy, a definitive **histopathologic diagnosis** is usually required, and surgical resection would provide tissue for this purpose. *Irradiation to the brain mass* - While **brain irradiation** (like stereotactic radiosurgery or whole-brain radiation therapy) is an option for brain metastases, especially for multiple or unresectable lesions, **surgical resection** is generally preferred for a solitary, accessible metastasis with significant mass effect. - Irradiation alone might not provide the same immediate symptomatic relief from brain edema as surgical decompression [2].

Q: Best treatment strategy for carcinoma of the anal canal:

Chemoradiation. ***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**.

Q: What is the most common tumor of the mediastinum?

Neurogenic tumor. ***Neurogenic tumor*** - **Neurogenic tumors** are the **most common primary tumors of the mediastinum** overall, accounting for approximately **35-40%** of all mediastinal masses. - They are the most common tumors of the **posterior mediastinum** and arise from nerve sheaths (e.g., **schwannomas, neurofibromas**) or sympathetic ganglia. - These tumors occur across all age groups, with higher prevalence when including both pediatric and adult populations. *Thymoma* - **Thymomas** are the most common primary tumor of the **anterior mediastinum** in adults, accounting for about **40-50%** of anterior mediastinal masses. - However, they represent only about **20-25%** of all mediastinal tumors overall. - Often associated with paraneoplastic syndromes like **myasthenia gravis** (30-50% of cases). *Lymphoma* - **Lymphoma** is a common mediastinal tumor, particularly **Hodgkin lymphoma** in young adults, accounting for approximately **15-20%** of mediastinal masses. - It often presents with bulky mediastinal masses and symptoms like **dyspnea, cough, or superior vena cava syndrome**. - While very common, it ranks second or third overall after neurogenic tumors. *Neuroblastic tumor* - **Neuroblastic tumors** (e.g., neuroblastoma, ganglioneuroblastoma) are a subset of neurogenic tumors more common in **children**. - They arise from the sympathetic nervous system and typically occur in the posterior mediastinum. - While important in pediatric populations, they are less common than all neurogenic tumors combined.

Q: Most favorable prognosis after radiotherapy is in -

Seminoma. ***Seminoma*** - **Seminoma** is highly **radiosensitive**, meaning it responds very well to radiation therapy, leading to excellent oncological outcomes. - Due to its sensitivity, even advanced seminomas can often be cured with radiotherapy, contributing to a **favorable prognosis**. *Teratoma* - **Teratomas** are generally **radioresistant**, meaning they do not respond well to radiation therapy. - Treatment for teratomas typically involves **surgical resection**, as radiation is largely ineffective. *Desmoid* - **Desmoid tumors** (aggressive fibromatosis) are locally aggressive but rarely metastasize, and their response to radiotherapy is variable. - While radiation can be used for local control, the prognosis is often complicated by **local recurrence** and challenging surgical margins. *Melanoma* - **Melanoma** is notoriously **radioresistant**, making radiation therapy a less effective primary treatment option. - It is often used for **palliative care** or in cases of local recurrence, but rarely leads to a cure or favorable prognosis when used alone.

Q: Testicular tumour which responds best to radiation is:

Seminoma. ***Seminoma*** - **Seminoma** is highly sensitive to radiotherapy due to its specific histological characteristics, making it the most responsive testicular tumor to radiation. - Radiation therapy is a common and effective treatment for seminoma, particularly in early stages (Stage I-IIA), often leading to excellent cure rates (>95%). - **Low-dose radiotherapy** to para-aortic and ipsilateral iliac lymph nodes is standard adjuvant treatment. *Embryonal cell carcinoma* - **Embryonal cell carcinoma** is a non-seminomatous germ cell tumor (NSGCT) that is relatively **radioresistant**. - Treatment primarily involves **cisplatin-based chemotherapy** (BEP regimen) and/or surgery. - Radiation plays minimal role in management of NSGCTs. *Teratoma* - **Teratomas** are typically resistant to both radiation therapy and chemotherapy. - Composed of differentiated mature or immature tissues that do not respond well to systemic treatments. - The primary treatment for teratoma is **surgical excision** with retroperitoneal lymph node dissection if needed. *Choriocarcinoma* - **Choriocarcinoma** is a highly aggressive NSGCT that is **radioresistant**. - Requires intensive **chemotherapy** due to high propensity for hematogenous spread. - Radiation has no role in primary treatment, though may be used for brain metastases.

Q: Which of the following tumours is radiosensitive?

Ewing's sarcoma. ***Ewing's sarcoma*** - **Ewing's sarcoma** is highly radiosensitive, meaning radiation therapy is an effective treatment modality, often used as a primary or adjuvant therapy. - Its high responsiveness to radiation helps control local disease and improve patient outcomes, especially when combined with chemotherapy. *Osteosarcoma* - **Osteosarcoma** is generally considered radioresistant, meaning it responds poorly to radiation therapy. - While radiation may be used in specific palliative settings, it is not a primary curative treatment for osteosarcoma, which primarily relies on surgery and chemotherapy. *Hepatocellular carcinoma* - **Hepatocellular carcinoma (HCC)** is largely radioresistant, and external beam radiation therapy has limited efficacy as a stand-alone treatment. - While certain advanced techniques like stereotactic body radiation therapy (SBRT) can be used for localized control, it is not considered broadly radiosensitive. *Malignant melanoma* - **Malignant melanoma** is historically considered highly radioresistant, requiring very high doses of radiation for any significant tumor control. - In recent years, high-dose, hypofractionated radiation therapy has shown some promise for local control, but it is not a universally radiosensitive tumor.

Q: A 48-year old woman comes with bilateral progressive weakness of both lower limbs, spasticity and mild impairment of respiratory movements. MRI shows an intradural mid-dorsal midline enhancing lesion. What is the diagnosis?

Meningioma. ***Meningioma*** - This is the most common **intradural extramedullary spinal tumor** in adults, typically presenting with progressive **myelopathy** due to spinal cord compression. - The MRI finding of an **intradural mid-dorsal midline enhancing lesion** is highly suggestive, as meningiomas are often well-circumscribed and enhance intensely. *Dermoid cyst* - These are **congenital lesions** that typically present in childhood or young adulthood and can be associated with **spinal dysraphism**. - While they are intradural, they are less common than meningiomas in this age group and often exhibit different imaging characteristics (e.g., lipid components) and less uniform enhancement. *Intradural lipoma* - **Spinal lipomas** are uncommon and usually associated with **congenital spinal anomalies** or can occur as a primary tumor. - They are characterized by **fat signal intensity** on MRI and do not typically show significant enhancement, differentiating them from the described lesion. *Neuroenteric cyst* - These are rare **congenital cysts** that can be intradural, often linked to **vertebral anomalies**, and may contain mucinous fluid. - While they can be intradural, they are much less common than meningiomas and typically do not show the same pattern of strong, uniform enhancement on MRI.

Q: All of the following modalities can be used for in situ ablation of liver secondaries, except:

Alcohol. ***Alcohol*** - While **percutaneous ethanol injection (PEI)** can be used for **ablation of small hepatocellular carcinomas**, it is generally not a primary modality for **in situ ablation of liver secondaries** due to less predictable ablation margins and diffusion. - Its use is more prevalent for very small, localized primary tumors or for cystic lesions, rather than for metastatic disease where more precise and extensive ablation is often required. *Radiofrequency* - **Radiofrequency ablation (RFA)** uses high-frequency electrical currents to generate heat, causing **coagulation necrosis** of tumor cells within the liver. - It is a widely accepted and effective modality for **in situ ablation of liver secondaries**, particularly for lesions up to 3-5 cm. *Ultrasonic waves* - **High-intensity focused ultrasound (HIFU)** uses focused ultrasonic waves to generate heat and destroy tumor tissue, and is an evolving non-invasive method for **liver tumor ablation**. - HIFU causes **thermal ablation** leading to coagulative necrosis and can be used for both primary and secondary liver tumors. *Cryotherapy* - **Cryoablation** involves the use of extreme cold to destroy tumor cells, typically by inserting probes into the tumor to create **ice balls**. - It is an effective method for **in situ ablation of liver secondaries**, causing **cellular injury** and **necrosis** through direct cold effects and microvascular thrombosis.

Q: Radiotherapy is most useful in:

Seminoma. ***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.

Q: An elderly male presents with T3N0 laryngeal carcinoma. What would be the management?

Concurrent chemoradiotherapy. ***Concurrent chemoradiotherapy*** - For **T3 laryngeal carcinoma (moderately advanced)**, concurrent chemoradiotherapy is the preferred management to preserve the larynx while offering a good chance of cure. - This approach combines **radiation** with **chemotherapy** given at the same time to enhance the effect of radiation and improve local control. *Neoadjuvant chemotherapy followed by radiotherapy* - **Neoadjuvant chemotherapy** is typically reserved for more advanced (T4) or unresectable tumors to reduce tumor burden before definitive local treatment. - For T3 disease, concurrent chemoradiotherapy is generally preferred for organ preservation over sequential approaches. *Radical radiotherapy followed by chemotherapy* - Sequential treatment with **radiotherapy first** followed by chemotherapy is less effective than concurrent chemoradiotherapy for organ preservation and disease control in T3 laryngeal carcinoma. - This approach may be considered in specific cases, but it's not the primary recommendation for T3 laryngeal cancer. *Radical radiotherapy without chemotherapy* - While **radical radiotherapy alone** can be used for selected early-stage (T1-T2) laryngeal cancers, it is generally insufficient for T3 disease. - The addition of chemotherapy concurrently significantly improves outcomes for T3 larynx cancer compared to radiotherapy alone, by addressing microscopic disease and sensitizing tumor cells to radiation.

Question 1

A 45-year-old female is admitted to the hospital after worsening headaches for the past month. She has noticed that the headaches are usually generalized, and frequently occur during sleep. She does not have a history of migraines or other types of headaches. Her past medical history is significant for breast cancer, which was diagnosed a year ago and treated with mastectomy. She recovered fully and returned to work shortly thereafter. CT scan of the brain now shows a solitary cortical 5cm mass surrounded by edema in the left hemisphere of the brain at the grey-white matter junction. She is admitted to the hospital for further management. What is the most appropriate next step in management for this patient?

Accepted Answer

Surgical resection of the mass

Answer

Seizure prophylaxis and palliative pain therapy

Answer

Chemotherapy

Answer

Irradiation to the brain mass

Question 2

Best treatment strategy for carcinoma of the anal canal:

Accepted Answer

Chemoradiation

Answer

Radiation

Answer

Surgery

Answer

Chemotherapy

Question 3

What is the most common tumor of the mediastinum?

Accepted Answer

Neurogenic tumor

Answer

Thymoma

Answer

Lymphoma

Answer

Neuroblastic tumor

Question 4

Most favorable prognosis after radiotherapy is in -

Accepted Answer

Seminoma

Answer

Teratoma

Answer

Desmoid

Answer

Melanoma

Question 5

Testicular tumour which responds best to radiation is:

Accepted Answer

Seminoma

Answer

Embryonal cell carcinoma

Answer

Teratoma

Answer

Choriocarcinoma

Question 6

Which of the following tumours is radiosensitive?

Accepted Answer

Ewing's sarcoma

Answer

Osteosarcoma

Answer

Hepatocellular carcinoma

Answer

Malignant melanoma

Question 7

A 48-year old woman comes with bilateral progressive weakness of both lower limbs, spasticity and mild impairment of respiratory movements. MRI shows an intradural mid-dorsal midline enhancing lesion. What is the diagnosis?

Accepted Answer

Meningioma

Answer

Dermoid cyst

Answer

Intradural lipoma

Answer

Neuroenteric cyst

Question 8

All of the following modalities can be used for in situ ablation of liver secondaries, except:

Accepted Answer

Alcohol

Answer

Radiofrequency

Answer

Ultrasonic waves

Answer

Cryotherapy

Question 9

Radiotherapy is most useful in:

Accepted Answer

Seminoma

Answer

Melanoma

Answer

Pancreatic carcinoma

Answer

Osteosarcoma

Question 10

An elderly male presents with T3N0 laryngeal carcinoma. What would be the management?

Accepted Answer

Concurrent chemoradiotherapy

Answer

Neoadjuvant chemotherapy followed by radiotherapy

Answer

Radical radiotherapy followed by chemotherapy

Answer

Radical radiotherapy without chemotherapy

Oncological Surgery — MCQs

Oncological Surgery — MCQs

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