Oncological Surgery Practice Questions

Q: Mohs micrographic excision for basal cell carcinoma is used for all the following Except

Superficial basal cell carcinoma on the trunk. ***Superficial basal cell carcinoma on the trunk*** - **Mohs micrographic surgery** is generally reserved for basal cell carcinomas (BCCs) in cosmetically and functionally sensitive areas, larger tumors, or those with aggressive features. - For **superficial BCCs** on the trunk, which is considered a low-risk area, standard excision, electrodessication and curettage, or topical therapies are often sufficient and preferred due to their less invasive nature and similar efficacy for this specific tumor type. *Tumors with perineural invasion* - **Perineural invasion** indicates a higher risk of recurrence and metastasis, making Mohs surgery an appropriate choice for complete tumor removal and margin control. - The precise, margin-controlled excision of Mohs helps ensure that all microscopic extensions along nerve sheaths are identified and removed. *Tumors with aggressive histology* - **Aggressive histologic subtypes** such as infiltrative, morpheaform, or micronodular BCCs have a higher risk of subclinical extension and recurrence. - Mohs surgery is highly effective for these types as it meticulously examines 100% of the surgical margins, maximizing tumor eradication while preserving healthy tissue. *Recurrent tumour* - **Recurrent BCCs** often have ill-defined borders and can grow more aggressively due to previous treatment altering the tissue architecture, making complete removal challenging. - Mohs surgery offers the highest cure rates for recurrent BCCs by precisely mapping and excising the tumor while preserving surrounding healthy tissue.

Q: Radiotherapy has the most significant therapeutic role in:

Sarcomas. ***Sarcomas*** - **Radiotherapy** plays a crucial therapeutic role in **sarcomas**, though typically as **adjuvant therapy** combined with surgical resection - Used for **local control** in soft tissue sarcomas, particularly when wide margins cannot be achieved - **Primary radiotherapy** is the treatment of choice for certain radiation-sensitive sarcomas like **Ewing's sarcoma** and in cases of **inoperable tumors** - Essential for reducing **local recurrence rates** in high-grade soft tissue sarcomas - Among the options listed, sarcomas have the **strongest and most established indication** for radiotherapy *Monoclonal gammopathy* - Generally **observation only** for MGUS (Monoclonal Gammopathy of Undetermined Significance) - Radiotherapy used only for **solitary plasmacytoma**, which is a specific localized manifestation - Multiple myeloma (if it progresses) is treated with **chemotherapy** and targeted agents, not radiotherapy as primary treatment *Tuberculosis* - An **infectious disease** caused by *Mycobacterium tuberculosis* - Treated exclusively with **anti-tubercular drug regimens** (RIPE: Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) - Radiotherapy has **no role** in treating infections *Sarcoidosis* - A **systemic inflammatory condition** with non-caseating granulomas - Primary treatment is **corticosteroids** for symptomatic cases - Immunosuppressants used for refractory cases - Radiotherapy has **no role** in inflammatory/granulomatous diseases

Q: In which type of hysterectomy are the uterine vessels ligated at the level of the ureter?

Type - II. ***Type - II*** - In a **Type II hysterectomy** (modified radical hysterectomy), the **uterine vessels** are ligated at the level of the **ureter** to ensure wider margins when excising the paracervical tissue. - This approach aims to resect the **medial portion of the cardinal and uterosacral ligaments**, along with the parametrial tissue, necessitating a more lateral ligation point. *Type - I* - **Type I hysterectomy** (simple or extrafascial hysterectomy) involves ligating the **uterine vessels** closer to the uterus, **medial to the ureter**, at the level of the internal os. - This type of hysterectomy is performed for benign conditions and does not require extensive paracervical tissue removal. *Type - IV* - **Type IV hysterectomy** (radical hysterectomy) involves an even wider dissection than Type III, extending to the **hypogastric vessels**, which is well beyond the ureter. - This procedure removes more of the **lateral parametrium and paravaginal tissue**, along with the superior vesical artery. *Type - III* - **Type III hysterectomy** (radical hysterectomy) involves ligating the **uterine vessels at their origin** from the internal iliac artery, which is significantly lateral to the ureter. - This extensive dissection is performed for invasive cervical cancer, requiring removal of the **entire cardinal and uterosacral ligaments** along with wide parametrial and paravaginal tissue.

Q: Management of RCC less than 4 cm in size:

Partial nephrectomy. ***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.

Q: A middle-aged man presented with a swelling over the neck since childhood. The swelling is irregular and involves large nerves and their branches. Most probable diagnosis is:

Plexiform neurofibroma. ***Plexiform neurofibroma*** - This condition presents as an **irregular swelling** evident since childhood, which is characteristic of the slow growth associated with **plexiform neurofibromas**. - Its involvement of **large nerves and their branches** is a hallmark feature, distinguishing it from other neck masses. *Toxic nodular goitre* - This would present primarily as a **thyroid swelling** and is typically associated with symptoms of **hyperthyroidism**, which are not mentioned. - It does not involve **peripheral nerves** in the manner described. *Lymphangioma* - Lymphangiomas are **benign lymphatic malformations** that typically present as soft, compressible masses. - While they can occur in the neck and be present from childhood, they do not specifically involve or originate from **nerve branches**. *Vasculitis* - Vasculitis is an **inflammation of blood vessels**, which can cause a variety of symptoms including pain, skin lesions, and organ dysfunction. - It does not present as a localized, irregular neck swelling involving **nerve branches** with a history since childhood.

Q: Sentinel lymph node biopsy is most useful for:

Carcinoma vulva. ***Carcinoma vulva*** - **Sentinel lymph node biopsy (SLNB)** is a standard procedure for early-stage vulvar carcinoma to assess nodal involvement with less morbidity than full inguinofemoral lymphadenectomy. - The procedure helps identify metastases in regional lymph nodes, guiding further treatment decisions while minimizing complications like **lymphedema**. *Carcinoma endometrium* - While SLNB can be used in endometrial cancer, its primary utility is in tailoring **lymphadenectomy** rather than being the "most useful" or universally preferred primary staging tool compared to vulvar cancer. - The anatomical spread often involves different lymphatic basins, and **comprehensive pelvic and para-aortic lymphadenectomy** or systematic nodal dissection remains a common approach, though SLNB is gaining traction. *Carcinoma vagina* - The lymphatic drainage of the vagina is complex and variable, making SLNB challenging and less standardized compared to vulvar cancer. - **Radical surgical excision** with **regional lymphadenectomy** remains the mainstay for staging and treatment of invasive vaginal carcinoma. *Carcinoma cervix* - For cervical cancer, SLNB is primarily used in **early-stage disease** to detect micrometastases and guide the extent of lymph node dissection. - However, **imaging** and comprehensive **pelvic lymphadenectomy** are often still crucial components for complete staging and treatment, depending on tumor characteristics.

Q: What is the preferred treatment approach for a patient diagnosed with locally advanced resectable squamous cell carcinoma of the lower esophagus?

Neoadjuvant chemoradiotherapy followed by surgery. ***Neoadjuvant chemoradiotherapy followed by surgery*** - For **locally advanced resectable squamous cell carcinoma of the lower esophagus**, neoadjuvant chemoradiotherapy (concurrent chemotherapy and radiation) followed by surgery is the **preferred treatment strategy**. - The **CROSS trial** and multiple studies have established this as the standard of care, demonstrating improved survival compared to surgery alone. - This approach aims to **downstage the tumor**, eradicate micrometastases, improve resectability, and achieve better locoregional control and overall survival. - **Neoadjuvant chemoradiotherapy** is superior to chemotherapy alone as it provides both systemic and local tumor control. *Radiotherapy alone* - Radiotherapy alone is generally reserved for patients who are **not surgical candidates** due to medical comorbidities or for **definitive chemoradiation** in selected cases. - It is less effective than the multimodality approach combining chemoradiation with surgery for resectable disease. *Palliative care* - Palliative care focuses on symptom management and improving quality of life, typically for **advanced, unresectable, or metastatic disease**. - It is not the primary treatment for resectable disease with curative intent. *Esophagectomy with lymph node dissection* - While surgery (esophagectomy with lymph node dissection) is a **crucial component** of curative treatment, it is typically performed **after neoadjuvant chemoradiotherapy** for locally advanced resectable tumors. - **Surgery alone upfront** for locally advanced disease carries a higher risk of recurrence and lower survival rates compared to the multimodality approach with neoadjuvant therapy.

Q: A 50-year-old male presents with progressive pain and swelling in the knee. A biopsy reveals chondrosarcoma. What is the most appropriate management?

Surgical resection. ***Surgical resection*** - **Chondrosarcoma** is a **radio-resistant** and **chemo-resistant** tumor, making surgical removal with **wide margins** the primary and most effective treatment. - The goal of surgery is to achieve **complete tumor eradication** to prevent local recurrence and improve patient survival rates. *Chemotherapy* - Chondrosarcoma generally shows a **poor response** to conventional chemotherapy due to low mitotic activity and increased resistance. - Chemotherapy is typically reserved for **high-grade, dedifferentiated, or metastatic chondrosarcomas** where other options are limited or as part of a multimodal approach. *Radiotherapy* - Chondrosarcomas are largely **radio-resistant**, meaning they do not respond well to radiation therapy in most cases. - Radiotherapy might be considered for **unresectable tumors**, cases where clear surgical margins cannot be achieved, or for **palliative care** in metastatic disease. *Observation* - **Observation** is not an appropriate management strategy for chondrosarcoma, as it is a **malignant tumor** that will progressively grow and can metastasize. - Delaying treatment allows the tumor to advance, potentially leading to **increased morbidity**, difficulty in complete resection, and a poorer prognosis.

Q: A 70-year-old man with a history of smoking presents with progressive weight loss and fatigue. A CT scan reveals a resectable mass in the left hilum with no evidence of distant metastases. What combination of therapies would offer the best chance of survival?

Surgery followed by chemotherapy. ***Surgery followed by chemotherapy*** - For **resectable non-small cell lung cancer (NSCLC)** without distant metastases, surgical resection is the cornerstone of curative therapy. - **Adjuvant chemotherapy** is recommended post-surgery to eradicate microscopic residual disease and improve overall survival. *Chemotherapy and radiation therapy* - This combination is typically offered for **unresectable or locally advanced NSCLC**, or for patients who are not surgical candidates. - While effective in controlling local disease, it does not offer the same **curative potential** as surgical removal for resectable tumors. *Immunotherapy only* - Immunotherapy is a significant advance in lung cancer treatment, particularly for **advanced or metastatic disease**, or as an adjuvant/neoadjuvant therapy in specific settings. - However, for **resectable early-stage NSCLC**, it is not considered the primary monotherapy and would likely lead to an inferior outcome compared to surgery. *Observation with routine imaging* - This approach is appropriate for **benign lung nodules**, very small tumors in patients with limited life expectancy, or those with significant comorbidities precluding active treatment. - For a **resectable mass** in a 70-year-old with progressive symptoms, observation would lead to disease progression and a lost opportunity for cure.

Q: In a patient with suspected malignant melanoma of the leg, what is the most appropriate next step to confirm the diagnosis and plan treatment?

Total excisional biopsy with narrow margins. ***Total excisional biopsy with narrow margins*** - A **total excisional biopsy** allows for complete histological evaluation of the lesion, including assessment of **tumor thickness (Breslow depth)**, which is crucial for staging and treatment planning in melanoma. - Using **narrow margins** (1-3 mm) minimizes disruption of surrounding tissue, preserving it for definitive wide local excision once the diagnosis is confirmed and staged. *Punch biopsy of the lesion* - A **punch biopsy** provides only a small sample of the lesion, which may not be representative of the entire tumor and can underestimate the Breslow depth, leading to inaccurate staging. - It involves sectioning the lesion, which can potentially interfere with the accurate measurement of tumor thickness if the deepest part of the tumor is missed. *Wide local excision as initial treatment* - Performing a **wide local excision** before confirming the diagnosis and staging is inappropriate. - This aggressive procedure is only indicated after a definitive diagnosis of melanoma and determination of appropriate margins based on Breslow depth to avoid unnecessary tissue removal or inadequate excision. *Immediate lymph node dissection* - **Immediate lymph node dissection** is an extensive surgical procedure with significant morbidity and is not indicated as an initial step. - It is reserved for cases where there is evidence of regional lymph node involvement, either clinically or confirmed by **sentinel lymph node biopsy**, after the primary tumor has been diagnosed and staged.

Question 1

Mohs micrographic excision for basal cell carcinoma is used for all the following Except

Accepted Answer

Superficial basal cell carcinoma on the trunk

Answer

Tumors with perineural invasion

Answer

Tumors with aggressive histology

Answer

Recurrent tumor

Question 2

Radiotherapy has the most significant therapeutic role in:

Accepted Answer

Sarcomas

Answer

Monoclonal gammopathy

Answer

Tuberculosis

Answer

Sarcoidosis

Question 3

In which type of hysterectomy are the uterine vessels ligated at the level of the ureter?

Accepted Answer

Type - II

Answer

Type - I

Answer

Type - IV

Answer

Type - III

Question 4

Management of RCC less than 4 cm in size:

Accepted Answer

Partial nephrectomy

Answer

Surgery followed by chemotherapy

Answer

Radical nephrectomy

Answer

Chemotherapy

Question 5

A middle-aged man presented with a swelling over the neck since childhood. The swelling is irregular and involves large nerves and their branches. Most probable diagnosis is:

Accepted Answer

Plexiform neurofibroma

Answer

Toxic nodular goitre

Answer

Lymphangioma

Answer

Vasculitis

Question 6

Sentinel lymph node biopsy is most useful for:

Accepted Answer

Carcinoma vulva

Answer

Carcinoma endometrium

Answer

Carcinoma vagina

Answer

Carcinoma cervix

Question 7

What is the preferred treatment approach for a patient diagnosed with locally advanced resectable squamous cell carcinoma of the lower esophagus?

Accepted Answer

Neoadjuvant chemoradiotherapy followed by surgery

Answer

Radiotherapy alone

Answer

Palliative care

Answer

Esophagectomy with lymph node dissection

Question 8

A 50-year-old male presents with progressive pain and swelling in the knee. A biopsy reveals chondrosarcoma. What is the most appropriate management?

Accepted Answer

Surgical resection

Answer

Chemotherapy

Answer

Radiotherapy

Answer

Observation

Question 9

A 70-year-old man with a history of smoking presents with progressive weight loss and fatigue. A CT scan reveals a resectable mass in the left hilum with no evidence of distant metastases. What combination of therapies would offer the best chance of survival?

Accepted Answer

Surgery followed by chemotherapy

Answer

Chemotherapy and radiation therapy

Answer

Immunotherapy only

Answer

Observation with routine imaging

Question 10

In a patient with suspected malignant melanoma of the leg, what is the most appropriate next step to confirm the diagnosis and plan treatment?

Accepted Answer

Total excisional biopsy with narrow margins

Answer

Punch biopsy of the lesion

Answer

Wide local excision as initial treatment

Answer

Immediate lymph node dissection

Oncological Surgery — MCQs

Oncological Surgery — MCQs

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