Oncological Surgery — MCQs
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What is the most common histological type of thyroid carcinoma?
What is the treatment for lower lip carcinoma less than 1 cm?
Which of the following immunohistochemical markers can be used for the diagnosis of rhabdomyosarcoma?
A 75-year-old woman presented with an enlarging lesion on the upper back of 3 years' duration. She had multiple co-morbidities. On examination, there was a 4-cm diameter erythematous, shiny plaque. A punch biopsy showed superficial basal cell carcinoma. It was decided to treat her with imiquimod. What is the recommended treatment regimen?
A 56-year-old man presents with a history of a small lump on his finger for some months, which has recently started leaking after an injury sustained while working in the garage. What is the single most likely diagnosis?
Masaoka staging is used in which of the following conditions?
Which of the following is one of the most important prognostic factors for colorectal carcinoma?
A 30-year-old male has papillary thyroid carcinoma with a nodule less than 3 cm confined to the neck, along with 2 palpable lymph nodes in the neck and micro-metastasis in the lungs. According to the AJCC 8th edition, how would you stage this patient?
Sentinel lymph node biopsy is used for which of the following conditions?
In a case of primary melanoma with a depth of 1-2 mm, what should be the margins of excision of surrounding normal skin?
Oncological Surgery Indian Medical PG Practice Questions and MCQs
Question 11: What is the most common histological type of thyroid carcinoma?
- A. Medullary type
- B. Follicular type
- C. Papillary type (Correct Answer)
- D. Anaplastic type
Explanation: **Explanation:** **Papillary Thyroid Carcinoma (PTC)** is the most common histological type of thyroid cancer, accounting for approximately **80–85%** of all cases. It is characterized by its indolent growth and excellent prognosis. The diagnosis is primarily based on distinct nuclear features, such as **Orphan Annie eye nuclei** (cleared-out chromatin), **Psammoma bodies** (laminated calcifications), and nuclear grooves. It typically spreads via the **lymphatics** to cervical lymph nodes. **Analysis of Incorrect Options:** * **Follicular Carcinoma (Option B):** The second most common type (approx. 10%). Unlike PTC, it spreads **hematogenously** (to bone and lungs) and cannot be diagnosed by FNAC alone, as it requires histological evidence of capsular or vascular invasion. * **Medullary Carcinoma (Option A):** Accounts for about 5% of cases. It arises from **Parafollicular C-cells** and secretes **Calcitonin**. It is associated with MEN 2A and 2B syndromes. * **Anaplastic Carcinoma (Option D):** The rarest (<2%) but most aggressive form. It has a very poor prognosis and typically presents in elderly patients as a rapidly enlarging neck mass. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factor:** Prior exposure to ionizing radiation is the most significant risk factor for PTC. * **BRAF Mutation:** The most common genetic mutation associated with Papillary Carcinoma. * **Investigation of Choice:** FNAC is the gold standard for initial evaluation (except for Follicular type). * **Prognosis:** PTC has the best 10-year survival rate (>90%) among all thyroid malignancies.
Question 12: What is the treatment for lower lip carcinoma less than 1 cm?
- A. Radiotherapy
- B. Chemotherapy
- C. Surgical excision (Correct Answer)
- D. Radiotherapy + Chemotherapy
Explanation: **Explanation:** The primary treatment for early-stage (T1) lower lip carcinoma, specifically lesions less than 1 cm, is **surgical excision**. The goal is to achieve a wide local excision with a 5–10 mm clear margin. For lesions of this size, a **V-shaped or wedge resection** is typically performed, allowing for primary closure with excellent functional and cosmetic outcomes. **Why the other options are incorrect:** * **Radiotherapy (A):** While radiotherapy is an alternative for T1-T2 lesions and offers similar control rates, it is generally reserved for patients who are medically unfit for surgery or for larger lesions where surgery would cause significant cosmetic deformity. Surgery is preferred for small lesions because it is quicker, more cost-effective, and avoids long-term radiation side effects (e.g., xerostomia, osteoradionecrosis). * **Chemotherapy (B):** Chemotherapy is not used as a primary or definitive treatment for localized lip cancer. It is typically reserved for palliative care or as part of a concurrent chemoradiation protocol for advanced, inoperable cases. * **Radiotherapy + Chemotherapy (D):** This combination is indicated for advanced (Stage III/IV) disease or high-risk features (positive margins, perineural invasion) but is overtreatment for a <1 cm lesion. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Lower lip (90%) due to chronic sun exposure (UV radiation). * **Histology:** Squamous Cell Carcinoma (SCC) is the most common type. * **Lymphatic spread:** Lower lip cancers primarily drain to **Submental (Level Ia)** and **Submandibular (Level Ib)** nodes. * **Rule of Thirds:** If a defect after excision is <1/3rd of the lip, perform primary closure; if 1/3rd to 2/3rd, use flaps like **Abbe or Estlander**; if >2/3rd, use a **Karapandzic** flap.
Question 13: Which of the following immunohistochemical markers can be used for the diagnosis of rhabdomyosarcoma?
- A. Myeloperoxidase
- B. Desmin (Correct Answer)
- C. Cytokeratin
- D. Synaptophysin
Explanation: **Explanation:** **Rhabdomyosarcoma (RMS)** is a highly malignant soft tissue tumor derived from primitive mesenchymal cells that show evidence of skeletal muscle differentiation. **Why Desmin is the Correct Answer:** Desmin is an intermediate filament protein found in smooth and skeletal muscle cells. It is the most widely used screening marker for myogenic tumors. In the context of rhabdomyosarcoma, **Desmin** is highly sensitive. Other specific markers for skeletal muscle differentiation include **Myogenin (Myf4)** and **MyoD1**, which are nuclear markers and are considered the "gold standard" for confirming the diagnosis of RMS. **Analysis of Incorrect Options:** * **A. Myeloperoxidase (MPO):** This is a marker for myeloid lineage cells. It is primarily used in the diagnosis of **Acute Myeloid Leukemia (AML)** and myeloid sarcoma. * **C. Cytokeratin:** This is a marker for epithelial differentiation. It is used to diagnose **Carcinomas** and certain sarcomas like Synovial Sarcoma, but not typically Rhabdomyosarcoma. * **D. Synaptophysin:** This is a marker for **Neuroendocrine** differentiation, used for tumors like carcinoids, small cell carcinoma, or pheochromocytoma. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Head and neck (overall), though it varies by subtype. * **Subtypes:** * **Embryonal:** Most common overall; includes the *Sarcoma Botryoides* variant (grape-like mass in the vagina/bladder). * **Alveolar:** Associated with t(2;13) or t(1;13) translocations; carries a poorer prognosis. * **IHC Summary:** Desmin (Sensitive) → Myogenin/MyoD1 (Specific).
Question 14: A 75-year-old woman presented with an enlarging lesion on the upper back of 3 years' duration. She had multiple co-morbidities. On examination, there was a 4-cm diameter erythematous, shiny plaque. A punch biopsy showed superficial basal cell carcinoma. It was decided to treat her with imiquimod. What is the recommended treatment regimen?
- A. 3 times per week for 8 weeks
- B. 5 times per week for 6 weeks (Correct Answer)
- C. Alternate days for 4 weeks
- D. Daily for 3 weeks
Explanation: **Explanation:** The patient presents with a **superficial Basal Cell Carcinoma (sBCC)**. While surgical excision is the gold standard for BCC, topical therapy with **Imiquimod 5% cream** is an FDA-approved, effective alternative for patients with small, superficial lesions or those who are poor surgical candidates due to advanced age and comorbidities. **1. Why Option B is Correct:** The standard, evidence-based regimen for treating superficial BCC with Imiquimod 5% is application **5 times per week for a duration of 6 weeks**. This schedule balances efficacy (achieving clearance rates of approximately 80-90%) with manageable local inflammatory side effects (erythema, crusting, and erosions), which are actually markers of the drug's immune-stimulating activity. **2. Why Other Options are Incorrect:** * **Option A (3 times/week for 8 weeks):** This is the standard regimen for **Anogenital Warts**, not sBCC. * **Option C & D:** These regimens are either too infrequent or too short to achieve the necessary histological clearance for a malignant lesion like BCC. Using sub-therapeutic durations increases the risk of recurrence. **3. High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** Imiquimod is an **immune response modifier**. It acts as an agonist at **Toll-like receptor 7 (TLR-7)**, stimulating the release of cytokines (IFN-α, TNF-α, IL-12) and activating cell-mediated immunity. * **Indications:** Superficial BCC, Actinic Keratosis (3x/week), and External Genital Warts. * **Contraindication:** It is generally avoided in "high-risk" BCC subtypes (morpheaform, infiltrating) or lesions in "H-zone" areas of the face where surgery is mandatory. * **Expected Reaction:** Patients should be warned that the lesion will look "worse" (red, inflamed) before it gets better; this indicates the medication is working.
Question 15: A 56-year-old man presents with a history of a small lump on his finger for some months, which has recently started leaking after an injury sustained while working in the garage. What is the single most likely diagnosis?
- A. Keratoacanthoma
- B. Myxoid cyst (Correct Answer)
- C. Pyogenic granuloma
- D. Sebaceous cyst
Explanation: **Explanation:** The clinical presentation of a small, long-standing lump on the finger that leaks fluid—especially after minor trauma—is classic for a **Myxoid cyst** (also known as a digital mucous cyst). **Why Myxoid Cyst is correct:** These are benign ganglion cysts typically located on the dorsum of the distal interphalangeal (DIP) joint or the proximal nail fold. They contain a clear, viscous, jelly-like fluid (hyaluronic acid). A hallmark feature is that they frequently rupture or leak a "clear, sticky fluid" following minor injury, which aligns perfectly with the patient's history of leakage after working in the garage. **Why the other options are incorrect:** * **Keratoacanthoma:** This is a rapidly growing, dome-shaped nodule with a central keratinous plug. It does not typically leak fluid; it is a solid, firm lesion that may undergo spontaneous regression. * **Pyogenic granuloma:** These are vascular lesions that occur after minor trauma. However, they are characterized by bright red, friable tissue that **bleeds profusely** rather than leaking clear fluid. * **Sebaceous cyst:** These are rare on the fingers because fingers lack sebaceous glands (except for the dorsal aspect, but even then, they are uncommon). They contain cheesy keratin and usually have a visible punctum. **NEET-PG High-Yield Pearls:** * **Association:** Myxoid cysts are frequently associated with **osteoarthritis** of the DIP joint (Heberden's nodes). * **Nail Changes:** If the cyst presses on the nail matrix, it can cause a characteristic **longitudinal groove** in the fingernail. * **Management:** Simple aspiration has a high recurrence rate; definitive treatment often requires excision of the cyst and the underlying osteophyte.
Question 16: Masaoka staging is used in which of the following conditions?
- A. Renal Cell Carcinoma (RCC)
- B. Hepatocellular Carcinoma (HCC)
- C. Thymoma (Correct Answer)
- D. Lymphoma
Explanation: **Explanation:** **Masaoka Staging** (specifically the Masaoka-Koga classification) is the most widely used clinical and pathological staging system for **Thymoma**. It is based on the degree of local extension and the presence of metastases. 1. **Why Thymoma is Correct:** The staging focuses on the integrity of the tumor capsule. * **Stage I:** Macroscopically and microscopically completely encapsulated. * **Stage II:** Microscopic (IIa) or Macroscopic (IIb) invasion into the capsule or surrounding fatty tissue. * **Stage III:** Macroscopic invasion into neighboring organs (pericardium, great vessels, or lungs). * **Stage IV:** Pleural/pericardial dissemination (IVa) or Lymphogenous/hematogenous metastasis (IVb). 2. **Why Other Options are Incorrect:** * **RCC:** Staged using the **TNM system** (Robson’s classification was used historically but is now obsolete). * **HCC:** Staged using the **BCLC (Barcelona Clinic Liver Cancer)** system, which incorporates tumor burden, liver function (Child-Pugh), and performance status. * **Lymphoma:** Staged using the **Ann Arbor Staging** system (or the Lugano classification). **High-Yield Clinical Pearls for NEET-PG:** * **Most common association:** Thymoma is strongly associated with **Myasthenia Gravis** (30-45% of patients). * **Surgical Approach:** The treatment of choice for Masaoka Stage I and II is **Total Thymectomy**. * **Radiology:** The "Silhouette sign" on a chest X-ray often helps localize these anterior mediastinal masses. * **WHO Classification:** While Masaoka stages the *extent*, the WHO classification (Type A, AB, B1, B2, B3, C) describes the *histology*.
Question 17: Which of the following is one of the most important prognostic factors for colorectal carcinoma?
- A. Site of lesion
- B. Tumour size and characteristics
- C. Age of patient
- D. Lymph node status (Correct Answer)
Explanation: ### Explanation **Correct Answer: D. Lymph node status** In colorectal carcinoma (CRC), the **extent of nodal involvement (N stage)** is the most significant independent prognostic factor for survival and the primary determinant for administering adjuvant chemotherapy. According to the TNM staging system, the presence of even a single positive lymph node upgrades the disease to **Stage III**, which significantly reduces the 5-year survival rate compared to Stage II (node-negative) disease. The "Lymph Node Ratio" (ratio of positive nodes to total nodes harvested) is also a critical prognostic indicator. **Analysis of Incorrect Options:** * **A. Site of lesion:** While right-sided (proximal) tumors often have a worse prognosis than left-sided tumors due to delayed presentation and different molecular pathways (MSI-H), the anatomical site is secondary to the pathological stage in predicting outcome. * **B. Tumour size and characteristics:** Unlike breast or soft tissue cancers, the absolute size of a colorectal tumor does not determine the T-stage or prognosis. The T-stage is defined by the **depth of wall invasion** (e.g., invasion into the muscularis propria or serosa), not the diameter. * **C. Age of patient:** While younger patients may present with more aggressive histological subtypes (e.g., signet ring cell), age itself is not a primary prognostic factor compared to the pathological stage. **Clinical Pearls for NEET-PG:** * **Minimum Node Harvest:** At least **12 lymph nodes** must be examined pathologically to accurately stage a colorectal specimen as Node Negative (N0). * **Most Important Factor overall:** While lymph node status is the most important for resectable disease, the presence of **Distant Metastasis (M stage)** is the single most important prognostic factor for overall survival. * **CEA Levels:** Pre-operative Carcinoembryonic Antigen (CEA) levels >5 ng/mL are associated with a poorer prognosis but are used for monitoring recurrence, not primary staging.
Question 18: A 30-year-old male has papillary thyroid carcinoma with a nodule less than 3 cm confined to the neck, along with 2 palpable lymph nodes in the neck and micro-metastasis in the lungs. According to the AJCC 8th edition, how would you stage this patient?
- A. Stage I
- B. Stage II (Correct Answer)
- C. Stage III
- D. Stage IV
Explanation: ### Explanation The staging of Papillary Thyroid Carcinoma (PTC) underwent a significant paradigm shift in the **AJCC 8th Edition**, primarily centered on the age of the patient. **1. Why Stage II is Correct:** In the AJCC 8th edition, the age cutoff for staging was increased from 45 to **55 years**. For patients **younger than 55 years**, there are only two possible stages: * **Stage I:** Any T, Any N, **M0** (No distant metastasis). * **Stage II:** Any T, Any N, **M1** (Distant metastasis present). Since this patient is 30 years old (under 55) and has **micro-metastasis in the lungs (M1)**, he is automatically classified as **Stage II**, regardless of the tumor size (T) or lymph node involvement (N). **2. Why Other Options are Incorrect:** * **Stage I:** This would be correct if the patient had no distant metastasis (M0). Even with positive lymph nodes, a patient <55 years remains Stage I if there is no M1. * **Stage III & IV:** These stages **do not exist** for patients under the age of 55 in the AJCC 8th edition. These categories are reserved exclusively for patients aged 55 and older. **3. NEET-PG High-Yield Pearls:** * **Age Cutoff:** Remember **55 years** is the magic number for thyroid cancer staging. * **Younger (<55):** Only Stage I (M0) or Stage II (M1). Death is rare in this group. * **Older (≥55):** Staging follows the traditional I-IV system based on T, N, and M. * **Nodal Status:** In patients <55, N1 (lymph node metastasis) does **not** change the stage from I to II; only M1 does. * **Prognosis:** PTC has an excellent prognosis; the change in age cutoff reflects the low mortality in younger patients even with nodal spread.
Question 19: Sentinel lymph node biopsy is used for which of the following conditions?
- A. Breast carcinoma (Correct Answer)
- B. Penile carcinoma
- C. Retroperitoneal sarcoma
- D. Hepatic carcinoma
Explanation: **Explanation:** **Sentinel Lymph Node Biopsy (SLNB)** is based on the concept that the lymphatic drainage from a primary tumor follows a predictable orderly pattern to a specific first node (or group of nodes), known as the **Sentinel Node**. If this node is negative for metastasis, the remaining nodes in the basin are likely clear, sparing the patient from the morbidity of a radical lymphadenectomy. * **Breast Carcinoma (Correct):** SLNB is the standard of care for clinically node-negative (cN0) breast cancer. It is performed using Technetium-99m labeled sulfur colloid, isosulfan blue dye, or both. It helps avoid the complications of Axillary Lymph Node Dissection (ALND), such as lymphedema and nerve injury. * **Penile Carcinoma (Incorrect):** While SLNB can be used in specific stages of penile cancer (using Dynamic Sentinel Node Biopsy), it is not the "classic" or most common application compared to breast cancer in standard surgical curricula. However, in the context of this MCQ, Breast Carcinoma is the primary established indication. * **Retroperitoneal Sarcoma (Incorrect):** These tumors primarily spread via the hematogenous route rather than predictable lymphatic channels. Surgical management focuses on wide local excision with clear margins (R0 resection) rather than nodal mapping. * **Hepatic Carcinoma (Incorrect):** Hepatocellular carcinoma (HCC) spreads via intrahepatic portal veins or hematogenously. Lymph node mapping is not a standard surgical protocol for HCC. **High-Yield Clinical Pearls for NEET-PG:** * **Most common indications for SLNB:** 1. Breast Carcinoma, 2. Malignant Melanoma. * **Contraindications in Breast Cancer:** Inflammatory breast cancer, clinically palpable nodes (cN1+), and large tumors (T3/T4). * **Identification:** The "Hot and Blue" technique (Radioisotope + Methylene/Isosulfan Blue) has the highest identification rate (>95%). * **Definition of Sentinel Node:** Any node that is blue, has a radioactive count >10% of the "ex vivo" hottest node, or is palpably suspicious.
Question 20: In a case of primary melanoma with a depth of 1-2 mm, what should be the margins of excision of surrounding normal skin?
- A. 0.5-1 cm
- B. 1 cm
- C. 1-2 cm (Correct Answer)
- D. > 2 cm
Explanation: The surgical management of primary cutaneous melanoma is based on the **Breslow Thickness** (depth of invasion), which is the most important prognostic factor and the primary determinant of wide local excision (WLE) margins. ### **Explanation of the Correct Answer** For a melanoma with a depth of **1.01 to 2.0 mm (Intermediate thickness)**, the current international guidelines (NCCN and WHO) recommend a surgical margin of **1–2 cm**. This margin is designed to minimize local recurrence while avoiding unnecessary morbidity associated with larger grafts or flaps. ### **Analysis of Incorrect Options** * **Option A (0.5-1 cm):** This is insufficient for invasive melanoma. A 0.5 cm margin is only considered for *Melanoma in situ* (though 0.5–1 cm is the standard for *in situ*). * **Option B (1 cm):** This is the standard margin for **thin melanomas (≤ 1 mm)**. While 1 cm is the lower limit for 1-2 mm lesions, the standard range is 1-2 cm. * **Option D (> 2 cm):** Margins of 2 cm are reserved for **thick melanomas (> 2 mm)**. Historically, 3-5 cm margins were used, but trials (like the Intergroup Melanoma Trial) showed no survival benefit of 4 cm over 2 cm margins. ### **High-Yield NEET-PG Clinical Pearls** | Breslow Thickness | Recommended Margin | | :--- | :--- | | **In situ** | 0.5 – 1.0 cm | | **≤ 1.0 mm** | 1 cm | | **1.01 – 2.0 mm** | 1 – 2 cm | | **> 2.0 mm** | 2 cm | * **Sentinel Lymph Node Biopsy (SLNB):** Generally indicated for lesions **≥ 0.8 mm** thickness or < 0.8 mm with ulceration. * **Excision Depth:** The excision should extend down to, but not include, the deep fascia. * **Biopsy Gold Standard:** Excisional biopsy with a narrow margin (1-3 mm) is preferred over incisional biopsy for initial diagnosis.
Practice by Chapter
Principles of Surgical Oncology
Practice Questions
Cancer Staging
Practice Questions
Surgical Margins in Cancer Surgery
Practice Questions
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
Practice Questions
Hereditary Cancer Syndromes
Practice Questions
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