Oncological Surgery — MCQs

Oncological Surgery Indian Medical PG Practice Questions and MCQs

Question 21: All of the following are treatment modalities in malignant mesothelioma except?

A. Talc Pleurodesis
B. Extrapleural pneumonectomy
C. Combination therapy with surgery, chemotherapy and radiotherapy
D. Exclusive Radiotherapy (Correct Answer)

Explanation: **Explanation:** Malignant Pleural Mesothelioma (MPM) is an aggressive tumor arising from the mesothelial surfaces, strongly associated with asbestos exposure. The management of MPM is primarily **multimodal**; single-modality treatment is rarely effective. **Why "Exclusive Radiotherapy" is the correct answer:** Radiotherapy is technically challenging in MPM because the tumor spreads circumferentially along the entire pleura. Delivering a radical dose to the entire hemithorax would cause fatal toxicity to the underlying lung, heart, and spinal cord. Therefore, radiotherapy is used only as an **adjuvant** (after surgery) or for **palliative** symptom control (e.g., painful chest wall nodules), but never as a definitive, exclusive treatment. **Analysis of other options:** * **Talc Pleurodesis:** This is a standard **palliative** procedure used to manage recurrent malignant pleural effusions, improving the patient's quality of life by preventing fluid re-accumulation. * **Extrapleural Pneumonectomy (EPP):** This is a radical surgical procedure involving the en bloc resection of the visceral and parietal pleura, the underlying lung, the ipsilateral diaphragm, and the pericardium. It is reserved for fit patients with early-stage disease. * **Combination Therapy:** This is the **gold standard** for resectable MPM. It typically involves "Trimality Therapy": Neoadjuvant chemotherapy (Pemetrexed + Cisplatin), followed by radical surgery (EPP or Pleurectomy/Decortication), and adjuvant radiotherapy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Pleura (followed by peritoneum). * **Strongest Risk Factor:** Asbestos exposure (latency period of 20–40 years). * **Histology:** The **Epithelioid** variant has the best prognosis; Sarcomatoid has the worst. * **Marker of choice:** Calretinin (+ve), WT-1 (+ve), and Cytokeratin 5/6 (+ve). It is typically **Carcinoembryonic Antigen (CEA) negative** (helps differentiate from Adenocarcinoma). * **Imaging:** CT shows "nodular pleural thickening" or a "pleural rind."

Question 22: Which is the most common type of thyroid carcinoma with the least hematogenous spread?

A. Follicular
B. Papillary (Correct Answer)
C. Anaplastic
D. Medullary

Explanation: ### Explanation **Correct Option: B. Papillary Thyroid Carcinoma (PTC)** Papillary carcinoma is the **most common** type of thyroid malignancy (accounting for ~80–85% of cases). The hallmark of PTC is its mode of metastasis: it spreads primarily via the **lymphatics** to the cervical lymph nodes. It has the **least tendency for hematogenous (blood-borne) spread** among all thyroid cancers. This localized spread and slow growth contribute to its excellent prognosis. **Incorrect Options:** * **A. Follicular Thyroid Carcinoma (FTC):** This is the second most common type. Unlike PTC, its hallmark is **hematogenous spread** (to bone and lungs) because it tends to invade blood vessels rather than lymphatics. * **C. Anaplastic Carcinoma:** This is the most aggressive and undifferentiated form. It spreads rapidly via both direct local invasion and hematogenous routes, carrying the worst prognosis. * **D. Medullary Thyroid Carcinoma (MTC):** Arising from parafollicular C-cells, it spreads via both lymphatics and blood. While it can involve lymph nodes early, it has a higher rate of distant hematogenous metastasis compared to PTC. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factor:** Prior exposure to ionizing radiation is the most significant risk factor for PTC. * **Microscopic Features:** Look for **Orphan Annie eye nuclei** (empty-appearing nuclei), **Psammoma bodies** (laminated calcifications), and **Nuclear grooves**. * **Prognosis:** Excellent; the 10-year survival rate is >90%. * **Management:** Usually involves total thyroidectomy or hemithyroidectomy followed by Radioiodine (RAI) ablation if indicated. Lymph node dissection is performed only if nodes are clinically involved (unlike MTC, where prophylactic dissection is common).

Question 23: What is the primary treatment for lower lip carcinoma?

A. Radiation
B. Chemotherapy
C. Excision (Correct Answer)
D. Radiation and chemotherapy

Explanation: **Explanation:** **Primary Treatment: Surgical Excision** The gold standard treatment for lower lip carcinoma (most commonly Squamous Cell Carcinoma) is **surgical excision** with adequate margins (typically 5–10 mm). Surgery is preferred because it offers high cure rates, allows for precise histopathological assessment of margins, and provides superior functional and cosmetic outcomes through various reconstructive techniques (e.g., V-excision, Abbe-Estlander flap, or Karapandzic flap). **Analysis of Options:** * **Radiation (Option A):** While lip cancer is radiosensitive, radiotherapy is generally reserved for patients who are medically unfit for surgery, have extensive lesions where surgery would be mutilating, or as adjuvant therapy for positive margins/perineural invasion. It can cause long-term complications like xerostomia and osteoradionecrosis. * **Chemotherapy (Option B):** Chemotherapy is not a primary curative modality for localized lip cancer. It is used in palliative settings or as part of induction protocols for advanced, unresectable disease. * **Radiation and Chemotherapy (Option D):** Concurrent chemoradiotherapy is the standard for advanced oropharyngeal cancers but is not the first-line approach for the easily accessible and surgically curable lower lip. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Chronic sun exposure (UV radiation) is the most significant risk factor. * **Most Common Site:** The lower lip is involved in ~90% of cases (due to greater sun exposure compared to the upper lip). * **Histology:** Squamous Cell Carcinoma (SCC) is the most common type on the lower lip, whereas Basal Cell Carcinoma (BCC) is more common on the upper lip. * **Lymphatic Spread:** Lower lip SCC primarily drains to **Submental (Level Ia)** and **Submandibular (Level Ib)** lymph nodes. * **Prognosis:** Lip cancer generally has a better prognosis than intraoral SCC because it is detected early and metastasizes late.

Question 24: Thyroglossal cyst may occasionally give rise to which type of carcinoma?

A. Papillary (Correct Answer)
B. Medullary
C. Anaplastic
D. Follicular

Explanation: **Explanation:** A thyroglossal cyst is a congenital anomaly resulting from the failure of the thyroglossal duct to obliterate. While most cysts are benign, malignancy occurs in approximately **1%** of cases. **Why Papillary Carcinoma is correct:** The thyroglossal duct is lined by respiratory or squamous epithelium, but it frequently contains **ectopic thyroid tissue** within its wall. Because this tissue is embryologically derived from the thyroid primordium, it is susceptible to the same neoplastic transformations as the thyroid gland itself. **Papillary carcinoma** is the most common type (occurring in >80% of malignant cases) because the ectopic tissue is most prone to this specific transformation. Diagnosis is often made incidentally after a Sistrunk operation. **Why other options are incorrect:** * **Medullary Carcinoma:** This arises from parafollicular C-cells, which are derived from the **ultimobranchial body** (not the thyroglossal duct). Therefore, medullary carcinoma is almost never found in a thyroglossal cyst. * **Anaplastic Carcinoma:** This is an undifferentiated, highly aggressive tumor of the elderly. It is extremely rare in the ectopic tissue of a thyroglossal duct. * **Follicular Carcinoma:** While possible, it is significantly less common than the papillary variety in this location. **High-Yield Clinical Pearls for NEET-PG:** * **Sistrunk Operation:** The definitive treatment for a thyroglossal cyst; it involves excision of the cyst, the entire duct, and the **central part of the hyoid bone** to prevent recurrence. * **Movement:** A thyroglossal cyst is unique because it moves upward on **protrusion of the tongue** (due to its attachment to the foramen caecum via the hyoid). * **Location:** Most commonly found in the **subhyoid** position.

Question 25: What is the treatment of choice for anaplastic carcinoma of the thyroid that infiltrates the trachea and sternum?

A. Radical excision
B. Chemotherapy
C. Radiotherapy
D. Palliative/Symptomatic treatment (Correct Answer)

Explanation: **Explanation:** Anaplastic Thyroid Carcinoma (ATC) is one of the most aggressive solid tumors in humans, characterized by rapid growth and early local invasion. By the time of diagnosis, most patients present with Stage IV disease. **1. Why Palliative/Symptomatic treatment is correct:** In this clinical scenario, the tumor has already infiltrated vital structures like the **trachea and sternum**, rendering it **unresectable**. The primary goal of management for advanced ATC is not curative, but to maintain the airway and improve quality of life. Palliative measures include tracheostomy (to prevent asphyxiation), gastrostomy (for nutrition), and palliative radiotherapy/chemotherapy to reduce tumor bulk. **2. Why the other options are incorrect:** * **Radical Excision:** Surgery is only indicated if the tumor is small and localized (rare). Once there is extensive infiltration of the trachea and sternum, radical surgery is morbid and does not improve survival. * **Chemotherapy & Radiotherapy:** While these are used in ATC, they are rarely curative. In the context of extensive infiltration, they are used as **adjuncts to palliative care** rather than the primary "treatment of choice" for cure. ATC is notoriously resistant to standard chemotherapy. **Clinical Pearls for NEET-PG:** * **Demographics:** Typically affects elderly patients (6th–7th decade). * **Presentation:** Rapidly enlarging neck mass, dysphagia, and hoarseness (vocal cord palsy). * **Histology:** Shows spindle, polygonal, or giant cells; p53 mutations are common. * **Prognosis:** Extremely poor; median survival is 3–6 months. * **Management Priority:** Always secure the airway first (Tracheostomy is often required).

Question 26: A 60-year-old man is suspected of having endobronchial carcinoma. What is the best investigation?

A. CT guided FNAC
B. Bronchoscopy and biopsy (Correct Answer)
C. Sputum cytology
D. X-ray chest

Explanation: **Explanation:** The diagnosis of lung cancer depends on the location of the lesion. For **endobronchial carcinoma** (centrally located tumors arising within the large airways), **Bronchoscopy and biopsy** is the investigation of choice. It allows for direct visualization of the tumor, assessment of its proximity to the carina (crucial for operability), and the collection of tissue for histopathological confirmation, which is essential for staging and treatment planning. **Analysis of Options:** * **A. CT-guided FNAC:** This is the investigation of choice for **peripheral lung lesions** that are inaccessible by a bronchoscope. In endobronchial cases, it carries a higher risk of pneumothorax and may not yield enough tissue for architectural grading. * **C. Sputum cytology:** While non-invasive and useful for screening central squamous cell carcinomas, it has low sensitivity and cannot provide the precise anatomical localization required for surgical planning. * **D. X-ray chest:** This is usually the initial screening tool. While it may show a mass, collapse, or obstructive pneumonitis, it is not diagnostic and cannot differentiate between malignancy and other pathologies. **Clinical Pearls for NEET-PG:** * **Central Tumors:** Squamous cell carcinoma and Small cell carcinoma (Best investigated via Bronchoscopy). * **Peripheral Tumors:** Adenocarcinoma and Large cell carcinoma (Best investigated via CT-guided FNAC). * **Staging:** Contrast-Enhanced CT (CECT) of the chest and upper abdomen is the standard for radiological staging, while PET-CT is used for detecting distant metastasis. * **Gold Standard for Mediastinal Nodes:** Endobronchial Ultrasound (EBUS) guided TBNA.

Question 27: Sarcoma Botryoides is also known as:

A. Embryonal rhabdomyosarcoma (Correct Answer)
B. Alveolar rhabdomyosarcoma
C. Leiomyosarcoma
D. Lipoblastomatosis

Explanation: **Explanation:** **Sarcoma Botryoides** is a distinct variant of **Embryonal Rhabdomyosarcoma (ERMS)**. The term "botryoides" is derived from the Greek word *botryos*, meaning "a bunch of grapes," which describes its characteristic macroscopic appearance. 1. **Why Option A is Correct:** Sarcoma Botryoides arises from primitive mesenchymal cells (rhabdomyoblasts) under the mucosal surface of hollow organs. It typically presents as a polypoid, friable, grape-like mass protruding from the **vagina** (most common in infants/toddlers), urinary bladder, or biliary tract. Histologically, it is characterized by a dense layer of undifferentiated tumor cells immediately beneath the epithelium, known as the **Cambium layer**. 2. **Why Other Options are Incorrect:** * **B. Alveolar Rhabdomyosarcoma:** This is a more aggressive subtype of rhabdomyosarcoma usually seen in adolescents. It involves the extremities and is characterized by a "cluster of grapes" appearance microscopically (alveolar pattern), but not macroscopically. It is associated with the **t(2;13)** translocation. * **C. Leiomyosarcoma:** A malignant tumor of smooth muscle origin, typically seen in older adults (e.g., uterus or retroperitoneum). It does not exhibit the botryoid growth pattern. * **D. Lipoblastomatosis:** A benign mesenchymal tumor of fetal white fat, usually occurring in children under age 3. It is not related to skeletal muscle (rhabdo) lineages. **High-Yield Clinical Pearls for NEET-PG:** * **Age Group:** Most common in children < 5 years of age. * **Classic Presentation:** A young girl (infant) with "grape-like" masses protruding from the vagina or blood-stained discharge. * **Pathognomonic Feature:** The **Cambium Layer** (subepithelial condensation of tumor cells). * **Marker:** Desmin, Myogenin, and MyoD1 (markers for skeletal muscle differentiation). * **Prognosis:** Generally has a better prognosis compared to the alveolar subtype.

Question 28: What is the recommended treatment for stage 2 anal canal cancer?

A. Chemoradiation (Correct Answer)
B. Abdominoperineal resection
C. Chemotherapy and surgery
D. Radiotherapy only

Explanation: **Explanation:** The primary treatment for squamous cell carcinoma (SCC) of the anal canal (Stages I, II, and III) is **definitive chemoradiation**, commonly known as the **Nigro Protocol**. 1. **Why Chemoradiation is Correct:** Unlike most gastrointestinal cancers where surgery is the mainstay, anal canal cancer is highly radiosensitive and chemosensitive. The Nigro Protocol (consisting of 5-Fluorouracil, Mitomycin-C, and external beam radiation) achieves high cure rates while **preserving the anal sphincter**, thereby avoiding a permanent colostomy and maintaining the patient's quality of life. 2. **Why Other Options are Incorrect:** * **Abdominoperineal Resection (APR):** Historically the gold standard, it is now reserved only for **salvage therapy** (persistent or recurrent disease) or for patients who cannot tolerate radiation. * **Chemotherapy and Surgery:** Surgery is not part of the initial multimodal management for Stage 2 disease. * **Radiotherapy only:** While radiation is effective, the addition of chemotherapy (Mitomycin-C) has been proven in clinical trials to significantly reduce local recurrence rates compared to radiation alone. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histology:** Squamous Cell Carcinoma (associated with HPV 16 and 18). * **Nigro Protocol components:** 5-FU + Mitomycin-C + Radiation. * **Anal Margin vs. Anal Canal:** Small (<2cm), well-differentiated tumors of the **anal margin** (not canal) can be treated with wide local excision. * **Follow-up:** Response to chemoradiation can be slow; clinical assessment of "cure" is usually done at 12–26 weeks post-treatment. * **Salvage Surgery:** APR is the treatment of choice for biopsy-proven residual disease after chemoradiation.

Question 29: What is a sentinel lymph node?

A. A group of lymph nodes
B. The first lymph node along the lymphatic drainage pathway from a tumor (Correct Answer)
C. A lymph node that is bypassed during distant metastasis
D. A lymph node that has metastasized distantly

Explanation: ### Explanation The **Sentinel Lymph Node (SLN)** is defined as the first lymph node (or group of nodes) in a regional lymphatic basin that receives direct lymphatic drainage from a primary tumor. The underlying medical concept is the **"Sentinel Node Hypothesis,"** which posits that if a tumor spreads via the lymphatic system, the sentinel node will be the first to harbor metastatic cells. If the SLN is negative for malignancy, there is a high probability (usually >95%) that the remaining nodes in that basin are also clear, allowing patients to avoid the morbidity of a formal lymph node dissection. **Analysis of Options:** * **Option B (Correct):** Accurately describes the anatomical and physiological role of the SLN as the primary filter in the drainage pathway. * **Option A:** While multiple nodes can sometimes be "sentinel" if they receive direct drainage simultaneously, the term specifically refers to the *position* in the drainage sequence, not just any group of nodes. * **Option C:** This describes "skip metastasis," where a tumor bypasses the first-tier nodes to involve distant ones—this is the exception to the sentinel node rule. * **Option D:** This is a description of a metastatic node in general, not specifically the sentinel node. **Clinical Pearls for NEET-PG:** * **Identification:** SLNs are identified using **Technetium-99m labeled sulfur colloid** (radioactive tracer) and/or **Isosulfan/Methylene blue dye**. * **Gold Standard Use:** Most commonly used in the management of **Breast Cancer** and **Malignant Melanoma**. * **Contraindications:** SLN biopsy is generally avoided if there are clinically palpable/positive nodes (cN1) or inflammatory breast cancer. * **Frozen Section:** Often performed intraoperatively to decide if a complete axillary lymph node dissection (ALND) is required.

Question 30: What is the standard treatment for verrucous carcinoma of the lip?

A. Surgery and radiotherapy
B. Surgical excision (Correct Answer)
C. Laser therapy
D. Interferon

Explanation: **Explanation:** Verrucous carcinoma (Ackerman’s tumor) is a distinct, well-differentiated variant of squamous cell carcinoma characterized by a slow-growing, "wart-like" exophytic appearance. **Why Surgical Excision is the Correct Answer:** The gold standard treatment is **wide local surgical excision**. Verrucous carcinoma is locally aggressive but rarely metastasizes to regional lymph nodes. Therefore, complete surgical removal with clear margins is usually curative. Unlike typical squamous cell carcinoma, routine neck dissection is not indicated unless there is clinical evidence of lymphadenopathy or a hybrid tumor component. **Analysis of Incorrect Options:** * **A. Surgery and Radiotherapy:** Radiotherapy is generally **contraindicated** as a primary or adjuvant treatment. Exposure to radiation can trigger "anaplastic transformation," turning a low-grade verrucous lesion into a highly aggressive, rapidly metastasizing spindle cell carcinoma. * **C. Laser Therapy:** While used for some superficial premalignant lesions, laser therapy is inadequate for verrucous carcinoma because it does not allow for precise margin assessment and may lead to incomplete removal of the deep "pushing" borders. * **D. Interferon:** Medical therapies like interferon or chemotherapy are not primary treatment modalities for localized verrucous carcinoma, which is primarily a surgical disease. **Clinical Pearls for NEET-PG:** * **Histology:** Characterized by a "pushing" rather than an "infiltrating" margin and minimal cellular atypia. * **Common Sites:** Most common in the oral cavity (buccal mucosa) and associated with smokeless tobacco (Snuff dipper’s cancer). * **Key Contraindication:** Avoid Radiotherapy due to the risk of **anaplastic transformation**. * **Prognosis:** Excellent if completely excised, as distant metastasis is extremely rare.

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

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Hereditary Cancer Syndromes

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