Oncological Surgery — MCQs

A 67-year-old retired judge is admitted to the emergency department with severe dyspnea after returning from vacation. On examination, inspiratory stridor, ecchymosis in his neck, and swelling of soft tissue and veins in his face and upper extremities are evident. The CT scan shows an expanding superior mediastinal hematoma. What is the most common source of mediastinal hemorrhage?

Q36Medium

Which of the following is NOT a risk factor for increased incidence of relapse in stage I carcinoma of the breast?

Q37Medium

A 1 cm coin lesion is seen on chest X-ray in the right upper lobe. FNAC shows adenocarcinoma. What is the appropriate management?

Q38Medium

In which type of cancer is immunoguided surgery typically performed?

Q39Medium

A 45-year-old woman presents with a pigmented lesion on her right thigh. An incisional biopsy reveals malignant melanoma with a thickness of 3 mm. Findings on examination of the groin are normal. What is the most appropriate next step in management?

Q40Easy

Sister Joseph's nodule is indicative of cancer of all the following except:

Oncological Surgery Indian Medical PG Practice Questions and MCQs

Question 31: Papillary carcinoma of the thyroid primarily spreads via which route?

A. Lymphatic (Correct Answer)
B. Hematogenous
C. Local spread
D. All of the above

Explanation: **Explanation:** **1. Why Lymphatic is Correct:** Papillary Thyroid Carcinoma (PTC) is the most common type of thyroid malignancy. Its hallmark characteristic is a strong predilection for **lymphatic spread**. Approximately 50-80% of patients have microscopic cervical lymph node involvement at the time of diagnosis. It typically spreads to the central compartment (Level VI) first, followed by the lateral neck nodes (Levels II-V). This occurs because the tumor cells easily invade the rich lymphatic network of the thyroid gland. **2. Why Other Options are Incorrect:** * **Hematogenous:** While PTC can spread via the blood, this is **rare** (seen in <5% of cases) and usually occurs late in the disease, primarily to the lungs and bones. In contrast, **Follicular Carcinoma** is the thyroid malignancy known for early hematogenous spread. * **Local Spread:** While PTC can invade the thyroid capsule and adjacent structures (like the trachea or recurrent laryngeal nerve), this is a feature of advanced T4 disease rather than the primary mode of metastasis. * **All of the Above:** Although all routes are theoretically possible, the question asks for the *primary* route. Lymphatic spread is the defining metastatic pathway for PTC. **3. High-Yield Clinical Pearls for NEET-PG:** * **Psammoma Bodies:** These are pathognomonic laminated calcifications often seen in PTC (representing infarcted papillae). * **Orphan Annie Eye Nuclei:** A classic histological finding (large, pale, clear nuclei). * **Prognosis:** Despite frequent lymph node metastasis, PTC has an excellent 10-year survival rate (>90%). * **Risk Factor:** Prior exposure to ionizing radiation is the most significant risk factor. * **BRAF Mutation:** The V600E mutation is the most common genetic alteration in PTC and is associated with a higher risk of lymph node metastasis.

Question 32: Which of the following is a risk factor for breast carcinoma in women?

A. Consumption of fatty food (Correct Answer)
B. Early menopause
C. Smoking
D. Multiple sexual partners

Explanation: **Explanation:** The correct answer is **A. Consumption of fatty food.** **1. Why "Consumption of fatty food" is correct:** Dietary fat intake is a recognized modifiable risk factor for breast carcinoma. High fat consumption leads to obesity, particularly in postmenopausal women. Adipose tissue contains the enzyme **aromatase**, which converts peripheral androgens into **estrone** (a type of estrogen). Since breast cancer is frequently hormone-dependent, increased cumulative exposure to estrogen promotes the proliferation of mammary epithelium, thereby increasing the risk of malignancy. **2. Why the other options are incorrect:** * **B. Early menopause:** This is a protective factor. **Late menopause** (after age 55) is the actual risk factor because it extends the duration of the "estrogen window." * **C. Smoking:** While smoking is a major risk factor for many cancers (lung, bladder, head, and neck), its direct causal link to breast cancer is less established compared to hormonal and genetic factors. * **D. Multiple sexual partners:** This is a risk factor for **Cervical Cancer** due to increased exposure to Human Papillomavirus (HPV), but it has no association with breast cancer. **3. NEET-PG High-Yield Clinical Pearls:** * **The "Estrogen Window" Concept:** Anything that increases the number of menstrual cycles (Early menarche <12y, Late menopause >55y, Nulliparity) increases breast cancer risk. * **Protective Factors:** Early pregnancy (<20 years), breastfeeding, and regular physical exercise. * **Genetic Risk:** BRCA1 (Chromosome 17) and BRCA2 (Chromosome 13) are the most significant genetic mutations. * **Atypical Hyperplasia:** Finding atypical ductal or lobular hyperplasia on biopsy increases risk by 4–5 times.

Question 33: What is described as the en bloc resection of a segment of bone?

A. Complete resection of the jaw bone
B. Resection of half of the affected jaw
C. Resection of the tumor only
D. The entire tumor is removed intact with a rim of uninvolved bone while maintaining continuity of the jaw (Correct Answer)

Explanation: **Explanation:** In oncological surgery, particularly concerning the mandible or maxilla, the term **"Segmental Resection"** or **"En Bloc Resection"** refers to the removal of a tumor as a single, intact piece along with a margin of healthy, uninvolved bone. The primary goal is to ensure negative margins (R0 resection) to prevent local recurrence. **Why Option D is Correct:** The defining feature of an en bloc resection is that the tumor is never breached; it is removed "in one block" with a surrounding rim of normal tissue. In the context of the jaw, this specific description implies a **marginal resection** where a portion of the bone is removed to ensure oncological safety while preserving the structural continuity of the mandible (i.e., the lower border remains intact). **Analysis of Incorrect Options:** * **Option A & B:** These describe **Total Mandibulectomy** or **Hemimandibulectomy**. While these are forms of en bloc resection, they involve a "discontinuity" resection where the entire thickness of the bone is removed, sacrificing the jaw's structural continuity. * **Option C:** This describes **Enucleation or Curettage**. This is generally contraindicated for malignant tumors as it involves entering the tumor capsule, leading to a high risk of seeding and recurrence. **High-Yield Clinical Pearls for NEET-PG:** * **Margin Requirement:** For malignant bone tumors, a 1–2 cm margin of healthy bone is typically required. * **Indication:** Marginal (en bloc) resection is preferred for tumors that are close to the bone but have not extensively invaded the medullary canal. * **Skip Lesions:** Always remember that certain bone tumors (like Osteosarcoma) can have skip lesions; hence, en bloc resection must be planned based on MRI findings. * **Continuity:** Preserving the inferior border of the mandible (Option D) significantly improves functional and cosmetic outcomes compared to segmental discontinuity.

Question 34: What is the most common tumor found in the posterior mediastinum?

A. Lung cyst
B. Neurofibroma (Correct Answer)
C. Dermoid cyst
D. Thyroid mass

Explanation: **Explanation:** The mediastinum is anatomically divided into compartments, each associated with specific pathologies. The **posterior mediastinum** is the space located between the pericardium and the spine. **Why Neurofibroma is correct:** The posterior mediastinum is primarily occupied by the paravertebral sulcus, which contains the spinal nerves and the sympathetic chain. Consequently, **neurogenic tumors** are the most common primary tumors found in this compartment (accounting for ~75% of posterior mediastinal masses). Among these, **Neurofibromas** and Neurilemmomas (Schwannomas) are the most frequent benign subtypes. In children, neuroblastoma is more common. **Why the other options are incorrect:** * **Lung cyst:** These are typically intrapulmonary or found in the middle mediastinum (e.g., bronchogenic cysts). * **Dermoid cyst:** These are germ cell tumors typically located in the **anterior mediastinum**. * **Thyroid mass:** Retrosternal goiters are almost exclusively found in the **superior or anterior mediastinum**. **Clinical Pearls for NEET-PG:** * **Anterior Mediastinum (The 4 Ts):** Thymoma (most common), Teratoma (Germ cell tumors), Thyroid (Ectopic/Goiter), and "Terrible" Lymphoma. * **Middle Mediastinum:** Most common site for lymphadenopathy and bronchogenic cysts. * **Posterior Mediastinum:** Most common site for neurogenic tumors. * **Dumbbell Tumor:** A classic presentation where a neurogenic tumor extends through the intervertebral foramen, causing both mediastinal and spinal cord compression.

Question 35: A 67-year-old retired judge is admitted to the emergency department with severe dyspnea after returning from vacation. On examination, inspiratory stridor, ecchymosis in his neck, and swelling of soft tissue and veins in his face and upper extremities are evident. The CT scan shows an expanding superior mediastinal hematoma. What is the most common source of mediastinal hemorrhage?

A. Parotid gland surgery
B. Trauma (Correct Answer)
C. Dissecting thoracic aneurysm
D. Mediastinal tumor

Explanation: **Explanation:** The clinical presentation of inspiratory stridor, neck ecchymosis, and Superior Vena Cava (SVC) syndrome-like symptoms (facial/upper extremity swelling) in the context of a superior mediastinal hematoma indicates acute compression of mediastinal structures. **1. Why Trauma is Correct:** Trauma is the **most common cause** of mediastinal hemorrhage. It typically results from rapid deceleration injuries (e.g., motor vehicle accidents) causing a blunt aortic injury (usually at the aortic isthmus) or fractures of the sternum and thoracic spine. The sudden accumulation of blood in the confined mediastinal space leads to "Mediastinal Syndrome," characterized by venous congestion and airway compression. **2. Analysis of Incorrect Options:** * **Parotid gland surgery (A):** This involves the facial and cervical regions. While it can cause local neck hematomas, it does not typically lead to superior mediastinal hemorrhage. * **Dissecting thoracic aneurysm (C):** While a life-threatening cause of mediastinal blood, it is statistically less common than trauma. It usually presents with "tearing" chest pain radiating to the back and asymmetric blood pressure, rather than isolated superior mediastinal symptoms. * **Mediastinal tumor (D):** Tumors (like thymomas or lymphomas) cause chronic SVC syndrome through gradual compression or invasion, but they rarely cause acute, massive hemorrhage unless there is a rare event like intratumoral bleeding. **Clinical Pearls for NEET-PG:** * **Imaging Gold Standard:** Contrast-Enhanced CT (CECT) is the investigation of choice for evaluating mediastinal hematomas and identifying the source (e.g., aortic tear). * **Radiological Sign:** On a plain Chest X-ray, a **widened mediastinum (>8 cm)** is the classic hallmark of mediastinal hemorrhage/aortic injury. * **Management:** Acute airway management is the priority if stridor is present, followed by surgical or endovascular repair of the vascular injury.

Question 36: Which of the following is NOT a risk factor for increased incidence of relapse in stage I carcinoma of the breast?

A. Negative estrogen/progesterone receptor status
B. High S phase fraction
C. Aneuploidy
D. Decreased Her-2/neu oncogene expression (Correct Answer)

Explanation: **Explanation:** In breast cancer management, prognostic factors are used to predict the risk of recurrence and guide adjuvant therapy. The question asks for the factor that is **NOT** associated with an increased risk of relapse. **1. Why Option D is Correct:** The **Her-2/neu (c-erbB2)** oncogene is a transmembrane tyrosine kinase receptor. **Increased expression (amplification)** of this gene is associated with aggressive tumor behavior, higher grade, and a significantly increased risk of relapse. Therefore, **decreased expression** would theoretically imply a better prognosis or a baseline risk, rather than an increased risk of relapse. **2. Analysis of Incorrect Options (Risk Factors for Relapse):** * **A. Negative ER/PR status:** Estrogen and Progesterone receptor-negative tumors are generally more aggressive, have a higher histological grade, and do not respond to endocrine therapies (like Tamoxifen), leading to a higher incidence of relapse. * **B. High S-phase fraction:** This is a measure of cellular proliferation (the percentage of cells replicating DNA). A high S-phase fraction indicates a rapidly dividing, aggressive tumor with a higher likelihood of recurrence. * **C. Aneuploidy:** DNA aneuploidy (abnormal amount of DNA) is a marker of genetic instability. Aneuploid tumors have a worse prognosis compared to diploid tumors in Stage I breast cancer. **Clinical Pearls for NEET-PG:** * **Most important prognostic factor** for breast cancer: Number of axillary lymph nodes involved. * **Most important prognostic factor in Node-Negative (Stage I) disease:** Tumor size. * **Triple Negative Breast Cancer (TNBC):** Lacks ER, PR, and Her-2 expression; carries the worst prognosis among molecular subtypes. * **Luminal A:** (ER/PR +, Her-2 -, low Ki-67) has the best prognosis.

Question 37: A 1 cm coin lesion is seen on chest X-ray in the right upper lobe. FNAC shows adenocarcinoma. What is the appropriate management?

A. Excision and observation (Correct Answer)
B. Excision and chemotherapy
C. Neoadjuvant chemotherapy followed by excision
D. Excision and chemoradiation

Explanation: ### Explanation **Correct Answer: A. Excision and observation** The clinical scenario describes a **Stage IA1 Non-Small Cell Lung Cancer (NSCLC)**. A 1 cm lesion is classified as **T1a** (≤1 cm), and in the absence of lymphadenopathy or distant metastasis, it is Stage IA. **Why Option A is correct:** For early-stage NSCLC (Stage I and II), the primary treatment is surgical resection (Lobectomy with hilar/mediastinal lymph node dissection is the gold standard, though sub-lobar resection may be considered for lesions <2 cm). According to current oncological guidelines (NCCN/ASCO), **adjuvant chemotherapy is NOT indicated for Stage IA tumors.** These patients have a high cure rate with surgery alone; therefore, the management plan is surgical excision followed by observation (surveillance). **Why other options are incorrect:** * **Option B & D:** Adjuvant chemotherapy (with or without radiation) is generally reserved for **Stage II and IIIA** disease or Stage IB patients with high-risk features (e.g., tumors >4 cm, vascular invasion). For a 1 cm (Stage IA) lesion, the risks of chemotherapy toxicity outweigh the survival benefits. * **Option C:** Neoadjuvant chemotherapy is typically considered for **Stage IIIA (N2 disease)** to downstage the tumor before surgery. It is not indicated for a small, localized 1 cm coin lesion. **Clinical Pearls for NEET-PG:** 1. **Staging Cut-offs:** T1a (≤1 cm), T1b (>1 to 2 cm), T1c (>2 to 3 cm). 2. **Adjuvant Chemotherapy Rule:** It is indicated for tumors **>4 cm (Stage IB)** or if there is **node-positive disease (Stage II/III)**. 3. **Solitary Pulmonary Nodule (SPN):** A "coin lesion" is an SPN. If malignancy is confirmed (as via FNAC here), surgical resection is the definitive treatment. 4. **Investigation of Choice:** While FNAC was done here, **CT-guided biopsy** or **PET-CT** are preferred for staging and characterization in clinical practice.

Question 38: In which type of cancer is immunoguided surgery typically performed?

A. Colon cancer (Correct Answer)
B. Pancreatic cancer
C. Jejunal cancer
D. Anal canal cancer

Explanation: **Explanation:** **Immunoguided Surgery (IGS)**, also known as Radioimmunoguided Surgery (RIGS), is a specialized technique that utilizes radiolabeled monoclonal antibodies to identify occult tumor deposits, lymph node involvement, or residual disease that may not be visible or palpable to the surgeon. 1. **Why Colon Cancer is Correct:** Colorectal cancer is the classic indication for immunoguided surgery. The procedure typically involves the preoperative injection of **125I-labeled B72.3** or **CC49** monoclonal antibodies, which target the **TAG-72 (Tumor-Associated Glycoprotein 72)** antigen commonly expressed on colorectal adenocarcinoma cells. During surgery, a handheld gamma detection probe is used to locate "hot spots," allowing for more precise staging and ensuring oncological clearance (R0 resection). 2. **Why Other Options are Incorrect:** * **Pancreatic and Jejunal Cancer:** While research into molecular imaging is ongoing, these are not the standard or "typical" clinical applications for immunoguided surgery compared to the established protocols for colorectal malignancies. * **Anal Canal Cancer:** The primary treatment for most anal canal cancers (Squamous Cell Carcinoma) is chemoradiotherapy (Nigro Protocol), not primary radical surgery. Therefore, intraoperative immunoguidance is not a standard part of its management. **High-Yield Clinical Pearls for NEET-PG:** * **Target Antigen:** TAG-72 is the most common target for RIGS in colorectal surgery. * **Isotope Used:** Iodine-125 ($^{125}I$) is preferred due to its low energy and long half-life, which is ideal for the handheld probe. * **Clinical Utility:** RIGS is particularly useful in **recurrent** colorectal cancer to differentiate between postoperative fibrosis and tumor recurrence. * **Sentinel Lymph Node Mapping:** Do not confuse RIGS with sentinel node mapping (which uses Technetium-99m sulfur colloid or isosulfan blue), though both use intraoperative probes.

Question 39: A 45-year-old woman presents with a pigmented lesion on her right thigh. An incisional biopsy reveals malignant melanoma with a thickness of 3 mm. Findings on examination of the groin are normal. What is the most appropriate next step in management?

A. Wide local excision with a 1-cm margin, followed by radiotherapy
B. Wide local excision with a 1-cm margin and groin lymph node dissection
C. Wide local excision with a 2-cm margin and sentinel lymph node biopsy (Correct Answer)
D. Wide local excision with a 2-cm margin and groin lymph node dissection

Explanation: ### Explanation The management of malignant melanoma is primarily determined by the **Breslow thickness**, which dictates the surgical margins and the need for nodal evaluation. **1. Why Option C is Correct:** * **Surgical Margins:** For a melanoma with a thickness of **3 mm** (Intermediate thickness: 2.01–4.0 mm), the current international guidelines (AJCC/NCCN) recommend a **wide local excision (WLE) with a 2-cm margin**. * **Nodal Management:** In patients with a Breslow thickness **>0.8 mm** (or <0.8 mm with ulceration) and **clinically negative nodes (cN0)**, a **Sentinel Lymph Node Biopsy (SLNB)** is indicated. It is the most accurate staging tool for regional micrometastasis. Since this patient has a 3 mm lesion and a normal groin exam, SLNB is the standard of care. **2. Why Other Options are Wrong:** * **Option A:** A 1-cm margin is insufficient for a 3-mm thick lesion (used for lesions ≤1 mm). Radiotherapy is not a standard primary treatment for localized melanoma. * **Option B:** The 1-cm margin is inadequate. Furthermore, a formal lymph node dissection (CLND) is not performed upfront for clinically negative nodes; SLNB must precede it. * **Option C:** While the margin is correct, a **Completion Lymph Node Dissection (CLND)** is only indicated if the SLNB is positive. Prophylactic node dissection in cN0 patients does not improve survival and increases morbidity. **3. High-Yield Clinical Pearls for NEET-PG:** * **Breslow Thickness & Margins:** * In situ: 0.5 cm * ≤1.0 mm: 1 cm * 1.01–2.0 mm: 1–2 cm * >2.0 mm: 2 cm * **SLNB Indications:** Breslow thickness >1 mm; or 0.8–1.0 mm if ulcerated or high mitotic rate. * **Most Important Prognostic Factor:** Breslow thickness (vertical growth) is the most significant prognostic indicator for Stage I and II melanoma. * **Biopsy Gold Standard:** Excisional biopsy with 1–3 mm margins. Incisional biopsy (as seen in this question) should generally be avoided unless the lesion is very large or in a sensitive area (e.g., face).

Question 40: Sister Joseph's nodule is indicative of cancer of all the following except:

A. Stomach
B. Large bowel
C. Rectum (Correct Answer)
D. Ovary

Explanation: **Explanation:** **Sister Mary Joseph’s Nodule (SMJN)** refers to a palpable nodule in the umbilicus resulting from the metastasis of a malignant intra-abdominal or pelvic tumor. **Why Rectum is the Correct Answer:** The umbilicus receives lymphatic drainage from the organ systems via the subperitoneal plexus. While SMJN is associated with various intra-abdominal malignancies, it is **least likely** to occur with **rectal cancer**. Rectal lymphatics primarily drain to the pararectal, internal iliac, and inferior mesenteric nodes. In contrast, cancers of the upper gastrointestinal tract and pelvic organs have more direct embryonic or ligamentous pathways to the umbilicus. **Analysis of Other Options:** * **Stomach (Option A):** Gastric adenocarcinoma is the **most common** cause of SMJN (approx. 25-30% of cases). Metastasis occurs via the lymphatics or the gastrocolic ligament. * **Large Bowel (Option B):** Colon cancer is a frequent primary site. Spread occurs through the lymphatics or via the persistent vestigial remnants of the urachus or vitelline duct. * **Ovary (Option C):** Ovarian cancer is the most common cause of SMJN in females. Spread occurs via the suspensory ligaments or transperitoneal seeding. **High-Yield Clinical Pearls for NEET-PG:** * **Eponym:** Named after Sister Mary Joseph, the surgical assistant to Dr. William Mayo, who noticed the association between umbilical nodules and intra-abdominal malignancy. * **Prognosis:** The presence of SMJN signifies **advanced stage (Stage IV)** disease and carries a poor prognosis. * **Most Common Primary:** Stomach (Overall); Ovary (in females). * **Routes of Spread:** Lymphatics (most common), venous (portal circulation), or via vestigial structures (ligamentum teres, urachus).

Practice by Chapter

Principles of Surgical Oncology

Practice Questions

Cancer Staging

Practice Questions

Surgical Margins in Cancer Surgery

Practice Questions

Sentinel Lymph Node Concepts

Practice Questions

Neoadjuvant and Adjuvant Therapy

Practice Questions

Metastasectomy

Practice Questions

Cytoreductive Surgery

Practice Questions

Hyperthermic Intraperitoneal Chemotherapy

Practice Questions

Palliative Surgical Procedures

Practice Questions

Minimally Invasive Approaches in Cancer Surgery

Practice Questions

Follow-up and Surveillance

Practice Questions

Hereditary Cancer Syndromes

Practice Questions

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free