Oncological Surgery — MCQs

Oncological Surgery Indian Medical PG Practice Questions and MCQs

Question 41: In a patient with Ca Breast, ipsilateral supraclavicular lymph nodes are positive. Which of the following represents the stage of malignancy in this patient?

A. Stage II
B. Stage III B
C. Stage III C (Correct Answer)
D. Stage IV

Explanation: ### Explanation The staging of Breast Cancer follows the **AJCC TNM Classification (8th Edition)**. The involvement of **ipsilateral supraclavicular lymph nodes** is a critical anatomical landmark in determining the N-stage and overall clinical stage. #### Why Stage III C is Correct? According to the TNM staging system: * **N3a:** Metastasis in ipsilateral infraclavicular lymph node(s). * **N3b:** Metastasis in ipsilateral internal mammary and axillary lymph nodes. * **N3c:** Metastasis in **ipsilateral supraclavicular lymph node(s)**. Any T (Tumor size) combined with **N3** nodal status automatically categorizes the malignancy as **Stage III C**. This represents advanced regional spread but is still considered "locoregionally advanced" rather than distant metastasis. #### Why Other Options are Incorrect: * **Stage II:** Represents smaller tumors (T1-T2) with limited mobile axillary nodes (N0-N1). Supraclavicular involvement is far too advanced for this stage. * **Stage III B:** This stage is defined by **T4 status** (tumor of any size with direct extension to the chest wall or skin, including inflammatory breast cancer) with N0-N2 nodes. It does not include N3 nodal involvement. * **Stage IV:** This represents **distant metastasis (M1)**. While supraclavicular nodes were once considered M1, they are now classified as **N3 (Stage III C)**. Only contralateral supraclavicular nodes or nodes beyond the regional basin (e.g., cervical, lungs, liver) would signify Stage IV. #### High-Yield Clinical Pearls for NEET-PG: * **N1:** Mobile ipsilateral level I, II axillary nodes. * **N2:** Fixed/matted ipsilateral axillary nodes or clinically detected internal mammary nodes. * **N3:** Infraclavicular, Supraclavicular, or both Internal Mammary + Axillary nodes. * **Prognostic Significance:** Stage III C is the most advanced stage of non-metastatic breast cancer. Treatment usually begins with Neoadjuvant Chemotherapy (NACT).

Question 42: Which of the following factors is not included in the TNM staging of carcinoma breast?

A. Satellite nodules
B. Inflammation
C. Nipple retraction (Correct Answer)
D. Skin ulceration

Explanation: In the AJCC TNM staging system for breast cancer, staging is determined by the anatomical extent of the disease. The correct answer is **Nipple Retraction** because it is considered a sign of underlying tumor tethering to the ducts rather than an indicator of advanced local invasion (T4 disease). ### **Explanation of Options:** * **Nipple Retraction (Correct):** This is a clinical finding often caused by tumor infiltration of the lactiferous ducts leading to fibrosis. Unlike skin involvement, it does **not** change the T-stage of the tumor. * **Satellite Nodules (Incorrect):** These are defined as separate tumor nodules in the skin ipsilateral to the primary breast tumor. They are classified as **T4b**. * **Inflammation (Incorrect):** Inflammatory breast cancer is a clinical diagnosis characterized by edema (peau d'orange), erythema, and warmth. It is classified as **T4d**. * **Skin Ulceration (Incorrect):** Direct ulceration of the skin by the tumor is a sign of advanced local disease and is classified as **T4b**. ### **High-Yield Clinical Pearls for NEET-PG:** * **T4 Category Breakdown:** * **T4a:** Extension to the chest wall (ribs, intercostals, serratus anterior; *pectoralis muscle involvement alone does not count*). * **T4b:** Edema (peau d'orange), ulceration, or satellite skin nodules. * **T4c:** Both T4a and T4b. * **T4d:** Inflammatory carcinoma. * **Dimpling vs. Retraction:** Skin dimpling or nipple retraction are localized findings and do not upgrade a T1/T2/T3 tumor to T4. * **Internal Mammary Nodes:** If detected clinically or by imaging, they are staged as **N2b** (if axillary nodes are present) or **N3b** (if axillary nodes are also involved).

Question 43: An elderly woman underwent a radical mastectomy with radiation to the axilla 20 years ago. For 25 years, she has had an open wound that has never healed. It is not a recurrence of breast cancer. What is the most likely diagnosis?

A. Basal cell carcinoma
B. Squamous cell carcinoma (Correct Answer)
C. Hypertrophic granulation tissue
D. Malignant melanoma

Explanation: **Explanation:** The correct diagnosis is **Squamous Cell Carcinoma (SCC)**, specifically presenting as a **Marjolin’s ulcer**. **Why it is correct:** A Marjolin’s ulcer refers to a squamous cell carcinoma arising in a site of chronic inflammation, long-standing non-healing wounds, or old scars (most commonly post-burn scars). In this patient, the combination of a chronic open wound (25 years) and previous radiation therapy (which causes tissue ischemia and chronic dermatitis) creates the ideal environment for malignant transformation. While the latency period is typically 30 years, any ulcer persisting for decades must be biopsied to rule out SCC. **Why the other options are incorrect:** * **Basal Cell Carcinoma (BCC):** While BCC is the most common skin cancer, it typically arises on sun-exposed areas (face) and presents as a "pearly" nodule with telangiectasia. It is less commonly associated with chronic scars compared to SCC. * **Hypertrophic granulation tissue:** This is a benign reactive process seen in healing wounds ("proud flesh"). It would not persist for 25 years without either healing or showing signs of malignancy. * **Malignant melanoma:** This arises from melanocytes, usually triggered by UV exposure or genetic factors. It does not typically arise from chronic non-healing ulcers or radiation scars. **NEET-PG High-Yield Pearls:** * **Marjolin’s Ulcer:** Most common histological type is **well-differentiated SCC**. * **Characteristics:** It is more aggressive than typical SCC and has a higher rate of regional lymph node metastasis. * **Diagnosis:** Requires a wedge biopsy from the edge of the ulcer. * **Stewart-Treves Syndrome:** Do not confuse this with the clinical scenario. Stewart-Treves is **Angiosarcoma** arising in a limb with chronic lymphedema (post-mastectomy), not from a chronic ulcer or radiation scar itself.

Question 44: Cock's peculiar tumor is:

A. Basal cell carcinoma
B. Squamous cell carcinoma
C. Infected sebaceous cyst (Correct Answer)
D. Cylindroma

Explanation: **Explanation:** **Cock’s Peculiar Tumor** is a clinical misnomer. It is not a true neoplastic malignancy but rather a **sebaceous cyst of the scalp** that has undergone infection and ulceration. 1. **Why Option C is correct:** When a sebaceous cyst on the scalp becomes infected, it can rupture and discharge its contents. The resulting chronic inflammation leads to the formation of exuberant, foul-smelling **granulation tissue** that fungates through the opening. This gives it a fleshy, cauliflower-like appearance that clinically mimics a malignant tumor (specifically squamous cell carcinoma), hence the name "peculiar tumor." 2. **Why other options are incorrect:** * **Basal Cell Carcinoma (A):** Typically presents as a "rodent ulcer" with pearly rolled edges and telangiectasia, not as a fungating mass arising from a cyst. * **Squamous Cell Carcinoma (B):** While Cock’s tumor clinically resembles SCC (fungation, everted edges), histological examination reveals only inflammatory granulation tissue without malignant cells. * **Cylindroma (D):** Also known as a "Turban tumor," this is a benign adnexal tumor of the scalp. It presents as multiple smooth, domed nodules rather than an ulcerated, infected cyst. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Almost exclusively found on the **scalp**. * **Clinical Feature:** It mimics malignancy because it is **fungating** and has **everted edges**, but it remains a benign inflammatory condition. * **Diagnosis:** Differentiated from SCC by the absence of induration at the base and confirmed via biopsy/histopathology. * **Treatment:** Wide local excision.

Question 45: In which of the following conditions is spontaneous regression not observed?

A. Malignant melanoma
B. Osteosarcoma (Correct Answer)
C. Neuroblastoma
D. Choriocarcinoma

Explanation: **Explanation:** Spontaneous regression refers to the partial or complete disappearance of a malignant tumor in the absence of any treatment or in the presence of therapy considered inadequate to exert a significant influence on neoplastic growth. This phenomenon is rare but well-documented in specific immunogenic tumors. **Why Osteosarcoma is the Correct Answer:** Osteosarcoma is a highly aggressive primary bone malignancy characterized by the production of osteoid. Unlike the other options, it does **not** exhibit spontaneous regression. Its management strictly requires a combination of neoadjuvant chemotherapy and radical surgical resection. **Analysis of Incorrect Options:** * **Neuroblastoma:** This is the classic example of spontaneous regression (especially Stage 4S in infants). It can undergo spontaneous involution or maturation into a benign ganglioneuroma via cellular differentiation. * **Malignant Melanoma:** Known for being highly immunogenic. Spontaneous regression occurs in about 0.2–1% of cases, often mediated by a robust T-cell immune response (clinically seen as "halo nevi" or depigmented patches). * **Choriocarcinoma:** This gestational trophoblastic neoplasm can occasionally regress spontaneously, likely due to the unique maternal immune response against paternal antigens present in the tumor cells. * **Renal Cell Carcinoma (RCC):** Though not listed, it is another classic example where the primary tumor or pulmonary metastases may regress after nephrectomy. **NEET-PG High-Yield Pearls:** * **Most common tumor to undergo spontaneous regression:** Neuroblastoma. * **Mechanism:** Most spontaneous regressions are attributed to immune system activation, hormonal changes, or cellular differentiation. * **Other tumors showing regression:** Retinoblastoma, Lymphomas, and Bladder cancer. * **Key Fact:** Osteosarcoma follows the "Skip Metastasis" pattern and most commonly spreads to the lungs (cannonball metastases).

Question 46: Troisier's sign is associated with which of the following?

A. Metastatic left supraclavicular lymphadenopathy (Correct Answer)
B. Carpopedal spasm in hypocalcemia
C. Migratory thrombophlebitis
D. Any of the above

Explanation: **Explanation:** **Troisier's sign** refers to the clinical finding of a hard, enlarged **left supraclavicular lymph node** (known as **Virchow’s node**). This sign is highly suggestive of an underlying occult intra-abdominal malignancy, most commonly **Gastric Adenocarcinoma**. The anatomical basis for this sign lies in the lymphatic drainage: the **thoracic duct** carries lymph from most of the body (including the abdomen) and drains into the left subclavian vein near its junction with the left internal jugular vein. Malignant cells from abdominal organs can spread via the thoracic duct and lodge in the left supraclavicular nodes. **Analysis of Options:** * **Option A (Correct):** As explained, Troisier's sign specifically denotes metastatic involvement of the left supraclavicular node, typically from the stomach, pancreas, or ovaries. * **Option B (Incorrect):** Carpopedal spasm in hypocalcemia is associated with **Trousseau’s sign of latent tetany** (elicited by inflating a BP cuff). * **Option C (Incorrect):** Migratory thrombophlebitis is known as **Trousseau’s sign of malignancy**, often seen in pancreatic cancer. * **Option D (Incorrect):** Only Option A is correct. **High-Yield Clinical Pearls for NEET-PG:** * **Virchow’s Node:** Also called the "Signal node" or "Seat of the Devil." * **Common Primary Sites:** Stomach (most common), Pancreas, Esophagus, and Testis. * **Differential:** Right supraclavicular lymphadenopathy usually suggests primary malignancy in the **thorax** (e.g., lung cancer or esophageal cancer). * **Confusing Names:** Do not confuse **Troisier’s sign** with the two different **Trousseau’s signs** (Tetany vs. Thrombophlebitis).

Question 47: Sister Mary Joseph nodules are found in which condition?

A. Gastric carcinoma (Correct Answer)
B. Pancreatic carcinoma
C. Lung carcinoma
D. Ovary carcinoma

Explanation: **Explanation:** **Sister Mary Joseph Nodule** refers to a palpable, firm, and often painful nodule at the umbilicus resulting from the metastasis of a malignant intra-abdominal or pelvic tumor. **1. Why Gastric Carcinoma is the Correct Answer:** The most common primary site for Sister Mary Joseph nodules is the **Gastrointestinal tract (52%)**, with **Gastric Carcinoma** being the single most frequent cause. The spread occurs via contiguous extension (peritoneal seeding), lymphatic channels, or hematogenous routes. In clinical practice and NEET-PG exams, it is considered a classic sign of advanced (Stage IV) gastric malignancy. **2. Analysis of Other Options:** * **Pancreatic Carcinoma:** While it is the second most common GI cause, it is statistically less frequent than gastric cancer. * **Ovary Carcinoma:** This is the most common **gynecological** cause (accounting for about 28% of cases), but it ranks behind gastric cancer in overall frequency. * **Lung Carcinoma:** This is an extremely rare cause. Sister Mary Joseph nodules almost exclusively represent primaries from the abdomen or pelvis. **3. High-Yield Clinical Pearls for NEET-PG:** * **Eponym:** Named after Sister Mary Joseph (born Julia Dempsey), who was the surgical assistant to Dr. William Mayo. She noticed the correlation between umbilical nodules and intra-abdominal malignancy during skin preparation for surgery. * **Prognosis:** Its presence signifies an **advanced stage** of malignancy and carries a poor prognosis. * **Differential Diagnosis:** Must be distinguished from an umbilical hernia or a benign "Caput Medusae" (portal hypertension). * **Other Classic Signs of Gastric Cancer:** * **Virchow’s Node:** Left supraclavicular lymphadenopathy. * **Irish Node:** Left axillary lymphadenopathy. * **Krukenberg Tumor:** Metastasis to the ovary. * **Blumer’s Shelf:** Palpable mass in the pouch of Douglas (rectal shelf).

Question 48: A patient with carcinoma has a tumour of 2.5 cm located close to and involving the lower alveolus. A single mobile homolateral node measuring 6 cm is palpable. Based on these clinical findings, what is the TNM stage of the tumour?

A. T2 N2 M0 (Correct Answer)
B. T2 N2 M0
C. T1 N2 M0
D. T2 N1 M0

Explanation: To determine the TNM stage for oral cavity cancers (like carcinoma of the lower alveolus), we apply the AJCC staging criteria. ### **1. Breakdown of the Correct Answer (T2 N2 M0)** * **T-Stage (Tumor):** The tumor size is **2.5 cm**. According to AJCC guidelines, a tumor >2 cm but ≤4 cm is classified as **T2**. (T1 is ≤2 cm; T3 is >4 cm). * **N-Stage (Nodes):** The patient has a **single homolateral (ipsilateral) node** measuring **6 cm**. * N1: Single ipsilateral node ≤3 cm. * N2a: Single ipsilateral node >3 cm but ≤6 cm. * N3: Any node >6 cm. Since the node is exactly 6 cm, it falls into the **N2** category (specifically N2a). * **M-Stage (Metastasis):** In clinical scenarios where no distant spread is mentioned, it is assumed to be **M0**. ### **2. Why Other Options are Incorrect** * **Option C (T1 N2 M0):** Incorrect because T1 is reserved for tumors ≤2 cm. This tumor is 2.5 cm. * **Option D (T2 N1 M0):** Incorrect because N1 is only for nodes ≤3 cm. A 6 cm node is significantly larger and qualifies as N2. * *Note: Options A and B are identical in the prompt; both represent the correct TNM classification.* ### **3. NEET-PG High-Yield Pearls** * **Depth of Invasion (DOI):** In the updated AJCC 8th Edition, T-staging for oral cancer now incorporates DOI. T1: ≤2cm and DOI ≤5mm; T2: ≤2cm and DOI >5mm OR >2-4cm and DOI ≤10mm. * **Extranodal Extension (ENE):** The presence of ENE (clinical or pathological) automatically upgrades the N-stage to N3b. * **N2 Sub-classification:** * **N2a:** Single ipsilateral (3–6 cm). * **N2b:** Multiple ipsilateral (all ≤6 cm). * **N2c:** Bilateral or contralateral (all ≤6 cm).

Question 49: What is true about Sentinel Lymph Node biopsy?

A. Requires a special operating theater
B. Blue dyes are injected (Correct Answer)
C. Contraindicated if axillary lymph node is involved
D. All of the above

Explanation: **Explanation:** **Sentinel Lymph Node Biopsy (SLNB)** is based on the principle that the lymphatic drainage from a primary tumor follows a predictable pathway to a specific first node (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 complete lymph node dissection. * **Why Option B is Correct:** To identify the sentinel node, a tracer is injected peritumoral or subareolar. This is typically a **blue dye** (such as Isosulfan blue or Methylene blue) and/or a **Radioactive Technetium-99m labeled sulfur colloid**. The dye travels through the lymphatics, staining the sentinel node blue, allowing for visual identification. * **Why Option A is Incorrect:** SLNB does not require a "special" operating theater. While a handheld Gamma probe is needed if using radioisotopes, it is a portable device used in standard surgical suites. * **Why Option C is Incorrect:** While SLNB is the standard of care for **clinically node-negative (cN0)** patients, it is not strictly "contraindicated" if a node is involved. However, if axillary nodes are clinically or pathologically positive (cN1/pN1) *before* surgery, the patient typically proceeds directly to Axillary Lymph Node Dissection (ALND). The presence of a positive node is an indication for ALND, not a contraindication to the technique itself. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** The combination of both blue dye and radioisotope (Dual Technique) has the highest identification rate (>95%) and the lowest false-negative rate. * **Most Common Site:** Most frequently used in **Breast Cancer** and **Malignant Melanoma**. * **Contraindications:** Inflammatory breast cancer (T4d), and cases where lymphatic drainage is disrupted (e.g., prior extensive axillary surgery). * **Hot & Blue:** A node is considered "Sentinel" if it is blue-stained, has a blue-stained lymphatic vessel leading to it, or has a radioactive count $\ge$ 10% of the "hottest" node.

Question 50: In a male patient who underwent laparoscopic cholecystectomy, the histopathology specimen shows carcinoma of the gallbladder, stage T1a. What is the appropriate management?

A. Conservative management and follow-up.
B. Extended cholecystectomy.
C. Excision of all port sites. (Correct Answer)
D. Radiotherapy.

Explanation: **Explanation:** The management of incidental gallbladder cancer (GBC) discovered after laparoscopic cholecystectomy depends strictly on the **T-stage** (depth of invasion). **Why Option C is Correct:** In the context of laparoscopic surgery for GBC, there is a significant risk of **port-site metastasis** due to bile spillage or "chimney effect" during pneumoperitoneum. For a patient with confirmed GBC, oncological principles dictate the **excision of all port sites** to prevent local recurrence in the abdominal wall. While T1a management is controversial, in the specific context of this MCQ, ensuring the clearance of potential seeding sites is the priority. **Why the other options are incorrect:** * **Option A (Conservative management):** While T1a (invasion of lamina propria only) has an excellent prognosis, simple follow-up is insufficient if the surgery was laparoscopic, as the risk of port-site seeding must be addressed. * **Option B (Extended cholecystectomy):** This involves wedge resection of the liver (Segments IVb and V) and lymphadenectomy. It is the standard of care for **T1b, T2, and T3** tumors. It is considered "over-treatment" for T1a, where simple cholecystectomy is oncologically adequate for the primary site. * **Option D (Radiotherapy):** GBC is relatively radioresistant. Radiotherapy is typically reserved for palliative care or as part of adjuvant chemoradiation in advanced stages (T3+ or node-positive), not for early-stage T1a. **NEET-PG High-Yield Pearls:** * **T1a:** Invasion of lamina propria. Treatment: Simple cholecystectomy (if open) or port-site excision (if laparoscopic). * **T1b:** Invasion of muscle layer. Treatment: **Extended Cholecystectomy.** * **Most common site of GBC:** Fundus. * **Most common histological type:** Adenocarcinoma. * **Porcelain Gallbladder:** Associated with a high risk of GBC (calcification of the wall).

Practice by Chapter

Principles of Surgical Oncology

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Cancer Staging

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Surgical Margins in Cancer Surgery

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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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