Oncological Surgery Practice Questions

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.

Q: A 65-year-old male presents with weight loss, cough, and hemoptysis. Imaging reveals a right upper lobe lung mass. After bronchoscopy with biopsy confirms squamous cell carcinoma, what steps should be taken for staging and treatment planning?

PET-CT and mediastinoscopy. ***PET-CT and mediastinoscopy*** - **PET-CT** is essential for detecting **distant metastases** and identifying **mediastinal lymph node involvement**, which are critical for accurate staging. - **Mediastinoscopy** provides histologic confirmation of **mediastinal lymph node metastases** (N2/N3 disease), guiding decisions regarding **surgical resectability** and the need for neoadjuvant therapies. *CT-guided biopsy and bronchoalveolar lavage* - A biopsy has already confirmed **squamous cell carcinoma**, rendering a repeat biopsy unnecessary at this stage for diagnosis. - **Bronchoalveolar lavage** primarily aids in diagnosing infections or diffuse lung diseases, and is not a standard staging tool for confirmed lung cancer. *Repeat bronchoscopy with lavage* - The initial bronchoscopy already yielded a **diagnostic biopsy**; repeating it primarily for lavage would not provide additional **staging information**. - Lavage is more useful for cytology in undiagnosed lesions or infections, not for comprehensive cancer staging after a definitive biopsy. *Chest MRI with contrast and pleural fluid analysis* - While **MRI** can provide detailed imaging of soft tissues, **PET-CT is superior** for detecting **distant metastases** and metabolically active lesions throughout the body for staging. - **Pleural fluid analysis** is indicated if a **pleural effusion** is present to check for malignant cells, but it's not a primary staging tool if no effusion is noted or for assessing distant spread or nodal involvement.

Q: What is the primary treatment for early-stage non-small cell lung cancer?

Surgical resection. ***Surgical resection*** - **Surgical resection** (lobectomy or segmentectomy with lymph node dissection) is the **primary and definitive treatment** for early-stage non-small cell lung cancer (Stage I-II). - For **Stage IA disease**, surgery alone provides excellent outcomes with 5-year survival rates of 70-90%, and adjuvant chemotherapy is generally **not indicated**. - For **Stage IB-II**, surgery remains primary, with adjuvant chemotherapy considered selectively based on tumor size (>4 cm), poor differentiation, vascular invasion, or other high-risk features. - Complete surgical resection offers the **best chance of cure** for resectable early-stage NSCLC. *Surgical resection with adjuvant chemotherapy* - While this combination is important for **select early-stage cases** (high-risk Stage IB, Stage II-IIIA), it is **not the universal primary treatment** for all early-stage disease. - Adjuvant chemotherapy is an **addition** to surgery in specific scenarios, not part of the primary treatment for the majority of early-stage (especially Stage IA) patients. - Current guidelines recommend risk stratification before adding adjuvant therapy. *Radiotherapy* - **Radiotherapy** (stereotactic body radiotherapy/SBRT) is reserved for **medically inoperable** patients or those who refuse surgery. - It is not the primary treatment when the patient is a **surgical candidate**. - May be used as adjuvant therapy in patients with positive margins or N2 disease. *Immunotherapy* - **Immunotherapy** has emerging roles in neoadjuvant/adjuvant settings for resectable NSCLC (recent trials showing benefit). - However, it is **not established as primary monotherapy** for early resectable disease. - More commonly used in advanced/metastatic NSCLC or as part of combination regimens in clinical trial settings for early disease.

Q: What is the treatment of choice in desmoid tumors?

Wide excision. ***Wide excision*** - For **desmoid tumors**, **complete surgical resection with clear margins** is the primary treatment of choice due to their infiltrative nature and high recurrence rates. - This approach aims to minimize local recurrence and prevent tumor progression, which can impact adjacent structures. *Irradiation* - **Radiation therapy** is typically reserved as an **adjuvant** treatment after surgery or for unresectable tumors, not as a primary standalone treatment. - While it can help reduce recurrence rates, it carries risks of **secondary malignancies** and local tissue damage. *Local excision* - **Local excision** alone is insufficient for desmoid tumors due to their **infiltrative growth pattern** and high propensity for **local recurrence** if positive margins remain. - It often leads to incomplete removal, necessitating further intervention and increasing the risk of tumor progression. *Local excision following radiation* - Combining local excision with initial radiation is not the preferred sequence; **wide surgical excision** is typically performed first. - Radiation might be considered preoperatively in specific cases to **reduce tumor size** or postoperatively for **positive margins**, but starting with local excision after initial radiation is not the standard primary management.

Q: Primary treatment for localized malignant melanoma is

Wide excision. ***Wide excision*** - This is the **primary treatment** for localized malignant melanoma, aiming to completely remove the tumor along with a surrounding margin of healthy tissue to reduce recurrence risk. - The excisional margin width depends on the **Breslow depth** (tumor thickness). *Radiotherapy* - Not the primary treatment for localized melanoma, as melanoma cells are often **radioresistant**. - It may be used as **adjuvant therapy** for local control in cases of positive margins or nodal involvement, or for palliative care in metastatic disease. *Excision* - While excision is part of the treatment, the term **"wide excision"** specifically implies removing a sufficient margin of healthy tissue around the tumor. - Simple excision without appropriate margins is generally inadequate for malignant melanoma and carries a **high risk of local recurrence**. *Chemotherapy* - It is generally **not the first-line treatment** for localized melanoma due to limited efficacy and significant side effects. - Chemotherapy agents are typically reserved for **advanced or metastatic melanoma** and are often replaced by targeted therapies or immunotherapy in modern practice.

Q: What is the standard excision margin for thick melanomas (>2 mm Breslow thickness)?

2 cm. **2 cm** - For **thick melanomas** with a Breslow thickness greater than 2 mm, a **2 cm excision margin** is recommended to minimize local recurrence risk. - This margin ensures adequate removal of microscopic disease, balancing complete tumor excision with cosmetic and functional outcomes. *5 cm* - A **5 cm excision margin** is not standard for melanoma regardless of thickness and would result in excessive tissue removal. - Such large margins are generally reserved for very rare, extremely aggressive soft tissue sarcomas or other extensive skin malignancies. *7 cm* - A **7 cm excision margin** is significantly wider than current recommendations for any melanoma thickness. - This would lead to unnecessary morbidity, including large wound defects that might require complex reconstructive surgery. *10 cm* - A **10 cm excision margin** is exceptionally wide and not medically indicated for melanoma management. - Applying such a large margin would result in substantial tissue loss and functional impairment without offering additional survival benefit.

Q: The surgeon is exploring the mediastinum and finds a thymic mass invading the neighboring pericardium and phrenic nerves. Frozen section shows a thymoma (low-risk histology). What is the next intraoperative plan?

Complete resection of tumor. ***Complete resection of tumor*** - Even with invasion into neighboring structures like the **pericardium** and **phrenic nerves**, a **thymoma** should be completely resected to achieve the best possible outcome. - **Complete surgical resection (R0 resection)** remains the cornerstone of treatment for thymomas, even in locally invasive cases (Masaoka Stage III), as it offers the best prognosis and potential for cure. - The goal is to achieve **negative margins** while resecting involved structures (pericardium, phrenic nerve if necessary) to ensure complete tumor removal. *Abandon the surgery & start chemotherapy* - **Chemotherapy** is generally reserved for **thymic carcinomas**, unresectable thymomas, or as neoadjuvant therapy for borderline resectable cases, none of which apply here. - Abandoning surgery prematurely for a resectable thymoma, even with local invasion, would significantly compromise the patient's long-term outcome and chance for cure. *Abandon the surgery & start radiotherapy* - **Radiotherapy** is used adjunctively after incomplete resection (R1/R2) or for advanced **unresectable cases**, but a locally invasive thymoma that appears resectable should be managed with surgery first. - Abandoning the opportunity for **complete surgical removal** based on local invasion alone is not the standard approach, as Stage III thymomas are often resectable. *Close the mediastinum and wait for final report* - Waiting for the **final pathology report** significantly delays definitive treatment, and the frozen section result indicating **thymoma** provides sufficient information to proceed with resection if technically feasible. - This approach would necessitate a **second surgery**, posing unnecessary risks, increased morbidity, and discomfort to the patient, given that frozen section histology guides appropriate intraoperative management.

Question 1

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

Question 2

What is the most effective treatment strategy for a young adult with newly diagnosed glioblastoma, based on current evidence?

Accepted Answer

Surgical resection followed by adjuvant radiation and chemotherapy, tailored by molecular profiling.

Answer

Surgical resection only, as it is the primary treatment.

Answer

Radiation therapy alone, to maximize quality of life.

Answer

Participation in clinical trials for experimental therapies only.

Question 3

A 65-year-old male presents with weight loss, cough, and hemoptysis. Imaging reveals a right upper lobe lung mass. After bronchoscopy with biopsy confirms squamous cell carcinoma, what steps should be taken for staging and treatment planning?

Accepted Answer

PET-CT and mediastinoscopy

Answer

CT-guided biopsy and bronchoalveolar lavage

Answer

Repeat bronchoscopy with lavage

Answer

Chest MRI with contrast and pleural fluid analysis

Question 4

What is the primary treatment for early-stage non-small cell lung cancer?

Accepted Answer

Surgical resection

Answer

Radiotherapy

Answer

Surgical resection with adjuvant chemotherapy

Answer

Immunotherapy

Question 5

What is the treatment of choice in desmoid tumors?

Accepted Answer

Wide excision

Answer

Irradiation

Answer

Local excision

Answer

Local excision following radiation

Question 6

Primary treatment for localized malignant melanoma is

Accepted Answer

Wide excision

Answer

Radiotherapy

Answer

Excision

Answer

Chemotherapy

Question 7

Which of the following statements about desmoid tumors is incorrect?

Accepted Answer

Highly radiosensitive

Answer

Show infiltrative growth pattern

Answer

Often seen below the umbilicus

Answer

More common in women

Question 8

What is the standard excision margin for thick melanomas (>2 mm Breslow thickness)?

Accepted Answer

2 cm

Answer

5 cm

Answer

7 cm

Answer

10 cm

Question 9

Which of the following statements about meningiomas is true?

Accepted Answer

95% cure rate following total surgical resection of benign meningiomas

Answer

Approximately 5% of meningiomas are malignant.

Answer

Arise from the dural layer

Answer

Meningiomas are more common in women due to hormonal influences.

Question 10

The surgeon is exploring the mediastinum and finds a thymic mass invading the neighboring pericardium and phrenic nerves. Frozen section shows a thymoma (low-risk histology). What is the next intraoperative plan?

Accepted Answer

Complete resection of tumor

Answer

Abandon the surgery & start radiotherapy

Answer

Close the mediastinum and wait for final report

Answer

Abandon the surgery & start chemotherapy

Oncological Surgery — MCQs

Oncological Surgery — MCQs

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