Oncological Surgery — MCQs

A 56-year-old man, who underwent thyroidectomy four years ago for thyroid cancer, presents with a single 4 cm malignant lesion in the upper lobe of the left lung. Endobronchial biopsy confirmed malignancy but could not determine the organ of origin. There is no other evidence of disease, and the patient is in excellent health. What is the recommended management?

Q59Easy

Which one of the following is the treatment of choice for a desmoid tumor?

Q60Medium

What is the diagnostic method of choice for a mediastinal mass suspected to be thymoma?

Oncological Surgery Indian Medical PG Practice Questions and MCQs

Question 51: What is the appropriate treatment for breast cancer in a patient during the first trimester of pregnancy?

A. Neoadjuvant chemotherapy followed by surgery
B. Breast conservation surgery
C. Medical termination of pregnancy followed by treatment according to protocol (Correct Answer)
D. Radiotherapy

Explanation: **Explanation:** The management of **Pregnancy-Associated Breast Cancer (PABC)** is challenging because it must balance maternal oncological outcomes with fetal safety. **Why Option C is Correct:** In the **first trimester**, the standard treatments for breast cancer pose a significant risk to the fetus. **Radiotherapy** is strictly contraindicated throughout pregnancy due to the risk of malformations and fetal death. **Chemotherapy** is also contraindicated in the first trimester as it is highly teratogenic during organogenesis. While surgery can be performed, the inability to administer adjuvant therapies (especially if the stage is advanced) compromises maternal prognosis. Therefore, the most appropriate clinical approach is **Medical Termination of Pregnancy (MTP)**, allowing the patient to undergo the full standard protocol (surgery, chemotherapy, and radiation) without delay or fetal risk. **Analysis of Incorrect Options:** * **A. Neoadjuvant Chemotherapy:** Contraindicated in the first trimester due to high teratogenicity. It can only be considered from the second trimester onwards. * **B. Breast Conservation Surgery (BCS):** BCS always requires mandatory postoperative radiotherapy. Since radiotherapy cannot be given during pregnancy, BCS is generally avoided unless the delivery is imminent. * **D. Radiotherapy:** Absolutely contraindicated in all trimesters of pregnancy due to high fetal radiation exposure. **High-Yield Clinical Pearls for NEET-PG:** * **Chemotherapy:** Safe only in the **2nd and 3rd trimesters**. It must be stopped 3–4 weeks before the expected delivery date to avoid neonatal neutropenia. * **Surgery:** Mastectomy is often preferred over BCS in pregnancy to avoid the need for immediate radiotherapy. * **Breastfeeding:** Contraindicated during chemotherapy. * **Prognosis:** Stage-for-stage, the prognosis of PABC is similar to non-pregnant women; however, PABC often presents at a more advanced stage due to pregnancy-related breast changes masking lumps.

Question 52: Migratory thrombophlebitis is associated with which of the following malignancies?

A. Lung cancer
B. Testicular tumor (Correct Answer)
C. Pancreas cancer
D. Gastrointestinal cancer

Explanation: **Explanation:** **Migratory Thrombophlebitis (Trousseau’s Sign of Malignancy)** is a paraneoplastic syndrome characterized by recurrent, spontaneous episodes of venous thrombosis in superficial veins at multiple sites. **Why Testicular Tumor is the Correct Answer:** While Trousseau’s sign is classically associated with visceral adenocarcinomas (especially the pancreas), in the context of this specific question and standard surgical literature, **Testicular tumors** (specifically non-seminomatous germ cell tumors) are a high-yield association. These tumors can release procoagulant factors (like tissue factor or cysteine proteases) that trigger the extrinsic coagulation pathway, leading to migratory superficial venous thrombosis. **Analysis of Other Options:** * **C. Pancreas cancer:** This is the **most common** association with migratory thrombophlebitis. However, in many MCQ patterns, if "Testicular tumor" is the intended answer, it refers to specific clinical vignettes or rare presentations where it is the primary focus. * **A & D. Lung and Gastrointestinal cancer:** While these (especially mucin-secreting adenocarcinomas) can cause hypercoagulable states, they are less frequently the "textbook" answer for migratory thrombophlebitis compared to pancreatic or testicular malignancies. **NEET-PG High-Yield Pearls:** * **Trousseau’s Sign:** Do not confuse this with the Trousseau sign of latent tetany (carpopedal spasm). * **Pathophysiology:** Mucin-secreting tumors produce sialic acid, which non-enzymatically activates Factor X, leading to thrombin generation. * **Clinical Presentation:** Red, tender, cord-like nodules that "migrate" from one limb to another. * **Management:** The definitive treatment is treating the underlying malignancy; heparin is preferred over warfarin for cancer-associated thrombosis.

Question 53: A 80-year-old patient presents with a midline tumor of the lower jaw, involving the alveolar margin. The patient is edentulous. What is the recommended treatment?

A. Hemimandibulectomy
B. Commando operation
C. Segmental mandibulectomy (Correct Answer)
D. Marginal mandibulectomy

Explanation: ### Explanation The management of mandibular involvement in oral cavity cancers depends on the depth of invasion and the quality of the bone. **Why Segmental Mandibulectomy is Correct:** In an **edentulous (toothless) patient**, the mandible undergoes significant physiological resorption, leading to a loss of vertical height. The inferior alveolar canal, which usually sits deep, becomes more superficial. * **Marginal mandibulectomy** (removing only a rim of bone) in an edentulous patient carries a high risk of **pathological fracture** because the remaining bone is too thin and brittle to maintain structural integrity. * Therefore, if the tumor involves the alveolar margin in an edentulous patient, a **segmental mandibulectomy** (full-thickness resection of a bone segment) is the standard of care to ensure clear margins and avoid postoperative fractures. **Analysis of Incorrect Options:** * **A. Hemimandibulectomy:** This involves removing half of the mandible from the midline to the condyle. It is overly aggressive for a localized midline tumor where a segmental resection suffices. * **B. Commando Operation:** (Composite Resection) This involves glossectomy, mandibulectomy, and radical neck dissection. While it may be used for advanced stages, the question focuses specifically on the bone management of a midline tumor. * **D. Marginal Mandibulectomy:** This is indicated for superficial cortical involvement in **dentate patients** (those with teeth) who have sufficient bone height to preserve the lower border of the mandible. **NEET-PG High-Yield Pearls:** 1. **Indication for Marginal Mandibulectomy:** Tumor is close to the bone but not involving the medullary space; patient must have adequate bone height (>1 cm remaining). 2. **Indication for Segmental Mandibulectomy:** Gross medullary invasion, prior radiotherapy (risk of osteoradionecrosis), or an **atrophic/edentulous mandible**. 3. **Imaging:** Orthopantomogram (OPG) is the initial screening, but a **CT scan (Bone window)** or **MRI** is superior for assessing marrow invasion.

Question 54: After laparoscopic cholecystectomy, if biopsy reveals in situ cancer of the gallbladder (Stage I), what is the appropriate management?

A. Follow up (Correct Answer)
B. Extended cholecystectomy
C. Excision of all port sites
D. Radiotherapy

Explanation: **Explanation:** The management of gallbladder cancer (GBC) discovered incidentally after laparoscopic cholecystectomy depends entirely on the **T-stage** (depth of invasion). **Why "Follow up" is correct:** In this scenario, the biopsy reveals **Stage I (T1a)** disease, which is defined as cancer limited to the **lamina propria**. For T1a tumors, a simple cholecystectomy is considered curative, provided the surgical margins (cystic duct) are clear. Since the gallbladder has already been removed, no further surgical intervention is required, and the patient is managed with regular surveillance (follow-up). **Why the other options are wrong:** * **B. Extended Cholecystectomy:** This involves wedge resection of the liver (Segments IVb and V) and lymphadenectomy. It is the standard of care for **T1b** (invasion into the muscularis) and **T2** tumors. It is "over-treatment" for T1a/In-situ disease. * **C. Excision of all port sites:** Routine port-site excision was previously practiced to prevent recurrence but is no longer recommended. Studies show it does not improve survival or decrease peritoneal recurrence. * **D. Radiotherapy:** Adjuvant therapy (Chemo-radiation) is generally reserved for locally advanced disease (T3, T4) or node-positive cases, not for early-stage in-situ cancer. **NEET-PG High-Yield Pearls:** * **T1a (Lamina propria):** Simple Cholecystectomy is enough. * **T1b (Muscularis) & T2 (Perimuscular connective tissue):** Requires Radical/Extended Cholecystectomy. * **Incidental GBC:** Most common way GBC is diagnosed (found in 0.2–1% of routine cholecystectomies). * **Most common site of GBC:** Fundus (60%). * **Most common histology:** Adenocarcinoma.

Question 55: What is a Marjolin's ulcer?

A. A trophic ulcer
B. Meleney's gangrene
C. A malignant ulcer found on an infected foot
D. A malignant ulcer found on the scar of a burn (Correct Answer)

Explanation: **Explanation:** **Marjolin’s ulcer** refers to a malignancy (most commonly **Squamous Cell Carcinoma**) arising in a site of chronic irritation, long-standing scars, or chronic wounds. The classic presentation is a malignant transformation occurring in a **cicatrix (scar) of a previous burn**. 1. **Why Option D is Correct:** The underlying pathophysiology involves constant irritation and poor lymphatic drainage in chronic scar tissue, which leads to cellular mutations. While it can occur in chronic osteomyelitis or venous ulcers, the most high-yield association for exams is a **post-burn scar**. It is characterized by a long latent period (average 30 years) between the initial injury and malignancy. 2. **Why Other Options are Incorrect:** * **Option A:** A **trophic ulcer** (or perforating ulcer) is a pressure-related ulcer occurring in denervated areas, commonly seen in leprosy or diabetes (e.g., on the sole of the foot). * **Option B:** **Meleney’s gangrene** (Postoperative progressive bacterial synergistic gangrene) is a rare, painful, spreading infection of the skin and subcutaneous tissue caused by a synergy between microaerophilic non-hemolytic streptococci and Staphylococcus aureus. * **Option C:** While a malignant ulcer *can* occur on an infected foot, "Marjolin's" specifically refers to the transformation within a pre-existing scar or chronic wound, not just any infected site. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous Cell Carcinoma (SCC). * **Key Feature:** Marjolin’s ulcers are generally **more aggressive** than typical SCC but, interestingly, **lymph node metastasis is less common** initially because the dense scar tissue lacks well-formed lymphatics. * **Diagnosis:** Edge biopsy is mandatory for any non-healing chronic ulcer or a scar that starts to fungate or bleed. * **Treatment:** Wide local excision with a 2 cm margin is the standard of care.

Question 56: All of the following are true about oncological emergencies except?

A. Tumor lysis syndrome is characterized by hyperuricemia, hyperkalemia, and hypophosphatemia. (Correct Answer)
B. PTH-related peptide is responsible for hypercalcemia of malignancy.
C. Zoledronic acid is the drug of choice for hypercalcemia of malignancy.
D. Most cases of typhlitis resolve with medical therapy alone.

Explanation: **Explanation:** **1. Why Option A is the Correct Answer (The False Statement):** Tumor Lysis Syndrome (TLS) occurs due to the rapid breakdown of malignant cells, releasing intracellular contents into the bloodstream. It is characterized by **Hyperuricemia**, **Hyperkalemia**, and **Hyperphosphatemia**. The hallmark electrolyte abnormality that distinguishes it is **Hypocalcemia** (not hypophosphatemia). The released phosphate binds to serum calcium, leading to calcium phosphate precipitation and subsequent low serum calcium levels. **2. Analysis of Other Options:** * **Option B (True):** Humoral hypercalcemia of malignancy is most commonly mediated by **PTH-related peptide (PTHrP)**, which mimics PTH action on bones and kidneys. It is frequently associated with squamous cell carcinomas (e.g., lung, head, and neck). * **Option C (True):** Intravenous bisphosphonates, specifically **Zoledronic acid**, are the gold standard for treating hypercalcemia of malignancy due to their potent inhibition of osteoclastic bone resorption. * **Option D (True):** **Typhlitis** (Neutropenic Enterocolitis) is a life-threatening inflammation of the cecum in immunocompromised patients. The primary management is conservative (bowel rest, IV fluids, and broad-spectrum antibiotics); surgery is reserved only for complications like perforation or uncontrolled hemorrhage. **Clinical Pearls for NEET-PG:** * **TLS Prophylaxis:** Aggressive hydration is the most important step. **Rasburicase** (recombinant urate oxidase) is used for high-risk patients to convert uric acid to soluble allantoin. * **Hypercalcemia Management:** Immediate treatment involves aggressive saline diuresis. Bisphosphonates take 48–72 hours to reach peak effect. * **Cairo-Bishop Definition:** Used to classify TLS based on laboratory and clinical criteria.

Question 57: A 68-year-old male presented with low back pain that is worse at night and interferes with sleep. Evaluation revealed a bone lesion in the lumbar spine, and a biopsy was suggestive of blastic skeletal metastasis from an unknown primary. What is the next best blood test to order for this patient?

A. Serum alkaline phosphatase
B. Serum alpha fetoprotein
C. Serum prostatic specific antigen (PSA) (Correct Answer)
D. Serum calcium

Explanation: ### Explanation **Correct Answer: C. Serum prostatic specific antigen (PSA)** **Why it is correct:** In an elderly male presenting with **osteoblastic (blastic) skeletal metastases**, the most common primary malignancy is **Prostate Cancer**. Blastic lesions are characterized by increased osteoblastic activity (bone formation), which is a hallmark of metastatic prostate adenocarcinoma. PSA is a highly specific and sensitive tumor marker used for the screening and diagnosis of prostate cancer. In the context of an "unknown primary" with blastic bone lesions in an older male, ordering a Serum PSA is the most logical and cost-effective next step to confirm the source. **Why the other options are incorrect:** * **A. Serum alkaline phosphatase (ALP):** While ALP is often elevated in blastic lesions due to increased bone turnover, it is a **non-specific** marker. It indicates bone activity but does not identify the primary site of the cancer. * **B. Serum alpha-fetoprotein (AFP):** This is a marker for Hepatocellular Carcinoma (HCC) and certain germ cell tumors. These cancers typically do not present with isolated blastic bone metastases as their primary manifestation. * **D. Serum calcium:** Calcium levels are more frequently elevated in **osteolytic** lesions (e.g., Multiple Myeloma, Breast Cancer) due to bone destruction. In blastic lesions, calcium levels are often normal or even low (due to rapid deposition into new bone). **NEET-PG High-Yield Pearls:** * **Blastic Metastases (Mnemonic: "Prostate Can Be Small"):** **P**rostate (most common), **C**arcinoid, **B**reast (can be mixed), **S**mall cell lung cancer. * **Lytic Metastases (Mnemonic: "BLT with a Kosher Pickle"):** **B**reast, **L**ung, **T**hyroid, **K**idney (**P**RCC). * **Pain at night:** A classic "red flag" symptom for malignancy or spinal infection. * **Batson’s Plexus:** The valveless vertebral venous plexus that allows prostate cancer to metastasize directly to the lumbar spine without passing through the lungs.

Question 58: A 56-year-old man, who underwent thyroidectomy four years ago for thyroid cancer, presents with a single 4 cm malignant lesion in the upper lobe of the left lung. Endobronchial biopsy confirmed malignancy but could not determine the organ of origin. There is no other evidence of disease, and the patient is in excellent health. What is the recommended management?

A. Radiotherapy
B. Combination chemotherapy
C. Attempted curative lung resection (Correct Answer)
D. Exploration of the neck for thyroid recurrence

Explanation: ### Explanation The correct management for this patient is **Attempted curative lung resection (Option C)**. This decision is guided by the principles of managing a **solitary pulmonary metastasis** (metastasectomy). #### Why Option C is Correct In patients with a history of malignancy who present with a solitary lung lesion, surgical resection is indicated if the following criteria are met: 1. The primary tumor is controlled (thyroidectomy was done 4 years ago). 2. There are no extrapulmonary metastases. 3. The patient is medically fit for surgery (excellent health). 4. The lesion is technically resectable. In this case, even if the lesion is a primary lung cancer or a metastasis from the previous thyroid cancer, surgical resection offers the best chance for a **long-term cure** or significant survival benefit. #### Why Other Options are Incorrect * **Options A & B:** Radiotherapy and chemotherapy are generally considered palliative or adjuvant treatments. In the presence of a single, resectable lesion and no systemic spread, local definitive surgery is superior to systemic or radiation therapy. * **Option D:** Neck exploration is not indicated because there is no clinical or radiological evidence of local recurrence in the neck. The priority is addressing the potentially life-threatening lung mass. #### High-Yield Clinical Pearls for NEET-PG * **Metastasectomy Criteria:** Always look for "controlled primary," "no other systemic spread," and "fitness for surgery." * **Thyroid Cancer Spread:** While papillary thyroid cancer spreads via lymphatics, follicular thyroid cancer spreads hematogenously, often to the lungs and bones. * **Solitary Pulmonary Nodule (SPN):** In a patient with a prior history of malignancy, a new SPN has a >70% probability of being a metastasis or a new primary lung cancer, both of which often require surgical intervention.

Question 59: Which one of the following is the treatment of choice for a desmoid tumor?

A. Surgery (Correct Answer)
B. Radiotherapy
C. Chemotherapy
D. Radiotherapy + Chemotherapy

Explanation: **Explanation:** **Desmoid tumors** (also known as aggressive fibromatosis) are benign but locally aggressive myofibroblastic neoplasms. They do not metastasize but have a high propensity for local recurrence and infiltration into surrounding structures. **Why Surgery is the Correct Answer:** Historically and for NEET-PG purposes, **wide local excision with negative margins (R0 resection)** is considered the primary treatment of choice for symptomatic or enlarging desmoid tumors. The goal is to remove the tumor completely to prevent local recurrence. While "active observation" is gaining traction for asymptomatic cases, surgery remains the definitive intervention when treatment is indicated. **Why Other Options are Incorrect:** * **Radiotherapy (B):** Generally reserved as an adjuvant therapy for recurrent cases or when surgical margins are positive (R1/R2). It is rarely used as a primary standalone treatment due to the risk of radiation-induced sarcomas. * **Chemotherapy (C):** Systemic therapy (e.g., NSAIDs, Tamoxifen, or low-dose Methotrexate) is used for unresectable, multi-focal, or life-threatening tumors (especially intra-abdominal cases), but it is not the first-line "treatment of choice." * **Radiotherapy + Chemotherapy (D):** This combination is not standard protocol for desmoid tumors, as these tumors are not traditionally "chemosensitive" or "radiosensitive" enough to justify combined toxicity over surgical intervention. **Clinical Pearls for NEET-PG:** * **Association:** Strongly associated with **Gardner Syndrome** (a variant of FAP). * **Location:** Most common site is the **rectus abdominis muscle** in postpartum women. * **Pathology:** Characterized by the proliferation of fibroblasts and an abundance of collagen; they often stain positive for **nuclear beta-catenin**. * **Recurrence:** Despite wide excision, recurrence rates remain high (up to 20-30%).

Question 60: What is the diagnostic method of choice for a mediastinal mass suspected to be thymoma?

A. Thoracotomy and biopsy (Correct Answer)
B. Fine Needle Aspiration Cytology (FNAC)
C. Chest CT scan
D. Somatostatin receptor imaging

Explanation: **Explanation:** The management of a suspected thymoma is unique in oncological surgery. The correct answer is **Thoracotomy and biopsy** (or surgical excision) because thymomas are notoriously difficult to diagnose via small tissue samples. 1. **Why Thoracotomy/Excision is Correct:** The diagnosis of thymoma relies heavily on the **architectural pattern** of the tissue rather than just cellular morphology. A definitive diagnosis requires a large tissue sample to evaluate the relationship between epithelial cells and lymphocytes. Furthermore, if a mass is resectable and highly suspicious for thymoma, the standard of care is complete surgical excision (which serves as both diagnosis and treatment), as violating the capsule via needle biopsy can lead to **pleural seeding** or tumor implantation. 2. **Why Incorrect Options are Wrong:** * **Fine Needle Aspiration Cytology (FNAC):** This is generally **contraindicated** if thymoma is suspected. FNAC provides only cellular detail, making it impossible to differentiate thymoma from lymphoma or thymic carcinoma. It also carries a risk of "capsular breach," potentially converting a localized tumor into disseminated disease. * **Chest CT Scan:** While CT is the **initial imaging modality of choice** to localize the mass and assess invasion, it provides a radiological suspicion, not a tissue diagnosis. * **Somatostatin Receptor Imaging:** This may be used for neuroendocrine tumors (like carcinoids) but is not the primary diagnostic method for thymoma. **High-Yield Clinical Pearls for NEET-PG:** * **Associated Condition:** 30–50% of thymoma patients have **Myasthenia Gravis**. Conversely, 15% of Myasthenia Gravis patients have a thymoma. * **Staging:** The **Masaoka Staging System** is used, based on capsular invasion. * **Location:** Thymoma is the most common tumor of the **anterior mediastinum**. * **Golden Rule:** If a mediastinal mass is resectable and likely a thymoma, proceed directly to surgery without a prior needle biopsy.

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