Oncological Surgery — MCQs

Oncological Surgery Indian Medical PG Practice Questions and MCQs

Question 61: Glomus tumor is typically seen in which location?

A. Liver
B. Adrenals
C. Pituitary
D. Finger (Correct Answer)

Explanation: **Explanation:** A **Glomus tumor** (also known as a glomangioma) is a rare, benign vascular neoplasm arising from the **glomus body**. The glomus body is a specialized arteriovenous anastomosis involved in thermoregulation, primarily located in the stratum reticulare of the dermis. **Why the Finger is correct:** The highest concentration of glomus bodies is found in the **subungual region (under the nail bed) of the fingers**. Clinically, these tumors present with a classic triad: 1. **Exquisite localized tenderness** (Point tenderness). 2. **Severe paroxysmal pain** (often triggered by cold). 3. **Sensitivity to cold.** On examination, a small, bluish-red discoloration may be visible under the nail. **Why other options are incorrect:** * **Liver:** Primary vascular tumors of the liver are typically Hemangiomas or Angiosarcomas, not glomus tumors. * **Adrenals:** The adrenal medulla is a common site for Pheochromocytomas (paragangliomas), which are neuroendocrine tumors, distinct from the vascular glomus tumor. * **Pituitary:** Tumors here are usually Adenomas. While "Glomus Jugulare" tumors occur in the head/neck, they are paragangliomas and not the classic glomus tumor found in the extremities. **Clinical Pearls for NEET-PG:** * **Hildreth’s Test:** Relief of pain upon application of a tourniquet at the base of the finger (Positive test). * **Love’s Pinhead Test:** Localizing the pain by pressing the head of a pin over the suspected area. * **Transillumination:** Helps in visualizing the lesion. * **Treatment:** Simple surgical excision of the tumor is curative.

Question 62: A 50-year-old male, working as a hotel cook and having four dependent family members, has been diagnosed with early-stage squamous cell carcinoma of the anal canal. He has more than a 60% chance of cure. What is the best treatment option?

A. Abdomino-perineal resection
B. Combined surgery and radiotherapy
C. Combined chemotherapy and radiotherapy (Correct Answer)
D. Chemotherapy alone

Explanation: **Explanation:** The primary goal in treating squamous cell carcinoma (SCC) of the anal canal is **organ preservation** without compromising survival. The standard of care for most stages of anal SCC is the **Nigro Protocol**, which consists of **concurrent Chemoradiotherapy (CRT)**. 1. **Why Option C is correct:** Unlike most gastrointestinal cancers where surgery is the mainstay, anal SCC is highly radiosensitive and chemosensitive. Combined CRT (typically using 5-Fluorouracil and Mitomycin-C) achieves high cure rates (60–90%) while preserving the anal sphincter. This is particularly crucial for this patient, a hotel cook and breadwinner, as it avoids a permanent colostomy and maintains his quality of life and functional status. 2. **Why other options are incorrect:** * **Option A (APR):** Abdomino-perineal resection involves removing the rectum and anus, resulting in a permanent colostomy. It is now reserved only for "salvage surgery" (persistent or recurrent disease after CRT). * **Option B:** Surgery is not typically combined with radiotherapy as a primary approach because CRT alone is usually curative. * **Option D:** Chemotherapy alone is palliative and insufficient for a cure in localized anal SCC. **Clinical Pearls for NEET-PG:** * **Nigro Protocol:** 5-FU + Mitomycin-C + Radiation (45–60 Gy). * **Most common histology:** Squamous Cell Carcinoma (associated with HPV 16 and 18). * **Follow-up:** Digital Rectal Examination (DRE) is the most important tool to assess response, usually 12–26 weeks post-treatment. * **Indication for Surgery (APR):** Only for residual disease, recurrence, or incontinence.

Question 63: Chemotherapy is not useful in which of the following conditions?

A. Chondrosarcoma (Correct Answer)
B. Wilm's tumor
C. Choriocarcinoma
D. All of the above

Explanation: **Explanation:** The effectiveness of chemotherapy depends on the metabolic activity and growth fraction of tumor cells. Chemotherapy primarily targets rapidly dividing cells; therefore, tumors with slow growth rates or specific histological barriers often exhibit chemoresistance. **1. Why Chondrosarcoma is the Correct Answer:** Chondrosarcoma is a malignant tumor of cartilaginous origin. It is notoriously **chemoresistant and radioresistant**. This resistance is attributed to its slow mitotic rate, poor vascularity, and a dense extracellular hyaline matrix that prevents the effective penetration of chemotherapeutic agents. The primary and definitive treatment for chondrosarcoma is **wide local surgical excision**. **2. Why the Other Options are Incorrect:** * **Wilms’ Tumor (Nephroblastoma):** This is a highly chemosensitive pediatric tumor. The standard of care involves a combination of surgery and chemotherapy (e.g., Vincristine, Dactinomycin). Modern multimodal therapy has pushed survival rates above 90%. * **Choriocarcinoma:** This is a germ cell tumor/gestational trophoblastic neoplasia that is **exquisitely sensitive** to chemotherapy. Even in cases of widespread metastasis, it can often be cured with methotrexate or the EMA-CO regimen. **Clinical Pearls for NEET-PG:** * **Highly Chemosensitive Tumors:** Choriocarcinoma, Wilms’ tumor, Ewing’s sarcoma, Hodgkin’s Lymphoma, and Germ Cell Tumors (Testicular cancer). * **Chemoresistant Tumors:** Chondrosarcoma, Renal Cell Carcinoma (RCC), and Pancreatic Adenocarcinoma (generally poor response). * **Management of Chondrosarcoma:** Since it does not respond to adjuvant therapy, achieving "negative margins" during surgery is the single most important prognostic factor. * **Exception:** The *Mesenchymal* variant of chondrosarcoma is an outlier and may show some sensitivity to chemotherapy, unlike the conventional type.

Question 64: Which carcinoma has the best prognosis?

A. Carcinoma of the Lip (Correct Answer)
B. Carcinoma of the Cheek
C. Carcinoma of the Tongue
D. Carcinoma of the Palate

Explanation: **Explanation:** The prognosis of oral cavity carcinomas is primarily determined by the site’s lymphatic drainage, the timing of clinical presentation, and the histological grade. **Why Carcinoma of the Lip is the Correct Answer:** Carcinoma of the lip (specifically the lower lip, which accounts for 90% of cases) has the **best prognosis** among all oral cancers, with a 5-year survival rate exceeding 90%. This is due to: 1. **Early Detection:** Being an external site, lesions are visible early. 2. **Slow Growth:** Most are well-differentiated squamous cell carcinomas (SCC). 3. **Late Metastasis:** Lymphatic spread occurs late, usually to the submental or submandibular nodes. **Analysis of Incorrect Options:** * **Carcinoma of the Tongue (Option C):** This has the **worst prognosis** among the options. The tongue is highly muscular with rich lymphatic drainage (often bilateral/crossed), leading to early and aggressive nodal metastasis. * **Carcinoma of the Cheek (Buccal Mucosa) (Option B):** Common in India due to tobacco/betel nut chewing. While it has a fair prognosis, it often presents with trismus and can involve the buccinator muscle, making it more aggressive than lip cancer. * **Carcinoma of the Palate (Option D):** These are often minor salivary gland tumors or SCCs. Hard palate lesions can invade the palatine bone early, complicating the prognosis compared to the lip. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of Oral Cancer (Global):** Lip. * **Most common site of Oral Cancer (India):** Buccal Mucosa (due to "Ghutka" use). * **Lower Lip vs. Upper Lip:** Lower lip cancer is more common (UV exposure), but **Upper lip cancer** has a worse prognosis because it drains directly to pre-auricular nodes. * **Field Cancerization:** This concept (Slaughter’s hypothesis) is most frequently associated with oral cavity cancers, explaining the risk of synchronous or metachronous lesions.

Question 65: What is the most common soft tissue tumor in adults?

A. Embryonal rhabdomyosarcoma
B. Liposarcoma (Correct Answer)
C. Synovial sarcoma
D. Malignant fibrous histiocytoma

Explanation: **Explanation:** **Liposarcoma** is currently recognized as the most common soft tissue sarcoma (STS) in adults, accounting for approximately 20–25% of all adult sarcomas. These tumors typically arise from adipocytes and are most frequently found in the retroperitoneum and the lower extremities (thigh). Histologically, the presence of **lipoblasts** is a characteristic feature. **Analysis of Options:** * **Liposarcoma (Correct):** It has overtaken Malignant Fibrous Histiocytoma (MFH) in recent classifications as the most frequent subtype. The most common histological variant is the well-differentiated liposarcoma. * **Embryonal Rhabdomyosarcoma (Incorrect):** This is the most common soft tissue sarcoma in **children** (0–14 years), typically occurring in the head, neck, and genitourinary tract. * **Synovial Sarcoma (Incorrect):** This is a common sarcoma in young adults (15–40 years), often occurring near joints (though not arising from the synovium itself). It is characterized by the **t(X;18)** translocation. * **Malignant Fibrous Histiocytoma (Incorrect):** Formerly considered the most common, this diagnosis is now largely obsolete. Most tumors previously labeled as MFH are now reclassified as **Pleomorphic Undifferentiated Sarcoma (PUS)** or specific subtypes of liposarcoma/leiomyosarcoma. **High-Yield NEET-PG Pearls:** * **Most common STS in Children:** Rhabdomyosarcoma. * **Most common STS in Adults:** Liposarcoma. * **Most common site for STS:** Lower extremity (Thigh). * **Route of spread:** Most sarcomas spread **hematogenously** (primarily to lungs), except for "SCARE" (Synovial, Clear cell, Angiosarcoma, Rhabdomyosarcoma, Epithelioid), which frequently spread via lymphatics. * **Investigation of Choice:** MRI is preferred for extremities; CT is preferred for retroperitoneal tumors. Diagnosis is confirmed via **Core Needle Biopsy**.

Question 66: What is characteristic of carcinoma of the lip?

A. It occurs mostly in females.
B. It metastasizes easily.
C. It occurs mostly on the lower lip. (Correct Answer)
D. It is mostly of the basal cell type.

Explanation: **Explanation:** Carcinoma of the lip is a common head and neck malignancy, primarily presenting as **Squamous Cell Carcinoma (SCC)**. **1. Why the Correct Answer is Right:** * **Option C (Lower Lip):** Approximately **90% of lip cancers occur on the lower lip**. This is primarily due to chronic cumulative exposure to ultraviolet (UV) radiation from sunlight. Because of the anatomical protrusion and angle of the face, the lower lip receives significantly more direct sun exposure than the upper lip. **2. Why the Other Options are Incorrect:** * **Option A:** Lip cancer occurs predominantly in **males** (ratio approx. 10:1), largely due to higher rates of outdoor occupations (sun exposure) and tobacco use (smoking/chewing). * **Option B:** Lip cancer is generally considered to have a **favorable prognosis** because it grows slowly and metastasizes late. Only about 5–10% of cases involve regional lymph node metastasis (usually to Submental or Submandibular nodes) at the time of diagnosis. * **Option D:** The most common histological type is **Squamous Cell Carcinoma (SCC)**. While Basal Cell Carcinoma (BCC) can occur, it more commonly affects the **upper lip** (often spreading from the adjacent skin). **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Chronic sun exposure (UVB), pipe smoking, and immunosuppression. * **Staging:** Follows the TNM system for the oral cavity. * **Management:** Small lesions are treated with surgical excision (V-excision or Shield excision) or radiotherapy with equal efficacy. * **Prognosis:** The lower lip has a better prognosis than the upper lip or the oral commissure. * **Field Cancerization:** Patients are at risk for synchronous or metachronous lesions in the oral cavity.

Question 67: Sentinel lymph node biopsy is an important part of the management of which of the following malignancies?

A. Carcinoma prostate
B. Carcinoma breast (Correct Answer)
C. Carcinoma lung
D. Carcinoma nasopharynx

Explanation: **Explanation:** **Sentinel Lymph Node Biopsy (SLNB)** is based on the concept that the lymphatic drainage from a primary tumor follows a predictable path to a specific "sentinel" node. If this first node is negative for metastasis, the remaining nodes in the basin are likely clear, allowing the surgeon to avoid morbid procedures like Axillary Lymph Node Dissection (ALND). **Why Carcinoma Breast is correct:** SLNB is the **standard of care** for clinically node-negative (cN0) breast cancer. It is performed using a radioactive tracer (Technetium-99m) and/or blue dye (Isosulfan or Methylene blue). If the sentinel node is negative, ALND is omitted, significantly reducing the risk of complications like lymphedema, seroma, and nerve injury. **Why other options are incorrect:** * **Carcinoma Prostate:** Lymph node assessment is usually done via pelvic lymph node dissection (PLND) during radical prostatectomy. While SLNB is being researched, it is not the standard clinical practice. * **Carcinoma Lung:** Staging involves mediastinoscopy or EBUS (Endobronchial Ultrasound). The lymphatic drainage of the lung is complex and multidirectional, making SLNB unreliable. * **Carcinoma Nasopharynx:** This is primarily a non-surgical disease treated with radiotherapy and chemotherapy. Lymph node management is addressed via radiation fields or neck dissection for residual disease. **High-Yield Clinical Pearls for NEET-PG:** * **Indications for SLNB:** Breast cancer (cN0), Early-stage Melanoma, and Carcinoma Penis (if nodes are non-palpable). * **Contraindications in Breast Cancer:** Inflammatory breast cancer, clinically positive nodes (cN1), and large tumors (T3/T4) where drainage patterns are disrupted. * **The "Hot and Blue" Rule:** Using both radioisotope and blue dye increases the identification rate to >95%. * **Skip Metastasis:** This refers to a positive non-sentinel node despite a negative sentinel node (rare in breast cancer, ~5-10%).

Question 68: What is an absolute contraindication of conservative breast cancer therapy?

A. History of previous radiation therapy and first-trimester pregnancy (Correct Answer)
B. Large pendulous breast and subareolar lump presence
C. History of previous radiation therapy and subareolar lump presence
D. Axillary node involvement and first-trimester pregnancy

Explanation: **Explanation:** Breast Conservative Surgery (BCS) aims to preserve the breast while ensuring oncological safety. However, its success depends on the ability to deliver adjuvant **Whole Breast Irradiation (WBI)**, which is mandatory to reduce local recurrence. **Why Option A is Correct:** * **Prior Radiation Therapy:** If a patient has previously received radiation to the chest wall or breast (e.g., for Hodgkin’s lymphoma or a prior breast cancer), further therapeutic radiation would exceed the safe cumulative dose to the skin, lungs, and heart, leading to severe tissue necrosis. * **First-Trimester Pregnancy:** Radiation is strictly contraindicated in the first trimester due to high teratogenic risks to the fetus. Since radiation cannot be delayed until after delivery without risking cancer progression, mastectomy is the preferred choice. **Analysis of Incorrect Options:** * **Option B:** A large pendulous breast is a **relative contraindication** (due to poor cosmetic outcomes and difficulty in radiation planning). A subareolar lump is no longer an absolute contraindication; the nipple-areola complex can be sacrificed while preserving the rest of the breast. * **Option C:** While prior radiation is absolute, a subareolar lump is not. * **Option D:** Axillary node involvement is **not** a contraindication for BCS; it simply necessitates axillary lymph node dissection or clearance. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications for BCS:** 1. Prior radiation to the breast/chest wall. 2. Pregnancy (1st and 2nd trimester, if radiation cannot be delayed). 3. Diffuse suspicious microcalcifications on mammography. 4. Multicentric disease (tumors in different quadrants). 5. Persistently positive surgical margins after re-excision. * **Relative Contraindications:** Active connective tissue diseases (e.g., Scleroderma, SLE) due to poor tolerance of radiation, and tumors >5cm (T3). * **Goal of BCS:** To achieve a survival rate equivalent to mastectomy while maintaining cosmesis.

Question 69: In which one of the following types of carcinoma of the breast is a biopsy of the opposite breast advised?

A. Inflammatory carcinoma
B. Medullary carcinoma
C. Lobular carcinoma (Correct Answer)
D. Scirrhous carcinoma

Explanation: **Explanation:** The correct answer is **Lobular Carcinoma (Invasive Lobular Carcinoma - ILC)**. **Why Lobular Carcinoma is correct:** Invasive Lobular Carcinoma is uniquely characterized by its high rate of **multicentricity** (multiple foci within the same breast) and **bilaterality** (involvement of the opposite breast). Approximately **10–15%** of patients with ILC will have synchronous or metachronous cancer in the contralateral breast, which is significantly higher than the rate seen in Invasive Ductal Carcinoma (IDC). Due to this high risk, a low threshold for clinical examination, imaging (MRI), or even a blind/directed biopsy of the opposite breast was historically recommended to rule out occult disease. **Why the other options are incorrect:** * **A. Inflammatory Carcinoma:** This is a clinical diagnosis characterized by rapid onset, dermal lymphatic invasion, and "peau d'orange" appearance. It is highly aggressive but does not specifically mandate a contralateral biopsy unless imaging suggests a lesion. * **B. Medullary Carcinoma:** This is a subtype of IDC often associated with BRCA1 mutations. While it has a better prognosis despite high-grade features, it does not share the same hallmark of diffuse bilaterality as ILC. * **C. Scirrhous Carcinoma:** This is an older term for Invasive Ductal Carcinoma (NOS) with significant fibrosis. It is the most common type of breast cancer but is typically a localized mass rather than a diffuse, bilateral process. **High-Yield Clinical Pearls for NEET-PG:** * **The "Indian File" Pattern:** ILC cells lack **E-cadherin** (due to CDH1 gene mutation), leading to a loss of cell-to-cell adhesion and a characteristic linear arrangement on histology. * **Diagnostic Challenge:** ILC is notorious for being "stealthy"—it often does not form a discrete lump and may be missed on mammography (false negative rate is higher than IDC). * **Metastatic Pattern:** Unlike IDC, ILC tends to metastasize to unusual sites like the peritoneum, GI tract, and ovaries. * **LCIS (Lobular Carcinoma In Situ):** If found, it is considered a **risk factor** (indicator) for developing invasive cancer in *either* breast, further emphasizing the bilateral nature of lobular pathology.

Question 70: What is the best chemotherapeutic regimen for breast cancer?

A. Cyclophosphamide, methotrexate, 5-fluorouracil (Correct Answer)
B. Methotrexate, cisplatin
C. Cisplatin, adriamycin, steroid
D. Methotrexate, adriamycin, steroid

Explanation: **Explanation:** The correct answer is **A. Cyclophosphamide, methotrexate, 5-fluorouracil (CMF)**. Historically, the **CMF regimen** was the gold standard for adjuvant chemotherapy in breast cancer. While modern oncology has shifted toward anthracycline-based (e.g., AC: Adriamycin/Cyclophosphamide) and taxane-based regimens for high-risk patients, CMF remains a classic, highly effective, and frequently tested regimen in surgical exams. It works through a synergistic mechanism: Cyclophosphamide (alkylating agent), Methotrexate (antimetabolite/folate antagonist), and 5-Fluorouracil (pyrimidine analog) collectively inhibit DNA synthesis and cell division in malignant breast cells. **Analysis of Incorrect Options:** * **Option B (Methotrexate, cisplatin):** Cisplatin is primarily used in triple-negative breast cancer (TNBC) or germline BRCA mutations, but it is not paired with methotrexate as a standard frontline regimen. * **Option C & D (Adriamycin/Steroids):** While Adriamycin (Doxorubicin) is a cornerstone of modern breast cancer treatment (AC regimen), it is typically paired with Cyclophosphamide, not Methotrexate. Steroids are supportive medications (anti-emetics) rather than primary chemotherapeutic agents. **High-Yield Clinical Pearls for NEET-PG:** * **CMF Side Effects:** Methotrexate can cause mucositis; Cyclophosphamide is associated with hemorrhagic cystitis (prevented by hydration/MESNA). * **Anthracyclines (Adriamycin):** Known for **cardiotoxicity** (dilated cardiomyopathy). Always check LVEF via ECHO before starting. * **Taxanes (Paclitaxel/Docetaxel):** Act on microtubules; major side effect is **peripheral neuropathy**. * **Trastuzumab (Herceptin):** Used specifically for **HER2-positive** breast cancer; also carries a risk of reversible cardiotoxicity. * **Tamoxifen:** The drug of choice for ER/PR positive pre-menopausal women; increases the risk of endometrial carcinoma and thromboembolism.

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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