Oncological Surgery — MCQs

Oncological Surgery Indian Medical PG Practice Questions and MCQs

Question 81: Surgical treatment of anal canal carcinoma is largely replaced by what?

A. Nigro protocol (Correct Answer)
B. UW protocol
C. Mootz protocol
D. Williams protocol

Explanation: **Explanation:** Historically, the standard treatment for anal canal carcinoma (specifically Squamous Cell Carcinoma) was Abdominoperineal Resection (APR), which required a permanent colostomy. This has been largely replaced by the **Nigro Protocol**, which prioritizes organ preservation. **1. Why Nigro Protocol is Correct:** The Nigro Protocol is a definitive **chemoradiotherapy (CRT)** regimen consisting of 5-Fluorouracil (5-FU), Mitomycin-C, and external beam radiation. It achieves high rates of complete clinical remission (80-90%) while preserving the anal sphincter. Surgery is now reserved only for "salvage" (residual or recurrent disease). **2. Analysis of Incorrect Options:** * **UW Protocol:** Refers to the University of Wisconsin solution used for organ preservation during transplantation, not oncology. * **Mootz Protocol:** This is not a recognized standard oncological treatment for anal cancer. * **Williams Protocol:** While there are various "Williams" techniques in surgery (e.g., for bladder exstrophy), it is not a standard protocol for anal canal carcinoma. **Clinical Pearls for NEET-PG:** * **Anatomical Landmark:** The Nigro protocol is the gold standard for tumors arising **below** the pectinate line (Squamous Cell Carcinoma). * **Adenocarcinoma exception:** If the pathology is Adenocarcinoma (usually arising from the upper anal canal), the treatment follows rectal cancer guidelines (Surgery/TME). * **Staging:** MRI of the pelvis and PET-CT are the preferred modalities for staging and monitoring response. * **Salvage Surgery:** If the Nigro protocol fails, the procedure of choice is **Abdominoperineal Resection (APR)**.

Question 82: Sister Joseph Nodules are present at which location?

A. Umbilicus (Correct Answer)
B. Diaphragm
C. Lung
D. Liver

Explanation: **Explanation:** **Sister Mary Joseph’s Nodule (SMJN)** refers to a palpable, firm, and often painful nodule at the **umbilicus** (Option A) that represents cutaneous metastasis from an intra-abdominal or pelvic malignancy. **Why the Umbilicus is Correct:** The umbilicus is a unique anatomical site where several embryonic remnants and vascular/lymphatic channels converge. Malignant cells reach the umbilicus via: 1. **Contiguous spread** (peritoneal seeding). 2. **Lymphatic spread** (via axillary, inguinal, or internal mammary nodes). 3. **Venous spread** (via the portal system or paraumbilical veins). 4. **Remnants** of the urachus or vitelline duct. **Why Other Options are Incorrect:** * **B. Diaphragm:** While the diaphragm is a common site for peritoneal seeding (e.g., scalloping of the liver in pseudomyxoma peritonei), it does not present as a "nodule" named after Sister Joseph. * **C & D. Lung and Liver:** These are common sites for visceral hematogenous metastasis. While they may harbor secondary deposits, they are internal organs and do not present as the classic superficial umbilical sign. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Source:** The most common primary site is **Stomach** (in men) and **Ovary** (in women). Other sources include the pancreas and colon. * **Significance:** Its presence usually indicates **advanced stage (Stage IV)** disease and carries a poor prognosis. * **Historical Fact:** Named after Sister Mary Joseph Dempsey, the surgical assistant to Dr. William Mayo, who first noticed the correlation between these nodules and intra-abdominal cancer. * **Differential Diagnosis:** Must be distinguished from an umbilical hernia or a primary umbilical tumor (e.g., melanoma).

Question 83: Sentinel node biopsy for breast cancer is performed for what purpose?

A. Early diagnosis of cancer
B. Staging the tumour (Correct Answer)
C. Frozen section
D. Detection of occult disease

Explanation: **Explanation:** **Sentinel Lymph Node Biopsy (SLNB)** is the standard of care for axillary evaluation in patients with clinically node-negative (cN0) breast cancer. 1. **Why "Staging the tumour" is correct:** The status of the axillary lymph nodes is the most important prognostic factor in early breast cancer. SLNB identifies the "sentinel node"—the first node(s) to receive lymphatic drainage from the primary tumor. If this node is negative, the rest of the axilla is likely negative, allowing the surgeon to avoid a morbid Axillary Lymph Node Dissection (ALND). Thus, SLNB is used for **pathological nodal staging (pN)** within the TNM classification system. 2. **Why other options are incorrect:** * **A. Early diagnosis:** Diagnosis is confirmed via Triple Assessment (Clinical exam, Imaging, and Core Needle Biopsy of the breast mass), not by sampling lymph nodes. * **C. Frozen section:** This is a *technique* used intraoperatively to analyze the node, but it is not the *purpose* of the biopsy itself. * **D. Detection of occult disease:** While SLNB can find micrometastases, its primary clinical utility in the surgical algorithm is to determine the stage to guide further treatment (chemotherapy/radiotherapy). **High-Yield Clinical Pearls for NEET-PG:** * **Tracers used:** Technetium-99m labeled sulfur colloid (radioactive) and/or Isosulfan blue/Methylene blue dye. * **Identification:** The "Hot" node (gamma probe) or "Blue" node. * **Indication:** T1-T2 tumors with clinically negative axilla. * **Contraindications:** Inflammatory breast cancer, clinically positive nodes (cN1), and large multicentric tumors (relative). * **The "10% Rule":** Any node with radioactivity ≥10% of the hottest node should be excised.

Question 84: Which of the following is the most radiosensitive tumor?

A. Ewing's sarcoma (Correct Answer)
B. Hodgkin's disease
C. Carcinoma cervix
D. Malignant fibrous histiocytoma

Explanation: **Explanation:** The radiosensitivity of a tumor is determined by its cell of origin, growth fraction, and inherent genetic susceptibility to DNA damage. In clinical oncology, tumors are categorized into groups based on their response to radiation. **1. Why Ewing’s Sarcoma is Correct:** Ewing’s sarcoma is a highly aggressive, small round blue cell tumor. These tumors typically have a very high growth fraction (rapidly dividing cells) and lack robust DNA repair mechanisms, making them **highly radiosensitive**. In the context of the given options, Ewing’s sarcoma belongs to the "Radiosensitive" category, often requiring radiotherapy as a primary or adjuvant modality for local control. **2. Analysis of Incorrect Options:** * **Hodgkin’s Disease:** While Hodgkin’s lymphoma is also highly radiosensitive (and often more curable with radiation than Ewing's), in standard surgical and oncological grading, small round blue cell tumors like Ewing's or Seminomas are often cited as the benchmark for extreme sensitivity among solid/bone tumors. * **Carcinoma Cervix:** This is considered **moderately radiosensitive**. While radiotherapy is a cornerstone of treatment (especially for advanced stages), it requires much higher doses to achieve local control compared to Ewing’s. * **Malignant Fibrous Histiocytoma (MFH):** Now largely reclassified as Pleomorphic Undifferentiated Sarcoma, this is a soft tissue sarcoma. Most soft tissue sarcomas are **radioresistant** and primarily managed with wide local excision. **NEET-PG High-Yield Pearls:** * **Most Radiosensitive Tumor:** Seminoma (often considered #1), followed by Lymphomas and Ewing’s Sarcoma. * **Most Radioresistant Tumors:** Malignant Melanoma, Osteosarcoma, and Pancreatic Adenocarcinoma. * **Bergonie-Tribondeau Law:** States that radiosensitivity is directly proportional to the reproductive rate and inversely proportional to the degree of differentiation of the cells. * **Small Round Blue Cell Tumors** (Ewing’s, Neuroblastoma, Wilms tumor) are generally highly sensitive to both chemo and radiotherapy.

Question 85: A female presents with a breast lump of size 6 cm. On examination, ipsilateral axillary lymph nodes are found to be enlarged and fixed. What is the TNM staging?

A. T3 N2 (Correct Answer)
B. T2 N2
C. T4 N2
D. T1 N1

Explanation: ### Explanation The TNM staging system for breast cancer is a cornerstone of surgical oncology. To solve this question, we must break down the clinical findings based on the AJCC 8th Edition criteria. **1. Tumor (T) Staging:** The size of the lump is **6 cm**. * T1: ≤ 2 cm * T2: > 2 cm but ≤ 5 cm * **T3: > 5 cm** * T4: Any size with extension to the chest wall or skin (edema/ulceration). Since the lump is 6 cm, it is classified as **T3**. **2. Node (N) Staging:** The examination reveals **ipsilateral axillary lymph nodes** that are **fixed** to one another or to other structures. * N1: Movable ipsilateral axillary lymph nodes. * **N2: Ipsilateral axillary lymph nodes that are fixed** or matted. * N3: Metastasis in ipsilateral infraclavicular, internal mammary, or supraclavicular nodes. The presence of fixed nodes confirms **N2**. **Conclusion:** Combining these gives **T3 N2**. --- ### Why Other Options are Incorrect: * **B (T2 N2):** Incorrect because T2 is limited to tumors ≤ 5 cm. * **C (T4 N2):** Incorrect because T4 requires involvement of the chest wall (Serratus anterior/Ribs) or skin (Peau d'orange/Ulceration). Size alone does not make a tumor T4. * **D (T1 N1):** Incorrect as T1 is ≤ 2 cm and N1 implies movable (not fixed) nodes. --- ### NEET-PG High-Yield Pearls: * **T4 Classification:** Note that involvement of the Pectoralis major muscle alone does **not** constitute T4; it must involve the chest wall (ribs, intercostals, or serratus anterior). * **Inflammatory Carcinoma:** This is clinically diagnosed and automatically staged as **T4d**. * **Dimpling vs. Peau d'orange:** Skin dimpling (tethering) is due to Cooper’s ligament involvement and does not change the T stage, whereas Peau d'orange (dermal lymphatic edema) signifies T4.

Question 86: What is the best treatment for a 2 cm thyroid nodule in a 50-year-old man, where Fine Needle Aspiration Cytology (FNAC) reveals papillary carcinoma?

A. Hemithyroidectomy
B. Total thyroidectomy with left sided modified neck dissection (Correct Answer)
C. Near total thyroidectomy with radiotherapy
D. Hemithyroidectomy with modified neck dissection

Explanation: **Explanation:** The management of Papillary Thyroid Carcinoma (PTC) is guided by risk stratification. In this case, the patient is a **50-year-old male** with a **2 cm nodule**. According to the AMES (Age, Metastasis, Extent, Size) and MACIS criteria, being male, over age 45, and having a tumor size ≥2 cm places him in a higher-risk category, necessitating a **Total Thyroidectomy**. While the question does not explicitly state the presence of lymphadenopathy, in the context of NEET-PG, if a "Modified Radical Neck Dissection (MRND)" is included in the correct option for PTC, it implies the clinical or radiological presence of lateral cervical lymphadenopathy. PTC is highly lymphophilic, and MRND is the standard of care for biopsy-proven lateral neck nodes (Levels II-V). **Analysis of Options:** * **Option A & D (Hemithyroidectomy):** Generally reserved for low-risk patients (age <45, tumor <1 cm, unifocal, no extra-thyroidal extension). This patient’s age and tumor size make this inadequate. * **Option C (Near-total thyroidectomy):** While historically used, modern surgical practice favors Total Thyroidectomy to facilitate the use of Radioiodine (RAI) ablation and Thyroglobulin monitoring post-operatively. Radiotherapy is rarely the primary adjuvant treatment for PTC. **Clinical Pearls for NEET-PG:** * **Most common site of metastasis:** PTC spreads primarily via **lymphatics** to the central compartment (Level VI) and then lateral neck. * **Psammoma bodies:** Pathognomonic histological finding in PTC (laminated calcifications). * **Orphan Annie Eye nuclei:** Characteristic nuclear clearing seen on histopathology. * **Prognosis:** PTC has an excellent 10-year survival rate (>90%), but age >45-55 is the most significant prognostic factor for recurrence and mortality.

Question 87: A patient with oral cancer involving the mandible is managed by which of the following treatment modalities?

A. Chemotherapy alone
B. Radiotherapy alone
C. Resection followed by radiotherapy (Correct Answer)
D. Radiotherapy followed by resection

Explanation: **Explanation:** The management of oral cancer depends on the stage and the involvement of adjacent structures. When oral cancer involves the **mandible**, it is classified as T4a disease (locally advanced). **1. Why Option C is Correct:** The standard of care for locally advanced oral squamous cell carcinoma (OSCC) with bone involvement is **upfront surgical resection** (composite resection/commando operation) with adequate margins. Bone involvement is a poor prognostic factor and a high-risk feature. Therefore, surgery is followed by **Adjuvant Radiotherapy (RT)** or Chemoradiotherapy (CRT) to eliminate microscopic residual disease and reduce the risk of local recurrence. **2. Why other options are incorrect:** * **Options A & B:** Chemotherapy or Radiotherapy alone are rarely curative for T4 lesions. Furthermore, radiotherapy is less effective when there is gross bone invasion because the hypoxic environment of the bone limits the efficacy of radiation, and there is a high risk of **osteoradionecrosis** if high doses are used on an involved mandible. * **Option D:** Neoadjuvant radiotherapy (RT before surgery) is generally avoided in the oral cavity as it increases surgical complications, impairs wound healing (especially for flaps), and delays definitive surgical clearance. **Clinical Pearls for NEET-PG:** * **Mandibular Involvement:** If the tumor is close to the bone but not invading the cortex, a **marginal mandibulectomy** is done. If the marrow is involved, a **segmental mandibulectomy** is required. * **Indications for Adjuvant RT:** T3/T4 stage, positive/close margins, perineural invasion (PNI), or lymphovascular invasion (LVI). * **Indications for Adjuvant CRT:** The "Gold Standard" for adding chemotherapy to radiation post-surgery is the presence of **Extracapsular Spread (ECS)** in lymph nodes or **positive surgical margins**.

Question 88: What is the treatment of choice for Stage I seminoma?

A. High inguinal orchidectomy
B. High inguinal orchidectomy and radiotherapy (Correct Answer)
C. Radiotherapy and chemotherapy
D. Trans-scrotal orchidectomy

Explanation: **Explanation:** The management of testicular tumors is a high-yield topic for NEET-PG. The treatment of choice for **Stage I Seminoma** is **High Inguinal Orchidectomy (HIO)** followed by **adjuvant Radiotherapy** to the retroperitoneal lymph nodes. **1. Why Option B is Correct:** * **High Inguinal Orchidectomy:** This is the primary diagnostic and therapeutic step for all suspected testicular malignancies. It involves ligation of the spermatic cord at the internal inguinal ring to prevent the lymphatic spread of tumor cells during manipulation. * **Radiotherapy:** Seminomas are exquisitely **radiosensitive**. Even in Stage I (disease confined to the testis), there is a 15–20% risk of occult micrometastasis to the retroperitoneal lymph nodes. Low-dose para-aortic radiation (20 Gy) significantly reduces the recurrence rate to <1%. **2. Why Other Options are Incorrect:** * **Option A:** While HIO is the first step, performing it alone (surveillance) is usually reserved for highly compliant patients. In the context of standard "treatment of choice" in exams, adjuvant therapy is included. * **Option C:** Chemotherapy (Single-agent Carboplatin) is an alternative to radiotherapy, but radiotherapy remains the classic textbook answer for Stage I. Chemotherapy is never the primary treatment without orchidectomy. * **Option D:** **Trans-scrotal orchidectomy is contraindicated** in testicular cancer because it disrupts the natural lymphatic drainage and leads to inguinal lymph node metastasis (scrotal interference). **Clinical Pearls for NEET-PG:** * **Tumor Markers:** Seminomas may show elevated **hCG** (in 10-15% of cases) but **never** elevated AFP. If AFP is raised, it is a Non-Seminomatous Germ Cell Tumor (NSGCT). * **Most Common Presentation:** Painless enlargement of the testis. * **Lymphatic Spread:** Testicular tumors primarily spread to **Para-aortic lymph nodes** (except if the scrotum is involved, then to inguinal nodes). * **NSGCT Stage I:** Unlike seminoma, NSGCT is radioresistant; treatment is HIO followed by surveillance or Nerve-Sparing Retroperitoneal Lymph Node Dissection (RPLND).

Question 89: In which of the following head and neck cancers is lymph node metastasis least common?

A. Tongue
B. Buccal mucosa
C. Hard palate (Correct Answer)
D. Lower alveolus

Explanation: **Explanation:** The frequency of cervical lymph node metastasis in oral cavity cancers is primarily determined by the density of the lymphatic network and the muscularity of the site. **Why Hard Palate is Correct:** The **hard palate** and the **upper maxillary alveolus** have a sparse lymphatic network and are composed of mucoperiosteum tightly bound to bone. Due to this anatomical lack of deep muscle involvement and low lymphatic density, the incidence of clinically positive nodes at presentation is the lowest among oral cavity sites (approx. 10–15%). **Analysis of Incorrect Options:** * **Tongue (Option A):** The tongue is highly muscular and has a rich, decussating lymphatic plexus. It has the **highest rate** of early lymphatic spread (often bilateral), with up to 40–50% of patients presenting with nodal disease. * **Buccal Mucosa (Option B):** This site is rich in lymphatics that drain into the submandibular (Level II) and facial nodes. It has a significantly higher metastatic potential than the hard palate. * **Lower Alveolus (Option D):** While the gingiva itself has modest lymphatics, tumors here frequently invade the underlying floor of the mouth or the mylohyoid muscle, leading to early involvement of Level I and II nodes. **Clinical Pearls for NEET-PG:** * **Most common site of Oral Cancer:** Lower lip (Global); Tongue/Buccal Mucosa (India). * **Highest risk of Nodal Metastasis:** Tongue and Floor of Mouth. * **Lowest risk of Nodal Metastasis:** Hard palate and Upper Alveolus. * **Nodal Levels:** Oral cavity cancers typically drain first to **Level I (Submental/Submandibular)** and **Level II (Upper Jugular)** nodes. * **Skip Metastasis:** Characteristically seen in Tongue cancers (nodes in Level III or IV involved without Level I or II).

Question 90: A 45-year-old chronic tobacco chewer presents with a 1.5 cm oral cavity mass and a single ipsilateral neck lymph node. What is the TNM stage of the tumor?

A. T1N3
B. T3N1
C. T2N2
D. T1N1 (Correct Answer)

Explanation: **Explanation:** The staging of oral cavity squamous cell carcinoma follows the **AJCC 8th Edition TNM classification**. To determine the stage, we must analyze the primary tumor (T) and the regional lymph nodes (N) separately. 1. **T-Stage (Primary Tumor):** * **T1:** Tumor size ≤ 2 cm and Depth of Invasion (DOI) ≤ 5 mm. * **T2:** Tumor size ≤ 2 cm with DOI > 5 mm OR tumor size 2–4 cm with DOI ≤ 10 mm. * In this case, the mass is **1.5 cm**, which falls under the **T1** category (assuming standard depth for a small lesion). 2. **N-Stage (Regional Lymph Nodes):** * **N1:** Metastasis in a **single ipsilateral** lymph node, **≤ 3 cm** in greatest dimension, and ENE (extranodal extension) negative. * The patient has a single ipsilateral node, making it **N1**. **Why the other options are incorrect:** * **T1N3:** N3 represents a node > 6 cm or any node with clinical extranodal extension. This is too advanced for a single node. * **T3N1:** T3 requires a tumor > 4 cm or DOI > 10 mm. A 1.5 cm mass does not meet this criteria. * **T2N2:** T2 requires a larger tumor size (2-4 cm). N2 involves multiple nodes, bilateral nodes, or a single node between 3–6 cm. **High-Yield Clinical Pearls for NEET-PG:** * **AJCC 8th Edition Update:** The most significant change in oral cavity staging is the inclusion of **Depth of Invasion (DOI)**, not just surface diameter. * **Most Common Site:** The lower lip is the most common site for oral cancer globally, but in India, the **buccal mucosa** (due to tobacco chewing) is most frequent. * **Nodal Level:** Oral cavity cancers typically spread first to **Level I, II, and III** neck nodes. * **Management:** T1N1 lesions are generally treated with wide local excision of the primary tumor and a neck dissection (usually Selective Neck Dissection).

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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