Principles of Surgical Oncology — MCQs
What is the standard excision margin for thick melanomas (>2 mm Breslow thickness)?
Which of the following stages of Breast Cancer corresponds to the following features: a breast mass of 6 x 3 cm, ipsilateral supraclavicular lymph node involvement, and distant metastasis that cannot be assessed?
N3a TNM staging of head and neck tumors (AJCC 8th edition) shows:
Which of the following is the platinum-based chemotherapeutic agent used as first-line treatment for ovarian carcinoma?
Which statement is incorrect about the pathology of the bone tumor?
Which of the following stages of lip carcinoma does not have nodal involvement?
Treatment of resectable T4N0M0 stage of head and neck carcinoma is?
A 10 cm tumor is found on the anterior surface of the thigh. What is the most appropriate procedure to obtain a diagnosis?
What is the functional capability of the instrument shown in the image?
Which of the following requires the maximum margin of excision?
Principles of Surgical Oncology Indian Medical PG Practice Questions and MCQs
Question 1: What is the standard excision margin for thick melanomas (>2 mm Breslow thickness)?
- A. 2 cm (Correct Answer)
- B. 5 cm
- C. 7 cm
- D. 10 cm
Explanation: **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.
Question 2: Which of the following stages of Breast Cancer corresponds to the following features: a breast mass of 6 x 3 cm, ipsilateral supraclavicular lymph node involvement, and distant metastasis that cannot be assessed?
- A. T4 N3 MX
- B. T4 N1 M1
- C. T4 N0 M0
- D. T3 N3c MX (Correct Answer)
Explanation: ***T3 N3c MX*** - A **breast mass of 6 x 3 cm** indicates a T3 tumor (tumor size > 5 cm). - **Ipsilateral supraclavicular lymph node involvement** is classified as N3c disease. **Distant metastasis that cannot be assessed** is denoted by MX. *T4 N3 MX* - A **T4 classification** is reserved for tumors with direct extension to the chest wall or skin, or inflammatory breast cancer, which is not mentioned here. - While N3c and MX are correct for the nodal and metastatic status, the T stage is inaccurate based on the provided tumor size. *T4 N1 M1* - A **T4 classification** is incorrect as the mass size alone (6 x 3 cm) does not meet T4 criteria. - **N1** denotes involvement of 1-3 axillary lymph nodes, which is less extensive than supraclavicular involvement (N3c). **M1** indicates confirmed distant metastasis, but the question states it "cannot be assessed" (MX). *T4 N0 M0* - **T4** is incorrect, as this stage is for direct chest wall/skin involvement or inflammatory breast cancer. - **N0** signifies no regional lymph node metastasis, contradicting the presence of supraclavicular lymph node involvement. **M0** indicates no distant metastasis, whereas the question specifies it cannot be assessed (MX).
Question 3: N3a TNM staging of head and neck tumors (AJCC 8th edition) shows:
- A. Metastasis in a lymph node >6 cm (Correct Answer)
- B. Metastasis in lymph nodes >2 cm
- C. Metastasis in lymph nodes >5 cm
- D. None of the options
Explanation: ***Metastasis in a lymph node >6 cm*** - **N3a disease** in head and neck cancer staging (AJCC 8th edition) specifically refers to metastasis in a single lymph node larger than 6 cm in greatest dimension **without extranodal extension (ENE)**. - This applies to oral cavity, oropharynx (HPV-negative), hypopharynx, and larynx cancers. - **Note:** N3 staging also includes **N3b** (metastasis in any node with clinically overt ENE), but this question specifically asks about N3a criteria. *Metastasis in lymph nodes >2 cm* - Lymph nodes in the 2-3 cm range typically fall within **N1 or N2a categories**, depending on laterality and number of involved nodes. - **N3a disease** requires a single lymph node to exceed 6 cm in greatest dimension without ENE. *Metastasis in lymph nodes >5 cm* - A lymph node between 3-6 cm is usually classified as **N2 disease** (N2a if single ipsilateral ≤6 cm, N2b if multiple ipsilateral ≤6 cm, N2c if bilateral or contralateral ≤6 cm). - To be classified as **N3a**, the lymph node must be **>6 cm** without extranodal extension. *None of the options* - This option is incorrect because the first option accurately describes the size criterion for **N3a TNM staging** in head and neck tumors according to AJCC 8th edition guidelines. - While N3 staging has two subcategories (N3a and N3b), the size criterion of >6 cm correctly defines N3a disease.
Question 4: Which of the following is the platinum-based chemotherapeutic agent used as first-line treatment for ovarian carcinoma?
- A. Cyclophosphamide
- B. Methotrexate
- C. Cisplatin (Correct Answer)
- D. Dacarbazine
Explanation: ***Cisplatin*** - **Cisplatin** is a platinum-based chemotherapy drug that forms **DNA cross-links**, inhibiting DNA synthesis and leading to the death of rapidly dividing cells, making it highly effective against **ovarian carcinoma**. - It is a cornerstone of chemotherapy regimens for ovarian cancer, often used in combination with other agents such as paclitaxel. *Methotrexate* - **Methotrexate** is an **antimetabolite** that inhibits dihydrofolate reductase, thereby interfering with DNA synthesis. - While it is used in various cancers like leukemia, lymphoma, and some solid tumors (e.g., breast cancer, gestational trophoblastic disease), it is **not a primary recommended drug for ovarian carcinoma**. *Cyclophosphamide* - **Cyclophosphamide** is an **alkylating agent** that causes DNA damage, leading to cell death. - It is used in many cancers, including lymphoma, breast cancer, and some leukemias, but it is **not a first-line or primary agent for ovarian carcinoma** in contemporary treatment guidelines. *Dacarbazine* - **Dacarbazine** is an **alkylating agent** primarily used in the treatment of **malignant melanoma** and Hodgkin lymphoma. - It is **not indicated for the treatment of ovarian carcinoma**.
Question 5: Which statement is incorrect about the pathology of the bone tumor?
- A. Tumor has distinct margin
- B. Tumor arises from epiphyseal to metaphyseal region
- C. Eccentric lesion
- D. Chemotherapy is the treatment of choice for all bone tumors. (Correct Answer)
Explanation: ***Tumor has distinct margin*** - A **distinct margin** often indicates a benign tumor, while malignant tumors typically show **infiltrative margins**. - In bone tumors, particularly malignant ones, the lack of clear demarcation is a key pathological feature. *Chemotherapy is the treatment of choice* - While chemotherapy may be used for certain **malignant bone tumors**, it is not the first-line treatment for most bone tumors [1]. - The primary treatment is often **surgical excision**, especially for localized lesions [1]. *Tumor arise from epiphyseal to metaphyseal region* - While some tumors can originate in these areas, many actually arise from the **diaphyseal** region in bone tumors like osteosarcoma. - This option misrepresents the common locations where various tumors develop, as osteochondromas tend to develop near the epiphyses of limb bones [2]. *Eccentric lesion* - Many bone tumors do indeed present as **eccentric lesions**, especially benign ones like **osteochondromas**. - However, this feature does not apply universally, as some malignant tumors can also be **central or infiltrative** in nature. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 673-674. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 672-673.
Question 6: Which of the following stages of lip carcinoma does not have nodal involvement?
- A. T2N1
- B. T3N0 (Correct Answer)
- C. T2N2
- D. T1N1
Explanation: ***T3N0*** - The **'N' classification** in the TNM staging system refers to **nodal involvement**. A stage with **'N0' indicates no regional lymph node metastasis**. - A **T3 lesion** signifies a large primary tumor, but if it's accompanied by **N0**, it means there's no evidence of spread to the lymph nodes. *T2N1* - The **'N1' classification** indicates the presence of **regional lymph node metastasis**, specifically in a **single ipsilateral lymph node** that is 3 cm or less in its greatest dimension. - This stage therefore **does have nodal involvement**, contradicting the premise of the question. *T2N2* - The **'N2' classification** signifies more advanced regional lymph node metastasis, such as a **single ipsilateral lymph node** greater than 3 cm but not more than 6 cm. - It could also refer to **multiple ipsilateral lymph nodes**, none greater than 6 cm, or bilateral/contralateral lymph nodes, none greater than 6 cm. In all these cases, **nodal involvement is present**. *T1N1* - Similar to T2N1, the **'N1' component** in T1N1 indicates the presence of **regional lymph node metastasis** in a single ipsilateral lymph node of 3 cm or less. - Therefore, this stage **does involve nodal spread**, despite having a smaller primary tumor (T1).
Question 7: Treatment of resectable T4N0M0 stage of head and neck carcinoma is?
- A. Radiotherapy alone
- B. Surgery and Radiotherapy (Correct Answer)
- C. Chemoradiation
- D. Surgery alone
Explanation: ***Surgery and Radiotherapy*** - For **resectable T4N0M0 head and neck carcinoma**, the standard treatment is **surgical resection** of the primary tumor followed by **adjuvant radiotherapy**. - This approach achieves optimal **local control** for advanced primary tumors without nodal involvement. - **Adjuvant radiotherapy** is essential for T4 tumors due to high risk of microscopic residual disease and local recurrence. - Surgery allows for complete tumor removal with negative margins, while radiotherapy addresses subclinical disease. *Radiotherapy alone* - Radiotherapy alone is **insufficient as monotherapy** for T4 tumors due to the large tumor burden and extensive local invasion. - Single modality radiation cannot reliably achieve adequate tumor control for advanced primary lesions. - Generally reserved for early-stage disease or patients unfit for surgery. *Chemoradiation* - **Definitive chemoradiation** is an alternative for **unresectable T4 tumors** or when organ preservation is desired (e.g., laryngeal cancer). - For **resectable** T4N0M0 disease, surgery with adjuvant RT is preferred as it provides better local control and allows pathological staging. - Chemoradiation may be used postoperatively if high-risk features are found (positive margins, perineural invasion, extranodal extension). - In this **N0 case with resectable tumor**, upfront surgery is the preferred initial approach. *Surgery alone* - While surgical resection is crucial for T4 tumors, **surgery alone is inadequate** due to high risk of locoregional recurrence. - T4 classification indicates extensive local invasion, necessitating **adjuvant radiotherapy** to eradicate microscopic disease. - Combined modality treatment (surgery + RT) significantly improves local control and survival compared to surgery alone.
Question 8: A 10 cm tumor is found on the anterior surface of the thigh. What is the most appropriate procedure to obtain a diagnosis?
- A. Incision biopsy (Correct Answer)
- B. Excision biopsy
- C. FNAC
- D. USG
Explanation: ***Incision biopsy*** - An **incision biopsy** is most appropriate for a large tumor (10 cm) to obtain a tissue diagnosis without performing a potentially morbid or disfiguring complete excision upfront. - It involves removing a representative section of the tumor for histopathological analysis, providing adequate tissue for diagnosis, grading, and subtyping. - This allows definitive treatment planning based on confirmed histopathology. *Excision biopsy* - **Excision biopsy** is generally reserved for smaller tumors (typically <3-5 cm) that can be completely resected with acceptable cosmetic and functional outcomes. - Excision of a 10 cm tumor on the thigh would be a significant surgical procedure, potentially causing substantial morbidity, without a prior definitive diagnosis. - Could compromise subsequent definitive surgery if margins are inadequate. *FNAC* - **FNAC (Fine Needle Aspiration Cytology)** provides only cytological diagnosis, which is insufficient for definitive diagnosis, grading, and subtyping of soft tissue tumors, especially sarcomas. - It misses crucial architectural features and tissue patterns needed for accurate classification. - May yield inadequate or non-diagnostic samples from large heterogeneous tumors. *USG* - **USG (Ultrasound)** is an imaging modality, not a tissue diagnosis procedure. - While useful for characterizing mass features (size, location, vascularity, solid vs cystic), it cannot provide histopathological diagnosis. - The question specifically asks for a procedure to "obtain a diagnosis," which requires tissue sampling for microscopic examination.
Question 9: What is the functional capability of the instrument shown in the image?
- A. Used for coagulation
- B. Used for cutting
- C. Used for both cutting and coagulation (Correct Answer)
- D. Cannot be used in patient with artificial valves
Explanation: ***Used for both cutting and coagulation*** - The image displays a **bipolar electrosurgical forceps**, which is specifically designed to deliver **high-frequency electrical current** for both cutting and coagulating tissue. - The electrical energy is localized between the two tips of the forceps, allowing for precise tissue manipulation with minimal collateral damage and reducing the risk of current spread to other parts of the body. *Used for coagulation* - While this instrument is excellent for **coagulation**, its capabilities extend beyond just stopping bleeding. - It can also be used for **cutting tissue efficiently** by using a different electrical waveform or power setting. *Used for cutting* - This instrument is indeed used for **cutting tissue**, but it also has the critical function of **coagulation**. - Restricting its description to only cutting would be incomplete and overlook its dual utility in surgery. *Cannot be used in patient with artificial valves* - Bipolar electrosurgery is generally considered **safe for patients with pacemakers, ICDs, or artificial valves** because the current is confined between the two tips of the instrument. - This localized current flow **minimizes the risk of interference** with implanted medical devices, unlike monopolar electrosurgery which has a greater risk of current dispersion.
Question 10: Which of the following requires the maximum margin of excision?
- A. Malignant melanoma
- B. Basal cell carcinoma (BCC)
- C. Squamous cell carcinoma (SCC)
- D. Dermatofibrosarcoma protuberans (Correct Answer)
Explanation: **Explanation:** The correct answer is **Dermatofibrosarcoma Protuberans (DFSP)**. The primary factor determining excision margins is the biological behavior and local invasiveness of the tumor. DFSP is a low-to-intermediate grade cutaneous sarcoma characterized by extensive, subclinical **tentacle-like lateral extensions** (microscopic projections) into the surrounding dermis and subcutaneous fat. Because these extensions often go beyond the clinically visible tumor, standard narrow margins lead to extremely high recurrence rates. Current guidelines recommend a wide local excision with a margin of **2 to 4 cm**, or ideally, Mohs Micrographic Surgery (MMS). **Analysis of Incorrect Options:** * **Malignant Melanoma:** Margins are determined by the **Breslow thickness**. Even for the thickest tumors (>2 mm), the maximum recommended margin is **2 cm**. * **Squamous Cell Carcinoma (SCC):** Standard margins for high-risk SCC are typically **6 mm to 10 mm**. * **Basal Cell Carcinoma (BCC):** This is the least aggressive of the group. Standard excision margins are usually **4 mm to 5 mm** for low-risk lesions. **High-Yield Clinical Pearls for NEET-PG:** * **DFSP Pathognomonic Feature:** Histology shows a characteristic **"storiform" (cartwheel) pattern** of spindle cells and a **"honeycomb" appearance** when invading subcutaneous fat. * **Cytogenetics:** Associated with a translocation **t(17;22)**, leading to overexpression of PDGFB. * **Treatment of Choice:** Mohs Micrographic Surgery (MMS) is preferred over wide local excision to minimize tissue loss while ensuring clear margins. * **Medical Management:** **Imatinib** (a tyrosine kinase inhibitor) is used for metastatic or unresectable DFSP.
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