Lymphadenectomy — MCQs
Which of the following group of lymph nodes does NOT receive direct lymphatic drainage from the perineum?
Ca vulva of the anterior part will spread primarily to which of the following lymph nodes?
Which of the following cancers are correctly matched with the criteria for the minimum number of lymph nodes required for pathological staging? A. CA stomach -10 B. CA colon -12 C. CA gall bladder -6 D. CA breast -15
Sentinel lymph node biopsy is most useful for:
Which of the following soft tissue sarcomas does not typically have a propensity for lymphatic spread?
Which of the following is not a relative contraindication for breast conservative surgery?
Which of these is the STRONGEST indication for giving adjuvant treatment in oral malignancy after resection and Modified Radical Neck Dissection (MRND)?
Which of the following stages of lip carcinoma does not have nodal involvement?
A patient presents with upper limb swelling after undergoing a modified radical mastectomy (MRM). What is the most likely cause?
Surgical treatment for a 40-years old lady with 3 x 3 cm. papillary carcinoma thyroid with level III enlarged lymph nodes is :
Lymphadenectomy Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following group of lymph nodes does NOT receive direct lymphatic drainage from the perineum?
- A. Superficial inguinal
- B. Internal iliac
- C. External iliac (Correct Answer)
- D. Deep inguinal
Explanation: ***External iliac*** - The external iliac lymph nodes do **NOT receive direct lymphatic drainage** from the perineum. - They primarily receive lymph from the **deep inguinal nodes**, pelvic organs (bladder, upper vagina), and lower anterior abdominal wall [1]. - Perineal lymphatics drain to superficial inguinal, deep inguinal, or internal iliac nodes first, making external iliac a **secondary or tertiary drainage station** rather than a direct recipient. *Superficial inguinal* - These are the **primary drainage site** for lymph from the superficial perineum. - They receive direct lymphatic vessels from the **vulva, distal vagina, labia majora**, scrotum, and skin of the perineum. - This is the main first-line drainage pathway for superficial perineal structures. *Internal iliac* - Internal iliac lymph nodes receive **direct lymphatic drainage** from the deep perineum, including the **male urethra, prostate**, and deep structures [2], [3]. - They serve as primary drainage for pelvic visceral structures and deep perineal tissues [3]. *Deep inguinal* - Deep inguinal lymph nodes receive lymph from the **superficial inguinal nodes** and from deep structures of the lower limb. - They are part of the drainage pathway from the perineum via the superficial inguinal nodes.
Question 2: Ca vulva of the anterior part will spread primarily to which of the following lymph nodes?
- A. Inguinal (Correct Answer)
- B. Obturator
- C. Femoral
- D. Para-aortic
Explanation: ***Inguinal*** - Carcinoma of the vulva, particularly the anterior part, primarily metastasizes to the **inguinal lymph nodes** (both superficial and deep inguinal nodes). - The lymphatic drainage pathway: vulva → superficial inguinal nodes → deep inguinal nodes → external iliac nodes. - **Superficial inguinal nodes** lie above the inguinal ligament and are the first-line drainage. - The anterior vulva (especially the clitoris) may have bilateral drainage, making sentinel lymph node mapping important. *Obturator* - **Obturator lymph nodes** are pelvic nodes that primarily drain the cervix, bladder, and medial thigh. - These nodes are NOT part of the primary drainage pathway for vulvar cancer. - Involvement would indicate advanced disease with secondary pelvic spread. *Femoral* - The **deep inguinal (femoral) nodes** are part of the inguinal lymphatic chain and lie along the femoral vessels medial to the femoral vein. - While these nodes DO receive vulvar drainage, they are considered part of the broader "inguinal node group." - The term **"inguinal"** is preferred in clinical practice as it encompasses both superficial and deep (femoral) components of the primary drainage pathway. *Para-aortic* - **Para-aortic lymph nodes** drain the ovaries, uterine fundus, kidneys, and testis. - These nodes are NOT involved in primary vulvar drainage. - Para-aortic involvement in vulvar cancer indicates distant metastasis and advanced stage disease.
Question 3: Which of the following cancers are correctly matched with the criteria for the minimum number of lymph nodes required for pathological staging? A. CA stomach -10 B. CA colon -12 C. CA gall bladder -6 D. CA breast -15
- A. A,B,C
- B. A,B,C,D
- C. B,C (Correct Answer)
- D. A,C,D
Explanation: ***B,C (Correct Answer)*** - **Colorectal cancer (B)** requires a minimum of **12 lymph nodes** for adequate pathological staging - **correctly matched** ✅ - **Gallbladder cancer (C)** requires at least **6 lymph nodes** for proper staging - **correctly matched** ✅ - These are the only two correctly matched pairs in the question - Adequate lymph node retrieval is essential to prevent **understaging** and ensure accurate prognostic assessment *A,B,C (Incorrect)* - While B and C are correct, **gastric cancer (A)** requires a minimum of **15 lymph nodes**, not 10 - The inclusion of A makes this combination incorrect *A,B,C,D (Incorrect)* - **Gastric cancer (A)** requires **15 lymph nodes**, not 10 - **incorrectly matched** - **Breast cancer (D)** requires a minimum of **10 lymph nodes**, not 15 - **incorrectly matched** - Only B and C are correctly matched *A,C,D (Incorrect)* - **Gastric cancer (A)** requires **15 lymph nodes**, not 10 - **incorrectly matched** - **Breast cancer (D)** requires **10 lymph nodes**, not 15 - **incorrectly matched** - C is correct, but A and D are both incorrectly matched
Question 4: Sentinel lymph node biopsy is most useful for:
- A. Carcinoma vulva (Correct Answer)
- B. Carcinoma endometrium
- C. Carcinoma vagina
- D. Carcinoma cervix
Explanation: ***Carcinoma vulva*** - **Sentinel lymph node biopsy (SLNB)** is a standard procedure for early-stage vulvar carcinoma to assess nodal involvement with less morbidity than full inguinofemoral lymphadenectomy. - The procedure helps identify metastases in regional lymph nodes, guiding further treatment decisions while minimizing complications like **lymphedema**. *Carcinoma endometrium* - While SLNB can be used in endometrial cancer, its primary utility is in tailoring **lymphadenectomy** rather than being the "most useful" or universally preferred primary staging tool compared to vulvar cancer. - The anatomical spread often involves different lymphatic basins, and **comprehensive pelvic and para-aortic lymphadenectomy** or systematic nodal dissection remains a common approach, though SLNB is gaining traction. *Carcinoma vagina* - The lymphatic drainage of the vagina is complex and variable, making SLNB challenging and less standardized compared to vulvar cancer. - **Radical surgical excision** with **regional lymphadenectomy** remains the mainstay for staging and treatment of invasive vaginal carcinoma. *Carcinoma cervix* - For cervical cancer, SLNB is primarily used in **early-stage disease** to detect micrometastases and guide the extent of lymph node dissection. - However, **imaging** and comprehensive **pelvic lymphadenectomy** are often still crucial components for complete staging and treatment, depending on tumor characteristics.
Question 5: Which of the following soft tissue sarcomas does not typically have a propensity for lymphatic spread?
- A. Rhabdomyosarcoma
- B. Synovial sarcoma
- C. Malignant Peripheral Nerve Sheath Tumor (MPNST) (Correct Answer)
- D. Epithelioid sarcoma
Explanation: ***Malignant Peripheral Nerve Sheath Tumor (MPNST)*** - **MPNSTs**, like most soft tissue sarcomas, primarily metastasize hematogenously to the lungs [3], and **lymphatic spread is rare** [1]. - Their origin from peripheral nerves explains their tendency for local invasion and distant blood-borne metastases rather than lymphatic involvement [1]. *Synovial sarcoma* - **Synovial sarcoma** is one of the soft tissue sarcomas that has a **higher propensity for lymphatic spread** compared to many others [2]. - While hematogenous spread is also common, clinicians should always assess regional lymph nodes when evaluating this type of tumor. *Rhabdomyosarcoma* - **Rhabdomyosarcoma** is a highly aggressive tumor, particularly in children, and frequently shows **lymphatic metastasis**, especially in parameningeal, genitourinary, and extremity sites. - Due to its high metastatic potential, regional lymph node involvement is a crucial prognostic factor. *Epithelioid sarcoma* - **Epithelioid sarcoma** is known for its **propensity for both regional lymphatic spread** and local recurrence. - The pattern of spread often mimics carcinomas, making thorough regional lymph node evaluation essential. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Peripheral Nerves and Skeletal Muscles, pp. 1250-1251. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1225-1226. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, p. 282.
Question 6: Which of the following is not a relative contraindication for breast conservative surgery?
- A. Multicentric disease
- B. Previous radiation to breast
- C. Large tumor size
- D. Small tumor size (<3cm) (Correct Answer)
Explanation: ***Small tumor size (<3cm)*** ✓ - A small tumor size is **NOT a contraindication** for breast-conserving surgery; it is actually a **favorable condition** and an indication for breast conservation. - Small tumors allow for complete tumor removal with good cosmetic outcomes and adequate margins. - This is the **correct answer** as it is the only option that is NOT a relative contraindication. *Multicentric disease* - **Multicentric disease** refers to the presence of multiple tumor foci in **different quadrants** of the breast, making complete surgical removal challenging with breast-conserving surgery. - This is a **relative contraindication** as it increases the risk of **positive margins** and local recurrence, making mastectomy often a more appropriate option. *Previous radiation to breast* - Prior radiation therapy to the breast is a **contraindication** (often considered absolute) for subsequent breast radiation, which is an essential component of breast-conserving therapy. - Re-irradiation carries a high risk of severe **skin and tissue toxicity**, making further breast conservation unfeasible. *Large tumor size* - A large tumor size is a **relative contraindication** as it can make it difficult to achieve **clear surgical margins** while maintaining an acceptable cosmetic result. - However, **neoadjuvant chemotherapy** may downstage large tumors to make them suitable for breast-conserving surgery. - Without tumor reduction, it often requires **mastectomy**.
Question 7: Which of these is the STRONGEST indication for giving adjuvant treatment in oral malignancy after resection and Modified Radical Neck Dissection (MRND)?
- A. Extranodal extension (Correct Answer)
- B. Multiple lymph node metastasis
- C. T3 tumor
- D. Close margin
Explanation: ***Extranodal extension*** - **Extranodal extension (ENE)** is the strongest adverse pathological feature (APF) indicating the highest risk of recurrence and significantly impacting prognosis. - ENE is associated with increased likelihood of regional and distant metastasis. - The presence of ENE mandates **adjuvant concurrent chemoradiotherapy** (not radiotherapy alone), as landmark trials (EORTC 22931, RTOG 9501) demonstrated survival benefit with combined modality treatment. - ENE and positive surgical margins are the two most critical features requiring intensified adjuvant therapy. *Multiple lymph node metastasis* - Multiple positive lymph nodes (≥2 nodes) indicate high risk of recurrence and warrant **adjuvant radiotherapy**. - While this is a significant adverse feature, it does not mandate chemoradiotherapy unless accompanied by ENE or positive margins. - Considered a high-risk feature but not as strong an indication as ENE. *T3 tumor* - T3 tumor indicates significant local invasion but is a clinical staging parameter, not a pathological adverse feature. - The decision for adjuvant therapy depends primarily on pathological findings (margins, lymph node status, ENE) rather than T-stage alone. - T3 status without adverse pathological features may not require adjuvant treatment after complete resection. *Close margin* - Close margin (tumor within 1-5 mm of resected edge) is a high-risk feature warranting **adjuvant radiotherapy** due to increased local recurrence risk. - However, it is less critical than ENE in terms of overall survival and regional control. - A **positive margin** (<1 mm or tumor at ink) would be equivalent to ENE as an indication for chemoradiotherapy, but a close margin typically requires radiotherapy alone.
Question 8: 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 9: A patient presents with upper limb swelling after undergoing a modified radical mastectomy (MRM). What is the most likely cause?
- A. Angiosarcoma
- B. Recurrence
- C. Upper limb Lymphedema (Correct Answer)
- D. Metastasis
Explanation: ***Upper limb Lymphedema*** - **Lymphedema** is a common complication after **modified radical mastectomy (MRM)** due to the removal of axillary lymph nodes and subsequent disruption of lymphatic drainage pathways. - This disruption leads to an accumulation of lymphatic fluid in the interstitial tissues, causing **swelling** in the ipsilateral upper limb. *Angiosarcoma* - **Angiosarcoma** (Stewart-Treves syndrome) is a very rare, aggressive tumor that can occur in the chronic lymphedematous limb after mastectomy. - It presents as multiple **violaceous nodules or plaques** in the affected limb, which is not described as the initial finding. *Recurrence* - **Recurrence** of breast cancer in the axilla or chest wall could cause swelling, but it would typically involve a palpable mass, skin changes, or pain, which are not mentioned as the primary symptom. - While recurrence can lead to lymphatic obstruction, **lymphedema** is a more direct and common post-operative complication. *Metastasis* - **Metastasis** to the axillary or supraclavicular lymph nodes could cause lymphatic obstruction and swelling. - However, lymphedema from direct surgical disruption of lymphatics is a more immediate and common cause of upper limb swelling following MRM, especially without other signs of widespread disease.
Question 10: Surgical treatment for a 40-years old lady with 3 x 3 cm. papillary carcinoma thyroid with level III enlarged lymph nodes is :
- A. Total thyroidectomy with radical neck dissection
- B. Total thyroidectomy with post-operative radio-iodine ablation
- C. Total thyroidectomy with excision of involved nodes
- D. Total thyroidectomy with functional neck dissection (Correct Answer)
Explanation: ***Total thyroidectomy with functional neck dissection*** - For **papillary thyroid carcinoma** with **level III lymph node involvement**, the standard approach is **total thyroidectomy** with **therapeutic lateral neck dissection** (functional/modified radical neck dissection). - **Level III nodes** are part of the **lateral compartment** (levels II-IV), requiring formal **compartment-oriented dissection** rather than selective node excision for adequate oncological clearance. *Total thyroidectomy with excision of involved nodes* - **"Excision of involved nodes"** is not standard terminology in thyroid surgery and **"berry-picking"** individual nodes is generally not recommended for therapeutic purposes. - **Compartment-oriented dissection** is preferred over selective node removal as it provides better oncological outcomes and staging accuracy. *Total thyroidectomy with radical neck dissection* - **Radical neck dissection** involves removal of cervical lymph node levels I-V along with the **sternocleidomastoid muscle**, **internal jugular vein**, and **spinal accessory nerve**. - This extensive procedure is reserved for cases with **extensive extranodal extension** or when these structures are directly involved, causing significant morbidity. *Total thyroidectomy with post-operative radio-iodine ablation* - **Radioiodine ablation** is an **adjuvant therapy** used after thyroidectomy to destroy remaining thyroid tissue and microscopic disease. - This option doesn't address the **surgical management** of enlarged lymph nodes, which is specifically what the question asks about.
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