Surgical Oncology Principles — MCQs

Surgical Oncology Principles Indian Medical PG Practice Questions and MCQs

Question 91: Which is the most reliable diagnostic method for staging esophageal cancer?

A. MRI
B. Endoscopic ultrasound (Correct Answer)
C. CT scan
D. Thoracoscopy

Explanation: ***Endoscopic ultrasound*** - **Endoscopic ultrasound (EUS)** provides the most accurate and reliable local staging of esophageal cancer by visualizing the depth of tumor invasion into the esophageal wall and assessing regional lymph node involvement. - Its high-frequency ultrasound transducer allows for detailed imaging of the esophageal wall layers and surrounding structures, crucial for determining T and N stages. *MRI* - While MRI can be useful for assessing **distant metastases** and involvement of adjacent organs, it is generally less effective than EUS for determining the precise depth of local esophageal wall invasion. - Its role is more prominent in later stages or when assessing response to neoadjuvant therapy rather than primary local staging. *CT scan* - A **CT scan** is excellent for detecting **distant metastases** and assessing the general extent of the disease, including involvement of surrounding structures and distant lymph nodes. - However, its resolution is insufficient to accurately determine the exact depth of tumor invasion within the esophageal wall, making it less reliable for precise T staging than EUS. *Thoracoscopy* - **Thoracoscopy** is an invasive surgical procedure primarily used for direct visualization and biopsy of suspicious lesions in the chest cavity, or for mediastinal lymph node staging, particularly when other methods are inconclusive. - It is not considered a primary diagnostic method for initial staging of esophageal cancer due to its invasiveness and inability to assess all aspects of local and regional spread as comprehensively as EUS.

Question 92: For which type of carcinoma is the Nigro protocol primarily used?

A. Anal (Correct Answer)
B. Colon
C. Hepatocellular
D. Pancreatic

Explanation: ***Correct: Anal carcinoma*** The **Nigro protocol** is the landmark chemoradiation regimen specifically developed for **anal squamous cell carcinoma**. Introduced by Norman Nigro in 1974, it consists of: - **Concurrent chemotherapy** (5-Fluorouracil + Mitomycin C) - **External beam radiotherapy** This protocol revolutionized anal cancer treatment by achieving complete pathological response in the majority of cases, making it the **standard of care** and avoiding the need for abdominoperineal resection (APR) in most patients. It preserves anal sphincter function and has excellent outcomes with 5-year survival rates exceeding 70%. *Incorrect: Colon carcinoma* - Colon cancer is primarily treated with **surgical resection** (hemicolectomy) followed by adjuvant chemotherapy (FOLFOX) in advanced stages - The Nigro protocol is not used for colonic malignancies *Incorrect: Hepatocellular carcinoma* - HCC treatment includes **hepatic resection**, liver transplantation, radiofrequency ablation, or systemic therapy (sorafenib, lenvatinib) - Chemoradiation protocols like Nigro are not the standard approach *Incorrect: Pancreatic carcinoma* - Pancreatic cancer is treated with **Whipple procedure** (pancreaticoduodenectomy) for resectable tumors or chemotherapy regimens like FOLFIRINOX or gemcitabine-based therapy - The Nigro protocol has no role in pancreatic malignancy management

Question 93: Biopsy of a clinically suspicious lesion is negative. The most appropriate treatment is

A. Repeat the biopsy for further evaluation. (Correct Answer)
B. Monitor the patient closely for twelve months.
C. Monitor the patient closely for three months.
D. Reassure the patient that the lesion is benign.

Explanation: ***Repeat the biopsy for further evaluation.*** - A **clinically suspicious lesion** with a negative biopsy result warrants a repeat biopsy because a **false negative** is possible, especially if the initial sample was inadequate or not representative. - The principle "**never let the sun set on a clinically suspicious lesion**" applies here - clinical suspicion should override a negative biopsy result. - Repeating the procedure ensures accurate diagnosis, which is crucial for lesions with **malignant potential**. *Monitor the patient closely for twelve months.* - This approach is too **conservative** for a clinically suspicious lesion with a negative biopsy, as a malignancy could progress significantly within a year. - Waiting this long without a definitive diagnosis carries an **unacceptable risk** of delayed treatment for a potential cancer. *Monitor the patient closely for three months.* - While more proactive than waiting a year, **three months** is still too long for a clinically suspicious lesion if the biopsy result is unreliable. - Early detection and diagnosis are paramount for better outcomes in potentially **malignant lesions**. *Reassure the patient that the lesion is benign.* - This is **inappropriate** as it accepts the false negative biopsy result at face value and dismisses the clinical suspicion. - **Clinical judgment** should take precedence over a negative biopsy when a lesion remains suspicious. - This approach could lead to **catastrophic delays** in diagnosing malignancy.

Question 94: What finding during surgery can change the staging of a tumor from Stage I to Stage II in a patient with a history of lung cancer?

A. Involvement of the chest wall
B. Small cell histology
C. Tumor at the carina
D. Positive hilar/peribronchial lymph nodes (Correct Answer)

Explanation: ***Positive bronchial lymph nodes*** - The presence of **positive bronchial lymph nodes** (N1) indicates regional lymph node involvement, necessitating an upgrade to Stage II from Stage I [1]. - This finding is significant in lung cancer staging, suggesting metastasis beyond the primary tumor. *Tumor at the carina* - A tumor at the **carina** may imply local invasion but does not specifically relate to lymph node involvement for upgrading the stage. - This would indicate a more advanced tumor stage only if it invaded adjacent structures directly. *Involvement of the chest wall* - Chest wall involvement typically refers to **direct extension of the tumor** and might upgrade the stage to III, not II. - The initial staging focused on **nodal involvement**, which is not indicated in this case. *Small cell histology* - Small cell carcinoma, while aggressive and often systemic, does not correspond with this staging system based on **N classification**. - It also usually presents with different clinical features and patterns compared to non-small cell lung cancers. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, p. 725.

Question 95: What are the potential symptoms of malignant transformation in a retroperitoneal lipoma?

A. All of the options (Correct Answer)
B. Abdominal pain
C. Weight loss
D. Renal failure due to compression

Explanation: ***All of the options*** - Malignant transformation of a lipoma, particularly into a **liposarcoma**, can cause a variety of symptoms due to its growth and potential invasion of surrounding structures. - This includes generalized symptoms like **weight loss**, and localized effects such as **abdominal pain** and **organ compression** (e.g., renal failure). *Abdominal pain* - As a retroperitoneal tumor grows, it can cause **mass effect** and pressure on nearby organs and nerves, leading to abdominal pain. - Pain relief is often sought by patients presenting with these growths, highlighting their clinical significance. *Weight loss* - **Unexplained weight loss** is a common constitutional symptom associated with malignancy, including liposarcoma. - This systemic symptom can indicate a more advanced or aggressive tumor. *Renal failure due to compression* - A growing liposarcoma in the retroperitoneum can **compress structures** such as the ureters, leading to hydronephrosis and ultimately **renal failure**. - Direct invasion or extrinsic compression of the kidney itself can also impair renal function.

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