Surgical Oncology Principles — MCQs

A 45-year-old patient presents with a 4 x 5 cm mass in the neck. Histopathological examination showed metastasis of squamous cell origin. The patient was thoroughly examined using laryngoscope, whole body CT and PET CT. No primary is found and the diagnosis of Carcinoma of Unknown Primary (CUP) is made. What is the TNM staging as per AJCC?

Q17Easy

Which of the following is a common tumor of the anterior mediastinum?

Q18Medium

A patient is diagnosed with cancer. The size of the lesion is found to be 5 cm in diameter and metastasis is found with a single ipsilateral lymph node. What is the stage according to TNM staging?

Q19Easy

All of the following are associated with carcinoid syndrome except?

Q20Medium

A 25-year-old patient presented with a mass in the iliac fossa. After laparotomy, it was found to be a 2.5 cm carcinoid tumor. What is the next step in management?

Surgical Oncology Principles Indian Medical PG Practice Questions and MCQs

Question 11: What is the recommended duration for tamoxifen therapy in breast carcinoma?

A. 2 years
B. 3 years
C. 5 years (Correct Answer)
D. Lifelong

Explanation: **Explanation:** Tamoxifen is a **Selective Estrogen Receptor Modulator (SERM)** that acts as a competitive antagonist of the estrogen receptor in breast tissue. It is the gold standard for adjuvant endocrine therapy in premenopausal women with Hormone Receptor-positive (ER/PR+) breast cancer. **Why 5 years is the correct answer:** Large-scale clinical trials (such as the EBCTCG meta-analysis) established that **5 years** of tamoxifen therapy significantly reduces the risk of recurrence and breast cancer mortality for at least 15 years after treatment. While recent trials (ATLAS and aTTom) suggest that extending therapy to 10 years may provide additional benefits in high-risk patients, **5 years remains the standard initial recommendation** and the conventional benchmark for NEET-PG. **Analysis of Incorrect Options:** * **A & B (2 or 3 years):** These durations are insufficient. Shorter courses are associated with significantly higher rates of recurrence compared to the 5-year standard. * **D (Lifelong):** Tamoxifen is not prescribed indefinitely due to the plateauing of benefits and the increased risk of serious side effects over time, such as endometrial carcinoma and thromboembolic events. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Competitive inhibitor of estrogen receptors in the breast; partial agonist in the endometrium and bone. * **Side Effects:** Increased risk of **Endometrial Carcinoma**, Deep Vein Thrombosis (DVT), and hot flashes. It is protective against osteoporosis in postmenopausal women. * **Drug Interaction:** Avoid strong CYP2D6 inhibitors (e.g., Paroxetine, Fluoxetine) as they prevent the conversion of tamoxifen to its active metabolite, **Endoxifen**. * **Aromatase Inhibitors (e.g., Anastrozole):** Preferred over tamoxifen in **postmenopausal** women.

Question 12: What is the primary treatment for extragonadal germ cell tumors?

A. Chemotherapy (Correct Answer)
B. Radiotherapy
C. Surgery
D. Immunotherapy

Explanation: **Explanation:** **Extragonadal Germ Cell Tumors (EGGCTs)** are rare neoplasms that arise outside the gonads, typically along the midline of the body (mediastinum, retroperitoneum, or pineal gland). 1. **Why Chemotherapy is Correct:** Germ cell tumors are inherently **exquisitely chemosensitive**. Because EGGCTs are often bulky, located in surgically challenging areas (like the anterior mediastinum), and have a high propensity for systemic spread, **platinum-based chemotherapy** (e.g., BEP regimen: Bleomycin, Etoposide, Cisplatin) is the primary treatment. It serves to treat both the primary site and any occult micrometastases simultaneously. 2. **Why Other Options are Incorrect:** * **Surgery:** While surgery plays a crucial role in managing *residual* masses after chemotherapy (especially in non-seminomatous GCTs to remove teratomas), it is rarely the primary treatment because these tumors are often invasive and unresectable at diagnosis. * **Radiotherapy:** Although seminomas are radiosensitive, chemotherapy is preferred as the primary modality because it addresses systemic disease and avoids the long-term toxicities of radiation (like secondary malignancies or radiation pneumonitis). * **Immunotherapy:** This is not currently a first-line standard of care for germ cell tumors, which are primarily managed with cytotoxic drugs. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Site:** The **mediastinum** is the most common extragonadal site in adults. * **Tumor Markers:** Always check **AFP and β-hCG**. Elevated AFP in a mediastinal mass strongly suggests a non-seminomatous EGGCT (Yolk sac component). * **Klinefelter Syndrome:** There is a strong clinical association between Klinefelter syndrome (47, XXY) and mediastinal germ cell tumors. * **Prognosis:** Primary mediastinal non-seminomatous GCTs are classified as "Poor Prognosis" according to the IGCCCG classification, regardless of marker levels.

Question 13: What is the most commonly performed surgery for sarcoma?

A. Wide excision (Correct Answer)
B. Compartmental excision/exenteration
C. Excision
D. Enucleation

Explanation: **Explanation:** The primary goal of surgical management in soft tissue sarcomas (STS) is to achieve a **R0 resection** (microscopically negative margins) to minimize the risk of local recurrence. **1. Why Wide Excision is Correct:** Wide excision is the standard of care for most sarcomas. It involves removing the tumor along with a **cuff of normal surrounding tissue** (usually 1–2 cm) in all dimensions. This ensures that microscopic extensions of the tumor (satellite nodules) beyond the pseudocapsule are removed, significantly reducing local recurrence rates while preserving limb function. **2. Why the Other Options are Incorrect:** * **Compartmental Excision/Exenteration:** This involves removing the entire anatomical compartment (from origin to insertion of muscles). While oncologically sound, it is highly morbid and rarely necessary today due to the efficacy of adjuvant radiotherapy. * **Excision (Marginal Excision):** This involves removing the tumor through its pseudocapsule. It leaves behind microscopic disease, leading to a high recurrence rate (up to 80%), and is generally considered inadequate. * **Enucleation:** This is "shelling out" the tumor. It is contraindicated for sarcomas as it inevitably leaves tumor cells behind, as the "capsule" seen in sarcomas is actually a compressed layer of tumor cells (pseudocapsule). **Clinical Pearls for NEET-PG:** * **Biopsy Principle:** The biopsy scar must be placed such that it can be completely incorporated into the definitive wide excision specimen. * **Staging:** The most important prognostic factor for STS is the **histological grade**. * **Adjuvant Therapy:** Radiotherapy is typically added to wide excision for high-grade, deep, or large (>5 cm) tumors to achieve local control comparable to amputation.

Question 14: Which of the following is NOT true about Marjolin's ulcer?

A. Locally malignant
B. Spreads to local lymph nodes (Correct Answer)
C. Painless ulcer
D. Squamous cell carcinoma

Explanation: **Explanation:** **Marjolin’s Ulcer** refers to a malignant transformation (most commonly Squamous Cell Carcinoma) occurring in chronic non-healing wounds, such as burn scars (most common), chronic osteomyelitis sinuses, or venous stasis ulcers. 1. **Why Option B is the Correct Answer (The "False" Statement):** The hallmark of Marjolin’s ulcer is that it arises in dense, avascular scar tissue. This cicatricial (scar) tissue lacks functional lymphatic channels. Consequently, despite being an aggressive malignancy, it **rarely spreads to local lymph nodes** early in the disease. If lymphadenopathy is present, it is often due to secondary infection rather than metastasis. 2. **Analysis of Other Options:** * **Option A (Locally Malignant):** This is true. It is an aggressive local malignancy that invades deep structures if left untreated. * **Option C (Painless Ulcer):** This is true. Because the ulcer develops within a chronic scar where nerve endings have been destroyed, the lesion is typically painless. This often leads to a delay in diagnosis. * **Option D (Squamous Cell Carcinoma):** This is true. SCC is the most common histological type (approx. 90%), followed by Basal Cell Carcinoma. **High-Yield Clinical Pearls for NEET-PG:** * **Latent Period:** The average time for malignant transformation is **25–30 years**. * **Diagnosis:** Requires an edge biopsy (wedge biopsy) from multiple sites. * **Treatment:** Wide local excision (with 2 cm margins) is the treatment of choice. Mohs surgery or amputation may be required depending on the site and depth. * **Prognosis:** Marjolin’s ulcer is generally more aggressive than primary SCC of the skin and has a higher recurrence rate.

Question 15: All of the following soft tissue sarcomas have a propensity for lymphatic spread except?

A. Neurofibrosarcoma (Correct Answer)
B. Synovial sarcoma
C. Rhabdomyosarcoma
D. Epithelioid sarcoma

Explanation: **Explanation:** The fundamental rule in surgical oncology is that **soft tissue sarcomas (STS) typically spread via the hematogenous route** (to the lungs), while carcinomas spread via the lymphatics. However, a specific subset of sarcomas defies this rule and frequently involves regional lymph nodes. **Why Neurofibrosarcoma is the correct answer:** Neurofibrosarcoma (also known as Malignant Peripheral Nerve Sheath Tumor or MPNST) follows the classic sarcoma pattern of hematogenous spread. It does **not** have a high propensity for lymphatic involvement. It is commonly associated with Neurofibromatosis Type 1 (NF1). **Why the other options are incorrect:** Options B, C, and D represent the rare exceptions that *do* spread via lymphatics. * **Synovial sarcoma:** One of the most common sarcomas to show nodal involvement, often occurring near joints in young adults. * **Rhabdomyosarcoma:** The most common soft tissue sarcoma in children; lymphatic spread is a key feature, especially in the alveolar subtype. * **Epithelioid sarcoma:** Characteristically involves lymph nodes and often presents as a firm nodule on the distal extremities (hand/forearm) of young adults. **High-Yield Clinical Pearls for NEET-PG:** To remember the sarcomas with lymphatic spread, use the mnemonic **"SCARE"** or **"CLEAR"**: * **S** – Synovial sarcoma * **C** – Clear cell sarcoma * **A** – Angiosarcoma * **R** – Rhabdomyosarcoma * **E** – Epithelioid sarcoma *Note: Epithelioid sarcoma is the most common STS to spread to lymph nodes in the upper extremity.*

Question 16: A 45-year-old patient presents with a 4 x 5 cm mass in the neck. Histopathological examination showed metastasis of squamous cell origin. The patient was thoroughly examined using laryngoscope, whole body CT and PET CT. No primary is found and the diagnosis of Carcinoma of Unknown Primary (CUP) is made. What is the TNM staging as per AJCC?

A. T1N1M0
B. T1N2M0
C. T0N1M0
D. T0N2M0 (Correct Answer)

Explanation: ### Explanation **1. Understanding the Correct Answer (T0N2M0):** In cases of **Carcinoma of Unknown Primary (CUP)**, by definition, the primary tumor cannot be identified despite a thorough diagnostic workup (clinical exam, endoscopy, and imaging like PET-CT). * **T (Tumor):** Since no primary site is found, the staging is designated as **T0**. * **N (Node):** The patient has a **4 x 5 cm** mass. According to the AJCC 8th Edition for Head and Neck cancers (specifically HPV-negative or non-viral related squamous cell carcinoma), a single ipsilateral lymph node **>3 cm but ≤6 cm** in greatest dimension is classified as **N2a**. Therefore, the nodal status is **N2**. * **M (Metastasis):** There is no mention of distant organ involvement, so it is **M0**. Combining these, the stage is **T0N2M0**. **2. Why Other Options are Incorrect:** * **A (T1N1M0) & B (T1N2M0):** These are incorrect because **T1** implies a primary tumor of $\leq$ 2 cm has been identified. In CUP, the primary is never T1; it is always T0. * **C (T0N1M0):** While T0 is correct, **N1** refers to a single ipsilateral lymph node **$\leq$ 3 cm**. This patient’s mass is 5 cm, which exceeds the N1 threshold. **3. Clinical Pearls for NEET-PG:** * **Definition of CUP:** Metastatic disease proven by biopsy where the primary site remains undetected after "comprehensive" evaluation (including PET-CT and Pan-endoscopy). * **Most Common Site:** The most common histology for CUP in the neck is **Squamous Cell Carcinoma (SCC)**. * **Diagnostic Gold Standard:** If imaging fails, **directed biopsies** (tongue base, tonsillectomy, and nasopharynx) are performed, as these are the most common "hidden" primary sites. * **AJCC 8th Ed Update:** For neck nodes, always check for **Extranodal Extension (ENE)**. If ENE is present, a single node $\leq$ 3cm becomes N2a, and any node >3cm becomes N3b. (In this question, ENE was not mentioned, so we use standard size criteria).

Question 17: Which of the following is a common tumor of the anterior mediastinum?

A. Thymoma (Correct Answer)
B. Neurogenic Fibroma
C. Lymphoma
D. Meningocele

Explanation: ### Explanation The mediastinum is anatomically divided into compartments, each associated with specific pathologies. The **Anterior Mediastinum** (the space between the sternum and the pericardium) is the most common site for mediastinal masses. **1. Why Thymoma is Correct:** Thymoma is the most common primary tumor of the anterior mediastinum in adults. The "4 Ts" mnemonic is a high-yield tool for remembering anterior mediastinal masses: * **T**hymoma (Most common) * **T**eratoma (and other Germ Cell Tumors) * **T**errible Lymphoma * **T**hyroid (Retrosternal Goiter) **2. Analysis of Incorrect Options:** * **Neurogenic Fibroma (Option B):** These are the most common tumors of the **Posterior Mediastinum**. They arise from spinal nerve roots or intercostal nerves. * **Lymphoma (Option C):** While Lymphoma is a common anterior mediastinal mass, **Thymoma** is statistically more frequent as a primary surgical pathology in this compartment. Lymphoma often presents with systemic symptoms and bulky lymphadenopathy. * **Meningocele (Option D):** This is a rare cystic lesion found in the **Posterior Mediastinum**, often associated with vertebral defects. **3. Clinical Pearls for NEET-PG:** * **Thymoma Association:** Approximately 30–50% of patients with thymoma have **Myasthenia Gravis**. Conversely, 15% of patients with Myasthenia Gravis are found to have a thymoma. * **Most Common Overall:** Neurogenic tumors are the most common mediastinal masses in children (Posterior), while Thymomas are the most common in adults (Anterior). * **Imaging:** Contrast-Enhanced CT (CECT) is the gold standard for evaluating mediastinal compartments.

Question 18: A patient is diagnosed with cancer. The size of the lesion is found to be 5 cm in diameter and metastasis is found with a single ipsilateral lymph node. What is the stage according to TNM staging?

A. Stage 1
B. Stage 2
C. Stage 3 (Correct Answer)
D. Stage 4

Explanation: ### Explanation The TNM (Tumor, Node, Metastasis) staging system is the universal language for cancer staging. To determine the stage in this scenario, we must break down the clinical findings: 1. **Tumor (T):** A 5 cm lesion typically corresponds to **T2 or T3** depending on the specific organ (e.g., in breast cancer, >5 cm is T3; in lung cancer, 5–7 cm is T3). 2. **Node (N):** The presence of a single ipsilateral lymph node metastasis signifies **N1** status. 3. **Metastasis (M):** No distant metastasis is mentioned, implying **M0**. **Why Stage 3 is Correct:** In the majority of solid tumor staging systems (such as Breast, Head and Neck, or Lung), the presence of **regional lymph node involvement (N1)** in a relatively large tumor (T2/T3) without distant metastasis automatically upgrades the disease to **Stage 3**. Stage 3 represents "locally advanced" disease where the cancer has spread beyond the primary site to regional nodes but has not yet reached distant organs. **Why Other Options are Wrong:** * **Stage 1:** Represents early-localized disease (small tumor, **N0**, M0). * **Stage 2:** Usually involves larger tumors but with **no nodal involvement (N0)**. * **Stage 4:** Defined by the presence of **distant metastasis (M1)**, regardless of T or N status. Since no distant spread is noted here, it cannot be Stage 4. **High-Yield Clinical Pearls for NEET-PG:** * **M1 = Stage 4:** This is a "golden rule." If distant metastasis is present, the stage is always 4. * **N+ = Stage 3:** In many common cancers (like Breast), any nodal positivity (N1 or higher) usually moves the patient to at least Stage 2B or 3. * **Prognostic Significance:** Staging is the most important predictor of survival and dictates whether the treatment should be curative (Stages 1-3) or palliative (Stage 4).

Question 19: All of the following are associated with carcinoid syndrome except?

A. Cyanosis (Correct Answer)
B. Diarrhoea
C. Flushing
D. Acute appendicitis

Explanation: **Explanation:** Carcinoid syndrome occurs when vasoactive substances (primarily **serotonin**, but also bradykinins and prostaglandins) enter the systemic circulation. This typically happens with metastatic midgut carcinoid tumors (to the liver) or primary bronchial carcinoids, as they bypass the first-pass metabolism in the liver. **Why Cyanosis is the correct answer:** Cyanosis is **not** a classic feature of carcinoid syndrome. While patients experience intense cutaneous **flushing** (vasodilation), this results in a bright red or violaceous hue, not the bluish discoloration associated with deoxygenated hemoglobin (cyanosis). In rare, severe cases of "carcinoid crisis," hypotension may occur, but cyanosis remains an atypical finding. **Analysis of other options:** * **Diarrhoea:** The most common gastrointestinal symptom (80% of cases), caused by serotonin-induced intestinal hypermotility. * **Flushing:** The hallmark sign (up to 90% of cases). It is often triggered by alcohol, stress, or tyramine-containing foods. * **Acute appendicitis:** The **appendix** is the most common site for gastrointestinal carcinoid tumors. A tumor at the base of the appendix can obstruct the lumen, leading to clinical presentation identical to acute appendicitis. **High-Yield Clinical Pearls for NEET-PG:** 1. **Diagnosis:** Best initial screening test is **24-hour urinary 5-HIAA** (metabolite of serotonin). 2. **Cardiac Involvement:** Right-sided heart failure (Tricuspid Regurgitation/Pulmonary Stenosis) is common. Left-sided lesions are rare as the lungs metabolize serotonin. 3. **Treatment:** **Octreotide** (Somatostatin analogue) is the mainstay for symptom control and perioperative management to prevent a carcinoid crisis. 4. **Pellagra:** Chronic serotonin overproduction can deplete Tryptophan, leading to Niacin (B3) deficiency (Dermatitis, Diarrhea, Dementia).

Question 20: A 25-year-old patient presented with a mass in the iliac fossa. After laparotomy, it was found to be a 2.5 cm carcinoid tumor. What is the next step in management?

A. Segmental resection
B. Appendicectomy
C. Right hemicolectomy (Correct Answer)
D. Yearly 5-HIAA assay

Explanation: **Explanation:** The management of an appendiceal carcinoid (neuroendocrine tumor) is primarily determined by the **size** and **location** of the tumor. 1. **Why Right Hemicolectomy is Correct:** According to standard surgical guidelines, a **Right Hemicolectomy** is indicated if: * The tumor size is **> 2 cm** (as in this case, where it is 2.5 cm). * The tumor involves the **base** of the appendix. * There is evidence of mesoappendiceal involvement or lymphovascular invasion. * High-grade histology (Goblet cell carcinoid). A 2.5 cm tumor carries a significant risk of nodal metastasis, necessitating a formal oncological resection rather than a simple appendicectomy. 2. **Why Other Options are Incorrect:** * **Appendicectomy (B):** This is the treatment of choice only for tumors **< 1 cm** located at the tip or body of the appendix. For tumors between 1–2 cm, appendicectomy may suffice unless there is mesoappendiceal invasion or high-grade features. * **Segmental Resection (A):** This is not a standard oncological procedure for appendiceal carcinoids; the lymphatic drainage follows the ileocolic artery, requiring a right hemicolectomy. * **Yearly 5-HIAA assay (D):** This is a biochemical marker used for monitoring/diagnosis of Carcinoid Syndrome. It is not a primary management step for a localized surgical mass. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site** of carcinoid tumor: Appendix (overall, though some recent data suggests small bowel/rectum, the appendix remains a classic exam answer). * **Most common location within the appendix:** The **tip** (distal 1/3rd). * **Carcinoid Syndrome:** Usually occurs only when there are **liver metastases** (bypassing first-pass metabolism). * **Gold Standard Diagnosis:** 24-hour urinary 5-HIAA (Screening) and Chromogranin A (Marker). * **Imaging:** Somatostatin receptor scintigraphy (OctreoScan) or Ga-68 DOTATATE PET/CT.

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