Surgical Oncology Principles — MCQs

Surgical Oncology Principles Indian Medical PG Practice Questions and MCQs

Question 21: An elderly male presents with a 4x5 cm lump in the right neck. FNAC revealed it to be squamous cell carcinoma. No primary was found, and a diagnosis of unknown primary was made. According to the AJCC system of classification, what would be the TNM staging of the tumor?

A. T1 N2 M0
B. T0 N2a M1
C. T1 N2c M0
D. T0 Nx M0 (Correct Answer)

Explanation: ### Explanation **1. Understanding the Correct Answer (T0 Nx M0)** In the AJCC (American Joint Committee on Cancer) staging system for **Carcinoma of Unknown Primary (CUP)** in the head and neck, specific rules apply when a primary tumor cannot be identified despite clinical and radiological evaluation: * **T (Primary Tumor):** Since no primary site was found after thorough investigation, the primary tumor is designated as **T0**. * **N (Regional Lymph Nodes):** While the clinical presentation shows a 4x5 cm lump (suggestive of N2a), the official staging for an unknown primary often utilizes **Nx** if the specific nodal involvement cannot be definitively categorized within the context of an "unknown" origin during initial assessment, or more specifically, the TNM staging for CUP defaults to T0. * **M (Distant Metastasis):** In the absence of documented distant spread, it is staged as **M0**. **2. Why Other Options are Incorrect** * **Options A & C (T1):** These are incorrect because a **T1** designation requires a visible primary tumor (typically <2 cm). In this case, "No primary was found," which mandates a **T0** status. * **Option B (M1):** This is incorrect because the question does not mention any evidence of distant metastasis (e.g., lung or bone lesions). M1 is only used when distant spread is confirmed. **3. Clinical Pearls for NEET-PG** * **Definition of CUP:** Metastatic squamous cell carcinoma in a cervical lymph node without an identifiable primary source after physical exam, imaging (CT/MRI/PET), and endoscopy (triple endoscopy). * **Most Common Site of Hidden Primary:** The **palatine tonsils** and **base of tongue** (lingual tonsils) are the most frequent sites for "hidden" head and neck primaries. * **Diagnostic Step:** If FNAC shows SCC in a neck node, the next gold standard investigation to find the primary is a **PET-CT** followed by **panendoscopy and directed biopsies**. * **HPV Status:** In modern AJCC (8th Ed), p16 (HPV) status significantly changes nodal staging for oropharyngeal/unknown primaries. However, for general MCQ purposes, T0 represents the "Unknown Primary."

Question 22: True about Pancoast tumour are all of the following except:

A. Only 3-5% are small cell carcinomas
B. Involves eighth cervical and first two thoracic nerves commonly
C. Homer's syndrome may be a manifestation
D. Lower lobe Carcinoma (Correct Answer)

Explanation: **Explanation:** A **Pancoast tumor** (also known as a Superior Sulcus Tumor) is a clinical entity defined by its specific location at the extreme apex of the lung. **1. Why "Lower lobe Carcinoma" is the correct (False) statement:** By definition, Pancoast tumors arise in the **superior pulmonary sulcus** at the **apex** of the lung (upper lobe). Therefore, they cannot be lower lobe carcinomas. This anatomical location allows the tumor to invade the thoracic inlet structures, leading to the characteristic "Pancoast Syndrome." **2. Analysis of other options:** * **Option A:** Most Pancoast tumors are Non-Small Cell Lung Carcinomas (NSCLC), predominantly **Squamous cell carcinoma** or Adenocarcinoma. Small cell carcinomas are rare in this location, accounting for only about **3-5%** of cases. * **Option B:** The tumor typically invades the **brachial plexus**, specifically the lower roots (**C8, T1, and T2**). This causes pain in the shoulder radiating down the ulnar aspect of the arm and atrophy of the intrinsic hand muscles. * **Option C:** Invasion of the **paravertebral sympathetic chain** and the stellate ganglion leads to **Horner’s Syndrome** (miosis, ptosis, anhidrosis, and enophthalmos), which is a classic manifestation. **Clinical Pearls for NEET-PG:** * **Most common presenting symptom:** Shoulder pain (often misdiagnosed as cervical spondylosis or frozen shoulder). * **Radiology:** Often missed on routine CXR; an **apical view** or CT/MRI is preferred for diagnosis. * **Treatment:** The standard of care for resectable tumors is **induction chemoradiotherapy** followed by surgical resection. * **Contraindications to surgery:** Presence of distant metastasis, N2 mediastinal node involvement, or invasion of the vertebral body/spinal canal.

Question 23: Five-year survival rates in excess of 20% may be expected following resection of pulmonary metastases if?

A. Other organ metastases are present
B. Lung lesions are solitary (Correct Answer)
C. Local tumor recurrence is found
D. The tumor doubling time is less than 20 days

Explanation: **Explanation:** The surgical resection of pulmonary metastases (Pulmonary Metastasectomy) is a curative-intent procedure based on the concept that the lung may be the only site of secondary spread. **Why Option B is Correct:** The prognosis following metastasectomy is primarily determined by the ability to achieve a complete (R0) resection and the biological aggressiveness of the tumor. **Solitary lung lesions** are associated with the highest survival rates (often exceeding 20-40%) because they represent a limited disease burden that is easily amenable to complete surgical clearance with adequate margins. **Why Other Options are Incorrect:** * **Option A (Other organ metastases):** The presence of extrapulmonary spread (e.g., liver or bone) usually indicates systemic dissemination, making local resection of lung nodules palliative rather than curative. * **Option C (Local tumor recurrence):** Recurrence at the primary site suggests uncontrolled systemic disease and is a poor prognostic indicator, often serving as a contraindication to metastasectomy. * **Option D (Tumor doubling time < 20 days):** A short doubling time indicates a highly aggressive, rapidly growing tumor. Generally, a doubling time of **>40 to 70 days** is preferred for a better prognosis; very short intervals are associated with early recurrence and poor survival. **NEET-PG High-Yield Pearls:** 1. **Criteria for Metastasectomy:** Primary tumor must be controlled, no extrapulmonary metastases (except in specific cases like colorectal cancer), and the patient must have adequate pulmonary reserve. 2. **Most Common Source:** In adults, colorectal cancer and soft tissue sarcomas are the most common indications. In children, it is Osteosarcoma and Wilms’ tumor. 3. **Disease-Free Interval (DFI):** A longer DFI (time between primary treatment and appearance of metastasis) is one of the strongest predictors of survival.

Question 24: Rhabdomyosarcoma is treated by which of the following modalities?

A. Chemotherapy
B. Radiation therapy
C. Surgery
D. All of the above (Correct Answer)

Explanation: **Explanation:** Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children and adolescents. The management of RMS is a classic example of a **multimodal treatment approach**, which is why "All of the above" is the correct answer. 1. **Why "All of the above" is correct:** The treatment strategy for RMS is risk-stratified based on the site, size, and histological subtype (Embryonal vs. Alveolar). * **Surgery:** The primary goal is complete surgical excision with negative margins (R0 resection), provided it does not cause major functional or cosmetic impairment. * **Chemotherapy:** RMS is highly chemosensitive. Systemic chemotherapy (commonly the VAC regimen: Vincristine, Actinomycin-D, and Cyclophosphamide) is administered to almost all patients to treat micrometastases and shrink the primary tumor. * **Radiation Therapy:** Used for local control in cases of incomplete surgical resection (microscopic or macroscopic residual disease) or in patients where surgery is not feasible due to the tumor's location (e.g., parameningeal sites). 2. **Why individual options are insufficient:** While Surgery, Chemotherapy, and Radiation are all used, none of them are typically used in isolation. Relying on surgery alone carries a high risk of recurrence, while radiation alone cannot address systemic spread. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Head and Neck (followed by the Genitourinary tract). * **Histology:** **Embryonal** is the most common type and has a better prognosis; **Alveolar** is more aggressive and often associated with t(2;13) or t(1;13) translocations. * **Sarcoma Botryoides:** A variant of embryonal RMS found in hollow organs (vagina/bladder), characterized by a "cluster of grapes" appearance. * **Staging:** Unlike most cancers, RMS uses a unique "Group" system (IRS Grouping) based on the extent of surgical resection.

Question 25: Which of the following markers increases the risk of recurrent carcinoma breast?

A. Ca 125
B. Ca 19-9
C. Ca 27-29 (Correct Answer)
D. PSA

Explanation: **Explanation:** The correct answer is **Ca 27-29**. **1. Why Ca 27-29 is correct:** Cancer Antigen 27-29 (Ca 27-29) is a highly specific tumor marker for breast carcinoma. It is a soluble form of the **MUC1 gene product** (mucin). In clinical practice, it is primarily used to monitor patients previously treated for Stage II or III breast cancer. An elevation in Ca 27-29 levels is often the first sign of **recurrence or metastasis**, frequently predating clinical or radiological evidence by several months. Along with **CA 15-3**, it is considered the standard marker for monitoring treatment response and disease progression in breast cancer. **2. Why the other options are incorrect:** * **Ca 125:** This is the primary marker for **Ovarian Cancer** (specifically epithelial types). While it can be elevated in various inflammatory conditions (endometriosis, PID), it is not a specific marker for breast cancer recurrence. * **Ca 19-9:** This is the gold-standard marker for **Pancreatic Adenocarcinoma** and is also associated with hepatobiliary and gastric cancers. * **PSA (Prostate-Specific Antigen):** This is a highly specific marker for **Prostate Cancer** screening and monitoring. **High-Yield Clinical Pearls for NEET-PG:** * **CA 15-3 and CA 27-29:** Both are MUC1 markers used for breast cancer. CA 27-29 is generally considered more sensitive than CA 15-3. * **CEA (Carcinoembryonic Antigen):** Also used in breast cancer monitoring, though it is more classically associated with Colorectal Cancer. * **Triple Negative Breast Cancer (TNBC):** These tumors often do not produce significant amounts of these markers, making imaging more critical for follow-up. * **HER2/neu:** While a prognostic marker and therapeutic target, it is not typically used as a "serum tumor marker" for recurrence in the same way as CA 27-29.

Question 26: All of the following malignancies are seen in the anterior mediastinum except?

A. Teratoma
B. Thymoma
C. Lymphoma
D. Neuroenteric cyst (Correct Answer)

Explanation: The mediastinum is divided into compartments, and knowing the specific tumors associated with each is a high-yield topic for NEET-PG. ### **Explanation** The correct answer is **D. Neuroenteric cyst**. The mediastinum is traditionally divided into anterior, middle, and posterior compartments. The **anterior mediastinum** is the space between the sternum and the pericardium/great vessels. The **posterior mediastinum** is the space between the pericardium and the vertebral column. * **Neuroenteric cysts** are congenital anomalies resulting from the failure of separation of the neuroectoderm from the endoderm. These are classic **posterior mediastinal masses**, often associated with vertebral anomalies (like hemivertebrae). Other posterior masses include neurogenic tumors (Schwannomas, Neurofibromas) and esophageal lesions. ### **Analysis of Incorrect Options** The "4 Ts" mnemonic is a useful tool for remembering anterior mediastinal masses: * **Thymoma (Option B):** The most common primary tumor of the anterior mediastinum in adults. * **Teratoma (Option A):** Represents Germ Cell Tumors (GCTs). Dermoid cysts are the most common benign GCT in this location. * **"Terrible" Lymphoma (Option C):** Often presents with bulky lymphadenopathy and systemic symptoms (fever, weight loss). * **Thyroid:** Ectopic or retrosternal goiters. ### **Clinical Pearls for NEET-PG** * **Most common mediastinal mass overall:** Neurogenic tumors (located in the posterior mediastinum). * **Most common anterior mediastinal mass:** Thymoma (associated with Myasthenia Gravis in 30-50% of cases). * **Middle Mediastinum:** Primarily contains lymph nodes, the heart, and the trachea. Common masses include bronchogenic cysts and lymphadenopathy (Sarcoidosis, TB). * **Imaging Gold Standard:** Contrast-Enhanced CT (CECT) is the investigation of choice for localizing and characterizing mediastinal masses.

Question 27: Definitive diagnosis of oral cancer is made by?

A. Complete radiographic survey
B. Biopsy (Correct Answer)
C. Exfoliative cytology
D. Pantograph

Explanation: **Explanation:** The definitive diagnosis of any malignancy, including oral cancer, is established through **histopathological examination**, which requires a **biopsy**. This is the "gold standard" because it allows a pathologist to visualize cellular architecture, assess the degree of differentiation, and confirm invasion through the basement membrane—the hallmark of malignancy. **Analysis of Options:** * **Biopsy (Correct):** For oral lesions, an **incisional biopsy** is typically preferred for large lesions to include the edge of the tumor and some healthy tissue. For small lesions (<1 cm), an **excisional biopsy** may be performed. * **Complete radiographic survey:** While essential for staging (assessing bone involvement or distant metastasis), imaging (CT, MRI, X-ray) cannot differentiate between inflammatory, benign, or malignant soft tissue changes at a cellular level. * **Exfoliative cytology:** This involves scraping surface cells. While useful for screening or follow-up, it has a high false-negative rate and cannot assess the depth of invasion. It is suggestive, not definitive. * **Pantograph (Orthopantomogram/OPG):** This is a dental X-ray used to visualize the mandible and maxilla. It helps detect bone erosion or dental involvement but cannot diagnose the primary soft tissue cancer. **Clinical Pearls for NEET-PG:** * **Toluidine Blue Staining:** Often used as a clinical adjunct to highlight areas of high DNA content, helping to select the best site for biopsy. * **Field Cancerization:** A key concept in oral cancer where the entire mucosal surface exposed to carcinogens (tobacco/alcohol) is at risk for multiple primary tumors. * **Most Common Site:** The lateral border of the tongue is the most common site for oral squamous cell carcinoma (SCC). * **Staging:** TNM staging is the most important prognostic factor, but diagnosis must always precede staging.

Question 28: What is the recommended treatment for Medullary carcinoma of the thyroid with lymph node metastasis?

A. Subtotal thyroidectomy with radioiodine ablation and TSH suppression
B. Subtotal thyroidectomy with radiotherapy
C. Total thyroidectomy with radioiodine ablation
D. Total thyroidectomy with radiotherapy (Correct Answer)

Explanation: **Explanation:** Medullary Carcinoma of the Thyroid (MTC) arises from the **parafollicular C-cells**, which are neuroendocrine in origin. Unlike follicular or papillary carcinomas, MTC cells do not concentrate iodine; therefore, **Radioiodine (I-131) ablation is ineffective.** 1. **Why Option D is Correct:** The primary treatment for MTC is aggressive surgery because it is relatively resistant to chemotherapy and radiation. **Total thyroidectomy** is mandatory due to the high incidence of multicentricity (especially in familial cases). In the presence of lymph node metastasis, a **Central Neck Dissection** (Level VI) is standard, often accompanied by a modified radical neck dissection. While MTC is not highly radiosensitive, **External Beam Radiotherapy (EBRT)** is indicated for patients with extrathyroidal extension or significant nodal involvement to reduce local recurrence. 2. **Why Other Options are Incorrect:** * **Options A & B (Subtotal Thyroidectomy):** Subtotal thyroidectomy is inadequate for MTC. Because MTC is often bilateral and multicentric (especially in MEN 2 syndromes), total thyroidectomy is the surgical gold standard. * **Options A & C (Radioiodine/TSH Suppression):** Since C-cells do not express the sodium-iodide symporter, **Radioiodine ablation has no role**. Furthermore, C-cells do not have TSH receptors; thus, **TSH suppression therapy is ineffective** (unlike in differentiated thyroid cancers). **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** Serum **Calcitonin** (for diagnosis and monitoring recurrence) and CEA. * **Genetic Screening:** All patients with MTC must be screened for **RET proto-oncogene** mutations and associated MEN 2A/2B syndromes (screen for Pheochromocytoma before surgery). * **Prophylactic Surgery:** Indicated in RET-positive children; timing depends on the specific codon mutation.

Question 29: A 43-year-old lady presents with a 5 cm lump in her right breast and a 3 cm node in the supraclavicular fossa. According to the latest AJCC staging system, which TNM stage does she belong to?

A. T2N0M1
B. T1N0M1
C. T2N3M0 (Correct Answer)
D. T2N2M0

Explanation: ### Explanation This question tests the application of the **AJCC TNM Staging System** for breast cancer, specifically focusing on the classification of regional lymph nodes. **1. Why T2N3M0 is Correct:** * **T (Tumor Size):** The lump is 5 cm. According to AJCC, **T2** is defined as a tumor >2 cm but ≤5 cm. * **N (Node Status):** The presence of a **supraclavicular lymph node** (level III axillary/supraclavicular) is classified as **N3c**. In the TNM system, any N3 involvement automatically places the patient in Stage IIIC, regardless of T size (provided no distant metastasis is present). * **M (Metastasis):** Supraclavicular nodes are considered **regional** lymph nodes in breast cancer, not distant metastasis (M1). Therefore, the stage is **M0**. **2. Why Other Options are Incorrect:** * **A & B (T2/T1 N0 M1):** These are incorrect because supraclavicular nodes are N3 (regional), not M1 (distant). M1 would involve organs like the lungs, liver, or bone. * **D (T2N2M0):** N2 refers to fixed/matted axillary nodes or internal mammary nodes. Supraclavicular involvement is more advanced and categorized as N3. **Clinical Pearls for NEET-PG:** * **N1:** Mobile ipsilateral level I/II axillary nodes. * **N2:** Fixed/matted axillary nodes OR internal mammary nodes in the absence of axillary nodes. * **N3:** Infraclavicular (N3a), Internal mammary + Axillary (N3b), or **Supraclavicular (N3c)** nodes. * **High-Yield Fact:** Ipsilateral supraclavicular node involvement was once considered M1 but is now classified as **N3c** (Stage IIIC). Contralateral supraclavicular nodes, however, are still considered **M1**.

Question 30: In colorectal cancer, what is the staging for tumor deposits in the subserosa without regional lymph node metastasis, according to the 8th AJCC?

A. T4b
B. N2b
C. N1c (Correct Answer)
D. M1c

Explanation: ### Explanation The correct answer is **N1c**. This classification is a specific nuance introduced in the AJCC staging to address the prognostic significance of **Tumor Deposits (TDs)**. **1. Why N1c is correct:** According to the AJCC 8th Edition, tumor deposits are defined as discrete foci of cancer in the pericolic or perirectal fat or adjacent mesocolon within the lymph drainage area of a primary carcinoma, without histological evidence of residual lymph node tissue. * If a patient has **no regional lymph node metastasis** but has one or more tumor deposits in the subserosa, mesentery, or non-peritonealized pericolic/perirectal tissues, the stage is classified as **N1c**. * If any regional lymph nodes are positive, the tumor deposits are ignored for N-staging, and the N-category is determined solely by the number of positive nodes. **2. Why other options are incorrect:** * **T4b:** This refers to the primary tumor invading or being adherent to other organs or structures. It describes the depth of invasion, not tumor deposits. * **N2b:** This indicates metastasis in 7 or more regional lymph nodes. * **M1c:** This refers to distant metastasis to the peritoneal surface, with or without other organ involvement. **3. Clinical Pearls for NEET-PG:** * **Definition of TD:** Foci of tumor in the lymphatic drainage area without identifiable lymph node, vascular, or neural structures. * **Prognostic Value:** The presence of N1c (tumor deposits) carries a poorer prognosis than N0 but generally better than N1a/b. * **Rule of Priority:** Always check for lymph nodes first. If even one lymph node is positive (N1a), the "N1c" designation is not used; the stage becomes N1a. * **High-Yield Fact:** In the TNM system for colorectal cancer, the **"N" stage** is the most significant prognostic factor for recurrence after surgical resection.

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Management of Metastatic Disease

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Targeted Therapy Concepts

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