Surgical Oncology Principles — MCQs

Surgical Oncology Principles Indian Medical PG Practice Questions and MCQs

Question 61: What is true about gastric stump carcinoma?

A. Enterogastric reflex is the cause. (Correct Answer)
B. Prognosis is good after surgery.
C. It is always adenocarcinoma in nature.
D. The diffuse type is the only variety.

Explanation: **Explanation:** Gastric stump carcinoma (GSC) is a malignancy arising in the gastric remnant at least 5 years after a primary surgery for benign disease (most commonly for peptic ulcer disease). **1. Why Option A is correct:** The primary pathophysiology involves the **enterogastric reflux** of bile acids and pancreatic enzymes into the gastric remnant. Chronic exposure to alkaline duodenal contents leads to chronic atrophic gastritis, intestinal metaplasia, and eventually dysplasia. This risk is significantly higher in **Billroth II** reconstructions compared to Billroth I due to the direct and constant bathing of the stoma with bile. **2. Why other options are incorrect:** * **Option B:** The prognosis is generally **poor**. GSC is often diagnosed at an advanced stage because symptoms (weight loss, anemia) are frequently attributed to post-gastrectomy syndromes. It also has a high propensity for lymphatic spread and involvement of adjacent organs. * **Option C:** While **adenocarcinoma** is the most common histological type (approx. 95%), it is not "always" the case. Rare instances of squamous cell carcinoma or primary gastric lymphoma in the stump have been reported. * **Option D:** Both **Lauren’s intestinal and diffuse types** can occur. While some studies suggest a higher prevalence of the diffuse type in the stump, the intestinal type is also frequently observed. **High-Yield Clinical Pearls for NEET-PG:** * **Latency Period:** Typically occurs **15–20 years** after the initial surgery. * **Risk Factor:** The risk is higher after surgery for **gastric ulcers** than for duodenal ulcers. * **Hypochlorhydria:** Post-gastrectomy achlorhydria allows for the colonization of nitrate-reducing bacteria, which produce carcinogenic **N-nitroso compounds**, further contributing to carcinogenesis. * **Screening:** Endoscopic surveillance is often recommended starting 10–15 years post-surgery.

Question 62: Sentinel lymph node biopsy is indicated in all of the following conditions except?

A. Carcinoma of the breast
B. Carcinoma of the penis
C. Malignant melanoma
D. Carcinoma of the colon (Correct Answer)

Explanation: **Explanation:** The concept of **Sentinel Lymph Node Biopsy (SLNB)** is based on the principle that lymphatic drainage from a primary tumor follows a predictable orderly pattern to a specific "first" node (the sentinel node). If this node is negative for metastasis, the remaining nodes in that basin are likely negative, sparing the patient from the morbidity of a radical lymph node dissection. **Why Carcinoma of the Colon is the Correct Answer:** In colon cancer, the lymphatic drainage is often unpredictable and "skip metastasis" can occur. More importantly, the standard surgical treatment for colon cancer is a **formal colectomy**, which inherently includes the wide excision of the associated mesentery and its regional lymph nodes (to ensure adequate oncological margins and staging). Therefore, identifying a single sentinel node does not change the extent of the surgery, making SLNB clinically redundant. **Why the other options are incorrect:** * **Carcinoma of the Breast:** SLNB is the standard of care for clinically node-negative (cN0) patients to avoid the complications of Axillary Lymph Node Dissection (ALND) like lymphedema. * **Malignant Melanoma:** SLNB is indicated for tumors with a thickness >0.75 mm or those with high-risk features to determine the need for therapeutic lymphadenectomy. * **Carcinoma of the Penis:** SLNB (or Dynamic Sentinel Node Biopsy) is indicated in patients with non-palpable inguinal nodes (cN0) but high-risk primary tumors (T1G2 or higher). **High-Yield Clinical Pearls for NEET-PG:** * **Tracer used:** Technetium-99m labeled sulfur colloid and/or isosulfan/methylene blue dye. * **Most common site for SLNB:** Breast cancer and Melanoma. * **Other indications:** Early-stage vulvar cancer and certain oral cavity cancers. * **Contraindication in Breast Cancer:** Inflammatory breast cancer and clinically positive (palpable) axillary nodes.

Question 63: Which of the following statements is FALSE regarding Gastric lymphoma?

A. Stomach is the most common site.
B. It is associated with H. pylori infection.
C. Total gastrectomy with adjuvant chemotherapy is the treatment of choice. (Correct Answer)
D. The 5-year survival rate after treatment is 60%.

Explanation: **Explanation:** The management of Gastric Lymphoma has shifted significantly from surgical intervention to medical management. **Why Option C is False (The Correct Answer):** Historically, surgery was the mainstay of treatment. However, modern management protocols prioritize **non-surgical approaches**. For low-grade MALT (Mucosa-Associated Lymphoid Tissue) lymphomas, **H. pylori eradication** is the primary treatment. For high-grade or diffuse large B-cell lymphomas (DLBCL), **systemic chemotherapy** (e.g., CHOP regimen) with or without radiotherapy is the treatment of choice. Surgery is now reserved only for complications like perforation, uncontrollable hemorrhage, or obstruction. **Analysis of Other Options:** * **Option A:** The **stomach** is indeed the most common site for extranodal non-Hodgkin lymphoma (NHL), accounting for approximately 60% of cases in the GI tract. * **Option B:** There is a strong causal link between **H. pylori infection** and gastric MALToma. Chronic antigenic stimulation by the bacteria leads to lymphoid proliferation. * **Option D:** Gastric lymphoma generally carries a better prognosis than gastric adenocarcinoma. With appropriate therapy, the **5-year survival rate** is approximately 50-60%. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Diffuse Large B-cell Lymphoma (DLBCL). * **Staging System:** The **Lugano classification** is used for staging GI lymphomas. * **Diagnostic Gold Standard:** Endoscopic biopsy (Multiple "big-bite" biopsies are often needed as the tumor is submucosal). * **Key Marker:** CD20 positivity is common, making **Rituximab** a valuable addition to chemotherapy.

Question 64: What is the treatment of choice for desmoid tumors?

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

Explanation: **Explanation:** **Desmoid tumors** (also known as aggressive fibromatosis) are benign but locally aggressive myofibroblastic neoplasms. They do not metastasize but have a high propensity for local recurrence due to their infiltrative growth pattern. **Why Option D is Correct:** The primary goal of treatment is local control. **Surgery with wide local excision** is the mainstay of treatment. However, because these tumors lack a true capsule and infiltrate surrounding tissues, achieving negative margins (R0 resection) is often difficult. **Radiotherapy** is added as an adjuvant to surgery to significantly reduce the high risk of local recurrence, especially in cases of positive margins or recurrent disease. The combination of surgery and radiotherapy provides the best long-term local control rates. **Why Other Options are Incorrect:** * **A. Surgery alone:** While surgery is the initial step, the recurrence rate for surgery alone is high (up to 20–50%), making it less ideal than combined therapy for aggressive cases. * **B. Chemotherapy:** This is generally reserved for systemic management of unresectable, multi-focal, or life-threatening intra-abdominal desmoids (often seen in Gardner syndrome). It is not the first-line treatment of choice. * **C. Radiotherapy alone:** This is typically reserved for patients who are not surgical candidates or for tumors located in areas where surgery would cause significant functional morbidity. **High-Yield Clinical Pearls for NEET-PG:** * **Association:** Strongly associated with **FAP (Familial Adenomatous Polyposis)** and **Gardner Syndrome**. * **Location:** Most common in the **rectus abdominis** muscle (especially in postpartum women). * **Molecular Marker:** Driven by mutations in the **CTNNB1 gene** (beta-catenin) or the **APC gene**. * **Current Trend:** In modern practice, "Active Surveillance" (Wait and Watch) is increasingly preferred for asymptomatic, non-progressive tumors, but for active treatment, Surgery + RT remains the classic surgical answer.

Question 65: Which tumor marker is used for the follow-up of colorectal cancer?

A. CEA (Correct Answer)
B. CA 125
C. CA 19-9
D. AFP

Explanation: **Explanation:** **CEA (Carcinoembryonic Antigen)** is the correct answer because it is the gold-standard tumor marker for the surveillance and follow-up of **Colorectal Cancer (CRC)**. It is a glycoprotein normally produced during fetal development; in adults, elevated levels are associated with adenocarcinomas, particularly of the colon. * **Clinical Utility:** CEA is **not** used for screening due to low sensitivity and specificity (it can be elevated in smokers, COPD, and inflammatory bowel disease). Its primary role is in **monitoring recurrence** after surgical resection. A postoperative rise in CEA levels often precedes clinical or radiological evidence of metastasis by months. **Analysis of Incorrect Options:** * **CA 125:** Primarily used for **Ovarian Cancer** (specifically epithelial types). It can also be elevated in endometriosis or pelvic inflammatory disease. * **CA 19-9:** The primary marker for **Pancreatic Cancer** and Cholangiocarcinoma. While it can be elevated in CRC, it is not the preferred marker for follow-up. * **AFP (Alpha-Fetoprotein):** Used for **Hepatocellular Carcinoma (HCC)** and non-seminomatous germ cell tumors (like Yolk Sac tumors). **High-Yield Pearls for NEET-PG:** 1. **Most common site of CRC metastasis:** Liver (spread via the portal venous system). 2. **CEA and Prognosis:** Pre-operative CEA levels correlate with the stage of the disease; failure of CEA to return to normal after surgery suggests residual tumor. 3. **Surveillance Schedule:** ASCO guidelines recommend checking CEA every 3–6 months for the first 5 years after curative resection for Stage II and III disease.

Question 66: Which is the most common tumor associated with superior vena cava syndrome?

A. Lung cancer (Correct Answer)
B. Lymphoma
C. Metastasis
D. Thyroid cancer

Explanation: ### Explanation **Superior Vena Cava (SVC) Syndrome** occurs due to the extrinsic compression, direct invasion, or thrombosis of the SVC, leading to venous congestion in the head, neck, and upper extremities. **1. Why Lung Cancer is Correct:** Lung cancer is the leading cause of SVC syndrome, accounting for approximately **60–75% of all cases**. Among lung cancers, **Small Cell Lung Cancer (SCLC)** is the most common histological subtype associated with this syndrome due to its central location and rapid growth. However, because Non-Small Cell Lung Cancer (NSCLC) is more prevalent overall, it also contributes significantly to the total number of cases. **2. Why Other Options are Incorrect:** * **Lymphoma (Option B):** This is the second most common cause (approx. 10–15%), particularly Non-Hodgkin Lymphoma (NHL). It is the most common cause of SVC syndrome in **children and young adults**, but not in the general population. * **Metastasis (Option C):** While metastatic spread to mediastinal lymph nodes (e.g., from breast or germ cell tumors) can cause SVC syndrome, it is statistically less frequent than primary bronchogenic carcinoma. * **Thyroid Cancer (Option D):** Retrosternal goiters or invasive thyroid malignancies can compress the SVC, but this is a rare clinical presentation compared to thoracic malignancies. **3. Clinical Pearls for NEET-PG:** * **Most common cause overall:** Lung Cancer (Small Cell > Squamous). * **Most common benign cause:** Iatrogenic (indwelling central venous catheters or pacemaker leads causing thrombosis). Historically, it was Syphilitic aneurysms. * **Clinical Triad:** Facial edema (Pemberton’s sign), cyanosis, and dilated collateral veins on the chest wall. * **Management:** SVC syndrome is a **clinical emergency** only if there is airway compromise or cerebral edema. Initial management includes head elevation, oxygen, and diuretics; definitive treatment depends on the histology (Chemotherapy for SCLC/Lymphoma; Radiotherapy for NSCLC).

Question 67: What is the most common malignancy affecting the spleen?

A. Angiosarcoma
B. Hemangioma
C. Metastases
D. Lymphoma (Correct Answer)

Explanation: **Explanation:** The spleen is the largest lymphoid organ in the body, making it a frequent site for involvement by hematological malignancies. **Correct Answer: D. Lymphoma** Lymphoma is the most common malignancy affecting the spleen. It can involve the spleen either as a **primary** site (Primary Splenic Lymphoma) or, more commonly, as part of **systemic** involvement (Secondary). Among these, Non-Hodgkin Lymphoma (NHL) is more frequent than Hodgkin Lymphoma. Splenic involvement is seen in approximately 30-40% of systemic lymphoma cases. **Analysis of Incorrect Options:** * **A. Angiosarcoma:** This is the most common **primary non-lymphoid malignant tumor** of the spleen. While highly aggressive with a poor prognosis, it is much rarer than lymphoma. * **B. Hemangioma:** This is the most common **benign** tumor of the spleen. It is usually an incidental finding and does not represent a malignancy. * **C. Metastases:** While the spleen is highly vascular, splenic metastases from solid tumors (e.g., breast, lung, melanoma) are relatively **uncommon** compared to other organs like the liver or lungs. This is attributed to the spleen’s high concentration of immune cells and the rhythmic contractions of its capsule. **High-Yield Clinical Pearls for NEET-PG:** * **Most common benign tumor:** Hemangioma. * **Most common primary malignancy:** Lymphoma (specifically Splenic Marginal Zone Lymphoma in primary cases). * **Most common primary non-lymphoid malignancy:** Angiosarcoma (associated with a high risk of spontaneous rupture). * **Indication for Splenectomy:** In lymphoma, splenectomy is usually reserved for diagnosis, staging, or management of symptomatic splenomegaly/hypersplenism.

Question 68: A Poly A base sequence would most likely be found at which location?

A. 5' end of a prokaryotic messenger RNA (mRNA)
B. 3' end of a prokaryotic mRNA
C. 5' end of a eukaryotic mRNA
D. 3' end of a eukaryotic mRNA (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. 3' end of a eukaryotic mRNA.** In eukaryotic cells, the maturation of pre-mRNA into functional messenger RNA (mRNA) involves a post-transcriptional modification known as **polyadenylation**. This process involves the addition of a "tail" consisting of 50 to 250 adenine nucleotides (the **Poly-A tail**) specifically to the **3' end** of the RNA molecule. **Why it is correct:** The Poly-A tail serves three critical functions: 1. **Stability:** It protects the mRNA from enzymatic degradation by exonucleases. 2. **Nuclear Export:** It facilitates the transport of the mRNA from the nucleus to the cytoplasm. 3. **Translation:** It enhances the recognition of the mRNA by ribosomes for protein synthesis. **Analysis of Incorrect Options:** * **A & B (Prokaryotic mRNA):** Prokaryotic mRNAs generally do not undergo polyadenylation. When polyadenylation does occur in bacteria, it ironically acts as a signal for *degradation* rather than stability. * **C (5' end of eukaryotic mRNA):** The 5' end of eukaryotic mRNA undergoes a different modification called **"Capping"** (addition of a 7-methylguanosine cap), which is essential for ribosome binding and protection from 5' exonucleases. **High-Yield Clinical Pearls for NEET-PG:** * **Sequence Signal:** The polyadenylation signal sequence is typically **AAUAAA**, located upstream of the poly-A site. * **Enzyme:** The addition of the tail is catalyzed by the enzyme **Poly(A) Polymerase**, which does *not* require a DNA template. * **Surgical Oncology Link:** Dysregulation of mRNA stability and polyadenylation patterns is often implicated in the overexpression of oncogenes and the progression of various solid tumors, making it a target for emerging molecular therapies.

Question 69: Antoni A and Antoni B patterns are seen in which of the following?

A. Schwannoma (Correct Answer)
B. Neurofibroma
C. Meningioma
D. Teratoma

Explanation: **Explanation:** **Schwannoma** (also known as Neurilemmoma) is a benign nerve sheath tumor derived from Schwann cells. Histologically, it is characterized by a distinct biphasic pattern consisting of **Antoni A** and **Antoni B** areas: * **Antoni A:** Highly cellular areas with spindle cells arranged in fascicles. A hallmark feature here is the **Verocay body**, which consists of two compact rows of well-aligned nuclei separated by an acellular zone. * **Antoni B:** Hypocellular, loosely arranged myxoid stroma with fewer cells and cystic changes. **Why other options are incorrect:** * **Neurofibroma:** Unlike Schwannomas, these are unencapsulated and contain a mixture of cell types (Schwann cells, fibroblasts, and perineural cells) in a "shredded carrot" collagenous background. They do not exhibit the Antoni A/B biphasic pattern. * **Meningioma:** Characterized histologically by whorled patterns and **Psammoma bodies** (laminated calcifications), not Antoni patterns. * **Teratoma:** A germ cell tumor containing tissues from all three germ layers (ectoderm, endoderm, mesoderm). Its histology shows a disorganized mixture of various tissues like hair, muscle, and epithelium. **High-Yield Clinical Pearls for NEET-PG:** * **S-100 Protein:** Schwannomas show strong and diffuse positivity for S-100 (immunohistochemistry). * **Nerve Relationship:** Schwannomas usually arise from the side of the nerve and are **encapsulated**, making them surgically separable from the nerve (unlike neurofibromas). * **Acoustic Neuroma:** The most common location is the Vestibulocochlear nerve (CN VIII) at the cerebellopontine angle. Bilateral acoustic neuromas are pathognomonic for **Neurofibromatosis Type 2 (NF2)**.

Question 70: Blood-stained sputum may be the only presenting symptom in which of the following conditions?

A. Bronchiectasis
B. Carcinoma of the bronchus
C. Adenoma of the bronchus (Correct Answer)
D. Pulmonary tuberculosis

Explanation: **Explanation:** The correct answer is **Adenoma of the bronchus** (specifically Bronchial Carcinoid). **Why it is correct:** Bronchial adenomas (most commonly **Carcinoid tumors**) are highly vascular, slow-growing epithelial tumors that arise from the bronchial mucosa. Because they are centrally located and extremely vascular, they often present with recurrent, painless hemoptysis (blood-stained sputum) as the **sole or earliest symptom**. Unlike malignant tumors, they do not typically cause rapid constitutional symptoms (weight loss, cachexia) or significant parenchymal destruction in the early stages, making hemoptysis the primary clinical feature. **Why the other options are incorrect:** * **Bronchiectasis:** While hemoptysis occurs, the hallmark presentation is a chronic, productive cough with **copious, foul-smelling purulent sputum**, often associated with finger clubbing. * **Carcinoma of the bronchus:** Hemoptysis is common, but it is rarely the *only* symptom. Patients usually present with a constellation of symptoms including persistent cough, chest pain, dyspnea, and significant systemic features like weight loss and anorexia. * **Pulmonary tuberculosis:** This is a systemic infection. While blood-stained sputum is a classic sign, it is almost always accompanied by constitutional symptoms such as low-grade evening fever, night sweats, and chronic productive cough. **NEET-PG High-Yield Pearls:** * **Bronchial Carcinoid** is the most common "adenoma" (80-90%). * They are characterized by **extreme vascularity**; biopsy during bronchoscopy carries a high risk of significant bleeding. * **Clinical Triad (rare):** Hemoptysis, localized wheeze (due to obstruction), and recurrent pneumonia in the same lobe. * On imaging, they may show the **"Iceberg sign"** (a small endobronchial component with a large extrabronchial mass).

Practice by Chapter

Cancer Biology Basics

Practice Questions

Principles of Cancer Therapy

Practice Questions

Screening and Early Detection

Practice Questions

Surgical Staging

Practice Questions

Surgical Resection Principles

Practice Questions

Lymphadenectomy

Practice Questions

Management of Metastatic Disease

Practice Questions

Combined Modality Therapy

Practice Questions

Targeted Therapy Concepts

Practice Questions

Cancer Survivorship

Practice Questions

Palliative Surgical Interventions

Practice Questions

Ethics in Cancer Care

Practice Questions

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free