Surgical Oncology Principles — MCQs

Surgical Oncology Principles Indian Medical PG Practice Questions and MCQs

Question 81: Most common presentation of abdominal desmoid tumor is?

A. Abdominal mass (Correct Answer)
B. Fever
C. Urinary retention
D. Abdominal pain

Explanation: ***Abdominal mass*** - Desmoid tumors are **non-metastasizing but locally invasive fibroblastic neoplasms** that most commonly present as a palpable abdominal mass. - This is the **most characteristic finding** on physical examination, though patients may be asymptomatic or have accompanying symptoms. - The mass is typically **firm, fixed, and may be painless** in early stages. *Fever* - Fever is generally **not a primary symptom** of desmoid tumors, as they are benign and do not typically cause systemic inflammation or infection. - If fever is present, it would suggest an **alternative diagnosis** or a complication such as infection or tumor necrosis, which is rare. *Urinary retention* - Urinary retention could occur if a desmoid tumor grows large enough to **compress the bladder or ureters**, but this is not the most common initial presentation. - This symptom would represent a **later-stage complication** rather than the typical first sign of the tumor. *Abdominal pain* - Abdominal pain is a **very common presenting symptom** of abdominal desmoid tumors, often accompanying or even preceding detection of the mass. - However, the most characteristic and consistent finding is the **palpable abdominal mass itself**, which is present in the majority of cases at presentation. - Pain may result from mass effect, infiltration of surrounding structures, or nerve involvement.

Question 82: A 50-year-old male with a long smoking history presents with a 2-month history of hoarseness, ear pain, and hemoptysis. Laryngoscopy reveals a mass on the vocal cords, and a chest X-ray shows a suspicious nodule. What is the most likely diagnosis?

A. Tuberculosis
B. Laryngeal carcinoma (Correct Answer)
C. Pneumonia
D. Chronic bronchitis

Explanation: ***Laryngeal carcinoma*** - The combination of **hoarseness, ear pain, and hemoptysis** in a patient with a **long smoking history** is highly suggestive of **laryngeal carcinoma**. - **Hoarseness** is the cardinal symptom of glottic laryngeal cancer, while **ear pain** (referred otalgia via Arnold's nerve) suggests advanced disease. - **Laryngoscopy identifying a vocal cord mass** provides direct visualization of the tumor. - The **suspicious nodule on chest X-ray** may represent a **synchronous primary lung cancer** (both share smoking as a major risk factor), **distant metastasis**, or requires further evaluation. Smokers are at high risk for multiple aerodigestive tract malignancies. *Tuberculosis* - While **hemoptysis** and a **suspicious nodule on chest X-ray** can be seen in tuberculosis, **hoarseness** and **ear pain** are not typical primary symptoms. - Laryngeal tuberculosis is rare and usually secondary to pulmonary TB with **constitutional symptoms** like fever, night sweats, and weight loss, which are not mentioned. - A **vocal cord mass** would be unusual for TB without systemic features. *Pneumonia* - **Pneumonia** typically presents with acute symptoms such as **cough, fever, dyspnea, and chills**. - **Hoarseness** and **ear pain** are not characteristic features of uncomplicated pneumonia. - A **mass on the vocal cords** is not associated with pneumonia, and the **2-month duration** is too prolonged for typical bacterial pneumonia. *Chronic bronchitis* - **Chronic bronchitis** is defined by a **chronic productive cough** for at least three months a year for two consecutive years. - While common in smokers, it typically does not cause **ear pain, hemoptysis**, or a **vocal cord mass**. - Chronic bronchitis does not produce discrete masses on laryngoscopy, differentiating it from a malignant process.

Question 83: What considerations should guide the decision-making process for offering neoadjuvant versus adjuvant chemotherapy in a patient with high-grade osteosarcoma of the distal femur?

A. The size of the tumor, presence of metastases at diagnosis, and expected surgical margins (Correct Answer)
B. Patient's preference for chemotherapy timing
C. Ease of scheduling for the healthcare team
D. Cost of the chemotherapy drugs

Explanation: ***The size of the tumor, presence of metastases at diagnosis, and expected surgical margins*** - **Neoadjuvant chemotherapy is the STANDARD OF CARE** for high-grade osteosarcoma (typically MAP protocol: Methotrexate, Adriamycin, Cisplatin) - Key considerations for neoadjuvant approach include: - **Tumor size and resectability**: Large tumors can be downstaged to facilitate limb-salvage surgery and improve surgical margins - **Assessment of tumor response**: Histological response (tumor necrosis ≥90%) serves as a prognostic marker and guides postoperative chemotherapy decisions - **Metastatic disease**: Presence of metastases at diagnosis mandates immediate systemic therapy, best delivered neoadjuvantly - **Time for surgical planning**: Allows comprehensive staging, prosthesis preparation, and multidisciplinary coordination - **Expected surgical margins** are crucial for local control; neoadjuvant therapy improves the likelihood of achieving wide negative margins *Patient's preference for chemotherapy timing* - While patient preferences are important in shared decision-making, the **timing of chemotherapy in high-grade osteosarcoma is dictated by established oncological protocols** - The decision between neoadjuvant and adjuvant therapy is based on **clinical evidence** demonstrating improved outcomes with neoadjuvant chemotherapy - Patient autonomy is respected in treatment acceptance, but the **sequence is standardized** based on biological principles *Ease of scheduling for the healthcare team* - **Operational convenience is never a consideration** in determining optimal cancer treatment sequencing - Treatment decisions must prioritize **maximum oncological benefit** and patient survival - Scheduling should adapt to clinical needs, not vice versa *Cost of the chemotherapy drugs* - While healthcare economics matter at a policy level, **drug costs do not influence the clinical decision** between neoadjuvant versus adjuvant chemotherapy - The **standard protocol remains the same** regardless of timing; therefore, cost is identical - Treatment selection is guided by **evidence-based guidelines** and clinical efficacy, ensuring the best possible survival and functional outcomes

Question 84: Metastasis to thyroid comes from which primary site of malignancy?

A. Liver
B. Testis
C. Prostate
D. Kidney (Correct Answer)

Explanation: ***Kidney*** - The **kidney** (specifically **renal cell carcinoma**) is a common primary source for metastases to the thyroid gland, although overall thyroid metastases are rare. - Metastases from renal cell carcinoma may present years after the initial diagnosis and treatment of the primary tumor. *Liver* - While the **liver** is a common site for metastases from various cancers, it is not a common primary source for metastasis to the thyroid. - Metastases to the liver typically originate from gastrointestinal, breast, or lung cancers. *Testis* - **Testicular cancers** (e.g., germ cell tumors) typically metastasize to retroperitoneal lymph nodes, lungs, and brain. - Metastasis to the thyroid from testicular primary tumors is exceedingly rare. *Prostate* - **Prostate cancer** commonly metastasizes to bones, lymph nodes, and lungs. - Metastasis to the thyroid from prostate cancer is uncommon.

Question 85: Which of the following cancers is sentinel lymph node biopsy commonly used to evaluate?

A. Breast cancer
B. Melanoma
C. Vulvar cancer
D. All of the options (Correct Answer)

Explanation: ***All of the options*** - **Sentinel lymph node biopsy (SLNB)** is a widely accepted and practiced technique for staging and guiding treatment in **melanoma**, **breast cancer**, and **vulvar cancer**. - Its utility lies in identifying whether cancer cells have spread to the first draining lymph node, thus indicating regional spread and the need for further intervention. **Breast cancer:** - **SLNB** is the standard of care for staging the axilla in early-stage **breast cancer**, replacing axillary lymph node dissection in many cases. - It helps determine the need for adjuvant therapy and guides patient prognosis. - **SLNB has the highest level of evidence** and is most commonly performed in breast cancer worldwide. **Melanoma:** - For patients with **melanoma** of intermediate thickness (>1 mm or 0.76-1 mm with ulceration), **SLNB** is crucial for identifying occult nodal metastasis. - Positive SLNB results may lead to consideration of complete lymph node dissection and adjuvant systemic therapy. - **SLNB is part of standard staging protocols** for melanoma. **Vulvar cancer:** - **SLNB** is increasingly used in early-stage **vulvar cancer** to assess groin lymph node involvement, especially in unifocal lesions <4 cm. - This technique can significantly reduce the morbidity associated with radical inguinal lymphadenectomy while providing accurate prognostic information. - **SLNB has become the standard approach** for clinically node-negative early vulvar cancer.

Question 86: What is the most common site of cancer in the esophagus?

A. Upper 1/3rd
B. Gastroesophageal junction (GEJ)
C. Middle 1/3rd (Correct Answer)
D. Lower 1/3rd

Explanation: ***Middle 1/3rd*** - The **middle 1/3rd of the esophagus** is the most common site for **esophageal cancer globally and in India**. - **Squamous cell carcinoma (SCC)** accounts for approximately **90-95% of esophageal cancers in India** and predominantly affects the middle third. - This pattern is consistent across most **Asian, African, and South American populations** where SCC remains the predominant histological type. - Risk factors include **tobacco, alcohol, hot beverages, and nutritional deficiencies**, which are common in endemic regions. *Lower 1/3rd* - The lower 1/3rd is the most common site for **adenocarcinoma**, which has become predominant in **Western countries (USA, Western Europe)**. - This is associated with **Barrett's esophagus** secondary to chronic **gastroesophageal reflux disease (GERD)**. - While adenocarcinoma incidence is rising globally, **SCC still predominates in India**, making the middle third the most common overall site. *Upper 1/3rd* - The upper 1/3rd (cervical esophagus) is the **least common site** for esophageal cancer, accounting for only 10-15% of cases. - Can be affected by SCC but represents a minority of esophageal malignancies. *Gastroesophageal junction (GEJ)* - GEJ cancers have increased in incidence, particularly in Western populations, and are often classified as **Siewert type tumors**. - These are frequently **adenocarcinomas** and may be classified separately from true esophageal cancers. - In the **Indian context**, where SCC predominates, GEJ adenocarcinomas are less common than middle third SCC.

Question 87: Sentinel lymph node biopsy is used for?

A. Melanoma (Correct Answer)
B. Thyroid carcinoma
C. Squamous cell carcinoma
D. Basal cell carcinoma

Explanation: ***Melanoma*** - Sentinel lymph node biopsy is a standard staging procedure for **intermediate-thickness (Breslow depth >0.8 mm)** or **ulcerated melanomas** to detect microscopic lymphatic metastatic disease. - It helps guide adjuvant therapy and predict prognosis in patients with no clinically evident nodal involvement. *Squamous cell carcinoma* - Sentinel lymph node biopsy is generally **not indicated** for squamous cell carcinoma unless it has **high-risk features** (e.g., perineural invasion, large size, poor differentiation, recurrence) or is located in certain high-risk anatomic sites, and even then, its role is less established than in melanoma. - Lymphadenectomy is more common for clinically positive nodes. *Thyroid carcinoma* - Sentinel lymph node biopsy is **not routinely performed** for thyroid carcinoma. - The detection of metastases typically relies on **preoperative ultrasound** of the neck and **fine-needle aspiration (FNA)** of suspicious nodes, followed by therapeutic neck dissection if indicated. *Basal cell carcinoma* - Basal cell carcinoma **rarely metastasizes** to regional lymph nodes, making sentinel lymph node biopsy **unnecessary** in almost all cases. - Local excision with clear margins is usually curative.

Question 88: What is the best marker to assess prognosis after surgery for colon carcinoma?

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

Explanation: ***CEA*** - Carcinoembryonic antigen (**CEA**) is a well-established tumor marker for monitoring colorectal cancer post-surgery and assessing prognosis [1]. - Elevated **CEA levels** after surgery may indicate recurrence or residual disease, making it valuable in follow-up care [1]. *CA 19-9* - Primarily associated with **pancreatic** and **biliary tract cancers**, and not specific for colon carcinoma. - While it may elevate in some gastrointestinal malignancies, it is not the best indicator for prognosis after colon cancer surgery. *Alpha fetoprotein* - Mostly used for monitoring **hepatocellular carcinoma** and germ cell tumors, not colorectal malignancies. - Elevated levels are not typically correlated with prognosis in colon cancer patients. *CA-125* - Mainly utilized as a tumor marker for **ovarian cancer** and some other malignancies, not specifically for colon carcinoma. - Its use in colorectal cancer prognosis is limited and lacks relevance in this context. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 253-254.

Question 89: Which of the following statements is true about Marjolin's ulcer?

A. Squamous cell carcinoma develops
B. Slow growing lesion
C. Develops in long standing scar
D. All of the options (Correct Answer)

Explanation: ***All of the options*** - Marjolin's ulcer is a **malignant transformation** that occurs in chronic wounds and scars, which tend to be **long-standing**. - It most commonly leads to the development of **squamous cell carcinoma (SCC)**, and these lesions are generally **slow-growing**. *Squamous cell carcinoma develops* - This statement is true; the most common histological type of malignancy arising in a Marjolin's ulcer is **squamous cell carcinoma (SCC)**. - Less frequently, **basal cell carcinoma** or other sarcomas can also arise, but **SCC** is the predominant form. - The SCC arising in Marjolin's ulcer tends to be **more aggressive** than conventional SCC, with higher rates of **local invasion** and **metastasis**. *Slow growing lesion* - This statement is true; Marjolin's ulcer lesions typically exhibit a **slow growth rate** over an extended period. - This characteristic often contributes to delayed diagnosis, as patients may initially dismiss the changes as non-malignant wound complications. - The latency period can range from **years to decades** after the initial injury. *Develops in long standing scar* - This statement is true; Marjolin's ulcer is defined by its development in areas of **chronic inflammation**, such as **burn scars**, **pressure sores**, **venous stasis ulcers**, and other non-healing wounds. - The latency period for malignant transformation in such scars can range from years to decades, indicating a **long-standing** nature. - **Burn scars** are the most common site, accounting for the majority of cases.

Question 90: A 10 cm tumor is found on the anterior surface of the thigh. What is the most appropriate procedure to obtain a diagnosis?

A. Incision biopsy (Correct Answer)
B. Excision biopsy
C. FNAC
D. USG

Explanation: ***Incision biopsy*** - An **incision biopsy** is most appropriate for a large tumor (10 cm) to obtain a tissue diagnosis without performing a potentially morbid or disfiguring complete excision upfront. - It involves removing a representative section of the tumor for histopathological analysis, providing adequate tissue for diagnosis, grading, and subtyping. - This allows definitive treatment planning based on confirmed histopathology. *Excision biopsy* - **Excision biopsy** is generally reserved for smaller tumors (typically <3-5 cm) that can be completely resected with acceptable cosmetic and functional outcomes. - Excision of a 10 cm tumor on the thigh would be a significant surgical procedure, potentially causing substantial morbidity, without a prior definitive diagnosis. - Could compromise subsequent definitive surgery if margins are inadequate. *FNAC* - **FNAC (Fine Needle Aspiration Cytology)** provides only cytological diagnosis, which is insufficient for definitive diagnosis, grading, and subtyping of soft tissue tumors, especially sarcomas. - It misses crucial architectural features and tissue patterns needed for accurate classification. - May yield inadequate or non-diagnostic samples from large heterogeneous tumors. *USG* - **USG (Ultrasound)** is an imaging modality, not a tissue diagnosis procedure. - While useful for characterizing mass features (size, location, vascularity, solid vs cystic), it cannot provide histopathological diagnosis. - The question specifically asks for a procedure to "obtain a diagnosis," which requires tissue sampling for microscopic examination.

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Management of Metastatic Disease

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Combined Modality Therapy

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Targeted Therapy Concepts

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Palliative Surgical Interventions

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Ethics in Cancer Care

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