Oncology Practice Questions

Q: A pediatrician discovers a large mass in the abdomen of a 3-year-old child. Ultrasound examination demonstrates that the mass appears to arise from the right kidney. Which of the following tumors is most likely present?

Nephroblastoma. **Explanation:** **Nephroblastoma (Wilms Tumor)** is the most common primary renal malignancy in children, typically presenting between **2 and 5 years of age**. The classic clinical presentation is a large, smooth, firm, and asymptomatic abdominal mass that rarely crosses the midline. It arises from embryonic nephrogenic rests. In the context of a 3-year-old with a renal mass, Wilms tumor is the "must-know" diagnosis for NEET-PG. **Analysis of Incorrect Options:** * **A. Cortical adenoma:** These are small, benign epithelial tumors often found incidentally in adults. They are extremely rare in the pediatric population. * **B. Hemangioma:** While vascular tumors can occur in various organs, primary renal hemangiomas are rare and do not typically present as a large, solid abdominal mass in a toddler. * **D. Oncocytoma:** This is a benign renal epithelial tumor that occurs almost exclusively in older adults (6th–7th decade). It is virtually unheard of in a 3-year-old. **High-Yield Clinical Pearls for NEET-PG:** * **WAGR Syndrome:** Wilms tumor, Aniridia, Genitourinary anomalies, and intellectual disability (formerly Retardation). Associated with **WT1 gene** deletion on Chromosome 11p13. * **Beckwith-Wiedemann Syndrome:** Macroglossia, organomegaly, and hemihypertrophy; associated with **WT2 gene** on Chromosome 11p15. * **Histology:** Characterized by a **triphasic pattern** (blastemal, stromal, and epithelial cells). * **Management Tip:** Avoid vigorous palpation of the abdomen to prevent rupture of the tumor capsule and subsequent peritoneal seeding.

Q: Which among the following is the most common thyroid malignancy in children?

Papillary carcinoma. **Explanation:** **1. Why Papillary Carcinoma is Correct:** Papillary Thyroid Carcinoma (PTC) is the most common pediatric thyroid malignancy, accounting for approximately **80–90%** of all cases. In children, it often presents as a painless, firm thyroid nodule or cervical lymphadenopathy. A key medical concept for NEET-PG is that while PTC in children is often more aggressive at presentation (higher rates of lymph node and pulmonary metastasis) compared to adults, the overall **prognosis remains excellent** with high survival rates. **2. Why the Other Options are Incorrect:** * **Follicular Carcinoma:** This is the second most common type but is significantly less frequent than PTC in the pediatric population. It typically spreads hematogenously (to bones/lungs) rather than via lymphatics. * **Medullary Carcinoma:** This arises from parafollicular C-cells. While rare, in children it is almost always associated with genetic syndromes like **MEN 2A or 2B**. * **Thyroid Lymphoma:** Extremely rare in children; it is more commonly seen in elderly patients, often arising in the background of Hashimoto’s thyroiditis. **3. Clinical Pearls for NEET-PG:** * **Risk Factor:** Prior **ionizing radiation** exposure to the head and neck is the most significant risk factor for pediatric PTC (e.g., survivors of childhood Hodgkin lymphoma). * **Histology:** Look for **Orphan Annie eye nuclei** (cleared-out chromatin) and **Psammoma bodies** (laminated calcifications). * **Genetics:** *RET/PTC* rearrangements are common in pediatric papillary carcinoma, whereas *BRAF* mutations are more frequent in adults. * **Management:** Total thyroidectomy followed by Radioactive Iodine (RAI) ablation is the standard of care.

Q: A child presents with proptosis, multiple skeletal limb secondaries, and sutural separation. What is the most likely diagnosis?

Neuroblastoma. **Explanation:** The clinical triad of **proptosis**, **skeletal limb secondaries**, and **sutural separation** in a pediatric patient is a classic presentation of metastatic **Neuroblastoma** (Stage M). 1. **Why Neuroblastoma is correct:** Neuroblastoma is the most common extracranial solid tumor of childhood, arising from neural crest cells. It has a high propensity for hematogenous spread to the bone and bone marrow. * **Proptosis:** Metastasis to the retro-orbital bones leads to "raccoon eyes" (periorbital ecchymosis) and proptosis. * **Skeletal Secondaries:** It frequently involves the long bones, causing pain and limping. * **Sutural Separation:** Metastasis to the skull bones and meninges increases intracranial pressure, which, in a child with open or non-fused sutures, leads to sutural diastasis (separation). 2. **Why other options are incorrect:** * **Medulloblastoma:** This is a primary CNS tumor of the posterior fossa. While it can spread via CSF (drop metastasis), systemic bony metastasis and proptosis are extremely rare. * **Retinoblastoma:** While it causes leukocoria (white reflex) and can cause proptosis if it invades the orbit locally, it does not typically present with widespread skeletal limb secondaries and sutural separation as the primary systemic feature. **Clinical Pearls for NEET-PG:** * **Most common site:** Adrenal medulla. * **Tumor Marker:** Elevated urinary VMA (Vanillylmandelic acid) and HVA (Homovanillic acid). * **Histology:** Homer-Wright rosettes. * **Opsoclonus-Myoclonus Syndrome:** A high-yield paraneoplastic syndrome associated with neuroblastoma ("dancing eyes, dancing feet"). * **N-myc amplification:** The most important poor prognostic factor.

Q: Which of the following malignancies is classified by the Chang staging system?

Medulloblastoma. **Explanation:** **Medulloblastoma** is the most common malignant brain tumor in children, arising from the embryonal cells in the posterior fossa. The **Chang Staging System** is the classic classification used to stage this tumor based on two parameters: 1. **T (Tumor) Stage:** Based on the size and local invasiveness of the primary tumor (T1 to T4). 2. **M (Metastasis) Stage:** Based on the presence of cerebrospinal fluid (CSF) seeding or extraneural spread (M0 to M4). *Note: M1 indicates microscopic tumor cells in CSF, while M2/M3 indicate gross nodular seeding in the brain or spine.* **Why the other options are incorrect:** * **Retinoblastoma:** Primarily staged using the **International Classification of Retinoblastoma (ICRB)** for intraocular disease and the **Reese-Ellsworth** system (historically used for predicting vision preservation). * **Rhabdomyosarcoma:** Utilizes the **IRS (Intergroup Rhabdomyosarcoma Study)** grouping system, which is based on the extent of surgical resection, combined with a TNM-based clinical staging system. * **Ewing's Sarcoma:** Does not have a specific named staging system like Chang; it is generally classified as **Localized** or **Metastatic** based on imaging and biopsy. **High-Yield Clinical Pearls for NEET-PG:** * **Homer-Wright Rosettes:** A classic histopathological finding in Medulloblastoma (also seen in Neuroblastoma). * **Drop Metastasis:** Medulloblastoma is notorious for spreading via CSF to the spinal cord; hence, "craniospinal axis" imaging is mandatory. * **Molecular Subgroups:** Modern classification now includes four groups: **WNT** (best prognosis), **SHH**, **Group 3** (worst prognosis), and **Group 4**. * **Zuckerkandl's criteria** is sometimes confused with staging, but it refers to the location of extra-adrenal pheochromocytoma.

Q: Wilm's tumor is associated with all of the following conditions EXCEPT:

Bilateral polycystic kidney. **Explanation:** Wilms tumor (Nephroblastoma) is the most common primary renal malignancy in children. It is frequently associated with specific congenital malformations and genetic syndromes, but **Bilateral Polycystic Kidney Disease (BPKD)** is not one of them. BPKD is a genetic ciliopathy and does not predispose patients to Wilms tumor. **Analysis of Options:** * **A. Hemihypertrophy:** This is a classic association, often seen in **Beckwith-Wiedemann Syndrome (BWS)**. BWS is characterized by macroglossia, omphalocele, and organomegaly. Children with isolated hemihypertrophy have an increased risk of embryonal tumors like Wilms and hepatoblastoma. * **B. Aniridia:** Absence of the iris is a hallmark of the **WAGR syndrome** (Wilms tumor, Aniridia, Genitourinary anomalies, and intellectual disability/Range of developmental delays). This results from a microdeletion on chromosome 11p13 involving the *WT1* and *PAX6* genes. * **C. Hypertension:** Hypertension is present in about 25% of Wilms tumor cases. It occurs due to increased **renin production** by the tumor cells or compression of the renal artery by the tumor mass (Goldblatt phenomenon). **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common presentation:** An asymptomatic, large, smooth abdominal mass that **does not cross the midline** (unlike Neuroblastoma). 2. **Denys-Drash Syndrome:** Characterized by the triad of Wilms tumor, male pseudohermaphroditism, and early-onset renal failure (diffuse mesangial sclerosis). 3. **Genetics:** Associated with mutations on **Chromosome 11** (*WT1* at 11p13 and *WT2* at 11p15). 4. **Staging:** Wilms tumor is staged surgically. The most common site of distant metastasis is the **Lungs**.

Q: A 5-year-old child presents with a history of intermittent fever for the past 2 weeks, petechial spots all over the body, and increasing pallor for the past 1 month. Examination reveals splenomegaly 2 cm below the costal margin. What is the most likely diagnosis?

Acute leukemia. ### Explanation The clinical presentation of **fever, pallor, and petechiae** represents the classic triad of **pancytopenia** (anemia, leukopenia/neutropenia, and thrombocytopenia). In a pediatric patient, this triad combined with **organomegaly** (splenomegaly) is highly suggestive of **Acute Leukemia** (most commonly ALL in this age group). **Why Acute Leukemia is correct:** Leukemic cells infiltrate the bone marrow, leading to "marrow failure." This results in decreased production of normal RBCs (pallor), WBCs (fever/infections), and platelets (petechiae). Crucially, the presence of **splenomegaly** indicates an infiltrative process or extramedullary hematopoiesis, which distinguishes it from simple marrow failure like aplastic anemia. **Why the other options are incorrect:** * **Idiopathic Thrombocytopenic Purpura (ITP):** Typically presents with isolated thrombocytopenia (petechiae/bruising) in a "well-looking" child. It does **not** cause pallor, fever, or splenomegaly. * **Aplastic Anemia:** While it presents with pancytopenia (pallor, fever, petechiae), it is characterized by an "empty" marrow. Therefore, **splenomegaly is characteristically absent**. * **Hypersplenism:** While it can cause cytopenias due to splenic sequestration, the primary cause of the splenomegaly would usually be more prominent, and it rarely presents with such acute, severe systemic symptoms in a 5-year-old without a known prior history (like portal hypertension or thalassemia). **Clinical Pearls for NEET-PG:** * **Acute Lymphoblastic Leukemia (ALL)** is the most common childhood malignancy (peak age 2–5 years). * **Bone pain** is a frequent additional finding in pediatric leukemia due to marrow expansion. * **Key Diagnostic Step:** Bone marrow aspiration showing **>20% blasts**. * **Differentiating Point:** Pancytopenia + Splenomegaly = Think Leukemia; Pancytopenia + No Splenomegaly = Think Aplastic Anemia.

Q: A child presents with a splenic mass and a mediastinal mass. The child appears pale, has red eyes, and suffers from recurrent infections. What is the most likely diagnosis?

Acute Lymphoblastic Leukemia. **Explanation:** The clinical presentation of a child with a **mediastinal mass, splenic mass (splenomegaly), and signs of bone marrow failure** (pallor indicating anemia, recurrent infections indicating functional neutropenia) is highly characteristic of **Acute Lymphoblastic Leukemia (ALL)**, specifically the **T-cell subtype**. 1. **Why ALL is correct:** ALL is the most common pediatric malignancy. T-cell ALL (approx. 15% of cases) typically presents in adolescent males with a **mediastinal (thymic) mass**, which can cause superior vena cava syndrome or respiratory distress. The "red eyes" mentioned are a classic sign of **conjunctival suffusion/injection**, often seen in SVC syndrome due to venous congestion from the mediastinal mass. Splenomegaly and marrow failure (pallor/infections) are hallmarks of leukemic infiltration. 2. **Why other options are incorrect:** * **Chronic Myeloid Leukemia (CML):** Rare in children; typically presents with massive splenomegaly but lacks a primary mediastinal mass or acute marrow failure signs. * **Graft versus Host Disease (GVHD):** Occurs post-transplant; presents with skin rash, diarrhea, and jaundice, not localized mediastinal/splenic masses. * **Pulmonary Metastasis:** While it can cause respiratory symptoms, it does not explain the systemic bone marrow failure (pallor/infections) or the primary splenic involvement seen in this age group. **Clinical Pearls for NEET-PG:** * **T-ALL mnemonic:** **T**eenagers, **T**hymic mass, **T**-cell markers (CD2, CD3, CD7). * **Most common subtype:** B-cell ALL (CD10/CALLA positive) is more common than T-cell ALL. * **Good Prognosis:** Age 1–9 years, low WBC count ( 10 years, high WBC count, and t(9;22) Philadelphia chromosome.

Q: What is the second most common neoplasm seen in children?

Brain tumor. **Explanation:** In pediatric oncology, the frequency of malignancies follows a specific hierarchy that is frequently tested in NEET-PG. **1. Why Brain Tumors are the Correct Answer:** Leukemia (specifically Acute Lymphoblastic Leukemia) is the most common malignancy in children, accounting for approximately 30% of all cases. **Brain tumors (Central Nervous System tumors)** are the **second most common** pediatric neoplasm and the most common **solid** tumor in children, representing about 20-25% of cases. In the pediatric population, the majority of brain tumors are infratentorial (e.g., Medulloblastoma, Juvenile Pilocytic Astrocytoma), unlike in adults where supratentorial tumors predominate. **2. Analysis of Incorrect Options:** * **A. Lymphoma:** This is the third most common pediatric malignancy. It includes both Hodgkin and Non-Hodgkin lymphomas. * **D. Neuroblastoma:** This is the most common **extracranial** solid tumor in children and the most common malignancy in infants (under 1 year of age). * **C. Wilm’s Tumor (Nephroblastoma):** While it is the most common primary renal tumor in children, it ranks lower in overall frequency compared to the options above. **High-Yield Clinical Pearls for NEET-PG:** * **Most common childhood cancer:** Leukemia (ALL). * **Most common solid tumor:** Brain tumor. * **Most common infratentorial tumor:** Juvenile Pilocytic Astrocytoma (overall) or Medulloblastoma (malignant). * **Most common extracranial solid tumor:** Neuroblastoma. * **Most common neonatal malignancy:** Neuroblastoma. * **Most common soft tissue sarcoma:** Rhabdomyosarcoma.

Q: What is the treatment for refractory histiocytosis?

Cladribine. **Explanation:** Langerhans Cell Histiocytosis (LCH) is a proliferative disorder of myeloid dendritic cells. The standard first-line treatment for multisystem LCH involves a combination of **Vinblastine and Prednisolone**. However, patients who fail to respond or relapse (refractory LCH) require salvage therapy. **1. Why Cladribine is correct:** **Cladribine (2-CdA)** is a purine nucleoside analog that is highly effective against histiocytic cells. It induces apoptosis in monocytes and dendritic cells by interfering with DNA synthesis and repair. It is currently considered the gold-standard salvage therapy for refractory LCH, often used alone or in combination with Cytarabine, showing high response rates in bone and skin lesions as well as multisystem disease. **2. Why the other options are incorrect:** * **High-dose Methotrexate:** While used in various pediatric malignancies (like ALL or Osteosarcoma), it is not the primary choice for refractory LCH. * **High-dose Cytarabine (Ara-C):** While Cytarabine is used in combination with Cladribine for high-risk refractory cases, Cladribine remains the specific "drug of choice" identified in standard protocols and NEET-PG patterns for this condition. * **Fludarabine:** This is another purine analog used primarily in chronic lymphocytic leukemia (CLL); it does not have the same established efficacy profile as Cladribine for LCH. **Clinical Pearls for NEET-PG:** * **Pathognomonic finding:** Birbeck granules (tennis-racket shaped) on Electron Microscopy. * **Immunophenotype:** Positive for **CD1a, CD207 (Langerin)**, and S100. * **Common Mutation:** **BRAF V600E** mutation is found in about 50-60% of cases, making BRAF inhibitors (e.g., Vemurafenib) a modern targeted therapy option for refractory cases. * **Hand-Schüller-Christian triad:** Diabetes insipidus, Exophthalmos, and Lytic bone lesions.

Q: All of the following is true about Wilm's tumor except?

It is always unilateral. **Explanation:** **Wilms Tumor (Nephroblastoma)** is the most common primary renal malignancy in children, typically occurring between 2–5 years of age. **Why Option C is the correct answer (The Exception):** Wilms tumor is **not** always unilateral. While approximately 90–95% of cases are unilateral, **5–10% of cases are bilateral** (synchronous or metachronous). Bilateral involvement is more frequently associated with genetic syndromes such as WAGR (Wilms, Aniridia, Genitourinary anomalies, Retardation), Denys-Drash, and Beckwith-Wiedemann syndrome. **Analysis of Incorrect Options:** * **Option A:** An asymptomatic, smooth, firm **abdominal lump** that rarely crosses the midline is the most common clinical presentation. * **Option B:** It is indeed the **most common renal neoplasm** in the pediatric age group, accounting for nearly 95% of all childhood kidney tumors. * **Option D:** Wilms tumor is highly **radiosensitive and chemosensitive**. The prognosis is excellent, with overall survival rates exceeding 90% for localized disease using a combination of surgery and chemotherapy (Vincristine, Dactinomycin). **High-Yield Clinical Pearls for NEET-PG:** * **Genetic Association:** Linked to the **WT1 gene** on chromosome **11p13**. * **Histology:** Classically shows a **triphasic pattern** (Blastemal, Stromal, and Epithelial cells). * **Metastasis:** The **lungs** are the most common site of distant hematogenous spread. * **Clinical Warning:** Avoid vigorous palpation of the abdomen in suspected cases to prevent accidental rupture of the tumor capsule and peritoneal seeding.

Question 1

A pediatrician discovers a large mass in the abdomen of a 3-year-old child. Ultrasound examination demonstrates that the mass appears to arise from the right kidney. Which of the following tumors is most likely present?

Accepted Answer

Nephroblastoma

Answer

Cortical adenoma

Answer

Hemangioma

Answer

Oncocytoma

Question 2

Which among the following is the most common thyroid malignancy in children?

Accepted Answer

Papillary carcinoma

Answer

Follicular carcinoma

Answer

Medullary carcinoma

Answer

Thyroid lymphoma

Question 3

A child presents with proptosis, multiple skeletal limb secondaries, and sutural separation. What is the most likely diagnosis?

Accepted Answer

Neuroblastoma

Answer

Medulloblastoma

Answer

Retinoblastoma

Answer

None of the above

Question 4

Which of the following malignancies is classified by the Chang staging system?

Accepted Answer

Medulloblastoma

Answer

Retinoblastoma

Answer

Rhabdomyosarcoma

Answer

Ewing's sarcoma

Question 5

Wilm's tumor is associated with all of the following conditions EXCEPT:

Accepted Answer

Bilateral polycystic kidney

Answer

Hemihypertrophy

Answer

Aniridia

Answer

Hypertension

Question 6

A 5-year-old child presents with a history of intermittent fever for the past 2 weeks, petechial spots all over the body, and increasing pallor for the past 1 month. Examination reveals splenomegaly 2 cm below the costal margin. What is the most likely diagnosis?

Accepted Answer

Acute leukemia

Answer

Idiopathic thrombocytopenic purpura

Answer

Hypersplenism

Answer

Aplastic anemia

Question 7

A child presents with a splenic mass and a mediastinal mass. The child appears pale, has red eyes, and suffers from recurrent infections. What is the most likely diagnosis?

Accepted Answer

Acute Lymphoblastic Leukemia

Answer

Chronic Myeloid Leukemia

Answer

Graft versus Host Disease

Answer

Pulmonary metastasis

Question 8

What is the second most common neoplasm seen in children?

Accepted Answer

Brain tumor

Answer

Lymphoma

Answer

Wilm's tumor

Answer

Neuroblastoma

Question 9

What is the treatment for refractory histiocytosis?

Accepted Answer

Cladribine

Answer

High-dose methotrexate

Answer

High-dose cytarabine

Answer

Fludarabine

Question 10

All of the following is true about Wilm's tumor except?

Accepted Answer

It is always unilateral

Answer

May present with an abdominal lump

Answer

It is the most common renal neoplasm in children

Answer

Responds well to chemotherapy

Oncology — MCQs

Oncology — MCQs

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