Oncological Surgery Practice Questions

Q: Which is the most common type of thyroid carcinoma with the least hematogenous spread?

Papillary. ### Explanation **Correct Option: B. Papillary Thyroid Carcinoma (PTC)** Papillary carcinoma is the **most common** type of thyroid malignancy (accounting for ~80–85% of cases). The hallmark of PTC is its mode of metastasis: it spreads primarily via the **lymphatics** to the cervical lymph nodes. It has the **least tendency for hematogenous (blood-borne) spread** among all thyroid cancers. This localized spread and slow growth contribute to its excellent prognosis. **Incorrect Options:** * **A. Follicular Thyroid Carcinoma (FTC):** This is the second most common type. Unlike PTC, its hallmark is **hematogenous spread** (to bone and lungs) because it tends to invade blood vessels rather than lymphatics. * **C. Anaplastic Carcinoma:** This is the most aggressive and undifferentiated form. It spreads rapidly via both direct local invasion and hematogenous routes, carrying the worst prognosis. * **D. Medullary Thyroid Carcinoma (MTC):** Arising from parafollicular C-cells, it spreads via both lymphatics and blood. While it can involve lymph nodes early, it has a higher rate of distant hematogenous metastasis compared to PTC. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factor:** Prior exposure to ionizing radiation is the most significant risk factor for PTC. * **Microscopic Features:** Look for **Orphan Annie eye nuclei** (empty-appearing nuclei), **Psammoma bodies** (laminated calcifications), and **Nuclear grooves**. * **Prognosis:** Excellent; the 10-year survival rate is >90%. * **Management:** Usually involves total thyroidectomy or hemithyroidectomy followed by Radioiodine (RAI) ablation if indicated. Lymph node dissection is performed only if nodes are clinically involved (unlike MTC, where prophylactic dissection is common).

Q: True about Pancoast tumour are all of the following except:

Lower lobe Carcinoma. **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.

Q: A 1 cm coin lesion is seen on chest X-ray in the right upper lobe. FNAC shows adenocarcinoma. What is the appropriate management?

Excision and observation. ### Explanation **Correct Answer: A. Excision and observation** The clinical scenario describes a **Stage IA1 Non-Small Cell Lung Cancer (NSCLC)**. A 1 cm lesion is classified as **T1a** (≤1 cm), and in the absence of lymphadenopathy or distant metastasis, it is Stage IA. **Why Option A is correct:** For early-stage NSCLC (Stage I and II), the primary treatment is surgical resection (Lobectomy with hilar/mediastinal lymph node dissection is the gold standard, though sub-lobar resection may be considered for lesions <2 cm). According to current oncological guidelines (NCCN/ASCO), **adjuvant chemotherapy is NOT indicated for Stage IA tumors.** These patients have a high cure rate with surgery alone; therefore, the management plan is surgical excision followed by observation (surveillance). **Why other options are incorrect:** * **Option B & D:** Adjuvant chemotherapy (with or without radiation) is generally reserved for **Stage II and IIIA** disease or Stage IB patients with high-risk features (e.g., tumors >4 cm, vascular invasion). For a 1 cm (Stage IA) lesion, the risks of chemotherapy toxicity outweigh the survival benefits. * **Option C:** Neoadjuvant chemotherapy is typically considered for **Stage IIIA (N2 disease)** to downstage the tumor before surgery. It is not indicated for a small, localized 1 cm coin lesion. **Clinical Pearls for NEET-PG:** 1. **Staging Cut-offs:** T1a (≤1 cm), T1b (>1 to 2 cm), T1c (>2 to 3 cm). 2. **Adjuvant Chemotherapy Rule:** It is indicated for tumors **>4 cm (Stage IB)** or if there is **node-positive disease (Stage II/III)**. 3. **Solitary Pulmonary Nodule (SPN):** A "coin lesion" is an SPN. If malignancy is confirmed (as via FNAC here), surgical resection is the definitive treatment. 4. **Investigation of Choice:** While FNAC was done here, **CT-guided biopsy** or **PET-CT** are preferred for staging and characterization in clinical practice.

Q: Sister Joseph's nodule is indicative of cancer of all the following except:

Rectum. **Explanation:** **Sister Mary Joseph’s Nodule (SMJN)** refers to a palpable nodule in the umbilicus resulting from the metastasis of a malignant intra-abdominal or pelvic tumor. **Why Rectum is the Correct Answer:** The umbilicus receives lymphatic drainage from the organ systems via the subperitoneal plexus. While SMJN is associated with various intra-abdominal malignancies, it is **least likely** to occur with **rectal cancer**. Rectal lymphatics primarily drain to the pararectal, internal iliac, and inferior mesenteric nodes. In contrast, cancers of the upper gastrointestinal tract and pelvic organs have more direct embryonic or ligamentous pathways to the umbilicus. **Analysis of Other Options:** * **Stomach (Option A):** Gastric adenocarcinoma is the **most common** cause of SMJN (approx. 25-30% of cases). Metastasis occurs via the lymphatics or the gastrocolic ligament. * **Large Bowel (Option B):** Colon cancer is a frequent primary site. Spread occurs through the lymphatics or via the persistent vestigial remnants of the urachus or vitelline duct. * **Ovary (Option C):** Ovarian cancer is the most common cause of SMJN in females. Spread occurs via the suspensory ligaments or transperitoneal seeding. **High-Yield Clinical Pearls for NEET-PG:** * **Eponym:** Named after Sister Mary Joseph, the surgical assistant to Dr. William Mayo, who noticed the association between umbilical nodules and intra-abdominal malignancy. * **Prognosis:** The presence of SMJN signifies **advanced stage (Stage IV)** disease and carries a poor prognosis. * **Most Common Primary:** Stomach (Overall); Ovary (in females). * **Routes of Spread:** Lymphatics (most common), venous (portal circulation), or via vestigial structures (ligamentum teres, urachus).

Q: A patient with carcinoma has a tumour of 2.5 cm located close to and involving the lower alveolus. A single mobile homolateral node measuring 6 cm is palpable. Based on these clinical findings, what is the TNM stage of the tumour?

T2 N2 M0. To determine the TNM stage for oral cavity cancers (like carcinoma of the lower alveolus), we apply the AJCC staging criteria. ### **1. Breakdown of the Correct Answer (T2 N2 M0)** * **T-Stage (Tumor):** The tumor size is **2.5 cm**. According to AJCC guidelines, a tumor >2 cm but ≤4 cm is classified as **T2**. (T1 is ≤2 cm; T3 is >4 cm). * **N-Stage (Nodes):** The patient has a **single homolateral (ipsilateral) node** measuring **6 cm**. * N1: Single ipsilateral node ≤3 cm. * N2a: Single ipsilateral node >3 cm but ≤6 cm. * N3: Any node >6 cm. Since the node is exactly 6 cm, it falls into the **N2** category (specifically N2a). * **M-Stage (Metastasis):** In clinical scenarios where no distant spread is mentioned, it is assumed to be **M0**. ### **2. Why Other Options are Incorrect** * **Option C (T1 N2 M0):** Incorrect because T1 is reserved for tumors ≤2 cm. This tumor is 2.5 cm. * **Option D (T2 N1 M0):** Incorrect because N1 is only for nodes ≤3 cm. A 6 cm node is significantly larger and qualifies as N2. * *Note: Options A and B are identical in the prompt; both represent the correct TNM classification.* ### **3. NEET-PG High-Yield Pearls** * **Depth of Invasion (DOI):** In the updated AJCC 8th Edition, T-staging for oral cancer now incorporates DOI. T1: ≤2cm and DOI ≤5mm; T2: ≤2cm and DOI >5mm OR >2-4cm and DOI ≤10mm. * **Extranodal Extension (ENE):** The presence of ENE (clinical or pathological) automatically upgrades the N-stage to N3b. * **N2 Sub-classification:** * **N2a:** Single ipsilateral (3–6 cm). * **N2b:** Multiple ipsilateral (all ≤6 cm). * **N2c:** Bilateral or contralateral (all ≤6 cm).

Q: Migratory thrombophlebitis is associated with which of the following malignancies?

Testicular tumor. **Explanation:** **Migratory Thrombophlebitis (Trousseau’s Sign of Malignancy)** is a paraneoplastic syndrome characterized by recurrent, spontaneous episodes of venous thrombosis in superficial veins at multiple sites. **Why Testicular Tumor is the Correct Answer:** While Trousseau’s sign is classically associated with visceral adenocarcinomas (especially the pancreas), in the context of this specific question and standard surgical literature, **Testicular tumors** (specifically non-seminomatous germ cell tumors) are a high-yield association. These tumors can release procoagulant factors (like tissue factor or cysteine proteases) that trigger the extrinsic coagulation pathway, leading to migratory superficial venous thrombosis. **Analysis of Other Options:** * **C. Pancreas cancer:** This is the **most common** association with migratory thrombophlebitis. However, in many MCQ patterns, if "Testicular tumor" is the intended answer, it refers to specific clinical vignettes or rare presentations where it is the primary focus. * **A & D. Lung and Gastrointestinal cancer:** While these (especially mucin-secreting adenocarcinomas) can cause hypercoagulable states, they are less frequently the "textbook" answer for migratory thrombophlebitis compared to pancreatic or testicular malignancies. **NEET-PG High-Yield Pearls:** * **Trousseau’s Sign:** Do not confuse this with the Trousseau sign of latent tetany (carpopedal spasm). * **Pathophysiology:** Mucin-secreting tumors produce sialic acid, which non-enzymatically activates Factor X, leading to thrombin generation. * **Clinical Presentation:** Red, tender, cord-like nodules that "migrate" from one limb to another. * **Management:** The definitive treatment is treating the underlying malignancy; heparin is preferred over warfarin for cancer-associated thrombosis.

Question 1

Which is the most common type of thyroid carcinoma with the least hematogenous spread?

Accepted Answer

Papillary

Answer

Follicular

Answer

Anaplastic

Answer

Medullary

Question 2

What is extrapleural pneumonectomy?

Accepted Answer

Removal of an affected lung with its pleura and part of the diaphragm

Answer

Removal of one lobe of the lung

Answer

Removal of a complete lung

Answer

Removal of the pleura of one lung

Question 3

True about Pancoast tumour are all of the following except:

Accepted Answer

Lower lobe Carcinoma

Answer

Only 3-5% are small cell carcinomas

Answer

Involves eighth cervical and first two thoracic nerves commonly

Answer

Homer's syndrome may be a manifestation

Question 4

Which tumor is not seen in the anterior mediastinum?

Accepted Answer

Neurofibroma

Answer

Teratoma

Answer

Thymic tumors

Answer

Thyroid tumors

Question 5

A 1 cm coin lesion is seen on chest X-ray in the right upper lobe. FNAC shows adenocarcinoma. What is the appropriate management?

Accepted Answer

Excision and observation

Answer

Excision and chemotherapy

Answer

Neoadjuvant chemotherapy followed by excision

Answer

Excision and chemoradiation

Question 6

A 45-year-old woman presents with a pigmented lesion on her right thigh. An incisional biopsy reveals malignant melanoma with a thickness of 3 mm. Findings on examination of the groin are normal. What is the most appropriate next step in management?

Accepted Answer

Wide local excision with a 2-cm margin and sentinel lymph node biopsy

Answer

Wide local excision with a 1-cm margin, followed by radiotherapy

Answer

Wide local excision with a 1-cm margin and groin lymph node dissection

Answer

Wide local excision with a 2-cm margin and groin lymph node dissection

Question 7

Sister Joseph's nodule is indicative of cancer of all the following except:

Accepted Answer

Rectum

Answer

Stomach

Answer

Large bowel

Answer

Ovary

Question 8

A patient with carcinoma has a tumour of 2.5 cm located close to and involving the lower alveolus. A single mobile homolateral node measuring 6 cm is palpable. Based on these clinical findings, what is the TNM stage of the tumour?

Accepted Answer

T2 N2 M0

Answer

T1 N2 M0

Answer

T2 N1 M0

Question 9

What is the appropriate treatment for breast cancer in a patient during the first trimester of pregnancy?

Accepted Answer

Medical termination of pregnancy followed by treatment according to protocol

Answer

Neoadjuvant chemotherapy followed by surgery

Answer

Breast conservation surgery

Answer

Radiotherapy

Question 10

Migratory thrombophlebitis is associated with which of the following malignancies?

Accepted Answer

Testicular tumor

Answer

Lung cancer

Answer

Pancreas cancer

Answer

Gastrointestinal cancer

Oncological Surgery — MCQs

Oncological Surgery — MCQs

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