Oncological Surgery Practice Questions

Q: A 56-year-old man, who underwent thyroidectomy four years ago for thyroid cancer, presents with a single 4 cm malignant lesion in the upper lobe of the left lung. Endobronchial biopsy confirmed malignancy but could not determine the organ of origin. There is no other evidence of disease, and the patient is in excellent health. What is the recommended management?

Attempted curative lung resection. ### Explanation The correct management for this patient is **Attempted curative lung resection (Option C)**. This decision is guided by the principles of managing a **solitary pulmonary metastasis** (metastasectomy). #### Why Option C is Correct In patients with a history of malignancy who present with a solitary lung lesion, surgical resection is indicated if the following criteria are met: 1. The primary tumor is controlled (thyroidectomy was done 4 years ago). 2. There are no extrapulmonary metastases. 3. The patient is medically fit for surgery (excellent health). 4. The lesion is technically resectable. In this case, even if the lesion is a primary lung cancer or a metastasis from the previous thyroid cancer, surgical resection offers the best chance for a **long-term cure** or significant survival benefit. #### Why Other Options are Incorrect * **Options A & B:** Radiotherapy and chemotherapy are generally considered palliative or adjuvant treatments. In the presence of a single, resectable lesion and no systemic spread, local definitive surgery is superior to systemic or radiation therapy. * **Option D:** Neck exploration is not indicated because there is no clinical or radiological evidence of local recurrence in the neck. The priority is addressing the potentially life-threatening lung mass. #### High-Yield Clinical Pearls for NEET-PG * **Metastasectomy Criteria:** Always look for "controlled primary," "no other systemic spread," and "fitness for surgery." * **Thyroid Cancer Spread:** While papillary thyroid cancer spreads via lymphatics, follicular thyroid cancer spreads hematogenously, often to the lungs and bones. * **Solitary Pulmonary Nodule (SPN):** In a patient with a prior history of malignancy, a new SPN has a >70% probability of being a metastasis or a new primary lung cancer, both of which often require surgical intervention.

Q: Which one of the following is the treatment of choice for a desmoid tumor?

Surgery. **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 and infiltration into surrounding structures. **Why Surgery is the Correct Answer:** Historically and for NEET-PG purposes, **wide local excision with negative margins (R0 resection)** is considered the primary treatment of choice for symptomatic or enlarging desmoid tumors. The goal is to remove the tumor completely to prevent local recurrence. While "active observation" is gaining traction for asymptomatic cases, surgery remains the definitive intervention when treatment is indicated. **Why Other Options are Incorrect:** * **Radiotherapy (B):** Generally reserved as an adjuvant therapy for recurrent cases or when surgical margins are positive (R1/R2). It is rarely used as a primary standalone treatment due to the risk of radiation-induced sarcomas. * **Chemotherapy (C):** Systemic therapy (e.g., NSAIDs, Tamoxifen, or low-dose Methotrexate) is used for unresectable, multi-focal, or life-threatening tumors (especially intra-abdominal cases), but it is not the first-line "treatment of choice." * **Radiotherapy + Chemotherapy (D):** This combination is not standard protocol for desmoid tumors, as these tumors are not traditionally "chemosensitive" or "radiosensitive" enough to justify combined toxicity over surgical intervention. **Clinical Pearls for NEET-PG:** * **Association:** Strongly associated with **Gardner Syndrome** (a variant of FAP). * **Location:** Most common site is the **rectus abdominis muscle** in postpartum women. * **Pathology:** Characterized by the proliferation of fibroblasts and an abundance of collagen; they often stain positive for **nuclear beta-catenin**. * **Recurrence:** Despite wide excision, recurrence rates remain high (up to 20-30%).

Q: Glomus tumor is typically seen in which location?

Finger. **Explanation:** A **Glomus tumor** (also known as a glomangioma) is a rare, benign vascular neoplasm arising from the **glomus body**. The glomus body is a specialized arteriovenous anastomosis involved in thermoregulation, primarily located in the stratum reticulare of the dermis. **Why the Finger is correct:** The highest concentration of glomus bodies is found in the **subungual region (under the nail bed) of the fingers**. Clinically, these tumors present with a classic triad: 1. **Exquisite localized tenderness** (Point tenderness). 2. **Severe paroxysmal pain** (often triggered by cold). 3. **Sensitivity to cold.** On examination, a small, bluish-red discoloration may be visible under the nail. **Why other options are incorrect:** * **Liver:** Primary vascular tumors of the liver are typically Hemangiomas or Angiosarcomas, not glomus tumors. * **Adrenals:** The adrenal medulla is a common site for Pheochromocytomas (paragangliomas), which are neuroendocrine tumors, distinct from the vascular glomus tumor. * **Pituitary:** Tumors here are usually Adenomas. While "Glomus Jugulare" tumors occur in the head/neck, they are paragangliomas and not the classic glomus tumor found in the extremities. **Clinical Pearls for NEET-PG:** * **Hildreth’s Test:** Relief of pain upon application of a tourniquet at the base of the finger (Positive test). * **Love’s Pinhead Test:** Localizing the pain by pressing the head of a pin over the suspected area. * **Transillumination:** Helps in visualizing the lesion. * **Treatment:** Simple surgical excision of the tumor is curative.

Q: Malignant change in a retroperitoneal lipoma may present with which of the following?

All of the above. **Explanation:** Retroperitoneal liposarcomas (the malignant transformation of lipomatous tissue) are the most common primary retroperitoneal sarcomas. Their clinical presentation is dictated by their anatomical location and their tendency to grow to a massive size before detection. 1. **Asymptomatic presentation:** Because the retroperitoneum is a large, compliant space, these tumors often grow silently. They are frequently discovered incidentally during imaging for unrelated complaints. 2. **Abdominal pain:** As the tumor enlarges, it stretches the peritoneum or exerts pressure on adjacent viscera and nerves, leading to vague abdominal discomfort, a sense of fullness, or chronic pain. 3. **Renal failure:** Due to their retroperitoneal location, these tumors can compress the ureters (obstructive uropathy) or the renal vasculature. Bilateral involvement or compression of a solitary functioning kidney can lead to post-renal azotemia and renal failure. Since the tumor can manifest in any of these ways depending on its size and local invasion, **"All of the above"** is the correct choice. **High-Yield Facts for NEET-PG:** * **Most common subtype:** Well-differentiated liposarcoma is the most frequent, though dedifferentiated subtypes have a poorer prognosis. * **Imaging of choice:** Contrast-Enhanced CT (CECT) is the gold standard for assessing size, fat content, and anatomical relationships. * **Management:** Wide surgical excision (often involving "compartmental resection" of adjacent organs like the kidney or colon) is the primary treatment. * **Recurrence:** These tumors have a very high rate of local recurrence, even after seemingly complete surgical resection.

Q: Symptoms from a retroperitoneal sarcoma are usually produced by which of the following mechanisms?

Compression of adjacent tissues. **Explanation:** **Why Option B is Correct:** Retroperitoneal sarcomas (RPS) are typically slow-growing tumors that arise in the expansive, compliant space of the retroperitoneum. Because this space can accommodate significant growth before vital structures are compromised, these tumors often reach a massive size (frequently >10 cm) before becoming symptomatic. The most common clinical presentation is a **vague abdominal pain or a palpable mass** caused by the **compression and displacement** of adjacent organs (such as the kidneys, ureters, or bowel) rather than direct invasion. **Why Other Options are Incorrect:** * **Option A:** While spontaneous hemorrhage into a large sarcoma can occur, it is a rare complication and not the usual mechanism for initial symptom production. * **Option C:** Although sarcomas can be locally aggressive, they characteristically tend to **push and displace** adjacent organs rather than invade them early in the disease course. This "pseudocapsule" often makes surgical planes identifiable, though true invasion can occur in high-grade variants. * **Option D:** Sarcomas are mesenchymal tumors that characteristically spread via the **hematogenous route** (most commonly to the lungs). Lymph node metastasis is rare (seen in <5% of cases), unlike carcinomas. **NEET-PG High-Yield Pearls:** * **Most common histological type:** Liposarcoma (specifically well-differentiated or dedifferentiated), followed by Leiomyosarcoma. * **Gold Standard Investigation:** Contrast-Enhanced CT (CECT) of the abdomen and pelvis. * **Biopsy Protocol:** If required, a **Core Needle Biopsy** (percutaneous) is preferred. Avoid transperitoneal biopsy to prevent tumor seeding. * **Treatment of Choice:** Radical surgical resection with negative margins (R0 resection). This often requires en-bloc resection of adjacent organs (e.g., kidney or colon) even if not directly invaded.

Q: What is the most common location of spinal tumors?

Extradural. **Explanation:** Spinal tumors are anatomically classified based on their relationship to the spinal cord and the dura mater. **1. Why Extradural is correct:** Extradural tumors are the **most common** type of spinal tumors, accounting for approximately **55-60%** of all spinal neoplasms. The primary reason for this high prevalence is that this space includes the vertebral column. Most extradural tumors are **metastatic** (secondary) lesions, commonly originating from primary cancers of the breast, lung, prostate, or kidney. Among primary extradural tumors, chordomas and osteosarcomas are notable examples. **2. Why other options are incorrect:** * **Intradural Extramedullary (Option B):** These occur within the dura but outside the spinal cord. They account for about **30-35%** of spinal tumors. The most common types are nerve sheath tumors (Schwannomas, Neurofibromas) and Meningiomas. * **Intramedullary (Option A):** These are the **least common** (~5-10%) and occur within the substance of the spinal cord itself. The most common types in adults are Ependymomas, followed by Astrocytomas. * **Equally Distributed (Option D):** This is incorrect as there is a clear hierarchical frequency: Extradural > Intradural Extramedullary > Intramedullary. **Clinical Pearls for NEET-PG:** * **Most common primary spinal tumor:** Nerve sheath tumors (Schwannoma). * **Most common intramedullary tumor in adults:** Ependymoma. * **Most common intramedullary tumor in children:** Astrocytoma. * **Red Flag:** New-onset back pain in an elderly patient with a history of malignancy should always be investigated for extradural metastasis. * **Imaging Gold Standard:** MRI with contrast is the investigation of choice for all spinal tumors.

Q: Surgical treatment of anal canal carcinoma is largely replaced by what?

Nigro protocol. **Explanation:** Historically, the standard treatment for anal canal carcinoma (specifically Squamous Cell Carcinoma) was Abdominoperineal Resection (APR), which required a permanent colostomy. This has been largely replaced by the **Nigro Protocol**, which prioritizes organ preservation. **1. Why Nigro Protocol is Correct:** The Nigro Protocol is a definitive **chemoradiotherapy (CRT)** regimen consisting of 5-Fluorouracil (5-FU), Mitomycin-C, and external beam radiation. It achieves high rates of complete clinical remission (80-90%) while preserving the anal sphincter. Surgery is now reserved only for "salvage" (residual or recurrent disease). **2. Analysis of Incorrect Options:** * **UW Protocol:** Refers to the University of Wisconsin solution used for organ preservation during transplantation, not oncology. * **Mootz Protocol:** This is not a recognized standard oncological treatment for anal cancer. * **Williams Protocol:** While there are various "Williams" techniques in surgery (e.g., for bladder exstrophy), it is not a standard protocol for anal canal carcinoma. **Clinical Pearls for NEET-PG:** * **Anatomical Landmark:** The Nigro protocol is the gold standard for tumors arising **below** the pectinate line (Squamous Cell Carcinoma). * **Adenocarcinoma exception:** If the pathology is Adenocarcinoma (usually arising from the upper anal canal), the treatment follows rectal cancer guidelines (Surgery/TME). * **Staging:** MRI of the pelvis and PET-CT are the preferred modalities for staging and monitoring response. * **Salvage Surgery:** If the Nigro protocol fails, the procedure of choice is **Abdominoperineal Resection (APR)**.

Question 1

All of the following are true about oncological emergencies except?

Accepted Answer

Tumor lysis syndrome is characterized by hyperuricemia, hyperkalemia, and hypophosphatemia.

Answer

PTH-related peptide is responsible for hypercalcemia of malignancy.

Answer

Zoledronic acid is the drug of choice for hypercalcemia of malignancy.

Answer

Most cases of typhlitis resolve with medical therapy alone.

Question 2

A 56-year-old man, who underwent thyroidectomy four years ago for thyroid cancer, presents with a single 4 cm malignant lesion in the upper lobe of the left lung. Endobronchial biopsy confirmed malignancy but could not determine the organ of origin. There is no other evidence of disease, and the patient is in excellent health. What is the recommended management?

Accepted Answer

Attempted curative lung resection

Answer

Radiotherapy

Answer

Combination chemotherapy

Answer

Exploration of the neck for thyroid recurrence

Question 3

Which one of the following is the treatment of choice for a desmoid tumor?

Accepted Answer

Surgery

Answer

Radiotherapy

Answer

Chemotherapy

Answer

Radiotherapy + Chemotherapy

Question 4

What is the diagnostic method of choice for a mediastinal mass suspected to be thymoma?

Accepted Answer

Thoracotomy and biopsy

Answer

Fine Needle Aspiration Cytology (FNAC)

Answer

Chest CT scan

Answer

Somatostatin receptor imaging

Question 5

Glomus tumor is typically seen in which location?

Accepted Answer

Finger

Answer

Liver

Answer

Adrenals

Answer

Pituitary

Question 6

Malignant change in a retroperitoneal lipoma may present with which of the following?

Accepted Answer

All of the above

Answer

Asymptomatic presentation

Answer

Renal failure

Answer

Abdominal pain

Question 7

Symptoms from a retroperitoneal sarcoma are usually produced by which of the following mechanisms?

Accepted Answer

Compression of adjacent tissues

Answer

Bleeding into the tumor mass

Answer

Invasion of retroperitoneal organs

Answer

Metastases to retroperitoneal lymph nodes

Question 8

What is the most common location of spinal tumors?

Accepted Answer

Extradural

Answer

Intramedullary

Answer

Intradural extramedullary

Answer

Equally distributed

Question 9

A 35-year-old female is diagnosed with ductal carcinoma in situ of the breast. What is the best possible management?

Accepted Answer

Breast-conservative surgery

Answer

Simple mastectomy

Answer

Modified radical mastectomy

Answer

Radical mastectomy

Question 10

Surgical treatment of anal canal carcinoma is largely replaced by what?

Accepted Answer

Nigro protocol

Answer

UW protocol

Answer

Mootz protocol

Answer

Williams protocol

Oncological Surgery — MCQs

Oncological Surgery — MCQs

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