Oncological Surgery Practice Questions

Q: Tumours of anterior mediastinum include the following except:

Schwannoma. ***Schwannoma*** - **Schwannomas** (neurilemmomas) are typically found in the **posterior mediastinum**, arising from **peripheral nerves** or nerve roots. - They are usually benign and grow slowly, presenting with symptoms due to compression of surrounding structures. *Lymphoma* - **Lymphoma** is a common tumor of the **anterior mediastinum**, often presenting as an **anterior mediastinal mass**. - Both Hodgkin and non-Hodgkin lymphomas can involve mediastinal lymph nodes. *Germ cell tumour* - **Germ cell tumors**, including **teratomas** and **seminomas**, frequently occur in the **anterior mediastinum**. - They arise from ectopic germ cell rests that migrate aberrantly during embryonic development. *Thymoma* - **Thymomas** are the most common primary tumor of the **anterior mediastinum**, originating from the **thymus gland**. - They are often associated with **myasthenia gravis** and other paraneoplastic syndromes.

Q: A 45-year-old female is admitted to the hospital after worsening headaches for the past month. She has noticed that the headaches are usually generalized, and frequently occur during sleep. She does not have a history of migraines or other types of headaches. Her past medical history is significant for breast cancer, which was diagnosed a year ago and treated with mastectomy. She recovered fully and returned to work shortly thereafter. CT scan of the brain now shows a solitary cortical 5cm mass surrounded by edema in the left hemisphere of the brain at the grey-white matter junction. She is admitted to the hospital for further management. What is the most appropriate next step in management for this patient?

Surgical resection of the mass. ***Surgical resection of the mass*** - The presence of a **solitary cortical mass** with significant edema [1], [2] in a patient with a history of **breast cancer** [3] strongly suggests a resectable brain metastasis that is causing symptomatic cerebral edema. - **Surgical resection** offers the best chance for immediate symptom relief, pathological diagnosis, and improved prognosis in cases conducive to complete removal [1]. *Seizure prophylaxis and palliative pain therapy* - While seizure prophylaxis might be considered due to the mass effect, it is a **supportive measure** and does not address the underlying cause of the symptoms (the mass) that can be surgically removed. - **Palliative pain therapy** would also be a supportive measure only and would not achieve a definitive diagnosis or treatment of the mass. *Chemotherapy* - **Chemotherapy** for brain metastases often has limited efficacy due to the **blood-brain barrier** and is generally reserved for systemic disease or multiple, unresectable brain lesions. - Prior to initiating chemotherapy, a definitive **histopathologic diagnosis** is usually required, and surgical resection would provide tissue for this purpose. *Irradiation to the brain mass* - While **brain irradiation** (like stereotactic radiosurgery or whole-brain radiation therapy) is an option for brain metastases, especially for multiple or unresectable lesions, **surgical resection** is generally preferred for a solitary, accessible metastasis with significant mass effect. - Irradiation alone might not provide the same immediate symptomatic relief from brain edema as surgical decompression [2].

Q: What is the most common tumor of the mediastinum?

Neurogenic tumor. ***Neurogenic tumor*** - **Neurogenic tumors** are the **most common primary tumors of the mediastinum** overall, accounting for approximately **35-40%** of all mediastinal masses. - They are the most common tumors of the **posterior mediastinum** and arise from nerve sheaths (e.g., **schwannomas, neurofibromas**) or sympathetic ganglia. - These tumors occur across all age groups, with higher prevalence when including both pediatric and adult populations. *Thymoma* - **Thymomas** are the most common primary tumor of the **anterior mediastinum** in adults, accounting for about **40-50%** of anterior mediastinal masses. - However, they represent only about **20-25%** of all mediastinal tumors overall. - Often associated with paraneoplastic syndromes like **myasthenia gravis** (30-50% of cases). *Lymphoma* - **Lymphoma** is a common mediastinal tumor, particularly **Hodgkin lymphoma** in young adults, accounting for approximately **15-20%** of mediastinal masses. - It often presents with bulky mediastinal masses and symptoms like **dyspnea, cough, or superior vena cava syndrome**. - While very common, it ranks second or third overall after neurogenic tumors. *Neuroblastic tumor* - **Neuroblastic tumors** (e.g., neuroblastoma, ganglioneuroblastoma) are a subset of neurogenic tumors more common in **children**. - They arise from the sympathetic nervous system and typically occur in the posterior mediastinum. - While important in pediatric populations, they are less common than all neurogenic tumors combined.

Q: Which of the following tumours is radiosensitive?

Ewing's sarcoma. ***Ewing's sarcoma*** - **Ewing's sarcoma** is highly radiosensitive, meaning radiation therapy is an effective treatment modality, often used as a primary or adjuvant therapy. - Its high responsiveness to radiation helps control local disease and improve patient outcomes, especially when combined with chemotherapy. *Osteosarcoma* - **Osteosarcoma** is generally considered radioresistant, meaning it responds poorly to radiation therapy. - While radiation may be used in specific palliative settings, it is not a primary curative treatment for osteosarcoma, which primarily relies on surgery and chemotherapy. *Hepatocellular carcinoma* - **Hepatocellular carcinoma (HCC)** is largely radioresistant, and external beam radiation therapy has limited efficacy as a stand-alone treatment. - While certain advanced techniques like stereotactic body radiation therapy (SBRT) can be used for localized control, it is not considered broadly radiosensitive. *Malignant melanoma* - **Malignant melanoma** is historically considered highly radioresistant, requiring very high doses of radiation for any significant tumor control. - In recent years, high-dose, hypofractionated radiation therapy has shown some promise for local control, but it is not a universally radiosensitive tumor.

Q: A 48-year old woman comes with bilateral progressive weakness of both lower limbs, spasticity and mild impairment of respiratory movements. MRI shows an intradural mid-dorsal midline enhancing lesion. What is the diagnosis?

Meningioma. ***Meningioma*** - This is the most common **intradural extramedullary spinal tumor** in adults, typically presenting with progressive **myelopathy** due to spinal cord compression. - The MRI finding of an **intradural mid-dorsal midline enhancing lesion** is highly suggestive, as meningiomas are often well-circumscribed and enhance intensely. *Dermoid cyst* - These are **congenital lesions** that typically present in childhood or young adulthood and can be associated with **spinal dysraphism**. - While they are intradural, they are less common than meningiomas in this age group and often exhibit different imaging characteristics (e.g., lipid components) and less uniform enhancement. *Intradural lipoma* - **Spinal lipomas** are uncommon and usually associated with **congenital spinal anomalies** or can occur as a primary tumor. - They are characterized by **fat signal intensity** on MRI and do not typically show significant enhancement, differentiating them from the described lesion. *Neuroenteric cyst* - These are rare **congenital cysts** that can be intradural, often linked to **vertebral anomalies**, and may contain mucinous fluid. - While they can be intradural, they are much less common than meningiomas and typically do not show the same pattern of strong, uniform enhancement on MRI.

Q: An elderly male presents with T3N0 laryngeal carcinoma. What would be the management?

Concurrent chemoradiotherapy. ***Concurrent chemoradiotherapy*** - For **T3 laryngeal carcinoma (moderately advanced)**, concurrent chemoradiotherapy is the preferred management to preserve the larynx while offering a good chance of cure. - This approach combines **radiation** with **chemotherapy** given at the same time to enhance the effect of radiation and improve local control. *Neoadjuvant chemotherapy followed by radiotherapy* - **Neoadjuvant chemotherapy** is typically reserved for more advanced (T4) or unresectable tumors to reduce tumor burden before definitive local treatment. - For T3 disease, concurrent chemoradiotherapy is generally preferred for organ preservation over sequential approaches. *Radical radiotherapy followed by chemotherapy* - Sequential treatment with **radiotherapy first** followed by chemotherapy is less effective than concurrent chemoradiotherapy for organ preservation and disease control in T3 laryngeal carcinoma. - This approach may be considered in specific cases, but it's not the primary recommendation for T3 laryngeal cancer. *Radical radiotherapy without chemotherapy* - While **radical radiotherapy alone** can be used for selected early-stage (T1-T2) laryngeal cancers, it is generally insufficient for T3 disease. - The addition of chemotherapy concurrently significantly improves outcomes for T3 larynx cancer compared to radiotherapy alone, by addressing microscopic disease and sensitizing tumor cells to radiation.

Q: A middle-aged man presented with a swelling over the neck since childhood. The swelling is irregular and involves large nerves and their branches. Most probable diagnosis is:

Plexiform neurofibroma. ***Plexiform neurofibroma*** - This condition presents as an **irregular swelling** evident since childhood, which is characteristic of the slow growth associated with **plexiform neurofibromas**. - Its involvement of **large nerves and their branches** is a hallmark feature, distinguishing it from other neck masses. *Toxic nodular goitre* - This would present primarily as a **thyroid swelling** and is typically associated with symptoms of **hyperthyroidism**, which are not mentioned. - It does not involve **peripheral nerves** in the manner described. *Lymphangioma* - Lymphangiomas are **benign lymphatic malformations** that typically present as soft, compressible masses. - While they can occur in the neck and be present from childhood, they do not specifically involve or originate from **nerve branches**. *Vasculitis* - Vasculitis is an **inflammation of blood vessels**, which can cause a variety of symptoms including pain, skin lesions, and organ dysfunction. - It does not present as a localized, irregular neck swelling involving **nerve branches** with a history since childhood.

Q: A 70-year-old man with a history of smoking presents with progressive weight loss and fatigue. A CT scan reveals a resectable mass in the left hilum with no evidence of distant metastases. What combination of therapies would offer the best chance of survival?

Surgery followed by chemotherapy. ***Surgery followed by chemotherapy*** - For **resectable non-small cell lung cancer (NSCLC)** without distant metastases, surgical resection is the cornerstone of curative therapy. - **Adjuvant chemotherapy** is recommended post-surgery to eradicate microscopic residual disease and improve overall survival. *Chemotherapy and radiation therapy* - This combination is typically offered for **unresectable or locally advanced NSCLC**, or for patients who are not surgical candidates. - While effective in controlling local disease, it does not offer the same **curative potential** as surgical removal for resectable tumors. *Immunotherapy only* - Immunotherapy is a significant advance in lung cancer treatment, particularly for **advanced or metastatic disease**, or as an adjuvant/neoadjuvant therapy in specific settings. - However, for **resectable early-stage NSCLC**, it is not considered the primary monotherapy and would likely lead to an inferior outcome compared to surgery. *Observation with routine imaging* - This approach is appropriate for **benign lung nodules**, very small tumors in patients with limited life expectancy, or those with significant comorbidities precluding active treatment. - For a **resectable mass** in a 70-year-old with progressive symptoms, observation would lead to disease progression and a lost opportunity for cure.

Q: In a patient with suspected malignant melanoma of the leg, what is the most appropriate next step to confirm the diagnosis and plan treatment?

Total excisional biopsy with narrow margins. ***Total excisional biopsy with narrow margins*** - A **total excisional biopsy** allows for complete histological evaluation of the lesion, including assessment of **tumor thickness (Breslow depth)**, which is crucial for staging and treatment planning in melanoma. - Using **narrow margins** (1-3 mm) minimizes disruption of surrounding tissue, preserving it for definitive wide local excision once the diagnosis is confirmed and staged. *Punch biopsy of the lesion* - A **punch biopsy** provides only a small sample of the lesion, which may not be representative of the entire tumor and can underestimate the Breslow depth, leading to inaccurate staging. - It involves sectioning the lesion, which can potentially interfere with the accurate measurement of tumor thickness if the deepest part of the tumor is missed. *Wide local excision as initial treatment* - Performing a **wide local excision** before confirming the diagnosis and staging is inappropriate. - This aggressive procedure is only indicated after a definitive diagnosis of melanoma and determination of appropriate margins based on Breslow depth to avoid unnecessary tissue removal or inadequate excision. *Immediate lymph node dissection* - **Immediate lymph node dissection** is an extensive surgical procedure with significant morbidity and is not indicated as an initial step. - It is reserved for cases where there is evidence of regional lymph node involvement, either clinically or confirmed by **sentinel lymph node biopsy**, after the primary tumor has been diagnosed and staged.

Question 1

Tumours of anterior mediastinum include the following except:

Accepted Answer

Schwannoma

Answer

Lymphoma

Answer

Germ cell tumour

Answer

Thymoma

Question 2

A 35-year-old woman with newly diagnosed metastatic breast cancer (liver and bone metastases) presents with a 6 cm primary tumor, skin involvement, and 4 palpable axillary nodes. Her oncologist recommends neoadjuvant chemotherapy, but she requests immediate surgery. Evaluate the most appropriate recommendation considering oncologic principles, patient preference, and evidence-based care.

Accepted Answer

Recommend systemic chemotherapy first and explain that surgery is not indicated initially in metastatic disease

Answer

Compromise with lumpectomy and sentinel node biopsy

Answer

Proceed with immediate mastectomy and axillary dissection per patient request

Answer

Refuse surgery and insist on systemic therapy first

Question 3

A 45-year-old female is admitted to the hospital after worsening headaches for the past month. She has noticed that the headaches are usually generalized, and frequently occur during sleep. She does not have a history of migraines or other types of headaches. Her past medical history is significant for breast cancer, which was diagnosed a year ago and treated with mastectomy. She recovered fully and returned to work shortly thereafter. CT scan of the brain now shows a solitary cortical 5cm mass surrounded by edema in the left hemisphere of the brain at the grey-white matter junction. She is admitted to the hospital for further management. What is the most appropriate next step in management for this patient?

Accepted Answer

Surgical resection of the mass

Answer

Seizure prophylaxis and palliative pain therapy

Answer

Chemotherapy

Answer

Irradiation to the brain mass

Question 4

What is the most common tumor of the mediastinum?

Accepted Answer

Neurogenic tumor

Answer

Thymoma

Answer

Lymphoma

Answer

Neuroblastic tumor

Question 5

Which of the following tumours is radiosensitive?

Accepted Answer

Ewing's sarcoma

Answer

Osteosarcoma

Answer

Hepatocellular carcinoma

Answer

Malignant melanoma

Question 6

A 48-year old woman comes with bilateral progressive weakness of both lower limbs, spasticity and mild impairment of respiratory movements. MRI shows an intradural mid-dorsal midline enhancing lesion. What is the diagnosis?

Accepted Answer

Meningioma

Answer

Dermoid cyst

Answer

Intradural lipoma

Answer

Neuroenteric cyst

Question 7

An elderly male presents with T3N0 laryngeal carcinoma. What would be the management?

Accepted Answer

Concurrent chemoradiotherapy

Answer

Neoadjuvant chemotherapy followed by radiotherapy

Answer

Radical radiotherapy followed by chemotherapy

Answer

Radical radiotherapy without chemotherapy

Question 8

A middle-aged man presented with a swelling over the neck since childhood. The swelling is irregular and involves large nerves and their branches. Most probable diagnosis is:

Accepted Answer

Plexiform neurofibroma

Answer

Toxic nodular goitre

Answer

Lymphangioma

Answer

Vasculitis

Question 9

A 70-year-old man with a history of smoking presents with progressive weight loss and fatigue. A CT scan reveals a resectable mass in the left hilum with no evidence of distant metastases. What combination of therapies would offer the best chance of survival?

Accepted Answer

Surgery followed by chemotherapy

Answer

Chemotherapy and radiation therapy

Answer

Immunotherapy only

Answer

Observation with routine imaging

Question 10

In a patient with suspected malignant melanoma of the leg, what is the most appropriate next step to confirm the diagnosis and plan treatment?

Accepted Answer

Total excisional biopsy with narrow margins

Answer

Punch biopsy of the lesion

Answer

Wide local excision as initial treatment

Answer

Immediate lymph node dissection

Oncological Surgery — MCQs

Oncological Surgery — MCQs

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