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Q1.

A 58 year women was referred to the gastroenterology clinic with a history of weight loss. Clinical examination including a breast and rectal examination was normal. A CT scan of the chest, abdomen and pelvis revealed enlarged right axillary lymph nodes only. Excision biopsy of the lymph node revealed adenocarcinoma. The case is being discussed in the cancer MDT. What is the most appropriate next step?

a. Mammogram

b. Tumour markers

c. PET scan

d. Oncology referral

e. Colonoscopy

Answer: a

These patients with axillary lymph node metastasis of adenocarcinoma should undergo mammography or breast MRI. Immunohistology for hormone status and c-erb2 should also be checked. These patients with compatible immunohistology (even in the absence of a breast primary) should be treated as breast cancer with lymph node involvement (stage II)

This is a cancer with unknown primary (CUP). The median survival of patients with the CUP syndrome is 3 to 6 months. However, certain subgroups of CUP have a good prognosis. Axillary lymph node metastasis of adenocarcinoma in a woman is a CUP with good prognosis.

Q2.

A 50 year old man with PSC presented with obstructive jaundice. A CT scan raised the possibility of cholangiocarcinoma. The following are true except:

a. ERCP and brush cytology usually yield the diagnosis

b. PSC is the commonest predisposing factor for cholangiocarcinoma in the western world.

c. The risk of developing cholangiocarcinoma is not associated with the duration of PSC.

d. Cholangiocarcinoma is often associated with intermittent rather than steadily progressive jaundice.

e. PET may be used is in screening patients with PSC for the presence of cholangiocarcinoma.

Answer: a

Tissue diagnosis of cholangiocarcinoma is difficult because it is highly desmoplastic tumour composed of a few malignant cholangiocytes within excessive fibrous tissue. Thus cytology is positive in only 1/3rd of cases.

Q3.

A 70 year old man presents with painless obstructive jaundice. A CT scan is suspicious for tumour involving common hepatic duct bifurcation (Klatskin tumour). The following statements are true except:

a. A raised Ca19-9 is diagnostic

b. Distant metastases are distinctly uncommon in cholangiocarcinoma.

c. Majority of cholangiocarcinoma are adenocarcinoma

d. Laparoscopy should be standard before resection

e. Biliary stents are often placed prior to surgery

Answer: a

A raised Ca19-9 is suggestive but not diagnostic. Laparoscopy will identify 25-30% of patients as unresectable who were thought to be operable before laparoscopy. Therefore laparoscopy should be standard before operation.

Many surgeons proceed directly to laparotomy without preoperative biliary drainage. On the other hand, there is often uncertainty as to resectability as well as the timetable of surgical evaluation and operative management in patients presenting with jaundice. As a practical issue, stents are often placed to alleviate jaundice while these issues are being settled.

Q4.

A 75 year old man presented with bleeding PR. A colonoscopy revealed a rectal adenocarcinoma at 10 cms from the dentate line. All the following tests are indicated except:

a. Staging CT scan

b. MRI pelvis for local staging (nodes and depth of invasion)

c. EUS rectum can also be used for local staging and is cheaper than MRI

d. CEA

e. All of the above

Q5.

A 55 year old man is found to have isolated liver metastases at the time of primary surgery for colon cancer. Choose the most appropriate answer?

a. The liver metastases should be resected synchronously with colon cancer resection.

b. Liver biopsy should be obtained without liver resection

c. Liver resection is always done after adjuvant chemotherapy for colon cancer

d. Surgery for colon cancer should be abandoned as the cancer is now inoperable

e. None of the above

Answer: e

Normally, colorectal cancer resection & liver resection would not be performed synchronously. Lesions discovered at operation should not be biopsied. Patients with potentially resectable liver disease and who have undergone radical resection of the primary tumour should be considered for liver resection before consideration of chemotherapy. Patients with unfavourable primary pathology such as perforated primary tumour or extensive nodal involvement should be considered for adjuvant chemotherapy prior to liver resection and be restaged at three months.

It has been argued that the limiting factor to the number of lesions that can be resected is whether it is technically possible to remove all tumours. Patients with solitary, multiple and bilobar metastatic disease are candidates for liver resection. The surgeon should define the acceptable residual functioning volume, approximately one third of the standard liver volume, or the equivalent of a minimum of two segments.

Q6.

Please choose the most appropriate answer for colorectal cancers?

a. Right sided cancers commonly present with iron deficiency anaemia and left sided tumours present with change in bowel habit

b. Streptococcus bovis bacteraemia and Clostridium septicum sepsis can be due to underlying colonic malignancies.

c. Synchronous cancer occur in up to 5 percent of patients

d. Serum CEA has prognostic utility in patients with newly diagnosed colorectal cancer

e. All of the above

Answer: e

Synchronous CRCs are defined as two or more distinct primary tumors separated by normal bowel and not due to direct extension or metastasis. It occurs in up to 5 percent of patients with colon cancer.

American Society of Clinical Oncology (ASCO) guidelines recommend that serum CEA levels be obtained preoperatively in patients with demonstrated colorectal cancer to aid in staging, surgical treatment planning, and in the assessment of prognosis

Q7.

A 65 year old gentleman was found to have a cystic mass in the head of pancreas on a CT scan done for abdominal pain. All of the following are true except:

a. Almost all cystic neoplasm’s of pancreas are symptomatic

b. The differential diagnosis includes serous cyst adenoma, mucinous cyst adenoma or Intraductal papillary mucinous neoplasm (IPMN).

c. EUS and fluid aspirate analysis for CEA and amylase can be diagnostic

d. Serous cyst adenomas are nearly always benign and can be managed conservatively

e. Mucinous cyst adenomas are benign but malignant transformation can occur and hence resection should be considered.

Answer: a

50% of patients do not have any symptoms and are detected incidentally at imaging studies performed for unrelated indications. Symptoms (abdominal pain and jaundice) when occur are due to mass effect. It is conceptually useful to think of serous cyst adenoma to be like hyperplastic polyps in colon and mucinous cyst adenoma to be like colonic adenomas.

Q8.

A 60 year old woman has been diagnosed with gall bladder cancer incidentally at cholecystectomy. What are the risk factors for gall bladder cancer? Choose the most appropriate answer

a. Gallstones

b. Porcelain gallbladder

c. Gallbladder polyps

d. All of the above

e. b and c

Answer: d

Q9.

All the following are the risk factors for gastric cancer except one:

a. Helicobacter pylori infection

b. Atrophic gastritis

c. Pernicious anaemia

d. Alcohol abuse

e. Smoking

Answer: d

Q10.

All the following investigations may be needed to stage gastric adenocarcinoma except one:

a. Staging CT

b. Laparoscopy

c. Bone scan

d. EUS

e. Exploratory laparotomy

Answer: e

Laparoscopy is routinely used following CT and EUS in patients with T2 or greater gastric cancer prior to radical treatment. It is also considered in any patients where there is suspicion of peritoneal spread on CT or EUS such as in the presence of small volume ascites. Patients with advanced disease (>T2N0) who have not undergone full body PET-CT require a bone scan to exclude bony metastases.

Q11.

All the following are true about fundic gland polyp (FGP) except :

a. Hamartomatous polyps

b. Associated with PPI use

c. Associated with FAP

d. Sporadic FGP are found exclusively in patients without H.Pylori infection

e. Usually more than 10 mm in size

Answer: e

FGP are smooth, glassy, sessile, circumscribed elevations (usually measuring < 5 mm).

Sporadic and PPI associated FGPs have low malignant potential and no ominous associations. By contrast, a definite risk of dysplasia (between 30% and 50%) is present in FAP associated FGPs. Thus FGP should be carefully biopsied in FAP. Dysplasia in FGPs is also associated with large polyp size (>1 cm).

Q12.

A 55 year old man underwent an OGD for dyspepsia. It showed a 2 cms polyp in the gastric antrum. It was excised and retrieved. The following is true about gastric polyps except:

a. Gastric polyps are mostly asymptomatic and are typically found incidentally at OGD

b. H. Pylori eradication causes regression of up to 70% of hyperplastic polyps.

c. Adenomatous gastric polyps are at increased risk for malignant change and should be excised

d. Hyperplastic polyps have also a low but definite potential for development of malignancy.

e. Surveillance endoscopy is indicated after removal of gastric polyps

Answer: e

The guidelines of the American Society of Gastrointestinal Endoscopy (ASGE) recommend surveillance endoscopy one year after removing adenomatous gastric polyps to assess recurrence at the prior excision site. Hyperplastic polyps have low malignant potential and further surveillance endoscopy is not recommended after excision.

Q13.

A 46 year old man was found to have a subepithelial mass in the antrum at OGD. An endoscopic evaluation of the mass includes all the following except:

a. Assessment for intramural mass vs. extrinsic compression

b. Estimating the size

c. Mobility and consistency

d. Biopsies

e. Margins

Answer: e

Assessment of intramural mass vs. extrinsic compression is facilitated by changing the patient’s position to see if the location and appearance of the mass changes. Also, a change in appearance of the mass with either air insufflation or deflation may help in determining if the lesion is due to extrinsic compression. The size of the lesion is important in its management. Endoscopic assessment of the size can be performed better with an open biopsy forceps (which is 5mm in diameter). Mobility and consistency: A mobile mass that is soft and indents when depressed using biopsy forceps (pillow sign) is highly suggestive of a lipoma. A firm, minimally mobile lesion is suggestive of a GIST or leiomyoma.

It is reasonable to obtain mucosal biopsies to exclude epithelial polyps or lesions arising from the deep mucosa. The yield of mucosal biopsies is low, however if the biopsies are positive further investigations may not be warranted.

Q14.

A 60 year woman was found to have a subepithelial mass in the gastric body at OGD. All is true about endoscopic evaluation of the mass except:

a. If the mass has a pillow sign and is yellow in appearance, it is probably a lipoma and no further evaluation is necessary.

b. Subepithelial masses less than 1 cm in diameter are rarely of clinical significance and can be left alone.

c. All other lesions larger than 1 cms should be evaluated further by EUS

d. Subepithelial mass with a central umbilication suggests heterotopic pancreatic tissue

e. Endoscopist can accurately assess intramural mass from extrinsic compression

Answer: e

It is difficult to assess the intramural or extramural nature of the subepithelial mass. However, even when the endoscopist suspects an intramural lesion is present, the mass may arise from outside the gastrointestinal wall in up to 30% of cases. Thus, CT may have a role (where EUS is not available) in defining the origin and extent of extramural masses. Subepithelial masses less than 1 cm in diameter are rarely, if ever, of clinical significance. A repeat endoscopy in one year is reasonable for these small masses, and if the mass is unchanged, then further follow-up evaluation may not be required if the patient remains asymptomatic.

Q15.

The following is true about gastric subepithelial masses except:

a. GIST is the most common cause

b. Lipomas are a rare cause

c. EUS is the investigation of choice

d. CT scan is required to distinguish intramural from extramural compression

e. EUS findings may be diagnostic without tissue sampling

Answer: d

EUS can differentiate intramural from extramural lesions. SO CT scan is not required unless EUS is not available

Q16.

A 47 year old gentleman was found to have a subepithelial mass at OGD. A subsequent EUS revealed a hypoechoic mass arising from the muscle layer. FNA of the lesion was performed. Cytology and immunohistochemistry was diagnostic of a GIST. The following is true about a GIST tumour except:

a. Stomach is the commonest site for GIST

b. Any symptomatic GIST is potentially aggressive

c. GIST virtually never metastases to lungs

d. Imatinib (Gleevac) is the treatment of choice.

e. GIST almost uniformly express c-kit (CD117)

Answer: d

Surgery is the treatment of choice. Imatinib is used for advanced or metastatic disease. GIST frequently metastases to liver, rarely to regional lymph nodes and virtually never to lungs. Site of primary tumour- Stomach (50%), Small bowel (25%), Colon (10%), Oesophagus (5%), Extra intestinal (7%).

Q17.

A 55 year old woman was found to have incidental gallstones and a 5 mm polyp on an ultrasound scan. Choose the most appropriate management for the patient:

a. Cholecystectomy should be offered

b. Surgery should only be offered if the polyp was more than 10 mm in size

c. The patient can be followed up by regular ultrasound scans

d. CT scan is needed before surgery

e. EUS should be considered

Answer: a

Patients who have gallbladder polyps and concomitant gallstones should undergo cholecystectomy regardless of the polyp size or symptoms since gallstones are a risk factor for gallbladder cancer in patients with gallbladder polyps. Cholecystectomy should also be recommended for patients who have biliary colic. Polyps 10 to 20 mm in diameter should be regarded as possibly malignant. Cancer of this size is usually an early stage cancer and laparoscopic cholecystectomy with full thickness dissection is recommended. Polyps less than 10 mm can be followed up by regular USS.

Q18.

A 55 year old man with established cirrhosis underwent a six monthly surveillance ultrasound scan (USS). It showed a suspicious focal liver lesion. A subsequent contrast enhanced CT scan of abdomen confirmed a 2.5 cms focal lesion in the liver. AFP was raised at 200 ng/ml. A previous AFP and USS were normal 6 months earlier. What is the most appropriate next step?

a. Ultrasound guided liver biopsy

b. PET scan

c. Liver transplant referral

d. Repeat scan in 6 weeks

e. Repeat AFP in 6 weeks

Answer- c

A raised AFP in a cirrhotic patient with a focal liver lesion confirms the diagnosis of hepatocellular carcinoma and further investigation is only required to establish the most appropriate therapy.

Biopsy of potentially operable lesions is avoided due to the risk of tumour seeding in the needle tract, which occurs in 1–3%.

The only proven potentially curative therapy for HCC remains surgical, either hepatic resection or liver transplantation. Liver transplantation should be considered in any patient with cirrhosis and HCC.

Q19.

A 60 year old man with established cirrhosis had a surveillance ultrasound scan (USS). It showed a 2 cms focal liver lesion. AFP levels were normal. What is the most appropriate next step?

a. Repeat AFP at 6 weeks

b. Ultrasound guided liver biopsy

c. Repeat USS at 6 weeks

d. Contrast enhanced CT scan

e. Liver transplant referral

Answer: d

If AFP is normal, further radiological imaging (CT/MRI) usually allow a confident diagnosis of HCC to be made and proceed to assessment of treatment without the need for biopsy.

The normal range for AFP is 10–20 ng/ml and a level >400 ng/ml is usually regarded as diagnostic. However, up to 20% of HCC do not produce AFP, even when very large. A rising AFP over time, even if the level does not reach 400 ng/ml, is virtually diagnostic of HCC.

Q20.

Surveillance for HCC is recommended in high risk patients with cirrhosis. All the following patients are considered to be high risk except one:

a. Males and females with established cirrhosis due to hepatitis B or C

b. Males and females with established cirrhosis due to genetic haemochromatosis

c. Males with alcohol related cirrhosis.

d. Males with cirrhosis due to primary biliary cirrhosis

e. Males and females with cirrhosis due to primary sclerosing cholangitis

Answer: e

The risk of HCC development in cirrhosis due to autoimmune hepatitis, primary sclerosing cholangitis in both sexes, and alcoholic and primary biliary cirrhosis in women is generally low. HCC in Wilson’s disease is well described despite adequate copper chelating therapy, although the true incidence is difficult to establish. Non-cirrhotic HCCs do occur in viral cirrhosis but the absolute risk is low.

If surveillance is offered, it should be six monthly abdominal ultrasound assessments in combination with serum AFP estimation. This is based on estimated median doubling time of 6 months for HCC.

Q21.

A 40 year old Chinese man with cirrhosis due to hepatitis C is worried about the risk of hepatocellular cancer (HCC) after reading a newspaper report. He seeks an earlier outpatient appointment to discuss the risks. The risk of HCC in him is:

a. 0.1% per year

b. 1 % per year

c. 3-5% per year

d. 7-9% per year

e. > 10% per year

Answer: c

There is a considerable variation in the risk of HCC development in cirrhosis of different aetiologies. Cirrhosis due to hepatitis B or C carries a higher risk (3-5% per year). Patients with cirrhosis due to genetic haemochromatosis who were iron loaded at presentation had a very high risk of HCC development (7–9% per year). The risk falls with venesection but not to baseline levels (1–3% per year). Alcoholic cirrhosis carries an increased risk of HCC development (1-4% per year for males).

Q22.

A 63 year old gentleman underwent OGD for abdominal pain. It showed an ulcer in the antrum. The biopsies taken from the ulcer confirmed a MALToma. Staging for MALToma includes all except:

a. Staging CT

b. Bone marrow aspiration

c. EUS

d. LDH, B2 microglobulin

e. Laparoscopy

Answer: e

All patients diagnosed with MALToma should have the following tests done:

• Baseline bloods-LDH, B2 microglobulin

• OGD- with multiple biopsies from all the visible lesions & the non-involved areas with complete mapping of the organ

• Staging CT

• Bone marrow biopsy

• EUS- for evaluation of depth of invasion and presence of perigastric lymph nodes

Regardless of the presentation site- all the above diagnostic studies should be done.

Q23.

The following is true about MALToma except:

a. Most common primary GI lymphoma worldwide

b. Stomach is the commonest site of MALToma

c. Gastric MALToma is caused by H. Pylori infection

d. Prognosis is generally good

e. Surgery is the treatment of choice for gastric MALToma

Answer: e

Surgery was once the cornerstone, but the role is limited at present. As MALToma is a multifocal disease, a total gastrectomy will be needed. This is associated with significant morbidity. H. Pylori infection has been definitively established as a cause of MALTomas. 90% of MALToma patients are infected with H. Pylori.

Q24.

Gastric MALTomas generally have a good prognosis. The following is true about the treatment of gastric MALTomas except:

a. H. Pylori eradication may be sufficient treatment in H. Pylori positive localised disease

b. Chemotherapy or radiotherapy can be successfully used for failed antibiotic treatment, H. Pylori negative or extensive disease

c. Regular surveillance OGD is needed to monitor response and recurrence

d. Prognosis is fairly good

e. MALToma is a focal disease

Answer: e

Gastric MALToma is a multifocal disease. Thus surgery is no longer used as the primary treatment as total gastrectomy will be needed. This has high morbidity.

Q25.

A 55 year old man had an endoscopy performed for abdominal pain and dyspepsia. It showed a nodule with a yellowish tinge in the proximal greater curve.

[pic]

The biopsies confirmed it to be a neuroendocrine tumour. The most appropriate next step is:

a. EUS

b. Urine HIAA

c. Staging CT scan

d. PET scan

e. Gut hormone profile

Answer: c

Neuroendocrine tumours express somatostatin receptors (SSTR) and this has led to the development of radio labelled somatostatin analogues for diagnostic imaging. SSRS (somatostatin receptor scan or octreoscan) is the diagnostic test of choice to locate secondaries. SSRS prior to surgery revised the staging and changed management in 33% in Krenning’s series

Q26.

A 55 year old has been diagnosed with metastatic oesophageal adenocarcinoma. You are due to see him in your gastroenterology clinic and refer him to oncology if appropriate. How is fitness for chemotherapy commonly assessed?

a. ASA classification of physical status

b. Groningen fitness test

c. WHO performance status

d. Echocardiogram

e. 6- minute walk test

Answer: c

Fitness for chemotherapy is generally assessed by using The World Health Organisation performance scale. It has categories from 0 to 4. 

0 - Fully active patient

1 - Cannot carry out heavy physical work, but can do anything else.

2 - Up and about more than half the day; can look after himself, but not well enough to work.

3 - In bed or sitting in a chair for more than half the day; need some help in looking after him

4 - In bed or a chair all the time and need a lot of looking after

Generally patients are considered fit for chemotherapy with good performance status (PS0, PS1). Good PS2 (leaning towards PS1) are also generally considered fit for chemotherapy

Q27.

A 55 year old has been diagnosed with oesophageal adenocarcinoma. You are due to see him in your gastroenterology clinic and refer him to an upper GI surgeon for curative surgery, if appropriate. How is fitness for surgery commonly assessed?

a. ASA classification of physical status

b. Groningen fitness test

c. WHO performance status

d. Echocardiogram

e. 6- minute walk test

Answer: a

The previous medical history and concurrent morbidity remain the strongest predictors regarding fitness for surgery. The American Society of Anaesthesiologists (ASA) classification of physical status is well recognised. Perioperative risk increases with increasing ASA score. Only those patients with an ASA score of 3 or less should be considered for surgery.

Q28:

A 70 year old man has been diagnosed with adenocarcinoma of the lower thoracic oesophagus. A staging CT scan revealed coeliac lymph node involvement with no distant metastases. He is managing to eat and drink normally currently. What is the most appropriate treatment?

a. Curative surgery

b. Radical radiotherapy

c. Palliative chemotherapy

d. Oesophageal stent

e. EMR

Answer: c

Thoracic oesophagus drains in posterior mediastinal nodes. Involvement of coeliac nodes in lower thoracic tumour makes it M1 (i.e. stage IV) disease and hence incurable. Endoscopic palliation (stent) is only needed in presence of dysphagic symptoms.

Q29.

The risk factors for pancreatic cancer includes all except:

a. Diabetes mellitus

b. Hereditary predisposition

c. Chronic pancreatitis

d. Smoking

e. Acute pancreatitis

Answer: e

Q30.

The differential diagnosis of a mass lesion in pancreas includes all except:

a. Lymphoma

b. Neuroendocrine tumour

c. Focal chronic pancreatitis

d. Autoimmune pancreatitis

e. None of the above

Answer: e

Q31.

A 65 year old gentleman presented with dull aching upper abdominal pain radiating through to the back and worsened by eating. He had also noticed yellow discoloration of his skin and had lost weight. In his past medical history, he was diagnosed with diabetes mellitus 6 months earlier. A CT scan revealed a localised mass lesion in the head of pancreas with biliary duct dilatation.

All the following are true except:

a. CT guided biopsy is needed to confirm the diagnosis

b. There is little evidence of benefit from routine biliary stenting of jaundiced patients before resection.

c. A diagnosis of pancreatic cancer should be considered in unexplained diabetes (no family history, obesity or steroids) in patients over 50 years of age.

d. Gastroduodenal artery encasement is not a contraindication for curative surgery

e. Whipple’s operation is the standard operation for cancer of pancreatic head

Answer: a

EUS guided FNA biopsy is used in patients with resectable tumours. This is less likely to cause intraperitoneal spread of the tumor since the biopsy is obtained through the bowel wall rather than percutaneously.

Biliary stenting may be helpful if the surgery is delayed for more than 10 days as patients with obstructive jaundice are at risk for associated coagulopathy, malabsorption, and malnutrition.

Q32.

A 69 year old man underwent a screening colonoscopy under National bowel cancer screening programme. A 1.5 pedunculated polyp in the sigmoid colon was excised and retrieved. The histology report details the polyp as a well differentiated adenocarcinoma with clear margins and no evidence of lymphovascular invasion and Haggitt level 2. Choose the most appropriate answer?

a. Cancerous polyps are classified according to Haggitt level

b. Polyps classified as Haggitt level 3 or lower have a less than 1% likelihood of lymph node metastasis

c. Decision to proceed to surgical resection needs to be individualized

d. Haggitt level 4 polyps have a 12-25% risk of lymph node metastasis and should be treated with segmental colectomy

e. All of the above

Answer: e

Cancerous polyps are classified according to Haggitt level:

Level 0- carcinoma in situ

Level 1- submucosa in the head of the polyp

Level 2- submucosa in the neck of the polyp

Level 3- submucosa in the stalk of the polyp

Level 4- submucosa beyond the stalk

Polyps classified as Haggitt level 3 or lower have a less than 1% likelihood of lymph node metastasis and can be treated with polypectomy alone when they meet the following pathologic criteria: specimen margins are greater than 2 mm, no evidence of lymphovascular invasion and the tumour is well differentiated

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