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ABPS General Surgery study materials
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ABPS General Surgery practice questions

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Question 1Alimentary Tract and Abdominal Surgery

A 22-year-old man has 12 hours of periumbilical pain that has moved to the right lower quadrant, with anorexia and low-grade fever. Which finding most supports acute appendicitis?

  1. Pain relieved by hip extension
  2. McBurney point tenderness with guarding Correct answer.
  3. Left lower quadrant rebound tenderness
  4. Diffuse pain with hyperactive bowel sounds

Explanation

Early appendiceal obstruction causes vague periumbilical visceral pain; inflammation reaching the parietal peritoneum localizes pain to the right lower quadrant at McBurney point. Guarding and rebound tenderness indicate localized peritoneal irritation.

Question 2Alimentary Tract and Abdominal Surgery

A 60-year-old man has a groin bulge that descends into the scrotum and arises lateral to the inferior epigastric vessels. What is the most likely diagnosis?

  1. Femoral hernia
  2. Obturator hernia
  3. Direct inguinal hernia
  4. Indirect hernia Correct answer.

Explanation

An indirect inguinal hernia passes through the deep inguinal ring lateral to the inferior epigastric vessels and may enter the scrotum. Direct hernias protrude medial to those vessels through Hesselbach triangle.

Question 3Alimentary Tract and Abdominal Surgery

A 70-year-old constipated man has a markedly distended abdomen. Abdominal radiography shows a hugely dilated sigmoid loop with a coffee-bean appearance. What is the most likely diagnosis?

  1. Cecal volvulus
  2. Sigmoid volvulus Correct answer.
  3. Toxic megacolon
  4. Small bowel obstruction

Explanation

Sigmoid volvulus produces a massively dilated sigmoid loop that resembles a coffee bean on plain films. The twist occurs on its mesenteric axis and causes large bowel obstruction.

Question 4Alimentary Tract and Abdominal Surgery

Which condition is the most common cause of acute major lower gastrointestinal bleeding in adults?

  1. Colorectal adenocarcinoma
  2. Hemorrhoidal bleeding
  3. Diverticular disease Correct answer.
  4. Ischemic colitis

Explanation

Diverticulosis is the most frequent source of acute major lower gastrointestinal bleeding in adults. Bleeding results from rupture of intramural vessels at the diverticular neck.

Question 5Alimentary Tract and Abdominal Surgery

A 45-year-old man has burning epigastric pain relieved by meals, and he regularly uses naproxen. Which organism is most strongly associated with his ulcer disease?

  1. Campylobacter jejuni
  2. Candida albicans
  3. Salmonella enterica
  4. Helicobacter pylori Correct answer.

Explanation

Helicobacter pylori colonizes the gastric mucosa and is a major cause of peptic ulcer disease, particularly duodenal ulcers. Nonsteroidal anti-inflammatory drugs are an independent ulcerogenic risk factor.

Question 6Alimentary Tract and Abdominal Surgery

A 45-year-old woman has postprandial right upper quadrant pain, fever, and a positive Murphy sign. Ultrasound shows gallstones and a thickened gallbladder wall. What is the most likely diagnosis?

  1. Gallstone ileus
  2. Cholangiocarcinoma
  3. Acute pancreatitis
  4. Cholecystitis Correct answer.

Explanation

Cystic duct obstruction by a gallstone causes gallbladder inflammation, producing right upper quadrant pain, fever, and a positive Murphy sign. Ultrasound supports the diagnosis with stones and wall thickening.

Question 7Alimentary Tract and Abdominal Surgery

A 35-year-old man has painless bright red bleeding per rectum and tissue that prolapses during defecation. What is the most likely diagnosis?

  1. Fistula-in-ano
  2. Perianal abscess
  3. Internal piles Correct answer.
  4. Anal fissure

Explanation

Internal hemorrhoids are submucosal vascular cushions that commonly cause painless bright red bleeding and prolapse. They arise above the dentate line, where visceral innervation makes them relatively painless.

Question 8Alimentary Tract and Abdominal Surgery

A 65-year-old man develops vomiting, abdominal distention, and high-pitched bowel sounds two days after laparotomy. What is the most likely diagnosis?

  1. Paralytic ileus
  2. Adhesive obstruction Correct answer.
  3. Large bowel obstruction
  4. Acute gastroenteritis

Explanation

Intraperitoneal surgery creates adhesions that can trap and obstruct small bowel, producing colicky pain, vomiting, distention, and high-pitched bowel sounds. A transition point on imaging supports mechanical obstruction.

Question 9Alimentary Tract and Abdominal Surgery

A 55-year-old woman has left lower quadrant pain and fever. CT shows sigmoid diverticulitis with a 2-cm pericolic abscess, and she is hemodynamically stable. What is the best initial management?

  1. Immediate colectomy
  2. Percutaneous drainage
  3. Urgent colonoscopy to decompress
  4. Bowel rest and antibiotics Correct answer.

Explanation

Uncomplicated diverticulitis and small pericolic abscesses in stable patients are usually managed with bowel rest and antibiotics. Percutaneous drainage is reserved for larger abscesses or patients who do not improve.

Question 10Alimentary Tract and Abdominal Surgery

Which feature favors Crohn disease over ulcerative colitis?

  1. Transmural inflammation with skip lesions Correct answer.
  2. Crypt abscesses and pseudopolyps
  3. Bloody diarrhea as the predominant symptom
  4. Continuous mucosal disease from rectum

Explanation

Crohn disease causes transmural inflammation that can affect any part of the gastrointestinal tract with skip lesions. Ulcerative colitis is limited to the mucosa and typically begins in the rectum with continuous proximal involvement.

Question 11Alimentary Tract and Abdominal Surgery

A 52-year-old man has a father diagnosed with colorectal cancer at age 58. When should colorectal cancer screening begin?

  1. Age 50
  2. Age 45
  3. Age 48
  4. Age 40 Correct answer.

Explanation

For a first-degree relative diagnosed before age 60, screening begins at age 40 or 10 years before the relative’s diagnosis, whichever is earlier. In this case, age 40 is earlier than 48.

Question 12Alimentary Tract and Abdominal Surgery

A 28-year-old man has severe tearing anal pain during defecation and a sentinel skin tag. Where is the fissure most likely located?

  1. Posterior midline Correct answer.
  2. Left lateral
  3. Anterior commissure
  4. Right lateral

Explanation

Primary anal fissures usually occur in the posterior midline, where the anal canal has relatively poor blood supply and is subjected to sphincter strain. Anterior fissures are more common in women after childbirth.

Question 13Alimentary Tract and Abdominal Surgery

A 40-year-old diabetic man has throbbing perianal pain, fever, and a fluctuant induration beside the anus. What is the best treatment?

  1. Fistulotomy at presentation
  2. Sitz baths alone
  3. Incision and drainage Correct answer.
  4. Oral antibiotics alone

Explanation

A perianal abscess requires prompt surgical drainage to control infection and prevent extension. Antibiotics alone do not reliably treat a fluctuant abscess collection.

Question 14Alimentary Tract and Abdominal Surgery

A 65-year-old man is on postoperative day 3 after laparotomy with a distended abdomen, no flatus, absent bowel sounds, and diffuse tenderness. CT shows dilated bowel without a transition point. What is the most likely diagnosis?

  1. Adhesive small bowel obstruction
  2. Colonic obstruction
  3. Mesenteric ischemia
  4. Postoperative paralytic ileus Correct answer.

Explanation

Postoperative paralytic ileus causes diffuse bowel dilation, absent bowel sounds, and failure to pass flatus without a mechanical transition point. It usually resolves with supportive care as bowel function returns.

Question 15Alimentary Tract and Abdominal Surgery

A 70-year-old man with atrial fibrillation has severe abdominal pain out of proportion to examination findings and an elevated lactate. CT angiography shows superior mesenteric artery occlusion. What is the best management?

  1. Colonoscopy with decompression
  2. Elective angiography in 24 hours
  3. Revascularization and resection Correct answer.
  4. Fluids, antibiotics, and observation

Explanation

Acute superior mesenteric artery occlusion causes rapid intestinal ischemia and requires urgent revascularization. Nonviable bowel must be resected, and a second-look operation is often needed.

Question 16Alimentary Tract and Abdominal Surgery

A 60-year-old man has weight loss, early satiety, and a palpable left supraclavicular lymph node. What is the most likely diagnosis?

  1. Neuroendocrine tumor
  2. Gastrointestinal stromal tumor
  3. Gastric adenocarcinoma Correct answer.
  4. Gastric lymphoma

Explanation

Weight loss, early satiety, and a Virchow node suggest gastric adenocarcinoma with lymphatic spread. The left supraclavicular node receives drainage from the thoracic duct and abdominal malignancies.

Question 17Alimentary Tract and Abdominal Surgery

A 50-year-old woman has a resectable gastric submucosal mass. Biopsy shows spindle cells positive for CD117. What is the best treatment for localized disease?

  1. Surgical resection with negative margins Correct answer.
  2. Endoscopic surveillance
  3. Wide resection with formal lymphadenectomy
  4. Imatinib alone without surgery

Explanation

Localized gastrointestinal stromal tumors are treated with complete surgical resection and negative margins. Lymph node metastasis is uncommon, so formal lymphadenectomy is not required.

Question 18Alimentary Tract and Abdominal Surgery

A 5-year-old boy has painless lower gastrointestinal bleeding, and a technetium-99m scan is positive. Which embryologic structure is involved?

  1. Urachus
  2. Pancreatic duct
  3. Vitelline duct Correct answer.
  4. Mesonephric duct

Explanation

A Meckel diverticulum is a remnant of the vitelline duct, also called the omphalomesenteric duct. Ectopic gastric mucosa in the diverticulum can ulcerate and cause painless lower gastrointestinal bleeding.

Question 19Alimentary Tract and Abdominal Surgery

A 9-month-old infant has intermittent crying, currant-jelly stools, and a sausage-shaped abdominal mass. What is the best initial management?

  1. Immediate laparotomy
  2. Nasogastric decompression alone
  3. Intravenous antibiotics
  4. Enema reduction Correct answer.

Explanation

Ileocolic intussusception is initially treated with air or contrast enema reduction in a stable child without peritonitis. Surgery is reserved for failure of enema reduction, perforation, or peritonitis.

Question 20Alimentary Tract and Abdominal Surgery

A 45-year-old woman has dysphagia to both solids and liquids. Barium swallow shows a bird-beak narrowing, and manometry shows absent peristalsis with incomplete lower esophageal sphincter relaxation. What is the best definitive treatment?

  1. Nissen fundoplication
  2. Laparoscopic Heller myotomy Correct answer.
  3. Long-term proton pump inhibitor
  4. Esophagectomy

Explanation

Achalasia results from loss of inhibitory ganglion cells, causing failed lower esophageal sphincter relaxation and absent peristalsis. Heller myotomy relieves the outflow obstruction and is combined with a partial antireflux procedure.

Question 21Alimentary Tract and Abdominal Surgery

A 30-year-old man is hypotensive after blunt abdominal trauma. FAST examination shows free fluid in the abdomen. What is the best next step?

  1. CT abdomen with contrast
  2. Diagnostic peritoneal lavage
  3. Angioembolization
  4. Emergent laparotomy Correct answer.

Explanation

Hemodynamic instability with free intraperitoneal fluid after blunt trauma is an indication for emergent laparotomy. CT and angiography are appropriate only when the patient is stable enough for further imaging.

Question 22Alimentary Tract and Abdominal Surgery

A 70-year-old man has an obstructing sigmoid colon cancer with perforation and fecal contamination. What is the best operative management?

  1. Loop colostomy alone
  2. Endoscopic stent placement
  3. Hartmann procedure Correct answer.
  4. Primary anastomosis without diversion

Explanation

A perforated obstructing left-sided colon cancer with fecal contamination is best managed by resection and end colostomy, typically a Hartmann procedure. Primary anastomosis is avoided because of the high risk of leak in contaminated, obstructed bowel.

Question 23Alimentary Tract and Abdominal Surgery

A 68-year-old ICU patient on vasopressors has abdominal pain and distention. CT shows diffuse bowel wall thickening without arterial occlusion. What is the best management?

  1. Catheter-directed thrombolysis
  2. Elective colectomy
  3. Supportive care with vasodilator Correct answer.
  4. Immediate surgical embolectomy and bypass

Explanation

Nonocclusive mesenteric ischemia results from splanchnic vasoconstriction and is treated by optimizing hemodynamics and using intra-arterial vasodilators. Laparotomy is indicated if peritonitis or bowel necrosis develops.

Question 24Alimentary Tract and Abdominal Surgery

A 45-year-old man has recurrent perianal drainage. MRI shows a fistula tract that crosses the external anal sphincter. How is this fistula classified?

  1. Extrasphincteric
  2. Suprasphincteric
  3. Transsphincteric Correct answer.
  4. Intersphincteric

Explanation

A transsphincteric fistula passes from the intersphincteric space through the external anal sphincter into the ischioanal fossa. This classification guides surgical planning because division of involved sphincter muscle risks incontinence.

Question 25Alimentary Tract and Abdominal Surgery

A patient develops progressive fatigue and paresthesias after massive terminal ileal resection. Which deficiency is most likely?

  1. Metabolic alkalosis
  2. Hypercalcemia
  3. Hyperkalemia
  4. B12 deficiency Correct answer.

Explanation

Vitamin B12 is absorbed in the terminal ileum after binding to intrinsic factor. Resection of this segment can cause B12 deficiency with megaloblastic anemia and neurologic symptoms.

Question 26Surgical Oncology including Breast and Endocrine

In a 55-year-old woman at average risk for breast cancer, which imaging test is recommended for routine screening?

  1. Breast MRI
  2. Positron emission tomography
  3. Digital mammography Correct answer.
  4. Whole-breast ultrasound

Explanation

Average-risk breast cancer screening begins with mammography, typically at age 40 to 50 depending on guideline, and continues at intervals thereafter. MRI is reserved for high-risk women, and ultrasound is generally an adjunct rather than a primary screening test.

Question 27Surgical Oncology including Breast and Endocrine

Which histologic type accounts for the largest proportion of invasive breast cancers?

  1. Invasive lobular carcinoma
  2. Medullary carcinoma
  3. Mucinous carcinoma
  4. Invasive ductal carcinoma Correct answer.

Explanation

Invasive ductal carcinoma, also called invasive carcinoma of no special type, accounts for roughly 70–80% of invasive breast cancers. Invasive lobular carcinoma is less common, and mucinous and medullary subtypes are rare.

Question 28Surgical Oncology including Breast and Endocrine

In a woman with early breast cancer and a clinically node-negative axilla, what is the standard axillary staging procedure?

  1. Axillary radiation alone
  2. No axillary staging
  3. Sentinel lymph node biopsy Correct answer.
  4. Complete axillary lymph node dissection

Explanation

Sentinel lymph node biopsy is the standard for axillary staging when the axilla is clinically node-negative. Complete dissection is reserved for clinically positive nodes or persistent disease after neoadjuvant therapy.

Question 29Surgical Oncology including Breast and Endocrine

Which thyroid malignancy is the most common?

  1. Anaplastic thyroid carcinoma
  2. Follicular thyroid carcinoma
  3. Medullary thyroid carcinoma
  4. Papillary thyroid carcinoma Correct answer.

Explanation

Papillary thyroid carcinoma is the most common thyroid malignancy, comprising about 80% of cases. Follicular carcinoma is less common, medullary carcinoma accounts for about 5%, and anaplastic carcinoma is rare.

Question 30Surgical Oncology including Breast and Endocrine

A thyroid nodule is referred for surgery because fine-needle aspiration shows a follicular neoplasm. Which finding on the surgical specimen establishes follicular carcinoma rather than adenoma?

  1. Orphan Annie eye nuclei with nuclear grooves
  2. Amyloid stroma
  3. Psammoma bodies in the tumor
  4. Capsular and vascular invasion Correct answer.

Explanation

The diagnosis of follicular carcinoma requires histologic evidence of capsular invasion, vascular invasion, or both; cytology cannot reliably distinguish it from a follicular adenoma. Psammoma bodies and Orphan Annie eye nuclei are associated with papillary carcinoma, while amyloid stroma suggests medullary carcinoma.

Question 31Surgical Oncology including Breast and Endocrine

What is the most common cause of primary hyperparathyroidism?

  1. Solitary parathyroid adenoma Correct answer.
  2. Four-gland parathyroid hyperplasia
  3. Parathyroid carcinoma of one gland
  4. Ectopic PTH secretion

Explanation

A single parathyroid adenoma causes about 80–85% of primary hyperparathyroidism. Four-gland hyperplasia is the next most common cause, whereas parathyroid carcinoma and ectopic PTH secretion are rare.

Question 32Surgical Oncology including Breast and Endocrine

Which medication should be started first in preoperative preparation for pheochromocytoma?

  1. Loop diuretic
  2. Beta-adrenergic blocker
  3. Alpha-adrenergic blocker Correct answer.
  4. Angiotensin-converting enzyme inhibitor

Explanation

Preoperative preparation requires alpha-adrenergic blockade first to control blood pressure and prevent hypertensive crisis. Beta-blockade is added only after alpha-blockade to manage reflex tachycardia without leaving unopposed vasoconstriction.

Question 33Surgical Oncology including Breast and Endocrine

Which feature is the strongest predictor of survival in localized cutaneous melanoma?

  1. Breslow tumor thickness Correct answer.
  2. Lesion pigmentation
  3. Presence of ulceration only
  4. Clark level of invasion

Explanation

Breslow thickness, measured in millimeters from the granular layer to the deepest tumor cell, is the strongest predictor of survival in localized melanoma. Ulceration adds prognostic information, while Clark level and pigmentation are less important.

Question 34Surgical Oncology including Breast and Endocrine

A 48-year-old woman has 1.5 cm low-grade DCIS of the right breast with clear margins after breast-conserving surgery. She is clinically node negative. What is the most appropriate next step?

  1. Completion mastectomy of the right breast
  2. Whole-breast radiation therapy Correct answer.
  3. Systemic chemotherapy with an anthracycline
  4. Sentinel lymph node biopsy of the axilla

Explanation

Breast-conserving surgery followed by whole-breast radiation is standard for localized DCIS because radiation reduces the risk of in-breast recurrence. Sentinel node biopsy is not routine for DCIS treated by lumpectomy, and chemotherapy has no role in DCIS.

Question 35Surgical Oncology including Breast and Endocrine

A woman presents with rapid onset of breast erythema, edema, and peau d'orange over one-third of the breast, without a discrete mass. What is the most appropriate initial diagnostic step?

  1. Observation and repeat examination in 6 weeks
  2. Skin punch biopsy of the involved breast Correct answer.
  3. Fine-needle aspiration of the axilla only
  4. Simple mastectomy for diagnosis

Explanation

Inflammatory breast cancer is a clinical diagnosis characterized by rapid erythema, edema, and peau d'orange; confirmation requires a skin punch biopsy that includes dermis to look for dermal lymphatic invasion. Treatment begins with systemic therapy, not immediate mastectomy.

Question 36Surgical Oncology including Breast and Endocrine

A 60-year-old woman has an eczematous, crusting lesion of the nipple-areola complex that has not responded to topical steroids. What is the most appropriate next step?

  1. Full-thickness biopsy of the nipple lesion Correct answer.
  2. Reassurance and continued topical therapy
  3. Nipple culture for bacterial infection
  4. Mastectomy without biopsy

Explanation

Paget disease of the breast presents as an eczematous nipple lesion and is often associated with underlying DCIS or invasive carcinoma. Full-thickness biopsy of the nipple-areola complex is required to confirm the diagnosis and guide further imaging and surgery.

Question 37Surgical Oncology including Breast and Endocrine

A postmenopausal woman has hormone receptor-positive, HER2-negative metastatic breast cancer with bone metastases and no visceral crisis. What is the preferred initial systemic therapy?

  1. Trastuzumab plus pertuzumab
  2. Combination cytotoxic chemotherapy with taxane
  3. Immune checkpoint inhibitor alone
  4. Aromatase inhibitor plus CDK4/6 inhibitor Correct answer.

Explanation

For hormone receptor-positive, HER2-negative metastatic breast cancer without visceral crisis, endocrine therapy is preferred over cytotoxic chemotherapy. Combining an aromatase inhibitor with a CDK4/6 inhibitor improves progression-free survival in postmenopausal patients.

Question 38Surgical Oncology including Breast and Endocrine

In a woman with early-stage HER2-positive breast cancer, which targeted agent is standard adjuvant therapy?

  1. Trastuzumab plus pertuzumab Correct answer.
  2. Tamoxifen alone
  3. Letrozole alone
  4. Capecitabine with bevacizumab

Explanation

HER2-directed therapy with trastuzumab, often combined with pertuzumab in high-risk disease, is standard adjuvant treatment for HER2-positive breast cancer. Tamoxifen and letrozole target hormone receptors, and capecitabine is not a standard HER2-targeted adjuvant agent.

Question 39Surgical Oncology including Breast and Endocrine

A woman carries a pathogenic BRCA1 mutation. Which malignancy pattern is most characteristic?

  1. Triple-negative breast and ovarian cancer Correct answer.
  2. Colorectal cancer and endometrial cancer
  3. Medullary thyroid cancer and pheochromocytoma
  4. Pancreatic neuroendocrine tumor and pituitary adenoma

Explanation

BRCA1 mutations impair homologous recombination and predispose to triple-negative breast cancer and high-grade serous ovarian cancer. BRCA2 also increases breast and ovarian cancer risk and is linked to prostate and pancreatic cancer.

Question 40Surgical Oncology including Breast and Endocrine

A patient with medullary thyroid carcinoma has a markedly elevated calcitonin level. Which additional evaluation is most important?

  1. Radioiodine whole-body scan
  2. Serum thyroglobulin measurement
  3. RET proto-oncogene testing Correct answer.
  4. Thyroid peroxidase antibody titer

Explanation

Medullary thyroid carcinoma arises from parafollicular C cells and secretes calcitonin. Germline RET proto-oncogene testing is essential because a positive result identifies MEN2 and triggers screening for pheochromocytoma and hyperparathyroidism.

Question 41Surgical Oncology including Breast and Endocrine

After total thyroidectomy for papillary thyroid carcinoma, which patient is the best candidate for radioactive iodine ablation?

  1. A patient with a 1 cm intrathyroidal tumor and no nodal disease
  2. A patient with extrathyroidal extension and cervical nodal metastases Correct answer.
  3. A patient with multifocal microcarcinoma confined to the thyroid
  4. A patient with completely resected disease and undetectable thyroglobulin

Explanation

Radioactive iodine ablation is most useful in higher-risk papillary thyroid carcinoma, such as tumors with extrathyroidal extension or cervical nodal metastases, after total thyroidectomy. Low-risk intrathyroidal disease and multifocal microcarcinoma generally do not benefit.

Question 42Surgical Oncology including Breast and Endocrine

A patient has hypertension and hypokalemia with an elevated aldosterone-to-renin ratio. After confirming primary aldosteronism, what is the next step to distinguish unilateral adenoma from bilateral hyperplasia?

  1. Dexamethasone suppression test
  2. Adrenal biopsy
  3. Adrenal venous sampling Correct answer.
  4. Plasma metanephrines

Explanation

Adrenal venous sampling is used to lateralize aldosterone secretion when primary aldosteronism is biochemically confirmed. Imaging alone cannot reliably distinguish a unilateral adenoma from bilateral hyperplasia, and adrenal biopsy is not used for this purpose.

Question 43Surgical Oncology including Breast and Endocrine

A patient has fasting hypoglycemia with symptoms relieved by glucose, and elevated insulin and C-peptide during a supervised fast. What is the most likely diagnosis?

  1. Insulinoma Correct answer.
  2. Adrenal cortical carcinoma
  3. Factitious hypoglycemia from insulin injection
  4. Pheochromocytoma

Explanation

Fasting hypoglycemia with inappropriately elevated insulin and C-peptide indicates endogenous hyperinsulinism, most often an insulinoma. Exogenous insulin injection would suppress C-peptide, and adrenal or pheochromocytoma tumors do not cause this pattern.

Question 44Surgical Oncology including Breast and Endocrine

A patient with recurrent peptic ulcers and diarrhea has a markedly elevated fasting gastrin level. Which test can help confirm Zollinger-Ellison syndrome?

  1. Serum chromogranin A
  2. Urinary 5-HIAA
  3. Dexamethasone suppression test
  4. Secretin stimulation test Correct answer.

Explanation

In Zollinger-Ellison syndrome, secretin administration paradoxically increases gastrin secretion. Proton pump inhibitors should be stopped before testing when safe, and tumor localization is pursued after biochemical confirmation.

Question 45Surgical Oncology including Breast and Endocrine

An asymptomatic 2.5 cm adrenal mass is found incidentally. Which evaluation is required before considering resection?

  1. Percutaneous adrenal biopsy
  2. Biochemical testing for pheochromocytoma Correct answer.
  3. Immediate open adrenalectomy
  4. Observation without any hormonal testing

Explanation

Every adrenal incidentaloma should be evaluated biochemically to exclude pheochromocytoma before any intervention, because unsuspected catecholamine excess can cause operative crisis. Hormonal testing also screens for cortisol and aldosterone excess, and biopsy is avoided when pheochromocytoma is possible.

Question 46Surgical Oncology including Breast and Endocrine

A woman has a 3 cm triple-negative breast cancer. Which statement best describes the expected response to neoadjuvant chemotherapy?

  1. Neoadjuvant chemotherapy is contraindicated in triple-negative disease
  2. Response can be assessed only by tumor markers
  3. Hormone therapy should be added before surgery
  4. Pathologic complete response is more common than in ER-positive disease Correct answer.

Explanation

Triple-negative breast cancer has a higher rate of pathologic complete response to neoadjuvant chemotherapy than hormone receptor-positive disease. Patients with residual disease after neoadjuvant therapy may receive adjuvant capecitabine, and endocrine therapy is not indicated for triple-negative disease.

Question 47Surgical Oncology including Breast and Endocrine

A patient with biopsy-proven axillary nodal metastasis receives neoadjuvant chemotherapy and has a complete clinical response. What is the standard surgical approach to the axilla?

  1. Routine complete axillary dissection without sentinel biopsy
  2. Sentinel node biopsy with retrieval of the clipped node Correct answer.
  3. Avoid all axillary surgery
  4. Axillary radiation without surgery

Explanation

After neoadjuvant chemotherapy, sentinel lymph node biopsy with dual tracers and retrieval of the clipped biopsy-proven node is the standard approach for axillary restaging. Completion axillary dissection is reserved for those with residual nodal disease.

Question 48Surgical Oncology including Breast and Endocrine

Fine-needle aspiration of a thyroid nodule is reported as Bethesda category IV, follicular neoplasm. What is the most appropriate management?

  1. Diagnostic thyroid lobectomy Correct answer.
  2. Repeat FNA in 3 months
  3. Total thyroidectomy without histology
  4. Radioactive iodine therapy

Explanation

Bethesda category IV indicates a follicular neoplasm, and cytology cannot distinguish a follicular adenoma from follicular carcinoma. Diagnostic thyroid lobectomy is therefore required to assess capsular and vascular invasion.

Question 49Surgical Oncology including Breast and Endocrine

A patient has primary hyperparathyroidism, a pituitary prolactinoma, and a pancreatic neuroendocrine tumor. Which syndrome is most likely?

  1. MEN2A
  2. Von Hippel-Lindau disease
  3. MEN2B
  4. MEN1 Correct answer.

Explanation

MEN1 is characterized by the triad of parathyroid adenomas or hyperplasia, pituitary tumors, and pancreatic neuroendocrine tumors. MEN2A and MEN2B feature medullary thyroid carcinoma and pheochromocytoma instead.

Question 50Surgical Oncology including Breast and Endocrine

A 55-year-old man has a large, painless retroperitoneal mass abutting the kidney. Core needle biopsy suggests a well-differentiated liposarcoma. Which management principle is most appropriate?

  1. Neoadjuvant imatinib before resection
  2. Biopsy the mass and observe if asymptomatic
  3. Percutaneous aspiration of the mass for drainage
  4. En bloc resection with involved organs if necessary Correct answer.

Explanation

Retroperitoneal sarcomas are treated primarily with complete en bloc resection, including adjacent organs when necessary to achieve negative margins. Incomplete resection or observation worsens prognosis, and imatinib is reserved for KIT-positive gastrointestinal stromal tumors.