Histopathology after wide excision of a buccal mucosa cancer with a modified radical neck dissection: tumour 3.5 cm, depth of invasion 9 mm, all mucosal and deep margins clear by more than 5 mm, perineural invasion absent; 2 of 31 nodes positive, one showing tumour breaching the nodal capsule into the surrounding fat. The patient has recovered well and has normal renal function and hearing. What is the best adjuvant treatment?

Radiotherapy with concurrent cisplatin

Observation with 3-monthly review

On examination of a fisherman with a 3 cm squamous cell carcinoma of the skin of the cheek, a firm, mobile 2 cm node is felt in the parotid region. Before the treatment plan is made, what is the best next step for the node?

Ultrasound-guided FNAC of the node

Open excision biopsy of the node

A course of antibiotics and review

Head and neck, salivary and skin cancers

35 NEET-PG practice questions on Head and neck, salivary and skin cancers, part of General Surgery. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Hard
Histopathology after wide excision of a buccal mucosa cancer with a modified radical neck dissection: tumour 3.5 cm, depth of invasion 9 mm, all mucosal and deep margins clear by more than 5 mm, perineural invasion absent; 2 of 31 nodes positive, one showing tumour breaching the nodal capsule into the surrounding fat. The patient has recovered well and has normal renal function and hearing. What is the best adjuvant treatment?
1. AObservation with 3-monthly review
2. BRadiotherapy with concurrent cisplatin
3. CRadiotherapy alone
4. DOral metronomic chemotherapy
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Answer: B · Radiotherapy with concurrent cisplatin
Extranodal extension (tumour breaching the node capsule) and a positive margin are the two high-risk features after head and neck cancer surgery. The EORTC 22931 and RTOG 9501 trials showed that adding concurrent cisplatin to postoperative radiotherapy improves locoregional control and survival in this group. Radiotherapy alone suits intermediate-risk features such as multiple nodes without extranodal extension. Key point: Extranodal extension or a positive margin after head and neck cancer surgery needs postoperative chemoradiotherapy with cisplatin.
- A: Observation is unsafe with two positive nodes and extranodal extension.
- C: Radiotherapy alone is for intermediate risk; extranodal extension needs added cisplatin.
- D: Metronomic chemotherapy is a palliative option, not standard adjuvant therapy.
Question 2 · Easy
A pearly, translucent nodule with rolled edges and fine telangiectasia over its surface has slowly grown on the lower eyelid of a retired gardener. What is the most likely diagnosis?
1. ABasal cell carcinoma
2. BNodular melanoma
3. CSquamous cell carcinoma
4. DKeratoacanthoma
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Answer: A · Basal cell carcinoma
A pearly nodule with a rolled edge and surface telangiectasia on the face is the typical nodular basal cell carcinoma. With time the centre ulcerates, leaving a rodent ulcer with a raised, beaded edge. SCC is usually keratotic or ulcerated with everted edges, and melanoma is usually pigmented. Key point: Pearly nodule, rolled edge, surface telangiectasia on the face: nodular BCC.
- B: Nodular melanoma is usually dark and grows fast.
- C: SCC is usually a keratotic nodule or an ulcer with everted edges.
- D: Keratoacanthoma grows over weeks with a central keratin plug.
Question 3 · Easy
A painless, slowly growing, firm, mobile lump has been present for 4 years in front of the right ear lobe of a woman; facial nerve function is normal. What is the most likely diagnosis?
1. AAdenoid cystic carcinoma
2. BMucoepidermoid carcinoma
3. CPleomorphic adenoma
4. DWarthin tumour
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Answer: C · Pleomorphic adenoma
About 80% of salivary tumours arise in the parotid, about 80% of parotid tumours are benign, and most of these are pleomorphic adenomas. A slowly growing, painless, mobile lump with a normal facial nerve is typical. Pain, rapid growth, fixity or facial palsy suggest malignancy. Key point: The commonest salivary tumour is pleomorphic adenoma of the parotid: painless, slow and mobile.
- A: Adenoid cystic carcinoma often causes pain or nerve palsy from perineural spread.
- B: Mucoepidermoid carcinoma is the commonest malignant parotid tumour but less common than pleomorphic adenoma.
- D: Warthin tumour is the second commonest benign tumour and is typically in older male smokers.
Question 4 · Medium
Bilateral, soft, painless swellings at the angles of the jaw are found in a man who has smoked bidis for 40 years. Fine-needle aspiration shows oncocytic epithelial cells in a lymphoid background, and the swellings take up technetium-99m pertechnetate avidly. What is the diagnosis?
1. AWarthin tumour
2. BOncocytoma
3. CAcinic cell carcinoma
4. DPleomorphic adenoma
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Answer: A · Warthin tumour
Warthin tumour (papillary cystadenoma lymphomatosum) occurs almost only in the parotid, mainly in older men who smoke, and is bilateral in about 10%. Histology shows a double layer of oncocytic epithelium over a lymphoid stroma. Its mitochondria-rich oncocytes concentrate pertechnetate, giving a 'hot' spot on scanning. Key point: Bilateral parotid tumour in an elderly smoker that is hot on Tc-99m scan: Warthin tumour.
- B: Oncocytoma is also hot on scanning but lacks the lymphoid background.
- C: Acinic cell carcinoma has serous acinar cells, not oncocytes with lymphoid stroma.
- D: Pleomorphic adenoma shows a chondromyxoid stroma and is cold on scanning.
Question 5 · Medium
On examination of a fisherman with a 3 cm squamous cell carcinoma of the skin of the cheek, a firm, mobile 2 cm node is felt in the parotid region. Before the treatment plan is made, what is the best next step for the node?
1. AOpen excision biopsy of the node
2. BA course of antibiotics and review
3. CUltrasound-guided FNAC of the node
4. DPET-CT and no tissue diagnosis
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Answer: C · Ultrasound-guided FNAC of the node
A palpable node near a cutaneous SCC of the face may be metastatic, as SCC spreads to the parotid and cervical nodes. FNAC, ideally under ultrasound guidance, confirms the diagnosis without disturbing the tissue planes. If positive, treatment is excision of the primary with parotidectomy and neck dissection, usually followed by radiotherapy. Key point: A node near a head and neck SCC needs FNAC, not open biopsy, before planning surgery.
- A: Open biopsy spills tumour and spoils later neck surgery.
- B: Antibiotics delay diagnosis of a likely metastasis.
- D: Imaging helps staging but does not replace tissue diagnosis.
Question 6 · Medium
Over just 6 weeks, a dome-shaped nodule with a central keratin-filled crater has grown to 1.5 cm on the cheek of a bus driver. It is firm and not fixed. He has heard such lumps can disappear on their own and wants to wait. What is the best advice?
1. AShave biopsy of the crater
2. BTopical steroid cream twice daily
3. CObservation for 3 months to allow regression
4. DComplete excision with histology
Answer and explanation in LearnFree account
Question 7 · Easy
Xeroderma pigmentosum predisposes to skin cancers in childhood because of a defect in which repair pathway?
1. ANucleotide excision repair
2. BBase excision repair
3. CNon-homologous end joining
4. DDNA mismatch repair
Answer and explanation in LearnFree account
Question 8 · Medium
Regarding basal cell carcinoma: 1. Ultraviolet radiation is the main risk factor. 2. Most tumours spread early to regional lymph nodes. 3. Mohs micrographic surgery gives the highest cure rate for high-risk lesions. 4. The hedgehog pathway is activated in most tumours. Which statements are correct?
1. A1 and 2 only
2. B1, 3 and 4 only
3. C1 and 3 only
4. D2, 3 and 4 only
Answer and explanation in LearnFree account
Question 9 · Medium
An excision biopsy from a slow-growing nodule beside the nose of a retired postman shows nests of basaloid cells whose outer layer is lined up in a row, with clefts separating the nests from the surrounding stroma. There are no keratin pearls. How does this tumour usually behave if left untreated?
1. AIt spreads early to the parotid nodes
2. BIt spreads mainly through the bloodstream to lung
3. CIt regresses on its own within months
4. DIt invades locally but rarely metastasises
Answer and explanation in LearnFree account
Question 10 · Medium
A histopathology report on an excised pigmented lesion from the back reads: superficial spreading melanoma, Breslow thickness 0.6 mm, no ulceration, margins clear. Which single feature of a primary melanoma is the most important predictor of outcome?
1. ABreslow thickness
2. BDiameter of the lesion
3. CColour variation
4. DClark level
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Question 11 · Medium
A scar-like, pale, indurated plaque with no clear edge has slowly enlarged on the forehead of a shopkeeper. Biopsy shows thin strands of basaloid cells infiltrating a dense, fibrous stroma. Why does this lesion often recur after simple excision?
1. AIt arises from melanocytes deep in the dermis
2. BIt is resistant to radiotherapy
3. CIt spreads early through dermal lymphatics
4. DTumour extends beyond the visible edge
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Question 12 · Hard
A firm, fixed lump has grown over 4 months at the angle of the left jaw of a retired teacher, and for 3 weeks the left side of his face has drooped: he cannot close the left eye or raise the left brow. Ultrasound-guided core biopsy shows high-grade mucoepidermoid carcinoma of the parotid. Clinical examination and CT show no enlarged neck nodes and there are no distant metastases. He is fit for surgery. What is the best surgical plan?
1. AEnucleation of the lump followed by radiotherapy
2. BSuperficial parotidectomy preserving the facial nerve
3. CRadical parotidectomy with nerve resection and neck dissection
4. DTotal parotidectomy preserving the nerve, no neck surgery
Answer and explanation in LearnFree account
Question 13 · Medium
Facial weakness involving the forehead has developed over 3 months on the left side in a woman with a hard, fixed left parotid mass; she also has pain and numbness along the jaw. Biopsy shows cribriform nests of basaloid cells with 'Swiss-cheese' spaces. Which feature of this tumour best explains her symptoms?
1. ACervical nodal metastasis
2. BHaematogenous spread to bone
3. CCystic degeneration
4. DPerineural invasion
Answer and explanation in LearnFree account
Question 14 · Hard
A farmer in his sixties from Palakkad has an irregular pigmented patch on the sole of his left heel that has slowly enlarged and recently started to bleed. Excision biopsy confirms acral lentiginous melanoma, Breslow thickness 2.6 mm, ulcerated, with clear but narrow margins. There are no palpable groin nodes, and staging CT shows no distant disease. His relatives ask whether the foot must be amputated. What is the most appropriate next surgical step?
1. ABelow-knee amputation
2. BElective groin dissection with 1 cm margins
3. CWide excision with 5 mm margins only
4. DWide excision, 2 cm margins, sentinel node biopsy
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Question 15 · Hard
FNAC of a painless, cystic, 3 cm level II node in the neck of a non-smoking software engineer shows squamous cell carcinoma, and p16 immunostaining of the cell block is strongly positive. Careful ENT examination, including flexible nasopharyngolaryngoscopy, shows no primary tumour. The nasopharynx, tonsils, tongue base and larynx look normal, and the thyroid is normal on ultrasound. He asks what happens next. What is the best next step?
1. ASystemic chemotherapy for unknown primary cancer
2. BImmediate radical neck dissection on that side
3. COpen excision biopsy of the node for histology
4. DPET-CT, then panendoscopy with directed biopsies and tonsillectomy
Answer and explanation in LearnFree account
Question 16 · Medium
A primary, well-defined 8 mm nodular basal cell carcinoma on the upper back of a farmer is to be removed by standard excision. What clinical margin of normal skin should be taken around it?
1. AAbout 4 mm
2. BAbout 1 cm
3. CAbout 2 cm
4. DAbout 1 mm
Answer and explanation in LearnFree account
Question 17 · Medium
While clearing level IB during a selective neck dissection, the surgeon ligates the facial vein low and reflects it upward to protect a nerve. Injury to which nerve would cause drooping of the corner of the mouth?
1. ALingual nerve
2. BHypoglossal nerve
3. CCervical branch of the facial nerve
4. DMarginal mandibular nerve
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Question 18 · Easy
Regarding Marjolin ulcer: 1. It is a squamous cell carcinoma arising in a long-standing scar such as an old burn. 2. It usually grows slowly. 3. It is often painless. 4. Early regional lymph node spread is the rule. Which statements are correct?
1. A1 and 4 only
2. B2, 3 and 4 only
3. C1, 2, 3 and 4
4. D1, 2 and 3 only
Answer and explanation in LearnFree account
Question 19 · Medium
About pleomorphic adenoma of the parotid: 1. It is the commonest salivary gland tumour. 2. Enucleation is the treatment of choice. 3. Incomplete excision leads to recurrence because of pseudopod-like extensions through the capsule. 4. Long-standing tumours can undergo malignant change. Which statements are correct?
1. A1, 3 and 4 only
2. B1, 2 and 3 only
3. C1 and 3 only
4. D2 and 4 only
Answer and explanation in LearnFree account
Question 20 · Hard
Biopsy of an indurated ulcer on the right lateral border of the tongue in a man who chews tobacco confirms well-differentiated squamous cell carcinoma. MRI shows a 2.8 cm primary tumour with a depth of invasion of 7 mm, and there are no palpable or radiologically enlarged neck nodes. He is fit for surgery and will have a wide excision of the tongue lesion. The tumour board is debating whether to treat the clinically negative neck now or to watch it with ultrasound. What is the best plan for the neck?
1. ANeck radiotherapy alone
2. BElective selective neck dissection, I-III
3. CBilateral radical neck dissection
4. DWait and watch with ultrasound
Answer and explanation in LearnFree account
Question 21 · Medium
Three months after a right radical neck dissection, a teacher complains that her right shoulder droops, aches by evening and she cannot lift her arm above her head to write on the board. There is winging only on shoulder abduction. Which muscle is paralysed?
1. ASupraspinatus
2. BSerratus anterior
3. CTrapezius
4. DDeltoid
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Question 22 · Hard
On the second day after a left modified radical neck dissection for a metastatic node, the suction drain of a patient who has started a normal diet changes from serous to milky white fluid, about 300 mL in 24 hours. Drain fluid triglyceride is 480 mg/dL. There is no swelling under the flap, the skin is healthy, and she is comfortable and afebrile. Serum albumin and electrolytes are normal, and the neck flap was closed over a single suction drain. The surgical resident wants to take her back to theatre at once. What is the best initial management?
1. AImmediate re-exploration and duct ligation
2. BMedium-chain triglyceride diet with pressure dressing
3. CRemove the drain and observe
4. DThoracic duct embolisation under radiology
Answer and explanation in LearnFree account
Question 23 · Medium
Operation note: all nodal levels I to V removed; spinal accessory nerve and internal jugular vein preserved; sternocleidomastoid excised as it was adherent to a level II node. How is this procedure classified?
1. AModified radical neck dissection type I
2. BSelective neck dissection
3. CModified radical neck dissection type III
4. DModified radical neck dissection type II
Answer and explanation in LearnFree account
Question 24 · Medium
A farmer from Murshidabad in West Bengal has rough, horny papules on both palms and soles, raindrop pigmentation on the trunk and several red, scaly plaques on covered skin of the trunk. Biopsy of one plaque shows squamous cell carcinoma in situ. His village drinks from a shallow tube well. What is the most likely cause of his skin lesions?
1. AArsenic in drinking water
2. BChronic sunlight exposure
3. COrganophosphate skin contact
4. DFluoride in drinking water
Answer and explanation in LearnFree account
Question 25 · Medium
Histopathology report of an ulcer with everted edges on the dorsum of the hand of a construction worker: sheets of atypical polygonal cells with abundant pink cytoplasm, intercellular bridges, and concentric whorls of keratin in the centre of tumour nests, invading the reticular dermis. What is the diagnosis?
1. ASquamous cell carcinoma
2. BAmelanotic nodular melanoma
3. CNodular basal cell carcinoma
4. DIrritated seborrhoeic keratosis
Answer and explanation in LearnFree account

10 more Head and neck, salivary and skin cancers questions

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Head and neck, salivary and skin cancers

A pearly, translucent nodule with rolled edges and fine telangiectasia over its surface has slowly grown on the lower eyelid of a retired gardener. What is the most likely diagnosis?

A painless, slowly growing, firm, mobile lump has been present for 4 years in front of the right ear lobe of a woman; facial nerve function is normal. What is the most likely diagnosis?

Bilateral, soft, painless swellings at the angles of the jaw are found in a man who has smoked bidis for 40 years. Fine-needle aspiration shows oncocytic epithelial cells in a lymphoid background, and the swellings take up technetium-99m pertechnetate avidly. What is the diagnosis?

On examination of a fisherman with a 3 cm squamous cell carcinoma of the skin of the cheek, a firm, mobile 2 cm node is felt in the parotid region. Before the treatment plan is made, what is the best next step for the node?

Over just 6 weeks, a dome-shaped nodule with a central keratin-filled crater has grown to 1.5 cm on the cheek of a bus driver. It is firm and not fixed. He has heard such lumps can disappear on their own and wants to wait. What is the best advice?

Xeroderma pigmentosum predisposes to skin cancers in childhood because of a defect in which repair pathway?

Regarding basal cell carcinoma: 1. Ultraviolet radiation is the main risk factor. 2. Most tumours spread early to regional lymph nodes. 3. Mohs micrographic surgery gives the highest cure rate for high-risk lesions. 4. The hedgehog pathway is activated in most tumours. Which statements are correct?

An excision biopsy from a slow-growing nodule beside the nose of a retired postman shows nests of basaloid cells whose outer layer is lined up in a row, with clefts separating the nests from the surrounding stroma. There are no keratin pearls. How does this tumour usually behave if left untreated?

A histopathology report on an excised pigmented lesion from the back reads: superficial spreading melanoma, Breslow thickness 0.6 mm, no ulceration, margins clear. Which single feature of a primary melanoma is the most important predictor of outcome?

A scar-like, pale, indurated plaque with no clear edge has slowly enlarged on the forehead of a shopkeeper. Biopsy shows thin strands of basaloid cells infiltrating a dense, fibrous stroma. Why does this lesion often recur after simple excision?

A primary, well-defined 8 mm nodular basal cell carcinoma on the upper back of a farmer is to be removed by standard excision. What clinical margin of normal skin should be taken around it?

While clearing level IB during a selective neck dissection, the surgeon ligates the facial vein low and reflects it upward to protect a nerve. Injury to which nerve would cause drooping of the corner of the mouth?

Regarding Marjolin ulcer: 1. It is a squamous cell carcinoma arising in a long-standing scar such as an old burn. 2. It usually grows slowly. 3. It is often painless. 4. Early regional lymph node spread is the rule. Which statements are correct?

Three months after a right radical neck dissection, a teacher complains that her right shoulder droops, aches by evening and she cannot lift her arm above her head to write on the board. There is winging only on shoulder abduction. Which muscle is paralysed?

Operation note: all nodal levels I to V removed; spinal accessory nerve and internal jugular vein preserved; sternocleidomastoid excised as it was adherent to a level II node. How is this procedure classified?