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xvi
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Contents
8 Liver Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Raafat Raoof Altur, Waseem M. Al Hamidy, Munthir A. Alobaidi,
and Aqeel Shakir Mahmood
9 Gallbladder Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Waseem M. Al Hamidy, Haider A. H. Ahmed,
Sabah Noori Abdulraheem, and Aqeel Shakir Mahmood
10 Cholangiocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Aqeel Shakir Mahmood, Noufel sh. Alshadood,
Munthir A. Alobaidi, Saleh Abdulkareem Saleh, and Mustafa Ismail
11 Anal Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Salih Ahmed Aljiburi, Aqeel Shakir Mahmood,
Saleh Abdulkareem Saleh, and Mustafa Ismail
Part II Surgical Endocrine Oncology
12 Breast Cancers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Salih Ahmed Aljiburi, Saleh Abdulkareem Saleh, Sajjad G. Al-Badri,
and Aqeel Shakir Mahmood
13 Pancreatic Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Raafat Raoof Altur, Sabah Noori Abdulraheem,
Noufel sh. Alshadood, Haider A. H. Ahmed,
and Aqeel Shakir Mahmood
14 Thyroid Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Talib A. Majeed, Sajjad G. Al-Badri, Saleh Abdulkareem Saleh,
and Aqeel Shakir Mahmood
15 Parathyroid Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Raafat Raoof Altur, Waseem M. Al Hamidy, Munthir A. Alobaidi,
and Mustafa Ismail
16 Adrenal Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Haider A. H. Ahmed, Sabah Noori Abdulraheem,
and Sajjad G. Al-Badri
Contributors
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SabahNooriAbdulraheem Baghdad Teaching Hospital, Baghdad, Iraq
HaiderA.H.Ahmed Medical City Complex, Baghdad, Iraq
SajjadG.Al-Badri College of Medicine, University of Baghdad, Baghdad, Iraq
Waseem M. Al Hamidy Gastroenterology and Hepatology Teaching Hospital,
Medical City, Baghdad, Iraq
AbdulazeezS.Al-Janabi College of Medicine, University of Baghdad, Baghdad, Iraq
SalihAhmedAljiburi Baghdad Teaching Hospital, Baghdad, Iraq
MunthirA.Alobaidi Department of Surgery, College of Medicine, University of
Baghdad, Baghdad, Iraq
Noufelsh.Alshadood Baghdad Teaching Hospital, Baghdad, Iraq
Raafat Raoof Altur Department of Digestive Surgery, Gastroenterology and
Hepatology Teaching Hospital, Baghdad, Iraq
MustafaIsmail Department of Surgery, College of Medicine, University of Bagh-
dad, Baghdad, Iraq
AqeelShakirMahmood Department of General Surgery, University of Baghdad,
Baghdad, Iraq
TalibA.Majeed GIT and Liver Hospital, Medical City Baghdad, Baghdad, Iraq
SamerSabri Department of Surgery, Baghdad Teaching Hospital, Medical City
Complex, Baghdad, Iraq
SalehAbdulkareemSaleh College of Medicine, University of Baghdad, Baghdad, Iraq
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Abbreviations
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ACC Adrenocortical carcinoma
ACTH Adrenocorticotropic hormone
AFP Alpha-fetoprotein
AIDS Acquired immunodeciency syndrome
AIN Anal intraepithelial neoplasia
AIP Autoimmune pancreatitis
AJCC/UICC American Joint Committee on Cancer/Union for International
Cancer Control
APC Adenomatous polyposis coli
APR Abdominoperineal resection
ART Antiretroviral therapy
BCLC Barcelona Clinic Liver Cancer
BP Bisphosphonate
CagA Cytotoxin-associated gene A
CC Cholangiocarcinoma
CDKN2A Cyclin-dependent kinase inhibitor 2A
CEA Carcinoembryonic antigen
CRC Colorectal cancer
CRLMs Colorectal liver metastases
CRM Circumferential resection margin
CRS Cytoreductive surgery
CRT Chemoradiotherapy
CSCO Chinese Society of Clinical Oncology
CT Computed tomography
CTP Child-Turcotte-Pugh
DCIS Ductal carcinoma in situ
Dmab Denosumab
DTC Differentiated thyroid carcinoma
ECC Extrahepatic cholangiocarcinoma
EGJ Esophago-gastric junction
ER Endoscopic resection
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ERCP Endoscopic retrograde cholangiopancreatography
ESMO European Society for Medical Oncology
EUS Endoscopic ultrasound
FAP Familial adenomatous polyposis
FDG Fluoro-2-deoxy-D-glucose
FMTC Familial medullary thyroid carcinoma
FNA Fine-needle aspiration
FNAB Fine-needle aspiration biopsy
FNAC Fine-needle aspiration cytology
FTC Follicular thyroid carcinoma
GBC Gallbladder cancer
GERD Gastroesophageal reux disease
GIST Gastrointestinal stromal tumor
H. pylori Helicobacter pylori
HBV Hepatitis B virus
HCC Hepatocellular carcinoma
HCC Hepatocellular cholangiocarcinoma
HCM Hypercalcemia of malignancy
HDGC Hereditary diffuse gastric carcinoma
HIPEC Hyperthermic intraperitoneal chemotherapy
HIV Human immunodeciency virus
HNPCC Hereditary nonpolyposis colorectal cancer
HPT-JT Hyperparathyroidism-jaw tumor syndrome
HPV Human papilloma virus
HSgFOBT High-sensitivity guaiac fecal occult blood test
HSIL High-grade squamous intraepithelial lesions
HU Hounseld units
IAC IgG4-associated cholangitis
IBD Inammatory bowel disease
IBS Irritable bowel syndrome
ICC Intrahepatic cholangiocarcinoma
IgG Serum immunoglobulin
ILC Invasive lobular carcinoma
IPMN Intraductal papillary mucinous neoplasms
ITPN Intraductal tubulopapillary neoplasm
IVC Inferior vena cava
KGCA Korean Gastric Cancer Association
LABC Locally advanced breast cancer
LCIS Lobular carcinoma in situ
LD Latissimus dorsi
LN Lymph node
LSIL Low-grade squamous intraepithelial lesions
MELD Model for end-stage liver disease
MEN Multiple endocrine neoplasia
MPM Malignant peritoneal mesothelioma
Abbreviations
Abbreviations
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xxi
MRI Magnetic resonance imaging
MTC Medullary thyroid carcinoma
NAFLD Nonalcoholic fatty liver disease
NCCN National Comprehensive Cancer Network
NETs Neuroendocrine tumors
NSAIDs Nonsteroidal anti-inammatory drugs
NSM Nipple sparing mastectomy
PC Parathyroid carcinoma
PCC Perihilar cholangiocarcinoma
PDT Photodynamic therapy
PET Positron emission tomography
PHPT Primary hyperparathyroidism
PJS Peutz–Jeghers syndrome
PSC Primary sclerosing cholangitis
PTC Papillary thyroid carcinoma
PTCp Percutaneous transhepatic cholangiopancreatography
PTEN A tumor suppressor gene
PTGs Parathyroid glands
PTH Parathyroid hormone
PTMC Papillary thyroid microcarcinoma
RAI Radioactive iodine
Ras A family of related proteins involved in transmitting signals within cells
RFA Radiofrequency ablation
RT Radiotherapy
SBFT Small bowel follow-through
SCC Squamous cell carcinoma
SEMS Self-expandable metallic stent
SIADH Syndrome of inappropriate antidiuretic hormone
SIL Squamous intraepithelial lesions
SLNB Sentinel lymph node biopsy
SMA Superior mesenteric artery
T3 Triiodothyronine
T4 Thyroxine
TACE Transarterial chemoembolization
TG Thyroglobulin
TCL Total caudate lobectomy
TSH Thyroid-stimulating hormone
VTE Venous thromboembolism
Part I
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Surgical Gastrointestinal Oncology
Chapter 1
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Esophageal Tumors
SabahNooriAbdulraheem, TalibA.Majeed, Noufelsh.Alshadood,
SalehAbdulkareemSaleh, andAqeelShakirMahmood
1. A 65-year-old man presents with progressive dysphagia over the past 6months.
He has a history of chronic gastroesophageal reux disease and heavy tobacco
use. Endoscopy reveals a malignant-looking lesion in the esophagus, and biopsy
conrms a diagnosis of esophageal cancer. In the context of the epidemiology
and pathogenesis of esophageal cancer, which of the following statements is
incorrect?
A. Squamous cell carcinoma (SCC) and adenocarcinoma account for over
95% of esophageal malignant tumors, with distinct etiological factors inuencing their prevalence.
B. Globally, SCC is more prevalent than adenocarcinoma, although there is
signicant geographic variation inuenced by risk factors such as tobacco
and alcohol use.
C. SCC typically arises in the upper two-thirds of the esophagus and is strongly
associated with smoking and alcohol consumption.
D. In Western countries, adenocarcinoma has surpassed SCC in incidence,
often arising in the distal esophagus and associated with Barrett’s esophagus.
E. The incidence of esophageal cancer has been decreasing globally, reecting
successful public health interventions in risk factor modication.
Answer: E
S. N. Abdulraheem · N. s. Alshadood
Baghdad Teaching Hospital, Baghdad, Iraq
T. A. Majeed
GIT and Liver Hospital, Medical City Baghdad, Baghdad, Iraq
S. A. Saleh
College of Medicine University of Baghdad, Baghdad, Iraq
A. S. Mahmood (*)
Department of General Surgery, University of Baghdad, Baghdad, Iraq
Switzerland AG 2024
A. S. Mahmood, A. Koulouris (eds.), MCQs in General Surgical Oncology,
https://doi.org/10.1007/978-3-031-65738-2_1
3© The Author(s), under exclusive license to Springer Nature
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S. N. Abdulraheem et al.
Explanation: Options A to D are accurate and highlight the epidemiological
differences between SCC and adenocarcinoma of the esophagus. Option E is
false. The global incidence of esophageal cancer, particularly adenocarcinoma,
has been increasing, partly due to rising rates of obesity and gastroesophageal
reux disease.
2. A 58-year-old woman with a long history of tobacco use and chronic alcoholism presents with weight loss and dysphagia. She reports no family history of
cancer. An upper endoscopy reveals a suspicious lesion in the mid-esophagus,
and a biopsy conrms SCC of the esophagus. In the context of this patient’s
diagnosis, which of the following statements is incorrect regarding the risk factors for SCC of the esophageal cancer?
A. A family history of cancer can increase the risk of developing SCC of the
esophagus.
B. Smoking is a signicant risk factor for developing SCC of the esophagus.
C. Chronic alcohol consumption is associated with an increased risk of SCC of
the esophagus.
D. Use of bisphosphonates (BP) has been linked with an increased risk of SCC
of the esophagus.
E. Barrett’s esophagus is a risk factor for SCC of the esophagus.
Answer: E
Explanation: Barrett’s esophagus, which involves intestinal metaplasia, is a
risk factor for adenocarcinoma of the esophagus, not SCC.The other statements
correctly identify known risk factors for SCC of the esophagus, although the
association with BP is less denitive compared to smoking and alcohol.
3. A 62-year-old man, a heavy smoker with a long history of dietary habits that
include high red meat and hot beverage consumption, presents with symptoms
suggestive of esophageal cancer. His dietary history is being reviewed as part of
the risk assessment and counseling. In the context of this patient’s risk prole,
which of the following statements is incorrect regarding dietary risk factors of
esophageal cancer?
A. Increased intake of red meat, particularly when processed or cooked at high
temperatures, has been associated with an increased risk of esophageal cancer due to the formation of carcinogenic compounds.
B. High selenium intake, contrary to its antioxidant properties, is linked with
an increased risk of esophageal cancer.
C. Regular consumption of extremely hot tea has been implicated in esopha-
geal mucosal injury, potentially increasing the risk of esophageal cancer.
D. Low zinc intake, contributing to impaired DNA repair and mucosal defense,
has been associated with an elevated risk of esophageal cancer.
E. Low folate intake, leading to disruptions in DNA methylation and repair, is
a recognized risk factor for esophageal cancer development.
Answer: B
1 Esophageal Tumors
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5
Explanation: Contrary to the assertion in the question, low selenium levels
are a risk factor for esophageal cancer, and selenium supplementation has been
associated with a reduced risk. The other options accurately describe dietary
factors that have been linked to an increased risk of esophageal cancer.
4. A 63-year-old patient with a history of heavy smoking and alcohol consumption presents with dysphagia and signicant weight loss. An endoscopy reveals
a lesion in the mid-thoracic esophagus, and biopsy conrms SCC.The oncology team is discussing the patient’s diagnosis in light of common characteristics and presentations of SCC of the esophagus. In the context of this patient’s
diagnosis, which of the following statements is incorrect regarding SCC of the
esophagus?
A. LN metastases are present in at least 75% of patients at the time of initial
diagnosis, indicating the aggressive nature of this cancer.
B. Carcinoma in situ in the esophagus typically progresses to invasive SCC
over a period of 2 to 4years.
C. The most common locations for SCC of the esophagus are the upper and
mid-thoracic segments, correlating with this patient’s lesion.
D. Esophageal carcinoma, including SCC, tends to present with multifocal
lesions, necessitating thorough evaluation of the entire esophagus.
E. Ulcerative lesions with extensive inltration of the adjacent esophageal
wall represent the most common macroscopic nding in SCC of the
esophagus.
Answer: E
Explanation: Macroscopically, the most common form of SCC of the esophagus is fungating intraluminal growths (60%), not ulcerative lesions with extensive inltration (25%). The other statements correctly describe aspects of SCC
of the esophagus: high prevalence of LN metastases at diagnosis, progression
timeline from carcinoma in situ to invasive cancer, common locations of tumors,
and the tendency for multifocality.
5. A 67-year-old man with a long-standing history of smoking and alcohol use
presents with progressive dysphagia, particularly to solid foods, and recent
unexplained weight loss. Given his risk factors and symptoms, the medical
team suspects esophageal cancer and plans a comprehensive diagnostic workup.
In the context of this patient’s clinical presentation, which of the following
statements is incorrect regarding the presentation of esophageal cancer?
A. Dysphagia, a hallmark symptom of esophageal cancer, typically manifests
when approximately 90% of the esophageal lumen is obstructed by
the tumor.
B. Dysphagia is generally the most common presenting symptom in patients
with esophageal cancer, often indicating advanced disease.
C. In cases of proximal and middle esophageal tumors, bronchoscopy may be
indicated to assess for potential airway involvement.
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S. N. Abdulraheem et al.
D. Implementing a widespread screening program for esophageal cancer is not
considered cost-effective due to the relatively low prevalence and the specicity of risk factors.
E. Positron emission tomography (PET) scan, offering metabolic information,
is often superior to computed tomography (CT) in assessing the extent of
esophageal cancer and detecting distant metastases.
Answer: A
Explanation: Dysphagia in esophageal cancer typically occurs when approximately two-thirds of the esophageal lumen is obstructed, not 90%. The other
options are accurate: dysphagia is a common presenting symptom, bronchoscopy may be necessary for tumors in certain locations, screening programs are
not widely implemented for esophageal cancer, and PET scans can provide
more detailed information compared to CT scans in certain aspects of staging.
6. A 62-year-old woman with a long history of GERD presents with recent worsening of her symptoms. She mentions a new onset of dyspepsia and has lost
weight over the past few months. Her family history is notable for gastrointestinal cancer. The clinical team is considering further investigations to rule out
serious underlying conditions. In the context of this patient’s presentation,
which of the following statements is incorrect regarding alarm features
of GERD?
A. New onset of dyspepsia in a patient aged 60years or older warrants further
investigation due to the increased risk of malignancy in this age group.
B. Iron-deciency anemia, which may indicate chronic gastrointestinal bleed-
ing, is a signicant alarm feature in patients with GERD.
C. Odynophagia, or painful swallowing, is an alarming symptom that can indi-
cate severe esophageal inammation or malignancy.
D. Gastrointestinal cancer in a rst-degree relative not related to the patient’s
current symptoms is considered an alarm feature in GERD.
E. Anorexia, particularly when associated with unintentional weight loss, is an
alarming symptom that may indicate a more serious underlying pathology
in GERD patients.
Answer: D
Explanation: While having a rst-degree relative with gastrointestinal cancer is an important consideration in the overall assessment, it is not directly
considered an alarm feature of GERD unless it specically relates to the
patient’s symptoms. The other options accurately describe alarm features that
necessitate further evaluation to rule out serious conditions such as esophageal cancer.
7. A 60-year-old man with a history of chronic gastroesophageal reux disease
(GERD) for over 15years presents for a routine checkup. He has been on longterm proton pump inhibitor therapy and occasionally takes nonsteroidal antiinammatory drugs (NSAIDs) for joint pain. An endoscopy reveals changes
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