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1 Esophageal Tumors
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Answer: A
Explanation: Laimer’s triangle is not superior to Killian’s triangle; in fact,
both are located at the same level, each at different parts of the esophagus.
Killian’s triangle is at the pharyngoesophageal junction, while Laimer’s triangle is adjacent to the esophagogastric junction. The other options, while complex, accurately describe the intricate anatomical relationships around the
esophagus that are crucial during esophageal surgeries.
25. A 58-year-old patient who underwent esophagectomy for esophageal cancer
6months ago is being followed up in clinic. The patient had a history of SCC
and received a combination of surgery and radiation therapy. The oncology
team is reviewing the patient’s posttreatment outcomes and discussing common
issues encountered in similar cases. In the context of this patient’s posttreatment follow-up, which of the following statements is incorrect regarding outcomes after esophageal cancer treatment?
A. Surgical bypass is seldom utilized for unresectable esophageal carcinoma
due to limited efcacy and the presence of less invasive palliative options.
B. The development of reux esophagitis following low intrathoracic esopha-
gogastric anastomosis is rare, as most patients with esophageal carcinoma
have limited life expectancy post-surgery.
C. Radical transthoracic esophagectomy with en bloc dissection of lymph
node-bearing tissues has not demonstrated a survival advantage over transhiatal esophagectomy.
D. Although SCC of the esophagus is generally considered radiosensitive,
radiation therapy alone rarely achieves a cure in most patients.
E. Endoscopic laser fulguration, used for palliative treatment of esophageal
tumors, achieves symptomatic improvement in up to 75% of patients.
Answer: B
Explanation: Contrary to the traditional teaching, the development of reux
esophagitis after low intrathoracic esophagogastric anastomosis is a signicant
concern, even in patients with esophageal carcinoma. These patients can experience severe reux symptoms and dysphagia from benign stenosis. The other
options accurately describe various aspects of esophageal cancer treatment outcomes: limited role of surgical bypass, comparison of radical transthoracic and
transhiatal esophagectomies, the efcacy of radiation therapy in SCC, and the
success rate of endoscopic laser fulguration.
26. A 42-year-old patient presents with dysphagia and mild chest pain. An endoscopy reveals a submucosal mass in the esophagus, and subsequent investigations suggest a benign neoplasm, likely a leiomyoma. The surgical oncology
team discusses the management options and the general characteristics of
benign esophageal neoplasms. In the context of this patient’s diagnosis, which
of the following statements is incorrect regarding benign esophageal neoplasms?
A. Benign tumors of the esophagus are relatively rare, constituting less than
1% of all esophageal neoplasms.
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B. Asymptomatic leiomyomas can often be managed with observation and fol-
lowed up with periodic barium esophograms and endoscopic
ultrasonography.
C. Leiomyomas in the esophagus characteristically occur in patients between
50 and 70years of age.
D. Benign esophageal tumors smaller than 5 cm in size infrequently cause
symptoms and are often found incidentally.
E. Leiomyomas are the most common type of benign intramural tumor found
in the esophagus.
Answer: C
Explanation: Leiomyomas typically occur in a younger age group, characteristically between 20 and 50years of age, not 50 to 70years as stated. The
other options correctly describe aspects of benign esophageal neoplasms: their
rarity, management approach for asymptomatic leiomyomas, symptomatology
related to tumor size, and the prevalence of leiomyomas as benign esophageal tumors.
27. In a multidisciplinary team meeting, a 68-year-old patient with end-stage
esophageal cancer is being discussed. The patient has undergone chemoradiation and is experiencing signicant dysphagia. The team reviews various aspects
of management and prognosis for patients in similar stages of esophageal cancer. In the context of this patient’s condition and treatment, which of the following statements is incorrect regarding end-stage esophageal cancer?
A. Patients with dysphagia secondary to esophageal cancer who are treated
with radiation can generally expect symptomatic relief to last for approximately 2–3months.
B. Surgery following chemoradiation induction is typically recommended to
occur after 6months.
C. The general 5-year relative survival rate for esophageal cancer in the United
States is around 21%.
D. Esophageal cancer is responsible for over 15,000 deaths annually in the
United States.
E. More than one-third of esophageal cancer cases are metastasized at the time
of diagnosis.
Answer: B
Explanation: Surgery after chemoradiation induction for esophageal cancer
is typically planned for 6 to 8weeks following the completion of therapy, not
after 6 months. The other statements correctly reect aspects of end-stage
esophageal cancer: the duration of symptomatic relief from radiation therapy
for dysphagia, the general 5-year survival rate, the annual mortality rate, and
the proportion of cases presenting with metastasis at diagnosis.
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18. Zhang S, Orita H, Fukunaga T.Current surgical treatment of esophagogastric junction adenocarcinoma. World J Gastrointest Oncol. 2019;11:567–78.
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A.Endoscopic balloon dilatation for benign brotic strictures after curative nonsurgical treatment for esophageal cancer. Surg Endosc. 2012;26(10):2877–83. Epub 2012 Apr 28. https://
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cancers14225556.
22. Shirinzadeh A, Talebi Y.Pulmonary complications due to esophagectomy. J Cardiovasc Thorac
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doi.org/10.5681/jcvtr.2011.020.
23. Rice TW, Kelsen D, Blackstone EH, etal. Esophagus and esophagogastric junction. In: Amin
MB, editor. AJCC Cancer Staging Manual. 8th ed. Chicago: AJCC; 2017. p.185. Corrected
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24. Oezcelik A, DeMeester SR. General anatomy of the esophagus. Thorac Surg Clin.
2011;21(2):289–97, x. https://doi.org/10.1016/j.thorsurg.2011.01.003.
25. Nishimura K, Tanaka T, Tanaka Y, Matono S, Murata K, Shirouzu K, Fujita H. Reux
esophagitis and columnar-lined esophagus after cervical esophagogastrostomy (following esophagectomy). Dis Esophagus. 2010;23(2):94–9. Epub 2009 Jul 31. https://doi.
org/10.1111/j.1442- 2050.2009.00998.x.
26. O’Hanlon DM, Clarke E, Lennon J, Gorey TF. Leiomyoma of the esophagus. Am J Surg.
2002;184(2):168–9. https://doi.org/10.1016/s0002- 9610(02)00905- 4.
27. Rampado S, Bocus P, Battaglia G, Ruol A, Portale G, Ancona E.Endoscopic ultrasound: accuracy in staging supercial carcinomas of the esophagus. Ann Thorac Surg. 2008;85(1):251–6.
https://doi.org/10.1016/j.athoracsur.2007.08.021.
28. Watanabe M, Otake R, Kozuki R, Toihata T, Takahashi K, Okamura A, Imamura Y.Recent
progress in multidisciplinary treatment for patients with esophageal cancer. Surg Today.
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31535225; PMCID: PMC6952324. https://doi.org/10.1007/s00595- 019- 01878- 7.
S. N. Abdulraheem et al.
Chapter 2
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Gastric Tumors
SalihAhmedAljiburi, MunthirA.Alobaidi, RaafatRaoofAltur,
SalehAbdulkareemSaleh, andAqeelShakirMahmood
1. A 55-year-old male presents with weight loss and epigastric pain. Endoscopy
reveals a gastric ulcer, and biopsy conrms adenocarcinoma. His family history
is signicant for gastric cancer in his father. Based on this case and your knowledge of gastric cancer epidemiology, identify the incorrect statement:
A. Gastric cancer is the fth most common malignancy globally, with higher
prevalence in East Asia, Eastern Europe, and South America.
B. The majority of cases (>70%) are diagnosed in developing countries, often
presenting at advanced stages.
C. The incidence of gastric cancer is higher in men than in women, with a
male-to-female ratio of approximately 2:1.
D. In high-incidence countries, distal gastric carcinomas are more common,
while in low-incidence countries, proximal tumors predominate.
E. H. pylori infection is a signicant risk factor, especially in early-onset cases
and those with a family history of gastric cancer.
Answer: A
S. A. Aljiburi
Baghdad Teaching Hospital, Baghdad, Iraq
M. A. Alobaidi
Department of Surgery, College of Medicine, University of Baghdad, Baghdad, Iraq
R. R. Altur
Department of Digestive Surgery, Gastroenterology and Hepatology Teaching Hospital,
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_2
21© The Author(s), under exclusive license to Springer Nature
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Explanation: While option A is partially correct in stating that gastric cancer
has a higher prevalence in certain regions, it inaccurately ranks gastric cancer as
the fth most common malignancy globally. Gastric cancer is actually the third
most common malignancy.
2. A 63-year-old female with a history of chronic gastritis presents with progressive dysphagia and weight loss. An endoscopic biopsy conrms gastric adenocarcinoma. Considering global epidemiological trends of gastric cancer,
identify the incorrect statement:
A. Gastric cancer incidence is higher in regions with more temperate or colder
climates, reecting geographic variations in risk factors.
B. Over the past four decades, there has been a signicant worldwide decline
in the incidence of gastric cancer, attributed to improved dietary and health
practices.
C. Gastric cancer ranks as the third most deadly cancer globally, following
lung and colorectal cancers.
D. Gastric cancer accounts for approximately 1 in 12 of all cancer-related
deaths, underscoring its signicant impact on global health.
E. Annually, gastric cancer is diagnosed in approximately one million indi-
viduals worldwide, highlighting its substantial prevalence.
Answer: C
Explanation: Gastric cancer is actually the fourth leading cause of cancer
deaths globally, after lung, colorectal, and liver cancers.
3. A 50-year-old male with a long-standing history of gastroesophageal reux disease and recent onset of anemia is diagnosed with gastric cancer. His dietary
history reveals a preference for smoked and pickled foods. Considering his
diagnosis, identify the incorrect risk factor for gastric cancer:
A. H. pylori infection, which is strongly associated with both intestinal and
diffuse types of gastric cancer.
B. Consumption of salt-preserved foods, which has been linked to gastric
mucosal injury and subsequent carcinogenesis.
C. Exposure to nitroso compounds, commonly found in processed and pre-
served meats, contributing to gastric carcinogenesis.
D. Obesity, particularly central obesity, which is associated with an increased
risk of cardia gastric cancer.
E. High consumption of citrus fruits, which, due to their high acid content,
may exacerbate gastritis and contribute to carcinogenesis.
Answer: E
Explanation: High consumption of fruits is generally considered a protective
factor against gastric carcinoma due to their antioxidant properties and ber
content. The other options correctly identify established risk factors for gastric
cancer. This question includes a subtle distraction (high citrus fruit consumption) which is plausible but not supported by current evidence as a risk factor
for gastric cancer.
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4. A 58-year-old female with a history of smoking and chronic gastritis, currently
undergoing treatment for H. pylori infection, is diagnosed with early-stage gastric cancer. Reecting on her history and the known risk factors for gastric
cancer, identify the incorrect risk factor:
A. Smoking, which is a well-established risk factor for gastric cancer due to its
carcinogenic effects on the gastric mucosa.
B. GERD, which can lead to Barrett’s esophagus and an increased risk of gas-
tric cardia cancer.
C. Chronic alcohol use, associated with increased gastric mucosal damage and
a heightened risk of gastric cancer.
D. Long-term use of nonsteroidal anti-inammatory drugs (NSAIDs), known
to reduce the risk of gastric cancer, especially in patients with a history of
H. pylori-associated ulcers.
E. Infection with Epstein-Barr virus (EBV), implicated in a subset of gastric
cancers, particularly those with lymphoepithelioma-like features.
Answer: D
Explanation: Contrary to the claim in the option, regular use of NSAIDs is
associated with a protective effect against the development of gastric carcinoma, especially in patients with gastric ulcers related to H. pylori infection.
The other options correctly identify known risk factors for gastric cancer.
5. A 62-year-old man with a 10-year history of intermittent dyspepsia presents
with recent onset of weight loss and epigastric pain. Endoscopic biopsy conrms a diagnosis of gastric adenocarcinoma, and H. pylori infection is detected.
Considering the role of H. pylori in gastric cancer, identify the incorrect statement about its association with gastric carcinoma:
A. H. pylori infection is considered the strongest known risk factor for the
development of gastric cancer, initiating a cascade of mucosal changes.
B. The pathogenesis involves H. pylori-induced chronic gastritis, leading to
mucosal atrophy, intestinal metaplasia, and progression to neoplasia.
C. The VacA toxin, produced by H. pylori, is the primary virulence factor
implicated in the direct development of gastric carcinoma.
D. H. pylori infection may cause oxidative DNA damage, which contributes to
the neoplastic transformation of gastric mucosal cells.
E. H. pylori is implicated in the development of both intestinal-type and
diffuse- type gastric cancers, affecting different gastric regions.
Answer: C
Explanation: While the VacA toxin of H. pylori is a signicant virulence factor, it is the strain of H. pylori containing the cytotoxin-associated gene A
(CagA) that carries the greatest risk for gastric carcinoma development. The
other options accurately reect the role of H. pylori in the pathogenesis of gastric cancer.
6. A 40-year-old woman with a family history of gastric cancer undergoes genetic
counseling. Her father and aunt were diagnosed with diffuse gastric cancer at
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ages 45 and 48, respectively. She is concerned about her risk for hereditary diffuse gastric cancer (HDGC). Based on your knowledge of HDGC, identify the
incorrect statement:
A. Individuals with HDGC have a lifetime risk exceeding 70% for developing
diffuse gastric cancer.
B. HDGC is often caused by mutations in the CDH1 tumor suppressor gene,
leading to an increased risk of developing this cancer.
C. Female carriers of the mutation also face an elevated risk of developing
lobular breast cancer.
D. The main management strategies for HDGC include prophylactic total gas-
trectomy or intensive endoscopic surveillance.
E. Familial HDGC is dened as having at least two family members diagnosed
with diffuse gastric cancer before the age of 50, or three close relatives
diagnosed at any age.
Answer: E
Explanation: Familial HDGC is dened as having two or more family members diagnosed with diffuse gastric cancer before the age of 50, or one member
diagnosed before 50 and another at any age, or three close relatives diagnosed
at any age
7. A 67-year-old male with a history of chronic gastritis undergoes gastrectomy
for gastric cancer. Histopathological examination reveals poorly differentiated
adenocarcinoma. Reecting on the Lauren classication of gastric cancer, identify the incorrect statement:
A. The Lauren classication categorizes gastric tumors based on microscopic
appearance into two main subtypes: intestinal and diffuse.
B. The diffuse type of gastric cancer is more commonly seen in older males
and is characterized by poorly cohesive cells.
C. Regardless of the local extent of the disease, poorly differentiated cancers,
as seen in the diffuse type, generally have a poorer prognosis.
D. The pathogenesis of gastric cancer involves epigenetic changes such as
DNA methylation, histone modications, and chromosomal
rearrangements.
E. Lauren classication plays a signicant role as a prognostic indicator and
inuences the surgical strategy in gastric cancer treatment.
Answer: B
Explanation: Diffuse-type gastric cancer is more commonly seen in younger
individuals and has a higher frequency in females, not predominantly in older
males as stated. The other options accurately describe aspects of the Lauren
classication and its implications in the pathogenesis, prognosis, and treatment
of gastric cancer.
8. A 72-year-old male presents with weight loss, abdominal pain, and irondeciency anemia. Gastroscopy reveals a mass in the gastric antrum, and biopsy
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conrms intestinal-type gastric carcinoma. Considering the characteristics of
intestinal-type gastric cancer, identify the incorrect statement:
A. Tumor cells in intestinal-type gastric carcinoma adhere together, forming
distinct tubular or glandular structures.
B. This cancer subtype is more prevalent in males and is typically diagnosed in
older age groups.
C. Despite its specic histological features, intestinal-type gastric carcinoma
generally has a poorer prognosis.
D. Intestinal-type gastric carcinoma is often associated with lymphatic and
vascular invasion, contributing to its metastatic potential.
E. The gastric antrum is the most common site for intestinal-type gastric car-
cinoma, correlating with specic epidemiological patterns.
Answer: C
Explanation: Intestinal-type gastric carcinoma, characterized by wellformed glandular structures, generally has a better prognosis compared to the
diffuse type, especially when diagnosed at an early stage. The other options
accurately describe the histopathological and clinical characteristics of
intestinal- type gastric carcinoma.
9. A 45-year-old female, with no signicant past medical history, presents with
early satiety and abdominal bloating. An endoscopy reveals linitis plastica, and
biopsies conrm a diagnosis of diffuse-type gastric cancer. Evaluating your
knowledge about this subtype, identify the incorrect statement:
A. The tumor cells in diffuse-type gastric cancer characteristically lack adhe-
sion, inltrating the stroma either as single cells or in small clusters.
B. A hallmark feature is the presence of signet ring cells, where intracellular
mucus displaces the nucleus to the periphery.
C. This cancer subtype is characterized by a lack of gland formation, with
tumor cells invading surrounding tissues.
D. Diffuse-type gastric cancer tends to occur more frequently in younger indi-
viduals and has a slight predilection for females.
E. Diffuse-type gastric cancer predominantly affects the gastric fundus, pre-
senting with distinct clinical features from other types.
Answer: E
Explanation: Diffuse-type gastric cancer most commonly affects the body of
the stomach, not the fundus. This subtype is known for its worse prognosis and
shorter duration of symptoms compared to intestinal-type gastric cancer. The
other options correctly describe the pathological features and demographic tendencies of diffuse-type gastric cancer.
10. A 40-year-old individual with a family history suggestive of hereditary diffuse
gastric cancer (HDGC) syndrome undergoes genetic counseling and testing.
They are found to have a mutation in the CDH1 gene. In light of this, assess
your knowledge about diffuse-type gastric cancer, and identify the incorrect
statement:
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A. Environmental factors play a less signicant role in the etiology of diffuse-
type gastric cancer compared to genetic predispositions.
B. The development of this cancer subtype is directly linked to chronic active
inammation within the gastric mucosa.
C. Active gastritis, particularly when persistent and severe, is considered a
major risk factor for diffuse-type gastric cancer.
D. The expression of E-cadherin is unrelated to the pathogenesis of diffuse-
type gastric cancer.
E. In certain scenarios, such as genetic predisposition, prophylactic total gas-
trectomy is recommended to prevent the development of diffuse-type gastric cancer.
Answer: D
Explanation: The loss of E-cadherin expression, often due to inactivation of
the gene encoding E-cadherin (CDH1), is a crucial event in the carcinogenesis
of diffuse-type gastric carcinoma. This loss leads to defective intracellular
adhesions, which is a hallmark of this cancer subtype.
11. During a multidisciplinary tumor board review, a case of a 55-year-old male
with newly diagnosed gastric cancer is discussed. Histopathology reveals a
mixed pattern of adenocarcinoma. Considering the WHO classication of gastric cancers, identify the incorrect statement:
A. The WHO classication categorizes gastric cancers based on the predomi-
nant histologic pattern, acknowledging the presence of less dominant elements of other histologic types.
B. This classication encompasses tubular, papillary, poorly cohesive (includ-
ing signet ring cell), mucinous, mixed, and rare variants of gastric carcinoma.
C. The most commonly diagnosed subtype of gastric cancer is poorly cohesive
signet ring cell carcinoma.
D. Papillary adenocarcinoma, typically occurring in the proximal stomach, is
notably associated with a higher incidence of liver metastases.
E. Mucinous gastric carcinoma, characterized by abundant extracellular mucin
production, accounts for about 10% of all gastric cancer cases.
Answer: C
Explanation: According to the WHO classication, the most common histologic subtype of gastric cancer is tubular adenocarcinoma, not poorly cohesive
signet ring cell carcinoma. The other options accurately reect the WHO classication’s categories and characteristics of gastric cancer subtypes.
12. A 60-year-old female with advanced gastric cancer undergoes diagnostic laparoscopy, revealing peritoneal and liver metastases. Considering the modes of
spread for gastric cancer, identify the incorrect statement:
A. Gastric cancer can inltrate locally, invading adjacent structures and tissues
in the abdominal cavity.
B. Hematogenous spread is a recognized pathway, with common sites of dis-
tant metastasis including the liver and lungs.
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