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General Oncology - Important Questions for DrNB Surgical Oncology

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1. CANCER BIOLOGY & CARCINOGENESIS

• Hallmarks of cancer (Hanahan & Weinberg) - describe each hallmark with examples
• Oncogenes vs tumor suppressor genes - give examples and mechanisms
• Cell cycle regulation and checkpoints in cancer
• Proto-oncogene activation mechanisms (amplification, point mutation, translocation)
• Apoptosis pathways and their role in tumorigenesis
• Role of p53 in cancer (Li-Fraumeni syndrome)
• Tumor angiogenesis - mechanisms and anti-angiogenic therapy
• Cancer stem cell hypothesis
• Epithelial-mesenchymal transition (EMT) and metastasis
• Tumor microenvironment - components and significance

• Describe cancer immunotherapy and its predictive markers (NEET SS 2024, Paper 3)
• Biochemical diagnostic assessment of pheochromocytoma (NEET SS 2024)

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2. CANCER IMMUNOLOGY & IMMUNOTHERAPY (High-Yield)

• Immune surveillance theory - concept and evidence
• Tumor antigens: Tumor-specific (TSA) vs Tumor-associated (TAA) antigens
• Immune checkpoints: CTLA-4, PD-1/PD-L1 - mechanisms of T-cell exhaustion and checkpoint blockade
• CAR T-cell therapy - structure, mechanism, indications (CD19 for B-cell malignancies, BCMA for multiple myeloma), toxicities (CRS)
• Tumor-infiltrating lymphocytes (TILs) - clinical significance
• Monoclonal antibodies in oncology: Trastuzumab, Cetuximab, Bevacizumab, Pembrolizumab, Nivolumab

• PD-L1 expression
• Microsatellite instability (MSI-H) / Mismatch repair deficiency (dMMR)
• Tumor mutational burden (TMB)
• EBV status, HER2 amplification

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3. STAGING & TNM CLASSIFICATION

• TNM staging system - principles, clinical vs pathological staging
• AJCC 8th edition staging updates (know breast, colon, stomach, melanoma)
• Staging investigations - role of CT, MRI, PET-CT, bone scan
• Staging laparoscopy - indications (gastric, pancreatic, hepatobiliary cancers)
• Performance status scales: ECOG / Karnofsky - significance in treatment decisions

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4. TUMOR MARKERS

• Tumor markers are NOT used alone for diagnosis
• CEA: NOT useful for screening; used for post-operative surveillance in CRC
• Oncomarkers vs genetic markers (BRCA, RET, APC, MLH1/MSH2)

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5. CANCER GENETICS & HEREDITARY SYNDROMES

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6. PRINCIPLES OF SURGERY IN ONCOLOGY

• R0, R1, R2 resection - definitions and implications for local recurrence and survival
• Margin assessment after tumor resection - intraoperative techniques (frozen section, IOUS, touch prep cytology) (NEET SS 2024)
• Wide local excision vs radical surgery - organ preservation trend
• En-bloc resection - principle and examples (Whipple, radical neck dissection)
• No-touch isolation technique in colorectal cancer surgery
• Cytoreductive surgery (CRS) + HIPEC - principles, peritoneal carcinomatosis index (PCI), Completeness of Cytoreduction (CC) score

• Chylous fistula after neck dissection - causes, management (NEET SS 2024)
• Osteoradionecrosis in oral cancer - management (NEET SS 2024)

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7. NEOADJUVANT & ADJUVANT THERAPY

• Neoadjuvant therapy - rationale, advantages (tumor downsizing, early treatment of micrometastases, assess response, organ preservation)
• Adjuvant therapy - indications based on risk stratification
• Pathological Complete Response (pCR) - significance as surrogate endpoint
• Preoperative vs postoperative radiotherapy in rectal cancer (short-course vs long-course CRT)
• Induction chemotherapy - head and neck cancers

• Neoadjuvant therapy in breast cancer - regimens (AC-T, TCH for HER2+)
• Adjuvant therapy for GIST - Imatinib (3 years vs 1 year, mutation type matters: exon 11 responds best) (NEET SS 2024)
• Adjuvant chemotherapy in colon cancer - FOLFOX for stage III; not routinely stage II (unless high risk)

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8. METRONOMIC THERAPY (Commonly Asked)

• Definition: Administration of cytotoxic drugs at low doses continuously or at frequent intervals without prolonged rest periods, targeting the tumor vasculature primarily
• Mechanism: Anti-angiogenic (reduces VEGF), immunomodulatory (reduces regulatory T cells), direct cytostatic effect on tumor cells
• Advantages: Low cost, low toxicity, applicable in resource-limited settings
• Examples: Oral cyclophosphamide + methotrexate in breast cancer; capecitabine in colorectal cancer
• Metronomic vs MTD (maximum tolerated dose): Metronomic avoids the "rebound" angiogenesis seen between conventional cycles

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9. RESEARCH METHODS & BIOSTATISTICS (High-Yield for Theory)

• Survival analysis methods: Kaplan-Meier curves, log-rank test, Cox proportional hazards regression (NEET SS 2024)
• Multivariate analysis - purpose, confounders, logistic regression vs Cox regression (NEET SS 2024)
• Randomized Controlled Trial (RCT) - design, phases of clinical trials (Phase I-IV)
• Meta-analysis vs systematic review - difference, forest plot, funnel plot, heterogeneity (I²)
• Number needed to treat (NNT), relative risk, absolute risk reduction
• CONSORT, PRISMA statements
• Cancer registry in India (NEET SS 2024) - PBCR (Population-Based Cancer Registry) vs HBCR (Hospital-Based), ICMR's NCDIR role, NCRP

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10. SOLITARY PULMONARY NODULE (SPN) (NEET SS 2024 - Full Question)

• Definition: Single, well-defined opacity ≤3 cm surrounded by lung parenchyma
• Fleischner Society Guidelines (2017): Based on size, solid vs subsolid (ground-glass vs part-solid), and risk factors (smoking, age, morphology)

• Ground-glass opacity (GGO) management: Longer follow-up (pure GGO may represent AIS - adenocarcinoma in situ); part-solid nodules have highest malignancy risk
• Biopsy options: CT-guided FNAC, bronchoscopic (if central), VATS resection

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11. NEUROENDOCRINE TUMORS & PHEOCHROMOCYTOMA

• Biochemical diagnosis of pheochromocytoma (NEET SS 2024):
  • 24-hour urinary metanephrines and normetanephrines (best sensitivity)
  • Plasma free metanephrines (best specificity)
  • Urinary VMA (older test, less sensitive)
  • CT/MRI adrenal for localization; MIBG scan for extra-adrenal/metastatic
  • Rule of 10s: 10% bilateral, 10% malignant, 10% extra-adrenal, 10% familial
• Metastatic neuroendocrine tumor of pancreas (NEET SS 2024): Somatostatin analogues (octreotide/lanreotide), PRRT (Lu-177 DOTATATE), everolimus, sunitinib, cytoreductive surgery

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12. OTHER IMPORTANT TOPICS

• Acellular dermal matrix (ADM) and applications in breast reconstruction (NEET SS 2024)
• Self-expanding metallic stents (SEMS) - types, indications (esophageal, colorectal, biliary obstruction), complications (NEET SS 2024)
• Transoral robotic surgery (TORS) - indications, advantages over open surgery (NEET SS 2024)
• Ablative therapy for liver tumors - RFA, MWA, cryotherapy, TACE, SBRT (NEET SS 2024)
• Mediastinal staging in NSCLC (NEET SS 2024) - EBUS-TBNA, EUS-FNA, mediastinoscopy, mediastinotomy; ESTS/ESMO guidelines
• Bladder cancer - palliative management of advanced disease (NEET SS 2024) - cystectomy, diversion, TURBT, chemotherapy, pembrolizumab
• Sentinel node biopsy in gynecological malignancies (NEET SS 2024) - technique (blue dye + technetium-99m / ICG), validation in endometrial and cervical cancer
• Oncoplastic breast surgery - volume displacement vs replacement; therapeutic mammoplasty

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HOW THE PAPER IS STRUCTURED

• Paper 1 & 2: MCQ-based (broad specialty + superspecialty)
• Paper 3: 10 descriptive questions (3 hours, 100 marks) - mix of 40% broad specialty (general surgery/oncology) and 60% superspecialty (organ-specific surgical oncology)

1. One question on cancer biology/immunotherapy
2. One on biostatistics/research methodology
3. One on staging/imaging
4. One on surgical principles (margins, techniques)
5. One on systemic therapy (chemo/targeted/hormonal)

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QUICK-REVISION HIGH-YIELD POINTS

• Checkpoint inhibitors work best in: MSI-H, high TMB, PD-L1 high tumors
• CAR T cells: CD19 (ALL/DLBCL), BCMA (myeloma) - cause cytokine release syndrome (CRS)
• Adjuvant imatinib in GIST: 3 years for high-risk; exon 11 mutation responds best; exon 9 needs higher dose
• Metronomic chemotherapy = low-dose continuous; anti-angiogenic + immunomodulatory
• pCR after neoadjuvant therapy = best predictor of long-term survival in breast cancer (event-free survival)
• Fleischner Society: No follow-up for solid nodules <6 mm in low-risk patients
• Pheochromocytoma diagnosis: Plasma/urine metanephrines (NOT VMA as first test)
• Cancer registry in India: NCRP under ICMR; first PBCR established in Mumbai (1963)

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