Colorectal Cancer: MCQ bank

A 66-year-old man has haemoglobin 8.4 g/dL, MCV 68 fL and ferritin 6 ng/mL. He has no gastrointestinal symptoms and eats a mixed diet. What is the most appropriate next step?

1. AStool for occult blood; endoscopy only if positive
2. BCEA estimation
3. CColonoscopy and upper GI endoscopy
4. DHaemoglobin electrophoresis
5. EOral iron and review in 3 months

Which presentation is most typical of a carcinoma of the caecum?

1. AEarly large-bowel obstruction
2. BPencil-thin stools
3. CTenesmus
4. DBright red blood coating the stool
5. EIron-deficiency anaemia and fatigue

A 58-year-old woman has bled per rectum for 4 months; haemorrhoids were seen on proctoscopy and treated, but bleeding continues. What should be done?

1. ARepeat proctoscopy in 6 months
2. BReassure, as the source is identified
3. CBarium meal follow-through
4. DColonoscopy to examine the whole colon
5. EHaemorrhoidectomy

Which hereditary syndrome is the commonest cause of inherited colorectal cancer?

1. ALynch syndrome
2. BMUTYH-associated polyposis
3. CFamilial adenomatous polyposis
4. DJuvenile polyposis
5. EPeutz–Jeghers syndrome

Familial adenomatous polyposis is caused by a germline mutation in which gene?

1. AMLH1
2. BAPC
3. CSTK11
4. DSMAD4
5. EMUTYH

A patient with Streptococcus gallolyticus (bovis) endocarditis should also have:

1. AUpper GI endoscopy only
2. BColonoscopy
3. CBone marrow biopsy
4. DCT brain
5. EMammography

Most colorectal cancers develop through which sequence?

1. AHyperplastic polyp → carcinoma in all cases
2. BNormal mucosa → carcinoma within months
3. CNormal mucosa → adenoma → carcinoma over about 10 years
4. DHamartoma → carcinoma
5. EUlcerative colitis → carcinoma in most cases

Which molecular route underlies most sporadic MSI-high colorectal cancers?

1. ASerrated pathway with BRAF V600E and MLH1 promoter methylation
2. BHER2 amplification
3. CGermline MSH2 mutation
4. DTP53 germline mutation
5. EAPC loss followed by KRAS mutation

The faecal immunochemical test (FIT) detects:

1. ATumour DNA
2. BHuman globin in stool
3. CCalprotectin
4. DCarcinoembryonic antigen
5. EPeroxidase activity of haem

What should happen after a positive FIT screening test?

1. AColonoscopy
2. BFlexible sigmoidoscopy only
3. CCT abdomen
4. DSerum CEA
5. ERepeat FIT in 1 year

For a person with one first-degree relative diagnosed with colorectal cancer at 52, screening colonoscopy should usually begin at:

1. A50 years
2. B40 years
3. C55 years
4. D60 years
5. E25 years

Which investigation is essential for local staging of rectal cancer?

1. ABarium enema
2. BPET-CT
3. CCEA
4. DHigh-resolution MRI pelvis
5. ETransabdominal ultrasound

In the AJCC 8th edition, a colon cancer invading through the visceral peritoneum without involving adjacent organs is:

1. AT2
2. BT4b
3. CT3
4. DT4a
5. ETis

A resected colon cancer is pT3 with 5 of 18 lymph nodes involved and no metastases. The stage is:

1. AStage III (N1b)
2. BStage IV
3. CStage III (N2a)
4. DStage II
5. EStage I

What is the minimum number of lymph nodes recommended for adequate staging of colon cancer?

1. A20
2. B4
3. C12
4. D6
5. E30

What is the main role of CEA in colorectal cancer?

1. AChoosing adjuvant chemotherapy
2. BBaseline and post-treatment surveillance
3. CDeciding RAS status
4. DDiagnosis of cancer in symptomatic patients
5. EPopulation screening

This schematic barium enema shows a short, irregular annular narrowing with overhanging edges. The most likely diagnosis is:

1. AIschaemic colitis
2. BSigmoid volvulus
3. CDiverticular stricture
4. DCrohn’s disease
5. EColorectal carcinoma

This schematic colonoscopy view shows a lobulated polyp on a stalk. Endoscopic removal shows adenocarcinoma confined to the head, grade 2, no lymphovascular invasion, margin 2 mm, low budding. What next?

1. ARepeat polypectomy at the same site immediately
2. BSurveillance colonoscopy; no further surgery
3. CRadiotherapy
4. DChemotherapy
5. ESegmental colectomy

Mismatch-repair (MMR) testing in colorectal cancer is recommended for:

1. AOnly right-sided tumours
2. BOnly metastatic disease
3. COnly patients with a family history
4. DOnly patients under 50
5. EEvery newly diagnosed colorectal cancer

This schematic immunohistochemistry shows tumour nuclei lacking MSH2 and MSH6 with retained MLH1 and PMS2. What is the next step?

1. AMLH1 promoter methylation testing
2. BRepeat the stain on another block
3. CGenetic counselling and germline testing for Lynch syndrome
4. DNo further action
5. EBRAF V600E testing to show it is sporadic

Before cetuximab or panitumumab is used in metastatic colorectal cancer, which test is mandatory?

1. ACEA level
2. BExtended RAS (KRAS and NRAS) mutation testing
3. CEGFR immunohistochemistry
4. DPD-L1
5. EUGT1A1 only

Total mesorectal excision (TME) involves:

1. ALateral pelvic node dissection in every patient
2. BExcising the anal sphincter in all cases
3. CRemoving the rectum with its intact fatty envelope and nodes along the mesorectal fascia
4. DRemoving only the tumour with a 1 cm margin
5. ERemoving the whole colon and rectum

Which operation is standard for a carcinoma of the caecum?

1. ARight hemicolectomy
2. BAnterior resection
3. CHartmann’s procedure
4. DLeft hemicolectomy
5. EAbdominoperineal resection

A low rectal cancer invades the external anal sphincter. The usual operation is:

1. ARight hemicolectomy
2. BLocal excision
3. CSigmoid colectomy
4. DLow anterior resection
5. EAbdominoperineal resection with a permanent colostomy

A 60-year-old has a resected stage III (pT3 N1) colon cancer, pMMR. Which adjuvant treatment is standard?

1. APelvic radiotherapy
2. BNo further treatment
3. COxaliplatin-based chemotherapy (CAPOX for 3 months)
4. DBevacizumab for 1 year
5. ECetuximab for 6 months

Which drug is an oral prodrug of 5-fluorouracil?

1. AOxaliplatin
2. BIrinotecan
3. CRegorafenib
4. DCapecitabine
5. ELeucovorin

Cold-induced tingling of the fingers and throat discomfort during infusion is typical of:

1. AOxaliplatin
2. BIrinotecan
3. CCetuximab
4. DCapecitabine
5. EBevacizumab

An acneiform rash on the face and upper trunk in a patient with metastatic colorectal cancer is most likely caused by:

1. ATrifluridine–tipiracil
2. BPanitumumab or cetuximab
3. CIrinotecan
4. DOxaliplatin
5. EBevacizumab

Which side effect is characteristic of bevacizumab?

1. ACold-triggered neuropathy
2. BHand-foot syndrome
3. CAcneiform rash
4. DHypomagnesaemia
5. EHypertension and proteinuria

Acute cholinergic syndrome (sweating, cramps, early diarrhoea) during infusion is typical of:

1. AIrinotecan
2. BCapecitabine
3. CPanitumumab
4. DBevacizumab
5. EOxaliplatin

After curative resection of colon cancer with a complete preoperative colonoscopy, the first surveillance colonoscopy is usually done at:

1. A3 months
2. B5 years
3. C1 year
4. D10 years
5. EOnly if symptoms develop

Which dietary factor is most consistently linked with increased colorectal cancer risk?

1. AVegetarian diet
2. BSpicy food
3. CRice
4. DMilk
5. EProcessed meat

A right iliac fossa mass with weight loss in a 40-year-old Indian man is reported on CT as “ileocaecal thickening, likely TB”. The most appropriate next step is:

1. ARight hemicolectomy without biopsy
2. BMantoux test and start ATT if positive
3. CUltrasound follow-up in 3 months
4. DColonoscopy with multiple biopsies for histology, TB PCR and culture
5. EStart antituberculous treatment for 6 months

This schematic axial T2-weighted MRI shows a mid-rectal tumour reaching to within 1 mm of the dashed line. What does the dashed line represent and what does the finding imply?

1. ASeminal vesicle; tumour is T4b
2. BRectal wall; tumour is T1
3. CPeritoneal reflection; no change in plan
4. DMesorectal fascia; threatened circumferential margin → total neoadjuvant therapy before surgery
5. ELevator ani; abdominoperineal resection needed

In NordICC, an invitation to a single screening colonoscopy reduced colorectal cancer incidence at 10 years but not significantly mortality (intention to screen). The main reason was:

1. AFIT was given to the control group
2. BOnly about 42% of those invited attended
3. CThe trial excluded people over 50
4. DPolypectomy increases cancer risk
5. EColonoscopy misses most cancers

A screening programme offers FIT every 2 years to 10,000 adults; 6% test positive and 4% of positives have cancer. How many colonoscopies are needed to find one cancer among FIT-positives?

1. A25
2. B100
3. C6
4. D250
5. E4

A 55-year-old has an obstructing sigmoid cancer; the colonoscope cannot pass it. CT shows no metastases. Before elective resection, how should the proximal colon be assessed?

1. ACT colonography, or colonoscopy within 3–6 months after surgery
2. BBarium meal
3. CNo assessment is needed
4. DPET-CT
5. ECapsule endoscopy of the small bowel

MRI pelvis of a rectal cancer shows the lower edge 4 cm from the anal verge, cT3b N1, CRM 6 mm, no EMVI, sphincter intact. Which of the following is TRUE?

1. AIt is T4b
2. BIt is a low rectal tumour; the CRM is clear
3. CThe CRM is threatened
4. DIt is an upper rectal tumour
5. EIt must be treated as anal cancer

A colon cancer shows loss of MLH1 and PMS2 on immunohistochemistry. Which result makes Lynch syndrome unlikely?

1. AEndometrial cancer in the mother
2. BLoss of MSH6 as well
3. CPatient age 38
4. DKRAS G12D mutation
5. EBRAF V600E mutation in the tumour

Which pair of proteins is usually lost together on MMR immunohistochemistry because they form heterodimers?

1. AMSH2 with PMS2
2. BMLH1 with PMS2, and MSH2 with MSH6
3. CMLH1 with MSH2
4. DPMS2 with MSH6
5. EMLH1 with MSH6

Two siblings both have about 40 colorectal adenomas each in their 40s; neither parent has polyps. The most likely diagnosis is:

1. ALynch syndrome
2. BClassic FAP
3. CSporadic adenomas
4. DPeutz–Jeghers syndrome
5. EMUTYH-associated polyposis

In MOSAIC, adding oxaliplatin to 5-FU/leucovorin improved 6-year overall survival in stage III colon cancer by about 4 percentage points. How many patients need adjuvant FOLFOX instead of 5-FU/LV for one additional survivor at 6 years?

1. AAbout 24
2. BAbout 100
3. CAbout 4
4. DAbout 2
5. EAbout 400

In the IDEA collaboration, which patients did as well with 3 months of CAPOX as with 6 months?

1. AStage IV after liver resection
2. BAll patients receiving FOLFOX
3. CStage II dMMR
4. DLow-risk stage III (T1–3 N1)
5. EHigh-risk stage III (T4 or N2)

A 50-year-old has a resected pT3 N0 colon cancer, 22 nodes examined, no high-risk features, dMMR. What is the best adjuvant approach?

1. ACAPOX for 3 months
2. BPelvic radiotherapy
3. CPembrolizumab for 1 year
4. DObservation
5. EFluoropyrimidine alone for 6 months

A 78-year-old with resected stage III colon cancer is fit but has diabetic neuropathy. Which adjuvant option is most appropriate?

1. AFOLFOX for 6 months
2. BFOLFOXIRI
3. CBevacizumab with capecitabine
4. DCapecitabine alone
5. ENo treatment because of age

During the first cycle of capecitabine a patient develops severe mucositis, diarrhoea and neutropenia. Which germline test is most relevant?

1. ATPMT genotyping
2. BUGT1A1 genotyping
3. CHLA-B*5801
4. DBRCA1/2
5. EDPYD genotyping

In FOxTROT, what happened when 6 weeks of FOLFOX was given before surgery for radiologically locally advanced colon cancer?

1. AFewer patients had residual or recurrent disease at 2 years, with tumour downstaging
2. BSurgical complications doubled
3. CAll patients avoided surgery
4. DOverall survival was worse
5. EdMMR tumours responded best

In the Dutch TME trial, short-course preoperative radiotherapy before TME:

1. AImproved overall survival in all subgroups
2. BMade TME unnecessary
3. CWas given with concurrent oxaliplatin
4. DIncreased local recurrence
5. EReduced local recurrence substantially

The German CAO/ARO/AIO-94 trial compared preoperative with postoperative chemoradiation for rectal cancer. Preoperative treatment:

1. AIncreased anastomotic leaks
2. BReduced sphincter preservation
3. CLowered local recurrence and toxicity, without changing overall survival
4. DImproved overall survival
5. EWas inferior for local control

Which statement about total neoadjuvant therapy (TNT) for rectal cancer is correct?

1. AIt means surgery first, then all chemotherapy
2. BIt omits radiotherapy in all patients
3. CIt gives all chemotherapy and radiotherapy before surgery and raises complete response rates
4. DIt is reserved for stage I disease
5. EIt replaces MRI staging

In PROSPECT, which patients could safely omit routine pelvic radiotherapy?

1. AAll T4 tumours
2. BMetastatic rectal cancer
3. CLow tumours invading the sphincter
4. DcT2N1 or cT3N0–1 rectal cancer, CRM clear, suitable for sphincter-sparing surgery, responding to FOLFOX
5. ETumours with a threatened CRM

After TNT for low rectal cancer, endoscopy shows a flat white scar with telangiectasia, there is no palpable tumour and MRI shows only fibrosis. The best option for a patient keen to avoid a stoma is:

1. APalliative care
2. BWatch-and-wait with intensive surveillance
3. CFurther chemotherapy for 6 months
4. DDischarge to the family doctor
5. EImmediate abdominoperineal resection

Which feature on rectal MRI most strongly suggests a need for lateral pelvic node assessment or treatment?

1. ATumour height 12 cm
2. BA mesorectal node of 3 mm
3. CCRM of 8 mm
4. DA lateral pelvic node with a short axis of 7 mm or more
5. ET2 tumour

Low anterior resection syndrome (LARS) refers to:

1. AUrinary retention after abdominoperineal resection
2. BUrgency, frequency, clustering and incontinence after sphincter-saving rectal surgery
3. CAnastomotic leak in the first week
4. DOxaliplatin-induced diarrhoea
5. EStoma prolapse

In PARADIGM, adding panitumumab rather than bevacizumab to first-line FOLFOX improved overall survival in which group?

1. ARight-sided tumours
2. BdMMR tumours
3. CRAS-mutant tumours
4. DRAS wild-type, left-sided metastatic colorectal cancer
5. EBRAF V600E tumours

A fit 52-year-old has metastatic right-sided colon cancer, KRAS G12D mutant, pMMR, unresectable liver metastases. Which first-line treatment is most appropriate?

1. AFOLFOX or FOLFIRI with bevacizumab (FOLFOXIRI + bevacizumab if very fit)
2. BPembrolizumab
3. CSotorasib
4. DFOLFOX with cetuximab
5. EEncorafenib with cetuximab

KEYNOTE-177 compared pembrolizumab with chemotherapy as first-line treatment for MSI-high metastatic colorectal cancer. The median progression-free survival was:

1. AAbout 40 vs 30 months, favouring chemotherapy
2. BAbout 16.5 vs 8.2 months, favouring pembrolizumab
3. CNot reported
4. DSimilar in both arms
5. EShorter with pembrolizumab

This schematic contrast CT shows several liver lesions in both lobes in a patient with a rectal primary. What determines whether they can be resected?

1. AAge over 60
2. BThe number of lesions alone (more than 4 is never resectable)
3. CWhether an R0 resection can leave an adequate future liver remnant with inflow, outflow and biliary drainage
4. DWhether the lesions are bilobar
5. EThe CEA level

In JCOG1007, patients with asymptomatic primary tumours and unresectable synchronous metastases were randomised to primary resection before chemotherapy or chemotherapy alone. The result was:

1. AChemotherapy alone was harmful
2. BNo survival benefit from resecting the primary, with more postoperative deaths
3. CResection reduced later obstruction to zero
4. DSurvival doubled with resection
5. EThe trial included only rectal cancers

Third-line treatment of RAS-mutant metastatic colorectal cancer in a patient with ECOG 1. Which option improved overall survival over its comparator in SUNLIGHT?

1. ACapecitabine alone
2. BTamoxifen
3. CCetuximab plus irinotecan
4. DTrifluridine–tipiracil plus bevacizumab
5. EPembrolizumab

Which statement about anti-EGFR rechallenge in metastatic colorectal cancer is correct?

1. AIt is first-line therapy
2. BIt works best when plasma ctDNA shows RAS wild-type again after a treatment-free interval
3. CIt requires a new tissue biopsy showing EGFR overexpression
4. DIt is effective in RAS-mutant tumours
5. EIt is contraindicated after any previous anti-EGFR therapy

Which of these patients most needs germline genetic testing?

1. AA 78-year-old with an MLH1-deficient, BRAF V600E-mutant caecal cancer
2. BA 60-year-old with a 6 mm tubular adenoma
3. CA 44-year-old with a dMMR colon cancer, MSH2 loss
4. DA 70-year-old with a hyperplastic rectal polyp
5. EA 65-year-old with a pMMR sigmoid cancer and no family history

This schematic H&E shows cells with large mucin vacuoles pushing the nuclei to one side. Which statement about this histology in colorectal cancer is correct?

1. AIt responds best to anti-EGFR therapy
2. BIt is a benign finding
3. CSignet-ring cell carcinoma carries a poor prognosis and a propensity for peritoneal spread; it is relatively more frequent in young Indian patients
4. DIt indicates a neuroendocrine tumour
5. EIt always arises in FAP

A patient on FOLFOX develops numbness in both hands that makes buttoning shirts difficult between cycles. What is the most appropriate action?

1. AGive steroids and continue
2. BAdd bevacizumab
3. CSwitch to cetuximab
4. DStop oxaliplatin and continue the fluoropyrimidine
5. EContinue FOLFOX unchanged

The CHALLENGE trial showed that, after adjuvant chemotherapy for colon cancer, a structured exercise programme:

1. AImproved disease-free and overall survival
2. BWas harmful in older patients
3. CImproved only quality of life
4. DIncreased recurrence
5. EHad no effect on outcomes

A 46-year-old has a resected stage IIIB colon cancer that is dMMR (MLH1/PMS2 loss, BRAF wild-type, no MLH1 methylation). Which adjuvant option is supported by a phase 3 trial specifically in this group?

1. AFOLFOX plus atezolizumab (ATOMIC)
2. BPembrolizumab alone for 1 year
3. CNo adjuvant therapy because dMMR has a good prognosis
4. DCapecitabine alone
5. EFOLFOXIRI

A 39-year-old has a radiologically T4 N2 dMMR sigmoid cancer without metastases. Which neoadjuvant approach produced major pathological responses in about 95% of patients?

1. ACapecitabine chemoradiation
2. BFOLFOX for 6 weeks (FOxTROT)
3. CShort-course radiotherapy
4. DBevacizumab plus FOLFOX
5. ENivolumab plus ipilimumab for two cycles (NICHE-2)

A 31-year-old with a mid-rectal cT3 N1 cancer is booked for chemoradiation. MMR IHC shows loss of MSH2 and MSH6. What is the most appropriate change?

1. AAdd oxaliplatin to chemoradiation
2. BGive bevacizumab with FOLFOX
3. CProceed with chemoradiation as planned
4. DOffer anti-PD-1 therapy alone with close response assessment, reserving chemoradiation and surgery
5. EProceed to abdominoperineal resection

In RAPIDO, short-course RT followed by chemotherapy before TME (versus long-course chemoradiation) was associated with which long-term concern?

1. ALower pathological complete response
2. BMore postoperative deaths
3. CHigher locoregional failure at 5 years
4. DHigher rates of distant metastasis
5. EWorse disease-related treatment failure

Which TNT sequence is generally favoured when the main goal is organ preservation in low rectal cancer?

1. AShort-course RT with immediate surgery
2. BInduction chemotherapy followed by chemoradiation
3. CChemoradiation followed by consolidation chemotherapy
4. DSurgery followed by adjuvant chemotherapy
5. EChemotherapy alone

In the International Watch & Wait Database, which statement about local regrowth after clinical complete response is correct?

1. AAbout a quarter regrow, and almost 90% of regrowths occur within 2 years
2. BMost regrowths appear after 5 years
3. CRegrowth is rare (under 2%)
4. DRegrowth is always accompanied by liver metastases
5. ERegrowth is never salvageable

A 68-year-old with an upper rectal cancer (lower edge 12 cm) has cT3a N0, CRM 9 mm, no EMVI. Which plan is most appropriate?

1. AAbdominoperineal resection
2. BShort-course RT then immediate surgery mandatory
3. CWatch-and-wait
4. DTNT with induction FOLFIRINOX
5. ETME (partial mesorectal excision) without neoadjuvant therapy

A stage II pMMR colon cancer patient has ctDNA testing after surgery. In DYNAMIC, a ctDNA-guided approach (chemotherapy only if ctDNA positive) compared with standard management:

1. AWas used in stage IV disease
2. BImproved overall survival significantly
3. CHalved the use of adjuvant chemotherapy with non-inferior recurrence-free survival
4. DRequired chemotherapy for all
5. EIncreased recurrence

Which statement about stage II colon cancer adjuvant therapy is most accurate?

1. AAll stage II patients need 6 months of FOLFOX
2. BAbsolute survival benefit from chemotherapy is about 3–4%, so risk features and patient preference guide the decision
3. CT4 is not a high-risk feature
4. DFewer than 12 nodes is reassuring
5. EdMMR stage II patients benefit most from 5-FU

A 58-year-old has metastatic BRAF V600E, pMMR, RAS wild-type colon cancer and has not had treatment. Which regimen improved overall survival over standard chemotherapy in BREAKWATER?

1. AFOLFOX + panitumumab
2. BPembrolizumab
3. CVemurafenib alone
4. DEncorafenib + cetuximab + mFOLFOX6
5. ERegorafenib

Why is single-agent BRAF inhibitor therapy, effective in melanoma, ineffective in BRAF V600E colorectal cancer?

1. ABRAF inhibition causes feedback activation of EGFR, reactivating MAPK signalling
2. BMSI-high tumours degrade BRAF inhibitors
3. CColorectal BRAF mutations are not V600E
4. DBRAF is not expressed in colon epithelium
5. EThe drug is not absorbed in colorectal cancer

A patient with KRAS G12C-mutant metastatic colorectal cancer has progressed on oxaliplatin and irinotecan. Which approach has randomised evidence?

1. AEncorafenib plus cetuximab
2. BSotorasib alone, as in lung cancer
3. CPembrolizumab
4. DCetuximab alone
5. ESotorasib plus panitumumab (CodeBreaK 300)

A RAS/BRAF wild-type, left-sided metastatic tumour is HER2-amplified (IHC 3+). After FOLFOX and FOLFIRI, which is a targeted option?

1. ASotorasib
2. BLapatinib alone
3. CCetuximab plus irinotecan, as HER2 predicts benefit
4. DPembrolizumab
5. ETucatinib plus trastuzumab

CheckMate 8HW in MSI-high metastatic colorectal cancer showed:

1. AChemotherapy was superior to immunotherapy
2. BNivolumab alone was superior to the combination
3. CBenefit only in RAS-mutant tumours
4. DNivolumab + ipilimumab improved progression-free survival over both chemotherapy and nivolumab alone
5. ENo difference between arms

A patient on first-line pembrolizumab for MSI-high colorectal cancer has a 20% increase in liver lesions at 9 weeks but feels better and CEA has fallen. What is the best approach?

1. AStop immunotherapy and switch to chemotherapy immediately
2. BResect the liver lesions urgently
3. CContinue and re-image in 4–8 weeks, as this may be pseudoprogression
4. DRefer for hospice
5. EAdd bevacizumab

A patient with metastatic colorectal cancer has a colonic stent in place and is starting first-line chemotherapy. Which biological agent is most problematic?

1. APanitumumab
2. BCetuximab
3. CPembrolizumab
4. DBevacizumab, because of stent-related perforation risk
5. ETrastuzumab

In EPOC, perioperative FOLFOX for resectable colorectal liver metastases compared with surgery alone:

1. AHad no effect on any endpoint
2. BWas given with cetuximab
3. CImproved progression-free survival but not overall survival
4. DIncreased mortality
5. EImproved overall survival by 20%

Which statement about cytoreductive surgery and HIPEC for colorectal peritoneal metastases (PRODIGE 7) is correct?

1. AAdding oxaliplatin HIPEC to complete cytoreduction gave no survival benefit and more late complications
2. BHIPEC is effective without cytoreduction
3. CThe trial used mitomycin and showed benefit
4. DHIPEC doubled overall survival
5. ECytoreduction is harmful in all patients

TRANSMET evaluated liver transplantation for permanently unresectable colorectal liver metastases. The key finding was:

1. ATransplant plus chemotherapy markedly improved 5-year overall survival over chemotherapy alone in highly selected patients
2. BAll patients were cured
3. CTransplant was useful even with lung metastases
4. DTransplant avoided the need for chemotherapy
5. ETransplant was inferior to chemotherapy

A fit 48-year-old has RAS-mutant, pMMR, right-sided colon cancer with liver-only metastases judged potentially resectable. Which first-line regimen gives the best chance of conversion?

1. ACapecitabine alone
2. BFOLFOXIRI plus bevacizumab
3. CPembrolizumab
4. DTrifluridine–tipiracil plus bevacizumab
5. EFOLFOX plus cetuximab

A colon cancer is MSI-high by PCR but MMR immunohistochemistry shows all four proteins intact. The most likely explanation is:

1. AThe tumour cannot be MSI-high
2. BBRAF mutation
3. CA missense variant producing a non-functional but antigenically intact protein (or technical discordance)
4. DLynch syndrome is excluded
5. EHER2 amplification

A dMMR colon cancer shows MSH2/MSH6 loss, but germline testing finds no pathogenic variant. What is the most likely explanation, and what should be tested next?

1. AMLH1 promoter methylation
2. BLaboratory error; ignore the result
3. CConstitutional MLH1 epimutation in MSH2
4. DBRAF V600E
5. EBiallelic somatic MMR mutations ("Lynch-like"); tumour sequencing of MMR genes

Which of the following is a recognised high-risk feature that makes surgery advisable after endoscopic removal of a malignant colorectal polyp?

1. AClear margin of 2 mm
2. BLymphovascular invasion
3. CSize of 1.5 cm
4. DPedunculated shape
5. EGrade 2 differentiation

In FACS and COLOFOL, more intensive follow-up after curative resection compared with less intensive follow-up:

1. AImproved overall survival substantially
2. BShowed CEA was useless for detecting relapse
3. CEliminated the need for colonoscopy
4. DIncreased mortality
5. EFound more resectable recurrences (FACS) but did not improve overall survival

In CAPP2, aspirin taken for at least 2 years by carriers of Lynch syndrome:

1. AHad no effect at any time point
2. BWas combined with celecoxib
3. CPrevented only endometrial cancer
4. DIncreased colorectal cancer
5. EReduced the incidence of colorectal cancer with long-term follow-up

In a fit patient with left-sided RAS/BRAF wild-type metastatic colorectal cancer who cannot afford anti-EGFR antibodies, which first-line option is evidence-based and affordable in India?

1. ACetuximab monotherapy
2. BSingle-agent oxaliplatin
3. CPembrolizumab
4. DDoublet chemotherapy (FOLFOX/CAPOX/FOLFIRI) with biosimilar bevacizumab, or chemotherapy alone
5. EBest supportive care only

A 45-year-old has a single (heterozygous) pathogenic MUTYH variant found on a panel done for her sister, who has MUTYH-associated polyposis. She has no polyps or family colorectal cancer apart from her sister. How should she be screened?

1. AProphylactic colectomy
2. BAs for the general population (her own risk is at most slightly raised)
3. CNo screening is ever needed
4. DUpper endoscopy every 2 years
5. EColonoscopy every year from now

A 32-year-old with primary sclerosing cholangitis and ulcerative pancolitis in remission asks how often she needs colonoscopy. The correct advice is:

1. AEvery 10 years from age 45
2. BNot needed while on ursodeoxycholic acid
3. COnly if she develops symptoms
4. DEvery 5 years from 8 years after colitis onset
5. EEvery year, from the time PSC is diagnosed

A 23-year-old is found to carry a pathogenic MLH1 variant through cascade testing. When should colonoscopy start, and how often?

1. AFrom 45, every 10 years
2. BOnly after symptoms appear
3. CFrom 30–35, every 3 years
4. DFrom 40, every 5 years
5. EFrom 20–25 (or 2–5 years before the youngest family case), every 1–2 years

A 38-year-old with Lynch syndrome (MSH2) has a resectable sigmoid cancer. If the aim is to minimise the risk of a new colon cancer, which operation is preferred?

1. ASigmoid colectomy
2. BEndoscopic resection
3. CAbdominoperineal resection
4. DTotal colectomy with ileorectal anastomosis
5. EHartmann’s procedure

After resection of a stage III colon cancer, NGS shows a PIK3CA exon 20 mutation. What adjunctive treatment has randomised evidence in this setting?

1. ANo adjunctive treatment has evidence
2. BCelecoxib for 6 months as the preferred agent
3. CHigh-dose vitamin D
4. DAdjuvant cetuximab
5. ELow-dose aspirin for 3 years (ALASCCA)

A patient with resected stage II colon cancer has a 25-hydroxyvitamin D level of 14 ng/mL. What is the most appropriate statement?

1. AVitamin D must not be given during follow-up
2. BReplace vitamin D; low levels are linked with worse outcomes but supplementation is not proven to improve survival
3. CVitamin D supplementation is proven to cure micrometastases
4. DVitamin D levels are irrelevant to bone health
5. EHigh-dose vitamin D replaces adjuvant chemotherapy

A patient has had 6 cycles of FOLFOX for colorectal liver metastases and now has steatohepatitis on imaging. For a safe major hepatectomy, the future liver remnant should generally be at least:

1. A30%
2. B70%
3. C50%
4. D10%
5. E20%

Before neoadjuvant chemotherapy for liver metastases, a 1.4 cm lesion lies 2 cm deep in segment 7. What should be done first?

1. ABiopsy all other lesions
2. BPlace a fiducial marker, because it may disappear on imaging yet still contain tumour
3. CRadioembolise it
4. DResect only lesions visible after chemotherapy
5. ENothing; if it disappears it is cured

In COLLISION, patients with small (≤3 cm) resectable colorectal liver metastases were randomised to thermal ablation or surgical resection. What did the trial show?

1. ASimilar overall survival with fewer complications after ablation
2. BAblation caused more deaths
3. CNo patients were eligible
4. DMuch better survival with surgery
5. EAblation was only feasible for lung metastases

A patient completed adjuvant FOLFOX 8 months ago and now has unresectable RAS-mutant liver and lung metastases. Which first-line backbone is preferred?

1. AFOLFOX with bevacizumab
2. BCapecitabine alone
3. CFOLFIRI with bevacizumab
4. DOxaliplatin alone
5. EFOLFOX with cetuximab

A pMMR, KRAS G12D-mutant metastatic colorectal cancer is HER2 IHC 3+ and has progressed on oxaliplatin- and irinotecan-based chemotherapy with bevacizumab. Which option is most appropriate?

1. ACetuximab plus irinotecan
2. BTucatinib plus trastuzumab
3. CTrastuzumab deruxtecan
4. DPembrolizumab
5. ESotorasib plus panitumumab

A metastatic, MMR-proficient colon cancer in a 41-year-old has a POLE exonuclease-domain mutation with a tumour mutational burden of 150 mutations/Mb. Which first-line treatment is suggested?

1. AAn immune checkpoint inhibitor regimen, as for dMMR tumours
2. BFOLFOX with cetuximab
3. CBest supportive care
4. DEncorafenib with cetuximab
5. ERegorafenib