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Part 1: 5 Basic-Level MCQs

MCQ 1

Question

Which of the following is NOT a recognized risk factor for cholangiocarcinoma?

Answer Choices

A. Primary sclerosing cholangitis

B. Chronic biliary parasitic infestation (Opisthorchis viverrini)

C. Cirrhosis

D. Hemochromatosis

Correct Answer: D. Hemochromatosis

Explanation

  • Why D is correct: While hemochromatosis is strongly linked to hepatocellular carcinoma, it is not listed in the excerpt as a known risk factor for cholangiocarcinoma.
  • Why A, B, C are incorrect:
    • Primary sclerosing cholangitis (PSC) (A) is an established risk factor.
    • Chronic parasitic infestation with Opisthorchis viverrini (B) is a well-documented etiology, especially in endemic regions (e.g., Thailand).
    • Cirrhosis (C) is also cited as a known risk factor.

Key Takeaways (4–5 sentences)

Risk factors for cholangiocarcinoma include PSC, choledochal cyst disease, chronic viral hepatitis, and certain chemical exposures (e.g., thorotrast, asbestos). Chronic infestation with liver flukes like Opisthorchis viverrini is a major contributor in parts of Asia. Cirrhosis is also mentioned as a predisposing factor. Hemochromatosis, although linked to other hepatic malignancies, is not listed as a clear risk factor for cholangiocarcinoma in the provided excerpt.

Reference

Shackleford’s Surgery of the Alimentary Tract, 8th edition,

Chapter 112: “Biliary Tract Tumors,” Subtopic: “Cholangiocarcinoma” (pp. 1327–1333)

MCQ 2

Question

What is the most common anatomical location of cholangiocarcinoma along the biliary tree?

Answer Choices

A. Intrahepatic bile duct

B. Distal common bile duct

C. Hilar region

D. Gallbladder neck

Correct Answer: C. Hilar region

Explanation

  • Why C is correct: The excerpt states that 40–60% of cholangiocarcinomas occur at the hilum, often referred to as Klatskin tumors or hilar cholangiocarcinomas.
  • Why A, B, D are incorrect:
    • Intrahepatic (A) accounts for only about 10%.
    • Distal CBD (B) represents 20–30%.
    • Gallbladder neck (D) is not a standard classification site for cholangiocarcinoma; that would be gallbladder carcinoma instead.

Key Takeaways (4–5 sentences)

Cholangiocarcinomas can arise anywhere along the biliary tree: intrahepatic, hilar, or distal. Hilar cholangiocarcinomas are the most prevalent subtype and often present with obstructive jaundice. The tumor’s location influences both clinical presentation and the surgical approach. Advanced disease at the time of diagnosis is unfortunately common.

Reference

Shackleford’s Surgery of the Alimentary Tract, 8th edition,

Chapter 112: “Biliary Tract Tumors,” Subtopic: “Cholangiocarcinoma” (pp. 1327–1333)

MCQ 3

Question

Regarding the tumor marker CA 19-9 in cholangiocarcinoma, which of the following statements is TRUE?

Answer Choices

A. CA 19-9 levels are reliable even in the presence of biliary obstruction.

B. CA 19-9 is elevated only in advanced disease and normal in early cholangiocarcinoma.

C. CA 19-9 can be falsely elevated in obstructive jaundice, and 10% of patients cannot produce CA 19-9 due to Lewis antigen negativity.

D. A normal CA 19-9 level definitively excludes cholangiocarcinoma.

Correct Answer: C. CA 19-9 can be falsely elevated in obstructive jaundice, and 10% of patients cannot produce CA 19-9

Explanation

  • Why C is correct: The excerpt notes that CA 19-9 is frequently elevated in cholangiocarcinoma, but levels can be falsely elevated in patients with biliary obstruction. Additionally, approximately 10% of individuals are Lewis antigen nonproducers, making CA 19-9 testing unhelpful for them.
  • Why A, B, D are incorrect:
    • (A) CA 19-9 is not reliable in the presence of biliary obstruction unless decompression is achieved.
    • (B) It can be elevated in both early and advanced cholangiocarcinoma.
    • (D) A normal CA 19-9 level does not exclude the diagnosis of cholangiocarcinoma.

Key Takeaways (4–5 sentences)

CA 19-9 is a commonly used tumor marker to support the diagnosis of cholangiocarcinoma. However, it must be interpreted carefully, especially in the presence of obstructive jaundice, where it can be spuriously high. After biliary drainage, CA 19-9 can be rechecked for more accurate values. Additionally, a subset of patients lack the Lewis antigen, rendering CA 19-9 testing ineffective.

Reference

Shackleford’s Surgery of the Alimentary Tract, 8th edition,

Chapter 112: “Biliary Tract Tumors,” Subtopic: “Cholangiocarcinoma” (pp. 1327–1333)

MCQ 4

Question

A 68-year-old patient is being evaluated for suspected hilar cholangiocarcinoma. Which imaging modality is generally considered most effective for assessing vascular involvement and guiding resectability?

Answer Choices

A. Conventional ultrasound only

B. Endoscopic retrograde cholangiopancreatography (ERCP)

C. MRI with MRCP

D. Thin-section multiphasic CT scan

Correct Answer: D. Thin-section multiphasic CT scan

Explanation

  • Why D is correct: The excerpt emphasizes that high-resolution, thin-section CT with arterial and portal venous phases is highly reliable in assessing vascular involvement and predicting resectability in most cholangiocarcinoma cases.
  • Why A, B, C are incorrect:
    • (A) Ultrasound alone is insufficient for detailed vascular mapping.
    • (B) ERCP primarily visualizes the ductal system rather than providing robust vascular detail.
    • (C) MRI/MRCP is excellent for defining intrahepatic bile duct anatomy but less accurate than CT for vascular assessment.

Key Takeaways (4–5 sentences)

Defining the extent of vascular involvement is critical in determining surgical resectability for hilar cholangiocarcinoma. Thin-section multiphasic CT scanning provides essential detail on arterial, venous, and ductal structures. MRI with MRCP offers superior delineation of biliary anatomy but is less effective in assessing vascular invasion. A combined approach sometimes improves accuracy, but CT remains a mainstay for resectability planning.

Reference

Shackleford’s Surgery of the Alimentary Tract, 8th edition,

Chapter 112: “Biliary Tract Tumors,” Subtopic: “Cholangiocarcinoma” (pp. 1327–1333)

MCQ 5

“All are true EXCEPT…” Question

Question

All of the following statements regarding the surgical management of cholangiocarcinoma are TRUE, EXCEPT:

Answer Choices

A. Intrahepatic cholangiocarcinomas often require anatomic hepatic resection.

B. Distal cholangiocarcinomas typically require pancreaticoduodenectomy (Whipple’s procedure).

C. Hilar cholangiocarcinomas may mandate partial hepatectomy plus extrahepatic bile duct resection to achieve negative margins.

D. Intrahepatic cholangiocarcinomas are routinely resected via transduodenal sphincteroplasty alone.

Correct Answer: D. Intrahepatic cholangiocarcinomas are routinely resected via transduodenal sphincteroplasty alone

Explanation

  • Why D is correct (the false statement): Intrahepatic cholangiocarcinomas are managed with hepatic resection (anatomic segmental or lobar resection), not by sphincteroplasty.
  • Why A, B, C are incorrect (all true):
    • (A) Intrahepatic tumors commonly require an anatomic liver resection to achieve clear margins.
    • (B) Distal cholangiocarcinomas are generally best approached with a Whipple procedure.
    • (C) Hilar lesions often require en bloc partial hepatectomy plus resection of involved bile ducts.

Key Takeaways (4–5 sentences)

Surgical resection is the mainstay of curative intent treatment for cholangiocarcinoma. The procedure depends on the tumor’s anatomical location: partial hepatectomy for intrahepatic and hilar tumors, and pancreaticoduodenectomy for distal lesions. Achieving a negative (R0) margin is crucial for improved survival. Simple procedures such as transduodenal sphincteroplasty have no curative role in intrahepatic disease.

Reference

Shackleford’s Surgery of the Alimentary Tract, 8th edition,

Chapter 112: “Biliary Tract Tumors,” Subtopic: “Cholangiocarcinoma” (pp. 1327–1333)

Please review these Basic-Level MCQs. Let me know if you would like any adjustments or further clarifications. Once approved, I will provide the 5 Advanced-Level MCQs.