Lymphatic System

Chapter: Head & Neck — Larynx; Topic: Lymphatic Drainage of the Larynx; Subtopic: Subglottic (below vocal cords) drainage & clinical relevance

Keyword Definitions:

• Larynx: Organ of voice and airway protection, divided into supraglottis, glottis, and subglottis.

• Subglottis: Region of larynx below the vocal cords extending to the inferior border of cricoid cartilage.

• Pretracheal lymph nodes: Lymph nodes anterior to trachea receiving drainage from lower larynx and trachea.

• Paratracheal nodes: Nodes alongside trachea that communicate with superior mediastinal nodes.

• Clinical significance: Pattern of lymphatic drainage determines sites of metastasis in laryngeal cancer and guides neck dissection and radiotherapy planning.

1) Lead Question – 2016
Larynx below the vocal cords drain into ?
a) Pretracheal lymph nodes
b) Occipital lymphnodes
c) Mediastinal nodes
d) Lymphatics along the superior laryngeal vein

Answer: a) Pretracheal lymph nodes

Explanation: The subglottic region (below the vocal cords) drains primarily to the pretracheal and paratracheal lymph nodes which lie anterior and lateral to the trachea; these nodes then communicate inferiorly with the superior mediastinal nodes. This drainage pattern contrasts with the supraglottis (which drains to upper deep cervical nodes) and the glottis (which has limited lymphatics). Clinically, tumors arising in the subglottic larynx more readily involve pretracheal/paratracheal nodes and may present with lower cervical or mediastinal metastases. Knowledge of this pathway guides neck dissection planning and radiotherapy fields in laryngeal cancer management.

2) The supraglottic larynx primarily drains to which nodes?
a) Submental nodes
b) Upper deep cervical (jugulodigastric) nodes
c) Pretracheal nodes
d) Occipital nodes

Answer: b) Upper deep cervical (jugulodigastric) nodes

Explanation: The supraglottic larynx — including the epiglottis, aryepiglottic folds, and false cords — has an abundant lymphatic plexus that drains principally to the upper deep cervical nodes, especially the jugulodigastric node. This explains why supraglottic cancers frequently present with cervical lymphadenopathy; early nodal metastasis is common and often occult. Surgical and radiotherapeutic strategies therefore target the upper jugular chains when supraglottic malignancy is present. Recognizing this drainage pattern is crucial for staging, prognostication, and planning therapeutic neck dissections or radiation target volumes.

3) The vocal cords (true cords) have relatively sparse lymphatics. Which statement is true?
a) True vocal cord tumors commonly metastasize early
b) Glottic cancers are frequently associated with nodal metastasis at presentation
c) Early glottic cancers rarely involve cervical lymph nodes
d) Glottic lymph drains to occipital nodes

Answer: c) Early glottic cancers rarely involve cervical lymph nodes

Explanation: The true vocal cords (glottis) have few lymphatic channels, particularly in their mid-portion, so early-stage glottic cancers (T1–T2) seldom metastasize to cervical lymph nodes. This contrasts with supraglottic lesions. Consequently, early glottic cancer can often be treated with local radiotherapy or limited surgery without elective neck dissection. However, lesions involving the anterior/posterior commissure or extending to supraglottic/subglottic areas may have higher nodal risk. Understanding this anatomic fact underpins clinical decision-making about elective neck treatment in laryngeal carcinoma.

4) Which nodes receive drainage directly from the hypopharynx and lower larynx and are thus important in spread of subglottic cancer?
a) Deep lateral cervical (levels II–IV)
b) Suboccipital nodes
c) Preauricular nodes
d) Superficial cervical nodes

Answer: a) Deep lateral cervical (levels II–IV)

Explanation: Although the subglottic region first drains to pretracheal/paratracheal nodes, subsequent spread commonly involves the deep lateral cervical chain (levels II–IV), which are critical pathways for metastatic dissemination of hypopharyngeal and lower laryngeal cancers. Clinicians evaluating neck metastases focus on these deep nodes; imaging and surgical dissections target levels II–IV when metastasis is suspected. Knowledge of these nodal basins is essential for accurate staging, choosing the extent of neck dissection, and tailoring radiotherapy fields to encompass likely sites of microscopic disease.

5) Clinically, involvement of pretracheal/paratracheal nodes by subglottic carcinoma most likely mandates consideration of which additional therapy approach?
a) Elective orchiectomy
b) Inclusion of superior mediastinal nodes in radiotherapy fields
c) Excision of parotid gland
d) Occipital node dissection

Answer: b) Inclusion of superior mediastinal nodes in radiotherapy fields

Explanation: Because pretracheal/paratracheal nodes communicate with the superior mediastinal nodal basin, documented involvement of these stations in subglottic cancer may warrant extending radiation fields inferiorly to cover superior mediastinal nodes or even performing targeted surgical sampling in appropriate cases. Treatment planning must account for the anatomic drainage pathway to reduce the risk of residual disease. This consideration is especially relevant for advanced tumors with suspicious lower cervical or mediastinal nodal disease on imaging.

6) In laryngeal cancer staging, cervical lymph node metastasis most strongly affects prognosis. Which laryngeal subsite carries the highest risk of nodal spread?
a) Glottis
b) Supraglottis
c) Subglottis
d) Epiglottis only

Answer: b) Supraglottis

Explanation: The supraglottic larynx has an extensive lymphatic network draining bilaterally to the upper deep cervical nodes, predisposing tumors in this subsite to early and frequent cervical metastases. Consequently, supraglottic carcinomas often have worse nodal-related prognosis compared with early glottic tumors. This higher propensity for nodal spread influences both staging and treatment: clinicians commonly perform elective neck dissection or include bilateral neck irradiation for supraglottic malignancies even when clinically node-negative.

7) Which nerve provides sensory innervation above the vocal cords (important for laryngeal reflexes and tumor symptomatology)?
a) Superior laryngeal branch of vagus (internal branch)
b) Recurrent laryngeal nerve
c) Glossopharyngeal nerve only
d) Hypoglossal nerve

Answer: a) Superior laryngeal branch of vagus (internal branch)

Explanation: The internal branch of the superior laryngeal nerve (from the vagus via the superior laryngeal) supplies sensory innervation to the mucosa of the supraglottis down to the level of the vocal cords. This afferent input mediates protective laryngeal reflexes and contributes to symptoms such as foreign body sensation or pain when supraglottic tumors are present. Recurrent laryngeal nerve supplies motor function to intrinsic laryngeal muscles (except cricothyroid) and sensory below the vocal cords; these distinctions are important for surgical planning and understanding presenting deficits in laryngeal disease.

8) A patient with subglottic carcinoma develops a metastatic node at the root of the neck and superior mediastinum on imaging. Which statement best describes the likely pathway?
a) Direct hematogenous spread to mediastinum only
b) Lymphatic spread from subglottis → pretracheal/paratracheal nodes → superior mediastinal nodes → root of neck
c) Spread via occipital nodes then to mediastinum
d) Lymphatic spread from supraglottis only

Answer: b) Lymphatic spread from subglottis → pretracheal/paratracheal nodes → superior mediastinal nodes → root of neck

Explanation: The described sequence reflects the anatomical lymphatic continuity: subglottic drainage to pretracheal/paratracheal nodes, which connect to superior mediastinal nodes and the lower deep cervical nodes at the root of neck. This predictable pathway explains why lower laryngeal cancers can present with lower cervical and mediastinal nodal disease, and it underlines the need for imaging of both neck and superior mediastinum when evaluating subglottic tumors. Hematogenous metastasis is less likely for initial regional nodal disease.

9) During a thyroidectomy with central neck dissection, surgeons must be aware that manipulation of which nodal group is anatomically close to the recurrent laryngeal nerve and parathyroids?
a) Pretracheal and paratracheal nodes (central compartment)
b) Submental nodes
c) Occipital nodes
d) Superficial cervical nodes

Answer: a) Pretracheal and paratracheal nodes (central compartment)

Explanation: The central compartment (level VI) includes pretracheal and paratracheal lymph nodes that sit adjacent to the trachea, recurrent laryngeal nerve, and parathyroid glands. Surgical clearance of these nodes risks injury to the nerve (causing vocal cord palsy) and devascularization of parathyroids (leading to hypocalcemia). In laryngeal and thyroid malignancies involving central nodes, meticulous dissection is required to balance oncologic clearance and preservation of these critical structures.

10) Which imaging modality is most sensitive for detecting small cervical nodal metastases from laryngeal cancer during staging?
a) Contrast-enhanced CT of neck
b) Plain radiograph of neck
c) Abdominal ultrasound
d) PET-CT and/or MRI complement CT for small-volume nodal disease

Answer: d) PET-CT and/or MRI complement CT for small-volume nodal disease

Explanation: Contrast-enhanced CT is commonly used for anatomic staging of head and neck cancers, but PET-CT (FDG PET) and MRI can provide superior sensitivity for small-volume or metabolically active nodal disease; PET-CT is particularly useful for detecting occult metastases and distant spread, while MRI offers excellent soft-tissue contrast for assessment of nodal extracapsular extension. Multimodality imaging is often employed to comprehensively stage laryngeal cancer and to delineate nodal disease for surgical and radiotherapy planning.

Chapter: Head & Neck Anatomy; Topic: Lymphatic Drainage; Subtopic: Submandibular Lymph Nodes

Keyword Definitions:

• Submandibular Lymph Nodes: Nodes located beneath the mandible draining major facial areas.

• Facial Lymph Drainage: Network collecting lymph from eyelids, cheeks, lips, and oral cavity.

• Buccal Region: Cheek area containing superficial lymphatics.

• Lower Lip Drainage: Central part drains to submental nodes, lateral parts to submandibular nodes.

• Forehead Drainage: Mainly into preauricular and parotid nodes.

• Periorbital Region: Medial eyelid lymph flows to submandibular nodes.

1) Lead Question – 2016
Submandibular lymph nodes drain the following areas of the face except?
a) Medial half of eyelids
b) Central part of lower lip
c) Medial part of cheek
d) Central part of forehead

Answer: d) Central part of forehead

Explanation: Submandibular lymph nodes primarily drain the medial half of eyelids, medial cheek, lateral lower lip, and lateral parts of the nose. However, the central part of the forehead drains into the preauricular and parotid lymph nodes, not the submandibular group. This distinction is essential in head and neck oncology and tracking lymphatic spread of infections or malignancies. Hence, the only area listed that does not drain into the submandibular lymph nodes is the central portion of the forehead, making option (d) correct.

2) Which lymph nodes drain the tip of the tongue?
a) Submandibular nodes
b) Submental nodes
c) Deep cervical nodes
d) Parotid nodes

Answer: b) Submental nodes

Explanation: The tip of the tongue drains to submental lymph nodes.

3) Lymph from palatine tonsil drains mainly into?
a) Jugulodigastric node
b) Submandibular node
c) Submental node
d) Retropharyngeal node

Answer: a) Jugulodigastric node

Explanation: Primary drainage is to the jugulodigastric node.

4) Central lower lip drains into?
a) Submandibular
b) Submental
c) Parotid
d) Buccal

Answer: b) Submental

Explanation: Midline structures often drain to submental nodes.

5) Lymph from lateral nose drains to?
a) Submental
b) Submandibular
c) Parotid
d) Mastoid

Answer: b) Submandibular

Explanation: Submandibular nodes receive lymph from lateral nose.

6) Preauricular lymph nodes drain?
a) Scalp anterior to ear
b) Tongue
c) Lower lip
d) Hard palate

Answer: a) Scalp anterior to ear

Explanation: Preauricular nodes drain forehead and anterior scalp.

7) Lymphatics of cheek primarily drain to?
a) Submental nodes
b) Parotid nodes
c) Submandibular nodes
d) Retropharyngeal nodes

Answer: c) Submandibular nodes

Explanation: Cheek drainage routes mainly to submandibular nodes.

8) Infection from central forehead spreads first to?
a) Submandibular nodes
b) Parotid nodes
c) Submental nodes
d) Jugular nodes

Answer: b) Parotid nodes

Explanation: Because the forehead drains to the parotid group.

9) Drainage of upper lip is mainly into?
a) Submandibular
b) Submental
c) Parotid
d) Retropharyngeal

Answer: a) Submandibular

Explanation: Most upper lip lymphatics reach submandibular nodes.

10) Lymph from the floor of mouth drains into?
a) Submental
b) Submandibular
c) Parotid
d) Occipital

Answer: a) Submental

Explanation: Floor of mouth drains into submental nodes.

11) Which node drains the lateral eyelid?
a) Parotid
b) Submandibular
c) Submental
d) Mastoid

Answer: a) Parotid

Explanation: Lateral eyelid lymphatics drain to parotid nodes.

Chapter: Abdomen; Topic: Spleen; Subtopic: Visceral Relations

Keyword Definitions:

• Spleen: Intraperitoneal lymphoid organ located in the left hypochondrium.

• Visceral Surface: Surface of spleen related to stomach, kidney, pancreas tail, and colon.

• Splenic Flexure: Left colic flexure in contact with spleen.

• Gastric Impression: Sleeve-shaped area for fundus of stomach.

• Renal Impression: Area related to left kidney.

1) Lead Question – 2016
All of the following organs are in direct contact with the spleen except?
a) Duodenum
b) Stomach
c) Left kidney
d) Colon

Answer: a) Duodenum

Explanation: The spleen lies in the left hypochondrium and makes impressions on its visceral surface from the stomach (gastric impression), left kidney (renal impression), splenic flexure of colon (colic impression), and tail of pancreas. The duodenum, however, is not in direct contact with the spleen; it is located more medially and inferiorly, separated by other structures. Thus, among the listed organs, the only one not touching the spleen directly is the duodenum.

2) Tail of pancreas lies in which splenic region?
a) Renal impression
b) Gastric impression
c) Hilum
d) Colic impression

Answer: c) Hilum

Explanation: The tail of the pancreas directly enters the splenic hilum enclosed within the splenorenal ligament.

3) Splenorenal ligament contains?
a) Left gastric artery
b) Splenic vessels
c) Hepatic artery proper
d) Cystic artery

Answer: b) Splenic vessels

Explanation: Splenorenal ligament houses splenic artery and vein along with tail of pancreas.

4) Accessory spleens are most commonly found near?
a) Greater omentum
b) Splenic hilum
c) Transverse colon
d) Right kidney

Answer: b) Splenic hilum

Explanation: 75% of accessory spleens occur adjacent to the hilum.

5) Spleen develops from?
a) Foregut endoderm
b) Hindgut endoderm
c) Mesoderm of dorsal mesogastrium
d) Intermediate mesoderm

Answer: c) Mesoderm of dorsal mesogastrium

Explanation: Spleen is a mesodermal organ—not endoderm-derived.

6) A patient with splenic rupture most likely bleeds into?
a) Pelvic cavity
b) Left subphrenic space
c) Right paracolic gutter
d) Lesser sac only

Answer: b) Left subphrenic space

Explanation: Spleen lies just below diaphragm; rupture bleeds largely into left subphrenic space.

7) Organ NOT forming impression on visceral surface?
a) Stomach
b) Left kidney
c) Tail of pancreas
d) Jejunum

Answer: d) Jejunum

Explanation: Jejunum is far inferior and does not touch spleen.

8) Splenic artery is a branch of?
a) Superior mesenteric artery
b) Celiac trunk
c) Inferior mesenteric artery
d) Aorta

Answer: b) Celiac trunk

Explanation: It is one of three main branches of celiac trunk.

9) Spleen lies opposite which ribs?
a) 9–11
b) 6–8
c) 4–6
d) 11–12

Answer: a) 9–11

Explanation: Spleen is located under ribs 9–11, hence protected in normal position.

10) Splenic enlargement first crosses which costal margin?
a) Right
b) Left
c) Midline
d) Suprasternal notch

Answer: b) Left

Explanation: Splenomegaly expands toward left lower quadrant along costal margin.

11) A wandering spleen predisposes to?
a) Volvulus
b) Splenic torsion
c) Bowel obstruction
d) Renal artery thrombosis

Answer: b) Splenic torsion

Explanation: Lack of ligamentous support allows rotation of the spleen around its pedicle.

Chapter: Stomach & Lymphatic Drainage; Topic: Gastric Lymphatics; Subtopic: Final Drainage Pathways

Keyword Definitions:

• Gastric lymphatics: Lymphatic vessels draining the stomach, following arterial supply.

• Pyloric nodes: Nodes around the pylorus receiving drainage from distal stomach.

• Short gastric nodes: Nodes along splenic artery draining the fundus and upper greater curvature.

• Gastroepiploic nodes: Nodes along greater curvature near gastroepiploic vessels.

• Celiac nodes: Final collecting nodes of gastric lymph before entering cisterna chyli.

1) Lead Question – 2016
All lymph of stomach drains into ?
a) Pyloric nodes
b) Short gastric vessel nodal group
c) Right gastroepiploic nodes
d) Coeliac nodes

Answer: d) Coeliac nodes

Explanation: Gastric lymph drainage begins in regional perigastric nodes, including left gastric, right gastric, short gastric, pyloric and gastroepiploic groups. Although these groups receive lymph from specific parts of the stomach, all gastric lymph ultimately converges into the coeliac lymph nodes. These central nodes lie around the coeliac trunk and act as the final collecting station before lymph enters the cisterna chyli. This anatomical fact is essential for understanding advanced gastric cancer spread and forms the rationale for extended lymphadenectomy in oncologic gastrectomy.

2) The first nodal group involved in carcinoma of the pylorus is?
a) Right gastric nodes
b) Pyloric (infra-pyloric) nodes
c) Short gastric nodes
d) Splenic hilum nodes

Answer: b) Pyloric (infra-pyloric) nodes

Explanation: The pyloric region drains lymph primarily to the pyloric or infra-pyloric nodes that lie near the origin of the gastroduodenal artery. Tumors arising in the antrum or pylorus therefore metastasize first to these nodes. Short gastric and splenic hilum nodes drain the fundus, while the right gastric nodes drain the lower lesser curvature. Understanding this first-echelon drainage is critical for accurate staging and surgical clearance during distal gastrectomy.

3) Which nodal group drains the fundus of the stomach?
a) Right gastric nodes
b) Left gastric nodes
c) Short gastric nodes
d) Pyloric nodes

Answer: c) Short gastric nodes

Explanation: The fundus of the stomach is supplied by and drains along the short gastric arteries. These lymphatics drain directly into nodes at the splenic hilum. This explains why fundal cancers frequently spread to splenic hilar nodes. Left gastric nodes drain lesser curvature regions near the cardia; pyloric nodes drain the antrum; right gastric nodes drain the lower lesser curvature. The short gastric pathway is therefore the primary route for fundal lymphatic drainage.

4) Blockage of which nodal group may result in splenic hilar adenopathy in fundic cancer?
a) Left gastric nodes
b) Short gastric nodes
c) Pyloric nodes
d) Pancreaticoduodenal nodes

Answer: b) Short gastric nodes

Explanation: Short gastric lymphatics drain directly into splenic hilar nodes. When these pathways are obstructed by malignant spread, splenic hilar nodal enlargement occurs. This finding is often associated with fundal tumors due to their drainage pattern. Other nodal groups are not typically involved early in fundic cancer. Recognition of splenic hilum nodal disease is important for planning extended lymphadenectomy (D2) when indicated.

5) Which of the following is classified as a second-tier (D2) node in gastric cancer surgery?
a) Perigastric right gastric nodes
b) Splenic artery nodes
c) Pyloric nodes
d) Short gastric nodes

Answer: b) Splenic artery nodes

Explanation: D1 nodes include the perigastric nodal stations surrounding the stomach. D2 nodes are second-tier nodes along the major arterial trunks such as the splenic artery, left gastric artery, and common hepatic artery. Splenic artery nodes receive lymph from the fundus and upper greater curvature region. Removal of these nodes is part of an extended D2 dissection that improves staging and may improve survival in selected gastric cancer patients.

6) Which region of the stomach drains predominantly into the left gastric nodes?
a) Fundus
b) Cardia and lesser curvature
c) Distal antrum
d) Greater curvature

Answer: b) Cardia and lesser curvature

Explanation: The left gastric artery runs along the lesser curvature toward the cardia, and lymphatic drainage from these regions follows the same path. Cardia cancers, especially near the gastroesophageal junction, typically involve left gastric nodes early. The fundus drains to short gastric nodes; the greater curvature drains to gastroepiploic nodes, while the distal antrum drains toward pyloric nodes. Understanding each region’s drainage helps refine surgical lymphadenectomy.

7) Virchow’s node involvement in gastric cancer indicates spread by which route?
a) Direct peritoneal invasion
b) Lymphatic spread via thoracic duct
c) Portal venous spread to liver
d) Systemic arterial spread

Answer: b) Lymphatic spread via thoracic duct

Explanation: Metastasis to Virchow’s node (left supraclavicular) occurs when gastric lymph reaches the cisterna chyli and travels superiorly through the thoracic duct before draining into the left venous angle. Tumor cells may lodge in nearby supraclavicular nodes, producing this classical clinical sign of advanced gastrointestinal malignancy. It reflects extensive lymphatic spread rather than direct local invasion or portal venous dissemination.

8) Right gastroepiploic nodes are located along which vessel?
a) Left gastric artery
b) Right gastroepiploic artery
c) Splenic artery
d) Inferior phrenic artery

Answer: b) Right gastroepiploic artery

Explanation: The right gastroepiploic artery runs along the distal portion of the greater curvature. Its associated nodes drain the antrum and distal greater curvature. These nodes are removed in standard gastric oncologic dissections. The splenic artery supplies fundal short gastric branches; the left gastric artery supplies the lesser curvature; the inferior phrenic artery has no major gastric lymphatic association.

9) Which lymph node group is closest to the gastroesophageal junction?
a) Left gastric nodes
b) Pyloric nodes
c) Short gastric nodes
d) Para-aortic nodes

Answer: a) Left gastric nodes

Explanation: The gastroesophageal junction lies adjacent to the left gastric artery and its accompanying lymph nodes. These nodes often form the primary drainage route for cancers at or near the cardiac region. Short gastric nodes are more lateral toward the fundus; pyloric nodes lie distally, and para-aortic nodes are secondary stations involved in advanced disease stages.

10) The final common pathway for all gastric lymph before entering systemic circulation is?
a) Cisterna chyli
b) Para-aortic nodes
c) Coeliac nodes
d) Splenic hilum nodes

Answer: c) Coeliac nodes

Explanation: Regardless of its starting point—whether short gastric, pyloric, gastroepiploic or left gastric—gastric lymph ultimately converges into the celiac node group. These nodes sit around the celiac trunk and form the central collecting drainage of the entire stomach. From here, lymph flows into the cisterna chyli and then the thoracic duct. This makes the celiac nodes the key nodal basin for staging advanced gastric cancer.

11) A tumor located on the distal greater curvature will most likely spread first to?
a) Left gastric nodes
b) Short gastric nodes
c) Right gastroepiploic nodes
d) Para-aortic nodes

Answer: c) Right gastroepiploic nodes

Explanation: The distal greater curvature receives arterial supply from the right gastroepiploic artery, and lymphatics follow this route to its nodal group. These nodes, located along the greater curvature near the gastroepiploic arcade, therefore represent the first site of lymphatic spread in cancers of the distal greater curvature. Para-aortic involvement occurs only in advanced metastatic disease, while left gastric and short gastric nodes drain different regions.

Chapter: Stomach & Lymphatic Drainage; Topic: Gastric Lymphatics; Subtopic: Nodal Stations & Clinical Relevance

Keyword Definitions:

• Gastric lymphatics: Network of lymphatic vessels draining stomach towards regional nodal groups along arterial trunks.

• Pyloric (infra-pyloric) nodes: Nodes around the pylorus and proximal duodenum receiving drainage from distal stomach and antral region.

• Short gastric nodes: Nodes along the splenic artery and at the hilum of the spleen draining the fundus and upper greater curvature.

• Gastroepiploic (right/left) nodes: Nodes along the gastroepiploic arcade draining the greater curvature regions.

• Sentinel node: The first lymph node(s) receiving direct drainage from a primary tumour—important in staging and guiding surgery.

1) Lead Question – 2016
Stomach wall is mainly drained by all lymph nodes except?
a) Pyloric nodes
b) Short gastric vessel nodal group
c) Right gastroepiploic nodes
d) Inguinal nodes

Answer: d) Inguinal nodes

Explanation: Gastric lymphatic drainage follows the arterial supply: the left gastric nodes drain the lesser curvature and cardia, right gastric nodes drain the distal lesser curvature, gastroepiploic nodes (right and left) drain the greater curvature, and short gastric nodes along the splenic artery drain the fundus. Pyloric (infra-pyloric) nodes drain the antrum and pylorus. Inguinal nodes are superficial nodes of the lower limb and lower anterior abdominal wall and are not involved in primary gastric drainage. Therefore, the stomach is not drained by inguinal nodes—this makes (d) the correct answer, which is clinically relevant because inguinal nodal enlargement would not suggest primary gastric cancer spread.

2) Which nodal group is most commonly involved first in carcinoma of the gastric fundus?
a) Pyloric nodes
b) Left gastric (lesser curvature) nodes
c) Short gastric nodes along the splenic artery
d) Right gastroepiploic nodes

Answer: c) Short gastric nodes along the splenic artery

Explanation: The fundus of the stomach drains predominantly along the short gastric arteries toward nodes at the splenic hilum and along the splenic artery. In gastric fundus carcinoma these short gastric nodes are therefore commonly the first echelon of nodal spread. Left gastric (lesser curvature) nodes are more important for cardia and lesser curvature lesions; pyloric nodes drain the antrum; right gastroepiploic nodes drain distal greater curvature. Recognising the fundic drainage route is essential for surgical planning and nodal sampling during oncologic gastrectomy.

3) The nodes along the right gastroepiploic artery primarily receive lymph from which region of the stomach?
a) Cardia and upper lesser curvature
b) Antrum and distal greater curvature
c) Fundus
d) Posterior surface only

Answer: b) Antrum and distal greater curvature

Explanation: The right gastroepiploic artery runs along the distal greater curvature supplying the antral and adjacent greater curvature region; lymphatic vessels follow this artery to the right gastroepiploic (gastro-omental) nodes. Tumours located in the distal greater curvature or antrum will therefore commonly metastasise to these nodal stations. Understanding the artery–node correspondence helps in tailoring lymphadenectomy (D1/D2 dissections) for gastric cancer and improves staging accuracy.

4) Involvement of which nodal group suggests possible retroperitoneal or para-aortic spread of gastric cancer?
a) Left gastric nodes only
b) Splenic hilum nodes only
c) Superior mesenteric nodes and para-aortic nodes
d) Inguinal nodes

Answer: c) Superior mesenteric nodes and para-aortic nodes

Explanation: Advanced gastric cancer can spread beyond perigastric nodes to secondary stations including nodes along the common hepatic artery, celiac axis, superior mesenteric vessels and ultimately the para-aortic (lumbar) nodes—indicative of systemic dissemination and a worse prognosis. Para-aortic node involvement often implies retroperitoneal extension and may change management from curative to palliative. Inguinal nodes are not part of this route. Recognising para-aortic nodal disease on imaging impacts staging (often M1) and therapeutic decisions.

5) Sentinel node biopsy in early gastric cancer aims to identify which of the following?
a) The first lymph node(s) that receive drainage from the tumor
b) The largest lymph node in the abdomen
c) Inguinal nodes exclusively
d) Nodes in the porta hepatis only

Answer: a) The first lymph node(s) that receive drainage from the tumor

Explanation: Sentinel node biopsy identifies the initial draining lymph node(s) for a primary tumour; if these nodes are free of metastasis, the likelihood of further nodal involvement is low, potentially permitting less extensive lymphadenectomy. In early gastric cancer, sentinel node mapping using dyes or radiotracers can help tailor the extent of surgery while maintaining oncologic safety. It is not about the largest node or specific anatomical node groups like inguinal or porta hepatis unless they are sentinel nodes for that tumour location.

6) Which nodal station is most relevant when assessing lymphatic spread from a tumour located on the lesser curvature near the cardia?
a) Right gastroepiploic nodes
b) Left gastric nodes along the lesser curvature
c) Superior mesenteric nodes
d) Inguinal nodes

Answer: b) Left gastric nodes along the lesser curvature

Explanation: The left gastric nodes lie along the lesser curvature and the left gastric artery; they drain the cardia and upper lesser curvature. A carcinoma at the lesser curvature near the cardia will typically send lymph to these nodes early. Right gastroepiploic nodes drain distal greater curvature, superior mesenteric nodes are more distal secondary stations, and inguinal nodes are unrelated. Accurate knowledge of these relationships is crucial for proper nodal dissection around the lesser curvature during gastrectomy.

7) A patient with distal gastric cancer undergoes D2 lymphadenectomy. Which node group is typically removed as part of a standard D2 dissection?
a) Only perigastric nodes (D1)
b) Perigastric nodes plus nodes along left gastric, common hepatic, splenic and celiac trunks
c) Only para-aortic nodes
d) Only inguinal nodes

Answer: b) Perigastric nodes plus nodes along left gastric, common hepatic, splenic and celiac trunks

Explanation: A D2 lymphadenectomy for gastric cancer includes removal of perigastric (D1) nodes and the second-tier nodes along the main supplying arteries: left gastric, common hepatic, splenic and celiac axis nodes. This extended nodal clearance aims to improve staging and oncologic control for resectable gastric cancers, though it requires surgical expertise due to increased operative complexity. Para-aortic nodes are beyond standard D2 unless specifically indicated; inguinal nodes are not part of gastric oncologic dissection.

8) Which statement about lymphatic drainage of the stomach and metastasis is TRUE?
a) Lymphatic spread always follows a single predictable path irrespective of tumor site
b) Drainage pathways correlate with arterial supply, but cross-drainage and skip metastases can occur
c) Superficial gastric veins determine lymphatic spread
d) Inguinal nodes are the common first station for all gastric tumors

Answer: b) Drainage pathways correlate with arterial supply, but cross-drainage and skip metastases can occur

Explanation: While gastric lymphatics broadly follow arterial routes (left gastric, right gastric, gastroepiploic, short gastric), considerable anatomical variation exists: cross-drainage between pathways and skip metastases (noncontiguous nodal involvement) can occur. Therefore, nodal spread is not absolutely predictable and justifies comprehensive staging and sometimes extended dissection. Superficial veins do not direct lymphatic spread, and inguinal nodes are not involved except in very unusual or metastatic contexts.

9) Which imaging modality is most useful to detect enlarged perigastric and celiac lymph nodes preoperatively?
a) Ultrasound of the groin
b) Contrast-enhanced CT abdomen and pelvis
c) Plain abdominal X-ray
d) Doppler study of the femoral vessels

Answer: b) Contrast-enhanced CT abdomen and pelvis

Explanation: Contrast-enhanced CT scanning of the abdomen and pelvis is the standard preoperative imaging modality to assess gastric wall thickening, regional perigastric, celiac and para-aortic nodal enlargement, and to evaluate resectability. It provides essential staging information. Ultrasound of the groin or plain X-rays are not appropriate for gastric nodal mapping; Doppler femoral studies assess vascular flow, not nodal disease.

10) A rare case of metastatic gastric carcinoma presenting with a palpable Virchow’s node (left supraclavicular) implies spread via which route?
a) Direct transperitoneal seeding only
b) Lymphatic route via thoracic duct to left supraclavicular nodes
c) Inguinal lymphatic pathway
d) Portal venous drainage only

Answer: b) Lymphatic route via thoracic duct to left supraclavicular nodes

Explanation: Virchow’s node (left supraclavicular) can become involved from abdominal malignancies due to lymphatic spread that reaches the thoracic duct and then drains into the left venous angle; tumour emboli can lodge in left supraclavicular nodes. This is a classic sign of advanced gastrointestinal cancer. Inguinal nodes are unrelated; portal venous spread leads to liver metastases rather than supraclavicular nodal enlargement. Therefore, the thoracic duct lymphatic route explains Virchow’s node involvement.

Chapter: Histology & Embryology; Topic: Thymus; Subtopic: Structure and Development

Keyword Definitions:

• Thymus: Primary lymphoid organ responsible for T-cell maturation.

• Cortex: Outer region of thymic lobules densely packed with immature T-lymphocytes.

• Medulla: Inner region containing mature T-cells and characteristic Hassall’s corpuscles.

• Hassall’s Corpuscles: Eosinophilic, concentric epithelial structures found only in thymic medulla.

• Pharyngeal Pouches: Endodermal outpouchings forming several endocrine and lymphoid organs; thymus arises from 3rd pouch.

1) Lead Question – 2016
All of the following are true about thymus except?
A) The cortical portion is mainly composed of lymphocytes
B) The medulla contains Hassall's Corpuscles
C) It is derived from the fourth Pharyngeal pouch
D) It undergoes atrophy puberty onwards

Answer: C) It is derived from the fourth Pharyngeal pouch

Explanation: The thymus plays a critical role in T-cell maturation. The cortex contains densely packed immature lymphocytes, and the medulla contains Hassall’s corpuscles, both of which are correct statements. The thymus undergoes physiological involution beginning at puberty, another true statement. However, embryologically, the thymus develops from the third pharyngeal pouch (ventral wing), not the fourth pouch. Hence, option C is false and therefore the correct answer. Understanding thymic microanatomy and development is essential for appreciating immunodeficiencies and congenital anomalies such as DiGeorge syndrome.

2) The thymus is primarily responsible for maturation of–
A) B-lymphocytes
B) Plasma cells
C) T-lymphocytes
D) NK cells

Answer: C) T-lymphocytes

Explanation: The thymus is the central lymphoid organ for T-cell maturation. B-cells mature in bone marrow. Thus, C is correct.

3) Hassall’s corpuscles are composed of–
A) Degenerating lymphocytes
B) Concentric epithelial cells
C) Fibroblasts
D) Reticular fibers

Answer: B) Concentric epithelial cells

Explanation: These eosinophilic medullary structures consist of keratinized epithelial cells. Thus, B is correct.

4) In DiGeorge syndrome, thymic aplasia results from failure of development of–
A) 1st pouch
B) 2nd pouch
C) 3rd and 4th pouches
D) 2nd and 3rd pouches

Answer: C) 3rd and 4th pouches

Explanation: Thymus (3rd pouch) and parathyroids (3rd & 4th) fail to develop in DiGeorge. Thus, C is correct.

5) Which cell type is responsible for positive selection of T-cells?
A) Dendritic cells
B) Macrophages
C) Thymic epithelial cells
D) Endothelial cells

Answer: C) Thymic epithelial cells

Explanation: Cortical thymic epithelial cells conduct positive selection by testing MHC recognition. Thus, C is correct.

6) A newborn with recurrent infections shows profound T-cell deficiency. The most likely organ affected is–
A) Spleen
B) Thymus
C) Liver
D) Bone marrow

Answer: B) Thymus

Explanation: Absent or defective thymus leads to T-cell deficiency, producing severe immunodeficiency. Thus, B is correct.

7) Thymus differs from lymph nodes because it lacks–
A) Cortex
B) Medulla
C) Afferent lymphatics
D) Efferent lymphatics

Answer: C) Afferent lymphatics

Explanation: Thymus contains no afferent lymphatics, distinguishing it from lymph nodes. Thus, C is correct.

8) Thymic epithelial cells arise from which germ layer?
A) Endoderm
B) Mesoderm
C) Ectoderm
D) Neural crest

Answer: A) Endoderm

Explanation: Thymic epithelium derives from endoderm of the 3rd pharyngeal pouch. Thus, A is correct.

9) Which hormone is secreted by the thymus to aid T-cell development?
A) Thymosin
B) Renin
C) Calcitonin
D) Glucagon

Answer: A) Thymosin

Explanation: Thymosin supports T-cell differentiation. Other options are unrelated. Thus, A is correct.

10) The blood-thymus barrier is found in which region?
A) Medulla
B) Cortex
C) Capsule
D) Septa

Answer: B) Cortex

Explanation: The barrier protects developing T-cells in the cortex from antigen exposure. Thus, B is correct.

11) Age-related thymic involution results in replacement by–
A) Smooth muscle
B) Bone marrow
C) Adipose tissue
D) Hyaline cartilage

Answer: C) Adipose tissue

Explanation: Thymus undergoes fatty replacement after puberty. Thus, C is correct.

Chapter: Anatomy; Topic: Abdomen – Spleen; Subtopic: Accessory Spleen (Spleniculi)

Keyword Definitions:
• Spleniculi (Accessory spleen): Congenital nodules of splenic tissue located outside the main spleen.
• Hilum of spleen: Site where splenic vessels enter/leave; common area for accessory spleens.
• Spleen: Lymphoid organ involved in filtration of blood and immune response.
• Gastrosplenic ligament: Ligament containing short gastric and left gastroepiploic vessels attached to spleen.
• Splenic hilum nodules: Localized accessory spleens near hilar region.
• Congenital anomaly: A developmental variation present from birth, such as accessory spleen.

Lead Question - 2015
Spleniculi are seen most commonly in:
a) Colon
b) Hilum
c) Liver
d) Lungs

Explanation (Answer: b) Hilum)
Spleniculi, also called accessory spleens, are most commonly found at the hilum of the spleen. They arise due to failure of fusion of splenic nodules during embryological development. They are functionally active and may hypertrophy after splenectomy. They are rarely seen near liver or colon and are never found in lungs. Their presence is important clinically when splenectomy is performed for hematologic disorders.

1. Accessory spleens are commonly found in which ligament?
a) Gastrosplenic ligament
b) Hepatoduodenal ligament
c) Omental bursa
d) Broad ligament

Explanation (Answer: a) Gastrosplenic ligament)
Accessory spleens frequently occur in the gastrosplenic ligament, second only to the splenic hilum. The ligament develops from dorsal mesogastrium and contains short gastric vessels. Spleniculi found here retain normal splenic tissue, immune function, and vascular supply. Identification during splenectomy is crucial to avoid recurrence of hematologic diseases.

2. An accessory spleen is usually:
a) Non-functional
b) Functional splenic tissue
c) Degenerated mass
d) Calcified organ

Explanation (Answer: b) Functional splenic tissue)
Accessory spleens are fully functional splenic tissues capable of normal immune and hematologic activity. They may enlarge when the main spleen is removed (splenectomy). Radiologically, they show uptake on Tc-99 scans. Their functionality is vital in understanding persistent disease after splenectomy for conditions like ITP or hereditary spherocytosis.

3. Which investigation is best to identify accessory spleen post-splenectomy?
a) Ultrasound
b) CT scan
c) Tc-99m sulfur colloid scan
d) MRI brain

Explanation (Answer: c) Tc-99m sulfur colloid scan)
Tc-99m sulfur colloid scan specifically highlights functional splenic tissue, making it ideal for locating accessory spleens. Accessory spleens may enlarge post-splenectomy, leading to recurrence of splenic disorders. CT and ultrasound may show nodules but cannot determine functional activity as accurately as radionuclide imaging.

4. Spleniculi are commonly associated with which condition?
a) Thoracic outlet syndrome
b) Splenectomy
c) Renal agenesis
d) Bronchiectasis

Explanation (Answer: b) Splenectomy)
Following splenectomy, accessory spleens often enlarge because they maintain residual splenic function. This may result in persistent symptoms in hematologic diseases. Knowledge of their presence helps surgeons perform complete removal when treating immune thrombocytopenia (ITP) or hemolytic disorders where splenic activity must be eliminated.

5. Where else besides hilum can accessory spleens be found?
a) In the scrotum
b) Within pancreatic tail
c) In the lungs
d) Inside gall bladder

Explanation (Answer: b) Within pancreatic tail)
Accessory spleens can occasionally be present in the pancreatic tail. They may mimic pancreatic masses radiologically. They demonstrate contrast enhancement similar to splenic tissue, helping radiologists differentiate them from tumors. Clinically, they may enlarge after splenectomy and continue disease progression if not recognized.

6. A surgeon finds a 1 cm mass near splenic hilum during splenectomy. What is it likely?
a) Splenic artery aneurysm
b) Lymph node
c) Accessory spleen
d) Pancreatic cyst

Explanation (Answer: c) Accessory spleen)
Small round nodules near the splenic hilum are most likely accessory spleens. They are congenital remnants containing normal splenic tissue. Failure to remove them in splenectomy may lead to persistence/recurrence of hematologic disorders. Their vascular supply branches from splenic artery, and they appear similar to main spleen histologically.

7. Accessory spleens originate from:
a) Endoderm
b) Mesoderm
c) Neural crest
d) Ectoderm

Explanation (Answer: b) Mesoderm)
The spleen and accessory spleens originate from mesoderm in dorsal mesogastrium. During development, splenic nodules fail to fuse, forming spleniculi. Their mesodermal origin explains their lymphoid function, reticular framework, and vascular pattern. They share structural and functional similarities with spleen proper.

8. Pain in left hypochondrium with persistent splenic tissue after splenectomy suggests presence of:
a) Liver cyst
b) Accessory spleen
c) Gastric diverticulum
d) Pancreatitis

Explanation (Answer: b) Accessory spleen)
Persistent splenic function after splenectomy indicates the presence of an accessory spleen. These spleniculi are normally asymptomatic but may present with abdominal discomfort when enlarged. They maintain immune function yielding ongoing sequestration of blood cells. Tc-99m scan confirms active splenic tissue postoperatively.

9. Which of the following is an ectopic accessory spleen site?
a) Pelvic cavity
b) Left iliac crest
c) Kidney cortex
d) Right lung apex

Explanation (Answer: a) Pelvic cavity)
Rarely, accessory spleens may migrate and be discovered in the pelvic cavity. They develop from mesoderm and are sometimes located along descending pathways of splenic tissue. These ectopic positions can complicate diagnosis of pelvic masses and influence surgical planning in persistent splenic diseases.

10. Accessory spleen may be confused radiologically with:
a) Pancreatic tail tumor
b) Hepatic hemangioma
c) Colon polyp
d) Lung nodule

Explanation (Answer: a) Pancreatic tail tumor)
An accessory spleen located in the pancreatic tail may mimic a pancreatic mass. Contrast-enhanced scans reveal enhancement patterns identical to splenic tissue. Recognizing this prevents unnecessary surgery. Functional imaging using Tc-99m confirms diagnosis, differentiating it from malignant pancreatic lesions or pseudocysts.

Chapter: Head and Neck Anatomy; Topic: Lymphatic Drainage of Head and Neck; Subtopic: Lymphatic Drainage of Lips

Key Definitions:

• Lymph nodes: Small, bean-shaped structures that filter lymph and help the body fight infection.

• Submandibular nodes: Nodes located beneath the jaw, receiving lymph from upper lip and lateral lower lip.

• Submental nodes: Nodes situated below the chin, draining the central lower lip and chin.

• Preauricular (parotid) nodes: Nodes located in front of the ear, receiving lymph from the eyelids and lateral face, not the lips.

Lead Question (NEET PG 2015):

1. Lips does not drain into which group of lymph nodes?

a) Submandibular nodes

b) Sublingual nodes

c) Preauricular parotid

d) None of the above

Answer: c) Preauricular parotid

Explanation: The lymphatic drainage of the lips is divided as follows: the upper lip and lateral parts of the lower lip drain into the submandibular nodes, while the central part of the lower lip and chin drain into the submental nodes. The preauricular (parotid) nodes receive lymph from the lateral eyelids, forehead, and scalp, not from the lips. Therefore, the lips do not drain into the preauricular group of lymph nodes. This knowledge is clinically important in oral cancer metastasis and infections of the oral region.

Guessed Questions (Related to Lymphatic Drainage of Head and Neck):

2. The central part of the lower lip drains into which lymph nodes?

a) Submandibular nodes

b) Submental nodes

c) Deep cervical nodes

d) Preauricular nodes

Answer: b) Submental nodes

Explanation: The submental lymph nodes receive lymph from the central lower lip, chin, and anterior floor of the mouth. These nodes lie in the submental triangle between the anterior bellies of digastric muscles.

3. The upper lip drains mainly into which lymph nodes?

a) Parotid nodes

b) Submandibular nodes

c) Submental nodes

d) Retropharyngeal nodes

Answer: b) Submandibular nodes

Explanation: The submandibular nodes receive lymph from the upper lip, lateral lower lip, and upper oral cavity. These nodes lie superficial to the submandibular gland and drain into deep cervical nodes.

4. A carcinoma at the midline of the lower lip will first spread to which nodes?

a) Submandibular

b) Submental

c) Parotid

d) Deep cervical

Answer: b) Submental

Explanation: The central lower lip and chin region drain to submental nodes; hence, metastasis from a carcinoma in this region will first involve submental nodes before spreading further.

5. Which of the following lymph node groups receives lymph from the scalp and forehead?

a) Submental nodes

b) Parotid (preauricular) nodes

c) Submandibular nodes

d) Deep cervical nodes

Answer: b) Parotid (preauricular) nodes

Explanation: The preauricular nodes drain the lateral scalp, forehead, and eyelids. They do not receive lymph from the lips or oral cavity, distinguishing them from submandibular nodes.

6. The deep cervical lymph nodes receive direct drainage from all of the following except:

a) Palatine tonsil

b) Tongue

c) Lips

d) Scalp

Answer: c) Lips

Explanation: The lips first drain into submental and submandibular nodes before reaching the deep cervical group. Other structures like the tonsil and tongue can have direct drainage to the deep cervical chain.

7. A 40-year-old patient presents with swelling under the chin after a dental infection of the central incisor. Which lymph node is enlarged?

a) Submandibular

b) Submental

c) Jugulodigastric

d) Parotid

Answer: b) Submental

Explanation: Infections from the central lower incisor region drain into the submental nodes due to their anatomic connection with the central lower lip and chin area.

8. Which lymph node group is referred to as the "tonsillar node"?

a) Submental node

b) Jugulodigastric node

c) Jugulo-omohyoid node

d) Parotid node

Answer: b) Jugulodigastric node

Explanation: The jugulodigastric node, a deep cervical node located near the posterior belly of digastric, is known as the tonsillar node as it drains the palatine tonsil and pharyngeal regions.

9. Lymph from the tip of the tongue drains first into:

a) Submandibular nodes

b) Submental nodes

c) Deep cervical nodes

d) Parotid nodes

Answer: b) Submental nodes

Explanation: The tip of the tongue and anterior floor of the mouth drain into submental nodes, while lateral borders of the anterior tongue drain into submandibular nodes.

10. In carcinoma of the lateral border of the tongue, the first group of lymph nodes involved are:

a) Submental nodes

b) Submandibular nodes

c) Jugulodigastric nodes

d) Parotid nodes

Answer: b) Submandibular nodes

Explanation: The anterior two-thirds of the tongue, especially its lateral borders, primarily drain into the submandibular lymph nodes before reaching the deep cervical nodes.

11. Infections of the upper lip and cheek are most likely to cause swelling in which lymph nodes?

a) Submandibular

b) Submental

c) Parotid

d) Buccal

Answer: a) Submandibular

Explanation: The submandibular lymph nodes drain the upper lip, lateral lower lip, and cheek area. Infection or inflammation in these regions commonly leads to enlargement of these nodes.

Chapter: Abdomen; Topic: Spleen and Its Ligaments; Subtopic: Peritoneal Attachments of Spleen

Keyword Definitions:

• Spleen: A lymphoid organ situated in the left upper quadrant of the abdomen, important for blood filtration and immune response.

• Phrenicolic Ligament: A peritoneal fold between the left colic flexure and diaphragm that supports the spleen and prevents it from descending into the iliac fossa.

• Splenic Ligaments: Peritoneal folds such as gastrosplenic and lienorenal ligaments connecting the spleen to stomach and kidney, respectively.

Lead Question – 2015
Ligament which prevents spleen to fall in left iliac fossa -
a) Leinorenal ligament
b) Phrenicolic ligament
c) Upper pole of right kidney
d) Sigmoid colon

Explanation: The phrenicolic ligament acts as a shelf supporting the spleen, extending between the left colic flexure and diaphragm. It prevents downward displacement of the spleen toward the left iliac fossa, especially in conditions like splenomegaly. The lienorenal ligament connects spleen to the left kidney. Hence, the correct answer is b) Phrenicolic ligament.

1. The spleen is located in which region of the abdomen?
a) Left hypochondrium
b) Left lumbar
c) Umbilical
d) Epigastric

Explanation: The spleen lies in the left hypochondrium, between the 9th and 11th ribs, following the axis of the 10th rib. It is intraperitoneal and surrounded by peritoneum except at its hilum. Its location provides protection under the rib cage. Thus, the correct answer is a) Left hypochondrium.

2. Clinical case: A patient with splenomegaly has the lower pole of the spleen palpable below the costal margin. Which ligament prevents further descent?
a) Phrenicolic ligament
b) Lienorenal ligament
c) Gastrosplenic ligament
d) Splenocolic ligament

Explanation: The phrenicolic ligament supports the spleen from below, forming a peritoneal shelf over the left colic flexure. Even in splenomegaly, this ligament prevents excessive descent into the left iliac fossa. It stabilizes the organ’s position within the left upper quadrant. Correct answer: a) Phrenicolic ligament.

3. Which ligament connects the spleen to the posterior abdominal wall?
a) Lienorenal ligament
b) Gastrosplenic ligament
c) Phrenicocolic ligament
d) Splenocolic ligament

Explanation: The lienorenal ligament (splenorenal) connects the spleen to the left kidney and contains splenic vessels and tail of pancreas. It secures the spleen posteriorly and provides a route for vascular supply. Correct answer: a) Lienorenal ligament.

4. Clinical case: A patient suffers trauma to the left lower ribs causing internal bleeding. Which organ is most likely injured?
a) Spleen
b) Left kidney
c) Stomach
d) Pancreas

Explanation: The spleen lies beneath the 9th to 11th ribs and is most commonly injured in blunt trauma to the left lower thorax. Its capsule is thin, making it prone to rupture with internal hemorrhage. Prompt splenectomy may be needed. Correct answer: a) Spleen.

5. Which peritoneal ligament contains the splenic artery?
a) Lienorenal ligament
b) Gastrosplenic ligament
c) Phrenicolic ligament
d) Hepatogastric ligament

Explanation: The lienorenal ligament contains the splenic vessels and tail of the pancreas as it connects spleen to the posterior abdominal wall. The gastrosplenic ligament, however, contains short gastric and left gastroepiploic vessels. Correct answer: a) Lienorenal ligament.

6. The spleen is derived embryologically from:
a) Endoderm
b) Mesoderm
c) Ectoderm
d) Neural crest

Explanation: The spleen develops from mesoderm within the dorsal mesogastrium. It appears as a lobulated structure that later fuses to form the adult organ. Its mesodermal origin explains its reticular tissue framework rather than epithelial lining. Correct answer: b) Mesoderm.

7. Clinical case: Following a splenectomy, which organ compensates for its phagocytic function?
a) Liver
b) Kidney
c) Pancreas
d) Adrenal gland

Explanation: After splenectomy, the liver and bone marrow compensate for phagocytosis and removal of damaged RBCs. Kupffer cells of the liver take over filtering functions of the spleen, though immune efficiency may decline. Correct answer: a) Liver.

8. The diaphragmatic surface of the spleen is related to:
a) Stomach
b) Left kidney
c) 9th–11th ribs and diaphragm
d) Pancreas tail

Explanation: The diaphragmatic surface of the spleen is smooth and convex, related to the diaphragm and 9th–11th ribs. This provides protection and respiratory mobility. In trauma, rib fractures may cause splenic rupture. Correct answer: c) 9th–11th ribs and diaphragm.

9. Clinical case: A patient undergoing splenectomy has the tail of pancreas injured. Which ligament transmits both structures?
a) Lienorenal ligament
b) Gastrosplenic ligament
c) Phrenicocolic ligament
d) Splenocolic ligament

Explanation: The lienorenal ligament carries the splenic vessels and tail of pancreas to the hilum of spleen. During splenectomy, accidental damage to pancreatic tail may cause pancreatitis or leakage of enzymes. Correct answer: a) Lienorenal ligament.

10. The spleen’s function in fetal life is mainly:
a) Bile secretion
b) Hematopoiesis
c) Lipid metabolism
d) Urine formation

Explanation: In fetal life, the spleen acts as a hematopoietic organ, producing red and white blood cells until bone marrow becomes functional. This role diminishes after birth, but splenic red pulp retains phagocytic activity. Correct answer: b) Hematopoiesis.

Chapter: Anatomy; Topic: Lymphoid Organs; Subtopic: Thymus and Hassall’s Corpuscles

Keyword Definitions:

• Hassall’s corpuscles: Eosinophilic, concentric structures found in the medulla of the thymus, derived from epithelial reticular cells.

• Thymus: Primary lymphoid organ responsible for T-cell maturation and central immune tolerance.

• T lymphocytes: Immune cells responsible for cell-mediated immunity, trained in the thymus.

• Lymphoid organs: Organs involved in immune cell formation and activation, such as spleen, lymph nodes, and thymus.

• Medulla of thymus: The central region containing mature T cells and Hassall’s corpuscles.

Lead Question - 2014

Hassall's corpuscles are found in?
a) Lymph nodes
b) Spleen
c) Liver
d) Thymus

Explanation: Hassall’s corpuscles are present in the thymus, specifically in its medulla. They are composed of concentrically arranged epithelial reticular cells, often showing keratinization. These corpuscles are unique to the thymus and play a role in the differentiation of regulatory T cells and the removal of apoptotic thymocytes, maintaining immune tolerance and preventing autoimmune responses.

1) Which of the following is a primary lymphoid organ?
a) Thymus
b) Lymph node
c) Spleen
d) Tonsil

Explanation: The thymus is a primary lymphoid organ where T lymphocytes mature. Bone marrow and thymus are primary lymphoid organs because they are sites of lymphocyte production and education. Secondary lymphoid organs like spleen and lymph nodes are sites where immune responses are initiated. The thymus is most active during childhood and involutes with age.

2) Hassall’s corpuscles are derived from which embryological layer?
a) Mesoderm
b) Endoderm
c) Ectoderm
d) Neural crest

Explanation: Hassall’s corpuscles originate from the endoderm of the third pharyngeal pouch, which forms the epithelial reticular cells of the thymus. These cells form concentric layers within the medulla and may show keratinization. The corpuscles contribute to T-cell education by releasing cytokines influencing the maturation of regulatory T cells essential for immune tolerance.

3) A child with DiGeorge syndrome will have which defect?
a) Absence of thymus
b) Enlarged thymus
c) Normal thymic function
d) Extra Hassall’s corpuscles

Explanation: In DiGeorge syndrome, there is congenital absence or hypoplasia of the thymus and parathyroids due to defective development of the third and fourth pharyngeal pouches. This results in T-cell immunodeficiency and hypocalcemia. Absence of Hassall’s corpuscles is also noted, contributing to poor immune regulation and susceptibility to recurrent infections in affected children.

4) Function of Hassall’s corpuscles includes:
a) T-cell proliferation
b) B-cell maturation
c) Induction of regulatory T cells
d) Formation of plasma cells

Explanation: Hassall’s corpuscles play a role in the induction of regulatory T cells by secreting thymic stromal lymphopoietin and other cytokines. This helps maintain immune self-tolerance and prevents autoimmunity. They also assist in the phagocytosis of apoptotic thymocytes. Thus, their function is central to establishing a functional and self-tolerant immune system.

5) The thymus is located in which part of the mediastinum?
a) Anterior
b) Middle
c) Posterior
d) Inferior

Explanation: The thymus lies in the anterior mediastinum, extending into the superior mediastinum in children. It consists of two lobes connected by connective tissue. The thymus provides a protected environment for T-cell maturation before they migrate to secondary lymphoid tissues. With age, it undergoes fatty degeneration, becoming less active immunologically.

6) A biopsy of thymic medulla reveals concentrically arranged epithelial cells. Identify the structure:
a) Germinal center
b) Hassall’s corpuscle
c) Lymphoid follicle
d) Macrophage aggregate

Explanation: Concentric whorls of epithelial reticular cells in the thymic medulla are known as Hassall’s corpuscles. They are keratinized, eosinophilic, and unique to the thymus. Their identification helps differentiate thymic tissue from lymph nodes or spleen histologically. They secrete cytokines influencing regulatory T-cell differentiation and thymocyte clearance mechanisms.

7) Which of the following structures is absent in the thymus?
a) Lymphatic nodules
b) Hassall’s corpuscles
c) T lymphocytes
d) Epithelial reticular cells

Explanation: The thymus lacks lymphatic nodules and germinal centers because it is not a site for antigenic stimulation or B-cell proliferation. It primarily functions in T-cell maturation. In contrast, structures like Hassall’s corpuscles, T lymphocytes, and epithelial reticular cells are typical components of thymic architecture, located predominantly in the cortex and medulla.

8) Which hormone is secreted by thymic epithelial cells?
a) Thymosin
b) Cortisol
c) Aldosterone
d) Melatonin

Explanation: Thymic epithelial cells secrete thymosin, a hormone that promotes differentiation and proliferation of T lymphocytes. Thymosin, along with thymopoietin and thymulin, regulates immune competence in developing T cells. The hormone’s levels decline with thymic involution, corresponding with the reduction of cellular immunity in elderly individuals.

9) A patient with autoimmune disease likely has dysfunction of which thymic structure?
a) Hassall’s corpuscles
b) Germinal centers
c) Peyer’s patches
d) White pulp of spleen

Explanation: Dysfunction of Hassall’s corpuscles can impair the generation of regulatory T cells, leading to loss of self-tolerance and development of autoimmune diseases. These corpuscles secrete cytokines that modulate Treg differentiation. Thus, their malfunction results in inappropriate immune activation against self-antigens, contributing to disorders such as myasthenia gravis or systemic lupus erythematosus.

10) Thymic involution starts at what age?
a) At birth
b) At puberty
c) After 40 years
d) During fetal life

Explanation: Thymic involution begins at puberty. The lymphoid tissue of the thymus is gradually replaced by adipose tissue with age, though functional thymic remnants persist throughout life. Despite its reduced size, the thymus continues minimal T-cell production to maintain immune surveillance, albeit at a lower efficiency compared to early life.

Chapter: Head and Neck Anatomy; Topic: Lymphatic Drainage of Nose; Subtopic: Anterior and Posterior Nasal Lymphatics

Keyword Definitions:

• Lymphatic drainage: Pathway by which lymph fluid from tissues drains into lymph nodes for immune filtration.

• Submandibular lymph nodes: Nodes located beneath the mandible, draining the anterior nasal cavity, cheek, and lips.

• Pretracheal nodes: Small lymph nodes in front of the trachea, draining thyroid and laryngeal regions.

• Superficial cervical nodes: Nodes along the external jugular vein, receiving lymph from the scalp and face.

Lead Question (2014):
Anterior lymphatics from the nose drain into?
a) Pretracheal nodes
b) Submandibular nodes
c) Sublingual nodes
d) Superficial cervical nodes

Explanation:
The anterior lymphatics of the nose, particularly from the anterior nasal cavity and vestibule, drain into the submandibular lymph nodes. Posterior nasal regions drain into retropharyngeal and upper deep cervical nodes. Understanding these pathways is important in diagnosing nasal and facial infections. Answer: Submandibular nodes. These nodes play a vital role in filtering lymph from anterior facial structures.

1) Posterior nasal cavity lymphatics primarily drain into:
a) Submandibular nodes
b) Retropharyngeal nodes
c) Pretracheal nodes
d) Submental nodes

Explanation:
Lymph from the posterior nasal cavity drains into retropharyngeal nodes, located behind the pharynx. These nodes later communicate with upper deep cervical nodes. Infections in posterior nasal structures, such as adenoids or nasopharyngeal carcinoma, often spread here first. Answer: Retropharyngeal nodes. Their deep location makes clinical detection difficult unless significantly enlarged.

2) Which lymph nodes drain the tip of the nose?
a) Submandibular nodes
b) Submental nodes
c) Superficial parotid nodes
d) Deep cervical nodes

Explanation:
The tip of the nose and adjacent alae drain primarily into the submandibular nodes. However, some lymph from the midline of the lower lip and chin may reach submental nodes. Answer: Submandibular nodes. This pattern is clinically important because infections at the nasal vestibule or furuncles can cause tender swelling beneath the jawline.

3) A patient with a nasal vestibular abscess will most likely have tenderness over which lymph nodes?
a) Pretracheal
b) Submandibular
c) Deep cervical
d) Retropharyngeal

Explanation:
A nasal vestibular abscess drains anteriorly into the submandibular lymph nodes, leading to tenderness and swelling under the mandible. These nodes filter lymph from the anterior nose, cheek, and upper lip. Answer: Submandibular nodes. Clinically, enlarged submandibular nodes help localize infections to anterior facial regions or vestibular furuncles.

4) Posterior nasal lymphatics ultimately reach which group of deep cervical nodes?
a) Jugulodigastric
b) Jugulo-omohyoid
c) Supraclavicular
d) Pretracheal

Explanation:
Posterior nasal lymphatics drain via retropharyngeal nodes into the jugulodigastric nodes, one of the key deep cervical lymph nodes. These receive lymph from nasopharynx, tonsils, and posterior scalp. Answer: Jugulodigastric nodes. Their enlargement may indicate infections like tonsillitis or malignancy in posterior nasal or pharyngeal regions.

5) Which lymph nodes receive drainage from both the nose and upper lip?
a) Submandibular
b) Submental
c) Retropharyngeal
d) Superficial cervical

Explanation:
Both the nose and upper lip drain into the submandibular lymph nodes. This overlap explains why infections around the mouth and nose can spread rapidly, even causing cavernous sinus thrombosis in severe cases. Answer: Submandibular nodes. These nodes are palpable below the jawline and are clinically relevant in facial cellulitis evaluation.

6) A carcinoma in the nasal septum anteriorly will first spread to:
a) Retropharyngeal nodes
b) Submandibular nodes
c) Deep cervical nodes
d) Prelaryngeal nodes

Explanation:
Cancer in the anterior nasal septum first metastasizes to submandibular lymph nodes. The anterior lymphatic drainage pattern directs lymph flow toward these superficial nodes before reaching deeper cervical nodes. Answer: Submandibular nodes. Palpation of submandibular nodes is vital in head and neck oncology to detect early regional spread.

7) The posterior nasal cavity and nasopharynx share lymphatic drainage with which structure?
a) Palatine tonsil
b) Parotid gland
c) Tongue tip
d) Lower lip

Explanation:
Both the posterior nasal cavity and palatine tonsil drain into retropharyngeal and upper deep cervical (jugulodigastric) nodes. This shared drainage explains why nasopharyngeal carcinoma may spread to tonsillar lymphatic pathways. Answer: Palatine tonsil. Awareness of these connections helps clinicians assess metastasis patterns in head and neck malignancies.

8) Inflammation over the bridge of the nose drains to which lymph node group?
a) Preauricular
b) Submandibular
c) Retropharyngeal
d) Occipital

Explanation:
The bridge of the nose drains into submandibular lymph nodes, while lateral aspects may communicate with preauricular nodes. In infections like cellulitis or furuncles, submandibular tenderness is a key sign. Answer: Submandibular nodes. Prompt management is crucial as facial veins lack valves, increasing risk of cavernous sinus spread.

9) Deep cervical lymph nodes receive indirect drainage from nasal structures via which group?
a) Retropharyngeal
b) Pretracheal
c) Submental
d) Submandibular

Explanation:
The deep cervical lymph nodes collect lymph from the nose indirectly through retropharyngeal and submandibular nodes. These act as intermediary stations before lymph enters the jugular trunk. Answer: Retropharyngeal nodes. The sequence reflects the structured lymphatic hierarchy in the head and neck drainage network.

10) A patient with posterior nasal carcinoma has enlarged deep cervical nodes. The spread occurred through which intermediate group?
a) Submandibular
b) Retropharyngeal
c) Pretracheal
d) Parotid

Explanation:
Posterior nasal or nasopharyngeal carcinomas first spread to the retropharyngeal nodes, then to the deep cervical (jugulodigastric) group. Answer: Retropharyngeal nodes. These nodes are often the first indicator of malignancy in this region. Their involvement provides essential clues in imaging and surgical planning for head and neck cancers.

Topic: Lymphatic System; Subtopic: Termination of Thoracic Duct

Keyword Definitions:

• Thoracic duct: Largest lymphatic channel, draining lymph from most of the body except right upper quadrant.

• Venous angle: Junction of internal jugular vein and subclavian vein.

• Subclavian vein: Major vein draining blood from the upper limb.

• Internal jugular vein: Vein draining blood from brain, face, and neck.

• Brachiocephalic vein: Large vein formed by union of subclavian and internal jugular veins.

Lead Question - 2014
Thoracic duct opens into ?
a) Subclavian vein
b) Internal jugular vein
c) Right brachiocephalic vein
d) Left brachiocephalic vein

Explanation: The thoracic duct terminates at the left venous angle, i.e., the junction of the left subclavian and left internal jugular veins. This anatomical site is critical in surgeries of the neck and mediastinum. Correct answer: a) Subclavian vein (at its junction with internal jugular vein).

Guessed Questions for NEET PG:

1) Which side of the venous angle receives thoracic duct?
a) Right
b) Left
c) Both sides
d) Variable

Explanation: The thoracic duct consistently terminates at the left venous angle, formed by left internal jugular and left subclavian veins. This is a fixed anatomical feature with great surgical relevance. Correct answer: b) Left.

2) Right lymphatic duct opens into?
a) Left venous angle
b) Right venous angle
c) Superior vena cava
d) Azygos vein

Explanation: The right lymphatic duct drains lymph from right upper limb, right thorax, and right side of head and neck. It opens into the right venous angle, i.e., junction of right internal jugular and subclavian veins. Correct answer: b) Right venous angle.

3) Length of thoracic duct is?
a) 10 cm
b) 20 cm
c) 40 cm
d) 60 cm

Explanation: The thoracic duct measures approximately 40 cm in adults. It extends from cisterna chyli at L1-L2 vertebrae to the left venous angle in the root of the neck. Correct answer: c) 40 cm.

4) Thoracic duct crosses from right to left at the level of?
a) T2
b) T4
c) T6
d) T8

Explanation: The thoracic duct ascends on the right side of vertebral column and crosses to the left side at the level of T4-T6 vertebrae, continuing upward to terminate in the left venous angle. Correct answer: b) T4.

5) A 45-year-old man develops chylothorax after oesophagectomy. Which structure is injured?
a) Azygos vein
b) Thoracic duct
c) Hemiazygos vein
d) Vagus nerve

Explanation: Chylothorax results from thoracic duct injury during mediastinal or esophageal surgery. Milky fluid rich in triglycerides accumulates in the pleural cavity, requiring drainage. Correct answer: b) Thoracic duct.

6) Cisterna chyli is located at?
a) T10
b) T12
c) L1-L2
d) S1

Explanation: The cisterna chyli is located anterior to the bodies of L1 and L2 vertebrae. It collects lymph from lumbar and intestinal trunks and continues as thoracic duct. Correct answer: c) L1-L2.

7) Thoracic duct drains all except?
a) Right lower limb
b) Left upper limb
c) Right thorax
d) Left thorax

Explanation: The thoracic duct drains both lower limbs, abdomen, left thorax, left upper limb, and left head and neck. The right thorax, right upper limb, and right head and neck are drained by the right lymphatic duct. Correct answer: c) Right thorax.

8) In a left neck dissection, accidental thoracic duct injury causes leakage of?
a) Blood
b) Serous fluid
c) Chyle
d) Bile

Explanation: Injury to thoracic duct causes leakage of chyle, a milky lymph rich in fats. Chylous fistula is a known complication in neck surgeries, particularly near left venous angle. Correct answer: c) Chyle.

9) In lymphoma, obstruction of thoracic duct may cause?
a) Pleural effusion
b) Ascites
c) Chylous ascites
d) Pericardial effusion

Explanation: Thoracic duct obstruction by lymphoma or tumor can cause chylous ascites, characterized by milky fluid in the peritoneal cavity due to blocked lymphatic flow. Correct answer: c) Chylous ascites.

10) During ligation of thoracic duct, surgeon aims to prevent?
a) Air embolism
b) Chylothorax
c) Pneumothorax
d) Pulmonary embolism

Explanation: Ligation of thoracic duct is done to prevent persistent chylothorax, which results from continuous leakage of chyle into pleural cavity. This is life-threatening due to nutritional loss. Correct answer: b) Chylothorax.

Subtopic: Thoracic Duct Formation

Keyword Definitions:

• Thoracic duct: The largest lymphatic vessel in the human body draining lymph from most areas.

• Cisterna chyli: Dilated sac at the lower end of thoracic duct collecting lymph from abdomen.

• Subclavian vein: Vein that drains blood from upper limb into brachiocephalic vein.

• Jugular vein: Vein draining blood from head and neck.

• Brachiocephalic vein: Large vein formed by subclavian and internal jugular veins.

Lead Question - 2014
Thoracic duct is formed by?
a) Union of left subclavian and left internal jugular vein.
b) Union of brachiocephalic vein and internal jugular vein
c) Continuation of upper end of cisterna chyli
d) None of the above

Explanation: The thoracic duct originates as the continuation of the cisterna chyli at the level of L1-L2 vertebrae, ascending through the thorax. It drains into the venous system at the junction of the left internal jugular and left subclavian veins. Correct answer: c) Continuation of upper end of cisterna chyli.

Guessed Questions for NEET PG:

1) Length of thoracic duct is approximately?
a) 10 cm
b) 20 cm
c) 40 cm
d) 50 cm

Explanation: The thoracic duct measures about 40 cm in adults. It starts from cisterna chyli in the abdomen and ascends to the venous angle. Its long course makes it prone to injury during surgery. Correct answer: c) 40 cm.

2) Thoracic duct pierces diaphragm through?
a) Aortic hiatus
b) Caval opening
c) Esophageal hiatus
d) None

Explanation: The thoracic duct passes through the diaphragm along with the aorta at the aortic hiatus at the level of T12 vertebra. This is a key anatomical relation during abdominal and thoracic surgeries. Correct answer: a) Aortic hiatus.

3) Which vein receives terminal drainage of thoracic duct?
a) Right subclavian vein
b) Left brachiocephalic vein
c) At junction of left internal jugular and left subclavian vein
d) Superior vena cava

Explanation: The thoracic duct terminates into the venous system at the left venous angle, i.e., the junction of the left subclavian vein and left internal jugular vein. This is a key anatomical landmark. Correct answer: c) Junction of left internal jugular and subclavian vein.

4) Thoracic duct drains all except?
a) Left upper limb
b) Right thorax
c) Left abdomen
d) Left thorax

Explanation: The thoracic duct drains lymph from entire body except the right upper limb, right thorax, right side of head and neck, which are drained by the right lymphatic duct. Correct answer: b) Right thorax.

5) In a neck surgery, thoracic duct injury leads to leakage of?
a) Blood
b) Bile
c) Chyle
d) Lymphocyte-depleted fluid

Explanation: Injury to thoracic duct leads to chylous fistula, with leakage of milky chyle rich in triglycerides. This complication is common during left neck dissections near the venous angle. Correct answer: c) Chyle.

6) Cisterna chyli is located at?
a) T8-T9
b) L1-L2
c) S1-S2
d) T12

Explanation: The cisterna chyli is located anterior to the bodies of L1 and L2 vertebrae, behind the right crus of diaphragm. It acts as the reservoir for intestinal and lumbar lymph trunks. Correct answer: b) L1-L2.

7) In chylothorax, fluid accumulates in?
a) Pleural cavity
b) Peritoneal cavity
c) Pericardial cavity
d) Subarachnoid space

Explanation: Chylothorax occurs when the thoracic duct is injured, leading to leakage of chyle into the pleural cavity. It is a serious surgical complication, requiring drainage and repair. Correct answer: a) Pleural cavity.

8) Right lymphatic duct drains lymph from?
a) Right upper limb
b) Right thorax
c) Right side of head and neck
d) All of the above

Explanation: The right lymphatic duct drains lymph from right upper limb, right thorax, and right side of head and neck. It terminates into the right venous angle. Correct answer: d) All of the above.

9) In case of lymphoma, thoracic duct obstruction may cause?
a) Ascites
b) Chylothorax
c) Chylous ascites
d) Edema

Explanation: Thoracic duct obstruction due to malignancy such as lymphoma may cause chylous ascites, characterized by milky fluid in peritoneum. This is a clinical indicator of lymphatic obstruction. Correct answer: c) Chylous ascites.

10) During oesophageal carcinoma surgery, thoracic duct is at risk at level of?
a) T2
b) T4
c) T8
d) T12

Explanation: Thoracic duct runs posterior to oesophagus in thorax, closely related at T4 to T8 levels. Surgical manipulation in esophagectomy carries risk of injury. Correct answer: c) T8.

Chapter: Anatomy

Topic: Pelvis

Subtopic: Lymphatic Drainage of Female Reproductive Organs

Keyword Definitions:

• Para-aortic lymph nodes: Lymph nodes along the abdominal aorta, draining ovaries, uterine tubes, and upper uterus.

• External iliac lymph nodes: Nodes along external iliac vessels, draining upper bladder, cervix, and upper vagina.

• Superior inguinal lymph nodes: Located in femoral triangle, draining lower vulva, lower vagina, and superficial structures of lower limb.

• Deep inguinal lymph nodes: Beneath fascia lata, draining glans penis/clitoris, deep lower limb structures.

• Pelvic lymph nodes: Network including obturator, internal iliac, external iliac, and sacral nodes.

• Clinical relevance: Knowledge of lymphatic drainage is vital for staging cervical and vaginal cancers and planning surgery or radiotherapy.

Lead Question - 2013

Which lymph nodes drain upper vagina & cervix?

a) Para aortic
b) External iliac
c) Superior inguinal
d) Deep inguinal

Explanation: The upper vagina and cervix primarily drain into the external iliac lymph nodes, with some drainage to internal iliac and obturator nodes. Para-aortic nodes mainly drain ovaries and uterine tubes. Correct answer is b) External iliac.

Guessed Question 2

Lower vagina primarily drains into?

a) External iliac nodes
b) Internal iliac nodes
c) Superior inguinal nodes
d) Para-aortic nodes

Explanation: The lower vagina and vulva drain primarily into superficial and superior inguinal lymph nodes, providing a pathway for potential metastasis. Correct answer is c) Superior inguinal nodes.

Guessed Question 3

Ovaries drain mainly to which lymph nodes?

a) External iliac
b) Internal iliac
c) Para-aortic
d) Inguinal

Explanation: Ovarian lymphatics follow the ovarian vessels to the para-aortic (lumbar) lymph nodes near the renal vessels. Correct answer is c) Para-aortic.

Guessed Question 4

Cervical cancer commonly metastasizes to which nodes first?

a) Para-aortic
b) External iliac
c) Superior inguinal
d) Sacral

Explanation: Early cervical cancer spreads to the external iliac, internal iliac, and obturator nodes. Para-aortic and sacral involvement occurs later. Correct answer is b) External iliac.

Guessed Question 5

Which lymph nodes lie along obturator vessels?

a) Obturator nodes
b) External iliac nodes
c) Superior inguinal nodes
d) Para-aortic nodes

Explanation: Obturator lymph nodes are situated along the obturator vessels, draining the pelvic floor, bladder, cervix, and upper vagina. Correct answer is a) Obturator nodes.

Guessed Question 6

Deep inguinal lymph nodes receive drainage from?

a) Lower limb
b) Upper vagina
c) Cervix
d) Para-aortic nodes

Explanation: Deep inguinal nodes lie beneath fascia lata and receive lymph from the lower limb, glans penis/clitoris, and deep structures of the lower pelvis. Correct answer is a) Lower limb.

Guessed Question 7

Which nodes are involved in vulvar carcinoma?

a) Para-aortic
b) Superior inguinal
c) External iliac
d) Obturator

Explanation: Vulvar carcinoma primarily drains to superficial and superior inguinal lymph nodes, which are first sites of metastasis. Correct answer is b) Superior inguinal.

Guessed Question 8

Internal iliac lymph nodes drain?

a) Upper bladder, cervix, uterus
b) Lower limb
c) Ovaries
d) Lower vagina only

Explanation: Internal iliac nodes drain the cervix, upper vagina, bladder, and uterus, forming an important part of pelvic lymphatic network. Correct answer is a) Upper bladder, cervix, uterus.

Guessed Question 9

Para-aortic nodes are clinically important in?

a) Staging ovarian cancer
b) Breast cancer
c) Colon cancer
d) Thyroid cancer

Explanation: Para-aortic lymph nodes receive lymph from ovaries, uterine tubes, and upper uterus, serving as a key site in staging ovarian and some uterine cancers. Correct answer is a) Staging ovarian cancer.

Guessed Question 10

Which pelvic node group is commonly biopsied in cervical cancer?

a) External iliac
b) Para-aortic
c) Superior inguinal
d) Deep inguinal

Explanation: External iliac nodes are commonly biopsied or sampled during pelvic lymphadenectomy in cervical cancer due to their early involvement. Correct answer is a) External iliac.

Guessed Question 11

Obturator nodes are located in relation to?

a) Obturator vessels
b) External iliac vessels
c) Internal thoracic artery
d) Para-aortic region

Explanation: Obturator lymph nodes lie along obturator vessels in the obturator fossa and are part of the primary drainage pathway of the cervix and upper vagina. Correct answer is a) Obturator vessels.

Keyword Definitions

• Ossification center – Specific area where bone formation begins.

• Primary ossification center – Appears before birth, usually in diaphysis of long bones.

• Secondary ossification center – Appears after birth, mostly at epiphyses.

• Epiphysis – End part of long bone, separated by growth plate.

• Growth plate (physis) – Cartilaginous zone responsible for bone lengthening.

• Femur – Longest bone in the body, crucial for weight bearing.

• Lower end of femur – Includes medial and lateral condyles, important for knee joint stability.

• Clinical correlation – Injuries near growth plate may cause deformity in children.

• Fusion of ossification centers – Indicates skeletal maturity, useful in forensic medicine.

• Pathology – Delay in ossification may suggest rickets or endocrinological disorders.

Chapter: Anatomy / Lower Limb

Topic: Ossification of Femur

Subtopic: Lower End of Femur

Lead Question – 2013

Lower end of femur is ossified from how many ossification centers?

a) 1

b) 2

c) 3

d) 4

Explanation: The lower end of femur is ossified from a single secondary ossification center, which appears at birth and is the largest epiphyseal center in the body. It helps determine gestational age in newborn radiographs. Correct answer: 1.

Guessed Questions for NEET PG

1) The first secondary ossification center to appear in the body is?

a) Head of femur

b) Lower end of femur

c) Upper end of tibia

d) Calcaneus

Explanation: The lower end of femur and upper end of tibia are the earliest secondary ossification centers, both appearing at birth. These are crucial in neonatal skeletal age estimation. Correct answer: Lower end of femur.

2) Which ossification center is used to determine fetal maturity in X-rays?

a) Upper end of humerus

b) Lower end of femur

c) Upper end of fibula

d) Clavicle

Explanation: The presence of the ossification center in the lower end of femur indicates intrauterine maturity after 36 weeks of gestation. Correct answer: Lower end of femur.

3) The lower end of femur fuses with shaft at what age?

a) 12 years

b) 16 years

c) 20 years

d) 25 years

Explanation: Fusion of the lower end of femur with diaphysis occurs around 20 years of age, making it a reliable marker for skeletal maturity in forensic medicine. Correct answer: 20 years.

4) Which epiphysis is the largest secondary ossification center?

a) Proximal humerus

b) Distal femur

c) Proximal tibia

d) Iliac crest

Explanation: The distal femoral epiphysis is the largest secondary ossification center, covering the condylar region. It plays a crucial role in knee growth. Correct answer: Distal femur.

5) In rickets, which ossification center shows delayed appearance?

a) Lower end of femur

b) Upper end of tibia

c) Distal radius

d) All of the above

Explanation: Rickets causes generalized delay in appearance of secondary ossification centers, including lower femur, tibia, and wrist bones. Correct answer: All of the above.

6) The ossification center at the head of femur appears at?

a) Birth

b) 1 year

c) 3 months

d) 6 years

Explanation: The head of femur ossification center appears at around 1 year of age, useful in pediatric radiology. Correct answer: 1 year.

7) Which bone has both membranous and cartilaginous ossification?

a) Femur

b) Clavicle

c) Tibia

d) Radius

Explanation: The clavicle develops from both intramembranous and endochondral ossification, unlike femur which is purely cartilaginous in origin. Correct answer: Clavicle.

8) A neonate with no ossification center at lower femur is likely?

a) Term baby

b) Preterm baby

c) Post-term baby

d) Growth restricted baby only

Explanation: Absence of ossification center at the lower femur suggests prematurity (

9) Which of the following is true about epiphyseal injuries in femur?

a) Common in adults

b) Affect growth potential

c) Do not cause deformity

d) Heals without complications

Explanation: Epiphyseal injuries in the distal femur can affect growth and cause angular deformities due to damage of growth plate. Correct answer: Affect growth potential.

10) The nutrient artery of femur enters from?

a) Upper end

b) Middle third posterior surface

c) Lower end

d) Anterior surface

Explanation: The nutrient artery enters the shaft of femur from the middle third on its posterior surface, directed towards the knee ("to the elbow I go, from the knee I flee"). Correct answer: Middle third posterior surface.

Keyword Definitions

• Lymph nodes – Small immune structures filtering lymphatic fluid.

• Superficial inguinal lymph nodes – Drain superficial structures of lower limb, external genitalia, and lower abdominal wall.

• Deep inguinal nodes – Located beneath fascia lata, drain deep lymphatics of lower limb.

• External iliac nodes – Drain lymph from pelvic organs and deep inguinal nodes.

• Internal iliac nodes – Drain pelvic viscera, perineum, and gluteal region.

• Great toe lymphatics – Superficial drainage follows great saphenous vein to superficial inguinal nodes.

• Popliteal lymph nodes – Located behind knee, drain deep tissues of leg.

• Clinical correlation – Swelling in groin may indicate infection or malignancy in drainage territory.

• Saphenous vein – Long superficial vein of leg, associated with superficial lymphatics.

• Sentinel lymph node – First node to receive lymph from cancer site, important in oncology.

Chapter: Anatomy / Lower Limb

Topic: Lymphatic Drainage

Subtopic: Drainage of Foot and Great Toe

Lead Question – 2013

Skin and fascia of great toe drains into?

a) Superficial inguinal lymph nodes

b) External iliac nodes

c) Internal iliac nodes

d) Deep inguinal nodes

Explanation: The superficial lymphatics of the great toe accompany the great saphenous vein and drain primarily into the superficial inguinal lymph nodes. Deep lymphatics, however, drain into deep inguinal and external iliac nodes. Correct answer: Superficial inguinal lymph nodes.

Guessed Questions for NEET PG

1) Lymph from the glans penis drains into?

a) Superficial inguinal nodes

b) Deep inguinal nodes

c) External iliac nodes

d) Internal iliac nodes

Explanation: Lymph from the glans penis and clitoris drains into deep inguinal lymph nodes (node of Cloquet). This clinical correlation is important in genitourinary cancers. Correct answer: Deep inguinal nodes.

2) Infection at the lateral side of the foot drains initially into?

a) Popliteal nodes

b) Superficial inguinal nodes

c) Deep inguinal nodes

d) External iliac nodes

Explanation: Lymphatics from the lateral foot follow the small saphenous vein and drain into popliteal lymph nodes before reaching deeper nodes. Correct answer: Popliteal nodes.

3) Which lymph nodes are involved in carcinoma of the anal canal below pectinate line?

a) Internal iliac nodes

b) External iliac nodes

c) Superficial inguinal nodes

d) Para-aortic nodes

Explanation: The anal canal below the pectinate line drains into superficial inguinal nodes, explaining why inguinal swelling may be an early sign of malignancy. Correct answer: Superficial inguinal nodes.

4) The node of Cloquet is located in?

a) Femoral ring

b) Adductor canal

c) Inguinal ligament

d) Popliteal fossa

Explanation: The node of Cloquet is the highest deep inguinal lymph node, located in the femoral canal, and communicates with external iliac nodes. Correct answer: Femoral ring.

5) Which lymph nodes drain the uterus near the round ligament?

a) Internal iliac nodes

b) Para-aortic nodes

c) Superficial inguinal nodes

d) External iliac nodes

Explanation: Lymphatics from the uterus near the round ligament follow the ligament to reach the superficial inguinal nodes. Correct answer: Superficial inguinal nodes.

6) Which is the sentinel node in carcinoma of the cervix?

a) Internal iliac nodes

b) External iliac nodes

c) Superficial inguinal nodes

d) Para-aortic nodes

Explanation: The primary lymphatic drainage of cervix is to the internal iliac and sacral nodes, making them sentinel nodes for carcinoma cervix. Correct answer: Internal iliac nodes.

7) Enlargement of which nodes may indicate infection in the great toe?

a) Deep inguinal nodes

b) Superficial inguinal nodes

c) External iliac nodes

d) Para-aortic nodes

Explanation: Infection of great toe skin or fascia drains to superficial inguinal nodes, which enlarge clinically. Correct answer: Superficial inguinal nodes.

8) Popliteal lymph nodes drain all except?

a) Lateral side of sole

b) Heel region

c) Lateral border of foot

d) Medial side of great toe

Explanation: The medial side of great toe drains into superficial inguinal nodes, not popliteal nodes. Correct answer: Medial side of great toe.

9) Lymphatic obstruction in the femoral canal primarily affects?

a) Deep inguinal nodes

b) Superficial inguinal nodes

c) Popliteal nodes

d) Internal iliac nodes

Explanation: The femoral canal contains the node of Cloquet, which is part of deep inguinal lymphatic drainage. Obstruction here causes lower limb lymphedema. Correct answer: Deep inguinal nodes.

10) Which lymph nodes are first affected in carcinoma of the testis?

a) Superficial inguinal nodes

b) Deep inguinal nodes

c) Para-aortic nodes

d) External iliac nodes

Explanation: Testicular lymphatics follow gonadal vessels and drain into para-aortic (lumbar) nodes, not inguinal nodes. Correct answer: Para-aortic nodes.

Keyword Definitions

• Axillary lymph nodes – Group of nodes in axilla draining upper limb, breast, thoracic wall.

• Anterior (pectoral) group – Along lateral thoracic vessels, drains anterior thoracic wall & breast.

• Posterior (subscapular) group – Along subscapular vessels, drains posterior thoracic wall & scapular region.

• Lateral group – Along axillary vein, drains upper limb.

• Central group – In fat of axilla, receives from anterior, posterior, lateral groups.

• Apical group – At apex of axilla, drains all other axillary nodes, terminal group.

• Axillary vein – Major vessel of axilla, closely related to lateral nodes.

• Sentinel lymph node – First node receiving lymph from primary tumor site.

• Breast carcinoma – Common malignancy spreading to axillary nodes.

• Radical mastectomy – Surgical removal of breast with axillary lymph node dissection.

• Lymphedema – Swelling due to lymphatic obstruction, common complication after axillary dissection.

Chapter: Anatomy / Upper Limb

Topic: Axilla

Subtopic: Axillary Lymph Nodes

Lead Question – 2013

All are true regarding axillary lymph nodes except?

a) Posterior group lies along subscapular vessels

b) Lateral group lies along lateral thoracic vessels

c) Apical group lies along axillary vessels

d) Apical group is terminal lymph nodes

Explanation: The lateral group lies along the axillary vein, not the lateral thoracic vessels. The anterior (pectoral) group lies along the lateral thoracic vessels. Correct answer: (b). Clinical: Understanding axillary lymph node anatomy is vital in breast cancer surgery for staging and prevention of lymphedema.

Guessed Questions for NEET PG

1) Which axillary lymph node group directly drains the breast?

a) Posterior

b) Anterior

c) Lateral

d) Central

Explanation: The anterior (pectoral) group, located along the lateral thoracic vessels, directly drains most of the breast. Correct answer: Anterior group. Clinical: In breast cancer, these are the first nodes involved and often targeted in sentinel lymph node biopsy.

2) Central lymph nodes receive lymph from:

a) Only anterior group

b) Anterior, posterior, lateral groups

c) Only posterior group

d) Apical group

Explanation: Central lymph nodes in the axillary fat collect lymph from anterior, posterior, and lateral groups. Correct answer: Anterior, posterior, lateral groups. Clinical: Their involvement suggests spread of malignancy beyond primary drainage pathways.

3) Which group of axillary nodes is considered terminal?

a) Lateral

b) Apical

c) Central

d) Posterior

Explanation: Apical group, at apex of axilla near axillary vein, serves as the terminal collecting group for all axillary lymph nodes. Correct answer: Apical group. Clinical: Spread to these nodes indicates advanced disease, often involving supraclavicular spread.

4) Sentinel lymph node biopsy in breast cancer is done to:

a) Remove all axillary nodes

b) Identify first draining node

c) Treat lymphedema

d) Block venous drainage

Explanation: Sentinel lymph node biopsy helps identify the first lymph node draining a tumor. Correct answer: Identify first draining node. Clinical: If negative, extensive axillary dissection may be avoided, reducing complications like lymphedema.

5) Which axillary group lies along the axillary vein?

a) Lateral

b) Central

c) Posterior

d) Apical

Explanation: The lateral group lies along the axillary vein and drains the majority of the upper limb. Correct answer: Lateral group. Clinical: Infections of hand and arm may cause painful swelling of this group.

6) A 40-year-old woman with carcinoma of upper outer quadrant breast: most likely first lymph node involved?

a) Posterior

b) Anterior

c) Apical

d) Central

Explanation: Carcinoma of upper outer quadrant drains to anterior group, which communicates with central nodes. Correct answer: Anterior group. Clinical: Upper outer quadrant tumors metastasize early due to rich lymphatic drainage.

7) Which axillary node group is closely related to subscapular vessels?

a) Anterior

b) Posterior

c) Lateral

d) Apical

Explanation: The posterior group, also called subscapular nodes, lies along subscapular vessels. Correct answer: Posterior group. Clinical: They receive lymph from posterior thoracic wall and scapular region.

8) Lymphedema of upper limb after mastectomy is due to removal of:

a) Posterior nodes

b) Apical nodes

c) Axillary nodes

d) Central nodes

Explanation: Removal of axillary nodes blocks lymphatic drainage of upper limb, causing lymphedema. Correct answer: Axillary nodes. Clinical: Patients are advised physiotherapy and arm care after surgery to reduce risk.

9) Which statement about apical lymph nodes is false?

a) They are terminal axillary nodes

b) They lie along axillary vein at apex

c) They receive lymph directly from breast

d) They drain into subclavian lymph trunk

Explanation: Apical nodes do not directly drain the breast; anterior group does. Correct answer: (c). Clinical: Apical nodes represent final common pathway before lymph enters subclavian trunk.

10) Which group of axillary nodes communicates with supraclavicular nodes?

a) Central

b) Apical

c) Lateral

d) Posterior

Explanation: Apical group communicates with supraclavicular nodes via subclavian lymph trunk. Correct answer: Apical group. Clinical: Supraclavicular involvement in breast cancer indicates advanced metastatic spread.

Keyword Definitions

• Lymph node – Small encapsulated lymphoid organ along lymphatic vessels; filters lymph and initiates immune responses.

• Cortex – Outer portion of lymph node containing lymphoid follicles; mainly B-cell areas.

• Medulla – Inner portion of lymph node; contains medullary cords and sinuses; plasma cells reside here.

• Follicles – Spherical aggregates of lymphocytes within cortex; primary follicles are inactive, secondary follicles contain germinal centers.

• Germinal center – Site of B-cell proliferation, differentiation, and somatic hypermutation after antigen stimulation.

• Paracortex – Area between cortex and medulla; rich in T-cells surrounding high endothelial venules (HEVs).

• Lymphatic sinuses – Channels within node for lymph flow; subcapsular, trabecular, and medullary sinuses.

• High endothelial venules (HEVs) – Specialized vessels allowing lymphocyte entry into lymph nodes.

• Clinical relevance – Follicular hyperplasia indicates infection or immune activation; neoplasms like follicular lymphoma arise from follicles.

• Embryology – Lymph nodes develop from mesenchymal cells; colonize by lymphocytes in late fetal life.

Chapter: Histology / Immunology

Topic: Lymphoid Organs

Subtopic: Lymph Node Structure

Lead Question – 2013

Follicles are present in which part of lymph nodes?

a) Red pulp

b) White pulp

c) Cortex

d) Medulla

Explanation: Lymphoid follicles are present in the cortex of lymph nodes, forming B-cell rich zones. Primary follicles are inactive, while secondary follicles contain germinal centers after antigen exposure. Correct answer: Cortex. Medulla contains plasma cells, and red/white pulp refer to spleen. Follicular hyperplasia occurs in infections or autoimmune conditions.

Guessed Questions for NEET PG

1) Paracortex of lymph node contains:

a) T-cells

b) B-cells

c) Plasma cells

d) Fibroblasts

Explanation: Paracortex is rich in T-lymphocytes surrounding HEVs. Correct answer: T-cells. Clinical: T-cell deficiency affects cell-mediated immunity and lymph node structure.

2) Medullary cords contain:

a) Plasma cells

b) T-cells

c) B-cells in follicles

d) Red pulp

Explanation: Medullary cords in lymph node medulla contain plasma cells and macrophages. Correct answer: Plasma cells. Clinical: antibody production is concentrated here.

3) Subcapsular sinus is located:

a) Beneath capsule

b) Cortex

c) Medulla

d) Follicles

Explanation: Subcapsular sinus lies just below the lymph node capsule, allowing lymph to flow into trabecular sinuses. Correct answer: Beneath capsule. Clinical: site for metastatic cancer cell entry.

4) Secondary follicles contain:

a) Germinal centers

b) T-cells only

c) Medullary cords

d) Capsule fibroblasts

Explanation: Secondary follicles develop germinal centers after antigen stimulation. Correct answer: Germinal centers. Clinical: hyperactive germinal centers appear in infections and autoimmune disease.

5) High endothelial venules (HEVs) are in:

a) Paracortex

b) Cortex follicles

c) Medullary cords

d) Sinuses

Explanation: HEVs in paracortex allow lymphocyte migration from blood to lymph node. Correct answer: Paracortex. Clinical: impaired HEV function reduces lymphocyte homing.

6) Primary follicles are:

a) Inactive B-cell clusters

b) Germinal centers

c) Medullary cords

d) Paracortex T-cells

Explanation: Primary follicles are small, inactive B-cell clusters in cortex. Correct answer: Inactive B-cell clusters. Clinical: may enlarge in early immune response.

7) Lymph node capsule is composed of:

a) Dense connective tissue

b) B-cell follicles

c) Medullary cords

d) Paracortex

Explanation: Capsule is dense connective tissue providing protection and structure. Correct answer: Dense connective tissue. Clinical: capsule rupture can spread infection or metastasis.

8) Trabeculae of lymph nodes carry:

a) Blood vessels and lymphatics

b) Only sinuses

c) Only follicles

d) Red pulp

Explanation: Trabeculae carry vessels and lymph channels from capsule into interior. Correct answer: Blood vessels and lymphatics. Clinical: obstruction can impair lymph flow.

9) Medullary sinuses drain into:

a) Efferent lymphatics

b) Afferent lymphatics

c) Capsule

d) Paracortex

Explanation: Medullary sinuses drain lymph into efferent lymphatic vessels. Correct answer: Efferent lymphatics. Clinical: blockage leads to lymph node swelling.

10) Follicular lymphoma arises from:

a) B-cell follicles

b) T-cell paracortex

c) Medullary cords

d) Capsule

Explanation: Follicular lymphoma is a B-cell malignancy originating from cortical follicles. Correct answer: B-cell follicles. Clinical: presents as painless lymphadenopathy and may involve multiple lymph nodes.

Keyword Definitions

• Spleen – Lymphoid organ in the left upper abdomen; filters blood, stores blood, and provides immune surveillance.

• White pulp – Lymphoid tissue surrounding central arteries; mainly composed of lymphocytes; site of immune responses.

• Red pulp – Vascular tissue with sinusoids and cords (Billroth’s cords); removes aged red blood cells and pathogens.

• B-cells – Lymphocytes responsible for humoral immunity; produce antibodies; primarily located in white pulp follicles.

• T-cells – Lymphocytes involved in cell-mediated immunity; mainly found in periarteriolar lymphoid sheath (PALS).

• Germinal centers – Sites of B-cell proliferation and differentiation within white pulp follicles.

• Central artery – Artery surrounded by PALS in white pulp.

• Billroth’s cords – Structures in red pulp containing macrophages, lymphocytes, and plasma cells.

• Capsule – Dense connective tissue surrounding spleen; provides protection.

• Clinical relevance – B-cell deficiencies lead to poor humoral response; splenectomy affects antibody production.

Chapter: Histology / Immunology

Topic: Lymphoid Organs

Subtopic: Spleen Cell Distribution

Lead Question – 2013

B-cells are dispersed in which part of spleen?

a) White pulp

b) Red pulp

c) Capsule

d) None

Explanation: B-cells are primarily located in the follicles of white pulp surrounding central arteries. They form germinal centers upon antigen stimulation and produce antibodies. Correct answer: White pulp. Red pulp contains mainly macrophages and plasma cells. Clinical relevance: B-cell deficiencies reduce humoral immunity, increasing susceptibility to infections.

Guessed Questions for NEET PG

1) T-cells are concentrated in:

a) PALS of white pulp

b) Red pulp

c) Capsule

d) Sinusoids

Explanation: T-cells mainly surround central arteries in PALS within white pulp. Correct answer: PALS of white pulp. Clinical: T-cell defects impair cell-mediated immunity, predisposing to viral infections.

2) Germinal centers are found in:

a) White pulp follicles

b) Red pulp cords

c) Capsule

d) Sinusoids

Explanation: B-cells proliferate and differentiate in germinal centers of white pulp follicles. Correct answer: White pulp follicles. Clinical: hyperactive germinal centers can occur in autoimmune diseases.

3) Plasma cells are abundant in:

a) Red pulp

b) White pulp

c) Capsule

d) PALS

Explanation: Plasma cells derived from B-cells are mainly in Billroth’s cords of red pulp. Correct answer: Red pulp. Clinical: splenic damage reduces antibody production.

4) Marginal zone of spleen contains:

a) Specialized B-cells

b) T-cells

c) Macrophages only

d) Capsule fibroblasts

Explanation: Marginal zone surrounds white pulp and contains specialized B-cells and macrophages. Correct answer: Specialized B-cells. Clinical: marginal zone lymphoma arises from these B-cells.

5) White pulp to red pulp ratio is approximately:

a) 1:3

b) 3:1

c) 1:1

d) 2:1

Explanation: Red pulp predominates (~3:1) over white pulp. Correct answer: 1:3. Clinical: splenomegaly increases red pulp proportion, affecting blood filtration.

6) Spleen's immune response to blood-borne antigens is mediated by:

a) White pulp B-cells

b) Red pulp macrophages

c) Capsule fibroblasts

d) Sinusoids

Explanation: White pulp B-cells produce antibodies in response to blood-borne antigens. Correct answer: White pulp B-cells. Clinical: asplenic patients have impaired humoral immunity.

7) Central arteries in spleen are surrounded by:

a) PALS

b) Billroth’s cords

c) Capsule

d) Sinusoids

Explanation: Central arteries are encircled by T-cell rich PALS in white pulp. Correct answer: PALS. Clinical: PALS destruction may impair cell-mediated immunity.

8) Billroth’s cords contain:

a) Macrophages, plasma cells, lymphocytes

b) Only erythrocytes

c) Fibroblasts only

d) Collagen fibers only

Explanation: Billroth’s cords in red pulp contain macrophages, plasma cells, and lymphocytes. Correct answer: Macrophages, plasma cells, lymphocytes. Clinical: damage to cords impairs clearance of aged RBCs.

9) Spleen functions include all except:

a) Filtering blood

b) Producing antibodies

c) Hematopoiesis in adult

d) Destroying aged RBCs

Explanation: Spleen filters blood, produces antibodies, and removes aged RBCs. Adult hematopoiesis is minimal. Correct answer: Hematopoiesis in adult. Clinical: extramedullary hematopoiesis can occur in disease.

10) Accessory spleens contain:

a) Both white and red pulp

b) Only white pulp

c) Only red pulp

d) Capsule only

Explanation: Accessory spleens contain both red and white pulp, functioning like main spleen. Correct answer: Both white and red pulp. Clinical: important in splenectomy to prevent recurrence of hematologic disease.

Keyword Definitions

• Spleen – Lymphoid organ in left upper abdomen; filters blood, immune surveillance, stores blood.

• White pulp – Lymphoid tissue surrounding central arteries; contains lymphocytes; immune function.

• Red pulp – Vascular sinusoids and cords; removes aged RBCs, stores platelets.

• Billroth’s cords – Also called splenic cords; connective tissue strands in red pulp containing macrophages, lymphocytes, and plasma cells.

• Central artery – Penetrates white pulp; surrounded by periarteriolar lymphoid sheath (PALS).

• Splenic sinusoids – Vascular channels in red pulp; allow filtration of blood cells.

• Capsule – Dense connective tissue surrounding spleen; provides protection and structure.

• Clinical relevance – Splenic injury affects hematological and immune function; red pulp disorders cause anemia.

• Embryology – Spleen develops from mesenchymal cells in dorsal mesogastrium during 5th week.

• Histology – Red pulp: cords and sinusoids; White pulp: lymphoid follicles with germinal centers.

Chapter: Histology / Embryology

Topic: Lymphoid Organs

Subtopic: Spleen Structure and Components

Lead Question – 2013

Billroth's cord are present in which part of spleen?

a) White pulp

b) Red pulp

c) Both

d) Capsule

Explanation: Billroth’s cords are connective tissue strands found in the red pulp of the spleen, containing macrophages, lymphocytes, plasma cells, and reticular fibers. Correct answer: Red pulp. They function in filtration and immune surveillance. White pulp contains lymphoid follicles; capsule is protective connective tissue. Damage can impair hematological and immune functions.

Guessed Questions for NEET PG

1) Central arteries are found in:

a) White pulp

b) Red pulp

c) Both

d) Capsule

Explanation: Central arteries pass through white pulp surrounded by periarteriolar lymphoid sheath (PALS). Correct answer: White pulp. Clinical: arterial occlusion can reduce immune cell activation.

2) Splenic sinusoids are located in:

a) Red pulp

b) White pulp

c) Capsule

d) Trabeculae

Explanation: Sinusoids are vascular channels in red pulp facilitating filtration of aged or damaged RBCs. Correct answer: Red pulp. Clinical: sinusoidal damage can lead to hemolytic anemia.

3) Periarteriolar lymphoid sheath (PALS) surrounds:

a) Central arteries

b) Red pulp cords

c) Capsule

d) Sinusoids

Explanation: PALS consists of T-lymphocytes surrounding central arteries in white pulp. Correct answer: Central arteries. Clinical: immune deficiencies can impair T-cell mediated responses.

4) Germinal centers are present in:

a) White pulp follicles

b) Red pulp

c) Capsule

d) Sinusoids

Explanation: Germinal centers in white pulp follicles are sites of B-cell proliferation and differentiation. Correct answer: White pulp. Clinical: germinal center hyperplasia occurs in infections or autoimmune diseases.

5) Trabeculae of spleen contain:

a) Connective tissue and vessels

b) White pulp only

c) Red pulp only

d) Sinusoids only

Explanation: Trabeculae provide structural support, carrying arteries and veins into spleen. Correct answer: Connective tissue and vessels. Clinical: trauma can rupture trabeculae, causing hemorrhage.

6) Macrophages in red pulp function to:

a) Phagocytose aged RBCs

b) Produce antibodies

c) Secrete collagen

d) Form germinal centers

Explanation: Macrophages in Billroth’s cords phagocytose old erythrocytes and pathogens. Correct answer: Phagocytose aged RBCs. Clinical: macrophage dysfunction leads to splenomegaly and anemia.

7) White pulp is rich in:

a) Lymphocytes

b) Erythrocytes

c) Platelets

d) Sinusoids

Explanation: White pulp contains lymphocytes around central arteries for immune surveillance. Correct answer: Lymphocytes. Clinical: loss leads to immunodeficiency.

8) Red pulp ratio to white pulp is approximately:

a) 3:1

b) 1:1

c) 1:3

d) 2:1

Explanation: Red pulp constitutes roughly 3/4 of splenic volume, responsible for filtration and blood storage. Correct answer: 3:1. Clinical: splenomegaly increases red pulp proportion causing anemia.

9) Capsule of spleen is composed of:

a) Dense connective tissue

b) Lymphoid tissue

c) Sinusoids

d) Cartilage

Explanation: Capsule is dense connective tissue surrounding spleen, providing protection and support. Correct answer: Dense connective tissue. Clinical: splenic rupture involves capsule laceration.

10) Accessory spleens are usually located near:

a) Hilum

b) Red pulp

c) White pulp

d) Capsule

Explanation: Accessory spleens develop near hilum, containing red and white pulp. Correct answer: Hilum. Clinically important in splenectomy to remove all functional splenic tissue.

Chapter: Head & Neck — Topic: Lymphatics — Subtopic: Retropharyngeal & Neck Nodes

Keywords:

• Rouviere nodes — Group of lateral retropharyngeal lymph nodes at the base of skull (often clinically important in nasopharyngeal carcinoma).

• Retropharyngeal nodes — Nodes located in the retropharyngeal space behind the pharynx; drain nasopharynx and nasal cavities.

• Nasopharynx — Upper part of pharynx behind the nasal cavity; common site for carcinoma with retropharyngeal nodal spread.

• Level II nodes — Upper jugular group; important neck nodes for head & neck cancers.

• Deep cervical chain — Major lymphatic drainage pathway along the internal jugular vein.

• Clavicular nodes — Supraclavicular nodes at the thoracic inlet; signal advanced disease if involved.

• Oral cavity nodes — Drain oral structures; different pattern from nasopharyngeal drainage.

• Imaging — CT/MRI used to detect retropharyngeal (Rouviere) nodes in head & neck cancer staging.

• Nodes of Rouviere clinical relevance — Key for staging nasopharyngeal carcinoma and planning radiotherapy fields.

• Jugulodigastric node — Prominent upper deep cervical node often involved in oropharyngeal infections and cancers.

Lead Question – 2012

1. Rouviere nodes are situated in ?
a) Nasopharynx
b) Oral cavity
c) Retropharynx
d) Clavicular nodes

Explanation: Rouviere nodes are lateral retropharyngeal lymph nodes located in the retropharyngeal space near the base of skull; they receive lymph from the nasopharynx and are clinically important in nasopharyngeal carcinoma staging. Therefore the correct answer is c) Retropharynx. (50 words)

2. Enlargement of Rouviere nodes most commonly suggests primary pathology in the:
a) Oral cavity
b) Nasopharynx
c) Larynx
d) Thyroid

Explanation: Rouviere (lateral retropharyngeal) nodes drain the nasopharynx and posterior nasal cavity; their enlargement often indicates nasopharyngeal infection or malignancy rather than oral cavity, larynx, or thyroid disease. This makes nasopharynx the most likely primary site. Correct answer: b) Nasopharynx. (50 words)

3. Best imaging modality to detect Rouviere nodes in suspected nasopharyngeal carcinoma is:
a) Chest X-ray
b) CT/MRI of head & neck
c) Abdominal ultrasound
d) PET only

Explanation: CT and MRI of the head and neck visualize soft tissue extent and retropharyngeal nodes including Rouviere nodes for staging nasopharyngeal cancer; PET may complement for metabolic activity but CT/MRI are primary for anatomic delineation. Correct answer: b) CT/MRI of head & neck. (50 words)

4. In radiation planning for nasopharyngeal carcinoma, Rouviere nodes are included because they are located in the:
a) Parotid gland region
b) Lateral retropharyngeal space near skull base
c) Anterior cervical triangle
d) Supraclavicular fossa

Explanation: Rouviere nodes sit in the lateral retropharyngeal space by the skull base and are common sites of microscopic spread in nasopharyngeal carcinoma; hence radiotherapy fields include this region. They are not in parotid, anterior triangle, or supraclavicular fossa. Correct answer: b) Lateral retropharyngeal space near skull base. (50 words)

5. Clinically palpable Rouviere nodes are:
a) Common on routine neck exam
b) Deep and usually not palpable unless markedly enlarged
c) Always tender in malignancy
d) Located superficially over sternocleidomastoid

Explanation: Rouviere nodes lie deep in the retropharyngeal space and are not palpable on routine exam; they become clinically evident only when significantly enlarged from infection or tumor. They are deep, not superficial or routinely tender in malignancy. Correct answer: b) Deep and usually not palpable unless markedly enlarged. (50 words)

6. Surgical access to enlarged Rouviere nodes for biopsy is most safely performed via:
a) Transoral approach without imaging guidance
b) Image-guided deep neck biopsy or endoscopic nasopharyngeal biopsy
c) Supraclavicular incision
d) Submandibular incision

Explanation: Due to deep location adjacent to skull base and vital structures, Rouviere nodes are best assessed by image-guided biopsy or endoscopic nasopharyngeal sampling; blind transoral or superficial neck incisions risk injury. Correct answer: b) Image-guided deep neck biopsy or endoscopic nasopharyngeal biopsy. (50 words)

7. Which statement about retropharyngeal space and nodes is TRUE?
a) Retropharyngeal nodes drain anterior chest primarily
b) Retropharyngeal space communicates with mediastinum allowing spread of infection
c) Retropharyngeal nodes are superficial neck nodes
d) Retropharyngeal nodes drain lower limb lymph

Explanation: The retropharyngeal space can extend into the posterior mediastinum, permitting downward spread of infection from the neck to chest; Rouviere nodes reside in this space. They do not drain chest primarily, are not superficial, nor related to lower limb drainage. Correct answer: b) Retropharyngeal space communicates with mediastinum allowing spread of infection. (50 words)

8. On MRI a metastatic Rouviere node typically shows which feature?
a) Small, fatty hilum preserved
b) Enlarged node with necrosis or contrast enhancement
c) Calcified only
d) Identical to normal muscle tissue

Explanation: Metastatic retropharyngeal nodes often enlarge and may show central necrosis and irregular contrast enhancement on MRI/CT, distinguishing them from reactive nodes which retain fatty hilum. Calcification is uncommon; they are not identical to muscle. Correct answer: b) Enlarged node with necrosis or contrast enhancement. (50 words)

9. Which tumor most commonly metastasizes to Rouviere nodes?
a) Nasopharyngeal carcinoma
b) Thyroid carcinoma exclusively
c) Cutaneous melanoma of leg only
d) Wilms tumor

Explanation: Nasopharyngeal carcinoma commonly spreads to retropharyngeal (Rouviere) nodes early due to lymphatic drainage pathways; thyroid and distal cutaneous tumors less commonly involve these nodes. Thus nasopharyngeal carcinoma is the most frequent primary causing Rouviere node metastasis. Correct answer: a) Nasopharyngeal carcinoma. (50 words)

10. Retropharyngeal abscess presenting with neck stiffness and dysphagia may involve which nodes? a) Submandibular nodes
b) Rouviere (retropharyngeal) nodes
c) Occipital nodes only
d) Inguinal nodes

Explanation: Retropharyngeal abscesses involve the retropharyngeal space and its nodes (including Rouviere nodes), causing dysphagia, neck stiffness, and potential airway compromise; prompt imaging and drainage are needed. Submandibular or distant nodes are not primary in this condition. Correct answer: b) Rouviere (retropharyngeal) nodes. (50 words)

11. Which clinical finding warrants evaluation of Rouviere nodes in an adult patient?
a) Persistent unilateral serous otitis media and nasopharyngeal mass suspicion
b) Bilateral ankle swelling only
c) Chronic cough without ENT symptoms
d) Isolated carpal tunnel syndrome

Explanation: Persistent unilateral serous otitis media in adults may signal nasopharyngeal carcinoma obstructing the Eustachian tube; evaluation must include imaging of Rouviere nodes and nasopharynx. Distant systemic symptoms without ENT signs do not directly implicate these nodes. Correct answer: a) Persistent unilateral serous otitis media and nasopharyngeal mass suspicion. (50 words)

Chapter: Obstetrics & Gynecology

Topic: Female Pelvic Anatomy & Oncology

Subtopic: Lymphatic Drainage of Cervix & Clinical Implications

Keywords (Definitions)

• Cervix: Lower part of uterus opening into the vagina; key site for HPV-related malignancy.

• Lymphatic drainage: Network conveying lymph from tissues to regional lymph nodes.

• Iliac lymph nodes: Pelvic nodes along external, internal, and common iliac vessels receiving cervical lymph.

• External iliac nodes: Nodes along external iliac vessels; frequent first-echelon nodes from cervix.

• Internal iliac (hypogastric) nodes: Pelvic nodes draining cervix via paracervical pathways.

• Obturator nodes: Nodes in obturator fossa around obturator nerve; common sentinel basin.

• Sacral nodes: Lateral/ presacral nodes receiving posterior cervical lymph.

• Para-aortic (lumbar) nodes: Nodes along aorta; second-echelon or advanced spread from pelvis.

• Inguinal nodes (superficial/deep): Groin nodes; drain vulva and lower third of vagina, not primary cervix.

• Sentinel lymph node (SLN): First draining node(s) from a tumor; used for targeted sampling/mapping.

• FIGO 2018 IIIC stage: Cervical cancer staging: IIIC1 pelvic node metastasis; IIIC2 para-aortic.

• PET-CT: Imaging modality sensitive for nodal metastasis, especially para-aortic.

• Upper vs lower vagina drainage: Upper to pelvic nodes; lower to inguinal nodes.

• Radical hysterectomy (Type C1): Nerve-sparing resection with parametrial and pelvic lymphadenectomy.

• Lymphocyst: Post-lymphadenectomy lymph collection in pelvis/retroperitoneum.

• Obturator nerve: Landmark within obturator fossa; guides identification of obturator nodes.

• 
  

Lead Question - 2012

Lymphatic drainage of cervix is to

a) Iliac lymph nodes
b) Para aortic lymph nodes
c) Superficial inguinal lymph nodes
d) Deep inguinal lymph nodes

Explanation (≈50 words): The primary lymphatic drainage of the cervix is to the pelvic (iliac) nodal groups—obturator, internal iliac, external iliac, and sacral. Inguinal nodes drain the lower third of the vagina and vulva; para-aortic nodes are second-echelon spread. Answer: a) Iliac lymph nodes.

Guessed MCQ 1

A 36-year-old with FIGO IA2 cervical cancer undergoes SLN mapping. Which tracer has the best bilateral detection in experienced hands?

a) Indigo carmine
b) Indocyanine green (ICG)
c) Trypan blue
d) Methylene blue

Explanation (≈50 words): Indocyanine green with near-infrared imaging achieves high bilateral sentinel detection and low false-negative rates in early cervical cancer. Blue dyes alone have lower sensitivity. Technetium may be combined but ICG is widely preferred for real-time visualization. Answer: b) Indocyanine green (ICG).

Guessed MCQ 2

First-echelon nodal basin most commonly involved in carcinoma cervix is

a) Popliteal nodes
b) Axillary nodes
c) Obturator nodes
d) Deep inguinal nodes

Explanation: Lymph from the cervix passes through paracervical channels to obturator and internal/external iliac nodes. Obturator nodes in the obturator fossa are the commonest first-echelon group sampled during pelvic lymphadenectomy or SLN biopsy. Popliteal and axillary nodes are unrelated; deep inguinal nodes drain lower limb and perineum. Answer: c) Obturator nodes.

Guessed MCQ 3 (Clinical)

A 48-year-old with bulky cervical mass has PET-CT showing FDG-avid common iliac nodes but no para-aortic uptake. FIGO 2018 stage is

a) IIB
b) IIIC1
c) IIIC2
d) IVA

Explanation: Nodal staging in FIGO 2018 classifies pelvic nodal metastasis (including common iliac) as stage IIIC1, while para-aortic nodal involvement is IIIC2. Local parametrial involvement defines IIB, and invasion of adjacent organs bladder/rectum indicates IVA. Here only pelvic nodes are positive. Answer: b) IIIC1.

Guessed MCQ 4 (Clinical)

A patient with cervical cancer and lower third vaginal involvement is likely to have additional drainage to

a) Superficial inguinal nodes
b) Mediastinal nodes
c) Popliteal nodes
d) Epitrochlear nodes

Explanation: The lower third of the vagina drains to superficial inguinal nodes, creating a pathway for groin metastasis when the disease extends inferiorly. Mediastinal, popliteal, and epitrochlear nodes are not involved in genital tract drainage. Hence groin evaluation is important if the lower vagina is affected. Answer: a) Superficial inguinal nodes.

Guessed MCQ 5 (Clinical)

Post-radical hysterectomy, histology shows metastasis in para-aortic nodes only. FIGO 2018 stage is

a) IIIC1
b) IIIC2
c) IIIA
d) IVB

Explanation: Isolated para-aortic nodal metastasis without distant organ spread upgrades to FIGO IIIC2. IIIC1 denotes pelvic nodal disease. IIIA involves lower vaginal invasion; IVB implies distant metastases beyond the abdomen/pelvis (e.g., lung, bone). Para-aortic positivity alone fits IIIC2. Answer: b) IIIC2.

Guessed MCQ 6

Best single imaging modality to detect occult para-aortic nodal metastasis pre-treatment in cervical cancer

a) Pelvic ultrasound
b) PET-CT
c) Plain CT
d) Chest X-ray

Explanation (≈50 words): PET-CT outperforms CT and MRI for detecting metabolically active nodal metastases, particularly in para-aortic chains, guiding field extension for chemoradiation. Ultrasound and chest X-ray lack sensitivity for retroperitoneal nodal disease. Tissue confirmation may still be required when management will change. Answer: b) PET-CT.

Guessed MCQ 7

Primary lymphatic drainage of the upper vagina is mainly to

a) External/internal iliac nodes
b) Superficial inguinal nodes
c) Axillary nodes
d) Popliteal nodes

Explanation: The upper two-thirds of the vagina drain predominantly to the internal and external iliac nodes, paralleling cervical drainage. The lower third drains to the superficial inguinal nodes. Axillary and popliteal nodes are unrelated to pelvic genital tract lymphatics. Answer: a) External/internal iliac nodes.

Guessed MCQ 8

Which surgical procedure routinely addresses parametrial tissue and pelvic nodes in operable cervical cancer?

a) Simple hysterectomy
b) Radical hysterectomy (Type C1, nerve-sparing)
c) Myomectomy
d) Endometrial ablation

Explanation: Radical hysterectomy Type C1 (Querleu–Morrow) removes uterus with parametria and includes pelvic lymphadenectomy while preserving pelvic nerves. Simple hysterectomy lacks adequate margins and nodal assessment; myomectomy and ablation are not oncologic procedures. Answer: b) Radical hysterectomy (Type C1, nerve-sparing).

Guessed MCQ 9

Posterior cervical lymph primarily drains to which nodal group?

a) Presacral/lateral sacral nodes
b) Axillary nodes
c) Epitrochlear nodes
d) Deep inguinal nodes

Explanation: The posterior cervix drains via uterosacral pathways to presacral and lateral sacral nodes, part of the pelvic (iliac–sacral) chains. Axillary and epitrochlear nodes are upper-limb related; deep inguinal nodes pertain to lower limb and perineum. Answer: a) Presacral/lateral sacral nodes.

Guessed MCQ 10 (Clinical)

After pelvic lymphadenectomy for early cervical cancer, a patient develops a painless pelvic mass causing leg edema. Most likely complication is

a) Hematoma
b) Lymphocyst
c) Abscess
d) Seroma from abdominal wall

Explanation: Disruption of pelvic lymphatics can lead to lymphocyst formation—an encapsulated lymph collection in the retroperitoneum causing mass effect and lower-limb edema or hydronephrosis. Hematoma or abscess are typically painful and inflammatory; abdominal wall seroma is superficial. Answer: b) Lymphocyst.

Guessed MCQ 11

During node dissection, which anatomic landmark confirms entry into the obturator fossa containing the obturator nodal packet?

a) Femoral artery
b) Obturator nerve
c) Round ligament
d) Ureteric orifice

Explanation: The obturator nerve traverses the obturator fossa and serves as a key landmark for identifying and clearing obturator nodes during pelvic lymphadenectomy. Femoral artery is outside the pelvis; round ligament is anterior; ureteric orifice relates to bladder trigone, not the obturator space. Answer: b) Obturator nerve.

Chapter: Head & Neck Anatomy  |  Topic: Nasal Cavity & Paranasal Sinuses  |  Subtopic: Lymphatic Drainage of Nose

Keyword Definitions

• Lateral wall of nose: Side wall bearing turbinates and meati.

• Submandibular nodes: Level Ib nodes draining anterior nasal cavity/vestibule.

• Retropharyngeal nodes: Nodes behind pharynx draining posterior nasal cavity.

• Deep cervical nodes: Jugular chain receiving lymph from head & neck.

• Anterior nasal cavity: Area near vestibule, drains anteroinferiorly.

• Posterior nasal cavity: Choanal region, drains to retropharyngeal/deep cervical.

• Kiesselbach’s area: Vascular plexus on anterior septum.

• Waldeyer’s ring: Lymphoid ring around naso-oropharynx.

• Level II nodes: Upper jugular nodes under sternomastoid.

• Sentinel node: First draining node from a primary site.

Lead Question – 2012

Lymphatic drainage of lateral wall of nose

a) Submandibular nodes
b) Retropharyngeal nodes
c) Deep cervical nodes
d) All of the above

Explanation (Answer: d)

Anterior parts of the lateral nasal wall drain to submandibular nodes, while posterior parts drain to retropharyngeal nodes; both channels ultimately reach the deep cervical chain. Hence all listed groups participate in drainage depending on subsite, making “All of the above” the correct option for comprehensive lateral wall drainage.

2) Posterior lateral nasal wall carcinoma most classically first drains to:

a) Submental nodes
b) Retropharyngeal nodes
c) Supraclavicular nodes
d) Occipital nodes

Explanation (Answer: b)

Posterior nasal cavity, including posterior lateral wall near choanae, frequently drains to retropharyngeal nodes before reaching the upper deep cervical chain. Submental drainage is for lower lip/anterior floor of mouth, supraclavicular for lower neck catchment, and occipital for posterior scalp.

3) Which statement about lymphatics of the nasal cavity is MOST accurate?

a) All nasal subsites drain only to submental nodes
b) Anterior subsites favor submandibular drainage
c) Posterior subsites drain only to Level IV
d) Lymph bypasses deep cervical nodes

Explanation (Answer: b)

Anterior nasal cavity, including vestibule and inferior meatus region, commonly drains to submandibular nodes. Posterior subsites use retropharyngeal and then deep cervical chains. Deep cervical involvement is common; exclusive Level IV or submental drainage is incorrect. Thus, anterior-to-submandibular is the most accurate.

4) A clinician suspects retropharyngeal nodal disease in a posterior choanal mass. The next echelon typically involved is:

a) Level II deep cervical nodes
b) Pretracheal nodes
c) Submental nodes
d) Parotid nodes

Explanation (Answer: a)

Posterior nasal cavity drains to retropharyngeal nodes, then commonly to upper deep cervical (Level II) nodes along the internal jugular chain. Pretracheal nodes are for lower airway/thyroid regions, submental for lower lip/anterior floor, and parotid for lateral face/scalp anterior to ear.

5) In epistaxis originating from anterior lateral wall near the vestibule, which nodal basin most likely shows reactive enlargement?

a) Level II nodes
b) Submandibular nodes
c) Level IV nodes
d) Retropharyngeal nodes

Explanation (Answer: b)

Inflammation or infection in anterior lateral nasal wall/vestibule commonly drains to submandibular nodes, which may become reactive. Retropharyngeal nodes are more posterior. Level II may be secondary, and Level IV is a lower jugular station not typically first involved in anterior nasal pathology.

6) A 42-year-old with posterior lateral nasal wall tumor has occult nodal spread. Which imaging-detected node best supports expected drainage?

a) Retropharyngeal node behind pharyngeal wall
b) Submental node below chin
c) Level V posterior triangle node
d) Supraclavicular node

Explanation (Answer: a)

Posterior lateral nasal wall drains to retropharyngeal nodes first. Submental, Level V, and supraclavicular nodes are not typical initial stations for nasal cavity primaries. Finding a retropharyngeal metastasis aligns with the anatomical lymphatic pathways of posterior nasal subsites.

7) Which subsite pairing is CORRECT regarding primary lymphatic drainage?

a) Anterior lateral wall → Submandibular nodes
b) Posterior lateral wall → Submental nodes
c) Anterior lateral wall → Retropharyngeal nodes
d) Posterior lateral wall → Occipital nodes

Explanation (Answer: a)

Anterior lateral wall and vestibule drain to submandibular nodes. Posterior lateral wall prefers retropharyngeal and then deep cervical nodes. Submental and occipital nodal groups are not the primary drainage for these nasal subsites, making option a the accurate pairing.

8) A child with posterior nasal infection develops torticollis and fever. Which node is classically implicated?

a) Retropharyngeal node (suppurative adenitis)
b) Submandibular node
c) Preauricular node
d) Level IV node

Explanation (Answer: a)

Retropharyngeal nodes drain the posterior nasal cavity and nasopharynx; suppurative adenitis can present with neck stiffness/torticollis and fever in children. Submandibular nodes typically reflect anterior oral/nasal infections. Preauricular and Level IV nodes are not the classical primary sites for posterior nasal infections.

9) For surgical planning in anterior lateral nasal wall cancer, which selective neck dissection levels are MOST relevant initially?

a) Levels I–III (emphasis on Level Ib)
b) Levels IV–V only
c) Level VI central compartment
d) Parotidectomy with Level V only

Explanation (Answer: a)

Anterior lateral wall tends to involve submandibular (Level Ib) first, with potential spread to Levels II–III. Levels IV–V are lower/posterior and less commonly initial. Level VI pertains to central compartment organs. Parotidectomy targets preauricular/parotid nodes, not primary anterior nasal drainage.

10) Which statement about deep cervical nodes in nasal drainage is TRUE?

a) They are never involved in nasal malignancies
b) They receive efferents from both submandibular and retropharyngeal nodes
c) They drain only the scalp and ear
d) They are equivalent to supraclavicular nodes exclusively

Explanation (Answer: b)

Deep cervical nodes (jugular chain) are final common pathways for multiple head-neck subsites. They receive efferents from submandibular and retropharyngeal nodes and are often involved in nasal malignancies. They do not exclusively serve scalp/ear, nor are they limited to supraclavicular territory.

11) A 60-year-old with recurrent posterior epistaxis and fullness behind the soft palate shows a node of Rouvière on MRI. Primary site drainage suggests:

a) Anterior vestibular lesion
b) Posterior lateral nasal wall involvement
c) External nasal skin carcinoma
d) Floor of mouth lesion

Explanation (Answer: b)

Node of Rouvière is the lateral retropharyngeal node, commonly receiving lymph from nasopharynx and posterior nasal cavity, including posterior lateral wall. Anterior vestibule and external nasal skin drain anteriorly to submandibular/preauricular nodes, while floor of mouth drains to submental/submandibular, not retropharyngeal.

Chapter: Abdomen
Topic: Spleen
Subtopic: Surface Anatomy

Keyword Definitions:

• Spleen: Largest lymphoid organ, located in the left hypochondrium.

• Surface Anatomy: Study of external landmarks that indicate internal structures.

• Ribs: Bony framework of thorax, important landmarks for organ projection.

Lead Question - 2012

Spleen extends from ?

a) 5th to 9th rib
b) 9th to 11th rib
c) 2nd to 5th rib
d) 11th to 12th rib

Explanation: The spleen lies in the left hypochondrium, deep to ribs 9–11 along the midaxillary line. Its long axis is parallel to the 10th rib. Correct Answer: b) 9th to 11th rib.

Guessed Question 1

The hilum of the spleen is located on which surface?

a) Diaphragmatic surface
b) Visceral surface
c) Inferior border
d) Superior border

Explanation: The hilum is present on the visceral surface where splenic vessels and lymphatics enter and leave. It is an important landmark for surgical procedures. Correct Answer: b) Visceral surface.

Guessed Question 2

Splenic artery is a branch of?

a) Celiac trunk
b) Superior mesenteric artery
c) Inferior mesenteric artery
d) Renal artery

Explanation: The splenic artery is a tortuous branch of the celiac trunk. It supplies the spleen, pancreas, and part of the stomach. Correct Answer: a) Celiac trunk.

Guessed Question 3

Which ligament connects the spleen to the stomach?

a) Gastrosplenic ligament
b) Splenorenal ligament
c) Phrenicocolic ligament
d) Hepatogastric ligament

Explanation: The gastrosplenic ligament connects the spleen to the greater curvature of the stomach and contains short gastric vessels. Correct Answer: a) Gastrosplenic ligament.

Guessed Question 4

Accessory spleens are most commonly found in?

a) Splenorenal ligament
b) Mesentery
c) Greater omentum
d) Pancreatic tail

Explanation: Accessory spleens are usually found near the splenic hilum or in the splenorenal ligament. They may mimic pathology in imaging. Correct Answer: a) Splenorenal ligament.

Guessed Question 5

In splenomegaly, spleen enlarges along the axis of?

a) 8th rib
b) 9th rib
c) 10th rib
d) 11th rib

Explanation: Splenomegaly causes the spleen to enlarge obliquely downward and medially along the 10th rib. This helps differentiate from renal enlargement. Correct Answer: c) 10th rib.

Guessed Question 6

Splenic vein joins with which vessel to form the portal vein?

a) Superior mesenteric vein
b) Inferior mesenteric vein
c) Left gastric vein
d) Right gastric vein

Explanation: The splenic vein unites with the superior mesenteric vein to form the portal vein behind the neck of the pancreas. Correct Answer: a) Superior mesenteric vein.

Guessed Question 7

Which of the following is NOT a relation of the spleen?

a) Left kidney
b) Stomach
c) Left colic flexure
d) Right adrenal gland

Explanation: The spleen is related to the stomach, left kidney, pancreas, and left colic flexure. The right adrenal gland lies on the opposite side. Correct Answer: d) Right adrenal gland.

Guessed Question 8

During trauma, spleen rupture leads to bleeding into?

a) Peritoneal cavity
b) Pleural cavity
c) Retroperitoneal space
d) Mediastinum

Explanation: Rupture of the spleen results in intraperitoneal hemorrhage, often massive, requiring immediate intervention. Correct Answer: a) Peritoneal cavity.

Guessed Question 9

Splenectomy most commonly predisposes a patient to infections by?

a) Gram-negative bacilli
b) Encapsulated organisms
c) Anaerobic bacteria
d) Mycobacteria

Explanation: Post-splenectomy, patients are more prone to infections with encapsulated bacteria such as Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. Correct Answer: b) Encapsulated organisms.

Guessed Question 10

Which hematological condition is splenectomy most useful in?

a) Thalassemia major
b) Sickle cell anemia
c) Hereditary spherocytosis
d) Iron deficiency anemia

Explanation: Splenectomy is indicated in hereditary spherocytosis as the spleen destroys the abnormal red cells. Correct Answer: c) Hereditary spherocytosis.

Thoracic Duct: Main lymphatic vessel draining lymph from the majority of the body into the venous system.

Lymphatic System: Network of vessels and nodes that drain interstitial fluid, transport immune cells, and absorb fats from the gut.

Vertebral Levels: Anatomical reference points of vertebrae; T2-T12 are thoracic vertebrae levels.

Lymph Drainage: Thoracic duct drains lymph from left side of body, including left upper limb, thorax, and lower limbs.

Right-to-Left Crossing: Point where thoracic duct crosses midline from right to left before draining into venous circulation at left venous angle.

Chapter: Lymphatic System

Topic: Thoracic Duct Anatomy

Subtopic: Thoracic Duct Course and Vertebral Levels

Lead Question 2012: The thoracic duct crosses from the right to the left at the level of

a) T12 vertebra

b) T6 vertebra

c) T5 vertebra

d) T2 vertebra

Answer: c) T5 vertebra

Explanation: The **thoracic duct** begins at the cisterna chyli and ascends through the thorax on the right side of the vertebral column. It crosses from right to left at approximately the **T5 vertebral level** before draining into the **left venous angle**. This anatomical landmark is important in thoracic surgery and central venous catheter placement to avoid injury to the duct.

1. Where does the thoracic duct drain its lymph?

a) Right subclavian vein

b) Left venous angle

c) Right atrium

d) Thoracic cavity

Answer: b) Left venous angle

Explanation: The **thoracic duct** drains lymph into the **left venous angle**, formed by the junction of the **left internal jugular and subclavian veins**. This drainage allows return of lymph to the systemic circulation, maintaining fluid balance and immune function.

2. The thoracic duct originates from:

a) Thoracic aorta

b) Cisterna chyli

c) Right lymphatic duct

d) Sternal lymph nodes

Answer: b) Cisterna chyli

Explanation: The **cisterna chyli**, located at L1-L2 vertebral level, serves as the origin of the thoracic duct. It collects lymph from the **lower limbs, pelvic cavity, and abdomen**, which then ascends through the thorax to drain into the venous system.

3. The thoracic duct passes through which opening of the diaphragm?

a) Aortic hiatus

b) Caval opening

c) Esophageal hiatus

d) None

Answer: a) Aortic hiatus

Explanation: The **thoracic duct** ascends from the abdomen into the thorax via the **aortic hiatus** of the diaphragm at the T12 level. Understanding its course prevents injury during thoracoabdominal procedures.

4. Clinical significance of thoracic duct injury includes:

a) Pleural effusion

b) Chylothorax

c) Pulmonary embolism

d) Pneumothorax

Answer: b) Chylothorax

Explanation: Injury to the thoracic duct can lead to **chylothorax**, accumulation of lymph in the pleural cavity. It occurs post-thoracic or neck surgery. Knowledge of the crossing at T5 and drainage into the left venous angle is crucial for surgical prevention.

5. On which side of the vertebral column does the thoracic duct ascend initially?

a) Left

b) Right

c) Midline

d) Alternating sides

Answer: b) Right

Explanation: The thoracic duct initially ascends **on the right side** of the vertebral column from the cisterna chyli and crosses to the left at **T5 level**. Awareness of this anatomy is essential during mediastinal and esophageal surgeries to prevent duct injury.

6. The thoracic duct carries lymph from all except:

a) Right upper limb

b) Left lower limb

c) Abdomen

d) Left thorax

Answer: a) Right upper limb

Explanation: The **right upper limb, right thorax, and right head and neck** are drained by the **right lymphatic duct**, while the thoracic duct drains **all left-sided regions and lower body**. This distinction is important for understanding lymphatic drainage patterns.

7. The thoracic duct terminates at:

a) Left brachiocephalic vein

b) Left subclavian vein

c) Left venous angle

d) Right venous angle

Answer: c) Left venous angle

Explanation: The thoracic duct empties into the **left venous angle**, the junction of the **left internal jugular and subclavian veins**. This allows lymph to re-enter the venous circulation efficiently.

8. Which vertebral level corresponds to the cisterna chyli?

a) T12

b) L1-L2

c) T5

d) L3-L4

Answer: b) L1-L2

Explanation: The **cisterna chyli** lies at **L1-L2**, serving as the origin of the thoracic duct. It collects lymph from the abdomen and lower limbs before ascending through the thorax.

9. Which imaging modality best visualizes the thoracic duct?

a) Ultrasound

b) MRI lymphangiography

c) X-ray

d) PET scan

Answer: b) MRI lymphangiography

Explanation: **MRI lymphangiography** provides high-resolution imaging of the thoracic duct, its course, and any obstructions or injuries, which is valuable in planning surgery or treating chylothorax.

10. Surgical injury to thoracic duct at T5 level may cause:

a) Chylopericardium

b) Chylothorax

c) Ascites

d) Pulmonary edema

Answer: b) Chylothorax

Explanation: Injury to the thoracic duct at the **T5 crossing point** can result in **chylothorax**, accumulation of lymph in the pleural cavity. Recognizing its course is essential to avoid this complication during thoracic and esophageal surgery.

Chapter: Anatomy | Topic: Lymphatic System | Subtopic: Axillary Lymph Nodes

Keyword Definitions

• Melanoma – A malignant tumor of melanocytes, often arising in skin.

• Axillary Lymph Nodes – Group of lymph nodes in the armpit that drain lymph from the upper limb, breast, and thoracic wall.

• Apical Lymph Nodes – Nodes located at the apex of the axilla, medial to the pectoralis minor.

• Central Lymph Nodes – Nodes lying in the center of the axilla, receiving drainage from other axillary groups.

• Lateral Lymph Nodes – Nodes along the humeral vessels, draining most lymph from the upper limb.

• Pectoral Lymph Nodes – Nodes along the lateral thoracic vessels, draining anterior thoracic wall and breast.

• Pectoralis Minor Muscle – A thin, triangular muscle in the chest beneath the pectoralis major.

• Lymphatic Drainage – The process of lymph movement through vessels and nodes.

• Lymph Node Dissection – Surgical removal of lymph nodes for cancer treatment or staging.

• Clinical Anatomy – Application of anatomical knowledge to clinical practice.

Lead Question (NEET PG 2012):

A patient is found to have a melanoma originating in the skin of the left forearm. After removal of the tumor from the forearm, all axillary lymph nodes lateral to the medial edge of the pectoralis minor muscle are removed. Which axillary nodes would not be removed?

a) Apical lymph nodes

b) Central lymph nodes

c) Lateral lymph nodes

d) Pectoral lymph nodes

Explanation: The apical lymph nodes lie medial to the pectoralis minor, at the apex of the axilla, and receive lymph from all other axillary groups. In this case, only nodes lateral to the medial border of pectoralis minor are excised, sparing the apical group. Therefore, they would not be removed. Correct answer: a) Apical lymph nodes.

Q2. Which group of axillary lymph nodes primarily drains the upper limb?

a) Lateral lymph nodes

b) Apical lymph nodes

c) Central lymph nodes

d) Pectoral lymph nodes

The lateral (humeral) lymph nodes, located along the humeral vessels, are the main drainage for most of the upper limb. Other groups, such as apical or central nodes, receive secondary drainage. Correct answer: a) Lateral lymph nodes.

Q3. Which axillary node group receives lymph from all other axillary node groups?

a) Central

b) Apical

c) Pectoral

d) Lateral

The apical lymph nodes are located at the apex of the axilla and act as a final collecting point for lymph before it enters the subclavian lymph trunk. Correct answer: b) Apical.

Q4. Lymph from the anterior thoracic wall, including most of the breast, drains first to:

a) Lateral nodes

b) Central nodes

c) Pectoral nodes

d) Apical nodes

The pectoral lymph nodes, situated along the lateral thoracic vessels, are the primary drainage site for the anterior thoracic wall and the majority of the breast. Correct answer: c) Pectoral nodes.

Q5. Which nodes lie centrally in the axilla and receive lymph from lateral, pectoral, and subscapular groups?

a) Central nodes

b) Apical nodes

c) Lateral nodes

d) Infraclavicular nodes

Central lymph nodes act as a hub, collecting lymph from major axillary node groups before passing it to apical nodes. Correct answer: a) Central nodes.

Q6. In a radical mastectomy, which group of axillary nodes is typically removed?

a) Only apical

b) Only pectoral

c) Pectoral, lateral, central, subscapular, and sometimes apical

d) Only lateral

Radical mastectomy involves removal of multiple axillary node groups (pectoral, lateral, central, subscapular) to ensure complete cancer clearance; apical nodes may also be removed if involved. Correct answer: c) Pectoral, lateral, central, subscapular, and sometimes apical.

Q7. Which structure is used as a landmark to divide axillary nodes into levels?

a) Pectoralis major

b) Pectoralis minor

c) Serratus anterior

d) Subclavius

The pectoralis minor muscle is the key landmark. Nodes are classified into Level I (lateral), Level II (posterior), and Level III (medial) relative to this muscle. Correct answer: b) Pectoralis minor.

Q8. Lymph from the skin of the lateral forearm drains primarily into:

a) Cubital nodes → lateral axillary nodes

b) Pectoral nodes directly

c) Central nodes directly

d) Apical nodes directly

Superficial lymphatics from the lateral forearm drain first to cubital lymph nodes and then to lateral axillary nodes for further filtration. Correct answer: a) Cubital nodes → lateral axillary nodes.

Q9. Which axillary node group is located along the subscapular vessels?

a) Lateral

b) Apical

c) Subscapular

d) Central

The subscapular (posterior) nodes lie along the subscapular vessels and drain the posterior thoracic wall and part of the scapular region. Correct answer: c) Subscapular.

Q10. Sentinel lymph node biopsy in breast cancer usually targets which axillary node group first?

a) Pectoral

b) Lateral

c) Central

d) Apical

Sentinel node biopsy identifies the first draining lymph node from the tumor site, often a pectoral node in breast cancer, to assess for metastasis. Correct answer: a) Pectoral.