1. A male patient presented with increasing weight loss and abdominal pain. He had a past history of Coeliac Disease, which up until now was asymptomatic on a gluten free diet. CT of the abdomen revealed a thickened loop of small bowel with a stricture and associated lymphadenopathy. A trucut of the nodes revealed a malignant neoplasm, Diagnosis is:
Correct : D. Enteropathic-associated T cell lymphoma
2. A 50 year old male presents with widespread lymphadenopathy. He has had recent fever and weight loss. A trucut biopsy reveals a malignant tumor with the following phenotype; Cytokeratin negative, CLA positive, CD3 positive, and CD30 positive
Correct : B. T-cell lymphoma
3. A 40 year old female presents with mediastinal hilar lymphadenopathy and she has recently noticed slight weight loss and a cough. Staging shows no other evidence of disease. A trucut biopsy reveals a lymphoma showing large cells with mirror image nuclei, lymphocytes, plasma cells and eosinophils. The following phenotype is seen; CD20 positive, CD3 negative, CLA positive, and CD15 positive
Correct : A. Hodgkin's lymphoma, mixed cellularity
4. A 55 year old male presents with a history of chronic dyspepsia and with recent weight loss. Investigation by gastroscopy reveals a reduction in specialised gastric glands and the presence of slender giemsa staining filaments on the mucosal surface. In addition a gastric mass is seen. This is composed of large B lymphocytes which are negative for cyclin D1 and BCL2. Monoclonality is identified.
Correct : A. Gastric DLBCL
5. A 28-year-old woman was found to have stage IV Burkitt‟s lymphoma. Her renal function was normal and a staging CT scan had shown no abnormality of the renal tract. Three days later, when she was about to start chemotherapy, she developed a temperature of 39.0°C with rigors and was treated with imipenem. Investigations (the following day):
serum sodium 138 mmol/L (137–144)
serum potassium 6.2 mmol/L (3.5–4.9)
serum creatinine 215 μmol/L (60–110)
serum corrected calcium 1.60 mmol/L (2.20–2.60)
serum phosphate 1.52 mmol/L (0.8–1.4)
serum lactate dehydrogenase 1238 U/L (10–250)
serum urate 0.69 mmol/L (0.19–0.36)
What is the most likely cause of the renal impairment?
Correct : E. tumor lysis syndrome
6. A 67-year-old man in previously good health is hospitalized because of a 2-day history of fever and diminished consciousness. The patient responds inconsistently to verbal commands. His temperature is 39.5 °C (103.1 °F); he has tachycardia, and his blood pressure is 80/58 mm Hg. There is no bleeding. His hemoglobin is 12.1 g/dL, leukocyte count is 29,000/μL with 80% neutrophils, and platelet count is 20,000/μL. Which of the following studies should be obtained in this patient?
Correct : D. Measurements of fibrin D-dimer and total fibrinogen
7. A 37-year-old man is hospitalized because of fever and right-sided chest pain. He has been having fatigue and recently developed dyspnea on exertion and intermittent chills. At the age of 29 years he was diagnosed with stage III Hodgkin‟s disease and treated with multiagent chemotherapy and radiation therapy. A year ago, he developed mild anemia with no obvious cause. He takes thyroid hormone replacement when he remembers and has used fexofenadine as needed for allergic rhinitis for the past 5 years. On physical examination, his temperature is 38.7 °C (101.7 °F), pulse rate is 112/min, and blood pressure is 110/70 mmHg. There is dullness at the right lower lung and egophony. The hemoglobin is 8.5 g/dL, hematocrit is 26 %, leukocyte count is 2200/μL,and platelet count is 70,000/μL.
What is the most likely diagnosis?
Correct : D. Secondary myelodysplastic syndrome
8. A 43-year-old man with severe acquired aplastic anemia has not responded to immunosuppressive agents. He remains neutropenic and transfusion-dependent for platelets and red cells. He has an HLA-identical brother who has been cleared as a donor for his planned allogeneic stem cell transplant.They are both cytomegalovirus-seronegative. Which of the following would be prevented by using irradiated cellular blood products for this patient?
Correct : C. Transfusion-related graft-versus-host disease
9. A 34-year-old woman is evaluated because of progressive fatigue and recurrent attacks of abdominal pain. She weighs 61.2 kg (135 Ib). Her pulse rate is 110/min and her blood pressure is 110/70 mm Hg. She is pale, and her spleen is palpable 4 cm below the costal margin. Laboratory studies: Hemoglobin 6 g/dL
Hematocrit 20% Leukocyte count 2500/μL Platelet count 80,000/μL Reticulocyte count 10%
Blood smear Anisocytosis and polychromatophilia Haptoglobin 0 mg/dL
Serum lactate dehydrogenase 645 U/L
There is high level of hemosiderin in the urine.
What is the most likely cause of this patients pancytopenia?
Correct : D. Paroxysmal nocturnal hemoglobinuria
10. In an office visit for an annual checkup, a 46-year-old man reports that he has had malaise and intermittent sweats for the past few months but has been able to continue his job as a high school teacher. Two years ago he was treated for stage III diffuse large-cell non-Hodgkin‟s lymphoma with six cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) and attained complete remission. He takes simvastatin for hypercholesterolemia and hydrochlorothiazide for hypertension. On physical examination, he has lymphadenopathy: a 3-cm right axillary node and a 2- cm right supraclavicular node. His spleen tip is palpable. Laboratory evaluation shows mild normochromic, normocytic anemia and an elevated serum lactate dehydrogenase level. CT scans of his chest and abdomen reveal additional mediastinal and retroperitoneal lymphadenopathy. What is the best next step in this patient‟s management?
Correct : B. Referral for salvage chemotherapy and autologous stem cell transplantation
11. A 74-year-old woman presents for an urgent office visit. She has been experiencing epigastric discomfort over the last 3 months. Discomfort is worse during meals and prevents her from eating full portions. She has lost 5.4 kg (12 Ib). She also reports dyspnea on exertion. She has been taking ramipril, aspirin, and simvastatin. On physical examination, her pulse rate is 88/min, and her blood pressure is 155/85 mm Hg. There is mild epigastric tenderness with palpation. Her spleen is massively enlarged and palpable at the umbilicus. The edge of her liver is also palpable 6 cm below the costal margin. Her hemoglobin is 7.5 g/dL, mean corpuscular volume 89 fL, leukocyte count 11,200/μL, and platelet count 114,000/μL. Peripheral blood smear shows numerous erythroblasts, myeloid precursors, and teardrop cells. Bone marrow cannot be aspirated, and biopsy specimen shows marked fibrosis. Analysis of blood is negative for t(9;22) by fluorescent in situ hybridization (FISH). What is the most l
Correct : E. Myelofibrosis
12. A 43-year-old man is evaluated because of crushing substernal chest pain that developed during a pickup basketball game with colleagues at work. He was treated 15 years ago for stage IIB massive mediastinal Hodgkin‟s disease. Treatment included doxorubicin, bleomycin, vinbiastine, and dacarbazine (ABVD) followed by mantle-field radiation therapy to a total dose of 4400 cGy. He has had no recurrence of his Hodgkin‟s disease. He takes thyroid medication because he developed hypothyroidism 2 years after completing his therapy for Hodgkins disease. What is the most likely diagnosis?
Correct : B. Myocardial infarction
13. A 68-year-old man is evaluated because of worsening chronic epigastric pain. He now has fatigue and early satiety. He has iron deficiency anemia. Results of upper gastrointestinal endoscopy reveal diffuse gastritis, along with mucosal thickening in the gastric antrum associated with a mass lesion. Abundant Helicobacter pylon organisms are noted on biopsy, and histologic evaluation of the mass lesion shows it to be a gastric lymphoma of mucosa-associated lymphoid tissue (MALT) type. What is the most appropriate next step in the management of this patients illness?
Correct : D. Eradication of Helicobacter pylori
14. A 64-year-old man is evaluated because of fatigue and shortness of breath on exertion. He has had three episodes of urinary tract infection in the past 7 months. On physical examination, he has pallor but is otherwise normal. He denies blood loss, and his stool is negative for occult blood on three measurements. He is anemic (hemoglobin 8.4 g/dL) with normochromic, normocytic indices, and his serum creatinine level is 2.9 mg/dL. The total serum protein level is elevated, and the serum albumin level is low normal. His serum calcium level is 11.8 mg/dL.What is the most likely cause of his symptoms?
Correct : A. Multiple myeloma
15. Regarding lymphomas, all are true except:
Correct : A. Mesenteric nodes are involved in HL more than in NHL
16. B cell CLL
Correct : B. reduced immunoglobulins are a risk for recurrent bacterial infections
17. Which one of the following statements is true of B cell CLL?
Correct : A. Autoimmune thrombocytopenia is uncommon
18. Which of the following associations is correct?
Correct : B. Hepatitis B and aplastic anaemia
19. Which of the following statements regarding lymphomas in childhood is correct?
Correct : D. The nodular sclerosing variety is the most common form of Hodgkin's disease.
20. Malignant melanoma:-
Correct : E. typically shows metastases to regional lymph nodes
21. A 68-year-old woman is evaluated because of a lump on her chest wall. Seventeen years ago she developed stage I ductal adenocarcinoma (estrogen receptor-positive) of the left breast; her disease was managed with lumpectomy, breast radiation therapy, and 5 years of tamoxifen therapy. The lump she now has is separate from the breast, subcutaneous in location, fixed to the underlying 4th rib, and nontender. The mass is excised and found to be a fibrosarcoma. What is the relationship of this fibroscarcoma to her original cancer and its treatment?
Correct : B. It is related to the radiation therapy given to control the breast cancer
22. A 70-year-old man with an 80-pack-year smoking history is evaluated because of a chronic cough of 6 months duration. Chest radiograph shows a 3-cm mass in the left perihilar region, and bronchoscopic biopsy confirms poorly differentiated adenocarcinoma. There are no significant findings on physical examination, and all blood studies are normal. Bone scan and CT scan of the head are normal, but CT scans of the chest and abdomen show the mass and two 1-cm nodules in the right lobe of the liver. Intravenous contrast perfusion of the two nodules during the CT scan is not suspicious for hemangioma. Positron emission tomography scan shows distinct uptake in the left perihilar mass but only faint focal activity in the right lobe of the liver.Pulmonary function tests show mild obstructive disease. What is the best next step in this patient‟s management?
Correct : C. CT-directed liver biopsy
23. A 25-year-old woman has her first routine check-up. Her mother died of lung cancer at the age of 60 years, and her father has had a head and neck cancer. She is very worried about getting cancer and wants to know what she can do to reduce her risk, as much as possible, of getting either of these cancers. In addition to avoidance of tobacco, which of the following approaches has been demonstrated to decrease risk for one or both of these cancers?
Correct : A. Avoidance of alcohol abuse
24. A 69-year old black man is evaluated because of a history of steadily increasing upper abdominal pain, loss of appetite, and a 4.6-kg (1 0-Ib) weight loss over the past several months. He recently noticed that the color of his urine was darker than usual. The patient had a 40-pack-year history of cigarette smoking, but quit smoking 4 years ago. He has hypertension that is controlled by medical management. Laboratory studies: Hemoglobin 11.5 g/dL Serum total bilirubin 3.3 g/dL Serum albumin 3.2 g/dL Serum aspartate aminotransferase 105 U/L Serum alanine aminotransferase 95 U/L Urinalysis shows elevated bilirubin. CT scan of the abdomen shows dilation of the common bile and pancreatic ducts, a 5.2-cm mass in the head of the pancreas, and compression of the superior mesenteric vein. A fine-needle aspirate of the mass reveals atypical cells that are suspicious for malignancy. What is the most appropriate course of action?
Correct : D. Refer the patient to a tertiary-care center with surgical expertise in the management of patients with pancreatic and hepatobiliary disease
25. Which of the following cancer screening tests has been shown in randomized trials to decrease the risk of death from the target cancer?
Correct : A. Fecal occult blood testing every 2 years for colorectal cancer
26. A 45-year-old woman is evaluated because of a palpable 2-cm right axillary lymph node. The lymph node is completely resected, and histologic study shows adenocarcinoma; hormone receptors are negative. Bilateral mammography is negative, as is MRI of the right breast. CT scans of the chest and abdomen are negative for tumor, and no further lymphadenopathy is detected. Results of bone scan and MRI of the head are also unremarkable. The patient had been previously healthy and has never smoked. Which of the following statements about this patients condition is correct?
Correct : A. Breast cancer is the most likely diagnosis, and optimal therapy for breast cancer paradigm should be initiated.
27. A 59-year-old man was referred because of a change in bowel habit. He had noticed no alteration in stool calibre, gastrointestinal bleeding or unintended weight loss. There was no family history of colonic polyps or gastrointestinal malignancy. Physical examination was normal. A rectal examination revealed no masses. A sigmoidoscopy revealed a 4-mm polyp in the mid-rectum, which was removed with forceps, and histology revealed a tubular adenoma. What is the most appropriate next step in management?
Correct : D. colonoscopy now
28. A 42-year-old woman is evaluated because she has noticed a thickening in her left breast over the past few weeks. She noticed it a few months ago, but because it seems to come and go, she put off seeking medical attention. She is premenopausal. She had menarche at age 13 years. When she was 35 years, she had one child (whom she breast-fed) after a normal first full-term pregnancy. She took oral contraceptives for 10 years before her pregnancy. She has no known radiation exposure and no family history of breast cancer. On physical examination, there appears to be some asymmetry in breast tissue density in the upper outer quadrant of the left breast compared with the right one, but no discrete mass. There are no palpable lymph nodes. Results of a mammogram are negative. What would be the most appropriate next step in this patients management?
Correct : A. Breast ultrasound; consultation with a surgeon experienced in breast diagnosis
29. A 26-year-old man with testicular cancer who is receiving chemotherapy is evaluated in the emergency department. His temperature is 38.9 °C (102 °F), and he complains of feeling flushed and tired. He has an indwelling central venous port, but there are no localizing symptoms to suggest a source of infection. Chest radiograph shows no abnormalities. The patients hemoglobin is 8.9 gIdL; the absolute neutrophil count is 165/μL and the platelet count is 56,000/μL. Results of other laboratory studies and urinalysis are within normal limits. Blood samples are obtained from a peripheral vein and through the port and sent for culture; a urine culture is also ordered. The patient is hospitalized and intravenous ceftazidime is initiated. Three days later, the patient‟s temperature is 37.8 °C (100 °F) and absolute neutrophil count is 4504/μL; his clinical condition is otherwise stable. Results of blood and urine cultures are negative. A repeat chest radiograph is normal, and blood and urine speci
Correct : A. Continue the current antibiotic regimen
30. Four years ago, a 67-year-old man had a serum prostate-specific antigen (PSA) level of 16 ng/mL. Biopsy specimen showed adenocarcinoma of the prostate gland. His Gleason score was 7. He was treated with external-beam radiation therapy. One month ago, the patient noted fatigue and rib pain. His PSA was found to be 87 ng/mL, and bone scan revealed diffuse metastatic disease. What is the best treatment for this patient?
Correct : C. Androgen ablation (medical or surgical)
31. A 68-year-old woman is evaluated because of rectal bleeding that began recently and a sense of fullness in the rectum. Flexible sigmoidoscopy shows a mass 11 cm from the anus, and biopsy reveals adenocarcinoma. The patient is referred to a colorectal surgeon, and a low anterior resection is performed. The primary tumor, a 4-cm moderately differentiated adenocarcinoma, penetrates the bowel wall. No lymph nodes are involved. What is the most appropriate next step in this patient‟s management?
Correct : B. Postoperative adjuvant chemotherapy and pelvic radiation therapy
32. A 58-year-old postmenopausal woman has been taking hormone replacement therapy with combined estrogen and progestin for the past 4 years because she was told it would decrease her risk for heart disease. Her father died at age 65 years of heart disease, and she is concerned that she is also at risk. Recently, her sister has been diagnosed with breast cancer. Her mother died of breast cancer. Three years ago, the patient had a breast biopsy that showed atypical hyperplasia. She has not had a hysterectomy. The patient is considering chemoprevention for breast cancer, but is nonetheless concerned about heart disease. Her calculated risk of breast cancer is 10.4% over the next 5 years. Which of the following options is reasonable to consider for this patient?
Correct : C. Discontinue hormone replacement therapy and start tamoxifen
33. A 68-year-old man with locally advanced non-small-cell lung cancer is evaluated because of the new onset of low back pain over the past 2 weeks. It is relieved with ibuprofen, and his only other symptom is mild fatigue. The patient completed combined chemotherapy and radiation therapy 6 months ago, and restaging scans afterward showed marked shrinkage of the right perihilar mass. He has no muscle weakness. Plain radiograph of the thoracic and lumbar spine shows no abnormalities other than signs of mild osteoarthritis. Neurologic examination is unremarkable. What is the most appropriate next step in the management of this patient?
Correct : D. MRI of the spine
34. A 72-year-old man is evaluated because of constipation, abdominal pain, and distention that have worsened over the past week. Two years ago, he was diagnosed with stage III rectal cancer (primary tumor and renal involvement) and underwent low anterior resection. Chemotherapy with 5-fluorouracil and leucovorin followed, and pelvic radiation was given with concurrent infusion of 5-fluorouracil. He has been having regular bowel movements, and results of his most recent colonoscopy (1 year ago) were unremarkable. On physical examination, his pulse rate is 100/min. He has orthostatic hypotension, a slightly distended abdomen with hyperactive bowel sounds, and some guarding to deep palpation in the left lower quadrant. Plain radiograph of the abdomen shows distended loops of small bowel, with no stool in the distal colon or rectum. The patient is hospitalized for bowel rest and intravenous hydration. What is the next step in this patient‟s management?
Correct : E. CT scan of the abdomen with oral and intravenous contrast
35. A 60-year-old postmenopausal woman at elevated risk for breast cancer is taking tamoxifen to reduce her risk. She has not had a hysterectomy. Which of the following surveillance strategies for the detection of endometrial cancer is most important to incorporate into this patient‟s care?
Correct : E. Annual routine bimanual pelvic examination
36. An 82-year-old woman who has never smoked is evaluated because of a persistent cough. Chest radiograph shows several lung nodules and infiltrates. There are no significant findings on physical examination. The patient reports no weight loss. Blood studies show no abnormalities. CT scans confirm pulmonary involvement only, and results of bone scan and CT scan of the head are normal. The patient most likely has which of the following histologic types of lung cancer?
Correct : A. Bronchoalveolar cell carcinoma
37. A 45-year-old woman has recently undergone lumpectomy and radiation therapy for a stage II breast cancer. She received chemotherapy for 6 months. Her periods ceased while she was receiving chemotherapy, and she remains amenorrheic. Her tumor was rich in estrogen receptor, and she is taking tamoxifen. Her hair is growing back, her energy is returning, and she has no specific complaints, but she is worried about recurrence. In addition to routine follow-up, what is the most appropriate management of this patient?
Correct : B. No further management
38. A 66-year-old black woman diagnosed with stage III colon cancer underwent definitive resection of the primary tumor 3 years ago. After surgery, she received adjuvant chemotherapy with 5-fluorouracil and leucovorin. Approximately 20 months later, she developed metastatic disease in the liver (five lesions in right and left lobe) and lungs (one lesion in the right and left lobe). She was treated with irinotecan, 5-fluorouracil, and leucovorin, and had a partial response to therapy. One month ago, disease progression was documented on restaging CT scans. The patient‟s laboratory studies show relatively normal organ function. She has fatigue, decreased appetite, and has noticed a 2.3-kg (5-Ib) weight loss over the past 3 months. She has stopped participating in weekend bike trips with a cycling club, but remains involved in church and family activities and states that she wants to be as aggressive as possible in fighting the cancer. What is the most reasonable recommendation for this patie
Correct : C. Second-line chemotherapy regimen with leucovorin and oxaliplatin
39. A 65-year-old woman has a modified radical mastectomy for a 1.0-cm, well-differentiated breast cancer. The tumor is positive for estrogen and progesterone receptors and negative for HER2. Sentinel node mapping and excision show that none of the three lymph nodes removed is positive for metastasis. She is otherwise healthy. What is the best treatment for this patient at this time?
Correct : C. Tamoxifen for 5 years
40. A 59-year-old woman with an 80-pack-year smoking history is evaluated because of weight loss and severe pain in the upper part of her left leg. She has lost 11.3 kg (25 Ib) from baseline weight of 59 kg (130 Ib). A large lytic lesion is noted on the left femur, with erosion into the cortex. Bone scan shows multiple lesions, and CT scan of the chest shows a large left hilar mass and med iastinal lymphadenopathy. Bronchoscopic biopsy specimen shows poorly differentiated adenocarcinoma. Radiation therapy to the left femur is initiated. Which of the following findings would preclude use of palliative chemotherapy for this patient?
Correct : E. Poor performance status
41. A 57-year-old man has tried to stop smoking unsuccessfully for the past year. He has tried smoking cessation counseling and use of nicotine gum. Although he has no new symptoms, the „smokers cough” that he has had for years is a constant reminder that he is at risk of dying of lung cancer. He wants to know what measures he can take that have been shown to reduce that risk. In addition to a smoking cessation program, what is the best recommendation for this patient?
Correct : C. Daily bupropion
42. A 71-year-old man with mild chronic obstructive pulmonary disease and mild hypertension is evaluated during an annual routine visit. Review of systems is notable for intermittent cough, increasing dyspnea on exertion, a 2.3-kg (5 Ib) weight loss, and fatigue. The patient takes aspirin, 81 mg/d, and hydrochlorothiazide, 50 mg/d orally. He smoked one pack of cigarettes per day for 49 years but quit smoking 2 years ago. On physical examination, distant breath sounds are audible in both lungs and there are scattered rhonchi. Chest radiograph shows a perihilar mass. Abnormal laboratory results include hemoglobin of 12.5 g/dL and a serum sodium of 127 meq/L. Endobronchial biopsy reveals small-cell lung cancer. Further staging studies suggest that the disease is limited-stage. What is the most appropriate treatment for this patient‟s hyponatremia?
Correct : D. Combination chemotherapy for the small-cell lung cancer
43. A 23-year-old man is evaluated because of a painless right-sided scrotal mass. Ciprofloxacin, 500 mg every 12 hours, is administered for 10 days, but he notes little improvement in the swelling. His serum α-fetoprotein level is elevated at 100 ng/mL, and his 13-human chorionic gonadotropin level is 64 m/UImL. Testicular ultrasound examination reveals a hypoechoic mass. Which of the following would be the most appropriate next step in his treatment?
Correct : D. Inguinal orchiectomy
44. A 40-year-old woman has a routine gynecologic examination. At the age of 32 years, she gave birth to twins after receiving fertility drugs. She has just seen a television program on ovarian cancer, and is concerned because previous use of fertility drugs and a family history of ovarian cancer were mentioned as possible risk factors. Her mother developed endometrial cancer at 56 years, and a paternal uncle was diagnosed with a type of lymphoma at 60 years. She has one older sister with hypertension and one younger brother who is healthy. Results of her pelvic examination are unremarkable, but she asks what additional tests she should have to look for ovarian cancer in the early stages that cannot be detected by physical examination. What is the most appropriate management for this patient?
Correct : B. Rectovaginal pelvic examination in 1 year
45. A 44-year-old woman has a lumpectomy and radiation therapy for stage II breast cancer. She receives 6 months of chemotherapy. Her periods cease while she is receiving chemotherapy, and she remains amenorrheic. Her tumor was found to be rich in estrogen receptor, and she is taking tamoxifen. Her hair is growing back and her energy is returning, but she is having severe hot flushes that keep her awake at night. She is so tired during the day that she is unable to perform her job in a satisfactory manner. She also relates that she and her husband have been unable to have satisfying sexual relations because intercourse is painful for her. What would be the most appropriate treatment for this patient?
Correct : A. A selective serotonin reuptake inhibitor and use of nonhormonal vaginal lubricating preparations
46. A 64-year-old white man presents for serum prostate-specific antigen (PSA) screening at his wife‟s urging. He is in generally good health, except for mild hypertension. His digital rectal examination reveals a mildly enlarged prostate gland with no discrete nodules. He has no family history of prostate cancer. What is the best advice to give him?
Correct : B. There is insufficient evidence to establish whether PSA screening affects overall mortality rates
47. A 58-year-old woman with a 60-pack-year smoking history is evaluated because of hemoptysis and weight loss. Chest radiograph and CT scan show a right perihilar mass with mediastinal adenopathy. The results of CT scans of the abdomen, bone scan, and MRI of the head are otherwise negative. Examination of a specimen by bronchoscopic biopsy confirms small-cell lung cancer, and the findings suggest limited-stage disease. After the patient completes mediastinal radiation therapy and four cycles of cisplatin and etoposide, repeat CT scans indicate that her disease is in complete remission. What is the best recommendation concerning further therapy?
Correct : A. Prophylactic cranial irradiation
48. A 63-year-old man is evaluated because of a several-month history of increasing fatigue and some vague upper abdominal discomfort. His medical history includes gastroesophageal reflux disease, coronary artery disease, and clinical depression, all of which are well controlled with medications. The patient has been working full time. On physical examination, he has mild hepatomegaly. His hemoglobin is 12.2 g/dL, serum alkaline phosphatase level 280 U/L, and serum aspartate aminotransferase level 65 U/L. CT scan of the abdomen and pelvis shows multiple hepatic lesions ranging in size from 1 cm to 4 cm; mesenteric, para-aortic, and paracaval lymphadenopathy, and a colonic mass at the splenic flexure. Colonoscopy reveals a nonobstructing, non bleeding lesion; biopsy shows it to be poorly differentiated adenocarcinoma. Fine- needle aspiration of one of the liver lesions confirms the presence of malignant cells consistent with a primary colon cancer. What is the most appropriate next step in
Correct : D. Systemic chemotherapy
49. A 69-year-old man underwent a radical prostatectomy ii years ago. His serum prostate-specific antigen (PSA) level was 7.1 ng/mL, clinical stage was Tic (clinically organ-confined and detected by screening PSA blood test only), and his Gleason score was 5. His PSA level became detectable 4 years ago. Over the past 3 years, his PSA values have been 1.4 ng/mL, 1 .8 ng/mL, and 2.2 ng/mL. He remains asymptomatic, and a recent bone scan revealed only degenerative disease. The patients risk for rapid metastasis is low for which of the following reasons?
Correct : C. He has had a slow, prolonged rise in his PSA.
50. A 61-year-old man with a 120-pack-year smoking history is evaluated for a persistent and worsening cough and found to have a 3-cm mass in the right upper lobe on chest radiography. CT-directed needle biopsy is positive for squamous cell carcinoma. CT scans of the abdomen and pelvis, bone scan, and MRI of the head are negative for metastatic disease. Positron emission tomography scan shows uptake only in the right upper lobe mass, and pulmonary function tests indicate that the patient has adequate pulmonary reserve to undergo resection. The patient undergoes a right upper lobectomy. All margins are clear, and all peribronchial lymph nodes are negative for tumor within the resected specimen. What is the most reasonable adjuvant therapy for this patient?
Correct : E. No radiation therapy or chemotherapy is required at this time
51. A 47-year-old woman is recovering from surgery for stage III ovarian cancer (spread to the peritoneal cavity but without parenchymal liver involvement). Not all of the visible cancer could be resected; the largest residual tumor was 3 cm in diameter. Her performance status is excellent. She is interested in pursuing aggressive therapy and wishes to be treated as soon as possible in her local community. The proposed systemic therapy will involve cisplatin or carboplatin and paclitaxel. What further treatment is appropriate for this patient?
Correct : A. No further treatment beyond the proposed standard therapy
52. A 62-year-old postmenopausal woman with a family history of breast cancer in two first-degree relatives wishes to consider taking tamoxifen to reduce her risk of breast cancer. Her baseline risk of breast cancer qualifies her for consideration of tamoxifen (i.e., an absolute risk of at least 1.66% over the next 5 years). She has had a prior hysterectomy, but her ovaries are intact. Which of the following effects of tamoxifen are relevant to the decision?
Correct : B. Increased risk of deep venous thrombosis
53. A 50-year-old perimenopausal woman is evaluated because of abdominal swelling. CT scan of the chest, abdomen, and pelvis shows mesenteric lymphadenopathy and a small amount of ascites but no ovarian masses. Needle biopsy specimen shows adenocarcinoma; the tumor is found to be negative for hormone receptors. The serum carcinoembryonic antigen level is normal at 2.0 ng/mL and the serum CA-125 is 1200 ng/mL (elevated). What is the best next step in her treatment?
Correct : B. Debulking surgery
54. A 50-year-old menstruating woman has a 1 .5-cm moderately differentiated breast cancer. The lesion is completely excised, and the margins of the excision are negative. Axillary node sampling shows that she has three positive nodes. The tumor is negative for estrogen and progesterone receptors and is highly positive for HER2. She is otherwise healthy. Her mother had breast cancer at 62 years and was treated by mastectomy; she is alive and healthy at the age of 80 years. The patients sister had breast cancer at 54 years and was treated by breast conservation therapy; 4 years later she died of a recurrence of breast cancer. The patient has seen two different surgeons with opposing viewpoints regarding the best treatment, and she has been reading extensively on the Internet and has become confused about her options. Which of the following represents the best treatment for this patient?
Correct : D. Chemotherapy and radiation therapy to the breast and axillary regions
55. A 32-year-old woman is evaluated because of a painless swelling in her lower neck. She noted the swelling about 3 weeks ago and now thinks it is getting larger. She has no history of foreign travel. She smokes but does not drink alcohol. She owns a cat. She has not had fever or unexplained weight loss, but has had night sweats twice in the past week. She has been feeling fatigued lately and has noted dyspnea on exertion. On physical examination, a 3 X 5-cm left supraclavicular lymph node is palpable. It is firm but not rock-hard and is nontender. The remainder of her physical examination and results of a complete blood count are normal. What is the best next step in this patient‟s management?
Correct : E. Perform a chest radiograph
56. A 63-year-old man is evaluated because of new-onset hemoptysis and a 100-pack-year smoking history. Chest radiograph shows a 4-cm right perihilar mass, and bronchoscopic biopsy and cytologic evaluation of sputum confirm squamous cell carcinoma. There are no significant findings on physical examination, and the patient reports no weight loss.Complete blood count is normal except for a serum alkaline phosphatase level at 110 U/L. CT scans of the chest and abdomen show no mediastinal adenopathy. Results of a positron emission tomography scan are negative, except for the right perihilar mass.In which of the following situations would surgical therapy be offered?
Correct : C. A solitary brain metastasis is noted on CT scan of the head.
57. A 40-year-old woman was treated for breast cancer 5 years ago by lumpectomy, breast irradiation, and 3 months of chemotherapy. Her original cancer was negative for estrogen and progesterone receptors and unequivocally positive for HER2. Her periods stopped during chemotherapy but resumed 4 months later, and she remains premenopausal now. She is evaluated now because of pain in her back, a nagging cough, and fatigue. Physical examination shows palpable skin nodules over the affected breast, axillary adenopathy, and dullness to percussion, and decreased breath sounds in the base of the left lung; her liver edge is palpable below the right costochondral border. Liver function values are approximately twice normal; serum bilirubin is normal. Radiograph of the chest shows multiple pulmonary nodules and a left pleural effusion confirmed by CT, which also shows the liver nodules. Bone scan and MRI are consistent with bone metastases. Biopsy of one of the skin lesions is consistent with metast
Correct : D. Trastuzumab and taxane-based chemotherapy
58. A 65-year-old man has a routine screening examination, and his serum prostate- specific antigen (PSA) level is found to be 6.7 ng/mL. Digital rectal examination reveals a mildly enlarged prostate gland, but no discrete nodules. One year ago, his PSA was 2.1 ng/mL. The patient is referred to a urologist who performs a biopsy of the gland. Biopsy specimen shows adenocarcinoma of the prostate with a Gleason score of 9. Which of the following best describes his prognosis on the basis of his Gleason score?
Correct : C. The Gleason score indicates that the patient would have a high risk of recurrence after a radical prostatectomy.
59. A 78-year-old man is evaluated because of shortness of breath of acute onset. The patient reports a 13.6-kg (30-Ib) weight loss, vague upper abdominal discomfort, nausea, loss of appetite, and fatigue. He has hypertension and symptomatic atherosclerotic coronary artery disease despite optimal medical management. Even before the recent episode of dyspnea, his physical activity has been limited; he spends most of the day resting either in bed or in a chair.
Laboratory studies: Hemoglobin 10.5 g/dL Serum albumin 2.6 g/dL
Serum alanine aminotransferase 65 U/L
Serum aspartate aminotransferase 78 U/L CA 19-94500 U/L
Arterial oxygen saturation 85% by pulse oximetry
Spiral CT scan of the chest shows a pulmonary embolism.
The patient is hospitalized for anticoagulation and oxygen therapy and gradually improves. Subsequent CT of the abdomen shows a 4-cm mass in the tail of the pancreas and numerous low-attenuation lesions in the liver. CT-guided biopsy of the hepatic lesions and the pancreatic m
Correct : A. Best supportive care and referral to a hospice
60. A 76-year-old man was diagnosed with prostate cancer 8 years ago. At that time he had a serum prostate-specific antigen (PSA) level of 12 ng/mL, a Gleason score of 6, and a clinical stage of T2b (organ-confined on digital rectal examination but involving both lobes of the prostate gland). He was treated with external-beam radiation therapy, and his PSA level dropped to a low of 1.4 ng/mL. Four years later, his PSA level began to rise and now is 14.1 ng/mL. A recent bone scan and CT scans revealed no metastatic disease. His urologist has suggested initiating a course of leuprolide. Which of the following is a potential side effect of leuprolide that the patient should be informed about before commencing therapy?
Correct : B. Bone thinning
61. A 68-year-old man with a 60-pack-year smoking history is evaluated because of hemoptysis. Radiograph of the chest shows a right hilar mass and mediastinal widening. CT scans of the chest and abdomen confirm the hilar mass and bulky lymphadenopathy in the mediastinum with no other overt metastases. Bronchoscopic biopsy specimen shows small-cell lung cancer. Bone scan and CT scan of the head are negative for tumor. A low serum sodium level and inappropriately high urine osmolality suggest that he has the syndrome of inappropriate antidiuretic hormone secretion. Which of the following is the most appropriate treatment recommendation?
Correct : D. Radiation therapy and concomitant chemotherapy
62. A 78-year-old woman with metastatic breast cancer involving the bones and soft tissues who has been taking hormone replacement therapy is evaluated in the emergency department because of lethargy and weakness, nausea, thirst, and dizziness. She is orthostatic and clinically dehydrated. She has a history of congestive heart failure that has been controlled with medications. Laboratory studies:
Blood urea nitrogen 42 mg/dL Total serum calcium 11 .4 mg/dL Serum creatinine 1.6 mg/dL Serum albumin 3.0 g/dL What is the most appropriate initial treatment?
Correct : C. Vigorous rehydration with normal saline
63. A 52-year-old woman who is a nonsmoker has a 3-cm right inguinal lymph node.Biopsy specimen shows a poorly differentiated malignancy that is difficult to characterize by light microscopy. The biopsy specimen is negative for leukocyte common antigen, cytokeratin, and estrogen receptors. Which of the following additional tests would best establish the source of this tumor?
Correct : C. Stain for S-100
64. A 59-year-old man who is a heavy smoker presents with cough, shortness of breath, and a sensation of head fullness. Physical examination is notable for cervical venous distention and facial edema. A chest radiograph shows a widened superior mediastinum. What is the most appropriate initial intervention for this patient?
Correct : B. CT of the chest and consultation with a pulmonologist and a thoracic surgeon
65. A 29-year-old man was diagnosed with stage II (that is, spread from the primary tumor to retroperitoneal lymph nodes) nonseminomatous germ cell tumor 1 year ago. Treatment included orchiectomy and retroperitoneal lymph node dissection. He now presents with an elevated level of β-human chorionic gonadotropin hormone and multiple pulmonary lesions ranging in size from 0.61 to 3.22 cm. Needle biopsy specimen of the largest lesion reveals a germ cell tumor consistent with the initial diagnosis. He is asymptomatic. What is the best treatment for this patient?
Correct : B. Combination chemotherapy with bleomycin, etoposide, and cisplatin
66. A 64-year-old woman has the following family history: One sister, who was a smoker, had lung cancer at the age of 63 years; another sister had breast cancer at the age of 70 years. Her father had prostate cancer at 82 years of age, and her mother had breast cancer at age 71 years. She has three other sisters, now aged 58, 60, and 65 years who have no history of cancer. She has two daughters and two sons between the ages of 25 and 39 years, who have no history of cancer. Her ancestry is European in general, and she is not of known Ashkenazi Jewish descent. She is concerned that “cancer runs in the family” and would like to have one of those “gene tests” she has read about.
What is the best advice to give her and her family?
Correct : D. Advise her that genetic testing is unnecessary, and recommend that she and her family continue screening and risk-reduction strategies as recommended for the general population.
67. A 72-year-old man is evaluated because of back pain and fatigue. Laboratory values indicate he is anemic, with normal leukocyte count and platelet count. He has mild hypercalcemia and a normal serum creatinine level. His gamma globulins are elevated, and serum protein electrophoresis shows the presence of a monoclonal protein, an IgG- K light chain containing immunoglobulin at 4.4 g/dL. His bone marrow contains 20% plasma cells. A skeletal survey reveals multiple osteolytic lesions in the spine, ribs, and skull. Therapy with melphalan and prednisone is initiated.
Which of the following agents would NOT be routinely used in his management?
Correct : C. Intravenous gamma globulin
68. Which of the following statements is correct about alpha-feto protein (AFP) ?
Correct : D. Hook effect can explain the apparently normal level of AFP in hepatoblastoma.
69. Which of the following statement about tumor markers is correct?
Correct : B. CEA is mainly used for determining prognosis and detecting relapse.
70. A 58-year-old man presents with weight loss and haemoptysis. He has smoked most
of his life. On examination he is clubbed and has clinical evidence of right pleural effusion. His serum calcium is 3.2mM. Which of the following histological type of lung cancer is he most likely to suffer from?
Correct : D. squamous cell carcinoma
71. Which of the following is an oncogene?
Correct : A. The N-Myc gene
72. Which of the following does not have a role in the management of chronic cancer pain?
Correct : E. Pinavarium
73. 4- A 64-year-old man is found to have squamous cell bronchogenic carcinoma. Which
of the following statements is true regarding surgical resection?
Correct : C. Is precluded if a CT scan of the thorax shows enlarged mediastinal lymph nodes.
74. An elderly lady with breast cancer is starting diamorphine elixir for painful bony metastases. Which of the following is the most appropriate comment to make to her caregiver.
Correct : C. A laxative will need to be used
75. A 45-year-old woman noticed tinnitus in her left ear which progressed over some weeks to hearing loss in that ear. On physical examination she is found to have a marked decrease in hearing on the left, with Rinne test indicating air conduction better than bone conduction. The other cranial nerves I - VII and IX - XII are intact. A brain MRI scan revealed a solitary, fairly discreet, 3 cm mass located in the region of the left cerebellopontine angle. Which of the following statements is most appropriate to tell the patient regarding these findings?
Correct : D. The lesion can be resected with a good prognosis
76. A 48-year-old woman presents to her GP with Cushingoid facies and hyperpigmentation of the skin on her face and chest. She has smoked 20 cigarettes per year for 30 years. Examination reveals no gross abnormalities. Her chest X-ray reveals a 2 cm irregularly shaped mass in the right upper lobe, in proximity to the mediastinum. A CT guided needle biopsy of the lung lesion is performed. Which would be the most likely cytologic finding?
Correct : D. Small cell (oat cell) carcinoma
77. A firm 2 to 3 cm mass is palpable in the upper outer quadrant of the right breast of a
52-year-old woman. There are no palpable axillary lymph nodes. A lumpectomy with axillary node dissection is performed and the breast lesion is found to have positive immunohistochemical staining for HER2/neu (c-erb B2). Staining for oestrogen and progesterone receptors is negative. Which of the following additional treatment options is most appropriate, based upon these findings?
Correct : D. Trastuzumab
78. Concerning Neurofibromatosis Type 1 (NF1), which one of the following statements is
true?
Correct : D. Pigmented spots on the iris are a characteristic feature
79. Regarding retinoblastoma which of the following statements is correct?
Correct : E. They usually present with leukocoria.
80. Which of the following regarding salivary gland pleomorphic adenomas is correct?
Correct : A. they are the most common salivary gland tumor
81. A 65-year-old man, with a history of smoking, presents with chronic cough, haemoptysis and weight loss. His Chest X-Ray shows a cavitating lesion. What is the likely diagnosis?
Correct : E. squamous cell carcinoma
82. In asbestos related disorders which of the following statements is correct?
Correct : B. increased incidence of primary lung cancer
83. Carcinoid tumors of the lung (bronchial adenomas) originate from which of the
following cell types?
Correct : C. Kulchitsky (K) cell
84. A 75-year-old man with squamous cell carcinoma is thought to have resectable disease. Which of the following would be a contraindication to surgery?
Correct : B. FEV1 of 0.75 L
85. 20- A 59 year old female smoker is diagnosed with oat cell carcinoma of the bronchus.
Which of the following relating to this diagnosis is true?
Correct : D. Is associated with the elaboration of ectopic ADH secretion
86. Mutations of the p53 gene frequently occur in:
Correct : D. Bronchial Carcinoma
87. A 30-year-old woman has a right mastectomy and axillary lymph node dissection for a
carcinoma diagnosed by fine needle aspiration cytology. The histologic pattern is that of a poorly differentiated carcinoma that is negative for oestrogen and progesterone receptors, but is positive for HER2/neu. One axillary lymph node demonstrates micro- metastases. Her 32 year old sister is found to have a similar lesion. Which of the following statements regarding risk factors for this lesion is the most appropriate?
Correct : E. These findings suggest a BRCA-1 mutation
88. A 56-year-old woman is recently diagnosed with small cell carcinoma of the lung.
Which of the following non-metastatic manifestations is she most likely to develop?
Correct : B. Eaton-Lambert syndrome
89. In which of the following cases of lung cancer would surgical resection of the tumor be a reasonable therapeutic option?
Correct : E. A 71-year-old man with a 3 cm tumor obstructing the right lower lobe bronchus. PFTs show an FEV1 of 1.98 L. (43% predicted).
90. 26- A 60-year-old man was diagnosed last year with adenocarcinoma of the lung, and a 4 cm mass lesion was treated with a right lower lobectomy. He now has an abdominal CT scan that reveals scattered hepatic mass lesions and hilar lymphadenopathy. For several weeks, he has had increasing malaise. A urinalysis reveals marked proteinuria, and a 24 hour urine protein collection is 2.7 g/24hr. His serum urea is 30 mmol/L (2.5 - 7.5) with creatinine of 450 µmol/L (60 - 110). A renal biopsy is performed, and there is focal deposition of IgG and C3 with a granular pattern. He is most likely to have which of the following conditions?
Correct : B. Membranous glomerulonephritis
91. A 56-year-old man from Thailand presented with abdominal pain and a mass in the
right upper quadrant. He reported that he had been diagnosed with viral hepatitis several years previously. Investigations showed: Serum alpha-fetoprotein 13,500 IU/L (< 10) What is the most likely underlying viral infection?
Correct : B. Hepatitis B virus
92. A 64-year-old man has terminal cancer with hepatic metastases. He is treated with
oral morphine (Oramorph) solution for pain relief.Which is the most important pharmacodynamic factor in determining the appropriate timing between doses?
Correct : B. first pass metabolism
93. A 51-year-old woman has had several syncopal episodes over the past year. Each
episode is characterized by sudden but brief loss of consciousness. She has no chest pain. She has no ankle edema. On brain MRI there is a 1.5 cm cystic area in the left parietal cortex. A chest X-ray shows no cardiac enlargement, and her lung fields are normal. Her serum total cholesterol is 6.5 mmol/L. Which of the following cardiac lesions is she most likely to have?
Correct : C. Left atrial myxoma
94. Which of the following statements regarding prognosis in lung cancer is true?
Correct : B. Overall lung cancer survival is < 15% at 5 years.
95. A 45-year-old man develops facial swelling and breathlessness. His chest X-ray reveals paratracheal lymphadenopathy. Which of the following statements is most accurate regarding the superior vena caval obstruction?
Correct : C. it may be associated with voice hoarseness
96. A 52-year-old woman presented with hot flushes. Her last menstrual period had been 1 year previously. She was treated with ethinylestradiol and medroxyprogesterone acetate.
Which potential consequence of oestrogen therapy is most reduced by co-prescription of a progestogen?
Correct : C. endometrial cancer
97. A 44 years old female with breast lump of one year duration, slowly progressed, examination revealed right inner lower quadrant mass with normal both axillae, biopsy revealed a benign nature with average risk to develop cancer, this pathology is mostly
Correct : B. Fibrocystic disease
98. Which of the following is associated with a GH secreting pituitary tumor
Correct : A. Gs alpha subunit mutation
99. 33- Which ONE of the following statements regarding colon cancer is correct:
Correct : E. In familial polyposis coli the increased cancer risk is due to inheritance of a mutated suppressor gene
100. The following are recognized features of Pancoast's tumor except:
Correct : E. weakness of abduction at the shoulder