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?

Related MCQs

• 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
• 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?
• 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?
• 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?
• 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?
• 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?
• 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
• 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?
• 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
• 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?