McqMate
These multiple-choice questions (MCQs) are designed to enhance your knowledge and understanding in the following areas: Uncategorized topics .
| 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: |
| A. | Maltoma |
| B. | Reactive lymphoid proliferation |
| C. | High grade B cell lymphom |
| D. | Enteropathic-associated T cell lymphoma |
| E. | Anaplastic large cell lymphoma |
| Answer» 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 |
| A. | Hodgkins disease mixed cellularity |
| B. | T-cell lymphoma |
| C. | Anaplastic large cell lymphoma |
| D. | Maltoma |
| E. | Reactive lymphoid proliferation |
| Answer» 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 |
| A. | Hodgkin's lymphoma, mixed cellularity |
| B. | Hodgkin's lymphoma, classical type |
| C. | Anaplastic large cell lymphoma |
| D. | Maltoma |
| E. | Reactive lymphoid proliferation |
| Answer» 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. |
| A. | Gastric DLBCL |
| B. | Anaplastic large cell lymphoma |
| C. | Maltoma |
| D. | Reactive lymphoid proliferation |
| E. | T-cell lymphoma. |
| Answer» 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):
|
| A. | imipenem toxicity |
| B. | intravenous contrast toxicity |
| C. | kidney infiltration |
| D. | septic shock |
| E. | tumor lysis syndrome |
| Answer» 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? |
| A. | Bone marrow aspiration and biopsy |
| B. | Factor VIII level |
| C. | Measurement of platelet-associated IgG |
| D. | Measurements of fibrin D-dimer and total fibrinogen |
| E. | Bleeding time |
| Answer» 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? |
| A. | Relapsed Hodgkin‟s disease |
| B. | Sepsis |
| C. | Hypothyroidism |
| D. | Secondary myelodysplastic syndrome |
| E. | Drug-induced bone marrow suppression |
| Answer» 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? |
| A. | Cytomegalovirus disease |
| B. | Alloimmunization |
| C. | Transfusion-related graft-versus-host disease |
| D. | Febrile nonhemolytic transfusion reaction |
| E. | Hemolytic transfusion reaction |
| Answer» 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
|
| A. | Autoimmune hemolytic anemia |
| B. | Aplastic anemia |
| C. | Myelodysplastic syndrome |
| D. | Paroxysmal nocturnal hemoglobinuria |
| E. | Acute myeloid leukemia |
| Answer» 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? |
| A. | A 2-week course of oral antibiotics |
| B. | Referral for salvage chemotherapy and autologous stem cell transplantation |
| C. | A repeat physical examination and CT scans in 3 months |
| D. | Referral for treatment with investigational agents |
| E. | A repeat course of CHOP |
| Answer» 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 |
| A. | Chronic myeloid leukemia |
| B. | Hairy cell leukemia |
| C. | Myelodysplastic syndrome |
| D. | Disseminated tuberculosis |
| E. | Myelofibrosis |
| Answer» 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? |
| A. | Recurrent Hodgkins disease |
| B. | Myocardial infarction |
| C. | Pulmonary fibrosis |
| D. | Anemia associated with secondary myelodysplasia evolving to acute leukemia |
| E. | Constrictive pericarditis |
| Answer» 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? |
| A. | Combination chemotherapy with 5-fluorouracil, doxorubicin, and mitomycin C (FAM) |
| B. | Combination chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) |
| C. | Four cycles of CHOP followed by involved-field radiation therapy |
| D. | Eradication of Helicobacter pylori |
| E. | Total gastrectomy followed by radiation therapy |
| Answer» 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? |
| A. | Multiple myeloma |
| B. | Chronic pyelonephritis |
| C. | Iron deficiency anemia |
| D. | Colon cancer |
| E. | Small-cell lung cancer |
| Answer» A. Multiple myeloma | |
| 15. |
Regarding lymphomas, all are true except: |
| A. | Mesenteric nodes are involved in HL more than in NHL |
| B. | Nodal extension is contiguous in HL |
| C. | Extranodal disease is common in NHL |
| D. | Testicular lymphoma is the most common testicular tumor in people aged over 60 years |
| E. | Bone marrow is common extranodal site for lymphomatous involvement |
| Answer» A. Mesenteric nodes are involved in HL more than in NHL | |
| 16. |
B cell CLL |
| A. | thrombocytopenia often autoimmune |
| B. | reduced immunoglobulins are a risk for recurrent bacterial infections |
| C. | Stage A disease should be treated with chemotherapy |
| D. | late transformation to ALL occur in the majority of patients |
| E. | diffuse infiltration of bone marrow indicates good prognosis |
| Answer» B. reduced immunoglobulins are a risk for recurrent bacterial infections | |
| 17. |
Which one of the following statements is true of B cell CLL? |
| A. | Autoimmune thrombocytopenia is uncommon |
| B. | Reduced immunoglobulins a risk of recurrent viral infections |
| C. | Stage A disease should be treated with chemotherapy |
| D. | Late transformation to ALL occur in the majority of patients |
| E. | Diffuse infiltration of bone marrow indicates good prognosis |
| Answer» A. Autoimmune thrombocytopenia is uncommon | |
| 18. |
Which of the following associations is correct? |
| A. | Renal transplantation and Non-Hodgkin's lymphoma |
| B. | Hepatitis B and aplastic anaemia |
| C. | Turner's syndrome and acute myeloid leukaemia |
| D. | Basophilia and chronic myeloid leukaemia |
| E. | Crohn's disease and TB |
| Answer» B. Hepatitis B and aplastic anaemia | |
| 19. |
Which of the following statements regarding lymphomas in childhood is correct? |
| A. | Hodgkin's disease is more common than non-Hodgkin's under the age of 5 years. |
| B. | Hodgkin's disease has equal sex incidence. |
| C. | Lymphocyte-predominant Hodgkin's disease has the worse prognosis. |
| D. | The nodular sclerosing variety is the most common form of Hodgkin's disease. |
| E. | The most common presenting clinical sign is splenomegaly. |
| Answer» D. The nodular sclerosing variety is the most common form of Hodgkin's disease. | |
| 20. |
Malignant melanoma:- |
| A. | is the commonest form of skin cancer |
| B. | is always related to acute sun exposure |
| C. | always arises in a pre-existing pigmented naevus |
| D. | is common in the pre-pubertal age group |
| E. | typically shows metastases to regional lymph nodes |
| Answer» 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? |
| A. | It is not related to the original cancer or its treatment |
| B. | It is related to the radiation therapy given to control the breast cancer |
| C. | It is related to the tamoxifen given to control the breast cancer |
| D. | It is related to the primary estrogen receptor-positive breast cancer |
| Answer» 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? |
| A. | Radiation therapy |
| B. | Chemotherapy |
| C. | CT-directed liver biopsy |
| D. | Serum carcinoembryonic antigen test |
| E. | Surgery |
| Answer» 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? |
| A. | Avoidance of alcohol abuse |
| B. | Daily intake of antioxidant vitamins |
| C. | Avoidance of exposure to benzene |
| D. | Daily intake of β-carotene |
| Answer» 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? |
| A. | Refer the patient for exploratory laparotomy, biopsy, and biliary bypass |
| B. | Request a CT-guided biopsy of the mass in the head of the pancreas to establish a diagnosis |
| C. | Obtain a consultation for endoscopic retrograde cholangiopancreatography and possible biopsy and biliary stent placement |
| D. | Refer the patient to a tertiary-care center with surgical expertise in the management of patients with pancreatic and hepatobiliary disease |
| Answer» 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? |
| A. | Fecal occult blood testing every 2 years for colorectal cancer |
| B. | Human papillomavirus DNA test for cervical cancer every year |
| C. | Pap smear of the cervix every year in sexually active women for uterine cancer |
| D. | Chest radiography every year in cigarette smokers for lung cancer |
| Answer» 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? |
| A. | Breast cancer is the most likely diagnosis, and optimal therapy for breast cancer paradigm should be initiated. |
| B. | Lung cancer is the most likely diagnosis, and optimal therapy for lung cancer paradigm should be initiated. |
| C. | All known disease has been resected, and the patient requires careful monitoring for possible future recurrence. |
| D. | Radiation therapy to the right axilla is required with fields encompassing the right breast. |
| Answer» 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? |
| A. | barium enema now |
| B. | colonoscopy in 3 years |
| C. | colonoscopy in 5 years |
| D. | colonoscopy now |
| E. | sigmoidoscopy in 1 year |
| Answer» 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? |
| A. | Breast ultrasound; consultation with a surgeon experienced in breast diagnosis |
| B. | Reassurance that because her family history is negative and the mammogram is negative, no additional studies or treatment is required |
| C. | MRI of the breast |
| D. | Measurement of circulating tumor markers, including CA15-3 and carcinoembryonic antigen A 68-year-old woman is |
| Answer» 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 |
| A. | Continue the current antibiotic regimen |
| B. | Add vancomycin |
| C. | Switch to oral ciprofloxacin and amoxicillin-clavulanic acid |
| D. | Add granulocyte colony-stimulating factor |
| E. | Remove the central venous port |
| Answer» 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? |
| A. | Chemotherapy with docetaxel |
| B. | Chemotherapy with mitoxantrone and prednisone |
| C. | Androgen ablation (medical or surgical) |
| D. | Radiation therapy with strontium-89 |
| Answer» 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? |
| A. | No chemotherapy or radiation therapy; annual flexible sigmoidoscopy |
| B. | Postoperative adjuvant chemotherapy and pelvic radiation therapy |
| C. | Postoperative pelvic radiation therapy |
| D. | Complete colonoscopy within the first year, repeated every 3 to 5 years |
| Answer» 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? |
| A. | Continue hormone replacement therapy alone for primary prevention of heart disease |
| B. | Continue hormone replacement therapy and add tamoxifen |
| C. | Discontinue hormone replacement therapy and start tamoxifen |
| D. | Change her hormone replacement therapy to estrogen alone and add tamoxifen |
| Answer» 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? |
| A. | Gallium scan |
| B. | Re-evaluation if the symptoms get worse |
| C. | CT scan of the chest and abdomen with bone windows of the spine |
| D. | MRI of the spine |
| E. | Intravenous dexamethasone and MRI of the spine |
| Answer» 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? |
| A. | Complete colonoscopy |
| B. | Upper gastrointestinal series with small-bowel follow-through |
| C. | Positron emission tomography scan of the abdomen |
| D. | Measurement of serum carcinoembryonic antigen |
| E. | CT scan of the abdomen with oral and intravenous contrast |
| Answer» 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? |
| A. | Annual transvaginal ultrasound |
| B. | Annual transabdominal pelvic ultrasound |
| C. | Annual endometrial aspiration sampling |
| D. | Biennial dilatation and curettage |
| E. | Annual routine bimanual pelvic examination |
| Answer» 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? |
| A. | Bronchoalveolar cell carcinoma |
| B. | Small-cell lung cancer |
| C. | Large-cell carcinoma |
| D. | Squamous cell carcinoma |
| E. | Carcinoid tumor |
| Answer» 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? |
| A. | Positron emission tomography now and annually |
| B. | No further management |
| C. | Routine tumor marker evaluation every 3 to 4 months (serum CAl 5-3, carcinoembryonic antigen) |
| D. | Bone scan and annual CT of the chest, abdomen, and pelvis |
| E. | Estrogen replacement therapy |
| Answer» 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 |
| A. | Metastatectomy |
| B. | Hepatic arterial infusion |
| C. | Second-line chemotherapy regimen with leucovorin and oxaliplatin |
| D. | High-dose chemotherapy with autologous peripheral stem cell transplantation |
| Answer» 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? |
| A. | Chest wall radiation therapy and tamoxifen for 5 years |
| B. | Chest wall radiation therapy and anastrozole for 5 years |
| C. | Tamoxifen for 5 years |
| D. | Tamoxifen and anastrozole for 5 years |
| Answer» 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? |
| A. | A solitary liver metastasis with normal serum bilirubin level |
| B. | Multiple liver metastases with a serum bilirubin level of 3.0 mg/dL |
| C. | A cytologically positive pleural effusion |
| D. | Hypercalcemia |
| E. | Poor performance status |
| Answer» 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? |
| A. | Daily dietary supplementation with the antioxidantl3-carotene |
| B. | Daily isotretinoin, titrated to limit skin toxicity |
| C. | Daily bupropion |
| D. | An annual low-dose spiral CT scan of the chest |
| E. | Sputum cytology every4 months |
| Answer» 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? |
| A. | Fluid restriction to 1 L/d |
| B. | Fluid restriction to 1 L/d and demeclocycline therapy |
| C. | Discontinuation of hydrochiorothiazide |
| D. | Combination chemotherapy for the small-cell lung cancer |
| Answer» 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? |
| A. | Retroperitoneal lymph node dissection |
| B. | Combination chemotherapy with bleomycin, etoposide, and cisplatin |
| C. | Radiation to the pelvis |
| D. | Inguinal orchiectomy |
| Answer» 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? |
| A. | Blood test for CA-125 |
| B. | Rectovaginal pelvic examination in 1 year |
| C. | Transvaginal ultrasound |
| D. | Screening test for BRCA-1 and BRCA-2 |
| Answer» 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? |
| A. | A selective serotonin reuptake inhibitor and use of nonhormonal vaginal lubricating preparations |
| B. | Reassurance that these normal physiologic responses to menopause will resolve in time |
| C. | Estrogen replacement therapy with a progesterone supplement |
| D. | Work-up for endometrial cancer because she is taking tamoxifen |
| Answer» 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? |
| A. | There is no evidence that PSA screening leads to the earlier detection of prostate cancer |
| B. | There is insufficient evidence to establish whether PSA screening affects overall mortality rates |
| C. | On the basis of his lack of symptoms it is unlikely that he has an elevated PSA |
| D. | Because a digital rectal examination is more sensitive than a serum PSA test, his normal examination makes it unlikely that he has cancer |
| Answer» 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? |
| A. | Prophylactic cranial irradiation |
| B. | Four more cycles of chemotherapy, including a taxane |
| C. | Resection of the localized disease |
| D. | No further therapy; follow-up only |
| Answer» 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 |
| A. | Resection of the primary tumor followed by systemic chemotherapy |
| B. | Combined regional chemotherapy to the liver and systemic chemotherapy |
| C. | Exploratory laparotomy with resection of the primary tumor and placement of a hepatic arterial infusion pump |
| D. | Systemic chemotherapy |
| E. | Best supportive care |
| Answer» 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? |
| A. | He was initially treated by radical prostatectomy. |
| B. | His PSA level became undetectable. |
| C. | He has had a slow, prolonged rise in his PSA. |
| D. | He is almost 70 years old. |
| Answer» 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? |
| A. | Four cycles of combination chemotherapy including a taxane |
| B. | Four cycles of combination chemotherapy including a taxane, followed by radiation therapy to the draining lymph node sites in the mediastinum |
| C. | Radiation therapy to the draining lymph node sites in the mediastinum |
| D. | Six cycles of combination chemotherapy including a platinum agent |
| E. | No radiation therapy or chemotherapy is required at this time |
| Answer» E. No radiation therapy or chemotherapy is required at this time | |
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