ONCOLOGY Flashcards
(152 cards)
1
Q
A 50/M was being treated for Lung CA. After initial chemotherapy, his tumor shrunk by 10% (computed from the sum of all perpendicular diameters) and further investigation did not reveal any new lesions. How is the patient’s response classified? (HPIM 20th ed. C65 P440)
a. Complete
b. Partial
c. Progressive
d. Stable
A
The correct answer is: Stable
2
Q
A 50/M, smoker, consulted due to a pulmonary mass on chest x-ray. Subsequent CT showed a 4x3 cm mass on the left upper lobe with enlarged lymph nodes on the ipsilateral and contralateral hilar lymph nodes. What is the most appropriate treatment for the patient? (HPIM 20th ed. C74 P546)
a. Surgery
b. Chemoradiation
c. Systemic chemotherapy
d. Palliation
A
The correct answer is: Chemoradiation
3
Q
What is the staging for a patient who was noted to have a colonic mass and after resection was noted to have an adenocarcinoma that reached the muscularis layer but with no note of nodal nor distant metastasis? (HPIM 20th ed. C77 P576 F77-3)
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
A
The correct answer is: Stage II
4
Q
A 60/F known melanoma patient consulted for progressive difficulty of breathing for the past week. This was associated dry cough and no note of sputum production, fever or weight loss. She had undergone chemotherapy for melanoma. Chest CT scan showed changes consistent with pulmonary fibrosis. What is the most likely offending agent in this patient? (HPIM 20th ed. C91 P675 T91-1)
a. Methotrexate
b. Vincristine
c. Cytarabine
d. Bleomycin
A
The correct answer is: Bleomycin
5
Q
A 45/F presented in the ER with confusion. She was noted to have increased sleeping time over the past week. PE revealed decreased breath sounds with increased fremiti. Initial tests showed hyponatremia and a lung mass. Without the benefit of a biopsy, what is the most likely histopathology of the lung mass? (HPIM 20th ed. C89 P664)
a. Squamous cell carcinoma
b. Small cell carcinoma
c. Adenocarcinoma
d. Lymphoma
A
The correct answer is: Small cell carcinoma
6
Q
A 36/F breast cancer patient who completed adjuvant chemotherapy last month, was admitted at the ER for dyspnea. On PE, facial edema and swelling of the right upper extremity were noted. She was placed her on oxygen support and diuretics. What is the next course of action? (HPIM 20th ed. C71 P511)
a. Administer intravenous steroid
b. Emergency referral to medical oncology for systemic chemotherapy
c. Emergency referral to radiation oncology
d. Referral to hospice and continue best supportive care
A
The correct answer is: Emergency referral to radiation oncology
7
Q
What is the best time to perform breast examination during menstrual cycle? (HPIM 20, C75, p557)
a. Day 1-3
b. Day 3-5
c. Day 5-7
d. Day 7-9
A
The correct answer is: Day 5-7
8
Q
Which of the following is not recommended for DCIS? (HPIM 20, C75, p558)
a. Breast preserving surgery is recommended if localized and with clear margins
b. Breast preserving surgery is followed by breast irradiation
c. Tamoxifen or anastrozole may be given
d. Axillary lymph node dissection is necessary
A
The correct answer is: Axillary lymph node dissection is necessary
9
Q
A patient with recurrent massive pleural effusion but with no apparent lung mass underwent thoracentesis and yielded a cell block that is negative for malignant cells. Which of the following is warranted if a malignant pleural effusion is highly suspected in this case?
a. Repeat thoracentesis
b. Transbronchial biopsy
c. Sputum cytology
d. Pleural biopsy
A
The correct answer is: Repeat thoracentesis
10
Q
In addition to whole body PET CT Scan, which of the following imaging modalities is recommended for the staging of all patients diagnosed with SCLC?
a. bone scan
b. thyroid scan
c. MRI of the brain
d. PET CT Scan alone is adequate for complete work-up
A
The correct answer is: MRI of the brain
11
Q
A 55 year old female diagnosed with SCLC was noted to have involvement of the contralateral supraclavicular nodes and superior vena caval obstruction. Which of the following is the recommended treatment plan in this case?
a. platinum-based chemotherapy with curative intent and prophylactic cranial irradiation
b. platinum-based chemotherapy with and cranial irradiation for palliation purposes
c. platinum-based chemotherapy alone with curative intent
d. cranial irradiation alone for palliation purposes
A
The correct answer is: platinum-based chemotherapy with curative intent and prophylactic cranial irradiation
12
Q
A 55 year old asymptomatic female undergoing colonoscopy was noted to have 5 adenomatous polyps. Given that all the polyps were excised with clean margins, when is the earliest time she should have her repeat coloscopy?
a. 1 year
b. 3 years
c. 5 years
d. 10 years
A
The correct answer is: 3 years
13
Q
Among patients with gastric adenocarcinoma which of the following determines prognosis following complete surgical resection?
a. degree of tumor penetration
b. tumor vascularity
c. H pylori status
d. tumor size
A
The correct answer is: degree of tumor penetration
14
Q
Among colon cancer patients, which of the following is the utility of preoperative CEA determination?
a. positive CEA determination confirms gastric lymphoma
b. high preoperative CEA value is predictive of tumor recurrence
c. low preoperative CEA value is a marker for less tumor invasion
d. negative CEA determination effectively rules out distant metastases
A
The correct answer is: high preoperative CEA value is predictive of tumor recurrence
15
Q
A lung cancer patient was diagnosed with and managed as febrile neutropenia 3 weeks post chemotherapy. One week after initiation of oral antibiotics, there was note of fever resolution. There were no other signs of infection at this time but his absolute neutrophil count remains to be 250/uL. Which of the following should be your next step in his antibiotic regimen?
a. Antibiotic regimen maybe discontinued at this time since there are no overt signs of infection.
b. Antibiotic regimen should be continued until ANC > 500/uL.
c. Antibiotic regimen should be shifted to intravenous.
d. A broad spectrum antifungal regimen should be added to current regimen.
A
The correct answer is: Antibiotic regimen should be continued until ANC > 500/uL.
16
Q
Which of the following clinical picture can be explained by a carcinoma with excessive production of IGF-II precursors?
a. hypoglycemia develops in association with fasting
b. migratory or recurrent thrombophlebitis
c. marked skin fragility and easy bruising
d. poor wound healing and predisposition to infections
A
The correct answer is: hypoglycemia develops in association with fasting
17
Q
Which of the following is the primary neoplastic-initiating event for the most lethal malignancy in women?
a. Familial hereditary germline mutation in BRCA1 and 2 genes
b. Acquired germ
c. Infection with high-risk strains of HPV
d. Chronic polyposis
A
The correct answer is: Infection with high-risk strains of HPV
18
Q
For cervical cancer, which of the following is the recommended population to receive vaccination as a form of primary prevention?
a. Postmenopausal women
b. High risk population at any age
c. Women with identified dysplasia at screening
d. Girls aged 11–13 years before the initiation of sexual activity
A
The correct answer is: Girls aged 11–13 years before the initiation of sexual activity
19
Q
A 35 year old female was diagnosed to have a complete molar pregnancy with widely metastatic non-pulmonary disease and very elevated hCG. Which of the following is role of chemotherapy in this patient?
a. Curative
b. Palliative
c. Debulking
d. Neoadjuvant
A
The correct answer is: Curative
20
Q
Which of the following characterizes the Pel Ebstein fever that maybe seen in Hodgkin Lymphoma?
a. Bouts of fever occurs daily (24-hour periodicity) for few hours
b. Fever occurs after an interval of two days (48-hour periodicity)
c. Fever persist for days to weeks, followed by afebrile intervals and then recurrence of the fever
d. Temperature remains above normal throughout the day with variation in temperature of more than 1°C in 24 hours
A
The correct answer is: Fever persist for days to weeks, followed by afebrile intervals and then recurrence of the fever
21
Q
Adult T Cell Leukemia/Lymphoma is most commonly associated with which of the following infectious agents?
a. EBV
b. HIV
c. HTLV-1
d. Hepatitis
A
The correct answer is: HTLV-1
22
Q
Which of the following are the two most common symptoms of carcinoid syndrome?
a. Impaired cognitive function and pellagra-like skin lesions
b. Tricuspid insufficiency and pulmonary stenosis
c. Asthma like symptoms and abdominal pain
d. Diarrhea and flushing
A
The correct answer is: Diarrhea and flushing
23
Q
On histopathologic examination of resected sample from a patient diagnosed with colon cancer, tumor involvement was through the muscularis level with no nodal involvement. What is the expected 5 year survival rate of this patient?
a. 86 – 95%
b. 70–85%
c. 50–69%
d. 25–49%
A
The correct answer is: 70–85%
24
Q
A 35 year old female had an incidental finding of a 3cm hepatic nodule on ultrasound. Which of the following should be the next step in her work-up?
a. Repeat ultrasound at 4 months
b. 4-phase CT Scan
c. T2* MRI
d. Biopsy
A
The correct answer is: 4-phase CT Scan
25
A 50 year old asymptomatic male had a pulmonary nodule on chest x-ray. The nodule is described as solitary, 3cm in diameter with well circumscribed smooth edges and a dense central nidus. These findings have been unchanged from x-rays done 3 years ago. What should be the next step in his work-up?
a. No further work-up needed at this time
b. Chest ultrasound
c. Chest CT Scan plain and with IV contrast
d. Tissue biopsy of the nodule
The correct answer is: No further work-up needed at this time
26
Which of the following non-small cell carcinoma histologic subtype of lung cancer is the most associated with heavy tobacco smoking?
a. Adenocarcinoma
b. Large-cell Carcinoma
c. Micropapillary Carcinoma
d. Squamous Cell Carcinoma
The correct answer is: Squamous Cell Carcinoma
27
A patient diagnosed with squamous cell lung cancer was brought to the ER due to vomiting, abdominal pain, constipation, polyuria and changes in sensorium. He had an unremarkable physical examination. Which of the following laboratory findings is most consistent with this paraneoplastic syndrome?
a. High Antidiuretic hormone
b. High Parathyroid hormone
c. Low Cortisol
d. Low ACTH
The correct answer is: High Parathyroid hormone
28
Which of the following diet types has been associated with an increased risk for colonic cancer?
a. High animal fat and high caloric content diet
b. Low fiber and high caloric content diet
c. High animal fat and low fiber diet
d. Low animal fat and low fiber diet
The correct answer is: High animal fat and high caloric content diet
29
Which of the following is the most effective class of chemopreventive agent for colon cancer?
a. Progesterone
b. Tocopherol
c. Vitamin D
d. Aspirin
The correct answer is: Aspirin
30
According to the American Cancer Society guidelines, how often should asymptomatic low risk individuals undergo an FOBT as form of screening for colorectal cancer?
a. once upon reaching age 60 then every 3 years if negative
b. quarterly until age 65 then yearly thereafter
c. FOBT has no role in colorectal screening
d. once a year starting at age 50
The correct answer is: once a year starting at age 50
31
Among patients with gastric adenocarcinoma which of the following determines prognosis following complete surgical resection?
a. degree of tumor penetration
b. tumor vascularity
c. H pylori status
d. tumor size
The correct answer is: degree of tumor penetration
32
A diffuse large B cell lymphoma patient came back for follow-up 2 weeks post chemotherapy. He is currently asymptomatic and afebrile but with an absolute neutrophil count of 110/uL. Which of the following should you advise the patient regarding antibiotic use?
a. No need for any antibiotics at this time as this is an expected event and patient should just be monitored.
b. No need for any antibiotics at this time but ideally he should be given Intravenous Immunoglobulin to reduce chances of infection.
c. Oral broad-spectrum prophylactic antibiotic should be initiated.
d. Intravenous broad-spectrum prophylactic antibiotic should be initiated.
The correct answer is: Oral broad-spectrum prophylactic antibiotic should be initiated.
33
A lung cancer patient was diagnosed with and managed as febrile neutropenia 3 weeks post chemotherapy. One week after initiation of oral antibiotics, there was note of fever resolution. There were no other signs of infection at this time but his absolute neutrophil count remains to be 250/uL. Which of the following should be your next step in his antibiotic regimen?
a. Antibiotic regimen maybe discontinued at this time since there are no overt signs of infection.
b. Antibiotic regimen should be continued until ANC > 500/uL.
c. Antibiotic regimen should be shifted to intravenous.
d. A broad spectrum antifungal regimen should be added to current regimen.
The correct answer is: Antibiotic regimen should be continued until ANC > 500/uL.
34
Which of the following dietary regimen is recommended among cancer patients ongoing chemotherapy to prevent infection?
a. Strict disinfection and sterilization of all food products should be observed
b. Increase raw fruits and vegetables in diet should be advised but vigorous washing of food products should be done prior to consumption
c. Avoid leftovers, deli foods, undercooked meat, and unpasteurized dairy products
d. Avoid canned or preserved food
The correct answer is: Avoid leftovers, deli foods, undercooked meat, and unpasteurized dairy products
35
The patient diagnosed with small cell lung cancer was diagnosed with SIADH. Which of the following should be your next step in management?
a. Discontinuation of chemotherapy
b. Start salt tablets and saline hydration
c. Start Demeclocycline or Tolvaptan
d. Fluid restriction
The correct answer is: Fluid restriction
36
Which of the following is a known risk factor for ovarian cancer?
a. multiparity
b. tubal ligation
c. aspirin use
d. obesity
The correct answer is: obesity
37
According to the American Cancer Society Guidelines, which of the following is the recommended cervical cancer screening for a 28 year old sexually active female?
a. Papsmear and HPV testing every 3 years
b. Papsmear screening every 3 years; HPV testing not recommended
c. Papsmear alone every 3 years or Papsmear and HPV testing every 5 years
d. No screening following adequate negative prior screening
The correct answer is: Papsmear screening every 3 years; HPV testing not recommended
38
For cervical cancer, which of the following is the recommended population to receive vaccination as a form of primary prevention?
a. Postmenopausal women
b. High risk population at any age
c. Women with identified dysplasia at screening
d. Girls aged 11–13 years before the initiation of sexual activity
The correct answer is: Girls aged 11–13 years before the initiation of sexual activity
39
Which of the following describes the clinical syndrome associated glucagonoma ?
a. acromegaly, weight gain, and muscle weakness
b. large-volume diarrhea, hypokalemia, and dehydration
c. dermatitis, glucose intolerance or diabetes, and weight loss
d. diabetes mellitus, gallbladder disease, diarrhea, and steatorrhea
The correct answer is: dermatitis, glucose intolerance or diabetes, and weight loss
40
A patient with chronic low back pain was noted to have anemia, lytic bone lesions, hypercalcemia, azotemia, serum M spike, and marrow plasmacytosis on work-up. Which of the following is the single most powerful predictor of survival for this disease?
a. Serum β2 –macroglobulin
b. Staging at time of diagnosis
c. Percentage of marrow plasmacytosis
d. Degree of hypercalcemia on diagnosis
The correct answer is: Serum β2 –macroglobulin
41
A patient diagnosed with Hodgkin lymphoma undergoing chemotherapy was noted to have new onset easy fatigability and exercise intolerance. On work-up lungs were noted to have architectural distortion, fibrosis and bronchiectasis. Which of the following is the most likely cause?
a. Anthracycline
b. Bleomycin
c. Cyclophosphamide
d. Steroids
The correct answer is: Bleomycin
42
A 55 year old chronic hepatitis B patient was noted to have a 5cm liver mass on contrast-enhanced CT Scan. Which of the following findings would point to a diagnosis of hepatocellular carcinoma?
a. vascular uptake in the arterial phase with washout in the portal venous phases
b. uneven calcification with a dense central nidus and pooling occurring in the arterial phase
c. homogenous solid mass with increased uptake in the delayed phase
d. masses >5cm would need biopsy confirmation regardless of CT Scan finding
The correct answer is: vascular uptake in the arterial phase with washout in the portal venous phases
43
A 22/M came in due to a lateral neck mass measured at 4cm in its widest diameter. Axillary LAD was noted bilaterally. The rest of PE was unremarkable. Initial CBC, serum chemistry and LDH were normal. Biopsy of the LN revealed Hodgkin’s lymphoma, nodular sclerosis subtype. CT scan showed mediastinal lymphadenopathy and the previously mentioned LADs. No infradiaphragmatic disease is observed. What is the most appropriate initial management for this patient?
a. Bone marrow biopsy
b. Chemotherapy
c. Radiation therapy
d. Staging laparotomy and splenectomy
The correct answer is: Chemotherapy
44
A 68/M underwent radical prostatectomy 2 years ago with regular serial PSA monitoring. Histopath showed localized prostatic disease (Gleason score 7), no nodal involvement and no distant metastases. All PSA levels were normal until 3 months ago which showed elevation > 15 ng/mL and less than 10 months doubling time. Imaging did not reveal active disease. What can you recommend thee patient?
a. Refer back to urology for salvage surgery
b. Refer to radiation oncology for radiotherapy
c. Refer to medical oncology for systemic cytotoxic chemotherapy
d. Start alpha-adrenergic receptor antagonist and phosphodiesterase-5
The correct answer is: Refer to radiation oncology for radiotherapy
45
The following are important risk factors in the development of melanomas, EXCEPT:
a. Presence of >30 melanocytic nevi
b. Giant melanocytic nevus (defined as having a size of >20 cm)
c. Family history of melanoma
d. All are strong risk factors
The correct answer is: Presence of >30 melanocytic nevi
46
Which of the following is not recommended for DCIS?
a. Breast preserving surgery is recommended if localized and with clear margins
b. Breast preserving surgery is followed by breast irradiation
c. Tamoxifen or anastrozole may be given
d. Axillary lymph node dissection is necessary
The correct answer is: Axillary lymph node dissection is necessary
47
70/M came in to your clinic due to 6-month history of urinary, frequency, urgency, weak stream, and sensation of incomplete voiding. He also complains of difficulty in ejaculating. He denied fever, urethral discharge, hypogastric or low back pain. You decided to perform a digital rectal exam (DRE). Which among the following is TRUE regarding DRE?
a. DRE is recommended as a screening for prostate cancer for men 55-69 years old
b. DRE significantly increases PSA level
c. Induration of the prostate on DRE is highly specific for cancer
d. Most prostate cancers occur in the peripheral zone and may be palpated during DRE
The correct answer is: Most prostate cancers occur in the peripheral zone and may be palpated during DRE
48
Which of the following is TRUE of paraneoplastic syndromes?
a. Endocrine paraneoplastic syndromes occur due to the cancer’s mass effect or invasion of endocrine glands resulting to excessive eutopic secretion of hormones.
b. Oncogenic osteomalacia is characterized by hyperphosphatemia and renal potassium wasting induced by phosphatonin commonly seen in mesenchymal tumors.
c. Paraneoplastic neurologic disorders are mediated by immune responses triggered by neuronal proteins expressed by tumors.
d. Paraneoplastic hematologic syndromes of solid tumors cause elevation of granulocyte, platelet and eosinophils due to the concurrent undiagnosed myeloproliferative disorders.
The correct answer is: Paraneoplastic neurologic disorders are mediated by immune responses triggered by neuronal proteins expressed by tumors.
49
A 50 year old asymptomatic male had a pulmonary nodule on chest x-ray. The nodule is described as solitary, 3cm in diameter with well circumscribed smooth edges and a dense central nidus. These findings have been unchanged from x-rays done 3 years ago. What should be the next step in his work-up?
a. No further work-up needed at this time
b. Chest ultrasound
c. Chest CT Scan plain and with IV contrast
d. Tissue biopsy of the nodule
The approach to a patient with a solitary pulmonary nodule is based on an estimate of the probability of cancer.
At present, only two radiographic criteria are thought to predict the benign nature of a solitary pulmonary nodule:
• lack of growth over a period >2 years
• certain characteristic patterns of calcification
Calcification patterns highly suggestive of a benign lesion:
• a dense central nidus
• multiple punctuate foci
• “bulls eye” (granuloma)
• “popcorn ball” (hamartoma)
The correct answer is: No further work-up needed at this time
50
Which of the following non-small cell carcinoma histologic subtype of lung cancer is the most associated with heavy tobacco smoking?
a. Adenocarcinoma
b. Large-cell Carcinoma
c. Micropapillary Carcinoma
d. Squamous Cell Carcinoma
WHO classification of epithelial lung cancers:
• small-cell lung carcinoma (SCLC)
• non-small-cell carcinoma (NSCLC)
o adenocarcinoma
o squamous cell carcinoma
o large-cell carcinoma
• squamous and small-cell carcinomas are most commonly associated with heavy tobacco use
With the decline in cigarette consumption adenocarcinoma has become the most frequent histologic subtype of lung cancer (in the United States at least)
In lifetime never smokers or former light smokers (<10 pack year smokers), women, and younger adults (<60 years) adenocarcinoma tends to be the most common form of lung cancer
The correct answer is: Squamous Cell Carcinoma
51
A patient with recurrent massive pleural effusion but with no apparent lung mass underwent thoracentesis and yielded a cell block that is negative for malignant cells. Which of the following is warranted if a malignant pleural effusion is highly suspected in this case?
a. Repeat thoracentesis
b. Transbronchial biopsy
c. Sputum cytology
d. Pleural biopsy
Tissue sampling is required to confirm a diagnosis in all patients with suspected lung cancer
Factors that affect biopsy diagnostic yield include:
• location (accessibility) of the tumor
• tumor size
• tumor type
• technical aspects of the diagnostic procedure
This becomes trickier when there is no apparent tumor where a tissue biopsy maybe taken.
Sputum cytology is inexpensive and noninvasive but has a lower yield than other specimen types due to poor preservation of the cells and more variability in acquiring a good-quality specimen.
In patients with a suspected malignant pleural effusion, if the initial thoracentesis is negative, a repeat thoracentesis is warranted.
The correct answer is: Repeat thoracentesis
52
A patient diagnosed with squamous cell lung cancer was brought to the ER due to vomiting, abdominal pain, constipation, polyuria and changes in sensorium. He had an unremarkable physical examination. Which of the following laboratory findings is most consistent with this paraneoplastic syndrome?
a. High Antidiuretic hormone
b. High Parathyroid hormone
c. Low Cortisol
d. Low ACTH
Paraneoplastic syndromes are common in patients with lung cancer, especially those with SCLC
Endocrine syndromes are seen in 12% of patients
Hypercalcemia is the most common life-threatening metabolic complication of malignancy, primarily occurring with squamous cell carcinomas of the lung
• Clinical symptoms include nausea, vomiting, abdominal pain, constipation, polyuria, thirst, and altered mental status
• results from ectopic production of parathyroid hormone (PTH) or more commonly PTH-related peptide
The correct answer is: High Parathyroid hormone
53
A patient diagnosed with NSCLC was noted to have a new mass at the R lung apex with of involvement of the first and second right ribs. He reports having shoulder pain that radiates in the ulnar distribution of the arm. Which of the following is the most likely explanation of this shoulder pain?
a. metastasis into the central nervous system
b. involvement of the first and second thoracic nerves
c. extension of the tumor into the rotator cuff muscles
d. paraneoplastic neoplastic syndrome with tumor secretion of ACTH
Pancoast (or superior sulcus tumor) syndrome
• result from local extension of a tumor growing in the apex of the lung with involvement of the eighth cervical and first and second thoracic nerves
• present with shoulder pain that characteristically radiates in the ulnar distribution of the arm
• often with radiologic destruction of the first and second ribs
• often co-exist with Horner’s syndrome
Horner’s syndrome
• enophthalmos, ptosis, miosis, and anhydrosis
• Caused by sympathetic nerve paralysis due to regional spread of tumor in the thorax (by contiguous growth or by metastasis to regional lymph nodes)
The correct answer is: involvement of the first and second thoracic nerves
54
In addition to whole body PET CT Scan, which of the following imaging modalities is recommended for the staging of all patients diagnosed with SCLC?
a. bone scan
b. thyroid scan
c. MRI of the brain
d. PET CT Scan alone is adequate for complete work-up
In SCLC patients, current staging recommendations include a PET-CT scan and MRI of the brain (positive in 10% of asymptomatic patients)
If a patient has signs or symptoms of spinal cord compression (pain, weakness, paralysis, urinary retention), a spinal CT or MRI scan and examination of the cerebrospinal fluid cytology should be performed
All NSCLC patients are recommended to undergo a PET-CT scan for staging
For brain metastases, MRI is the most effective method. MRI can also be useful in selected circumstances, such as superior sulcus tumors to rule out brachial plexus involvement, but in general, MRI does not play a major role in NSCLC staging
The correct answer is: MRI of the brain
55
A patient with Stage IA NSCLC underwent resection of the tumor. Histopathologic analysis of the surgical specimen revealed clean margins. How often should chest CT Scan with contrast be done for monitoring after surgery?
a. every 3 months for the 1st 3 years
b. every 6 months for the 1st 3 years
c. every 3 months for the 1st 6 years
d. every 6 months for the 1st 6 years
In should be noted that all patients with resected NSCLC are at high risk of recurrence or developing a second primary lung cancer
• Thus, it is reasonable to follow these patients with periodic imaging studies.
• Most of recurrence occurs within 18–24 months of surgery
Periodic CT scans appear to be the most appropriate screening modality
Based on the timing of most recurrences, some guidelines recommend a contrasted chest CT scan every 6 months for the first 3 years after surgery, followed by yearly CT scans of the chest without contrast thereafter
The correct answer is: every 6 months for the 1st 3 years
56
Which of the following is the cornerstone of the cytotoxic chemotherapy regimens used for patients with metastatic NSCLC?
a. EGFR tyrosine kinase inhibitors
b. Immune checkpoint inhibitors
c. gemcitabine-based regimens
d. platinum-based regimens
A landmark meta-analysis published in 1995 provided the earliest meaningful indication that chemotherapy could provide a survival benefit in metastatic NSCLC as opposed to supportive care alone
However, the survival benefit was seemingly confined to cisplatin-based chemotherapy regimens (hazard ratio 0.73; 27% reduction in the risk of death; 10% improvement in survival at 1 year)
For a cohort of NSCLC patients, the presence of an oncogenic driver allows the use of oral therapies with significant tumor regression.
• Lung tumors that harbor activating mutations within the EGFR kinase domain display high sensitivity to small-molecule EGFR TKIs.
```
Immune checkpoint inhibitors are a novel class of agents that have significantly improved the quality of life and survival for a group of patients with advanced NSCLC.
• Immune checkpoint inhibitors work by blocking interactions between T cells and antigen presenting cells (APCs) or tumor cells that lead to T-cell inactivation.
```
The correct answer is:
platinum-based regimens
57
A 55 year old female diagnosed with SCLC was noted to have involvement of the contralateral supraclavicular nodes and superior vena caval obstruction. Which of the following is the recommended treatment plan in this case?
a. platinum-based chemotherapy with curative intent and prophylactic cranial irradiation
b. platinum-based chemotherapy with and cranial irradiation for palliation purposes
c. platinum-based chemotherapy alone with curative intent
d. cranial irradiation alone for palliation purposes
Patients with limited-stage disease (LD) have cancer that is confined to the ipsilateral hemithorax and can be encompassed within a tolerable radiation port. Thus, contralateral supraclavicular nodes, recurrent laryngeal nerve involvement, and superior vena caval obstruction can all be part of LD.
Patients with extensive-stage disease (ED) have overt metastatic disease by imaging or physical examination.
Chemotherapy significantly prolongs survival in patients with SCLC.
• Four to six cycles of platinum-based chemotherapy has been the mainstay of treatment and is recommended over other chemotherapy regimens irrespective of initial stage.
Prophylactic cranial irradiation (PCI) should be considered in all patients with either LD-SCLC or ED-SCLC who have responded well to initial therapy.
• A meta-analysis with LD-SCLC who had achieved a complete remission after upfront chemotherapy yielded a 5.4% improvement in overall survival for patients treated with PCI.
• In patients with ED-SCLC who have responded to first-line chemotherapy, a prospective randomized phase III trial showed that PCI reduced the occurrence of symptomatic brain metastases and prolonged disease-free and overall survival compared to no radiation therapy.
The correct answer is: platinum-based chemotherapy with curative intent and prophylactic cranial irradiation
58
A 55 year old asymptomatic female undergoing colonoscopy was noted to have 5 adenomatous polyps. Given that all the polyps were excised with clean margins, when is the earliest time she should have her repeat coloscopy?
a. o1 year
b. 3 years
c. 5 years
d. 10 years
Following the detection of an adenomatous polyp, the entire large bowel should be visualized endoscopically because synchronous lesions are noted in about one-third of cases.
Colonoscopy should then be repeated periodically, even in the absence of a previously documented malignancy, because such patients have a 30–50% probability of developing another adenoma and are at a higher-than average risk for developing a colorectal carcinoma.
Adenomatous polyps are thought to require >5 years of growth before becoming clinically significant; colonoscopy need not be carried out more frequently than every 3 years for the vast majority of patients.
The correct answer is: 3 years
59
Which of the following diet types has been associated with an increased risk for colonic cancer?
a. High animal fat and high caloric content diet
b. Low fiber and high caloric content diet
c. High animal fat and low fiber diet
d. Low animal fat and low fiber diet
The weight of epidemiologic evidence, implicates diet as being the major etiologic factor for colorectal cancer, particularly diets high in animal fat and in calories
• Mortality from colorectal cancer is directly correlated with per capita consumption of calories, meat protein, and dietary fat and oil
• Migrant groups tend to assume the large-bowel cancer incidence rates of their adopted countries
• Population groups such as Mormons and Seventh Day Adventists, whose lifestyle and dietary habits differ somewhat from those of their neighbors, have significantly lower-than-expected incidence and mortality rates for colorectal cancer
• Despite correlations, dietary fat has not been proven to cause cancer
In observational studies, dietary fiber is associated with a reduced risk of colonic polyps and invasive cancer of the colon
• However, cancer-protective effects of increasing fiber and lowering dietary fat have not been proven in the context of a prospective clinical trial.
The correct answer is: High animal fat and high caloric content diet
60
Which of the following is the most effective class of chemopreventive agent for colon cancer?
a. Progesterone
b. Tocopherol
c. Vitamin D
d. Aspirin
The most effective class of chemopreventive agents in colon cancer is aspirin and other NSAIDs
• thought to suppress cell proliferation by inhibiting prostaglandin synthesis
• regular aspirin use reduces the risk of colon adenomas and carcinomas as well as death from large-bowel cancer
• this effect of aspirin on colon carcinogenesis increases with the duration and dosage of drug use
Emerging data linking adequate plasma levels of vitamin D with reduced risk of adenomatous polyps and colorectal cancer appear promising
Antioxidant vitamins such as ascorbic acid, tocopherols, and β-carotene are ineffective at reducing the incidence of subsequent adenomas in patients who have undergone the removal of a colon adenoma
Estrogen replacement therapy has been associated with a reduction in the risk of colorectal cancer in women, conceivably by an effect on bile acid synthesis and composition or by decreasing synthesis of IGF-I
The correct answer is: Aspirin
61
Colon cancers may have variable presentations based on the location of the tumor itself. Which tumor location is most consistent with a patient presenting with abdominal cramping, possible obstruction or perforation, and radiographs of the abdomen revealing an “apple-core” lesion?
a. Ascending Colon
b. Descending Colon
c. Rectosigmoid
d. Cecum
Because stool is relatively liquid as it passes through the ileocecal valve into the right colon, cancers arising in the cecum and ascending colon may become quite large without resulting in any obstructive symptoms or noticeable alterations in bowel habits.
Lesions of the right colon commonly ulcerate, leading to chronic, insidious blood loss without a change in the appearance of the stool. Consequently, patients with tumors of the ascending colon often present with symptoms such as fatigue, palpitations, and even angina pectoris and are found to have a hypochromic, microcytic anemia indicative of iron deficiency. Because the cancers may bleed intermittently, a random fecal occult blood test may be negative.
Because stool becomes more formed as it passes into the transverse and descending colon, tumors arising there tend to impede the passage of stool, resulting in the development of abdominal cramping, occasional obstruction, and even perforation. Radiographs of the abdomen often reveal characteristic annular, constricting lesions (“apple-core” or “napkin-ring”).
Cancers arising in the rectosigmoid are often associated with hematochezia, tenesmus, and narrowing of the caliber of stool; anemia is an infrequent finding.
The correct answer is: Descending Colon
62
A 45 year old female was brought in for consult due to severe acne. On history you note that 2 weeks prior she was started on Cetuximab for colon cancer. Which of the following should you advise the patient?
a. Acne-like rash is a known side effect of Cetuximab and she should consult her oncologist.
b. Biopsy of the lesions is recommended as this could be a form of skin metastasis.
c. She should stop Cetuximab immediately as this is a sign of severe allergic reaction.
d. Oral estrogen supplementation is recommended as acne is from a hormonal imbalance.
Cetuximab (Erbitux) is a monoclonal antibody directed against the epidermal growth factor receptor (EGFR), a transmembrane glycoprotein involved in signaling pathways affecting growth and proliferation of tumor cells.
Cetuximab appears to have therapeutic synergy with such chemotherapeutic agents as irinotecan, even in patients previously resistant to this drug; this suggests that cetuximab can reverse cellular resistance to cytotoxic chemotherapy.
The use of both cetuximab can lead to an acne-like rash, with the development and severity of the rash being correlated with the likelihood of antitumor efficacy.
The correct answer is: Acne-like rash is a known side effect of Cetuximab and she should consult her oncologist.
63
According to the American Cancer Society guidelines, how often should asymptomatic low risk individuals undergo an FOBT as form of screening for colorectal cancer?
a. once upon reaching age 60 then every 3 years if negative
b. quarterly until age 65 then yearly thereafter
c. FOBT has no role in colorectal screening
d. once a year starting at age 50
The correct answer is: once a year starting at age 50
64
Among patients with gastric adenocarcinoma which of the following determines prognosis following complete surgical resection?
a. degree of tumor penetration
b. tumor vascularity
c. H pylori status
d. tumor size
Complete surgical removal of the tumor with resection of adjacent lymph nodes offers the only chance for cure.
• this is possible in less than a third of patients
• subtotal gastrectomy is the treatment of choice for patients with distal carcinomas, whereas total or near-total gastrectomies are required for more proximal tumors
• inclusion of extended lymph node dissection in these procedures appears to confer an added risk for complications without providing a meaningful enhancement in survival
The prognosis following complete surgical resection depends on the degree of tumor penetration into the stomach wall and is adversely influenced by regional lymph node involvement and vascular invasion.
The correct answer is: degree of tumor penetration
65
Among colon cancer patients, which of the following is the utility of preoperative CEA determination?
a. positive CEA determination confirms gastric lymphoma
b. high preoperative CEA value is predictive of tumor recurrence
c. low preoperative CEA value is a marker for less tumor invasion
d. negative CEA determination effectively rules out distant metastases
Regardless of the clinicopathologic stage, a preoperative elevation of the plasma carcinoembryonic antigen (CEA) level predicts eventual tumor recurrence.
The correct answer is: high preoperative CEA value is predictive of tumor recurrence
66
A diffuse large B cell lymphoma patient came back for follow-up 2 weeks post chemotherapy. He is currently asymptomatic and afebrile but with an absolute neutrophil count of 110/uL. Which of the following should you advise the patient regarding antibiotic use?
a. No need for any antibiotics at this time as this is an expected event and patient should just be monitored.
b. No need for any antibiotics at this time but ideally he should be given Intravenous Immunoglobulin to reduce chances of infection.
c. Oral broad-spectrum prophylactic antibiotic should be initiated.
d. Intravenous broad-spectrum prophylactic antibiotic should be initiated.
Use of antibiotics for afebrile neutropenic patients as broad-spectrum prophylaxis against infections has decreased both mortality and morbidity even further.
The current approach to treatment of severely neutropenic patients (e.g., those receiving high-dose chemotherapy for leukemia or high-grade lymphoma) is based on initial prophylactic therapy at the onset of neutropenia, subsequent “empirical” antibacterial therapy targeting the organisms whose involvement is likely in light of physical findings (most often fever alone), and finally “empirical” antifungal therapy based on the known likelihood that fungal infection will become a serious issue after 4–7 days of broad-spectrum antibacterial therapy
Randomized trials have indicated the safety of oral antibiotic regimens in the treatment of “low-risk” patients.
The correct answer is: Oral broad-spectrum prophylactic antibiotic should be initiated.
67
A patient with diffuse large B cell lymphoma is about to undergo his 1st cycle of chemotherapy and on routine pre-chemotherapy work-up he was noted to have a latent hepatitis B infection. Which of the following should you advise this patient in the conduct of this chemotherapy?
a. There are no additional steps needed since the hepatitis infection is latent and he can proceed with chemotherapy.
b. Hepatitis reactivation is a possibility with combination of steroids and monoclonal antibody therapy hence monitoring of hepatitis should be done and prophylactic antivirals maybe initiated.
c. Hepatitis is an absolute contraindication to therapy and should be treated first prior to chemotherapy.
d. Hepatitis is a hallmark of disease progression and chemotherapy goal should be shifted to palliative care.
The recommended 1st line chemotherapy regimen for DLBCL is R-CHOP (Rituximab, Doxorubicin, Cyclophosphamide, Prednisone, Vincristine).
The use of monoclonal antibodies that target B and T cells as well as drugs that interfere with lymphocyte signal transduction events is associated with reactivation of latent infections. The use of rituximab, the antibody to CD20 (a B cell surface protein), is associated with the development of reactivation tuberculosis as well as other latent viral infections, including hepatitis B and cytomegalovirus (CMV) infection.
Patients with latent bacterial disease (like tuberculosis) and latent viral disease (like herpes simplex or zoster) should be carefully monitored for reactivation disease.
The correct answer is: Hepatitis reactivation is a possibility with combination of steroids and monoclonal antibody therapy hence monitoring of hepatitis should be done and prophylactic antivirals maybe initiated.
68
A lymphoma patient developed fever 2 weeks after chemotherapy infusion. Other than mild erythema over the exit site of his port-a-catheter he has no other PE findings suggestive of infection. After sending for blood cultures, which of the following should be your next step in his management?
a. Start antibiotic regimen with gram positive organism coverage and observe exit site erythema response.
b. Remove port-a-catheter ASAP and start antibiotic regimen with gram positive organism coverage.
c. Remove port-a-catheter ASAP. No antibiotics should be initiated yet pending culture results.
d. Start broad spectrum antibiotic and replace port-a-catheter.
The correct answer is: Start antibiotic regimen with gram positive organism coverage and observe exit site erythema response.
69
Which of the following dietary regimen is recommended among cancer patients ongoing chemotherapy to prevent infection?
a. Strict disinfection and sterilization of all food products should be observed
b. Increase raw fruits and vegetables in diet should be advised but vigorous washing of food products should be done prior to consumption
c. Avoid leftovers, deli foods, undercooked meat, and unpasteurized dairy products
d. Avoid canned or preserved food
The presence of large numbers of bacteria (particularly P. aeruginosa) in certain foods, especially fresh vegetables, has led some authorities to recommend a special “low-bacteria” diet.
• A diet consisting of cooked and canned food is satisfactory to most neutropenic patients and does not involve elaborate disinfection or sterilization protocols.
• However, there are no studies to support even this type of dietary restriction.
Counseling of patients to avoid leftovers, deli foods, undercooked meat, and unpasteurized dairy products is recommended since these foods have been associated with outbreaks of listerial infection.
The correct answer is: Avoid leftovers, deli foods, undercooked meat, and unpasteurized dairy products
70
6 weeks after chemotherapy, a breast cancer patient was noted to have new onset hypertension, azotemia, anemia and thrombocytopenia. Since she was noted to have weakness and easy fatigability at this time blood transfusion with packed RBC and platelets was done. However, with transfusion there was onset of dyspnea and an increasing severity of hypertension and azotemia with a faster decline in hemoglobin and platelet levels. Which of the following is most important factor in the pathogenesis of this condition?
a. Endothelial damage in involved organs
b. Transfusion related volume overload
c. Antibody deposition in kidneys
d. Recurrence of primary tumor
This is a classic chemotherapy-related HUS presentation
• onset 4–8 weeks after the last dose of chemotherapy
• characterized by microangiopathic hemolytic anemia, thrombocytopenia, and renal failure
• dyspnea, weakness, fatigue, oliguria, and purpura are common initial symptoms and findings
• Systemic hypertension and pulmonary edema frequently occur
• Severe hypertension, pulmonary edema, and rapid worsening of hemolysis and renal function may occur after a blood or blood product transfusion
Laboratory findings include:
• red blood cell fragmentation and numerous schistocytes on peripheral smear
• Coombs’ test negative
• serum creatinine level is elevated at presentation and shows a pattern of subacute worsening within weeks of the initial azotemia
The pathogenesis of cancer treatment–related HUS is not completely understood, but probably the most important factor is endothelial damage.
The basic pathologic lesion appears to be deposition of fibrin in the walls of capillaries and arterioles, and these deposits are similar to those seen in HUS due to other causes. These microvascular abnormalities involve mainly the kidneys and rarely occur in other organs.
The correct answer is: Endothelial damage in involved organs
71
The tumor of a patient diagnosed with small cell lung cancer was documented to produce high ACTH levels. Which of the following should you expect to see in his laboratory tests?
a. Hyponatremia
b. Hypercalcemia
c. Hypokalemia
d. Hyperglycemia
Ectopic secretion of ACTH by SCLC and pulmonary carcinoids usually results in additional electrolyte disturbances, especially hypokalemia, rather than the changes in body habitus that occur in Cushing’s syndrome from a pituitary adenoma
Treatment with standard medications, such as metyrapone and ketoconazole, is largely ineffective due to extremely high cortisol levels.
The most effective strategy for management of the Cushing’s syndrome is effective treatment of the underlying SCLC.
Bilateral adrenalectomy may be considered in extreme cases.
The correct answer is: Hypokalemia
72
The patient diagnosed with small cell lung cancer was diagnosed with SIADH. Which of the following should be your next step in management?
a. Discontinuation of chemotherapy
b. Start salt tablets and saline hydration
c. Start Demeclocycline or Tolvaptan
d. Fluid restriction
The diagnostic features of tumor-related ectopic vasopressin production are the same as those of other causes of SIADH
• Hyponatremia and reduced serum osmolality occur in the setting of an inappropriately normal or increased urine osmolality
• Urine sodium excretion is normal or increased
• Vasopressin measurements are not usually necessary to make the diagnosis
Fluid restriction to less than urine output, plus insensible losses, is often sufficient to correct hyponatremia partially. However, strict monitoring of the amount and types of liquids consumed or administered intravenously is required for fluid restriction to be effective.
Salt tablets and saline are not helpful unless volume depletion is also present.
Demeclocycline can be used to inhibit vasopressin action on the renal distal tubule, but its onset of action is relatively slow.
Tolvaptanis another vasopressin antagonist is particularly effective when used in combination with fluid restriction in euvolemic hyponatremia
Severe hyponatremia or mental status changes may require treatment with hypertonic or normal saline infusion together with furosemide to enhance free water clearance
The correct answer is: Fluid restriction
73
A patient who was newly diagnosed with ovarian cancer was noted to have noted to have new onset changes in sensorium. Work-up was unremarkable save for a Crea level 600 mmol/L and Calcium level of 7.5 mmol/L. Which of the following is the most appropriate management?
a. Bisphosphonates
b. Dialysis
c. Forced Diuresis
d. Steroids
Saline rehydration is used to dilute serum calcium and promote calciuresis; exercise caution in patients with cardiac, hepatic, or renal insufficiency.
Forced diuresis with furosemide or other loop diuretics can enhance calcium excretion but provides relatively little value except in life-threatening hypercalcemia. When used, loop diuretics should be administered only after complete rehydration and with careful monitoring of fluid balance.
Oral phosphorus should be given until serum phosphorus is >1 mmol/L
Bisphosphonates can reduce serum calcium within 1–2 days and suppress calcium release for several weeks.
Calcitonin should be considered when rapid correction of severe hypercalcemia is needed.
Hypercalcemia associated with lymphomas, multiple myeloma, or leukemia may respond to glucocorticoid treatment (e.g., prednisone 40–100 mg PO in four divided doses).
Dialysis should be considered in severe hypercalcemia when saline hydration and bisphosphonate treatments are not possible or are too slow in onset.
The correct answer is: Dialysis
74
Which of the following clinical picture can be explained by a carcinoma with excessive production of IGF-II precursors?
a. hypoglycemia develops in association with fasting
b. migratory or recurrent thrombophlebitis
c. marked skin fragility and easy bruising
d. poor wound healing and predisposition to infections
A variety of large tumors have been reported to produce excessive amounts of insulin like growth factor type II (IGF-II) precursor, which binds weakly to insulin receptors and more strongly to IGF-I receptors, leading to insulin-like actions.
In most cases, a tumor causing hypoglycemia is clinically apparent (usually >10 cm in size), and hypoglycemia develops in association with fasting.
The diagnosis is made by documenting low serum glucose and suppressed insulin levels in association with symptoms of hypoglycemia.
Serum IGF-II levels may not be increased (IGF-II assays may not detect IGF-II precursors).
The correct answer is: hypoglycemia develops in association with fasting
75
Which of the following is a known risk factor for ovarian cancer?
a. multiparity
b. tubal ligation
c. aspirin use
d. obesity
Nulliparity, obesity, diet, infertility treatments, and possibly hormone replacement therapy have all been linked to an increase in risk in ovarian cancer.
Protective factors include the use of oral contraceptives, multiparity, tubal ligation, aspirin use, and breast-feeding.
The correct answer is: obesity
76
Which of the following is the primary neoplastic-initiating event for the most lethal malignancy in women?
a. Familial hereditary germline mutation in BRCA1 and 2 genes
b. Acquired germ
c. Infection with high-risk strains of HPV
d. Chronic polyposis
Cervical cancer is the second most common and the most lethal malignancy in women worldwide.
Infection with high-risk strains of human papillomavirus (HPV) is the primary neoplastic-initiating event in the vast majority of women with invasive cervical cancer.
The correct answer is: Infection with high-risk strains of HPV
77
According to the American Cancer Society Guidelines, which of the following is the recommended cervical cancer screening for a 28 year old sexually active female?
a. Papsmear and HPV testing every 3 years
b. Papsmear screening every 3 years; HPV testing not recommended
c. Papsmear alone every 3 years or Papsmear and HPV testing every 5 years
d. No screening following adequate negative prior screening
The Pap smear is the primary detection method for asymptomatic preinvasive cervical dysplasia of squamous epithelial lining during a gynecologic examination. Because of the delay between dysplasia and frank cervical cancer is years long; annual (or longer) screening and prevention strategies that detect precancerous dysplasia and carcinoma in situ can be implemented successfully. Annual or biannual cervical scraping for cytology (Pap Smear) is highly effective in reducing the incidence of cervical cancer by early detection and subsequent surgical treatment.
The correct answer is: Papsmear screening every 3 years; HPV testing not recommended
78
For cervical cancer, which of the following is the recommended population to receive vaccination as a form of primary prevention?
a. Postmenopausal women
b. High risk population at any age
c. Women with identified dysplasia at screening
d. Girls aged 11–13 years before the initiation of sexual activity
A primary prevention strategy relies on HPV vaccines.
Vaccination of girls aged 11–13 years with two injections (one year apart) before the initiation of sexual activity dramatically reduces the rate of high-risk HPV infection and subsequent dysplasia.
There is also partial protection against other HPV types, although vaccinated women are still at risk for HPV infection and still benefit from standard Pap smear screening.
The correct answer is: Girls aged 11–13 years before the initiation of sexual activity
Question 32
79
Which of the following class of hormones is the principal risk factor for the development of endometrioid tumors?
a. Estrogen
b. Testosterone
c. Progesterone
d. Human chorionic gonadotropin hormone
Development of these endometrioid tumors is a multistep process with estrogen playing an important early role in driving endometrial gland proliferation. Relative overexposure to this class of hormones is the principal risk factor for the subsequent development of endometrioid tumors.
In contrast, progestins drive glandular maturation and are protective. Hence, women with high endogenous or pharmacologic exposure to estrogens, especially if unopposed by progesterone, are at higher risk for endometrial cancer.
The correct answer is: Estrogen
80
A 35 year old female was diagnosed to have a complete molar pregnancy with widely metastatic non-pulmonary disease and very elevated hCG. Which of the following is role of chemotherapy in this patient?
a. Curative
b. Palliative
c. Debulking
d. Neoadjuvant
Trophoblastic disease is exquisitely sensitive to chemotherapy and guided by serial serum hCG testing, successful, curative treatment is the rule.
For women with evidence of rising hCG or radiologic confirmation of metastatic or persistent regional disease, prognosis can be estimated through a variety of scoring algorithms that identify those women at low, intermediate, and high risk for requiring multiagent chemotherapy. In general, women with widely metastatic nonpulmonary disease, very elevated hCG, and prior normal antecedent term pregnancy are considered at high risk and typically require multiagent chemotherapy at an expert center for cure.
Even very advanced gestational trophoblastic disease is almost uniformly curable when managed by an expert in this rare malignancy
The correct answer is: Curative
81
Which of the following confirms the diagnosis of Zollinger-Ellison Syndrome?
a. increased plasma serotonin levels
b. elevated plasma VIP level and the presence of large-volume diarrhea
c. hypergastrinemia occurring with an increased basal gastric acid output
d. histologic confirmation of a carcinoid morphology without any clinical symptoms or plasma elevation typical of neuroendocrine tumors
The diagnosis of ZES requires the demonstration of inappropriate fasting hypergastrinemia, usually by demonstrating hypergastrinemia occurring with an increased basal gastric acid output (BAO) (hyperchlorhydria).
More than 98% of patients with ZES have fasting hypergastrinemia, although in 40–60% the level may be elevated less than tenfold. Therefore, when the diagnosis is suspected, a fasting gastrin is usually the initial test performed.
It is important to remember that potent gastric acid suppressant drugs such as proton pump inhibitors can suppress acid secretion sufficiently to cause hypergastrinemia; because of their prolonged duration of action, these drugs have to be tapered or frequently discontinued for a week before the gastrin determination.
The correct answer is: elevated plasma VIP level and the presence of large-volume diarrhea
82
Which of the following describes the clinical syndrome associated glucagonoma ?
a. acromegaly, weight gain, and muscle weakness
b. large-volume diarrhea, hypokalemia, and dehydration
c. dermatitis, glucose intolerance or diabetes, and weight loss
d. diabetes mellitus, gallbladder disease, diarrhea, and steatorrhea
A glucagonoma is NET of the pancreas that secretes excessive amounts of glucagon, which causes a distinct syndrome characterized by dermatitis, glucose intolerance or diabetes, and weight loss.
The somatostatinoma syndrome is due to an NET that secretes excessive amounts of somatostatin, which causes a distinct syndrome characterized by diabetes mellitus, gallbladder disease, diarrhea, and steatorrhea.
VIPomas are NETs that secrete excessive amounts of vasoactive intestinal peptide (VIP), which causes a distinct syndrome characterized by large-volume diarrhea, hypokalemia, and dehydration. This syndrome also is called Verner-Morrison syndrome, pancreatic cholera, and WDHA syndrome for watery diarrhea, hypokalemia, and achlorhydria, which some patients develop.
GRFomas are NETs that secrete excessive amounts of growth hormone– releasing factor (GRF) that cause acromegaly.
The correct answer is: dermatitis, glucose intolerance or diabetes, and weight loss
83
A patient with chronic low back pain was noted to have anemia, lytic bone lesions, hypercalcemia, azotemia, serum M spike, and marrow plasmacytosis on work-up. Which of the following is the single most powerful predictor of survival for this disease?
a. Serum β2 –macroglobulin
b. Staging at time of diagnosis
c. Percentage of marrow plasmacytosis
d. Degree of hypercalcemia on diagnosis
This is a classic case of multiple myeloma with marrow plasmacytosis, serum M protein component and myeloma defining events (anemia, hypercalcemia, lytic lesions, and high creatinine)
Serum β2 -microglobulin is the single most powerful predictor of survival and can substitute for staging.
The correct answer is: Serum β2 –macroglobulin
84
Which of the following characterizes the Pel Ebstein fever that maybe seen in Hodgkin Lymphoma?
a. Bouts of fever occurs daily (24-hour periodicity) for few hours
b. Fever occurs after an interval of two days (48-hour periodicity)
c. Fever persist for days to weeks, followed by afebrile intervals and then recurrence of the fever
d. Temperature remains above normal throughout the day with variation in temperature of more than 1°C in 24 hours
Occasionally, HL can present as a fever of unknown origin. This is more common in older patients who are found to have mixed-cellularity HL in an abdominal site.
Rarely, the fevers persist for days to weeks, followed by afebrile intervals and then recurrence of the fever. This pattern is known as Pel Ebstein fever.
The correct answer is: Fever persist for days to weeks, followed by afebrile intervals and then recurrence of the fever
85
Adult T Cell Leukemia/Lymphoma is most commonly associated with which of the following infectious agents?
a. EBV
b. HIV
c. HTLV-1
d. Hepatitis
The correct answer is: HTLV-1
86
Which of the following is the imaging modality of choice is staging a patient diagnosed with follicular lymphoma?
a. CT Scan
b. PET-CT Scan
c. MRI
d. Ultrasound
Lymphoma histology and clinical presentation dictates which imaging studies should be ordered.
• Chest, abdominal, and pelvic computed tomography (CT) scans are essential for accurate staging to assess lymphadenopathy for indolent lymphomas
• positron emission tomography (PET) using 18F-fluorodeoxyglucose (FDG PET) is useful for aggressive lymphomas
For Follicular lymphoma, staging is typically done with CT scans of the chest, abdomen and pelvis, as well as the neck if neck disease is suspected
• PET/CT scans can be helpful in cases where disease transformation is suspected
The correct answer is: CT Scan
87
Which of the following is the most likely primary site of a patient that is concomitantly diagnosed carcinoma with Cushing’s Syndrome?
a. islet cell tumor
b. thymic carcinoid
c. small cell lung cancer
d. pheochromocytomas
Ectopic ACTH production accounts for 10–20% of cases of Cushing’s syndrome. The syndrome is particularly common in neuroendocrine tumors.
SCLC is the most common cause of ectopic ACTH, followed by bronchial and thymic carcinoids, islet cell tumors, other carcinoids, and pheochromocytomas
The correct answer is: small cell lung cancer
88
A patient with HIV and newly diagnosed hodgkin lymphoma was noted to obtunded and tachycardic. Serum lactatic acid was noted to be at 20 mmol/L. Which of the following should be added in your management?
a. Steroids
b. Allopurinol
c. Saline diuresis
d. Sodium bicarbonate
Lactic acidosis in the absence of hypoxemia may occur in patients with leukemia, lymphoma, or solid tumors.
Extensive involvement of the liver by tumor is often present.
HIV-infected patients have an increased risk of aggressive lymphoma; lactic acidosis that occurs in such patients may be related either to the rapid growth of the tumor or from toxicity of nucleoside reverse transcriptase inhibitors.
Symptoms of lactic acidosis include tachypnea, tachycardia, change of mental status, and hepatomegaly. The serum level of lactic acid may reach 10–20 mmol/L (90–180 mg/dL).
Treatment is aimed at the underlying disease.
Sodium bicarbonate should be added if acidosis is very severe or if hydrogen ion production is very rapid and uncontrolled.
Other treatment options include renal replacement therapy, such as hemodialysis, and thiamine replacement.
The correct answer is: Sodium bicarbonate
89
A patient diagnosed with Hodgkin lymphoma undergoing chemotherapy was noted to have new onset easy fatigability and exercise intolerance. On work-up lungs were noted to have architectural distortion, fibrosis and bronchiectasis. Which of the following is the most likely cause?
a. Anthracycline
b. Bleomycin
c. Cyclophosphamide
d. Steroids
Bleomycin is the most common cause of chemotherapy-induced lung disease. Other causes include alkylating agents (such as cyclophosphamide, chlorambucil, and melphalan), nitrosoureas (carmustine [BCNU], lomustine [CCNU], and methyl-CCNU), busulfan, procarbazine, methotrexate, and hydroxyurea. Both infectious and noninfectious (drug- and/or radiation-induced) pneumonitis can cause fever and abnormalities on chest x-ray; thus, the differential diagnosis of an infiltrate in a patient receiving chemotherapy encompasses a broad range of conditions
The correct answer is: Bleomycin
90
Which of the following are the two most common symptoms of carcinoid syndrome?
a. Impaired cognitive function and pellagra-like skin lesions
b. Tricuspid insufficiency and pulmonary stenosis
c. Asthma like symptoms and abdominal pain
d. Diarrhea and flushing
Flushing and diarrhea are the two most common symptoms in carcinoid syndrome, occurring in a mean of 69–70% of patients initially and in up to 78% of patients during the course of the disease.
The characteristic flush is of sudden onset; it is a deep red or violaceous erythema of the upper body, especially the neck and face, often associated with a feeling of warmth and occasionally associated with pruritus, lacrimation, diarrhea, or facial edema. Flushes may be precipitated by stress; alcohol; exercise; certain foods, such as cheese; or certain agents, such as catecholamines, pentagastrin; and serotonin reuptake inhibitors. Flushing episodes may2 be brief, lasting 2–5 min, especially initially, or may last hours, especially later in the disease course.
Diarrhea usually occurs with flushing (85% of cases). The diarrhea usually is described as watery, with 60% of patients having < 1 L/d of diarrhea.
The correct answer is: Diarrhea and flushing
91
Which of the following is the pathognomonic cytogenetic finding in Mantle Cell Lymphoma?
a. t(9;22)
b. t(8;21)
c. t(11;14)
d. t(2;3)
The pathognomonic cytogenetic finding in MCL is t(11;14), which brings the gene for the cell cycle control protein cyclin D1 under the control of the immunoglobulin heavy chain gene promoter on chromosome 14.
This translocation is present in >90% of cases.
The correct answer is: t(11;14)
92
Which of the following is a possible cause of hemorrhagic cystitis among patients undergoing chemotherapy?
a. RS virus
b. BK virus
c. Cytomegalovirus
d. Epstein Barr Virus
Certain viruses are typically seen only in immunosuppressed patients. BK virus (polyomavirus hominis 1) has been documented in the urine of bone marrow transplant recipients and, like adenovirus, may be associated with hemorrhagic cystitis.
The correct answer is: BK virus
93
On histopathologic examination of resected sample from a patient diagnosed with colon cancer, tumor involvement was through the muscularis level with no nodal involvement. What is the expected 5 year survival rate of this patient?
a. 86 – 95%
b. 70–85%
c. 50–69%
d. 25–49%
The correct answer is: 70–85%
94
A 55 year old chronic hepatitis B patient was noted to have a 5cm liver mass on contrast-enhanced CT Scan. Which of the following findings would point to a diagnosis of hepatocellular carcinoma?
a. vascular uptake in the arterial phase with washout in the portal venous phases
b. uneven calcification with a dense central nidus and pooling occurring in the arterial phase
c. homogenous solid mass with increased uptake in the delayed phase
d. masses >5cm would need biopsy confirmation regardless of CT Scan finding
Radiological diagnosis is achieved with a high degree of confidence if the lesion is ≥2 cm in diameter and shows the radiological hallmarks of HCC by one imaging technique.
Using contrast-enhanced imaging techniques, the typical hallmark of HCC consists of vascular uptake of the nodule in the arterial phase with washout in the portal venous or delayed phases. This radiological pattern captures the hypervascular nature characteristic of HCC.
In these scenarios the diagnostic specificity is ~95–100% and a biopsy is not necessary
The correct answer is: vascular uptake in the arterial phase with washout in the portal venous phases
95
A 35 year old female had an incidental finding of a 3cm hepatic nodule on ultrasound. Which of the following should be the next step in her work-up?
a. Repeat ultrasound at 4 months
b. 4-phase CT Scan
c. T2* MRI
d. Biopsy
The correct answer is: 4-phase CT Scan
96
Which of the following is the most appropriate treatment strategy for a patient diagnosed with Hepatocellular carcinoma with scores of Child Pugh C and ECOG 2?
a. Liver Transplant
b. Chemoembolization
c. Systemic Therapy
d. Best Supportive Care
The correct answer is: Systemic Therapy
97
Vaccination against human papilloma viruses appears to reduce the eventual risk for which of the following carcinomas?
a. Anal Cancer
b. Colon Cancer
c. Gallbladder Cancer
d. Hepatocellular Cancer
Vaccination against human papilloma viruses appears to reduce the eventual risk for anal cancer.
The development of anal cancer is associated with infection by human papillomavirus, the same organism etiologically linked to cervical cancer. The virus is sexually transmitted. The infection may lead to anal warts (condyloma acuminata), which may progress to anal intraepithelial neoplasia and on to squamous cell carcinoma.
The correct answer is: Anal Cancer
98
A 22/M came in due to a lateral neck mass measured at 4cm in its widest diameter. Axillary LAD was noted bilaterally. The rest of PE was unremarkable. Initial CBC, serum chemistry and LDH were normal. Biopsy of the LN revealed Hodgkin’s lymphoma, nodular sclerosis subtype. CT scan showed mediastinal lymphadenopathy and the previously mentioned LADs. No infradiaphragmatic disease is observed. What is the most appropriate initial management for this patient?
a. Bone marrow biopsy
b. Chemotherapy
c. Radiation therapy
d. Staging laparotomy and splenectomy
The correct answer is: Chemotherapy
99
A 68/M underwent radical prostatectomy 2 years ago with regular serial PSA monitoring. Histopath showed localized prostatic disease (Gleason score 7), no nodal involvement and no distant metastases. All PSA levels were normal until 3 months ago which showed elevation > 15 ng/mL and less than 10 months doubling time. Imaging did not reveal active disease. What can you recommend thee patient?
a. Refer back to urology for salvage surgery
b. Refer to radiation oncology for radiotherapy
c. Refer to medical oncology for systemic cytotoxic chemotherapy
d. Start alpha-adrenergic receptor antagonist and phosphodiesterase-5
The correct answer is: Refer to radiation oncology for radiotherapy
100
A patient with Burkitt’s lymphoma received his first cycle of R-HyperCVAD 2 days ago. He was noted to have a WBC count of 55, serum K of 6.5, hyperuricemia, creatinine of 1.8mg/dL and LDH of 1500 U/L. Which of the following diagnostics is NOT appropriate?
a. ECG (R: also checks for pseudohyperkalemia, in cases of high WBC/platelets counts)
b. Serum Ca, phosphorus (R: also seen in TLS; hyperphosphatemia and hypocalcemia causes severe neuromuscular irritability and tetany)
c. KUBP-UTZ or CT(R: rule out obstructive uropathy)
d. None of the above
The correct answer is: None of the above
101
Which of the following nevi characteristics would prompt you to work-up for possible malignancy?
a. Size of 4 mm
b. Symmetric shape
c. Development of crusting
d. Looks similar to other nevi
The correct answer is: Development of crusting
102
Unlike other types of melanoma which presents with radial growth, this type instead penetrates deeply into the skin (vertical growth) which may give rise to early metastasis
a. Nodular
b. Lentigo maligna
c. Acral lentiginous
d. Superficial spreading
The correct answer is: Nodular
103
The following are important risk factors in the development of melanomas, EXCEPT:
a. Presence of >30 melanocytic nevi
b. Giant melanocytic nevus (defined as having a size of >20 cm)
c. Family history of melanoma
d. All are strong risk factors
The correct answer is: Presence of >30 melanocytic nevi
104
What is the best predictor of metastatic risk of melanomas?
a. Size of lesion
b. Thickness of lesion
c. Number of involved lymph nodes
d. Elevated LDH
The correct answer is: Thickness of lesion
105
All of the following are treatment options for metastatic melanoma, EXCEPT:
a. Immunotherapy
b. Surgery
c. Oncolytic virus
d. None of the above
The correct answer is: None of the above
106
Which of the following is true regarding treatment of head and neck cancers?
a. Localized disease is treated with curative intent by either surgery or radiation therapy alone
b. Concomitant chemotherapy + radiation therapy is the most commonly used treatment modality in patients with locally or regionally advanced disease
c. Current standard for induction chemotherapy includes a three-drug regimen with paclitaxel, cisplatin, and 5-fluorouracil
d. Patients with recurrent and/or metastatic disease are treated with palliative intent, with most receiving chemotherapy for transient symptomatic relief
The correct answer is: Current standard for induction chemotherapy includes a three-drug regimen with paclitaxel, cisplatin, and 5-fluorouracil
107
A 65/M, heavy smoker and alcoholic, presented with an 8-month history of enlarging mass on the right anterior tongue. On consult, it measured ~3.5 x 4.6 cm. Further work-up revealed multiple confluent lymph nodes on the right, with the largest measuring ~6.5 cm. There was no evidence of distant metastasis. Which of the following will be the appropriate treatment regimen for this patient?
a. Surgery alone
b. Radiotherapy + EGFR monoclonal antibody (cetuximab)
c. Concomitant surgery/radiation therapy + chemotherapy
d. Chemotherapy alone
The correct answer is: Chemotherapy alone
108
What is the best time to perform breast examination during menstrual cycle?
a. Day 1-3
b. Day 3-5
c. Day 5-7
d. Day 7-9
The correct answer is: Day 5-7
109
Which of the following is not recommended for DCIS?
a. Breast preserving surgery is recommended if localized and with clear margins
b. Breast preserving surgery is followed by breast irradiation
c. Tamoxifen or anastrozole may be given
d. Axillary lymph node dissection is necessary
The correct answer is: Axillary lymph node dissection is necessary
110
Based on their gene expression pattern, breast cancer with ER+ PR- Her2- is classified as:
a. Luminal A
b. Luminal B
c. Normal breast-like
d. Basal
The correct answer is: Luminal B
111
Which of the following patient has the highest risk of developing breast cancer?
a. 35/F who recently underwent radiation therapy for Hodgkin’s disease
b. 40/F who underwent bilateral salpingoophorectomy for ovarian cancer
c. 47/F, G1P1, who has regular menstrual cycles
d. 65/F obese and with high fat intake
```
BREAST CANCER
• hormone-dependent disease
• Length of menstrual life
o particularly the fraction occurring before first full-term pregnancy
o substantial component of the total risk
o early menarche
o late first full-term pregnancy
o late menopause
Breast Cancer Risk
```
The correct answer is: 47/F, G1P1, who has regular menstrual cycles
112
Which of the following is TRUE of BRCA mutation? (HPIM 20, C75, p555)
a. BRCA1 mutation usually associated with ER/PR positivity
b. BRCA2 mutation usually associated with the so called “triple negative” tumors
c. Incidence in the general population is < 1% therefore, screening everyone is not cost-effective
d. Increases the risk of malignancy only in women
The correct answer is: Incidence in the general population is < 1% therefore, screening everyone is not cost-effective
113
After 4 weeks, the patient returned to your clinic due to persistence of the right breast lump. You ordered breast mammogram and subsequently referred to a breast specialist who did a core needle biopsy. The result of the biopsy showed ductal carcinoma in situ. What is the best management for the patient?
a. Lumpectomy + radiation therapy
b. Mastectomy + radiation therapy
c. Modified radical mastectomy
d. Tamoxifen or anastrozole therapy for 5 years
DUCTAL CARCINOMA IN SITU
• Breast-preserving surgery for patients who have a localized focus of DCIS
• Lumpectomy with clear margins followed by breast irradiation followed by tamoxifen or anastrozole
The correct answer is: Lumpectomy + radiation therapy
114
Which of the following is TRUE of male breast cancers?
a. Majority are triple negative cancers
b. Most are diagnosed during the early stages
c. Risk of cancer is greater in men with gynecomastia
d. Treatment of choice is lumpectomy.
MALE BREAST CANCER
• unilateral lump and diagnosed late
• increased risk: gynecomastia, hepatic failure, hyperestrogenism, BRCA2, Klinefelter’s syndrome
• 90% are ER (+)
• Treatment of choice: mastectomy and axillary lymph node dissection or sentinel lymph node biopsy
• Endocrine agent of choice: tamoxifen
o unknown value of aromatase inhibitors
The correct answer is: Risk of cancer is greater in men with gynecomastia
115
Which of the following breast cancer treatment is CORRECTLY matched with its side effect?
a. Anastrozole: endometrial hyperplasia
b. Doxorubicin: pulmonary fibrosis
c. Paclitaxel: neuropathy
d. Tamoxifen: osteoporosis
The correct answer is: Paclitaxel: neuropathy
116
Histopathology report also showed that the cancer is ER/PR (-), HER2 (+). What would be your management?
a. Chemotherapy + Tamoxifen
b. Chemotherapy + Fulvestrant
c. Chemotherapy + Trastuzumab
d. Chemotherapy only
The correct answer is: Chemotherapy + Trastuzumab
117
70/M came in to your clinic due to 6-month history of urinary, frequency, urgency, weak stream, and sensation of incomplete voiding. He also complains of difficulty in ejaculating. He denied fever, urethral discharge, hypogastric or low back pain. You decided to perform a digital rectal exam (DRE). Which among the following is TRUE regarding DRE?
a. DRE is recommended as a screening for prostate cancer for men 55-69 years old
b. DRE significantly increases PSA level
c. Induration of the prostate on DRE is highly specific for cancer
d. Most prostate cancers occur in the peripheral zone and may be palpated during DRE
DIGITAL RECTAL EXAMINATION
• most cancers occur in the peripheral zone and palpated on DRE
• Cancers – hard, nodular, irregular
o induration – may also be due to BPH or calculi
• DRE DOES NOT increase PSA level
• DRE is NOT recommended as screening by USPSTF
The correct answer is: Most prostate cancers occur in the peripheral zone and may be palpated during DRE
118
The above patient was eventually diagnosed with localized prostate cancer. He decided to forego radical prostatectomy and just opted for radiation therapy. Which among the statement is TRUE?
a. Androgen deprivation therapy (ADT) is recommended for all patients after radiotherapy.
b. Choice of treatment for prostate cancer must always consider complete removal of the tumor regardless of the clinical state of the patient.
c. Radiation therapy is given either by external beam or brachytherapy.
d. Radical prostatectomy is the treatment of choice for all patients with biopsy proven prostate cancer
```
PROSTATE CANCER TREATMENT
Localized disease
• Radical prostatectomy
• Radiation therapy
• Active surveillance
Metastatic disease
• Non-castrate: testosterone lowering, ADT
• Castrate: chemotherapy (docetaxel, cabazitaxel), biologics (sipuleucel-T), ADT
```
The correct answer is: Radical prostatectomy is the treatment of choice for all patients with biopsy proven prostate cancer
119
What is the most common cause of ectopic ACTH production?
a. Adrenal carcinomas
b. Bronchial carcinoids
c. Lymphoma
d. Small cell lung cancer
```
ECTOPIC ACTH PRODUCTION
#1 SCLC
#2 bronchial and thymic carcinoids
#3 islet cell tumors
#4 other carcinoids
#5 pheochromocytomas
```
The correct answer is: Small cell lung cancer
120
Which of the following is TRUE of paraneoplastic syndromes?
a. Endocrine paraneoplastic syndromes occur due to the cancer’s mass effect or invasion of endocrine glands resulting to excessive eutopic secretion of hormones.
b. Oncogenic osteomalacia is characterized by hyperphosphatemia and renal potassium wasting induced by phosphatonin commonly seen in mesenchymal tumors.
c. Paraneoplastic neurologic disorders are mediated by immune responses triggered by neuronal proteins expressed by tumors.
d. Paraneoplastic hematologic syndromes of solid tumors cause elevation of granulocyte, platelet and eosinophils due to the concurrent undiagnosed myeloproliferative disorders.
```
PARANEOPLASTIC SYNDROMES
• produced by products of neoplastic cells stimulating responses:
o endocrinologic/hormonal
o hematologic
o dermatologic
o rheumatologic
o renal
o Neurologic
• NOT by mass effect or tumor invasion
• ENDOCRINE
o ectopic hormone production
• ONCOGENIC OSTEOMALACIA
o hypophosphatemia, renal phosphate wasting
o Phosphatonin = fibroblast growth factor 23
o weakness, bone pain, ostemalacia
• HEMATOLOGIC
o NOT by underlying myeloproliferative disorder
o ectopic hormone or cytokines
```
• NEUROLOGIC
o mediated by immune responses triggered by neuronal proteins expressed by tumors
o ONCONEURAL ANTIGENS expressed by tumors
The correct answer is: Paraneoplastic neurologic disorders are mediated by immune responses triggered by neuronal proteins expressed by tumors.
121
Which of the following is TRUE on the management of superior vena cava syndrome?
a. Glucocorticoids remain to be the mainstay first-line treatment to prevent progression of upper airway obstruction.
b. Chemotherapy is effective when the underlying cancer is squamous cell lung cancer and metastatic breast cancer.
c. Radiotherapy is the primary treatment for SVCs caused by small-cell lung cancer, lymphoma or germ cell tumors.
d. Use of diuretics may produce temporary symptomatic relief.
The correct answer is: Use of diuretics may produce temporary symptomatic relief.
122
60/F diagnosed with breast cancer stage IIIB, left, underwent modified radical mastectomy, chemotherapy, trastuzumab and adjuvant radiotherapy. She came to your clinic due to easy fatigability, orthopnea and bipedal edema. Which of the following is TRUE regarding her condition?
a. Doxorubicin induced heart failure is not dose-dependent and not associated with pathologic changes on endomyocardial biopsy.
b. Radiation therapy can cause interstitial myocardial fibrosis, and accelerated premature atherosclerotic coronary disease.
c. Trastuzumab cardiotoxicity is dose-related, irreversible and associated with pathologic changes in cardiac myofibrils.
d. Trastuzumab-induced cardiac toxicity is due to chemical free radical damage by iron complexes.
Cardiovascular Dysfunction
The correct answer is: Radiation therapy can cause interstitial myocardial fibrosis, and accelerated premature atherosclerotic coronary disease.
123
60/F diagnosed with breast cancer stage IIIB, left, underwent modified radical mastectomy, chemotherapy, trastuzumab and adjuvant radiotherapy. She came to your clinic due to easy fatigability, orthopnea and bipedal edema. Which of the following is TRUE regarding her condition?
a. Doxorubicin induced heart failure is not dose-dependent and not associated with pathologic changes on endomyocardial biopsy.
b. Radiation therapy can cause interstitial myocardial fibrosis, and accelerated premature atherosclerotic coronary disease.
c. Trastuzumab cardiotoxicity is dose-related, irreversible and associated with pathologic changes in cardiac myofibrils.
d. Trastuzumab-induced cardiac toxicity is due to chemical free radical damage by iron complexes.
Cardiovascular Dysfunction
The correct answer is: Radiation therapy can cause interstitial myocardial fibrosis, and accelerated premature atherosclerotic coronary disease.
124
Which of the following is TRUE regarding cardiovascular dysfunction after radiation therapy? (HPIM 20th ed. C91 P675)
a. Endocarditis is a possible sequelae of radiation therapy
b. Acute pericarditis peaks at 6 months after radiation therapy
c. Chronic pericarditis may develop 5-10 years post-radiation
d. Radiation therapy does not cause accelerated coronary artery disease
CARDIOVASCULAR DYSFUNCTION POST RADIATION
Increased risk if exposure is >6000 cGy
Manifestations:
• Interstitial myocardial fibrosis
• Acute (peaks at 9 months) and chronic pericarditis (5-10 years)
• Valvular disease: AR from fibrosis, MR from papillary dysfunction
• Accelerated premature atherosclerotic CAD: 3x increased risk for MI
• Embolic stroke post carotid radiation
The correct answer is: Chronic pericarditis may develop 5-10 years post-radiation
125
Which of the following malignancies can manifest with Raynaud’s phenomenon as a long-term treatment effect? (HPIM 20th ed. C91 P678 T91-2)
a. Acute leukemia
b. Breast cancer
c. Testicular cancer
d. Prostate cancer
The correct answer is: Testicular cancer
126
A 30/F with acute lymphocytic leukemia underwent chemotherapy. After a few days, laboratory tests showed elevated potassium, phosphorus and uric acid and low calcium. Which of the following is NOT recommended for the management of this patient? (HPIM 20th ed. C71 P519)
a. Rasburicase for patients with renal failure
b. Urinary alkalinization to increase uric acid solubility
c. Aggressive hydration as prophylaxis
d. Febuxostat to lower uric acid
TUMOR LYSIS SYNDROME
Characterized by hyperuricemia, hyperkalemia, hyperphosphatemia and hypocalcemia, acidosis may also develop, renal failure may occur
Caused by destruction of a large number of cancer cells
Often associated with Burkitt’s lymphoma, ALL, other rapidly proliferating lymphomas, chronic leukemias, rarely with solid tumors
The correct answer is: Urinary alkalinization to increase uric acid solubility
127
Which of the following carcinogens is correctly paired with the associated cancer or neoplasm? (HPIM 20th ed. C66 P445 T66-1)
a. Asbestos: peritoneum
b. EBV: Hodgkin’s lymphoma
c. Tobacco: colon cancer
d. Vinyl chloride: hepatocellular CA
The correct answer is: Asbestos: peritoneum
128
A 52/F consulted for cancer screening for the first time after menopause, as advised. Past and family medical histories were unremarkable. She was a previous smoker who quit 5 years ago with a 10-pack year smoking history. Which of the following tests is NOT appropriate for her? (HPIM 20th ed. C66 P449 T66-3)
a. Pap Smear
b. Mammography
c. Colonoscopy
d. Low dose lung CT scan
The correct answer is: Pap Smear
129
A 50/M was being treated for Lung CA. After initial chemotherapy, his tumor shrunk by 10% (computed from the sum of all perpendicular diameters) and further investigation did not reveal any new lesions. How is the patient’s response classified? (HPIM 20th ed. C65 P440)
a. Complete
b. Partial
c. Progressive
d. Stable
The correct answer is: Stable
130
A 50/M, smoker, consulted due to a pulmonary mass on chest x-ray. Subsequent CT showed a 4x3 cm mass on the left upper lobe with enlarged lymph nodes on the ipsilateral and contralateral hilar lymph nodes. What is the most appropriate treatment for the patient? (HPIM 20th ed. C74 P546)
a. Surgery
b. Chemoradiation
c. Systemic chemotherapy
d. Palliation
The correct answer is: Chemoradiation
131
What is the staging for a patient who was noted to have a colonic mass and after resection was noted to have an adenocarcinoma that reached the muscularis layer but with no note of nodal nor distant metastasis? (HPIM 20th ed. C77 P576 F77-3)
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
The correct answer is: Stage II
132
A 60/F known melanoma patient consulted for progressive difficulty of breathing for the past week. This was associated dry cough and no note of sputum production, fever or weight loss. She had undergone chemotherapy for melanoma. Chest CT scan showed changes consistent with pulmonary fibrosis. What is the most likely offending agent in this patient? (HPIM 20th ed. C91 P675 T91-1)
a. Methotrexate
b. Vincristine
c. Cytarabine
d. Bleomycin
The correct answer is: Bleomycin
133
A 45/F presented in the ER with confusion. She was noted to have increased sleeping time over the past week. PE revealed decreased breath sounds with increased fremiti. Initial tests showed hyponatremia and a lung mass. Without the benefit of a biopsy, what is the most likely histopathology of the lung mass? (HPIM 20th ed. C89 P664)
a. Squamous cell carcinoma
b. Small cell carcinoma
c. Adenocarcinoma
d. Lymphoma
The correct answer is: Small cell carcinoma
134
A 36/F breast cancer patient who completed adjuvant chemotherapy last month, was admitted at the ER for dyspnea. On PE, facial edema and swelling of the right upper extremity were noted. She was placed her on oxygen support and diuretics. What is the next course of action? (HPIM 20th ed. C71 P511)
a. Administer intravenous steroid
b. Emergency referral to medical oncology for systemic chemotherapy
c. Emergency referral to radiation oncology
d. Referral to hospice and continue best supportive care
The correct answer is: Emergency referral to radiation oncology
135
What is the best time to perform breast examination during menstrual cycle? (HPIM 20, C75, p557)
a. Day 1-3
b. Day 3-5
c. Day 5-7
d. Day 7-9
The correct answer is: Day 5-7
136
Which of the following is not recommended for DCIS? (HPIM 20, C75, p558)
a. Breast preserving surgery is recommended if localized and with clear margins
b. Breast preserving surgery is followed by breast irradiation
c. Tamoxifen or anastrozole may be given
d. Axillary lymph node dissection is necessary
The correct answer is: Axillary lymph node dissection is necessary
137
A patient with recurrent massive pleural effusion but with no apparent lung mass underwent thoracentesis and yielded a cell block that is negative for malignant cells. Which of the following is warranted if a malignant pleural effusion is highly suspected in this case?
a. Repeat thoracentesis
b. Transbronchial biopsy
c. Sputum cytology
d. Pleural biopsy
The correct answer is: Repeat thoracentesis
138
In addition to whole body PET CT Scan, which of the following imaging modalities is recommended for the staging of all patients diagnosed with SCLC?
a. bone scan
b. thyroid scan
c. MRI of the brain
d. PET CT Scan alone is adequate for complete work-up
The correct answer is: MRI of the brain
139
A 55 year old female diagnosed with SCLC was noted to have involvement of the contralateral supraclavicular nodes and superior vena caval obstruction. Which of the following is the recommended treatment plan in this case?
a. platinum-based chemotherapy with curative intent and prophylactic cranial irradiation
b. platinum-based chemotherapy with and cranial irradiation for palliation purposes
c. platinum-based chemotherapy alone with curative intent
d. cranial irradiation alone for palliation purposes
The correct answer is: platinum-based chemotherapy with curative intent and prophylactic cranial irradiation
140
A 55 year old asymptomatic female undergoing colonoscopy was noted to have 5 adenomatous polyps. Given that all the polyps were excised with clean margins, when is the earliest time she should have her repeat coloscopy?
a. 1 year
b. 3 years
c. 5 years
d. 10 years
The correct answer is: 3 years
141
Among patients with gastric adenocarcinoma which of the following determines prognosis following complete surgical resection?
a. degree of tumor penetration
b. tumor vascularity
c. H pylori status
d. tumor size
The correct answer is: degree of tumor penetration
142
Among colon cancer patients, which of the following is the utility of preoperative CEA determination?
a. positive CEA determination confirms gastric lymphoma
b. high preoperative CEA value is predictive of tumor recurrence
c. low preoperative CEA value is a marker for less tumor invasion
d. negative CEA determination effectively rules out distant metastases
The correct answer is: high preoperative CEA value is predictive of tumor recurrence
143
A lung cancer patient was diagnosed with and managed as febrile neutropenia 3 weeks post chemotherapy. One week after initiation of oral antibiotics, there was note of fever resolution. There were no other signs of infection at this time but his absolute neutrophil count remains to be 250/uL. Which of the following should be your next step in his antibiotic regimen?
a. Antibiotic regimen maybe discontinued at this time since there are no overt signs of infection.
b. Antibiotic regimen should be continued until ANC > 500/uL.
c. Antibiotic regimen should be shifted to intravenous.
d. A broad spectrum antifungal regimen should be added to current regimen.
The correct answer is: Antibiotic regimen should be continued until ANC > 500/uL.
144
Which of the following clinical picture can be explained by a carcinoma with excessive production of IGF-II precursors?
a. hypoglycemia develops in association with fasting
b. migratory or recurrent thrombophlebitis
c. marked skin fragility and easy bruising
d. poor wound healing and predisposition to infections
The correct answer is: hypoglycemia develops in association with fasting
145
Which of the following is the primary neoplastic-initiating event for the most lethal malignancy in women?
a. Familial hereditary germline mutation in BRCA1 and 2 genes
b. Acquired germ
c. Infection with high-risk strains of HPV
d. Chronic polyposis
The correct answer is: Infection with high-risk strains of HPV
146
For cervical cancer, which of the following is the recommended population to receive vaccination as a form of primary prevention?
a. Postmenopausal women
b. High risk population at any age
c. Women with identified dysplasia at screening
d. Girls aged 11–13 years before the initiation of sexual activity
The correct answer is: Girls aged 11–13 years before the initiation of sexual activity
147
A 35 year old female was diagnosed to have a complete molar pregnancy with widely metastatic non-pulmonary disease and very elevated hCG. Which of the following is role of chemotherapy in this patient?
a. Curative
b. Palliative
c. Debulking
d. Neoadjuvant
The correct answer is: Curative
148
Which of the following characterizes the Pel Ebstein fever that maybe seen in Hodgkin Lymphoma?
a. Bouts of fever occurs daily (24-hour periodicity) for few hours
b. Fever occurs after an interval of two days (48-hour periodicity)
c. Fever persist for days to weeks, followed by afebrile intervals and then recurrence of the fever
d. Temperature remains above normal throughout the day with variation in temperature of more than 1°C in 24 hours
The correct answer is: Fever persist for days to weeks, followed by afebrile intervals and then recurrence of the fever
149
Adult T Cell Leukemia/Lymphoma is most commonly associated with which of the following infectious agents?
a. EBV
b. HIV
c. HTLV-1
d. Hepatitis
The correct answer is: HTLV-1
150
Which of the following are the two most common symptoms of carcinoid syndrome?
a. Impaired cognitive function and pellagra-like skin lesions
b. Tricuspid insufficiency and pulmonary stenosis
c. Asthma like symptoms and abdominal pain
d. Diarrhea and flushing
The correct answer is: Diarrhea and flushing
151
On histopathologic examination of resected sample from a patient diagnosed with colon cancer, tumor involvement was through the muscularis level with no nodal involvement. What is the expected 5 year survival rate of this patient?
a. 86 – 95%
b. 70–85%
c. 50–69%
d. 25–49%
The correct answer is: 70–85%
152
A 35 year old female had an incidental finding of a 3cm hepatic nodule on ultrasound. Which of the following should be the next step in her work-up?
a. Repeat ultrasound at 4 months
b. 4-phase CT Scan
c. T2* MRI
d. Biopsy
The correct answer is: 4-phase CT Scan
