Transplants, Immunology, and Oncology

Question 1

43yo man with a gangrenous gallbladder and Gram neg sepsis agrees to participate in a research study. an assay of tumor necrosis factor (TNF) is performed. which of the following is the origin of this peptide?

a. fibroblasts
b. damaged vascular endothelial cells
c. monocytes/macrophages
d. activated T lymphocytes
e. activated killer lymphocytes

Answer 1

C

TNF = by endotoxin-activated monocytes and macrophages.

• PMN activation and dgranulation
• increased nonspecific host resistance
• increased vascular permeability
• lymphopenia
• promotion of IL1, 2, 6
• capillary leak syndrome
• microvascular thrombosis
• anorexia & cachexia
• protective & adverse effects in sepsis.

Question 2

49yo man who underwent liver transplantation 5y ago for alcoholic cirrhosis presents with a gradually increasing bilirubin level. he undergoes a liver biopsy, which demonstrates a paucity of bile ducts. which of the following is his best option for treatment?

a. increase his imunosuppression
b. administration of a monoclonal antibody against T cells.
c. exploratory laparotomy with hepatic arterial reconstruction
d. exploratory laparotomy with thrombectomy of the portal vein
e. retransplantation

Answer 2

E. chronic rejection

paucity = barely any bile ducts –> due to immune-mediated injury in the biliary epithelium “vanishing bile duct syndrome”

If portal vein thrombosis –> exploratory laparotomy and thrombecty

If hepatic arterial thrombosis (–> can lead to biliary structures secondary to ischemia) = reexploration adnd thrombectomy with revision of anastamosis

Question 3

52yo woman with renal failure is listed as a transplant candidate. in order to assess the propriety of the transplant, which of the following combos represents how a cross-match is performed?

a. donor serum with recipient lymphocytes and complement
b. donor lymphocytes with recipient serum and complement
c. donor lymphocytes with recipient lymphocytes
d. recipient serum with a known panel of multiple donor lymphocytes
e. recipient serum with donor RBCs and complement.

Answer 3

B. Whether recipient has circulating Abx against donor HLA antigens

a. do see if the donor lymphocytes would attack the recipient/s serum - body?
b. or if the host’s lympcytes would attack the donor’s serum (transplant)
c. disaster

Question 4

39yo woman presents with generalized malaise and lymphadenopathy. biopsy of a supraclavicular lymph node reveals non-Hodgkin lymphoma. 48h after initiation of chemotherapy. she develops a high grade fever and her lab studies demonstrates hyperkalemia, hyperphosphatemia, and hypocalcemia. which of the following cells mediate this syndrome

a. macrophages
b. cytotoxic T lymphocytes
c. natural killer cells
d. PMN leukocytes
e. helper T lymphcytes

Answer 4

B. cytotoxic T cells.

tumor lysis syndrome –> after initially of chemotherapy = due to destruction of tumor cells.

• tumor lysis = hyperkalemia; hyperphosphatemia
• precipitation of phosphate & Ca = hypocalcemia (opposite to PO4)

timeline - macrophages, natural killer cells, & PMNs act fastest

Question 5

33yo diabetic man receives a renal allograft. the physicians choose cyclosporine as one of the antirejection meds. which of the following functions does cyclosporine A primarily inhibit?

a. macrophages function
b. antibody production
c. IL-1 production
d. IL-2 production
e. cytotoxic T cell effectiveness

Answer 5

D

IL-1, 2, 3, 4, 5
Hot T Bone stEAk

IL-2 = T cells

Question 6

24yo woman presents with lethargy, anorexia, tachypnea, and weakness. lab studies reveal a BUN of 150, serum creatinine of 16, and K of 6.2. CXR shoes increased pulmonary vascularity and dilated heart. which of the following is the most appropriate management of this pt?

a. emergency kidney transplantation
b. creation and immediate use of a forearm arteriovenous fistula
c. placement of a catheter in the internal jugular vein and initiation of hemodialysis
d. a 100g protein / day diet
e. renal biopsy

Answer 6

C. needs to be more immediate. Fistula takes a while to get along

Indications for dialysis
A = acidosis
E = excess 
I = intoxication
O = overload of fluids
U = uremia

Question 7

a hypertensive 47yo man is proposed for kidney transplantation. he is anemic but is otherwise functional. which of the following would preclude renal transplantation

a. positive cross-match
b. donor blood type O
c. 2-antigen HLA match with donor
d. BP of 180/100 mmHg
e. Hgb of 8.2

Answer 7

A. positive cross-match = recipient has circulating Abs that are cytotoxic to donor-strain lymphcytes –> will lead to acute rejection of graaft

hypertensive due to what reason? - most common = renal stenosis. don’t want to risk the new kidney if have something intrinsically wrong

low Hgb likely because of bad kidney

Question 8

56yo woman is undergoing a cadaveric renal transplant. after revascularization of the transplanted kidney, the transplanted renal parenchyma becomes swollen and blue. the surgeon suspects hyperacute rejection. what is the treatment of choice for this pt?

a. there is no therapy for hyperacute rejction
b. systemic anticoagulation
c. catheter-directed anticoagulation into the renal artery
d. IV steroids
e. IV steroids & cyclosporine

Answer 8

A. hyperacute rejection - within minutes after transplantation (preformed antibody). usually occurs during surgery after the clamps are released from teh vascular anastamosis & recipient Abs are exposed to donor passenger lymphocytes and kidney tissue.

can’t do anything - take out the kidney

Question 9

56 yo man has end-stage heart failure due to atherosclerosis. his cardiologist refers him for evaluation for heart transplantation. which of the following is an absolute contraindication for heart transplantation?

a. cirrhosis
b. age > 65
c. diabetes w/out end-organ damage
d. reversible high pulmonary vascular resistance
e. hx of colon cancer resected 5y ago with no evidence of recurrence.

Answer 9

A

b/c can lead to RHF

Contraindications to heart transplant

• high, irreversible pulmonary vascular resistance
• irreversible renal insufficiency
• DM with end-organ damage
• symptomatic extravascular dx
• current / recent malignancy (<2y)
• noncardiac comorbidity limiting survival = cirrhosis, symptomatic COPD)
• active infection
• active PUD
• high risk for inability to comply with medical regimen

the others are relative contraindications

Question 10

47yo man with hypertensivee nephropathy develops fever, graft tenderness, and oligura 4w following cadaveric renal transplantation. serum creatinine is 3.1. a renal U/S reveals mild edema of renal papilla but normal flow in both the renal artery and the renal vein. nuclear scan demonstrates sluggist uptake and excretion.

a. perform an angiogram
b. decreasing steroid and cyclosprine dose
c. begin IV antibiotics
d. perform renal biopsy, steroid boost, and Ig therapy
e. beginning FK 506.

Answer 10

D

Acute rejection (1w-3mo)? - the organ is failing.

the blood vessels look fine.

Dx = biopsy of renal tissue
Tx = high dose steroids; anti-T cell Ab

Question 11

approx 6w following a kidney transplant, a 59yo woman develops fever, malaise, and myalgias and is found to have a CMV infection. which of the following is a potential sequela of CMV infection?

a. pyelonephritis
b. GI ulceration and hemorrhage
c. cholecystitis
d. intra-abdominal abscess
e. parotitis

Answer 11

B

Gi hemorrhage, inflammation of any GI organs (including pancreas)
blindness
flu-like sxs
electrolyte abnormalities
dizziness / neurological sxs

bacterial infections = pyelonephritis, cholecystitis, intra-abdominal abscess, parotitis

Question 12

55yo man presents with with worsening cirrhosis. after evaluation by a hepatologist, he presents for evaluation for hepatic transplantation. he is informed that prioritzation is based on the MELD score, and that patients with higher MELD scores have a greater benefit from transplantation. which of the following contributes to the MELD score?

a. platelet count
b. total bilirubin
c. albumin
d. encephalopathy
e. ascites

Answer 12

B

very numerically based

• tbili
• INR
• creatinine

DOES NOT assess based on subjective clinical parameters - degree of ascites / encephalopathy

Question 13

a young woman who has received a transplant has posttransplant fever and malaise. GVHD is diagnosed. this has occurred most commonly with the transplantation of which of the following?

a. kidney
b. lung
c. heart
d. bone marrow
e. pancreas

Answer 13

D

• bone marrow / spleen –> b/c WBCs present in graft tissue
• liver

Question 14

a brain dead potential donor has become available. you must plan for the dispersal of the thoracic organs. which of the following will necessitate a heart-lung transplant?

a. primary pulmonary HTN
b. cystic fibrosis
c. end-stage emphysema
d. idiopathic dilated cardiomyopathy with long-standing secondary pulmonary HTN
e. end-stage pulmonary fibrosis secondary to sarcoidosis

Answer 14

D

unexplained (primary, sarcoidosis) - means that their new transplants will also get affected

the others would require one but not the other

Question 15

a 35yo man who has had T1DM for many years undergoes a pancreas transplant with enteric drainage (connection of the donor duodenum to the recipient jejunum). postop, he has increased pain near his pancreas transplant. which of the following should be performed to confirm a diagnosis of rejection?

a. percutaneous biopsy of the transplanted pancreas
b. measurement of serum amylase levels
c. measurement of serum lipase levels
d. measurement of urinary amylase levels
e. determination of the ratio of the level of urinary amylase to serum amylase

Answer 15

A

Question 16

55yo woman who has end-stage liver disease is referred to a hepatologist for evaluation. which of the following would prevent her from a transplantation candidate?

a. use of EtOH 3 mo ago
b. two 2cm HCC in the R lobe of the liver
c. a 4cm HCC in the R lobe of the liver
d. development of the hepatorenal syndrome requiring hemodialysis
e. hx of breast cancer 5y ago w/ no evidence of disease currently

Answer 16

A

contraindications to liver transplant

• ongoing / recent substance abuse
• active sepsis infection
• extrahepatic malignancy
• poor cardiac / pulmonary fx
• HCC + metastatic dz
• obvious vascular invasion
• significant tumor burden

Question 17

a kidney transplant recipient presents with severe acute rejection that does not respond to steroid treatment. administration of which of the following agents is the best step in her management?

a. cyclosporine
b. tacrolimus
c. azathioprine
d. muromonab-CD3
e. sirolimus

Answer 17

D

Question 18

19yo college student presents with a testicular mass, and after treatment he returns for regular follow up visits. which of the following is the most useful serum amrker for detecting recurrent disease after treatment of nonseminomatous testicular cancer?

a. CEA
b. hCG
c. PSA
d. CA-125
e. p53 oncogene

Answer 18

B
nonseminomatous –> AFP, hcg, ldh

seminomatous –> hCG

Question 19

edentulous 72 yo man with a 5y hx of cigarette smoking presents with a nontender hard mass in the lateral neck. which of the following is the best diagnostic test for establishing a diagnosis of malignancy

a. fine-need aspiration cytology
b. bone marrow biopsy
c. nasopharyngoscopy
d. CT scan of the head and neck
e. sinus xray

Answer 19

A

80% of isolated enlarged cervical lymph nodes in adults are malignant
- metastatic SCC

Dx = FNA

Question 20

49yo woman undergoes surgical resection of a malignancy. the family asks about the prognosis. the histopathology is available for review. for which of the following malignancies does histologic grade best correlate with prognosis?

a. lung cancer
b. melanoma
c. colonic adenocarcinoma
d. hepatocellular carcinoma
e. soft tissue sarcoma

Answer 20

E

grade –> stage –> prognosis

tumors where histologic GRADING has prognostic value
- soft tissue sarcoma, TCC of bladder, astrocytoma, chondrosarcoma

tumors where STAGING has better prognostic value
- melanoma, HCC, osteosarcoma, lung, CRC

Question 21

a mother notices an abdominal mass on her 3yo son while giving him a bath. there is no hx of any sxs, but thte boy’s BP is elevated at 105/85. metastatic workup is negative and the pt is explored. the mass shown here is found within the L kidney. genetic testing reveals 2deletion of 2 genes on chromosome band 11p13. which of the following anomalies in addition to the identified tumor is associated with these chromosomal deletions?

a. cardiac anomalies
b. hemihypertrophy
c. hypoglycemia
d. macroglossia
e. aniridia

Answer 21

B

Wilm’s tumor - abdominal mass deep it.

Me WAGu Beef
- mental retardation
- Wilms
- Aniridia
- GU problems
- Beckwith Widemann syndrome (overgrowth d/o) --> gigantism, macroglossia, hypoglycemia, hemihypertrophy 
-

Question 22

11yo girl presents to your office b/c of a family hx of medullary carcinoma of the thyroid. physician examination is normal. which of the following tests should you perform?

a. urine vanillymandelic acid (VMA) level
b. serum insulin level
c. serum gastrin level
d. serum glucagon level
e. serum somatostatin level

Answer 22

A

medullary carcinoma –> MEN 2a

p heochromocytoma –> VMA and metanephrines
p arathyroid
m edullary carcinoma

Question 23

37yo woman has developed a 6cm mass on her anterior thigh over the past 10mo the mass appears to be fixed to the underlying muscle, but the overlying skin is movable. which of the following is the most appropriate next step in management?

a. above-knee amputation
b. excisional biopsy
c. incisional biopsy
d. bone scan
e. abdominal CT scan

Answer 23

C

sarcoma / rhambdomyoma

risk for malignancy –> for tumors > 5cm; symptomatic; rapid growth in short period of time

Small tumor (<5cm) --> excisional
Large tumor (>5cm) --> incisional

Question 24

50yo man is incidentally discovered to have a low grade MALT lymphoma on biopsy of the stomach during esophagogastroduodenoscopy for dyspepsia. CT scans of the chest, abdomen, and pelvis demonstrate no evidence of enlarged regional lymph nodes or distant metastates. which of the following is the initial treatment of choice?

a. total gastrectomy with esophagojejunostomy
b. total gastrectomy with esophagojejunostomy and adjuvant chemotherapy
c. cheotherapy
d. steroids
e. antibiotics

Answer 24

E

no evidence of mets or lymph nodes.

MALT lymphoma - still low grade. so can treat as very localized.

1) 2abx + PPI to treat H pylor –> eradication of H pylori assocaited with complete regression of low-grade MALT lymphoma
2) chemotherapy + external beam radiation –> for persistent / advanced MALT lymphoma

** SURGERY RARELY DONE

Question 25

33yo woman seeks assistance b/c of a swelling of her R parotid gland. biopsy is performed and reveals acinar carcinoma. you consent the pt for resection and informed her that at the very least, she will require superficial parotidectomy. which of the following intraoperative findings would require sacrifice of the facial nerve.

a. invasion of the deep lobe of the parotid
b. invasion of the lateral lobe of the parotid
c. proximity of the carcinoma to the facial nerve
d. encasement of the facial nerve by carcinoma
e. the facial nerve should always be preserved regardless of intraoperative findings.

Answer 25

D

b/c it’s important -. so only take it if absolutely necessary

Question 26

42yo man is undergoing chemotherapy after resection of a cecal adenocarcinoma with positive lymph nodes. you are asked to see him regarding surgical complication. which of the following potentially operable complications is a common occurrence among pts receiving systemic chemotherapy?

a. acute cholecystitis
b. perirectal abscess
c. appendicitis
d. incarcerated femoral hernia
e. diverticulitis

Answer 26

B

+ anal fistula

Question 27

28yo medical student seeks your attention b/c of a testicular mass. biopsy is consistent with a pure seminoma. there is no evidence of enlarged retroperitoneal lymph nodes on CT scan. which of the following is the best treatment strategy for this pt?

a. orchiectomy alone
b. orchiectomy, then chemotherapy
c. orchiectomy with retroperitoneal lymph node dissection
d. orchiectomy with retroperitoneal lymph node dissection, then external beam radiation
e. orchiectomy, then external beam radiation to the retroperitoneal lymph nodes

Answer 27

E

sentinel nodes?

seminomas have the best prognosis –. very radiosensitive & thus don’t need to go after the retroperitoneal LN

Question 28

25yo woman with end stage renal disease is exploring the benefits of renal transplantation. which of the following is an advantage of dialysis over renal transplantation

a. better pt survival
b. more cost-effective long term
c. improved quality of life
d. no need for lifelong immunosuppression
e. more cost-effective if the renal transplant functions for >2y

Answer 28

D

Pro

• better pt survival
• improved QoL
• decreased long-term costs, if graft lasts >2y

Con
- lifelong immunosuppression

Question 29

a 30yo previously healthy man presents with refractory HTN on 4 medications. UA is positive for metanephrines. he was adopted as an infant and therefore does not know his family hx which of the following inherited syndromes is NOT associated with this dz?

a. MEN2A
b. MEN2B
c. von Hippel-Lindau disease
d. neurofibromatosis I
e. neurofibromatosis II

Answer 29

E

MEN1a = pituitary, pancreatic, parathyroid
MEN2a = parathryoid, pheo, medullary thyroid
MEN2b = pheo, medullary thyroid, Marfan, mucosal neuroma

Question 30

24yo man whose father was just diagnosed with colon cancer presents to hsi family physician to discuss screening colonoscopy. his physician suspets that he has hereditary nonpolyposis colon cancer (HNPCC) or lynch syndrome and recommends screening colonoscoopy beginning at age 25. which of the following is the most supportive of a clinical diagnosis of HNPCC?

a. a father with colon cancer at 52yo
b. a father & uncle (same side of family) with colon cancer
d. a father and 2 uncles (same side of family) with colon cancer
e. a father, uncle, and grandfather (same side of family) with colon cancer at 50yo.

Answer 30

E

anything =/<50yo

• at least 3 relatives with CRC, one of whom is a first degree relative
• 2 successive generations
• diagnosis of at least one of the cancers <50yo

start screening at 20-25yo or 10y earlier than the youngest family member with CRC (whichever earlier)

Question 31

53yo woman presents with bright redblood per rectum, increasing abdominal distention and weight loss. she is found to have a large fungating mass 8cm from the anal verge. no other lesions are identified. biopsy is consistent with invasive rectal adenocarcinoma. endorectal U/S shows invasion of the tumor into theperirectal fat and multiple enlarged lymph nodes. CT scans of the chest, abdomen, and pelvis do not show any metastases. she would like to preserve her sphincter if possible. which of the following is the best treatment option for this pt given her preferences?

a. abdominoperineal resection
b. neoadjuvant chemoradiation, then low anterior resection
c. neoadjuvant chemoradiation, then abdominoperineal resection
d. transanal excision , then adjuvant chemoradiation
e. neoadjuvant chemoradiation followed by transanal excision

Answer 31

B

lymph nodes –> Stage 3

neoadjuvant first –> to help shrink tumor burden

• EARLY STAGE = transanal excision, within 10cm of anal verge
• LAR (low anterior resection) - rectal resection with colorectal anastamoss
• APR (abdominoperineal resection) - resection of rectum & anus with formation of permanent colostomy (against her wishes)

Question 32

35yo woman presents with a R breast mass. you perform a thorough H&P as well as core biopsy of the R breast mass. in which of the following circumstances would a sentinel node biopsy be indicated?

a. the core biopsy is consistent with DCIS without comedo necrosis for which the pt desires partial mastectomy only
b. the core biopsy is consistent with ductal carcinoma and the pt has a positive pregnancy test
c. the core biopsy is consistent with ductal carcinoma and the pt desires a partial mastectomy
d. the core biopsy is consistent with ductal carcinoma and the pt has palpable axillary lymph nodes
e. the core biopsy is consistent with ductal carcinoma and the pt has a bone scan suspicious metastasis

Answer 32

C. extensive disease (multifocal DCIS or ductal carcinoma –> b/c total mastectomy + radiation + LN dissection). can’t find it after if take the whole breast

LN biopsy –> if there is something that can be done with the info

• no palpable LN –> b/c would otherwise just get the LN disssection intraoperatively
• no Mets –> b/c wouldn’t do the surgery anyway
• not unifocal DCIS alone –> b/c would only do a partial mastectomy. (as long as get negative margins, can stop excision and any LN)

not D, E

Question 33

a pt reqruies both cardiac & renal transplantation. preparation for the procedures has begun. how do cardiac allografts differ from renal allografts?

a. cardiac allografts are matched by HLA tissue typing and renal allografts are not
b. cardiac allografts can tolerate a longer period of cold ischemia than renal allografts
c. one year graft survival for cardiac allografts is substantially lower than that for renal allografts
d. cardiac allografts are matched only by size and ABO blood type
e. cyclosporine is a critical component of the immunosuppressive regimen for cardiac allografts but not renal allografts.

Answer 33

D.

NOT a, e

CARDIAC only

• matching by size & ABO blood type (rather than tissue typing)
• short cold-preservation time of 4-5 house (tissue typing is not possible with that short time frame)

RENAL only
- tissue typing (esp. for cadaveric kidney allograft matching)

Renal & cardiac similarities

• > 80% one-year survival rate
• immunosuppression with calcineurin inhibitors (FK506, cyclosporine0, steroids, antimitotic agents (azathiorpine, mycophenolate mofetil)

Question 34

a pt with colon cancer has a mass in the upper lobe of his L lung 2.5y following resectin of his colon cancer and subsequent 12mo of chemotherapy. his CEA level is rising. which of the following predicts a 5y survival rate of >20% following resection of pulmonary metastases?

a. other organ metastases are prsent
b. lung lesions are solitary
c. local tumor recurrence is found
d. the tumor doubling rate is <20d
e. the pt has received prior chemotherapy

Answer 34

B. Surgery is indicated ONLY if primary tumor is controlled, r/out diffuse metastatic disease, safely resectable location.

Good prognosis
- solitary lesions –> resction of pulmonary mets (if solitary) has high survival rates = 25-35% (»> resection for primary bronchogenic carcinoma)

bad prognosis

• other mets present
• local tumor recurrence
• rapid tumor growth (short doubling rate)
• prior chemo = risk of causing tumorgenesis elsewhere

Question 35

61yo man undergoes upper endoscopy for evaluation of weight loss and is identified to have a submucosal mass in the stomach. biopsy is consistent with GIST. w/up reveals the presence of liver mets. which of the following is the best initial treatment for this pt?

a. tyrosine kinase inhibitor (imatinib)
b. mAb against IL2 (daclizumab)
c. mAb against TNF-alpha (infliximab)
d. mAb against vascular endothelial growth factor A (bevacizumab)
e. mAb against epidermal growth factor receptor (cetuximab)

Answer 35

A

For GIST = c-kit (tyrosine kinase) receptors
- treatment of metastatic GIST = imatinib

Bevacizumab, cetuximab = for various caners

Infliximab = for autoimmune dz (IBD)

Daclizumab = immunosuppression for rejection in organ transplantation

Question 36

57yo woman develops bony metastases 1y after R modified radical mastectomy for breast Ca. the tumor was ER-, PR-, Her2/Neu +. which of the following agents is indicated for the treatment of her metastatic disease?

a. antiestrogen (tamoxifen)
b. SERM (raloxifene)
c. mAb (trastuzumab)
d. aromatase inhibitor (anastrozole)
e. 5-fluorouracil

Answer 36

C

Question 37

42yo man is diagnosed with an osteosarcoma. his Fhx is significant for a 37yo sister with breast Ca and an uncle with adrenocortical carcinoma. his family doc suspects that he may have Li-Fraumeni syndrome and suggests genetic testing which of the following genes is most likely to be mutated if he has the syndrome?

a. APC gene
b. RET
c. p53
d. PTEN
e. p16

Answer 37

C

p53 = Li-Fraumeni
APC = FAP
RET = MEN2
PTEN = Cowden disease, multile hamartoma
p16 = hereditary malignant melanoma

Question 38

a pt with a solid malignancy discusses chemotherapy with is oncologist. he is interested in the risks of the treatment. which of is the primary toxicity of doxorubicin (adriamycin)

a. cardiomyopathy
b. pulmonary fibrosis
c. peripheral neuropathy
d. uric acid nephropathy
e. hepatic dysfunction

Answer 38

A

“D” –> heart
“B” –> lungs

Question 39

22yo woman has a known family hx of breast ca in her first degree relatives. she undergoes genetic testing and is found to be a BRCA1 mutation carrier. she does not currently desire b/l prophylactic mastectomy. which of the following is the next best option to manage her risk for breast cancer?

a. mammography q6mo starting at age 25
b. mammography q6mo starting at age 35
c. mammography q12mo starting at age 25
d. mammography q12mo starting at age 35
e. tamoxifen for chemoprevention

Answer 39

C
biannual clinical exams and annual mammograms starting at age 25

most women start mammography at 40yo

NOT tamoxifen b/c is a serm (estrogen+ and -) –> would like to bone building (GOOD!) and endometrial hyperplasia (BAD!)

Question 40

56yo woman is undergoing chemotherapy. she presents today with complains of burning on urination and bloody urine. which of the following agents causes hemorrhagic cystitis?

a. bleomycin
b. 5-fluorouracil
c. cisplatin
d. vincristine
e. cyclophosphamide

Answer 40

E

"c" - ototoxicity
"cy" - hemorrhagic cystitis
"b" - lungs
"vincristine" - peripheral neuropathy
"5-fu, 6-MP" - myellosuppression

Question 41

38yo woman who underwent a cadaveric renal transplant 8y ago presents with fevers, fatigue, and weight loss. evaluation included CT scans of the head, neck, chest, abdomen and pelvis. she is noted to have diffuse lymphadenopathy and pulmonary nodules. a biopsy and histoogic examination of a lymph node is performed. which of the following viruses is most likely to be present in the lymph node?

a. CMV
b. HPV
c. HHV8
d. EBV
e. coxsackie virus

Answer 41

D

EBV –> for secondary lymph cancers = “posttransplant lymphoproliferative disorders.

chronic immunosuppression

Question 42

41yo man undewent a sucessful living-related kidney transplantation 1y ago with good results. preop, he was noted to have an elevated Ca level. Post-transplantation, he continues to have elevated Ca lvels and associated sxs. which of the following is the most appropriate next step in management?

a. 99m-Tc sestamibi scanning
b. US of the neck
c. CT scan of the neck and mediastinum
d. total parathyroidectomy with autotransplantation of a portion of a gland into the forearm
e. measurement of urinary Ca levels

Answer 42

D

hypercalcemia in a hospitalized pt –> most likely due to cancer.

hypercalcemia in an outpatient –> hyperparathyroidism (tertiary)
d/t automatous parathyroid fx after renal transplantation

Question 43

53yo man presents with constipation and a 20lb weight loss over the course of 6mo. colonoscopy reveals a fungating mass in the sigmoid colon. biopsy is consistent with adenocarcinoma. his metastatic workup is negative. a CEA level is obtained and is 4x greater than normal. which of teh following is the appropriate use of this test?

a. as an indication for neoadjuvant chemotherapy
b. as an indication for postoperative radiation therapy
c. as an indication for preoperative PET scanning
d. as an indication for more aggressive sigmoid rsection
e. as a baseline measurement prior to monitoring postoperative for recurrence

Answer 43

E

CEA –> for CRC

Question 44

for each stage in the pt's treatment, select the appropriate next step. 
a. L hemicolectomy
b. R hemicolectomy
c. subtotal colectomy
d. total colectomy
e. hepatic resection
f. external beam irradiation
g. 5-fluorouracil and leucovorin
h. external beam irradiation and chemotherapy
i. abdominal MRI
j. no further treatment
65yo man presents to his PCP with complaints of intermittent constipation and is found to have microcytic anemia. colonoscopy reveals a fungating mass in the proximal sigmoid colon with no other synchronous lesions. biopsy of the mass confirms adenocarcinoma

Answer 44

A. L hemicolectomy with 5cm margin of proximal & distal ends, with dissection of the draining lymph node basin

R hemicolectomy is more concerning for bowel death

Question 45

for each stage in the pt's treatment, select the appropriate next step. 
a. L hemicolectomy
b. R hemicolectomy
c. subtotal colectomy
d. total colectomy
e. hepatic resection
f. external beam irradiation
g. 5-fluorouracil and leucovorin
h. external beam irradiation and chemotherapy
i. abdominal MRI
j. no further treatment
the pt undergoes surgery and recovers uneventfully. pathology of the resected specimen is reported as T3, N1 with negative surgical margins

Answer 45

G

any nodes –> need chemofor more distant stuff

radiation –> if tumor is large / locally extensive

Question 46

for each stage in the pt's treatment, select the appropriate next step. 
a. L hemicolectomy
b. R hemicolectomy
c. subtotal colectomy
d. total colectomy
e. hepatic resection
f. external beam irradiation
g. 5-fluorouracil and leucovorin
h. external beam irradiation and chemotherapy
i. abdominal MRI
j. no further treatment
at 6mo follow up an abdominal CT scan shows a 2cm isolated lesion in the R lobe of the liver. repeat colonoscopy shows no evidence of recurrent or metachronous lesions. CXR and bone scan are normal

Answer 46

E. resect if it’s possible (segment-wise) & able to get negative margins,, and no other evidence of metastasis.

at least - resect and send frozen sections.

either new cancer or metastasis

liver is a very common place for CRC to go.

Question 47

32yo man with diabetic nephropathy undergoes an uneventful renal transplant from his sister (2-haplotype match) his immunosuppressive regimen includes azathioprine, steroids, and cyclosporine. for each development in the postop period, select the most appropriate next step. 
a. begin gancyclovir
b. administer steroid boost
c. withhold steroids
d. decrease cyclosporine
e. increase cyclosporine
f. decrease azathioprine
g. obttain renal US
h. begin broad-spectrum antibiotics
on postop day 3, the pt is doing well, but you notice that on his routine lab tests that his WBC is 2.0 (= 2K)

Answer 47

F
—> leukopenia

initial rxn to steroids –> leukocytosis due to let down of the neutrophils

azathioprine –> myelosuppression

Question 48

32yo man with diabetic nephropathy undergoes an uneventful renal transplant from his sister (2-haplotype match) his immunosuppressiv regimen includes azathioprine, steroids, and cyclosporine. for each development int he pstop period, select the most appropriate next step. 
a. begin gancyclovir
b. administer steroid boost
c. withhold steroids
d. decrease cyclosporine
e. increase cyclosporine
f. decrease azathioprine
g. obttain renal US
h. begin broad-spectrum antibitoics
the pts WBC gradually returns to normal, but on POD7 he develops a fever of 39.4 (103F) and a nonproductive cough. a CXR reveals diffuse interstitial infiltrates and a buffy coat is positive for viral inclusions

Answer 48

A

DNA-based virus

CMV pneumonitis

Question 49

32yo man with diabetic nephropathy undergoes an uneventful renal transplant from his sister (2-haplotype match) his immunosuppressiv regimen includes azathioprine, steroids, and cyclosporine. for each development int he pstop period, select the most appropriate next step. 
a. begin gancyclovir
b. administer steroid boost
c. withhold steroids
d. decrease cyclosporine
e. increase cyclosporine
f. decrease azathioprine
g. obttain renal US
h. begin broad-spectrum antibiotics
the pt recovers from his illness and is discharged home on POD18. at 3mo follow up he is doing well, but you notice that his creatinine is 2.8. he has no fever, his graft is not tender, and his renal US is normal.

Answer 49

D

cyclosporine can cause hemorrhagic cystitis (nephrotoxic)

diffdx

• anastomotic problems
• urologic complications
• infection
• nephrotoxicity

Question 50

32yo man with diabetic nephropathy undergoes an uneventful renal transplant from his sister (2-haplotype match) his immunosuppressiv regimen includes azathioprine, steroids, and cyclosporine. for each development int he pstop period, select the most appropriate next step. 
a. begin gancyclovir
b. administer steroid boost
c. withhold steroids
d. decrease cyclosporine
e. increase cyclosporine
f. decrease azathioprine
g. obttain renal US
h. begin broad-spectrum antibiotics
6mo following is transplant, the pt begins to develop fever, malaise, pain of the RLQ. on palpation, the graft is tender. CXR and urine and blood cultures are normal. renal U/S shows an edematous graft

Answer 50

B
Chronic rejection

first acute rejection tx

• steroid boost
• mab (muromonab CD3)
• pooled antibodies against lymphocytes (ALGs)