For previous patients, after the appropriate evaluation, the patient undergoes surgery. No intraoperative evidence of metastases is identified. Postoperatively, the pathology report reveals that the tumor is an adenocarcinoma invading into the pericolonic fat, with 2 involved lymph nodes. After the patient recovers from surgery, which of the following is the most appropriate next step in his management?

Measurement of CEA levels yearly

Abdominal CT scan every 6 months

No further therapy is indicated, because the involved nodes were removed

Chemotherapy with 5-fluorouracil (5-FU) based regimen

Measurement of CEA levels yearly

A 78-year-old woman with coronary artery disease and severe chronic obstructive pulmonary disease is admitted to the hospital with painless jaundice. CT scan reveals the presence of multiple lesions in the liver, suggestive of metastases, and a nearly obstructing upper rectal mass. Colonoscopy demonstrates a large, ulcerated tumor in the proximal rectum and a residual lumen of less than 1 cm in diameter. While in the hospital, the patient develops a large bowel obstruction. What is the best treatment modality for this patient?

Immediate radiation therapy of the rectal mass

Placement of a colonic decompression tube

Emergency surgery with resection of the mass

Emergency surgery with creation of a diverting colostomy

Placement of a rectal self-expanding metal stent

Which of the following adjuvant systemic therapies would be most appropriate to recommend for an otherwise healthy patient who has HER-2/neu-positive (FISH) ER/PR-negative breast cancer with positive axillary lymph nodes?

Four cycles of paclitaxel, four cycles of AC with concurrent trastuzumab, and continuation of trastuzumab for 1 year.

Four cycles of dose-dense doxorubicin and cyclophosphamide (AC) in conjunction with four cycles of paclitaxel.

Four cycles of AC, four cycles of paclitaxel with concurrent trastuzumab, and continuation of trastuzumab for 1 year.

Four cycles of paclitaxel, four cycles of AC with concurrent trastuzumab, and continuation of trastuzumab for 1 year.

Six cycles of docetaxel, doxorubicin, and cyclophosphamide.

A 23-year-old man is evaluated because of a painless right-sided scrotal mass. Ciprofloxacin, 500 mg every 12 hours, is administered for 10 days, but he notes little improvement in the swelling. His serum -fetoprotein level is elevated at 100 ng/mL, and his 13-human chorionic gonadotropin level is 64 m/UImL. Testicular ultrasound examination reveals a hypoechoic mass. Which of the following would be the most appropriate next step in his treatment?

Retroperitoneal lymph node dissection

Combination chemotherapy with bleomycin, etoposide, and cisplatin

A 68-year-old man presents to his primary care physician for a routine physical examination. The patient s medical history is significant for hypertension. The patient is found to have guaiac-positive stools and is subsequently referred for colonoscopy. Colonoscopy reveals a golf ball -size, near-obstructing tumor in the descending colon, not admitting the scope. The biopsy is positive for adenocarcinoma of the colon. Which of the following is the next step in the management of this patient?

Schedule a barium enema to evaluate the proximal colon

Full metastatic workup first, and if negative, then plan for colon resection

A course of radiation therapy prior to any resection

Plan for pre-operative chemotherapy

Do metastatic work up, but plan for colon resection anyway

Schedule a barium enema to evaluate the proximal colon

A 59-year-old woman with an 80-pack-year smoking history is evaluated because of weight loss and severe pain in the upper part of her left leg. She has lost 11.3 kg (25 Ib) from baseline weight of 59 kg (130 Ib). A large lytic lesion is noted on the left femur, with erosion into the cortex. Bone scan shows multiple lesions, and CT scan of the chest shows a large left hilar mass and med iastinal lymphadenopathy. Bronchoscopic biopsy specimen shows poorly differentiated adenocarcinoma. Radiation therapy to the left femur is initiated. Which of the following findings would preclude use of palliative chemotherapy for this patient?

A solitary liver metastasis with normal serum bilirubin level

Multiple liver metastases with a serum bilirubin level of 3.0 mg/dL

A cytologically positive pleural effusion

A 63-year-old man is evaluated because of new-onset hemoptysis and a 100-pack-year smoking history. Chest radiograph shows a 4-cm right perihilar mass, and bronchoscopic biopsy and cytologic evaluation of sputum confirm squamous cell carcinoma. There are no significant findings on physical examination, and the patient reports no weight loss.Complete blood count is normal except for a serum alkaline phosphatase level at 110 U/L. CT scans of the chest and abdomen show no mediastinal adenopathy. Results of a positron emission tomography scan are negative, except for the right perihilar mass.In which of the following situations would surgical therapy be offered?

A small effusion is noted in the right hemithorax, and cytopathologic examination of the pleural fluid is positive for tumor.

A solitary bone metastasis is noted on bone scan, and a lytic lesion is confirmed radiographically.

A solitary liver metastasis is noted on CT scan and confirmed by needle biopsy and positron emission tomography scan.

A solitary brain metastasis is noted on CT scan of the head.

A small effusion is noted in the right hemithorax, and cytopathologic examination of the pleural fluid is positive for tumor.

A 50-year-old perimenopausal woman is evaluated because of abdominal swelling. CT scan of the chest, abdomen, and pelvis shows mesenteric lymphadenopathy and a small amount of ascites but no ovarian masses. Needle biopsy specimen shows adenocarcinoma; the tumor is found to be negative for hormone receptors. The serum carcinoembryonic antigen level is normal at 2.0 ng/mL and the serum CA-125 is 1200 ng/mL (elevated). What is the best next step in her treatment?

Radiation therapy to a wide port

Positron emission tomography scan to assess other sites of disease

Bone scan to rule out skeletal metastases

A 58-year-old woman with a 60-pack-year smoking history is evaluated because of hemoptysis and weight loss. Chest radiograph and CT scan show a right perihilar mass with mediastinal adenopathy. The results of CT scans of the abdomen, bone scan, and MRI of the head are otherwise negative. Examination of a specimen by bronchoscopic biopsy confirms small-cell lung cancer, and the findings suggest limited-stage disease. After the patient completes mediastinal radiation therapy and four cycles of cisplatin and etoposide, repeat CT scans indicate that her disease is in complete remission. What is the best recommendation concerning further therapy?

Four more cycles of chemotherapy, including a taxane

Prophylactic cranial irradiation

Four more cycles of chemotherapy, including a taxane

Resection of the localized disease

No further therapy; follow-up only

A 68-year-old man with a 60-pack-year smoking history is evaluated because of hemoptysis. Radiograph of the chest shows a right hilar mass and mediastinal widening. CT scans of the chest and abdomen confirm the hilar mass and bulky lymphadenopathy in the mediastinum with no other overt metastases. Bronchoscopic biopsy specimen shows small-cell lung cancer. Bone scan and CT scan of the head are negative for tumor. A low serum sodium level and inappropriately high urine osmolality suggest that he has the syndrome of inappropriate antidiuretic hormone secretion. Which of the following is the most appropriate treatment recommendation?

Chemotherapy followed by radiation therapy

Surgery followed by chemotherapy

Radiation therapy followed by chemotherapy

Radiation therapy and concomitant chemotherapy

Chemotherapy followed by radiation therapy

A 65-year-old woman has a modified radical mastectomy for a 1.0-cm, well-differentiated breast cancer. The tumor is positive for estrogen and progesterone receptors and negative for HER2. Sentinel node mapping and excision show that none of the three lymph nodes removed is positive for metastasis. She is otherwise healthy. What is the best treatment for this patient at this time?

Tamoxifen and anastrozole for 5 years

Chest wall radiation therapy and tamoxifen for 5 years

Chest wall radiation therapy and anastrozole for 5 years

Tamoxifen and anastrozole for 5 years

A 30-year-old woman has a right mastectomy and axillary lymph node dissection for a carcinoma diagnosed by fine needle aspiration cytology. The histologic pattern is that of a poorly differentiated carcinoma that is negative for oestrogen and progesterone receptors, but is positive for HER2/neu. One axillary lymph node demonstrates micro- metastases. Her 32 year old sister is found to have a similar lesion. Which of the following statements regarding risk factors for this lesion is the most appropriate?

A history of late menarche is likely to be present in females in this family

Fibrocystic changes were present for many years

She had a history of exposure to hydrocarbon compounds

She has a positive antinuclear antibody test

These findings suggest a BRCA-1 mutation

A 30-year-old man presented with a swelling in the testis and an ultrasound scan confirmed the presence of a malignant mass. Following orchidectomy, he was found to have a 40-mm seminomatous germ cell tumour without non-seminomatous components. There was evidence of vascular invasion within the testis.Investigations: serum lactate dehydrogenase (LDH) 1250 U/L (10 250) serum -fetoprotein normal serum -human chorionic gonadotrophin (HCG) 700 U/L (

good prognosis because of the raised HCG and LDH

good prognosis because of the absence of liver, bone and brain metastases

good prognosis because of the raised HCG and LDH

intermediate prognosis because of the presence of lung metastases

intermediate prognosis because of the raised serum HCG and LDH

poor prognosis because of the raised serum HCG and LDH

A 76-year-old male was admitted for symptoms including constipation, change in stool character and weight loss. Colonoscopy revealed multiple polyps in the rectosigmoid area. An adenomatous polyp was removed. Another colonic tumor was seen in the same patient which was flat with irregular shaggy rug surface. A biopsy showed frond-like glandular architecture. Atypical epithelial cells in clusters were seen beneath the muscularis mucosae. The most likely diagnosis is:

focus of adenocarcinoma arising in villous adenoma

A 48-year-old woman presents to her GP with Cushingoid facies and hyperpigmentation of the skin on her face and chest. She has smoked 20 cigarettes per year for 30 years. Examination reveals no gross abnormalities. Her chest X-ray reveals a 2 cm irregularly shaped mass in the right upper lobe, in proximity to the mediastinum. A CT guided needle biopsy of the lung lesion is performed. Which would be the most likely cytologic finding?

Bronchoalveolar cell carcinoma (BAC)

Small cell (oat cell) carcinoma

A 72-year-old man is evaluated because of back pain and fatigue. Laboratory values indicate he is anemic, with normal leukocyte count and platelet count. He has mild hypercalcemia and a normal serum creatinine level. His gamma globulins are elevated, and serum protein electrophoresis shows the presence of a monoclonal protein, an IgG- K light chain containing immunoglobulin at 4.4 g/dL. His bone marrow contains 20% plasma cells. A skeletal survey reveals multiple osteolytic lesions in the spine, ribs, and skull. Therapy with melphalan and prednisone is initiated. Which of the following agents would NOT be routinely used in his management?

Adequate analgesia (including narcotics, if necessary)

A 45-year-old woman is evaluated because of a palpable 2-cm right axillary lymph node. The lymph node is completely resected, and histologic study shows adenocarcinoma; hormone receptors are negative. Bilateral mammography is negative, as is MRI of the right breast. CT scans of the chest and abdomen are negative for tumor, and no further lymphadenopathy is detected. Results of bone scan and MRI of the head are also unremarkable. The patient had been previously healthy and has never smoked. Which of the following statements about this patients condition is correct?

Lung cancer is the most likely diagnosis, and optimal therapy for lung cancer paradigm should be initiated.

Breast cancer is the most likely diagnosis, and optimal therapy for breast cancer paradigm should be initiated.

Lung cancer is the most likely diagnosis, and optimal therapy for lung cancer paradigm should be initiated.

All known disease has been resected, and the patient requires careful monitoring for possible future recurrence.

Radiation therapy to the right axilla is required with fields encompassing the right breast.

26- A 60-year-old man was diagnosed last year with adenocarcinoma of the lung, and a 4 cm mass lesion was treated with a right lower lobectomy. He now has an abdominal CT scan that reveals scattered hepatic mass lesions and hilar lymphadenopathy. For several weeks, he has had increasing malaise. A urinalysis reveals marked proteinuria, and a 24 hour urine protein collection is 2.7 g/24hr. His serum urea is 30 mmol/L (2.5 - 7.5) with creatinine of 450 mol/L (60 - 110). A renal biopsy is performed, and there is focal deposition of IgG and C3 with a granular pattern. He is most likely to have which of the following conditions?

Minimal change glomerulonephritis

Rapidly progressive glomerulonephritis

A 71-year-old man with mild chronic obstructive pulmonary disease and mild hypertension is evaluated during an annual routine visit. Review of systems is notable for intermittent cough, increasing dyspnea on exertion, a 2.3-kg (5 Ib) weight loss, and fatigue. The patient takes aspirin, 81 mg/d, and hydrochlorothiazide, 50 mg/d orally. He smoked one pack of cigarettes per day for 49 years but quit smoking 2 years ago. On physical examination, distant breath sounds are audible in both lungs and there are scattered rhonchi. Chest radiograph shows a perihilar mass. Abnormal laboratory results include hemoglobin of 12.5 g/dL and a serum sodium of 127 meq/L. Endobronchial biopsy reveals small-cell lung cancer. Further staging studies suggest that the disease is limited-stage. What is the most appropriate treatment for this patient s hyponatremia?

Fluid restriction to 1 L/d and demeclocycline therapy

Discontinuation of hydrochiorothiazide

Combination chemotherapy for the small-cell lung cancer

A 70-year-old man is found to have distal rectal cancer during a screening colonoscopy. The patient undergoes preoperative staging and is found to have a 1.5-cm rectal mass that does not invade the muscularis propria of the rectal wall. There is no regional lymphadenopathy and no evidence of distant metastases. The patient is staged at T1N0M0. The patient is advised to undergo APR but refuses because it will lead to anal sphincter loss and permanent colostomy. Which of the following represents a viable alternate therapeutic option for this patient?

Endoscopic ablation of the tumor with Argon Plasma Coagulator (APC).

Full-thickness surgical removal of tumor (transanal excision)

Endoscopic ablation of the tumor with Argon Plasma Coagulator (APC).

A 68-year-old man with locally advanced non-small-cell lung cancer is evaluated because of the new onset of low back pain over the past 2 weeks. It is relieved with ibuprofen, and his only other symptom is mild fatigue. The patient completed combined chemotherapy and radiation therapy 6 months ago, and restaging scans afterward showed marked shrinkage of the right perihilar mass. He has no muscle weakness. Plain radiograph of the thoracic and lumbar spine shows no abnormalities other than signs of mild osteoarthritis. Neurologic examination is unremarkable. What is the most appropriate next step in the management of this patient?

Intravenous dexamethasone and MRI of the spine

Re-evaluation if the symptoms get worse

CT scan of the chest and abdomen with bone windows of the spine

Intravenous dexamethasone and MRI of the spine

A 40-year-old woman was treated for breast cancer 5 years ago by lumpectomy, breast irradiation, and 3 months of chemotherapy. Her original cancer was negative for estrogen and progesterone receptors and unequivocally positive for HER2. Her periods stopped during chemotherapy but resumed 4 months later, and she remains premenopausal now. She is evaluated now because of pain in her back, a nagging cough, and fatigue. Physical examination shows palpable skin nodules over the affected breast, axillary adenopathy, and dullness to percussion, and decreased breath sounds in the base of the left lung; her liver edge is palpable below the right costochondral border. Liver function values are approximately twice normal; serum bilirubin is normal. Radiograph of the chest shows multiple pulmonary nodules and a left pleural effusion confirmed by CT, which also shows the liver nodules. Bone scan and MRI are consistent with bone metastases. Biopsy of one of the skin lesions is consistent with metast

Combination endocrine therapy with ovarian ablation and an aromatase inhibitor

Hospice care and comfort measures

Combination endocrine therapy with tamoxifen and an aromatase inhibitor

High-dose chemotherapy with bone marrow stem cell support

Trastuzumab and taxane-based chemotherapy

Combination endocrine therapy with ovarian ablation and an aromatase inhibitor

A 65-year-old woman with no significant past medical history presents to the emergency department with a 2-day history of left lower quadrant abdominal pain. The patient denies nausea and vomiting, although she claims decreased oral intake. She also reports a low-grade fever and mild diarrhea. She describes a milder episode several years ago, which resolved on its own. On physical examination, the patient is found to have left lower quadrant tenderness with some mild guarding, but no rebound. She is hemodynamically stable, and her heart rate is 82 per minute. In the initial management of this patient, which of the following is the most sensitive diagnostic test?

Abdominal/pelvic CT with oral contrast

A 61-year-old man with a 120-pack-year smoking history is evaluated for a persistent and worsening cough and found to have a 3-cm mass in the right upper lobe on chest radiography. CT-directed needle biopsy is positive for squamous cell carcinoma. CT scans of the abdomen and pelvis, bone scan, and MRI of the head are negative for metastatic disease. Positron emission tomography scan shows uptake only in the right upper lobe mass, and pulmonary function tests indicate that the patient has adequate pulmonary reserve to undergo resection. The patient undergoes a right upper lobectomy. All margins are clear, and all peribronchial lymph nodes are negative for tumor within the resected specimen. What is the most reasonable adjuvant therapy for this patient?

Four cycles of combination chemotherapy including a taxane

Four cycles of combination chemotherapy including a taxane, followed by radiation therapy to the draining lymph node sites in the mediastinum

Radiation therapy to the draining lymph node sites in the mediastinum

Six cycles of combination chemotherapy including a platinum agent

No radiation therapy or chemotherapy is required at this time

A 63-year-old man is evaluated because of a several-month history of increasing fatigue and some vague upper abdominal discomfort. His medical history includes gastroesophageal reflux disease, coronary artery disease, and clinical depression, all of which are well controlled with medications. The patient has been working full time. On physical examination, he has mild hepatomegaly. His hemoglobin is 12.2 g/dL, serum alkaline phosphatase level 280 U/L, and serum aspartate aminotransferase level 65 U/L. CT scan of the abdomen and pelvis shows multiple hepatic lesions ranging in size from 1 cm to 4 cm; mesenteric, para-aortic, and paracaval lymphadenopathy, and a colonic mass at the splenic flexure. Colonoscopy reveals a nonobstructing, non bleeding lesion; biopsy shows it to be poorly differentiated adenocarcinoma. Fine- needle aspiration of one of the liver lesions confirms the presence of malignant cells consistent with a primary colon cancer. What is the most appropriate next step in

Resection of the primary tumor followed by systemic chemotherapy

Combined regional chemotherapy to the liver and systemic chemotherapy

Exploratory laparotomy with resection of the primary tumor and placement of a hepatic arterial infusion pump

A 78-year-old man is evaluated because of shortness of breath of acute onset. The patient reports a 13.6-kg (30-Ib) weight loss, vague upper abdominal discomfort, nausea, loss of appetite, and fatigue. He has hypertension and symptomatic atherosclerotic coronary artery disease despite optimal medical management. Even before the recent episode of dyspnea, his physical activity has been limited; he spends most of the day resting either in bed or in a chair.Laboratory studies: Hemoglobin 10.5 g/dL Serum albumin 2.6 g/dLSerum alanine aminotransferase 65 U/LSerum aspartate aminotransferase 78 U/L CA 19-94500 U/LArterial oxygen saturation 85% by pulse oximetrySpiral CT scan of the chest shows a pulmonary embolism.The patient is hospitalized for anticoagulation and oxygen therapy and gradually improves. Subsequent CT of the abdomen shows a 4-cm mass in the tail of the pancreas and numerous low-attenuation lesions in the liver. CT-guided biopsy of the hepatic lesions and the pancreatic m

Diagnostic CT-guided biopsy under a heparin window when the patients clinical status improves

Best supportive care and referral to a hospice

Diagnostic CT-guided biopsy under a heparin window when the patients clinical status improves

A 26-year-old man with testicular cancer who is receiving chemotherapy is evaluated in the emergency department. His temperature is 38.9 C (102 F), and he complains of feeling flushed and tired. He has an indwelling central venous port, but there are no localizing symptoms to suggest a source of infection. Chest radiograph shows no abnormalities. The patients hemoglobin is 8.9 gIdL; the absolute neutrophil count is 165/ L and the platelet count is 56,000/ L. Results of other laboratory studies and urinalysis are within normal limits. Blood samples are obtained from a peripheral vein and through the port and sent for culture; a urine culture is also ordered. The patient is hospitalized and intravenous ceftazidime is initiated. Three days later, the patient s temperature is 37.8 C (100 F) and absolute neutrophil count is 4504/ L; his clinical condition is otherwise stable. Results of blood and urine cultures are negative. A repeat chest radiograph is normal, and blood and urine speci

Continue the current antibiotic regimen

Switch to oral ciprofloxacin and amoxicillin-clavulanic acid

Add granulocyte colony-stimulating factor

A 60-year-old man presents for an annual physical examination. The examination is normal except for a palpable mass in the rectum on digital rectal examination. The patient denies any change in bowel habits and feels well. Rectal cancer is suspected. What is the next best step in the evaluation of this patient?

Magnetic resonance imaging scan of the abdomen and pelvis

Computed tomography scan of the abdomen and pelvis

Flexible sigmoidoscopy with biopsy of the lesion

Full colonoscopy with biopsy of the lesion

Magnetic resonance imaging scan of the abdomen and pelvis

A 68-year-old woman is evaluated because of rectal bleeding that began recently and a sense of fullness in the rectum. Flexible sigmoidoscopy shows a mass 11 cm from the anus, and biopsy reveals adenocarcinoma. The patient is referred to a colorectal surgeon, and a low anterior resection is performed. The primary tumor, a 4-cm moderately differentiated adenocarcinoma, penetrates the bowel wall. No lymph nodes are involved. What is the most appropriate next step in this patient s management?

Postoperative pelvic radiation therapy

No chemotherapy or radiation therapy; annual flexible sigmoidoscopy

Postoperative adjuvant chemotherapy and pelvic radiation therapy

Postoperative pelvic radiation therapy

Complete colonoscopy within the first year, repeated every 3 to 5 years

A 64-year-old white man presents for serum prostate-specific antigen (PSA) screening at his wife s urging. He is in generally good health, except for mild hypertension. His digital rectal examination reveals a mildly enlarged prostate gland with no discrete nodules. He has no family history of prostate cancer. What is the best advice to give him?

On the basis of his lack of symptoms it is unlikely that he has an elevated PSA

There is no evidence that PSA screening leads to the earlier detection of prostate cancer

There is insufficient evidence to establish whether PSA screening affects overall mortality rates

On the basis of his lack of symptoms it is unlikely that he has an elevated PSA

Because a digital rectal examination is more sensitive than a serum PSA test, his normal examination makes it unlikely that he has cancer

A 66-year-old black woman diagnosed with stage III colon cancer underwent definitive resection of the primary tumor 3 years ago. After surgery, she received adjuvant chemotherapy with 5-fluorouracil and leucovorin. Approximately 20 months later, she developed metastatic disease in the liver (five lesions in right and left lobe) and lungs (one lesion in the right and left lobe). She was treated with irinotecan, 5-fluorouracil, and leucovorin, and had a partial response to therapy. One month ago, disease progression was documented on restaging CT scans. The patient s laboratory studies show relatively normal organ function. She has fatigue, decreased appetite, and has noticed a 2.3-kg (5-Ib) weight loss over the past 3 months. She has stopped participating in weekend bike trips with a cycling club, but remains involved in church and family activities and states that she wants to be as aggressive as possible in fighting the cancer. What is the most reasonable recommendation for this patie

High-dose chemotherapy with autologous peripheral stem cell transplantation

Second-line chemotherapy regimen with leucovorin and oxaliplatin

High-dose chemotherapy with autologous peripheral stem cell transplantation

A 72-year-old man is evaluated because of constipation, abdominal pain, and distention that have worsened over the past week. Two years ago, he was diagnosed with stage III rectal cancer (primary tumor and renal involvement) and underwent low anterior resection. Chemotherapy with 5-fluorouracil and leucovorin followed, and pelvic radiation was given with concurrent infusion of 5-fluorouracil. He has been having regular bowel movements, and results of his most recent colonoscopy (1 year ago) were unremarkable. On physical examination, his pulse rate is 100/min. He has orthostatic hypotension, a slightly distended abdomen with hyperactive bowel sounds, and some guarding to deep palpation in the left lower quadrant. Plain radiograph of the abdomen shows distended loops of small bowel, with no stool in the distal colon or rectum. The patient is hospitalized for bowel rest and intravenous hydration. What is the next step in this patient s management?

Upper gastrointestinal series with small-bowel follow-through

Positron emission tomography scan of the abdomen

Measurement of serum carcinoembryonic antigen

CT scan of the abdomen with oral and intravenous contrast

A 69-year-old man underwent a radical prostatectomy ii years ago. His serum prostate-specific antigen (PSA) level was 7.1 ng/mL, clinical stage was Tic (clinically organ-confined and detected by screening PSA blood test only), and his Gleason score was 5. His PSA level became detectable 4 years ago. Over the past 3 years, his PSA values have been 1.4 ng/mL, 1 .8 ng/mL, and 2.2 ng/mL. He remains asymptomatic, and a recent bone scan revealed only degenerative disease. The patients risk for rapid metastasis is low for which of the following reasons?

He was initially treated by radical prostatectomy.

His PSA level became undetectable.

He has had a slow, prolonged rise in his PSA.

A 60-year-old postmenopausal woman at elevated risk for breast cancer is taking tamoxifen to reduce her risk. She has not had a hysterectomy. Which of the following surveillance strategies for the detection of endometrial cancer is most important to incorporate into this patient s care?

Annual transabdominal pelvic ultrasound

Annual endometrial aspiration sampling

Biennial dilatation and curettage

Annual routine bimanual pelvic examination

Which of the following cancer screening tests has been shown in randomized trials to decrease the risk of death from the target cancer?

Human papillomavirus DNA test for cervical cancer every year

Fecal occult blood testing every 2 years for colorectal cancer

Human papillomavirus DNA test for cervical cancer every year

Pap smear of the cervix every year in sexually active women for uterine cancer

Chest radiography every year in cigarette smokers for lung cancer

396 + Mcqs in Important Questions Repeated in MD Exams Page 8 McqOptions

351.	For previous patients, after the appropriate evaluation, the patient undergoes surgery. No intraoperative evidence of metastases is identified. Postoperatively, the pathology report reveals that the tumor is an adenocarcinoma invading into the pericolonic fat, with 2 involved lymph nodes. After the patient recovers from surgery, which of the following is the most appropriate next step in his management?
A.	Abdominal CT scan every 6 months
B.	No further therapy is indicated, because the involved nodes were removed
C.	Chemotherapy with 5-fluorouracil (5-FU) based regimen
D.	Measurement of CEA levels yearly
E.	Colonoscopy every 6 months
Answer» D. Measurement of CEA levels yearly

Discussion

352.	A 78-year-old woman with coronary artery disease and severe chronic obstructive pulmonary disease is admitted to the hospital with painless jaundice. CT scan reveals the presence of multiple lesions in the liver, suggestive of metastases, and a nearly obstructing upper rectal mass. Colonoscopy demonstrates a large, ulcerated tumor in the proximal rectum and a residual lumen of less than 1 cm in diameter. While in the hospital, the patient develops a large bowel obstruction. What is the best treatment modality for this patient?
A.	Immediate radiation therapy of the rectal mass
B.	Placement of a colonic decompression tube
C.	Emergency surgery with resection of the mass
D.	Emergency surgery with creation of a diverting colostomy
E.	Placement of a rectal self-expanding metal stent
Answer» F.

Discussion

353.	A 59-year-old man was referred because of a change in bowel habit. He had noticed no alteration in stool calibre, gastrointestinal bleeding or unintended weight loss. There was no family history of colonic polyps or gastrointestinal malignancy. Physical examination was normal. A rectal examination revealed no masses. A sigmoidoscopy revealed a 4-mm polyp in the mid-rectum, which was removed with forceps, and histology revealed a tubular adenoma. What is the most appropriate next step in management?
A.	barium enema now
B.	colonoscopy in 3 years
C.	colonoscopy in 5 years
D.	colonoscopy now
E.	sigmoidoscopy in 1 year
Answer» E. sigmoidoscopy in 1 year

Discussion

354.	A 29-year-old woman had a 2.5-mm Breslow thickness melanoma removed from her right shin. She was referred for wide local excision of the scar and consideration of sentinel node biopsy. In what proportion of patients with a negative sentinel node biopsy does nodal recurrence subsequently develop in the same lymph node basin?
A.	<1%
B.	1 4%
C.	5 9%
D.	10 14%
E.	15 25%
Answer» C. 5 9%

Discussion

355.	A firm 2 to 3 cm mass is palpable in the upper outer quadrant of the right breast of a 52-year-old woman. There are no palpable axillary lymph nodes. A lumpectomy with axillary node dissection is performed and the breast lesion is found to have positive immunohistochemical staining for HER2/neu (c-erb B2). Staining for oestrogen and progesterone receptors is negative. Which of the following additional treatment options is most appropriate, based upon these findings?
A.	Radical mastectomy
B.	St John's wort
C.	Tamoxifen
D.	Trastuzumab
E.	Vancomycin
Answer» E. Vancomycin

Discussion

356.	Which of the following adjuvant systemic therapies would be most appropriate to recommend for an otherwise healthy patient who has HER-2/neu-positive (FISH) ER/PR-negative breast cancer with positive axillary lymph nodes?
A.	Four cycles of dose-dense doxorubicin and cyclophosphamide (AC) in conjunction with four cycles of paclitaxel.
B.	Four cycles of AC, four cycles of paclitaxel with concurrent trastuzumab, and continuation of trastuzumab for 1 year.
C.	Four cycles of paclitaxel, four cycles of AC with concurrent trastuzumab, and continuation of trastuzumab for 1 year.
D.	Six cycles of docetaxel, doxorubicin, and cyclophosphamide.
Answer» C. Four cycles of paclitaxel, four cycles of AC with concurrent trastuzumab, and continuation of trastuzumab for 1 year.

Discussion

357.	A 23-year-old man is evaluated because of a painless right-sided scrotal mass. Ciprofloxacin, 500 mg every 12 hours, is administered for 10 days, but he notes little improvement in the swelling. His serum -fetoprotein level is elevated at 100 ng/mL, and his 13-human chorionic gonadotropin level is 64 m/UImL. Testicular ultrasound examination reveals a hypoechoic mass. Which of the following would be the most appropriate next step in his treatment?
A.	Retroperitoneal lymph node dissection
B.	Combination chemotherapy with bleomycin, etoposide, and cisplatin
C.	Radiation to the pelvis
D.	Inguinal orchiectomy
Answer» E.

Discussion

358.	A 68-year-old man presents to his primary care physician for a routine physical examination. The patient s medical history is significant for hypertension. The patient is found to have guaiac-positive stools and is subsequently referred for colonoscopy. Colonoscopy reveals a golf ball -size, near-obstructing tumor in the descending colon, not admitting the scope. The biopsy is positive for adenocarcinoma of the colon. Which of the following is the next step in the management of this patient?
A.	Full metastatic workup first, and if negative, then plan for colon resection
B.	A course of radiation therapy prior to any resection
C.	Plan for pre-operative chemotherapy
D.	Do metastatic work up, but plan for colon resection anyway
E.	Schedule a barium enema to evaluate the proximal colon
Answer» E. Schedule a barium enema to evaluate the proximal colon

Discussion

359.	A 59-year-old woman with an 80-pack-year smoking history is evaluated because of weight loss and severe pain in the upper part of her left leg. She has lost 11.3 kg (25 Ib) from baseline weight of 59 kg (130 Ib). A large lytic lesion is noted on the left femur, with erosion into the cortex. Bone scan shows multiple lesions, and CT scan of the chest shows a large left hilar mass and med iastinal lymphadenopathy. Bronchoscopic biopsy specimen shows poorly differentiated adenocarcinoma. Radiation therapy to the left femur is initiated. Which of the following findings would preclude use of palliative chemotherapy for this patient?
A.	A solitary liver metastasis with normal serum bilirubin level
B.	Multiple liver metastases with a serum bilirubin level of 3.0 mg/dL
C.	A cytologically positive pleural effusion
D.	Hypercalcemia
E.	Poor performance status
Answer» F.

Discussion

360.	A 63-year-old man is evaluated because of new-onset hemoptysis and a 100-pack-year smoking history. Chest radiograph shows a 4-cm right perihilar mass, and bronchoscopic biopsy and cytologic evaluation of sputum confirm squamous cell carcinoma. There are no significant findings on physical examination, and the patient reports no weight loss.Complete blood count is normal except for a serum alkaline phosphatase level at 110 U/L. CT scans of the chest and abdomen show no mediastinal adenopathy. Results of a positron emission tomography scan are negative, except for the right perihilar mass.In which of the following situations would surgical therapy be offered?
A.	A solitary bone metastasis is noted on bone scan, and a lytic lesion is confirmed radiographically.
B.	A solitary liver metastasis is noted on CT scan and confirmed by needle biopsy and positron emission tomography scan.
C.	A solitary brain metastasis is noted on CT scan of the head.
D.	A small effusion is noted in the right hemithorax, and cytopathologic examination of the pleural fluid is positive for tumor.
Answer» D. A small effusion is noted in the right hemithorax, and cytopathologic examination of the pleural fluid is positive for tumor.

Discussion

361.	A 50-year-old perimenopausal woman is evaluated because of abdominal swelling. CT scan of the chest, abdomen, and pelvis shows mesenteric lymphadenopathy and a small amount of ascites but no ovarian masses. Needle biopsy specimen shows adenocarcinoma; the tumor is found to be negative for hormone receptors. The serum carcinoembryonic antigen level is normal at 2.0 ng/mL and the serum CA-125 is 1200 ng/mL (elevated). What is the best next step in her treatment?
A.	Combination chemotherapy
B.	Debulking surgery
C.	Radiation therapy to a wide port
D.	Positron emission tomography scan to assess other sites of disease
E.	Bone scan to rule out skeletal metastases
Answer» C. Radiation therapy to a wide port

Discussion

362.	A 58-year-old woman with a 60-pack-year smoking history is evaluated because of hemoptysis and weight loss. Chest radiograph and CT scan show a right perihilar mass with mediastinal adenopathy. The results of CT scans of the abdomen, bone scan, and MRI of the head are otherwise negative. Examination of a specimen by bronchoscopic biopsy confirms small-cell lung cancer, and the findings suggest limited-stage disease. After the patient completes mediastinal radiation therapy and four cycles of cisplatin and etoposide, repeat CT scans indicate that her disease is in complete remission. What is the best recommendation concerning further therapy?
A.	Prophylactic cranial irradiation
B.	Four more cycles of chemotherapy, including a taxane
C.	Resection of the localized disease
D.	No further therapy; follow-up only
Answer» B. Four more cycles of chemotherapy, including a taxane

Discussion

363.	A 68-year-old man with a 60-pack-year smoking history is evaluated because of hemoptysis. Radiograph of the chest shows a right hilar mass and mediastinal widening. CT scans of the chest and abdomen confirm the hilar mass and bulky lymphadenopathy in the mediastinum with no other overt metastases. Bronchoscopic biopsy specimen shows small-cell lung cancer. Bone scan and CT scan of the head are negative for tumor. A low serum sodium level and inappropriately high urine osmolality suggest that he has the syndrome of inappropriate antidiuretic hormone secretion. Which of the following is the most appropriate treatment recommendation?
A.	Surgery followed by chemotherapy
B.	Radiation therapy followed by chemotherapy
C.	Chemotherapy alone
D.	Radiation therapy and concomitant chemotherapy
E.	Chemotherapy followed by radiation therapy
Answer» E. Chemotherapy followed by radiation therapy

Discussion

364.	A 65-year-old woman has a modified radical mastectomy for a 1.0-cm, well-differentiated breast cancer. The tumor is positive for estrogen and progesterone receptors and negative for HER2. Sentinel node mapping and excision show that none of the three lymph nodes removed is positive for metastasis. She is otherwise healthy. What is the best treatment for this patient at this time?
A.	Chest wall radiation therapy and tamoxifen for 5 years
B.	Chest wall radiation therapy and anastrozole for 5 years
C.	Tamoxifen for 5 years
D.	Tamoxifen and anastrozole for 5 years
Answer» D. Tamoxifen and anastrozole for 5 years

Discussion

365.	A 30-year-old woman has a right mastectomy and axillary lymph node dissection for a carcinoma diagnosed by fine needle aspiration cytology. The histologic pattern is that of a poorly differentiated carcinoma that is negative for oestrogen and progesterone receptors, but is positive for HER2/neu. One axillary lymph node demonstrates micro- metastases. Her 32 year old sister is found to have a similar lesion. Which of the following statements regarding risk factors for this lesion is the most appropriate?
A.	A history of late menarche is likely to be present in females in this family
B.	Fibrocystic changes were present for many years
C.	She had a history of exposure to hydrocarbon compounds
D.	She has a positive antinuclear antibody test
E.	These findings suggest a BRCA-1 mutation
Answer» F.

Discussion

366.	Which of the following pathological stages of breast cancer is associated with a patient who has a 5.0-cm primary tumor and 12/15 positive, non-fixed lymph nodes?
A.	pT3N2
B.	pT3N3
C.	pT2N1
D.	pT2N3
Answer» E.

Discussion

367.	A 30-year-old man presented with a swelling in the testis and an ultrasound scan confirmed the presence of a malignant mass. Following orchidectomy, he was found to have a 40-mm seminomatous germ cell tumour without non-seminomatous components. There was evidence of vascular invasion within the testis.Investigations: serum lactate dehydrogenase (LDH) 1250 U/L (10 250) serum -fetoprotein normal serum -human chorionic gonadotrophin (HCG) 700 U/L (
A.	good prognosis because of the absence of liver, bone and brain metastases
B.	good prognosis because of the raised HCG and LDH
C.	intermediate prognosis because of the presence of lung metastases
D.	intermediate prognosis because of the raised serum HCG and LDH
E.	poor prognosis because of the raised serum HCG and LDH
Answer» B. good prognosis because of the raised HCG and LDH

Discussion

368.	A bulky tumor of the rectum exhibits a delicate, velvety, easily bleeding surface. It has no pedicel and its base appears to be as wide as its apex. The process is most probably:
A.	inflammatory polyp
B.	villous adenoma
C.	mucinous adenocarcinoma
D.	lymphoid polyp
E.	leiomyoma
Answer» C. mucinous adenocarcinoma

Discussion

369.	A 76-year-old male was admitted for symptoms including constipation, change in stool character and weight loss. Colonoscopy revealed multiple polyps in the rectosigmoid area. An adenomatous polyp was removed. Another colonic tumor was seen in the same patient which was flat with irregular shaggy rug surface. A biopsy showed frond-like glandular architecture. Atypical epithelial cells in clusters were seen beneath the muscularis mucosae. The most likely diagnosis is:
A.	adenomatous polyp
B.	villous adenoma with atypism
C.	focus of adenocarcinoma arising in villous adenoma
D.	colitis cystica profunda
E.	NONE of above
Answer» D. colitis cystica profunda

Discussion

370.	A 44-year-old woman presented with post-coital bleeding. Investigation revealed a 2-cm grade 1, stage IB1 squamous cell carcinoma of the cervix. There was no evidence of lymphovascular space invasion. She had completed her family.What is the most appropriate treatment?
A.	brachytherapy
B.	chemo-radiotherapy
C.	excision cone biopsy only
D.	radical hysterectomy
E.	vaginal trachelectomy
Answer» E. vaginal trachelectomy

Discussion

371.	What is the stage of a 5-cm gastric tumor that extends into, but not through, the muscularis propria with 16 of 23 positive lymph nodes?
A.	I
B.	II
C.	III
D.	IV
Answer» E.

Discussion

372.	A 72-year-old man was found to have an anterior rectal cancer at 2 cm from the anal verge. A CT scan of chest, abdomen and pelvis showed no evidence of metastatic disease. An MR scan of pelvis showed an anterior tumour abutting the prostate gland, radiologically staged as a T3, N1, M0 cancer. What is the most appropriate next step in management?
A.	abdominoperineal resection
B.	chemotherapy
C.	long-course chemoradiation
D.	short-course radiotherapy
E.	total mesorectal excision
Answer» D. short-course radiotherapy

Discussion

373.	An elderly male had rectal bleeding. A flat velvety mass was observed in the cecum. The provisional diagnosis was villous adenoma. A partial colectomy was performed. Invasion through the muscularis mucosae, but not into the muscularis propria, was observed on paraffin sections. Therefore, the final diagnosis was:
A.	pseudopolyp
B.	adenomatous polyp
C.	adenocarcinoma Dukes A
D.	adenocarcinoma Dukes B
E.	adenocarcinoma Dukes C
Answer» D. adenocarcinoma Dukes B

Discussion

374.	A 48-year-old woman presents to her GP with Cushingoid facies and hyperpigmentation of the skin on her face and chest. She has smoked 20 cigarettes per year for 30 years. Examination reveals no gross abnormalities. Her chest X-ray reveals a 2 cm irregularly shaped mass in the right upper lobe, in proximity to the mediastinum. A CT guided needle biopsy of the lung lesion is performed. Which would be the most likely cytologic finding?
A.	Adenocarcinoma
B.	Benign bronchial adenoma
C.	Bronchoalveolar cell carcinoma (BAC)
D.	Small cell (oat cell) carcinoma
E.	Squamous cell carcinoma
Answer» E. Squamous cell carcinoma

Discussion

375.	A 72-year-old man is evaluated because of back pain and fatigue. Laboratory values indicate he is anemic, with normal leukocyte count and platelet count. He has mild hypercalcemia and a normal serum creatinine level. His gamma globulins are elevated, and serum protein electrophoresis shows the presence of a monoclonal protein, an IgG- K light chain containing immunoglobulin at 4.4 g/dL. His bone marrow contains 20% plasma cells. A skeletal survey reveals multiple osteolytic lesions in the spine, ribs, and skull. Therapy with melphalan and prednisone is initiated. Which of the following agents would NOT be routinely used in his management?
A.	Erythropoietin
B.	Radiation therapy
C.	Intravenous gamma globulin
D.	Adequate analgesia (including narcotics, if necessary)
E.	A bisphosphonate
Answer» D. Adequate analgesia (including narcotics, if necessary)

Discussion

376.	An 82-year-old woman who has never smoked is evaluated because of a persistent cough. Chest radiograph shows several lung nodules and infiltrates. There are no significant findings on physical examination. The patient reports no weight loss. Blood studies show no abnormalities. CT scans confirm pulmonary involvement only, and results of bone scan and CT scan of the head are normal. The patient most likely has which of the following histologic types of lung cancer?
A.	Bronchoalveolar cell carcinoma
B.	Small-cell lung cancer
C.	Large-cell carcinoma
D.	Squamous cell carcinoma
E.	Carcinoid tumor
Answer» B. Small-cell lung cancer

Discussion

377.	A 45-year-old woman is evaluated because of a palpable 2-cm right axillary lymph node. The lymph node is completely resected, and histologic study shows adenocarcinoma; hormone receptors are negative. Bilateral mammography is negative, as is MRI of the right breast. CT scans of the chest and abdomen are negative for tumor, and no further lymphadenopathy is detected. Results of bone scan and MRI of the head are also unremarkable. The patient had been previously healthy and has never smoked. Which of the following statements about this patients condition is correct?
A.	Breast cancer is the most likely diagnosis, and optimal therapy for breast cancer paradigm should be initiated.
B.	Lung cancer is the most likely diagnosis, and optimal therapy for lung cancer paradigm should be initiated.
C.	All known disease has been resected, and the patient requires careful monitoring for possible future recurrence.
D.	Radiation therapy to the right axilla is required with fields encompassing the right breast.
Answer» B. Lung cancer is the most likely diagnosis, and optimal therapy for lung cancer paradigm should be initiated.

Discussion

378.	26- A 60-year-old man was diagnosed last year with adenocarcinoma of the lung, and a 4 cm mass lesion was treated with a right lower lobectomy. He now has an abdominal CT scan that reveals scattered hepatic mass lesions and hilar lymphadenopathy. For several weeks, he has had increasing malaise. A urinalysis reveals marked proteinuria, and a 24 hour urine protein collection is 2.7 g/24hr. His serum urea is 30 mmol/L (2.5 - 7.5) with creatinine of 450 mol/L (60 - 110). A renal biopsy is performed, and there is focal deposition of IgG and C3 with a granular pattern. He is most likely to have which of the following conditions?
A.	Goodpasture's syndrome
B.	Membranous glomerulonephritis
C.	Minimal change glomerulonephritis
D.	Nodular glomerulosclerosis
E.	Rapidly progressive glomerulonephritis
Answer» C. Minimal change glomerulonephritis

Discussion

379.	A 71-year-old man with mild chronic obstructive pulmonary disease and mild hypertension is evaluated during an annual routine visit. Review of systems is notable for intermittent cough, increasing dyspnea on exertion, a 2.3-kg (5 Ib) weight loss, and fatigue. The patient takes aspirin, 81 mg/d, and hydrochlorothiazide, 50 mg/d orally. He smoked one pack of cigarettes per day for 49 years but quit smoking 2 years ago. On physical examination, distant breath sounds are audible in both lungs and there are scattered rhonchi. Chest radiograph shows a perihilar mass. Abnormal laboratory results include hemoglobin of 12.5 g/dL and a serum sodium of 127 meq/L. Endobronchial biopsy reveals small-cell lung cancer. Further staging studies suggest that the disease is limited-stage. What is the most appropriate treatment for this patient s hyponatremia?
A.	Fluid restriction to 1 L/d
B.	Fluid restriction to 1 L/d and demeclocycline therapy
C.	Discontinuation of hydrochiorothiazide
D.	Combination chemotherapy for the small-cell lung cancer
Answer» E.

Discussion

380.	A 58-year-old man presented with haemoptysis, weight loss and worsening breathlessness. He was a lifelong heavy smoker. His chest X-ray was abnormal. A CT scan of chest and abdomen demonstrated a large mass in the right lower lobe invading into the mediastinum and pericardium, extensive mediastinal lymphadenopathy, and bone metastasis (T4, N3, M1b). Bronchoscopy and biopsy confirmed a squamous cell carcinoma. Mutation analysis revealed that EGFR and K-ras genes were both wild type. What is the most appropriate first-line therapy?
A.	docetaxel
B.	erlotinib
C.	gefitinib
D.	gemcitabine and cisplatin
E.	pemetrexed and cisplatin
Answer» E. pemetrexed and cisplatin

Discussion

381.	A 70-year-old man is found to have distal rectal cancer during a screening colonoscopy. The patient undergoes preoperative staging and is found to have a 1.5-cm rectal mass that does not invade the muscularis propria of the rectal wall. There is no regional lymphadenopathy and no evidence of distant metastases. The patient is staged at T1N0M0. The patient is advised to undergo APR but refuses because it will lead to anal sphincter loss and permanent colostomy. Which of the following represents a viable alternate therapeutic option for this patient?
A.	Chemotherapy alone
B.	Radiation therapy alone
C.	Chemoradiation therapy
D.	Full-thickness surgical removal of tumor (transanal excision)
E.	Endoscopic ablation of the tumor with Argon Plasma Coagulator (APC).
Answer» E. Endoscopic ablation of the tumor with Argon Plasma Coagulator (APC).

Discussion

382.	A 68-year-old man with locally advanced non-small-cell lung cancer is evaluated because of the new onset of low back pain over the past 2 weeks. It is relieved with ibuprofen, and his only other symptom is mild fatigue. The patient completed combined chemotherapy and radiation therapy 6 months ago, and restaging scans afterward showed marked shrinkage of the right perihilar mass. He has no muscle weakness. Plain radiograph of the thoracic and lumbar spine shows no abnormalities other than signs of mild osteoarthritis. Neurologic examination is unremarkable. What is the most appropriate next step in the management of this patient?
A.	Gallium scan
B.	Re-evaluation if the symptoms get worse
C.	CT scan of the chest and abdomen with bone windows of the spine
D.	MRI of the spine
E.	Intravenous dexamethasone and MRI of the spine
Answer» E. Intravenous dexamethasone and MRI of the spine

Discussion

383.	A 40-year-old woman was treated for breast cancer 5 years ago by lumpectomy, breast irradiation, and 3 months of chemotherapy. Her original cancer was negative for estrogen and progesterone receptors and unequivocally positive for HER2. Her periods stopped during chemotherapy but resumed 4 months later, and she remains premenopausal now. She is evaluated now because of pain in her back, a nagging cough, and fatigue. Physical examination shows palpable skin nodules over the affected breast, axillary adenopathy, and dullness to percussion, and decreased breath sounds in the base of the left lung; her liver edge is palpable below the right costochondral border. Liver function values are approximately twice normal; serum bilirubin is normal. Radiograph of the chest shows multiple pulmonary nodules and a left pleural effusion confirmed by CT, which also shows the liver nodules. Bone scan and MRI are consistent with bone metastases. Biopsy of one of the skin lesions is consistent with metast
A.	Hospice care and comfort measures
B.	Combination endocrine therapy with tamoxifen and an aromatase inhibitor
C.	High-dose chemotherapy with bone marrow stem cell support
D.	Trastuzumab and taxane-based chemotherapy
E.	Combination endocrine therapy with ovarian ablation and an aromatase inhibitor
Answer» E. Combination endocrine therapy with ovarian ablation and an aromatase inhibitor

Discussion

384.	A 65-year-old woman with no significant past medical history presents to the emergency department with a 2-day history of left lower quadrant abdominal pain. The patient denies nausea and vomiting, although she claims decreased oral intake. She also reports a low-grade fever and mild diarrhea. She describes a milder episode several years ago, which resolved on its own. On physical examination, the patient is found to have left lower quadrant tenderness with some mild guarding, but no rebound. She is hemodynamically stable, and her heart rate is 82 per minute. In the initial management of this patient, which of the following is the most sensitive diagnostic test?
A.	Complete blood count, SMA-7
B.	An obstructive series
C.	A barium enema study
D.	Abdominal/pelvic CT with oral contrast
E.	Abdominal ultrasound
Answer» E. Abdominal ultrasound

Discussion

385.	A 61-year-old man with a 120-pack-year smoking history is evaluated for a persistent and worsening cough and found to have a 3-cm mass in the right upper lobe on chest radiography. CT-directed needle biopsy is positive for squamous cell carcinoma. CT scans of the abdomen and pelvis, bone scan, and MRI of the head are negative for metastatic disease. Positron emission tomography scan shows uptake only in the right upper lobe mass, and pulmonary function tests indicate that the patient has adequate pulmonary reserve to undergo resection. The patient undergoes a right upper lobectomy. All margins are clear, and all peribronchial lymph nodes are negative for tumor within the resected specimen. What is the most reasonable adjuvant therapy for this patient?
A.	Four cycles of combination chemotherapy including a taxane
B.	Four cycles of combination chemotherapy including a taxane, followed by radiation therapy to the draining lymph node sites in the mediastinum
C.	Radiation therapy to the draining lymph node sites in the mediastinum
D.	Six cycles of combination chemotherapy including a platinum agent
E.	No radiation therapy or chemotherapy is required at this time
Answer» F.

Discussion

386.	A 63-year-old man is evaluated because of a several-month history of increasing fatigue and some vague upper abdominal discomfort. His medical history includes gastroesophageal reflux disease, coronary artery disease, and clinical depression, all of which are well controlled with medications. The patient has been working full time. On physical examination, he has mild hepatomegaly. His hemoglobin is 12.2 g/dL, serum alkaline phosphatase level 280 U/L, and serum aspartate aminotransferase level 65 U/L. CT scan of the abdomen and pelvis shows multiple hepatic lesions ranging in size from 1 cm to 4 cm; mesenteric, para-aortic, and paracaval lymphadenopathy, and a colonic mass at the splenic flexure. Colonoscopy reveals a nonobstructing, non bleeding lesion; biopsy shows it to be poorly differentiated adenocarcinoma. Fine- needle aspiration of one of the liver lesions confirms the presence of malignant cells consistent with a primary colon cancer. What is the most appropriate next step in
A.	Resection of the primary tumor followed by systemic chemotherapy
B.	Combined regional chemotherapy to the liver and systemic chemotherapy
C.	Exploratory laparotomy with resection of the primary tumor and placement of a hepatic arterial infusion pump
D.	Systemic chemotherapy
E.	Best supportive care
Answer» E. Best supportive care

Discussion

387.	A 78-year-old man is evaluated because of shortness of breath of acute onset. The patient reports a 13.6-kg (30-Ib) weight loss, vague upper abdominal discomfort, nausea, loss of appetite, and fatigue. He has hypertension and symptomatic atherosclerotic coronary artery disease despite optimal medical management. Even before the recent episode of dyspnea, his physical activity has been limited; he spends most of the day resting either in bed or in a chair.Laboratory studies: Hemoglobin 10.5 g/dL Serum albumin 2.6 g/dLSerum alanine aminotransferase 65 U/LSerum aspartate aminotransferase 78 U/L CA 19-94500 U/LArterial oxygen saturation 85% by pulse oximetrySpiral CT scan of the chest shows a pulmonary embolism.The patient is hospitalized for anticoagulation and oxygen therapy and gradually improves. Subsequent CT of the abdomen shows a 4-cm mass in the tail of the pancreas and numerous low-attenuation lesions in the liver. CT-guided biopsy of the hepatic lesions and the pancreatic m
A.	Best supportive care and referral to a hospice
B.	Diagnostic CT-guided biopsy under a heparin window when the patients clinical status improves
C.	Neurolytic celiac axis block
D.	Palliative chemotherapy
E.	Palliative radiation therapy
Answer» B. Diagnostic CT-guided biopsy under a heparin window when the patients clinical status improves

Discussion

388.	A 26-year-old man with testicular cancer who is receiving chemotherapy is evaluated in the emergency department. His temperature is 38.9 C (102 F), and he complains of feeling flushed and tired. He has an indwelling central venous port, but there are no localizing symptoms to suggest a source of infection. Chest radiograph shows no abnormalities. The patients hemoglobin is 8.9 gIdL; the absolute neutrophil count is 165/ L and the platelet count is 56,000/ L. Results of other laboratory studies and urinalysis are within normal limits. Blood samples are obtained from a peripheral vein and through the port and sent for culture; a urine culture is also ordered. The patient is hospitalized and intravenous ceftazidime is initiated. Three days later, the patient s temperature is 37.8 C (100 F) and absolute neutrophil count is 4504/ L; his clinical condition is otherwise stable. Results of blood and urine cultures are negative. A repeat chest radiograph is normal, and blood and urine speci
A.	Continue the current antibiotic regimen
B.	Add vancomycin
C.	Switch to oral ciprofloxacin and amoxicillin-clavulanic acid
D.	Add granulocyte colony-stimulating factor
E.	Remove the central venous port
Answer» B. Add vancomycin

Discussion

389.	A 60-year-old man presents for an annual physical examination. The examination is normal except for a palpable mass in the rectum on digital rectal examination. The patient denies any change in bowel habits and feels well. Rectal cancer is suspected. What is the next best step in the evaluation of this patient?
A.	Computed tomography scan of the abdomen and pelvis
B.	Double-contrast barium enema
C.	Flexible sigmoidoscopy with biopsy of the lesion
D.	Full colonoscopy with biopsy of the lesion
E.	Magnetic resonance imaging scan of the abdomen and pelvis
Answer» E. Magnetic resonance imaging scan of the abdomen and pelvis

Discussion

390.	A 68-year-old woman is evaluated because of rectal bleeding that began recently and a sense of fullness in the rectum. Flexible sigmoidoscopy shows a mass 11 cm from the anus, and biopsy reveals adenocarcinoma. The patient is referred to a colorectal surgeon, and a low anterior resection is performed. The primary tumor, a 4-cm moderately differentiated adenocarcinoma, penetrates the bowel wall. No lymph nodes are involved. What is the most appropriate next step in this patient s management?
A.	No chemotherapy or radiation therapy; annual flexible sigmoidoscopy
B.	Postoperative adjuvant chemotherapy and pelvic radiation therapy
C.	Postoperative pelvic radiation therapy
D.	Complete colonoscopy within the first year, repeated every 3 to 5 years
Answer» C. Postoperative pelvic radiation therapy

Discussion

391.	A 64-year-old white man presents for serum prostate-specific antigen (PSA) screening at his wife s urging. He is in generally good health, except for mild hypertension. His digital rectal examination reveals a mildly enlarged prostate gland with no discrete nodules. He has no family history of prostate cancer. What is the best advice to give him?
A.	There is no evidence that PSA screening leads to the earlier detection of prostate cancer
B.	There is insufficient evidence to establish whether PSA screening affects overall mortality rates
C.	On the basis of his lack of symptoms it is unlikely that he has an elevated PSA
D.	Because a digital rectal examination is more sensitive than a serum PSA test, his normal examination makes it unlikely that he has cancer
Answer» C. On the basis of his lack of symptoms it is unlikely that he has an elevated PSA

Discussion

392.	A 66-year-old black woman diagnosed with stage III colon cancer underwent definitive resection of the primary tumor 3 years ago. After surgery, she received adjuvant chemotherapy with 5-fluorouracil and leucovorin. Approximately 20 months later, she developed metastatic disease in the liver (five lesions in right and left lobe) and lungs (one lesion in the right and left lobe). She was treated with irinotecan, 5-fluorouracil, and leucovorin, and had a partial response to therapy. One month ago, disease progression was documented on restaging CT scans. The patient s laboratory studies show relatively normal organ function. She has fatigue, decreased appetite, and has noticed a 2.3-kg (5-Ib) weight loss over the past 3 months. She has stopped participating in weekend bike trips with a cycling club, but remains involved in church and family activities and states that she wants to be as aggressive as possible in fighting the cancer. What is the most reasonable recommendation for this patie
A.	Metastatectomy
B.	Hepatic arterial infusion
C.	Second-line chemotherapy regimen with leucovorin and oxaliplatin
D.	High-dose chemotherapy with autologous peripheral stem cell transplantation
Answer» D. High-dose chemotherapy with autologous peripheral stem cell transplantation

Discussion

393.	A 72-year-old man is evaluated because of constipation, abdominal pain, and distention that have worsened over the past week. Two years ago, he was diagnosed with stage III rectal cancer (primary tumor and renal involvement) and underwent low anterior resection. Chemotherapy with 5-fluorouracil and leucovorin followed, and pelvic radiation was given with concurrent infusion of 5-fluorouracil. He has been having regular bowel movements, and results of his most recent colonoscopy (1 year ago) were unremarkable. On physical examination, his pulse rate is 100/min. He has orthostatic hypotension, a slightly distended abdomen with hyperactive bowel sounds, and some guarding to deep palpation in the left lower quadrant. Plain radiograph of the abdomen shows distended loops of small bowel, with no stool in the distal colon or rectum. The patient is hospitalized for bowel rest and intravenous hydration. What is the next step in this patient s management?
A.	Complete colonoscopy
B.	Upper gastrointestinal series with small-bowel follow-through
C.	Positron emission tomography scan of the abdomen
D.	Measurement of serum carcinoembryonic antigen
E.	CT scan of the abdomen with oral and intravenous contrast
Answer» F.

Discussion

394.	A 69-year-old man underwent a radical prostatectomy ii years ago. His serum prostate-specific antigen (PSA) level was 7.1 ng/mL, clinical stage was Tic (clinically organ-confined and detected by screening PSA blood test only), and his Gleason score was 5. His PSA level became detectable 4 years ago. Over the past 3 years, his PSA values have been 1.4 ng/mL, 1 .8 ng/mL, and 2.2 ng/mL. He remains asymptomatic, and a recent bone scan revealed only degenerative disease. The patients risk for rapid metastasis is low for which of the following reasons?
A.	He was initially treated by radical prostatectomy.
B.	His PSA level became undetectable.
C.	He has had a slow, prolonged rise in his PSA.
D.	He is almost 70 years old.
Answer» D. He is almost 70 years old.

Discussion

395.	A 60-year-old postmenopausal woman at elevated risk for breast cancer is taking tamoxifen to reduce her risk. She has not had a hysterectomy. Which of the following surveillance strategies for the detection of endometrial cancer is most important to incorporate into this patient s care?
A.	Annual transvaginal ultrasound
B.	Annual transabdominal pelvic ultrasound
C.	Annual endometrial aspiration sampling
D.	Biennial dilatation and curettage
E.	Annual routine bimanual pelvic examination
Answer» F.

Discussion

396.	Which of the following cancer screening tests has been shown in randomized trials to decrease the risk of death from the target cancer?
A.	Fecal occult blood testing every 2 years for colorectal cancer
B.	Human papillomavirus DNA test for cervical cancer every year
C.	Pap smear of the cervix every year in sexually active women for uterine cancer
D.	Chest radiography every year in cigarette smokers for lung cancer
Answer» B. Human papillomavirus DNA test for cervical cancer every year

Discussion

Explore topic-wise MCQs in Uncategorized topics.

Which of the following adjuvant systemic therapies would be most appropriate to recommend for an otherwise healthy patient who has HER-2/neu-positive (FISH) ER/PR-negative breast cancer with positive axillary lymph nodes?

Which of the following pathological stages of breast cancer is associated with a patient who has a 5.0-cm primary tumor and 12/15 positive, non-fixed lymph nodes?

A bulky tumor of the rectum exhibits a delicate, velvety, easily bleeding surface. It has no pedicel and its base appears to be as wide as its apex. The process is most probably:

A 44-year-old woman presented with post-coital bleeding. Investigation revealed a 2-cm grade 1, stage IB1 squamous cell carcinoma of the cervix. There was no evidence of lymphovascular space invasion. She had completed her family.What is the most appropriate treatment?

What is the stage of a 5-cm gastric tumor that extends into, but not through, the muscularis propria with 16 of 23 positive lymph nodes?

A 60-year-old postmenopausal woman at elevated risk for breast cancer is taking tamoxifen to reduce her risk. She has not had a hysterectomy. Which of the following surveillance strategies for the detection of endometrial cancer is most important to incorporate into this patient s care?

Which of the following cancer screening tests has been shown in randomized trials to decrease the risk of death from the target cancer?