Select the ONE answer that is BEST in each case.
A 65-year-old man, with a 45-pack-per-year history of smoking, presents with hematuria and flank pain. He reports no fever, chills, or dysuria, but he has lost 15 lb. On examination the abdomen is soft, no mass is felt, and there is no flank tenderness on percussion. His hemoglobin (Hb) is 18.5 g/dL, and his liver enzymes are normal. A CT scan of the abdomen reveals a mass in the left kidney with involvement of the renal vein. Which of the following is the most likely diagnosis?
Age, history of smoking, and polycythemia in a patient with hematuria strongly suggests a renal cell carcinoma. The elevated hemoglobin represents increased erythropoietin production and is not related to prognosis. Involvement along the renal vein and metastases to the lungis also characteristic of renal cell carcinoma. Elevated liver enzymes and weight loss can represent nonmetastatic effects of malignancy and can reverse with resection. Almost half of patients will have a palpable abdominal mass on presentation. The CT of the thorax is a useful test because three-quarters of those with metastatic disease will have lung metastases
A 53-year-old woman presents with a 1-cm invasive carcinoma of the breast, detected on mammography. She feels well and has no other symptoms. On examination the lump is palpable, and there are no axillary lymph nodes. Which of the following is the most appropriate local therapy for her tumor?
Breast-conserving surgery is now recommended for small tumors. Radiation therapy will decrease local recurrence rates. For tumors <1 cm, adjuvant therapy is indicated only if axillary nodes are positive. Therefore, in this case, an axillary dissection will provide important therapeutic information. However, this is an area of rapidly changing knowledge and practice.
A 68-year-old woman presents to her attending physician feeling unwell and having lost 10 lb. Physical examination reveals left axillary lymphadenopathy. Biopsy reveals welldifferentiated adenocarcinoma. Liver scan and bone scan suggest widespread metastases. Which statement concerning her further management is correct?
Patients with adenocarcinoma of unknown origin are typically elderly and have metastatic tumors at many sites. Generally, the prognosis is poor, but some subsets, in which effective treatment is available, can be identified by clinical criteria with only moderate investigations. These include peritoneal carcinomatosis in women (responds to treatment for ovarian cancer), predominant skeletal metastases in men (can reflect prostatic cancer), and women with axillary lymphadenopathy (can reflect breast cancer). In the latter scenario, studies for estrogen and progesterone receptors are very useful in guiding therapy.
A 47-year-old woman with cancer phobia comes to the office for counseling. Which of the following statements is true?
When men and women of all ages are considered, cardiovascular diseases are the most common cause of death. However, among women age 35–74 years, cancer is the leading cause of death. Lung cancer is the number one cause of death from cancer, when both men and women are considered. Men generally have higher incidence rates for cancer: breast, gallbladder, and thyroid cancers are the exceptions. It is felt that 75–80% of all cancers in the United States are due to environmental factors. The environmental contribution is estimated by comparing age-adjusted U.S. rates of specific cancers to the rates for the country with the lowest risk.
A 63-year-old man, with chronic heartburn symptoms for many years, presents for reevaluation because of increased abdominal discomfort. He is taking a proton pump inhibitor for his symptoms but experiences little relief. He undergoes upper endoscopy that reveals no masses or tumors, but there is esophagitis. Biopsy of the lower esophagus reveals columnar cells. Which of the following statements is correct?
Barrett’s esophagus, characterized by a columnar cell-lined esophageal mucosa, is a major risk factor for adenocarcinoma of the esophagus. Although acid reflux may be a predisposing factor, there is no evidence that either medical or surgical antireflux measures alter the outcome. It is found in about 20% of patients undergoing endoscopy for esophagitis, and up to 50% may develop a malignancy.
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A 59-year-old man develops jaundice and pruritus. He has no abdominal pain, and on physical examination he is icteric, the liver span is 10 cm, and no masses are felt. Ultrasound reveals dilated intrahepatic bile ducts. He undergoes endoscopic retrograde cholangiopancreatography(ERCP), which suggests a cholangiocarcinoma. Which of the following is the most likely predisposing factor for cholangiocarcinoma?
Worldwide, the presence of liver flukes (e.g., Clonorchis sinensis) is the most likely predisposing factor for cholangiocarcinoma. Part of this increased risk is caused by the development of hepatolithiasis. The highest rate of cholangiocarcinoma is found in Southeast Asia. It is thought that liver flukes and a diet high in nitrosamine are the prime reasons for this. In North America, primary sclerosing cholangitis and chronic ulcerative colitis are the most common predisposing factors. Cholelithiasis, alcohol, smoking, and chronic hepatitis B are not known to be risk factors.
A 53-year-old woman notices a lump in her left breast. She reports no symptoms of breast discharge or previous breast disease. She is postmenopausal, menarche was at age 13, and her family history is negative for breast cancer. Examination reveals a 2-cm palpable lump, which is mobile and nontender, and there are no axillary lymph nodes. Biopsy of the lump is positive for breast cancer, and she undergoes a lumpectomy and lymph node dissection. Which of the following factors is important in deciding about adjuvant therapy for breast cancer?
The size of the tumor is a prognostic factor, as is knowing menopausal status, endocrine receptor status, and lymph node involvement. These four factors are used to decide who will benefit from adjuvant chemotherapy, radiotherapy, or tamoxifen treatment.
A 45-year-old man is worried about a dark pigmented skin lesion on his arm. The “mole” is 3 mm wide, symmetric with a regular border and even pigmentation. He reports no change in size or other symptoms. Which of the following is the most appropriate next step in management?
Observation alone is adequate for this lesion. The “ABCD” rules are helpful in distinguishing benign skin lesions from malignant melanoma. (A) asymmetry, benign lesions are symmetric; (B) border irregular, most nevi have clear-cut borders; (C) color variation, benign lesions have uniform color; (D) diameter, >6 mm is more likely to be malignant. In addition, recent rapid change in size is also helpful in distinguish benign from malignant lesions. Thickness of the tumor is the most important prognostic factor in the majority of cases, and ulceration indicates a more aggressive cancer with a poorer prognosis. Although cumulative sun exposure is a major factor in melanoma (e.g., more frequent near the equator), it cannot explain such things as the more common occurrence of some types in relatively young people. It is possible that brief, intense exposure tosunlight may contribute to, or initiate, carcinogenic events.
A 73-year-old man presents with fatigue and multiple lymph nodes in his neck. He has multiple large nontender lymph nodes in his neck and axilla. The spleen is not palpable, and the remaining examination is normal. A biopsy of the lymph node reveals lymphocytic lymphoma. Which of the following factors predicts poor prognosis?
Prognosis of patients with non-Hodgkin’s lymphoma is best assessed with the International Prognostic Index. It is an index with five clinical risk factors that helps to predict the 5-year survival. Poor prognostic factors are age >60 years, high serum LDH level, poor performance status (either Eastern Cooperative Oncology Group [ECOG] >2, or Karnofsky 1 extranodal involvement.
An asymptomatic 74-year-old man has a high erythrocyte sedimentation rate (ESR) noted on routine blood work done in a yearly physical examination. A follow-up protein electrophoresis reveals a monoclonal immunoglobulin G (IgG) spike. Which of the statements would suggest a plasma cell myeloma, rather than a monoclonal gammopathy of unknown significance?
IgG spikes >3.5 g/dL or IgA >2 g/dL strongly suggest myeloma rather than monoclonal gammopathies of undetermined significance (MGUS). MGUS is suggested when the spike is <3.5 g/dL, the marrow has fewer than 10% plasma cells, and the Bence Jones proteinuria is <1.0 g/day. Depressed hemoglobin levels, elevated calcium levels, progressive bone lesions, and impaired renal function suggest more advanced stages of multiple myeloma.
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Have the lowest cancer rates for both sexes.
Native Americans of both sexes have low cancer rates, but cancer rates (for women) for stomach, biliary tract, cervix, and kidney are surprisingly high.
Have very high rates of melanoma.
Whites have high rates for melanoma, lymphoma, leukemia, and lip cancer.
Have the highest rates for breast, corpus uteri, and ovarian cancers.
Whites have high rates for breast, corpus uteri, testis, bladder, brain, colon, and rectum cancer.
Have especially high rates for cervical cancer
Although Hispanic Americans have relatively low cancer rates (66% of that for White Americans and 54% of that for Black Americans), they do have high rates for cancer of the cervix.
Have elevated rates for nasopharynx and liver cancers.
Chinese Americans have a rate of nasopharyngeal cancer 23 times greater than White Americans and liver cancer rates 7 times greater than White Americans.
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Have high rates for stomach cancer.
Japanese Americans have a threefold increase in stomach cancer rate compared to White Americans, but this is lower than rates in Japan.
Have high cancer rates, at least partially, due to socioeconomic factors.
The excess risk of cancers of the stomach, esophagus, lung, and cervix among Black Americans is diminished when socioeconomic variations are factored in.
A56-year-old man notices an ulcer on his tongue. The lesion persists for a month and becomes more painful and larger in size. There is a 5-mm pale lesion on the lateral border of his tongue, and the remaining examination is normal. A biopsy of the site is positive for squamous cell cancer.
Alcoholic beverages combine with tobacco smoking to increase cancer of the mouth and, by causing cirrhosis, can lead to liver cancer
A 68-year-old man develops shortness of breath on exertion and right-sided chest pain. Air entry is reduced to the right lower lobe and the area is dull on percussion. A CXR reveals a right pleural effusion. A CT scan of the chest reveals a pleural-based tumor in the right lower lobe, and areas of calcification on the pleura. A biopsy of the lesion is positive for mesothelioma.
Asbestos exposure causes more deaths from lung cancer (two-fold increase) than from mesothelioma (hundredfold increase) because the latter tumor is so rare.
A 64-year-old woman notices a nodule on her face that persists for more than a month. It appears as a raised lesion with small vessels on it. Excisional biopsy of the lesion confirms a diagnosis of basal cell carcinoma.
Sun exposure severe enough to cause sunburn is associated with increased risk of melanoma, whereas other skin cancers are more related to cumulative exposure.
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21. A 65-year-old man, with a 45-pack-per-year history of smoking, presents with hematuria and flank pain. He reports no fever, chills, or dysuria, but he has lost 15 lb. On examination the abdomen is soft, no mass is felt, and there is no flank tenderness on percussion. His hemoglobin (Hb) is 18.5 g/dL, and his liver enzymes are normal. A CT scan of the abdomen reveals a mass in the left kidney with involvement of the renal vein. Which of the following is the most likely diagnosis? (A) renal cyst (B) renal cell carcinoma (C) renal metastases (D) renal abscess (E) lymphoma |
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22. A 53-year-old woman presents with a 1-cm invasive carcinoma of the breast, detected on mammography. She feels well and has no other symptoms. On examination the lump is palpable, and there are no axillary lymph nodes. Which of the following is the most appropriate local therapy for her tumor? (A) simple mastectomy with axillary dissection (B) radiation therapy to breast and axilla (C) local excision plus radiation therapy |
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23. A 68-year-old woman presents to her attending physician feeling unwell and having lost 10 lb. Physical examination reveals left axillary lymphadenopathy. Biopsy reveals welldifferentiated adenocarcinoma. Liver scan and bone scan suggest widespread metastases. Which statement concerning her further management is correct? (A) the response rate for metastatic adenocarcinoma (well-differentiated) of unknown primary site is so poor that no investigation or treatment is indicated (B) special stains might guide management (C) extensive workup, including colonoscopy, abdominal CT scan, and mammography, will define subsets that benefit from treatment (D) special studies of the excised lymph node are not useful in determining the site of origin (E) metastatic breast cancer is the most common cause of adenocarcinoma of unknown primary site in women |
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24. A 47-year-old woman with cancer phobia comes to the office for counseling. Which of the following statements is true? (A) cancer is the most common cause of death in the United States (B) cancer is the most common cause of death in middle-aged women (C) incidence rates for cancer are generally higher in women than men (D) colon and rectum cancers have the highest mortality rate when considering both men and women (E) about 25% of all cancers in the United States are due to environmental factors |
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25. A 63-year-old man, with chronic heartburn symptoms for many years, presents for reevaluation because of increased abdominal discomfort. He is taking a proton pump inhibitor for his symptoms but experiences little relief. He undergoes upper endoscopy that reveals no masses or tumors, but there is esophagitis. Biopsy of the lower esophagus reveals columnar cells. Which of the following statements is correct? (A) it is a major risk factor for squamous cell cancer of the esophagus (B) it can be found in up to 20% of patients undergoing esophagoscopy for esophagitis (C) the histologic changes include development of keratinized squamous cells (D) medical control of reflux will decrease the likelihood of malignant changes (E) only 10% of patients with Barrett’s esophagus may develop malignancy |
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26. A 59-year-old man develops jaundice and pruritus. He has no abdominal pain, and on physical examination he is icteric, the liver span is 10 cm, and no masses are felt. Ultrasound reveals dilated intrahepatic bile ducts. He undergoes endoscopic retrograde cholangiopancreatography(ERCP), which suggests a cholangiocarcinoma. Which of the following is the most likely predisposing factor for cholangiocarcinoma? (A) smoking (B) excess alcohol intake (C) chronic hepatitis B virus (HBV) infection (D) history of ulcerative colitis or sclerosing cholangitis (E) gallstones |
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27. A 53-year-old woman notices a lump in her left breast. She reports no symptoms of breast discharge or previous breast disease. She is postmenopausal, menarche was at age 13, and her family history is negative for breast cancer. Examination reveals a 2-cm palpable lump, which is mobile and nontender, and there are no axillary lymph nodes. Biopsy of the lump is positive for breast cancer, and she undergoes a lumpectomy and lymph node dissection. Which of the following factors is important in deciding about adjuvant therapy for breast cancer? (A) menopausal status (B) tumor size (C) endocrine receptor status (D) lymph node status (E) all of the above |
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28. A 45-year-old man is worried about a dark pigmented skin lesion on his arm. The “mole” is 3 mm wide, symmetric with a regular border and even pigmentation. He reports no change in size or other symptoms. Which of the following is the most appropriate next step in management? (A) observation only (B) excisional biopsy (C) punch biopsy (D) chemotherapy, then surgical excision (E) surgical excision and regional node dissection |
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29. A 73-year-old man presents with fatigue and multiple lymph nodes in his neck. He has multiple large nontender lymph nodes in his neck and axilla. The spleen is not palpable, and the remaining examination is normal. A biopsy of the lymph node reveals lymphocytic lymphoma. Which of the following factors predicts poor prognosis? (A) no extranodal involvement (B) poor performance status (C) age <60 (D) low serum lactate dehydrogenase (LDH) levels (E) fever and weight loss |
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30. An asymptomatic 74-year-old man has a high erythrocyte sedimentation rate (ESR) noted on routine blood work done in a yearly physical examination. A follow-up protein electrophoresis reveals a monoclonal immunoglobulin G (IgG) spike. Which of the statements would suggest a plasma cell myeloma, rather than a monoclonal gammopathy of unknown significance? (A) Bence Jones protein 2 g/day (B) normal hemoglobin (C) M component level of 2 g/dL (D) bone marrow plasma cells of 5% (E) normal serum calcium level |
| 31. Have the lowest cancer rates for both sexes.
(A) Hispanic Americans |
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32. Have very high rates of melanoma.
(A) Hispanic Americans |
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33. Have the highest rates for breast, corpus uteri, and ovarian cancers.
(A) Hispanic Americans |
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34. Have especially high rates for cervical cancer
(A) Hispanic Americans |
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35. Have elevated rates for nasopharynx and liver cancers.
(A) Hispanic Americans |
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36. Have high rates for stomach cancer.
(A) Hispanic Americans |
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37. Have high cancer rates, at least partially, due to socioeconomic factors.
(A) Hispanic Americans |
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38. A56-year-old man notices an ulcer on his tongue. The lesion persists for a month and becomes more painful and larger in size. There is a 5-mm pale lesion on the lateral border of his tongue, and the remaining examination is normal. A biopsy of the site is positive for squamous cell cancer.
(A) alcoholic beverages |
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39. A 68-year-old man develops shortness of breath on exertion and right-sided chest pain. Air entry is reduced to the right lower lobe and the area is dull on percussion. A CXR reveals a right pleural effusion. A CT scan of the chest reveals a pleural-based tumor in the right lower lobe, and areas of calcification on the pleura. A biopsy of the lesion is positive for mesothelioma.
(A) alcoholic beverages |
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40. A 64-year-old woman notices a nodule on her face that persists for more than a month. It appears as a raised lesion with small vessels on it. Excisional biopsy of the lesion confirms a diagnosis of basal cell carcinoma.
(A) alcoholic beverages |
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