Deck 4: Clinical Cases in Oncology and Nephrology

Question 1

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 1

Small cell (oat cell) carcinoma

Question 2

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 2

Trastuzumab

Question 3

Concerning Neurofibromatosis Type 1 (NF1), which one of the following statements is true?

A)Bilateral acoustic neuromas are common
B)Clinical severity in individuals is similar in a given family
C)New mutations occur rarely
D)Pigmented spots on the iris are a characteristic feature
E)The diagnosis is likely if two café-au-lait patches are present

Answer 3

Pigmented spots on the iris are a characteristic feature

Question 4

Regarding retinoblastoma which of the following statements is correct?

A)Bilateral involvement is found in 70% of cases.
B)The predisposition may be inherited as an autosomal dominant condition.
C)There is an increased risk of autoimmune disease.
D)They have often metastasised by the time of diagnosis.
E)They usually present with leukocoria.

Question 5

Which of the following regarding salivary gland pleomorphic adenomas is correct?

A)they are the most common salivary gland tumor
B)are commoner in the sub-mandibular than the parotid gland
C)in the parotid gland most commonly arise medial to the facial nerve
D)are more common in males than in females
E)typically enhance following intravenous contrast injection in CT

Question 6

A 65-year-old man, with a history of smoking, presents with chronic cough, haemoptysis and weight loss. His Chest X-Ray shows a cavitating lesion. What is the likely diagnosis?

A)adenocarcinoma
B)alveolar cell carcinoma
C)large cell carcinoma
D)small cell carcinoma
E)squamous cell carcinoma

Question 7

In asbestos related disorders which of the following statements is correct?

A)basal fibrotic shadowing on CXR suggests coincidental idiopathic fibrosing alveolitis
B)increased incidence of primary lung cancer
C)pleural effusion develops more than 20 years after causative asbestos exposure
D)pleural plaques are recognized precursors of mesothelioma
E)the risk of malignant mesothelioma is greatly increased in smokers compared with non-smokers

Question 8

Carcinoid tumors of the lung (bronchial adenomas) originate from which of the following cell types?

A)Ciliated cell
B)Clara cell
C)Kulchitsky (K) cell
D)Mucus (goblet) cell
E)Type 2 Alveolar cell

Question 9

A 75-year-old man with squamous cell carcinoma is thought to have resectable disease. Which of the following would be a contraindication to surgery?

A)clubbing
B)FEV1 of 0.75 L
C)his age of 75 years
D)pleural effusion
E)Syndrome of Inappropriate ADH

Question 10

20- A 59 year old female smoker is diagnosed with oat cell carcinoma of the bronchus. Which of the following relating to this diagnosis is true?

A)The tumor is likely to be radiosensitive
B)occurs with equal frequency in smokers and non-smokers
C)has a 5 year survival greater than 20%
D)Is associated with the elaboration of ectopic ADH secretion
E)Is typically associated with ectopic parathormone secretion.

Question 11

Mutations of the p53 gene frequently occur in:

A)Huntingdon's Disease
B)Type 2 Diabetes Mellitus
C)Cystic fibrosis
D)Bronchial Carcinoma
E)Colonic polyps

Question 12

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

Question 13

A 56-year-old woman is recently diagnosed with small cell carcinoma of the lung. Which of the following non-metastatic manifestations is she most likely to develop?

A)myasthenia gravis
B)Eaton-Lambert syndrome
C)ectopic PTH-related peptide secretion
D)erythema gyratum repens
E)hypertrophic pulmonary osteoarthropathy (HPOA)

Question 14

In which of the following cases of lung cancer would surgical resection of the tumor be a reasonable therapeutic option?

A)A 56-year-old woman with an adenocarcinoma of the right lung. CT scan shows enlarged lymph nodes in the right and left hilum. PFTs show an FEV1 of 2.25 L. (55% predicted).
B)A 59-year-old man who is found at bronchoscopy to have a tumor in the right mainstem bronchus extending to within 1 cm of the carina. Pulmonary Function Tests (PFTs) show an FEV1 of 2.1 liters (65% of predicted normal).
C)A 62-year-old lady with a small peripheral mass who has elevated liver enzymes and a computed tomography (CT) scan showing probable metastatic deposits in the liver PFTs show an FEV1 of 3.5 Liters (80% of predicted normal).
D)A 70-year-old man with a right lower lobe tumor 2 cm in diameter with no evidence of regional adenopathy or distant spread of disease. PFTs show an FEV1 of 0.8 Liters (28% predicted).
E)A 71-year-old man with a 3 cm tumor obstructing the right lower lobe bronchus. PFTs show an FEV1 of 1.98 L. (43% predicted).

Question 15

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 µmol/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

Question 16

A 56-year-old man from Thailand presented with abdominal pain and a mass in the right upper quadrant. He reported that he had been diagnosed with viral hepatitis several years previously. Investigations showed: Serum alpha-fetoprotein 13,500 IU/L (< 10) What is the most likely underlying viral infection?

A)Hepatitis A virus
B)Hepatitis B virus
C)Hepatitis C virus
D)Hepatitis D virus
E)Hepatitis E virus

Question 17

A 64-year-old man has terminal cancer with hepatic metastases. He is treated with oral morphine (Oramorph) solution for pain relief.Which is the most important pharmacodynamic factor in determining the appropriate timing between doses?

A)bioavailability
B)first pass metabolism
C)gastric emptying
D)plasma half-life
E)renal clearance

Question 18

A 51-year-old woman has had several syncopal episodes over the past year. Each episode is characterized by sudden but brief loss of consciousness. She has no chest pain. She has no ankle edema. On brain MRI there is a 1.5 cm cystic area in the left parietal cortex. A chest X-ray shows no cardiac enlargement, and her lung fields are normal. Her serum total cholesterol is 6.5 mmol/L. Which of the following cardiac lesions is she most likely to have?

A)Cardiac amyloidosis
B)Ischemic cardiomyopathy
C)Left atrial myxoma
D)Mitral valve prolapse
E)Tuberculous pericarditis

Question 19

Which of the following statements regarding prognosis in lung cancer is true?

A)Combined modality therapy (chemotherapy, radiation therapy and surgery) has improved overall lung cancer survival to 40% at 5 years.
B)Overall lung cancer survival is < 15% at 5 years.
C)Patients undergoing radiation therapy have a 5 year survival of 40%.
D)Patients who qualify for surgery have a 50% 5 year survival.
E)With chemotherapy, overall survival in small cell (oat cell) carcinomas has risen to 60% at 5 years.

Question 20

A 45-year-old man develops facial swelling and breathlessness. His chest X-ray reveals paratracheal lymphadenopathy. Which of the following statements is most accurate regarding the superior vena caval obstruction?

A)the most common cause is squamous cell carcinoma
B)treatment of choice is radiotherapy
C)it may be associated with voice hoarseness
D)it is associated with Kussmaul's sign
E)the commonest symptom is stridor

Question 21

A 52-year-old woman presented with hot flushes. Her last menstrual period had been 1 year previously. She was treated with ethinylestradiol and medroxyprogesterone acetate. Which potential consequence of oestrogen therapy is most reduced by co-prescription of a progestogen?

A)breast cancer
B)breast pain
C)endometrial cancer
D)mood changes
E)weight gain

Question 22

A 44 years old female with breast lump of one year duration, slowly progressed, examination revealed right inner lower quadrant mass with normal both axillae, biopsy revealed a benign nature with average risk to develop cancer, this pathology is mostly

A)Sclerosing adenosis
B)Fibrocystic disease
C)Hyperplasias with atypia increases the risk of developing invasive breast cancer by:
D)Papillomas
E)Lobular carcinoma in situ

Question 23

Which of the following is associated with a GH secreting pituitary tumor

A)Gs alpha subunit mutation
B)Pit-1 mutation
C)H-ras mutation
D)Rb 1 mutation
E)p53 mutation

Question 24

33- Which ONE of the following statements regarding colon cancer is correct:

A)In non-familial cases, gene mutations in the cancer cells are unusual
B)In familial cases the inheritance pattern is typically autosomal recessive
C)It occurs most commonly in the ascending colon
D)It is a characteristic feature of the Peutz-Jegher syndrome
E)In familial polyposis coli the increased cancer risk is due to inheritance of a mutated suppressor gene

Question 25

The following are recognized features of Pancoast's tumor except:

A)ipsilateral Horner's syndrome
B)wasting of the dorsal interossei
C)pain in the arm radiating to the fourth and fifth fingers
D)erosion of the first rib
E)weakness of abduction at the shoulder