Internal medicine - Clinical oncology Flashcards
1
Q
INT - 17.1
Who decides to start a complex oncology treatment for a newly diagnosed cancer patient?
A) The surgeon, because the tumor primarily requires resection
B) The oncologist, because he/she knows best about chemotherapy protocols
C) The pathologist, who determines the exact diagnosis using immunohistochemical methods
D) The radiotherapy specialist
E) All of the above
A
ANSWER
E) All of the above
EXPLANATION
Treatment of newly-diagnosed tumorous patients is decided by an Onko-Team, which consists of a surgeon, an oncologist, a pathologist, a radiotherapist, and a psychologist beeing an expert in psycho-oncology.
2
Q
INT - 17.3
What is the relationship between dysplasia and cancer?
A) Dysplasia always leads to the development of a cancer.
B) All cancer is preceded by dysplasia.
C) The progression of cancer is dysplasia.
D) A and C.
E) All of the above.
A
ANSWER
B) All cancer is preceded by dysplasia.
EXPLANATION
Dysplasia means insufficient differentiation and elevated number of mitosis. At precancerous stage, all types of cancer are preceded by dysplasia, but not all dyplasia leads to cancer.
3
Q
INT - 17.4
At cellular level tumor growth does not depend on the following:
A) time of cell cycle
B) growth fraction (proliferating tumor cell ratio)
C) cell death rate inside the tumor
D) time of duplication of tumor volume
E) apoptosis
A
ANSWER
E) apoptosis
EXPLANATION
Tumor growth depends on four factors: time of cell cycle, growth fraction (proliferating tumor cell ratio), time to duplicate tumor volume, and tumor cell loss (cell death rate). With these variations, the different behavior of various histologic and primary and metastatic histopathological tumors can be well described.
4
Q
INT - 17.6
The prognosis of the following tumor was the most significantly improved by combined chemotherapy:
A) Small cell lung cancer
B) Medulloblastoma
C) Seminoma
D) Neuroblastoma
A
ANSWER
C) Seminoma
EXPLANATION
The cure rate of seminoma with combined chemotherapy after surgery is above 90% if there was no distant metastases. Even if distant metastases are present, cure rate is still above 70%.
5
Q
INT - 17.7
Chemotherapy before surgery is important for the treatment of the following tumor:
A) Wilms-tumor
B) medulloblastoma
C) Burkitt-lymphoma
D) retinoblastoma
E) Gallbladder cancer
A
ANSWER
A) Wilms-tumor
EXPLANATION
Prognosis of Wilms tumor was significantly improved by preoperative chemotherapy. The results of course depend on the stage and the histological type (preferred / disadvantageous). In case of stage I-II disease, the relapse-free survival is usually around 90%. Neoadjuvant therapy is also important for other tumors, e.g. esophagus-, rectum-, breast- or bone cancer. For Burkitt-lymphoma, no surgical intervention is used for therapeutic purposes.
6
Q
INT - 17.8
After a curative surgery, the treatment for the prevention of recurrence:
A) neoadjuvant
B) adjuvant
C) palliative
D) supportive
E) none of the above
A
ANSWER
B) adjuvant
EXPLANATION
After surgical treatment of a cancer, the treatment used to prevent recurrence is called adjuvant therapy.
7
Q
INT - 17.9
To evaluate the effectiveness of adjuvant treatment, the following parameter is chosen:
A) The time to relapse
B) Disease-free survival
C) Overall survival
D) All of the above
A
ANSWER
D) All of the above
EXPLANATION
There are three basic patient-related parameters to evaluate the effectiveness of adjuvant therapy: time to relapse (TR), disease-free survival (DFS), total patient lifetime (“overall Survival “, OS).
8
Q
INT - 17.10
In case of treatment of cancer patients, improvement of the disease is called:
A) remission
B) stable disease
C) progression
D) refractory disesase
E) none of the above
A
ANSWER
A) remission
EXPLANATION
Remission means the improvement of the disease. In the case of stable disease, the changes observed during treatment do not change significantly, while in case of deterioration we speak of progression. In refractory state, the disease does not respond to the treatment.
9
Q
INT - 17.11
Criteria for evaluating the therapeutic response during treatment of cancer patients:
A) Dukes-staging system
B) RECIST-staging system
C) Forrest-staging system
D) Bismuth-staging system
E) All of the above
A
ANSWER
B) RECIST-staging system
EXPLANATION
Dukes classification is used for the staging of colorectal carcinoma. RECIST (Response Evaluation Criteria In Solid Tumors) is used for evaluating the therapeutic response in solid tumors. In case of a gastroduodenal ulcer disease, Forrest-classification is used to evaluate the bleeding activity of the ulcer. Bismut-classification aims to provide an anatomical description of hilar biliary tract cancers.
10
Q
INT - 17.12
In oncological clinical studies progression free survival (PFS) is often evaluated. How do you define this term?
A) Progression-Free Survival (PFS) is the time that elapses in a progressive/metastatic tumor from starting treatment (from clinical trial randomization) to repeated tumor growth and/or death of a patient.
B) PFS is the time that elapses from the onset of the therapy of an advanced / metastatic disease (in clinical trials from randomization) to the death of a patient.
A
ANSWER
A) Progression-Free Survival (PFS) is the time that elapses in a progressive/metastatic tumor from starting treatment (from clinical trial randomization) to repeated tumor growth and/or death of a patient.
EXPLANATION
The FDA (Food and Drug Administration, United States Department of Food and Drug Administration) issued detailed guidelines on the clinical endpoint of oncological clinical trials. Progression-free survival ranges from treatment initiation, i.e. randomization to objective tumor progression or to the patient’s death. (TTP, time-to-pregression: only time to progression is observed, death of patients is not taken into account, censorship of mortality data by terminology.)
11
Q
INT - 17.13
Definition of overall survival (OS):
A) Overall Survival (OS) is the time that elapses in a progressive / metastatic tumor from starting treatment (from randomization in clinical trials) to repeatedly confirmed tumor growth and / or death of the patient.
B) Overall survival (OS) is the time that elapses from the onset of tumor treatment (in clinical trials from randomization) to the death of a patient.
A
ANSWER
B) Overall survival (OS) is the time that elapses from the onset of tumor treatment (in clinical trials from randomization) to the death of a patient.
EXPLANATION
The FDA (Food and Drug Administration, United States Department of Food and Drug Administration) issued detailed guidelines on the clinical endpoint of oncology clinical trials. (The Clinical Trial Endpoints for the Approval of Cancer Drugs and Biology, 2007) Overall survival (OS) according to the guidelines, is the time elapsed from randomization (that is, the commencement of a trial after randomized election of patients) until patients’ death from any reason. This is a very realistic endpoint in oncology clinical trials. It is accurate, easy to measure and document, and is therefore a preferred endpoint in oncology clinical trials.
12
Q
INT - 17.14
The overall response rate (ORR) is used to express the effectiveness of treatment in clinical trials. Which components does the ORR consist of? (CR is the complete response, PR is partial response, SD is stable disease / and PD is progressive disease /.)
A) ORR= CR+PR+ SD + PD
B) ORR= CR+PR+ SD
C) ORR= CR+PR
A
ANSWER
C) ORR= CR+PR
EXPLANATION
Clinical trials often use the ORR or RR (response rate) expressions for treatment of malignant diseases. The response rate is directly related to the activity of an anticancer drug. The FDA (Food and Drug Administration, US Food and Drug Administration) has issued detailed guidelines with endpoints of clinical trials of oncology which also defines ORR. In general, the ORR is the amount of partial response and complete response. Stable disease (SD) is not part of the response rate.
13
Q
INT - 17.15
PRO abbreviation is often used in oncology drug development. It is the abbreviation of:
A) Progression Related Outcome
B) Patient Reported Outcome
A
ANSWER
B) Patient Reported Outcome
EXPLANATION
Patient’s opinion regarding the particular medication has an increasing role in clinical studies of oncology. The information about the patient’s medical condition comes directly from the patient (not interpreted by a doctor or someone else). In clinical trials, such questionnaires are used to measure the effectiveness of an intervention. To collect such data, various quality of life questionnaires are in use.
14
Q
INT - 17.16
What is the RECIST criteria used for in oncology and in oncological clinical trials?
A) In solid tumors, the response to anticancer treatment in imaging studies is evaluated by these criteria.
B) RECIST relates to the determination of cell surface receptors in solid tumors.
A
ANSWER
A) In solid tumors, the response to anticancer treatment in imaging studies is evaluated by these criteria.
EXPLANATION
RECIST: Response Evaluation Criteria in Solid Tumors, provides framework how to evaluate therapeutic response in solid tumors using various imaging platforms (CT, MRI, PET-CT). Based on this system we can differentiate among complete response, partial response, stable disease or progression.
15
Q
INT - 17.17
In ca. 10% of cancer patients, hypercalcaemia occurs due to tumor cells producing materials. Such materials are the following, except:
A) production of parathormon-like peptide
B) calcitonin
C) active metabolits of Vitamin-D
D) prostaglandins
E) TGF-α és TGF-β
A
ANSWER
B) calcitonin
EXPLANATION
Increased calcitonin production may occur in medullary carcinomas of thyreoid gland, or can be ectopic in many tumors, such as in small celllung cancer, breast cancer and leukemia. Calcitonin does not cause hypercalcaemia, although, there is also no exact data that it would lead to hypocalcaemia in a tumorous patient.
16
Q
INT - 17.18
Which gene’s defect is the most common in human tumors?
A) c-raf
B) c-myc
C) K-ras
D) p53
E) c-fos
A
ANSWER
D) p53
EXPLANATION
Error of p53 (mutations, deletions, protein inactivation) is the most common.
17
Q
INT - 17.19What is the meaning of MDR?
A) minimal disease residue
B) multiple drug resistance
C) maximal dose rate
D) mesenchymal disease risk
E) medulloblastoma gene receptor
A
ANSWER
B) multiple drug resistance
EXPLANATION
Multidrug resistance means that there are proteins (plasma membrane transporters - MDR1, MRP1) which are able to “pump out” the chemotherapeutic agents from cells, including tumor cells, to hinder effective intracellular concentrations. For certain drugs, it is recommended to determine the MDR1 activity to reach the expected therapeutic effect.
18
Q
INT - 17.20
For which chemotherapeutic agent is the citrovorum factor or folic acid used as a “rescue” compound (for the protection of normal tissues and thus high dosage chemotherapy)?
A) methotrexat
B) bleomycin
C) cyclophosphamid
D) adriamycin
E) vincristin
A
ANSWER
A) methotrexat
EXPLANATION
Methotrexate ultimately reduces the level of reduced folate, thereby, level of thymidine nucleotides and / or purine nucleotides. This effect leading to cytotoxicity is related to the plasma concentration of the agent. Leucovorin (citrovorum factor, folic acid), provided to the patient after treatment, can rescue normal tissues without diminishing the antitumor effect. This protection allows the administration of methotrexate at high doses. (The folic acid is also co-administered with 5-fluorouracils.) In combinations, there are many variations of the order and dose of these drugs.
19
Q
INT - 17.21
Mesna may reduce the toxic damage of the bladder. Which cytostatic agent is it used for?
A) 5-fluorouracil
B) adriamycin
C) cisplatin
D) cyclophosphamid
E) methotrexat
A
ANSWER
D) cyclophosphamid
EXPLANATION
Cyclophosphamide is activated in the body, its alkylating metabolite is the anti-tumor phosphoramidic mustard and acrolein which causes bladder irritation. At high doses, severe haemorrhagic cystitis may occur which can be prevented by mesna (sodium 2-mercaptoethanesulfonate). Mesna neutralizes the harmful metabolite and does not affect the anti-tumor effect. Cyclophosphamide treatment may increase the risk of developing bladder cancer.
20
Q
INT - 17.22
The following side effects may occur immediately or early after cytotoxic therapy except (indicate the exception):
A) nausea / vomiting
B) urocystitis
C) renal failure
D) phlebitis
E) azoospermia
A
ANSWER
E) azoospermia
EXPLANATION
Oncological emergency cases include cardiovascular, haematological, metabolic and neurological complications. Azoospermia can be a late side effect.
21
Q
INT - 17.23
Which phase of the cell cycle is affected by taxane type cytostatics?
A) G0
B) G1
C) S
D) G2
E) M
A
ANSWER
E) M
22
Q
INT - 17.24
What is the machanism of action of camptothecin cytostatics (irinotecan, topotecan)?
A) inhibits the depolymerization of microtubules
B) topoizomerase II. inhibitors
C) topoizomerase I. inhibitors
D) Inhibition of DNA function and cell division in phase M
A
ANSWER
C) topoizomerase I. inhibitors
EXPLANATION
They block the DNA replication by blocking the topoisomerase I.
23
Q
INT - 17.25
The following is valid for antimitotic chemotherapeutic drugs:
A) causes covalent crosslinking of the two polynucleotide chains in the dual spiral of DNA
B) they inhibit DNA synthesis through the inhibition of important enzymes of purine or pyrimidine synthesis.
C) they inhibit the polymerization of tubulins, i.e. the formation of mitotic spindles.
D) They inhibit the depolymerization of tubulins, i.e. blocking the mitotic spindle.
E) C and D
A
ANSWER
E) C and D
EXPLANATION
Antimitotic chemotherapeutic drugs inhibit the polymerization of tubulins, and so, the formation of mitotic spindles. They also inhibit the depolymerization of tubulins, i.e. block the mitotic spindle.
24
Q
INT - 17.26
Which compound belongs to the strong opiates?
A) codein
B) oxycodon
C) tramadol
D) dextropropoxyphen
A
ANSWER
B) oxycodon
EXPLANATION
Fentanyl, Hydromorphone and oxycodon are the strongest opiates in order.
25
INT - 17.27
Targeted therapies for treatment of solid tumors, except (indicate the exception):
A) adalimumab
B) imatinib
C) sorafenib
D) cetuximab
E) sunitinib
ANSWER
A) adalimumab
EXPLANATION
Adalimumab is a human monoclonal antibody used to treat inflammatory bowel disease, and has no indications in treatment of solid tumor. B-E responses are targeted treatment options for solid tumors (imatinib - gastrointestinal stroma tumor, sorafenib - hepatocellular carcinoma, kidney cancer, cetuximab - colorectal carcinoma, non-small cell lung cancer, sunitinib kidney cancer, gastrointestinal stromal tumor).
26
INT - 17.28
CA-19-9 tumor marker test is the most valuable in the follow-up of the following disease:
A) ovarian cancer
B) hepatocellular carcinoma
C) testicular cancer
D) breast cancer
E) pancreas cancer
ANSWER
E) pancreas cancer
EXPLANATION
In cases of pancreatic cancer, the CA 19-9 value is often elevated.
27
INT - 17.29
CA-15-3 tumor marker test is the most valuable in the follow-up of the following disease:
A) ovarian cancer
B) hepatocellular carcinoma
C) testicular cancer
D) breast cancer
E) pancreatic cancer
ANSWER
D) breast cancer
EXPLANATIONThe most specific tumor marker for breast cancer is CA 15-3. Therefore, they are followed up.
28
INT - 17.30
AFP (alfa-foeto-protein) tumor marker test is the most valuable in the follow-up of the following disease:
A) ovarian cancer
B) hepatocellular carcinoma
C) testicular cancer
D) breast cancer
E) pancreatic cancer
ANSWER
B) hepatocellular carcinoma
EXPLANATION
In case of hepatocellular carcinoma, AFP value is often elevated.
29
INT - 17.31
CA-125 tumor marker test is the most valuable in the follow-up of the following disease:
A) ovarian cancer
B) hepatocellular carcinoma
C) testicular cancer
D) breast cancer
E) pancreatic cancer
ANSWER
A) ovarian cancer
EXPLANATION
CA-125 tumor marker is often elevated in gynecological tumors, especially in ovarian cancer.
30
INT - 17.32
β-HCG tumor marker test is the most valuable in the follow-up of the following disease:
A) ovarian cancer
B) hepatocellular carcinoma
C) testicular cancer
D) breast cancer
E) pancreatic cancer
ANSWER
C) testicular cancer
EXPLANATION
In some of testicular cancer, beta-HCG (= human choriogonadotropic hormone) is elevated, and can be used for monitoring the disease.
31
INT - 17.33
In case of prostate cancer, which of the following tumor markers should be followed?
A) β-HCG
B) CEA
C) PSA
D) CA-125
ANSWER
C) PSA
EXPLANATION
PSA, i.e. prostate specific antigen is a specific marker of prostate cancer, most of the times, it is sensitive to the development and change of the disease.
32
INT - 17.34
Which factor is not used for monitoring or as prognostic factor in tumors?
A) CEA
B) PSA
C) β-HCG
D) TSH
E) p53
ANSWER
D) TSH
EXPLANATION
TSH can not be considered to be a tumor marker. The others are used as tumor markers, however, opinions about their advantage - specificity, sensitivity - vary considerably.
33
INT - 17.35
What is the most common histological type of malignant oesophageal cancer?
A) leiomyosarcoma
B) epithelial carcinoma
C) adenocarcinoma
D) rhabdomyosarcoma
E) melanoma
ANSWER
B) epithelial carcinoma
EXPLANATION
80-90% of malignant esophageal tumors are squamous-cell carcinoma.
34
INT - 17.36
What is the most common primary tumor site in Krukenberg tumor?
A) breast cancer
B) gallbladder cancer
C) rectum cancer
D) pancreas cancer
E) gastric cancer
ANSWER
E) gastric cancer
EXPLANATION
Krukenberg tumor (metastases in the ovaries) is the result of a gastric cancer in ca. 75% of the cases, the rest is in majority a metastasis of colon cancer.
35
INT - 17.37
In case of haematogenous dissemination, the following tumors usually give a pulmonary metastases first, except one type of tumor:
A) gastric cancer
B) breast cancer
C) renal cancer
D) chorionepithelioma
E) osteosarcoma
ANSWER
A) gastric cancer
EXPLANATION
Because of venous discharge, in the first wave of hematogenous spread of gastric cancer, liver metastases are typical. (However, it is important to take account of the possibility of "unusual" lymphogenic metastasis over the diaphragm, eg. the supraclavicular lymph node.)
36
INT - 17.40
Which drug was the first approved „targeted therapy” in the treatment of hepatocellular carcinoma?
A) sorafenib
B) bevacizumab
C) gefitinib
D) vandetanib
E) ipilimumab
ANSWER
A) sorafenib
EXPLANATION
In the treatment of hepatocellular carcinoma approving the first „targeted therapy”was a real breakthrough. This drug is called sorafenib, which was approved under the name of Nexavar.
37
INT - 17.41
According to clinical studies, the sorafenib treatment in patients diagnosed with primary hepatic cancer (hepatocellulray carcinoma),increases the overral survival. Is this true or false?
A) true
B) false
ANSWER
A) true
EXPLANATION
According to the results of the international,multicentric, double blind, randomized phase III study SHARP, treatment with sorafenib in the case of patients with advanced hepatocellular cancer, (and ECOG 0-2 status), resulted in significant increase of overal survival.
38
INT - 17.42
Choose the correct answer.
A) The mortality of colon cancer is constantly increasing.
B) The mortality of colon cancer has been decreasing since the introduciton of effective chemotherapy.
C) The mortality of colon cancer was rapidly increasing between 1965 and 2000, since then it has been stagnant.
D) The mortality of colon cancer hasn’t changed significantly in the past few decades.
E) In first world countries,colon cancer has the highest mortality rate of all cancers
ANSWER
C) The mortality of colon cancer was rapidly increasing between 1965 and 2000, since then it has been stagnant.
EXPLANATION
The mortality of colorectal cancer increased rapidly between 1965 and 2000, since then it has been stagnant..
39
INT - 17.43
Chemotherapy drugs used in the treatment of colorectal cancer, except:
A) 5-fluorouracil
B) capecitabine
C) oxaliplatin
D) irinotecan
E) docetaxel
ANSWER
E) docetaxel
EXPLANATION
Docetaxel therapyis currently not applied in the treatment of colorectal cancer.
40
INT - 17.44
Treatment option in the therapy of rectal cancer:
A) total mesorectal excision
B) neoadjuvant chemotherapy
C) adjuvant chemotherapy
D) VEGF inhibitor drugs
E) all of the above
Answer
E) all of the above
EXPLANATION
All of above are part of the treatment of the rectal cancer respectively.
41
INT - 17.45
In which malignant disease ”DNA mismatch repair error” is the most frequent?
A) Li–Fraumeni-sydrome
B) MEN-2 syndrome
C) retinoblastoma
D) hereditary, non polyposis colon cancer (HPNCC)
E) Wilms-tumor
ANSWER
D) hereditary, non polyposis colon cancer (HPNCC)
EXPLANATION
The prototype disease of mismatch-repair-error is the HNPCC: hereditary non-polyposis colorectal cancer (the affected genes are the hMSH2, PMS family – hMLH1, hPMS1, hPMS2, hMSH3, hMSH6 genes). In Li-Fraumeni syndrome the mutation is in the p53 gene, in retinoblastoma in the RB1 gene, in MEN-2 syndrome in the Ret gene, and in the case of Wilms-tumor in the WT1 gene.
42
INT - 17.46
Which of the following malignant cancers don’t ususally metastatize to the bones?
A) thyroid cancer
B) breast cancer
C) renal cancer
D) colon cancer
E) prostate cancer
ANSWER
D) colon cancer
EXPLANATION
Colon cancer rarely metastatizes to the bones, even in it’s disseminated form, however bone pain, or even bone fracture can be the first sypmtom of the other tumors.
43
INT - 17.47
Correct statements regarding the neuroendocrine tumor (NET), except:
A) Neuroendocrine tumors are rare entities
B) The incidence of neuroendocrine tumors has been increasing in the past 30 years.
C) Most of the neuroendocrine tumors are classified as "non-functioning" types.
D) Neuroendocrine tumor most typically affects the pancreas.
E) Carcinoid syndrome is present in less than 10% of all neuroendocrine tumors.
ANSWER
D) Neuroendocrine tumor most typically affects the pancreas.
EXPLANATION
Neuroendocrine tumors are rare entities, alhough, the incidency has increased five times greater in the last 30 years, and has been increasing year by year. The most commonly affected site are the intestines. Most of them are non-functioning types as their secreted peptides or hormones do not manifest in clinical symptoms, like carcinoid sydrome which is only present in less than 10% of neuroendocrine tumors.
44
INT - 17.48
The following malignant tumors,during hematogenous spreading metastatize at first to the liver, except:
A) gastric cancer
B) colon cancer
C) panreatic cancer
D) adrenal gland carcinoma
E) gallblader cancer
ANSWER
D) adrenal gland carcinoma
EXPLANATION
Along the the anatomy of the venous system, tumors of the adrenal gland metastatize to the lungs first, meanwhile, the other tumors usually metastatize to the liver in the begining.
45
INT - 17.49
Of the following factors which ones should be measured-calculating the Notthingham Prognostic Index?
A) size of the tumor in centimeter
B) histological grade
C) lymph node status
D) all of the above three factors
ANSWER
D) all of the above three factors
EXPLANATION
Notthingham Prognostic Index (NPI) refers to the long-term prognosis of breast cancer. It is a calculated value which takes the histological characteristics of the tumor into account, providing information on the long-term prognosis and the risk of relapse of breast cancer. It takes account of the size of the tumor, the lymph node status, and the histological grade. Calculating the NPI the size of tumour in centimeter is multiplied by 0,2, then the histological grade is added to it, as well as the number referring to the lymh node status: 1 if there are not lymph node metastasis; 2 if metastases are confirmed in 1, 2, or 3 lymph nodes; 3 if metastases are confirmed in four or more lymph nodes.
46
INT - 17.50
During the histological evaluation of breast cancer we use the „NPI” abbreviation. What does it stand for?
A) Norfolk Predictive Index
B) Notthingam Prognostic Index
ANSWER
B) Notthingam Prognostic Index
EXPLANATION
NPI is the abbreviation of Notingham Prognostic Index which is a calculated value, that relate to thelong-term prognosis of breast cancer.
47
INT - 17.51
In the case of breast cancer which NPI score is considered as poor prognosis?
A) below 3,14
B) above 5,4
ANSWER
B) above 5,4
EXPLANATION
If the Nottingham Prognostic Index is below 3, we see excellent prognosis, there is long–term survival perspetive among breast cancer patients after surgery. Below 3,14 the prognosis is good; between 3,14 and 5,4 we talk about moderate long-term prognosis; above 5,4 the life expectancy is poor with high chance of relapse.
48
INT - 17.52
Which of the following ones is NOT a risk factor of breast cancer?
A) no children
B) early menarche, late menopause
C) promiscuity
D) BRCA1 mutation
E) sister’s breast cancer
ANSWER
C) promiscuity
EXPLANATION
Sexual promiscuity has little effect on the pathogenesis of breast cancer, however, it is a major risk factor of cervical cancer.
49
INT - 17.53
What is the most common sypmtom of the intraductal papilloma of the breast?
A) peau d’orange symptom (orange peel symptom)
B) enlarged lymph node at the unilateral side
C) bloody fluid discharging from the nipple
D) ekzematous skin lesion
E) painful,red, swollen, palpable mass in the breast
ANSWER
C) bloody fluid discharging from the nipple
EXPLANATION
Intraductal papilloma usually originates from the larger ducts of the breast (it is not a variation of papillomatosis which can be seen in mastopathy). Bloody discharge from the nipple is a common symptom.It is usually a benign lesion, nevertheless sometimes it is difficult to differentiate it histologically from the malignant papillar carcinoma
50
INT - 17.54
Which type of breast cancer affects typically both sides?
A) invasive ductuscarcinoma
B) medullar carcinoma
C) mucinosus carcinoma
D) lobular carcinoma
E) papiliar carcinoma
ANSWER
D) lobular carcinoma
EXPLANATION
Of these subtypes of breast cancer, the invasive lobular carcinoma occurs multicentric most frequently although, it can be seen in other types as well.
51
INT - 17.55
In the case of an 22-years-old female patient, a mobile, non-painful palpable mass was discovered in the right breast with a diameter of 2,5 cm, and no change in size during the menstrual cycle. What is the most probable diagnosis?
A) fat necrosis
B) fibroadenoma
C) carcinoma phylloides
D) mastopathia fibrocystica
E) tubularis carcinoma
ANSWER
B) fibroadenoma
EXPLANATION
The most likely option is fibroadenoma, however, that must be confirmed with patological examination.
52
INT - 17.56
Which one is not a paraneoplastic symptom of renal cancer?
A) anaemia
B) weight loss
C) fever, subfebrility
D) tiredness and fatigue
E) hematuria
ANSWER
E) hematuria
EXPLANATION
Hematuria is not a paraneoplastic symptom, but a classic, direct sign of renal cancer.
53
INT - 17.58
Choose the INCORRECT answer!
A) The survival rate of renal cancer- thanks to the widely used screening methods- has increased in the last few years.
B) In the case of obvious imaging test findings, which suggest malignant tumor, surgical therapy can be indicated.
C) In the treatment of renal cancer, surgery is the only definitive and possibly curative option.
D) In the case of metastatic.renal cancer palliative nephrectomy should be performed, even if the patients are in good general condition
E) In the case of small peripheric tumor of the kidney laparoscopic partial neprehctomy is an option. The most common indication of radiotherapy is the palliative treatment of intracranial and bone metastasis.
ANSWER
A) The survival rate of renal cancer- thanks to the widely used screening methods- has increased in the last few years.
EXPLANATIONCurrently, there is no widely used method for the screening of renal cancer.It is generally discovered by accident.
54
INT - 17.59
Diagnostic methods in the screening of prostate cancer:
A) rectal digital examination
B) PSA-test
C) PET-CT
D) transrectal ultrasound-guided biopsy
E) A, B and D
ANSWER
E) A, B and D
EXPLANATION
For the screening and early detection of prostate cancer, the most useful methods are the digital rectal examination, the PSA blood test, and the ultrasound-guided transrectal biopsy.
55
INT - 17.60
The gold standard for treatment of bone metastases of prostate cancer is:
A) GnRh analogue drugs
B) radiotherapy
C) antiandrogen drugs
D) bisphophonates
E) chemotherapy
ANSWER
D) bisphophonates
EXPLANATION
Currently, the gold standard for treating the bone metastases of prostate cancer is the use of bisphosphonate drugs.
56
INT - 17.61
Choose the CORRECT answer!
A) In spite of the increasing incidence of prostate cancer, the mortality caused by the disease has been slightly decreasing.
B) Increased risk was observed with family history of the disease, as hereditary genes which can cause susceptibility to prostate cancer were indentified.
C) Although prostate carcinoma can be observed in 30-40 % of men above the age of 55, the disease is ususally diagnosed over the age of 65.
D) In 95% of the cases, prostate cancer orginates from the “peripherial zone”, and it is usually multifocal.
E) All statements are true.
Answer E) All statements are true..
57
INT - 17.62
Choose the INCORRECT answer.
A) After radical prostectomy, if the PSA level is above 0,4 ng/ml, hormone and/or radiotherapy is necessary.
B) Treatment with antiandrogene drug should be introduced few days before applying the LHRH analogue at the start of hormone therapy.
C) In the case of metastatic prostate cancer systemic chemotherapy should be started as soon as possible.
D) During intermittent hormone therapy, in the "treatment holidays" the sexual potential of the patient usually is restored.
E) When prostate cancer metastatizes to the bones, hormone and bisphosphonate therapy is the first choice treatment.
F) Radiotherapy in prostate can be used for curative or palliative purpose as well.
ANSWER
C) In the case of metastatic prostate cancer systemic chemotherapy should be started as soon as possible.
EXPLANATION
The first-line treatment is hormonal therapy. Administrating the LHRH analogue drugs the FSH and LH blood levels rise for about 5-7 days, then decrease again. During this temporarly elevation, the testosteron-level increases as well (this is called flare-up phenomeon) which is anticipated by the prior antiandrogen therapy.
58
INT - 17.63
Elder man is hospitalized with back pain. X-ray describes oval masses in the lumbal spine, and PSA-level is elevated What is the most likely diagnosis?
A) metastatic thyroid cancer
B) multiple myeloma
C) metastatic prostate cancer
D) metastatic pacreatic cancer
E) Ewing-sarcoma
ANSWER
C) metastatic prostate cancer
EXPLANATION
With these findings and symptoms (elevated PSA-level, and bone metastasis suspect lesions) the most probable option is the progression of prostate cancer among elderly men.
59
INT - 17.64
Which type of germ-cell testicular tumor cannot be classified into the non-seminoma group?
A) choriocarcinoma
B) Yolksac tumor
C) teratoma
D) spermatocytic
E) polyembrioma
ANSWER
D) spermatocytic
EXPLANATION
It belongs to the seminoma group of testicular cancer.
60
INT - 17.65
Which cell-type does the majority of testicular cancers originate from?
A) Leydig-cell
B) Sertoli-cell
C) germ cell
D) endothel cell
E) epithelial cell
ANSWER
C) germ cell
EXPLANATION
90% of testicular cancers are germ-cell tumors.
61
INT - 17.66
Which one is the most common testicular germ-cell tumor?
A) teratoma
B) endodermal sinus tumor
C) embryonal carcinoma
D) choriocarcinoma
E) seminoma
ANSWER
E) seminoma
EXPLANATION
Almost 50% of testicular cancers are “pure” seminomas, the other cases are frequently “mixed forms” with seminomatosous parts.
62
INT - 17.68
Choose the CORRECT answer.
A) The additon of cisplatin chemotherapy to the treatment of testicular cancer led to excellent results.
B) In the case of metastatic testicular cancer surgery is not recommended, only systemic chemotherapy and radiotherapy.
C) In the case of advanced testicular cancer prior to surgery, neoadjuvant chemotherapy is recommended.
D) In the case of relapse of testicular cancer salvage chemotherapy is useless since the disease is threapy-resistent.
E) Since testicular seminoma is highly-sensitive to radiotherapy, after-surgery irradiation of paraaortic and parailiac lymph node region on the same side is part of standard treatment.
ANSWER
A) The additon of cisplatin chemotherapy to the treatment of testicular cancer led to excellent results.
EXPLANATION
Cisplatin treatment was a breakthrough in the therapy of germ-cell tumours. With cispaltin-based chemotherapy more than 90% remission rate can be archieved. In the case of relapse, disseminated disease using systemic chemotherapy, remission can be achieved in 20-30% of all cases, hence, salvage chemotherapy can absolutely be indicated. During animal experiments good results were seen using tirosine-kinase inhibitors, but currently, no studies with human subjects are available.
63
INT - 17.69
Choose the INCORRECT answer!
A) Choosing the most adequate treatment centre is essential in the aspect of complex therapy since testicular cancer has excellent healing results.
B) In the majority of testicular cancer cases the first step of treatment is surgical high-castration.
C) In the case of testicular seminoma the cumulative dose of supplementary irradiaton of the primary lymph node regions has been decreasing in the last few years.
D) In the case of stage I. testicular cancer, after surgery only regular check-ups are necessary.
E) In the case of early testicular seminoma, according to recent studies, the carboplatin-based monochemotherapy is equivalent to the irradiation of the paraaortic region.
ANSWER
D) In the case of stage I. testicular cancer, after surgery only regular check-ups are necessary.
EXPLANATION
In the therapy of non-seminoma,regular survialliance („wait and see”) can only be indicated in the case of I/A stadium, and patients with good compliance.
64
INT - 17.70
Which one is the most important risk factor of the transitional-cell carcioma of the bladder?
A) alcohol
B) smoking
C) HPV infection
D) E. coli infection
E) HBV infection
ANSWER
B) smoking
EXPLANATION
The most important risk factor of the above in the development of bladder cancer (2,5x) is smoking. Naturally, there are more risk factors such as other assumed or proven toxic agents ( evaluation of the data is difficult,especially because of the long time between the exposition to the toxins and the onset of malignant tumor), infections (for example schistosomiasis).
65
INT - 17.71
Which one is NOT typical to the familiar ovarian cancer?
A) Family history of two or more breast/ovarian tumor
B) It is usually diagnosed at young age.
C) It is an agressive cancer.
D) The genotype of the disease is already well-known.
ANSWER
D) The genotype of the disease is already well-known.
EXPLANATION
The exact genotype of familiar ovarian cancer is not yet fully known.
66
INT - 17.73
Typical of germ-cell ovarian cancer:
A) It is more frequent in old age.
B) It is often discovered during pregnancy.
C) It is always bilateral.
D) It is usually resistent to chemo- and radiotherapy.
ANSWER
B) It is often discovered during pregnancy.
EXPLANATION
Germ-cell tumors are seen among young women, usually are unilateral, and sensitive to chemo- and radiotherapy. In many cases they are discovered during pregnancy.
67
INT - 17.74
Which one is NOT part of the treatment of the epithelial ovarian cancer?
A) combined systemic chemotherapy
B) hysterectomy, bilateral salpingo-oophorectomy, omentectomy
C) P32 intraabdominal irradiation
D) intraperitoneal chemotherapy
ANSWER
C) P32 intraabdominal irradiation
EXPLANATION
Intraabdominal radiotherapy with phosphore isotope is no longer used in the treatment of ovarian cancer.
68
INT - 17.75
The incidence of cervical cancer:
A) It is the most frequent among women in their thirties and forties.
B) The primary risk factor is HPV 15 and 17 infection.
C) It is usually occurs among women of higher social-economical status.
D) It is usually discovered in older age and at early stage.
ANSWER
A) It is the most frequent among women in their thirties and forties.
EXPLANATION
Cervical cancer usually develops in women in their 30s-40s, with low social-economic status, detection in older age usually means advanced disease, and the HPV 16-18 are the most patogenic types.
69
INT - 17.76
Choose the correct answer regarding cervical cancer:
A) The most common type is the planocellular carcinoma
B) the adenocarcinoma is extremely rare
C) the neuroendocrine type has good prognosis
D) the incidence of planocellular carcinoma has been increasing
ANSWER
A) The most common type is the planocellular carcinoma
EXPLANATION
The adenocarcinoma/planocellular cancer incidence ratio is 20% : 80%, neuroendocrine type is rare and has poor prognosis, the incidence of planocellular cancer is decreasing.
70
INT - 17.77
The treatment of early cervical cancer:
A) Can be administered in every surgical department
B) Radiotherapy is ineffective
C) The standard therapy is surgery
D) Neoadjuvant chemotherapy is widely used
ANSWER
C) The standard therapy is surgery
EXPLANATION
The operation can only be performed by experienced gynecologist/oncologist, cervical cancer is radiotherapy sensitive. The use of neoadjuvant chemotherapy has decreased, and is primarly administrated in clinical studies.
71
INT - 17.78
Most effective treatment of advanced cervix cancer:
A) radical surgery
B) chemotherapy and irradiation
C) only chemotherapy
D) only irradiation
ANSWER
B) chemotherapy and irradiation
EXPLANATION
Standard treatment of advanced cervix cancer is chemo-irradiation.
72
INT - 17.79
In case of a recurrent, disseminated cervix cancer:
A) the primary care is the palliation
B) recto- and vesico-vaginal fistulas are frequently onset
C) chemotherapy is usually ineffective
D) all of the listed above
ANSWER
D) all of the listed above
EXPLANATION
Disseminated cervix cancer is usually chemo resistant, the fistulas can cause severe complaints, and palliation is the primary therapeutic goal.
73
INT - 17.80
In case of endometrium cancer:
A) most frequent symptom is the onset of ascites
B) can be prevented by screening
C) In case of a postmenopausal hemorrhage you should think about this
D) curettage is no longer used in the diagnosis
ANSWER
C) In case of a postmenopausal hemorrhage you should think about this
EXPLANATION
The first symptom of uterine-/endometrium cancer is the postmenopausal hemorrhage. There is a lack of an accurate screening method. In the diagnosis curettage is the standardly used procedure. Ascites is the sign of advanced disease.
74
INT - 17.81
In the treatment of uterine cancer
A) The most commonly used treatment is surgery
B) pre- and postoperative radiotherapy is indispensable
C) hormone therapy and chemotherapy are equally effective
D) all of the above
ANSWER
A) The most commonly used treatment is surgery
EXPLANATION
In the treatment of endometrium cancer routine radiotherapy and hormone therapy are outdated methods, the curative treatment is predominantly surgical, chemotherapy can only be used in selected cases.
75
INT - 17.82
Endometrial carcinoma
A) is the most common gynecological tumor
B) it practically does not occur in premenopausal status
C) squamous cell cancer is more frequent than the glandular origin
D) Estrogen excess is not a risk factor
ANSWER
A) is the most common gynecological tumor
EXPLANATION
In case of estrogen excess endometrium cancer is the most frequently onset gynecological tumor. Endometrium cancer is most frequent onset in postmenopausal status. Histologically, it is dominantly adenocarcinoma.
76
INT - 17.83
Cuboidal epithelium of the bronchi is replaced by squamosal cells. What is this phenomenon?
A) dysplasia
B) metaplasia
C) anaplasia
D) hyperplasia
E) neoplasia
ANSWER
B) metaplasia
EXPLANATION
This phenomenon is the transformation of the bronchus epithelium due to a chronic irritation (smoking, chronic bronchitis) with squamous metaplasia (indirect metaplasia).
77
INT - 17.84
It is true for lung cancer screening:
A) Pulmonary X-ray screening is one of the primary prevention tools.
B) Regular, yearly performed chest X-ray tests reduce lung cancer mortality.
C) Regular lung chest x-rays combined with sputum cytology will further reduce the mortality rate caused by lung cancer.
D) Regular chest CT scan is not considered as a screening test due to overdiagnosis and radiation exposure.
E) PET-CT test is a general cancer screening test, also suitable for the screening of lung cancer.
ANSWER
D) Regular chest CT scan is not considered as a screening test due to overdiagnosis and radiation exposure.
EXPLANATION
Screening is secondary prevention. Based on randomized studies, regular chest X-ray combined with sputum cytology does not reduce the mortality caused by lung cancer. However, based on randomized studies, a low dose chest CT scan may cause a reduction in the mortality of lung cancer among those in the high-risk lung cancer group. The PET / CT scan is not a screening test.
78
INT - 17.86
For the relationship between smoking habits and malignant tumors of the lungs are not true:
A) 85-90% of the tumors are related to smoking habits.
B) Female smokers are more vulnerable to lung cancer than men.
C) Small cell lung tumors are almost always produced in smokers.
D) Smoking habits do not affect the response to oncological treatment.
E) There is a nicotinerg receptor antagonist that has been clinically proven to be able to help to quit smoking.
ANSWER
D) Smoking habits do not affect the response to oncological treatment.
EXPLANATION
In the case of lung tumors, the K-RAS mutation - which has got a negative predictive value for EGFR-TKI treatment - is significantly more frequent in smoking patients. The efficacy of nicotinerg receptor antagonist varenicline (Champix) in smoking cessation has been demonstrated by clinical trials.
79
INT - 17.87
It is not true for the neuroendocrine tumors of the lung:
A) Small cell lung cancer is a neuroendocrine carcinoma.
B) 80-85% of the lung neuroendocrine tumors are well and moderately differentiated tumors.
C) Good and moderately differentiated carcinomas can produce biologically active mediators.
D) Small cell lung cancer is considered to be a systemic disorder, so surgical intervention is not recommended.
E) Primary treatment of small cell lung cancer is chemotherapy and radiochemotherapy.
F) If SCLCs show full or partial remission, prophylactic skull radiation is recommended.
ANSWER
D) Small cell lung cancer is considered to be a systemic disorder, so surgical intervention is not recommended.
EXPLANATION
In early clinical stages (I.A-II.A), or if the tumor does not respond to primary treatment, surgical intervention could be performed.
80
INT - 17.88
It is true for medullary thyroid cancer, except (indicate the exception):
A) Sporadic medullary thyroid cancer is usually a solitaer lesion, while familial cancers are more often multifocal. 20-30% of medullary thyroid cancer is sporadic.
B) In the case of tumors above 1 cm, surgery should be followed by radio-iodine treatment.
C) In case of the diagnosis of medullary thyroid gland cancer, genetic testing is always recommended to be performed.
D) If a RET protooncogene mutation is detectable during the screening of the family, prophylactic thyroidectomy is recommended.
E) Serum calcitonin and CEA level is essential to be controlled after thyreoidectomy to follow-up of medullary thyroid cancer.
ANSWER
B) In the case of tumors above 1 cm, surgery should be followed by radio-iodine treatment.
EXPLANATION
Medullary thyroid cancer has not got any TSH receptor, therefore, the tumors do not take up the radioiodine.
81
INT - 17.89
Which disease does not belong to the cutaneous lymphoma group?
A) blastic plasmacytoid dendritic cell neoplasia
B) Sezary-syndrome
C) lupus vulgaris
D) mycosis fungoides
ANSWER
C) lupus vulgaris
EXPLANATION
Lupus vulgaris is the most common form of skin tuberculosis.
82
INT - 17.90
What is the most important prognostic factor in malignant melanoma?
A) type of melanoma cells
B) proliferation rate of melanoma cells
C) the degree of depth propagation
D) the intensity of the peritumoral reaction of the host
E) tumor localization
ANSWER
C) the degree of depth propagation
EXPLANATION
For melanoma – without any lymph node or distant propagation (stage I) - the most important prognostic factor is the thickness of the tumor. This is followed by factors such as ulceration and gender. In case of lymph node metastases, the number of these and the extent of the propagation under the capsule of the node are the most important prognostic factors.
83
INT - 17.91
Gene mutations that are involved in the development of melanoma malignant – please indicate the one exception:
A) C-KIT
B) B-RAF
C) Her 2
D) CDKN2A
ANSWER
C) Her 2
EXPLANATION
HER 2 gene amplification has a prognostic role in breast cancer. In the 60% of superficial and nodular MM, mutations of B-RAF and CDKN2A gene are onset. In case of lentigo and mucosal MM the mutation of the C-KIT signaling pathway is onset in 28-39% of the tumors.
84
INT - 17.92
What is the main direction of haematogenic spread of malignant melanoma of the skin?
A) lungs
B) bone
C) brain
D) liver
E) adrenal gland
ANSWER
D) liver
EXPLANATION
During hematogenic spread of melanoma practically all organs can be reached, most often the liver is affected. The worst prognosis is in case of brain metastases.
85
INT - 17.93
What is the most common intraocular tumor in adults?
A) meningioma
B) lymphoma
C) metastasis
D) melanoma
E) rhabdomyosarcoma
ANSWER
C) metastasis
EXPLANATION
The most common primary tumor is melanoma, but the most common tumor is metastasis (most commonly due to breast cancer, lung cancer, leukemia / lymphoma).
86
INT - 17.94
COPP protocol is a highly effective chemotherapeutic regimen to treat the tumor - first of all in which cancer?
A) squamous cell pulmonary cancer
B) gastric cancer
C) colorectal cancer
D) Hodgkin-disease
E) CML
ANSWER
D) Hodgkin-disease
EXPLANATION
The combination COOP (cyclophosphamide, vincristine, procarbazine, prednisolone) is primarily used to treat Hodgkin's disease, similar to others such as MOPP, MVPP, ABVD etc. protocols. They differ primarily in toxicity and in the induced resistance.
87
INT - 17.96
Select the correct statement from the following:
A) During teletherapy irradiation an external radiation source is used.
B) During brachytherapy the radioactive source is delivered directly to the tumor or its immediate vicinity.
C) Brachytherapy can be divided into interstitial, intracavital, intraluminal and moulage based on the technique of insertion into the irradiated area.
D) The combination of teletherapy and brachytherapy is frequently adviced to reach the optimal tumor destruction.
E) All of the above are true.
ANSWER
E) All of the above are true.
88
INT - 17.99
Which of the two tumor marker tests is recommended for gastric cancer?
1) beta-HCG
2) CEA
3) CA 19-9
4) CA 125
A) 1st, 2nd and 3rd answers are correct
B) 3rd and 4th answers are correct
C) 2nd and 3rd answers are correct
D) all of the answers are correct
ANSWER
C) 2nd and 3rd answers are correct
EXPLANATION
In case of gastric cancer, two tumormarkers may be elevated, CEA (carcinoembryonic antigen) and CA-19-9. (Moreover, these two markers may be increased in several gastrointestinal tumors, e.g. CEA is often higher in colorectal cancer and rectal cancer and CA 19-9 may also be increased in pancreatic cancer.)
89
INT - 17.100
Palliative treatment for esophageal cancer:
1) esophageal stent implantation
2) implantation of percutaneous endoscopic gastrostoma (PEG)
3) preparation of a nourishing jejunostoma
4) making a gastro-entero-anastomosis (GEA)
5) radiofrequency ablation
A) 1st, 2nd and 3rd answers are correct
B) 3rd, 4th and 5th answers are correct
C) 4th and 5th answers are correct
D) all of the answers are correct
ANSWER
A) 1st, 2nd and 3rd answers are correct
EXPLANATION
In the case of an inability to swallow, nutrition can be solved by stent implantation, percutaneous endoscopic gastrostoma implantation or a preparation of a nourishing jejunostoma. There is no indication to link the stomach and the small intestine in the case of an oesophageal cancer. Radiofrequency ablation may be used in the case of malignant lesions of the liver, if the conditions are ideal for this approach.
90
INT - 17.101
Criteria for liver resection:
1) Three or less metastases, located in one lobe.
2) The metastasis is smaller than 5 cm.
3) Keep at least 1 cm intact surgical margin.
4) For synchronous metastases, if all metastases can be removed.
5) Residual liver tissue is expected to be sufficient, good functioning.
A) 1st, 2nd and 3rd answers are correct
B) 3rd, 4th and 5th answers are correct
C) 4th and 5th answers are correct
D) all of the answers are correct
ANSWER
D) all of the answers are correct
91
INT - 17.102
The following factors may play a role in the development of primary liver cancer (primary hepatocellular carcinoma):
1) chronic hepatitis C infection
2) chronic hepatitis B infection
3) toxic liver diseases.
4) metabolic liver disease
A) 1st, 2nd and 3rd answers are correct
B) 1st and 2nd answers are correct
C) none of the answers are correct
D) all of the answers are correct
ANSWER
D) all of the answers are correct
EXPLANATION
Hepatocellular carcinoma may be associated with several etiologic factors, the most common ones are hepatitis (chronic hepatitis B and C infections) and hepatic cirrhosis (either alcoholic or caused by other toxic agents).
92
INT - 17.103
Select which radiological intervention method can be used to treat liver metastasis of colorectal carcinoma!
1) percutaneous alcohol infiltration
2) J-131-MIBG treatment
3) radiofrequency ablation
4) embolization
A) 1st, 2nd and 3rd answers are correct
B) 1st, 3nd and 4rd answers are correct
C) 2nd and 4th answers are correct
D) all of the answers are correct
ANSWER
B) 1st, 3nd and 4rd answers are correct
EXPLANATION
J-131-MIBG is used for the treatment of neuroendocrine tumors which are rich in adrenergic receptors. J131MIBG is not even an intervention radiological method.
93
INT - 17.104
Classification systems used for the staging of colorectal carcinoma (CRC):
1) TNM assignment
2) Modified Astler-Coller (MAC) classification
3) Dukes Classification
4) FIGO position
5) each of the above listed
A) 1st, 2nd and 3rd answers are correct
B) 3rd, 4th and 5th answers are correct
C) 4th and 5th answers are correct
D) all of the answers are correct
ANSWER
A) 1st, 2nd and 3rd answers are correct
EXPLANATION
The TNM, the modified Astler Coller and the Dukes are used for the staging of colorectal carcinoma. The FIGO classification can be used in case of ovarian cancer.
94
INT - 17.105
What malignant disease(s) can be treated with tyrosine kinase inhibitor imatinib (Glivec)?
1) colon cancer
2) gastrointestinal stromal tumor (GIST)
3) pancreatic cancer
4) breast cancer
5) chronic myeloid leukemia (CML)
A) 1st, 2nd and 3rd answers are correct
B) 3rd, 4th and 5th answers are correct
C) 2nd and 5th answers are correct
D) all of the answers are correct
ANSWER
C) 2nd and 5th answers are correct
EXPLANATION
Imatinib (Glivec) treatment is used currently for GIST and CML.
95
INT - 17.106
The following approaches are used to treat breast cancer:
1) neoadjuvant chemotherapy
2) chemotherapy according to the DeGramont protocol
3) radiotherapy
4) trastuzumab treatment in HER-2 negative tumors
5) each of the above listed
A) 1st, 2nd and 3rd answers are correct
B) 3rd, 4th and 5th answers are correct
C) 1st and 3rd answers are correct
D) all of the answers are correct
ANSWER
C) 1st and 3rd answers are correct
EXPLANATION
In breast cancer, prior to surgery, neoadjuvant chemotherapy may be used for the purpose of downstaging. DeGramont chemotherapy protocol can be used in colorectal cancer, but not breast cancer. With proper indication, radiation therapy has the potential to treat breast cancer. Trastuzumab is a targeted treatment option for breast cancer, but only for HER-2 positive tumors, as the agent exerts its effect through inhibition of the HER-2 receptor.
96
INT - 17.108
It is true for prostate tumors:
1) Patients can be divided into three risk groups based on T stage, PSA value and Gleason score.
2) In case of a prostate tumor detected by rectal digital examination (RDV) and diagnostic imaging modalities, with an elevated PSA level FNAB is enough to be performed to confirm the diagnosis and initiate the primary treatment.
3) If malignant cells are found in the map-biopsy specimen of the prostate, the oncological treatment must be initiated as soon as possible.
4) Radical prostatectomy is recommended only if the patient's life expectancy exceeds 10 years.
5) If the histological finding of prostate cancer in a pure or mixed form suggests a neuroendocrine tumor, it means a poor prognosis.
A) 1st, 2nd and 3rd answers are correct
B) 3rd, 4th and 5th answers are correct
C) 1st, 4th and 5th answers are correct
D) all of the answers are correct
ANSWER
C) 1st, 4th and 5th answers are correct
EXPLANATION
When choosing the treatment of prostate cancer Gleason-score should be taken into account, so it is recommended in each case to perform a good quality map biopsy. Close-track follow-up can be a reasonable choice in case of an early-stage, well-defined or moderately differentiated prostate cancer when the patient is asymptomatic.
97
INT - 17.109
It is true for prostate cancer:
1) Lymph node metastases are most commonly onset in the triangle of vena iliaca externa and n. obturatorius.
2) Distant metastases most often appear in the bones.
3) Radical prostatectomy is still recommended even in case of already onset bone metastases.
4) Treatment of localized prostate cancer radiotherapy with curative doses can be a reasonable alternative to radical surgery.
5) The total dose of radiotherapy has been reduced in the recent years to minimize side effects.
A) 1st, 2nd and 4th answers are correct
B) 3rd, 4th and 5th answers are correct
C) 4th and 5th answers are correct
D) all of the answers are correct
ANSWER
A) 1st, 2nd and 4th answers are correct
EXPLANATION
Radical prostatectomy is not recommended if distant metastases are onset. In recent years, radiation therapy of prostate tumors resulted in better biochemical response and tumor control when dose-escalation was performed.
98
INT - 17.110
Which of the following statement (s) are true for non-seminomas?
1) increased AFP level
2) elevated beta HCG level
3) radiation sensitivity
4) chemotherapy sensitivity
A) 1st, 2nd and 3rd answers are correct
B) 1st, 2nd and 4th answers are correct
C) 3rd and 4th answers are correct
D) all of the answers are correct
ANSWER
B) 1st, 2nd and 4th answers are correct
EXPLANATION
Non-seminomas do not respond to radiation therapy, seminomas are characterized by radiation-sensitivity.
99
INT - 17.111
Select the correct statements from the following.
1) In case of primary testis/retroperitoneal non-seminoma if the AFP, HCG, and LDH levels are low before the surgery the tumor has good prognosis; even if pulmonary metastases are already onset.
2) Since seminomas rarely produce beta hCG and never produce AFP, when elevated AFP level is detected histological revision is needed to clarify the diagnosis if pure seminoma was described earlier.
3) Because of its pulmonary toxicity, bleomycin is no longer recommended to be used in combinational chemotherapy protocols
4) Since non-seminomas with good prognosis are sensitive to chemotherapy, the therapeutic goal must be the achievement of a long lasting result with the lowest possible toxicity, even in advanced disease.
5) For patients with non-seminomas belonging to the moderate or poor prognostic group, radiotherapy is part of standard therapy.
6) Although non-seminomas are less sensitive to irradiation, a good palliative effect can be achieved by radiotherapy in a chemotherapy-resistant, inoperable cases.
A) 1st, 2nd, 4th and 6th answers are correct
B) 2nd, 3rd, 4th and 5th answers are correct
C) 4th and 5th answers are correct
D) all of the answers are correct
ANSWER
A) 1st, 2nd, 4th and 6th answers are correct
EXPLANATION
In the case of different histological types of testis cancer different laboratory results are expected. In the case of yolk sac tumors AFP increases but in choriocarcinomas beta-hCG is elevated. 60-80% of non-seminomas indicate beta-hCH and AFP elevations (it also has a role in prognostic subgrouping). Regarding seminomas beta -hCG increase is very rare (ca. 7%) but NSE and placental alkaline phosphatase levels are frequently increased. For stromal tumors sex hormones may be used as tumor markers. Non-seminomas are chemotherapy sensitive and less responsive to radiotherapy. Since their healing rate is over 90%, minimizing late-onset toxicities is a very important goal. Pulmonary toxicity of bleomycin is more frequently onset in case of extensive lung metastases, mediastinal irradiation, elderly patients, severe emphysema or pulmonary fibrosis or if bleomycin is applied above the regularly used cumulative dose, however, toxicity appears in less than 1% of the treated patients when usual dosage is applied.
100
INT - 17.112
It's true for the bladder tumors:
1) About 90% of the bladder tumors are transitional cell carcinomas.
2) The symptoms cannot be used to distinguish between superficial and muscle-infiltrating tumors.
3) After a transurethral resection (TUR) it is recommended to wait at least 4 weeks to perform CT or MRI examination due to post procedure edema, inflammation and lymph node enlargement.
4) Definitive radiotherapy is not recommended because of the high risk of bladder- shrinkage.
5) Palliative radiotherapy of the urinary bladder should be performed with fewer fractions with a higher daily dose and a lower total dosage compared to the treatment of definitive irradiation.
6) Concomitant radiochemotherapy is not used in urinary bladder tumors.
A) 1st, 2nd, 4th and 6th answers are correct
B) 1st, 2nd, 3rd, 4th and 5th answers are correct
C) 4th and 5th answers are correct
D) all of the answers are correct
ANSWER
B) 1st, 2nd, 3rd, 4th and 5th answers are correct
EXPLANATION
Definitive radiotherapy is not recommended if blister capacity is initially low because, in this case, bladder-shrinkage is more frequent. In the case of definitive radiotherapy concomittans chemotherapy is recommended.
101
INT - 17.114
The tumors of the head and neck region are (select the true statements):
1) Squamous cell carcinoma of the tonsils and tongue are more common in HPV infection.
2) In the case of epipharynic tumors, radiotherapy is contraindicated due to the proximity of the surrounding dose-limiting organs (e.g. brain stem, cerebral cortex, hypophysis, etc.).
3) Radiochemotherapy and radio-target therapies can also be used for the definitive treatment of head and neck cancer.
4) The development of second primary tumors in the lungs or esophagus is relatively common in patients with head and neck squamous cell carcinoma associated with smoking and alcohol abuse.
5) Definitive radiotherapy in this region is only relevant for advanced disease.
A) 1st, 3rd and 4th answers are correct
B) 1st, 2nd, 4th and 5th answers are correct
C) 2nd and 4th answers are correct
D) all of the answers are correct
ANSWER
A) 1st, 3rd and 4th answers are correct
EXPLANATION
In case of epipharynx tumors resection with clear margins is rarely performed, therefore, – with the correct radiation protection of the dose-limiting surrounding tissues – radiation therapy has an important role in this disease. It is generally true for the cancer of the head and neck region that in T1-2 N0-1 stages the results of definitive radio (chemo) therapy are near the same as of primary surgeries, but in case of a more advanced diseases radiochemotherapy is strongly recommended.
102
INT - 17.116
It is true for the tumors of the central nervous system:
1) Metastases are more common than primary tumors.
2) Most common first symptoms of a CNS tumor in the case of low-grade tumors are the symptoms of increased brain pressure. In case of high grade tumors, epileptic seizures are more common signs.
3) The survival probability of oligodendroglioma is worse than astrocytoma.
4) Glioblastoma multiforme is the most common adult primary brain tumor.
5) Anaplastic gliomas have worse prognosis than glioblastomas.
6) Cancers of the central nervous system do not give any metastasis.
A) 1st, 2nd and 4th answers are correct
B) 1st, 3rd, 5th and 6th answers are correct
C) 2nd, 3rd and 5th answers are correct
D) 1st, 2nd, 4th and 6th answers are correct
E) 1st and 4th answers are correct
ANSWER
E) 1st and 4th answers are correct
EXPLANATION
In the case of low-grade tumors, i.e. more differentiated cancers, perifocal oedema is smaller, and therefore epileptic seizures are more common first signs in these cases. Whereas in high grade tumors perifocal oedema is more extensive. 5-year survival probability of oligodendroglioma vs. astrocytoma is 70% vs. 37%, although both are Gr.II tumors. Anaplastic gliomas are usually Gr.III, while glioblastomas are Gr.IV lesions. Although, tumors of the central nervous system do not resulted in extramedullary metastases, medulloblastoma can give drop metastases and glioblastoma could extend along the white matter fibers.
103
INT - 17.117
It is true for the treatment of brain tumors:
1) In case of cerebral metastases, active oncological treatment is not an option.
2) Stereotactic brain irradiation is possible even in case of multiple brain lesions.
3) Cancers of the central nervous system cannot be treated by chemotherapy because chemotherapeutic agents do not pass through the blood-brain barrier.
4) In case of radical surgery, adjuvant therapy is not recommended, due to expected late toxicities even in case of highly malignant tumors.
5) Although there is no lymphoid tissue in the nervous system, lymphoma may occur in central nervous system
6) In some cases of central nervous system irradiation of the tumor is the first choice therapy, not surgery.
A) 1st, 2nd, and 4th answers are correct
B) 1st, 2nd, 3rd and 5th answers are correct
C) 2nd, 5th and 6th answers are correct
D) 1st, 2nd, 4th and 6th answers are correct
ANSWER
C) 2nd, 5th and 6th answers are correct
EXPLANATION
For example, in small cell lung cancer or in the case of melanoma, cytostatic therapy may be effective, in other tumors (e.g., breast or lung cancer) molecularly targeted therapy can be useful. nullStereotactic irradiation may be recommended for 2-4 brain metastases which do not exceed the 3 cm in size. After surgical treatment of malignant central nervous system tumors supplementary radiotherapy is usually recommended, moreover, after the recurrence of glioma or in case of glioblastoma chemo-radiotherapy is required. Lymphoma can show brain propagation. In the case of germinoma, lymphoma or other tumors which are inoperable due to their localization, radiotherapy may be the first treatment choice.
104
INT - 17.118
It is true for the treatment of malignant melanoma:
1) In case of a suspected melanoma, it is strictly forbidden to take a biopsy, immediate excision with 2-3 mm intact edges of the suspected lesion is required.
2) Superficially spreading melanoma is lentigo maligna.
3) The necessary edge of the excision depends on the depth of the tumor.
4) In the treatment of melanoma, clinical studies have shown that new molecularly targeted therapies and vaccination may play a significant role.
5) Metastasectomy is not recommended due to the high metastatic tendency of melanoma malignant.
6) In case of melanoma with a thickness greater than 4 mm, or with an ulceration, regional block dissection is required.
A) 1st, 2nd, and 3rd answers are correct
B)1st, 3rd, and 5th answers are correct
C) 3rd, 4th, and 6th answers are correct
D) 3rd and 4th answers are correct
E) 1st, 2nd, 5th and 6th answers are correct
ANSWER
D) 3rd and 4th answers are correct
EXPLANATION
Partial excision is to be avoided, but in case of a large tumor or before truncating surgery biopsy is necessary. Lentigo maligna and superficial spreading melanoma are different histological types. Lentigo maligna is a preinvasive form. Ipilimumab immunotherapy is proven to be effective but may have autoimmune side effects. Clinical studies have also demonstrated the efficacy of the selective BRAF kinase inhibitor vemurafenib. In metastatic melanoma, in case of only one organ involvement or slowly progressing process metastasectomia may be suggested. In case of sentinel lymph node positivity regional block dissection is required.
105
INT - 17.119
It is true for the malignant tumors of the lung:
1) 80-85% of the tumors are non-small cell lung cancer (NSCL).
2) 80% of the adenocarcinomas are centrally localized processes.
3) Squamous cancers are more commonly peripheral.
4) Squamous cancers have worse prognosis than adenocarcinomas and evolve especially in smokers.
5) Pulmonary malignancies are generally histologically homogeneous, combinations of different tumor types are rarely observed.
6) Non-small cell lung cancer is not a separate entity, segregation into subgroups is essential to determine personalized therapy.
A) 1st, 2nd, and 3rd answers are correct
B) 2nd, 3rd,4th and 5th, answers are correct
C) 1st, 4th, and 6th answers are correct
D) 1st, 4th, 5th and 6th answers are correct
E) all of the answers are correct
ANSWER
C) 1st, 4th, and 6th answers are correct
EXPLANATION
Adenocarcinomas are generally peripheral, while squamous cell carcinomas are often centrally localized. Most of the tumors containnull various histological types (most commonly adeno- and planocellular carcinomas). With the appearance of targeted therapies, a more precise characterization of non-small cell lung tumors became necessary.
106
INT - 17.120
It is true for the treatment of non-small cell lung cancer:
1) In case of a reduced cardiopulmonary reserve or if the patient rejects the surgery, definitive radio- or radiochemotherapy is recommended.
2) Positive resection edge or pN1-2 status requires additional chemotherapy or radiotherapy.
3) In case of potentially resectable cases, curative perioperative chemo- or radiochemotherapy is recommended.
4) If the tumor is greater than 5 cm or lymph nodes are involved, chemotherapy is required, even if R0 resection was performed.
5) Brachytherapy is an option in case of central bronchus cancers
6) Active tbc, inflammation, empyema or haemoptoe are contraindications for radiation therapy.
A) 1st, 2nd and 3rd answers are correct
B) 2nd, 3rd, 4th and 5th answers are correct
C) 1st, 4th, and 6th answers are correct
D) 1st, 4th, 5th and 6th answers are correct
E) all of the answers are correct
ANSWER
E)
all of the answers are correct
107
INT - 17.121
It is true for locally advanced, recurrent and metastatic non-small cell lung cancer:
1) A paradigm-change was made in their treatment.
2) In the case of non-squamous cell carcinoma, EGFR and KRAS mutation analysis are essential for therapeutic decision.
3) The use of VEGF and EGFR inhibitors is part of everyday practice.
4) If EGFR activating mutation cannot be detected, but if an ALK mutation is onset, ALK
5) EGFR tyrosine kinase inhibitors do not pass through the blood-brain barrier, so they cannot be used in brain metastases.
6) Vaccination is proven to be effective in clinical trials.
A) 1st, 2nd and 3rd answers are correct
B) 1st, 2nd, 3rd and 4th answers are correct
C) 1st, 4th, and 6th answers are correct
D) 1st, 4th, 5th and 6th answers are correct
E) all of the answers are correct
ANSWER
B) 1st, 2nd, 3rd and 4th answers are correct
EXPLANATION
EGFR tyrosine kinase inhibitors pass through the blood-brain barrier, so they can be effective in brain metatases. There are currently no studies on vaccination.
108
INT - 17.122
What are the “B” symptoms of Hodgkin's disease?
1) Sweat
2) Weight loss
3) Fever
4) Diarrhoea
5) Itching
A) 1st, 2nd and 3rd answers are correct
B) 3rd, 4th and 5th answers are correct
C) 4th and 5th answers are correct
D) all of the answers are correct
ANSWER
A) 1st, 2nd and 3rd answers are correct
EXPLANATION
According to the clinical stage of Hodgkin's disease, the absence of certain clinical signs means “category A”, whilst their existence means “category B”. B symptoms are an unknown cause of 10% weight loss in the last 6 months (before the initial staging), fever of unknown origin (persistent or recurrent), above 38 ° C, and night sweats in the last month.
109
INT - 17.123
Which factors help in the development of lymphomas?
1) AIDS
2) Wiskott-Aldrich syndrome
3) Wegener granulomatosis
4) effective chemotherapy
5) Immunizations
A) 1st, 2nd, 3rd and 4th answers are correct
B) 1st and 4th answers are correct
C) only answer 1 is correct
D) 1st, 2nd, and 4th answers are correct
E) all of the answers are correct
ANSWER
D) 1st, 2nd, and 4th answers are correct
EXPLANATION
Essentially, any condition, either congenital or acquired, that results in immunosuppression, predisposes to development of lymphomas.
110
INT - 17.124
Which factors or diseases caused by them can be associated with the onset of malignant tumors?
1) Schistosoma haematobium
2) Helicobacter pylori
3) Streptococcus pyogenes
4) Aspergillus flavus
5) Actinomycosis
A) 1st, 2nd, 4th and 5th answers are correct
B) 1st, 2nd, and 4th answers are correct
C) 2nd, 3rd, and 4th answers are correct
D) 1st and 5th answers are correct
E) all of the answers are correct
ANSWER
B) 1st, 2nd, and 4th answers are correct
EXPLANATION
Schistosoma haematobium (schistosomiasis) is primarily related to bladder cancer, Helicobacter pylori is associated with gastric cancer and with gastric lymphomas which are formed from the lymphoid tissue associated to the gastric mucosa. Aspergillus flavus (aflatoxin B1) is associated with liver cancer
111
INT-17.126-17.130
Which cytostaticum belongs to which group of compounds?
A) Actinomycin D
B) vinblastine
C) carmustin
D) melphalan
E) 5-fluorouracil
INT - 17.126 - Alkylating agent
INT - 17.127 - Antimetabolite
INT - 17.128 - Alkaloid
INT - 17.129 - Antibiotic
INT - 17.130 - Nitrosourea
ANSWER
INT - 17.126 - Alkylating agent- D)
INT - 17.127 - Antimetabolite- E)
INT - 17.128 - Alkaloid- B)
INT - 17.129 - Antibiotic- A)
INT - 17.130 - Nitrosourea- C)
112
INT-17.131-17.135
Which cytostatic agent causes toxic damage to the listed organs - primarily?
A) kidney
B) heart
C) lung
D) bladder
E) Intestine
INT - 17.132 - cisplatin
INT - 17.133 - cyclophosphamide
INT - 17.134 - adriamycin
INT - 17.135 - bleomycin
ANSWER
INT - 17.132 - cisplatin- A) Kidney
INT - 17.133 - cyclophosphamide- D) Bladder
INT - 17.134 - adriamycin - B) Heart
INT - 17.135 - bleomycin- C) Lung
113
INT-17.136-17.140
Which factor plays an important role in the development of certain listed tumors?
A) larynx cancer
B) mesothelioma
C) Hodgkin's disease
D) skin cancer
E) leukemia
INT - 17.136 - Asbestos
INT - 17.137 - Benzene exposition
INT - 17.138 - UV radiation
INT - 17.139 - Chemotherapy
INT - 17.140 - Cigarette
ANSWER
INT - 17.136 - Asbestos- B) mesothelioma
INT - 17.137 - Benzene exposition- E) Luekemia
INT - 17.138 - UV radiation- D) Skin Cancer
INT - 17.139 - Chemotherapy- C) Hodgkins
INT - 17.140 - Cigarette- A) Larynx cancer
114
INT-17.141-17.145
Find a correlation between viruses and tumors that are probably involved in the development of the tumors.
A) cervical cancer
B) Burkitt lymphoma
C) Kaposi sarcoma
D) liver cancer
E) T-cell lymphoma
INT - 17.141 - EBV
INT - 17.142 - HBV
INT - 17.143 - HTLV-1
INT - 17.144 - HHV-8
INT - 17.145 - HPV
ANSWER
INT - 17.141 - EBV- B) Burkitt
INT - 17.142 - HBV- D) Liver Cancer
INT - 17.143 - HTLV-1- E) T-cell Lymphoma
INT - 17.144 - HHV-8- C) Karposi
INT - 17.145 - HPV- A) Cervical
115
INT-17.146-17.150
Find a correlation between tumors and the products often secreted by them which are frequently causing paraneoplastic symptoms:
A) Serotonin
B) AFP
C) erythropoetin
D) catecholamines
E) ADH
INT - 17.146 - Kidney cancer
INT - 17.147 - Lung cancer
INT - 17.148 - Phaeochromocytoma
INT - 17.149 - Carcinoid
INT - 17.150 - Hepatoblastoma
ANSWER
INT - 17.146 - Kidney cancer- C) Erythro
INT - 17.147 - Lung cancer- E) ADH
INT - 17.148 - Phaeochromocytoma- D) Catecholamines
INT - 17.149 - Carcinoid- A) Serotonin
INT - 17.150 - Hepatoblastoma- B) AFP
116
INT - 17.151
A milk-like ascites indicates what of the following? (simple choice)
A 65 year old woman is complaining about an abdominal distension which increased in the last 2 weeks. In the last 6 months she had a 5.5 kg weight loss, however, in the last 2 weeks her weight increased with almost 3 kg. Physical examination showed a cachectic woman, with faint mucous membranes and with a visible ascites. During the discharge of ascites it proved to be milk-like. Also a painless, 3x4 cm sized, enlarged left inguinal lymph node is detected. Htc: 0,30, fvs: 9,8 G / l.
A) transsudatum
B) chylus
C) none
D) all
ANSWER
B) chylus
EXPLANATION
A milk-like ascites may only refer to chylous of the above listed.
117
INT - 17.152
The milk-like, above listed type of ascites may occur in the following cases:
A 65 year old woman is complaining about an abdominal distension which increased in the last 2 weeks. In the last 6 months she had a 5.5 kg weight loss, however, in the last 2 weeks her weight increased with almost 3 kg. Physical examination showed a cachectic woman, with faint mucous membranes and with a visible ascites. During the discharge of ascites it proved to be milk-like. Also a painless, 3x4 cm sized, enlarged left inguinal lymph node is detected. Htc: 0,30, fvs: 9,8 G / l.
1) lymphoma
2) pancreatic cancer
3) tuberculosis
4) nephrosis syndrome
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
A) 1st, 2nd and 3rd answers are correct
EXPLANATION
Chylous ascites is most commonly caused by obstruction of ductus thoracic (lymph vessels). Among nullthe listed ones, partially based on such a mechanismnull, lymphoma, pancreatic cancer as well as tuberculosis are also eligible choices as etiological factors.
118
INT - 17.153
The final diagnosis can be determined by the following test:
A 65 year old woman is complaining about an abdominal distension which increased in the last 2 weeks. In the last 6 months she had a 5.5 kg weight loss, however, in the last 2 weeks her weight increased with almost 3 kg. Physical examination showed a cachectic woman, with faint mucous membranes and with a visible ascites. During the discharge of ascites it proved to be milk-like. Also a painless, 3x4 cm sized, enlarged left inguinal lymph node is detected. Htc: 0,30, fvs: 9,8 G / l.
A) gastrointestinal examinations
B) lymph node biopsy
C) rectum biopsy
D) iv. pyelographia
E) arteriogram
ANSWER
B) lymph node biopsy
EXPLANATION
Because of the enlarged lymph node found nullby physical examination, its biopsy is the next most logical step. However, It is not certain, of course, that it leads to a primer diagnosis, as it could be caused by a reactive lymphadenitis.
119
INT - 17.154
The most likely diagnosis: (simple choice)
A 65 year old woman is complaining about an abdominal distension which increased in the last 2 weeks. In the last 6 months she had a 5.5 kg weight loss, however, in the last 2 weeks her weight increased with almost 3 kg. Physical examination showed a cachectic woman, with faint mucous membranes and with a visible ascites. During the discharge of ascites it proved to be milk-like. Also a painless, 3x4 cm sized, enlarged left inguinal lymph node is detected. Htc: 0,30, fvs: 9,8 G / l.
A) colon cancer
B) lymphoma
C) syphilis
D) gastric cancer
E) pneumococcal peritonitis
ANSWER
B) lymphoma
EXPLANATION
Based on the above and the possible answers, the most likely diagnosis is lymphoma.
