Rx Oncology/MSK Flashcards
A 60-year-old man comes to the clinic because a 6-week history of vague epigastric pain. The patient also reports fatigue and mentions that the epigastric pain is mostly postprandial. Fecal occult blood test is positive. Gastroduodenoscopy shows a mass in the pyloric region. The tumor is centered near the pyloric sphincter on the lesser curvature. Biopsies from the margin of the mass are consistent with adenocarcinoma.
Which of the following physical examination findings is most likely to be seen in this patient due to the mass effect of the tumor?
options;
A. Decreased bowel sounds
B.Jaundice
C.Koilonychia
D.Palpable cord in the calf
E.Periumbilical nodule
Jaundice
The hepatoduodenal ligament contains the common bile duct, the hepatic artery, and the hepatic portal vein. Neoplasia in this area may disrupt the hepatobiliary system, resulting in jaundice.
others
Koilonychia (related to iron deficiency anemia potentially from bleeding), palpable calf cordfrom underlying deep vein thrombosis, and metastasis to the periumbilical region are potential complications of the patient’s gastrointestinal cancer; however, these are not related to mass effect. Cancer of the pyloric region would not be likely to cause mass effect that leads to decreased bowel sounds. This symptom is more likely to be associated with obstruction of the left colon.
A 40-year-old man comes to the physician because of a 2-week history of gradually worsening fatigue, nausea, vomiting, and abdominal distention. Physical examination is remarkable for scleral icterus; sublingual jaundice; a nodular, palpable liver; and a flapping tremor with wrist extension. Abdominal imaging reveals a large, irregular lesion in the caudate lobe of the liver.
Which of the following is most representative of the severity of organ involvement?
A. Decreased estrogen level
B.Decreased level of circulating von Willebrand factor
C.Elevated transaminases
D.Increased β-human chorionic gonadotropin level
E.Increased prothrombin time
F.Increased serum albumin level
Increased prothrombin time
Chronic liver disease can cause a deficiency in vitamin K-dependent clotting factors, leading to an increased prothrombin time.
others
Although liver enzymes (eg, AST and ALT) are often elevated in chronic liver disease, they are not indicative of liver function and therefore not best representative of severity of organ involvement. Liver failure would not cause decreased estrogen levels, but rather would result in increased estrogen levels. Likewise, serum albumin levels would decrease, not increase, in chronic liver disease. Levels of von Willebrand factor and β-human chorionic gonadotropin levels are not generally affected by hepatocellular carcinoma or liver disease.
A 50-year-old woman comes to her physician’s office complaining of headaches that are localized on the right side of her head. The pain increases when she gets out of bed in the morning. Her symptoms have gradually worsened over the past 6 months. MRI demonstrates a tumor attached to the dura mater. She is referred to a neurosurgeon who resects the mass, confirming that the tumor arises from the arachnoid.
Which of the following histologic features of this tumor is most likely to be observed?
Psammoma bodies
Psammoma bodies can be found in meningiomas, which arise from meningothelial cells of the meninges. They are typically found in middle-aged women, and cause symptoms of headache and focal neurologic defects.
other options
Oligodendrogliomas are characterized by cells with a “fried egg” appearance, due to the presence of dark nuclei within a small amount of cytoplasm. Ependymomas demonstrate perivascular pseudorosettes that represent round-to-oval nuclei and long, delicate processes around vessels. Glioblastoma multiforme cells have a pseudopalisading appearance. Medulloblastomas are indicated by hyperchromatic nuclei with scant cytoplasm, appearing as small blue cells.
A 2-year-old boy is brought to a clinic because of a painless abdominal mass that his mother noticed while bathing him. She explains that the patient has been eating well and producing normal amounts of urine and stool. Development is normal and the patient has met all of his milestones. On evaluation today, vital signs are within normal limits. Physical examination is normal without focal deficits, but a right abdominal pass is palpated. While performing an ultrasound, the technician notes that the kidney calyces on the right are highly distorted by a mass. A CT scan of the child’s abdomen is shown below.
Which of the following is the cause of this patient´s most likely diagnosis?
Abnormal proliferation of the metanephric blastema
Wilms tumor originates from embryonic renal cells, metanephros, and manifests as a unilateral palpable mass in a young child. It is the most common renal malignancy in children age 2–4 years.
There are many mutations associated with Wilms tumor such as WT1, FWT1m FWT2 and p53.
In the case of WT1 mutation, Wilms tumor can also be associated with WAGR syndrome and Denys-Drash syndrome. It is associated with the deletion of tumor suppressor gene WT1 on chromosome 11.
Hemihypertrophy is seen with Beckwith-Wiedemann syndrome, a syndrome associated with Wilms tumor. Yet hemihypertrophy is not a feature of sporadic Wilms tumor.
A 69-year-old man complains that he has been experiencing dizziness, tinnitus, and poor balance for the past 3 months. On CT scan he is found to have a 2-cm, sharply circumscribed mass at the cerebellopontine angle. The mass is surgically removed, and the specimen appears as multiple irregular fragments of tan-pink soft tissue. A photomicrograph of the specimen is shown below.
Which of the following tumors would most likely result in these findings?
Schwannoma
Schwann cell tumors often affect cranial nerve VIII (and are called acoustic neuromas), and thus are commonly seen at the cerebellopontine angle. The most common signs and symptoms of schwannomas include hearing loss, tinnitus, vertigo, hydrocephalus, and increased intracranial pressure.
A 46-year-old woman comes to her primary care physician after visiting the optometrist. While being fitted for new glasses, the patient was found to have persistent constriction of the right pupil. The patient also complains of a chronic nonproductive cough for the past 4 months.
She has a temperature of 37.3° C (99° F), her heart rate is 78/min, and her respiratory rate is 18/min. Her blood pressure is 135/78 mm Hg, and pulse oximetry is 97%. There is marked drooping of the right eyelid. An X-ray of the chest is ordered, and results are shown.
Second-order (preganglionic) sympathetic neuron
The sympathetic nerve fibers of the inferior cervical or stellate ganglion may be compressed by Pancoast tumors, leading to Horner syndrome (unilateral ptosis, miosis, and anhidrosis - “PAM is horny”). Pancoast tumors may cause hoarseness (compress recrrent laryngeal nerve in neck). In addition, a right-sided Pancoast tumor may cause SVC syndrome (distended neck veins and right arm swelling).
A 57-year-old man presents to his physician with skin lesions on his ear. These lesions are removed and sent for pathologic examination, but results indicate they are not cancerous. Within 6 months of removal, one of the lesions reappears, and is shown in the image below. The physician explains to the patient that he may be at risk for developing a type of skin neoplasm that carries a risk of metastasis.
Which of the following is a feature of the malignancy this patient is at risk for developing?
Keratin formation in well-differentiated cases
Actinic keratosis is the most common precancerous dermatosis and can progress to squamous cell carcinoma. Histologically, well-differentiated SCCs can have keratinized pearls or bridges.
A 16-year-old girl comes to her dermatologist with a skin lesion on her forearm (shown in the image). She has had numerous skin lesions similar to this one removed since childhood. While in the office, her dermatologist performs a brief physical examination that, in addition to the skin finding, reveals an unsteady gait and signs of numbness in the extremities.
Which of the following is most likely to be found in this patient?
Defective nucleotide excision repair
Xeroderma pigmentosum (familial dyspllastic melanocytic nevi) is caused by a defect of nucleotide excision repair proteins. It is associated with a 2000-fold increased risk of skin cancer.
An otherwise healthy 8-year-old boy is brought to the pediatrician because of headaches during the past 7-10 days. Physical examination shows normal vital signs. However, the patient is in the 5th percentile of the growth curve, even though he was in the 60th percentile last year. Neurologic examination reveals the patient is not able to notice the movement of the physician’s fingers in the temporal visual field of both sides. The rest of the physical examination is unremarkable. A non-contrast CT scan of the head is shown.
Which of the following laboratory findings is most likely in this patient?
Decreased growth hormone level
Craniopharyngioma is the most common childhood supratentorial tumor and presents with headaches and bitemporal hemianopia. It is derived from remnants of Rathke’s pouch and can appear as a calcified cyst on imaging. In normal development, Rathke’s pouch gives rise to the anterior pituitary gland - deficiencies of the anterior pituitary hormones, such as growth hormone, are responsible for the symptoms of growth failure, hypothyroidism, and diabetes insipidus often seen in these patients.
A 35-year-old man comes to his primary care provider because of a 2-month history of fever, a 7-kg (15-lb) weight loss, and night sweats. Physical examination shows painless generalized lymphadenopathy. Cytotoxic chemotherapy is initiated; however, 4 days into his treatment the patient develops severe pain in his left great toe, which is accompanied by nausea. He also has developed a rash and now has multiple excoriations on his extremities. Results of laboratory studies are shown.
Na+: 140 mEq/L
K+: 6.5 mEq/L
Ca2+: 7.5 mEq/L
Phosphorus: 5.1mg/dL (normal: 3.0 - 4.5mg/dL)
Uric acid: 23 mg/dL (normal: 3.5 - 8.0 mg/dL)
Lactate dehydrogenase: 5000 U/L (normal: 118 - 273 U/L)
Given this patient’s current presentation, he is at greatest risk for which of the following complications?
Cardiac arrhythmia
Tumor lysis syndrome (TLS) is a common result of cytotoxic chemotherapy for lymphoma/leukemia and bulky cancers. It can cause excess potassium and low calcium (leading to weakness and arrhythmias) and excess uric acid (leading to gout and renal failure). TLS is treated with allopurinol, a xanthine oxidase inhibitor, or rasburicase, an exogenous enzyme that converts uric acid to allantoin which is then excreted in urine.
A 57-year-old woman who was diagnosed with lung cancer 4 months ago presents with weight gain. She reports that her weight gain has caused her clothes to fit tighter around the waist. Additionally, she has noticed purple streaks on the skin of her abdomen, and her face has recently “ballooned.” Physical examination shows facial hair above the upper lip, fatty tissue deposits between the shoulders, and muscular atrophy of her arms and legs.
Which of the following additional symptoms is this patient most likely experiencing?
Poor wound healing and facial plethora
Cushing syndrome is characterized by weight gain, abdominal striae, moon facies, poor wound healing, and facial plethora. Small cell lung carcinoma can cause paraneoplastic syndromes including Cushing syndrome, SIADH, and Lambert-Eaton myasthenic syndrome.
A 42-year-old woman (gravida 1, para 1) presents to her physician with an unintentional weight loss of 15 lb over the past 3 months. She reports that her appetite has increased, and she has had to change shirts more often because of frequent perspiration. Physical examination reveals a pelvic mass that is tender to palpation. On further workup, the mass is resected and sent for pathologic examination. The specimen is shown in the image.
Which of the following is the most likely diagnosis?
Struma ovarii
A biopsy specimen of a struma ovarii, a monodermal teratoma, shows mature thyroid follicles. A minority of patients present with symptoms of hyperthyroidism and are at risk for malignant thyroid carcinoma.
A 26-year-old man visits a physician because of progressively worsening vision in his right eye and slightly decreased balance over the past few months. Ophthalmoscopic examination reveals the image shown. MRI of the brain shows a small, vascular mass in the cerebellum. The physician also finds a cavernous hemangioma on the patient’s right arm. The patient notes that his father suffered from a similar decline in vision and was treated surgically.
Which of the following symptoms is the patient most likely to develop in the future?
Hematuria
Von Hippel-Lindau disease, an autosomal dominant disorder caused by a deletion on chromosome 3, is associated with hemangioblastomas (in the retina, brainstem, and cerebellum). It causes renal cell carcinoma in 50%–60% of cases.
A 50-year-old man who has a 50 pack-year smoking history comes to his physician because of flank tenderness. He has no history of signifcant illness. Family history is significant for myocardial infarction in his paternal grandfather at age 76 years, and breast cancer in his sister at age 58 years. On physical examination, the patient has flank tenderness and a palpable abdominal mass. A CT scan is shown.
Which of the following is the most likely diagnosis?
Renal cell carcinoma
Renal cell renal carcinoma is the most common renal malignancy overall, and usually presents with flank pain and hematuria. Its highest incidence is in men between 50 and 70 years of age. Be aware that Wilms’ tumor is the most common cause of renal malignancy in children.
A 59-year-old man comes for evaluation because of intermittent dysphagia during the past year. He reports a 30-year history of postprandial heartburn and regurgitation, and he states his symptoms are worsened when lying down or leaning forward. He denies smoking or alcohol use. His family history is negative for malignancy. He undergoes an endoscopic study of the esophagus. A biopsy specimen is obtained from a red, irregular lesion in the distal esophagus.
Which of the following pathologic findings on examination of the lesion is most likely?
Mucin-positive cells
Barrett esophagus describes intestinal metaplasia of the distal esophagus. In Barrett esophagus, the normal squamous epithelium changes to columnar epithelium with mucin-positive goblet cells.
A 15-year-old high school student visits an outpatient clinic with a 3-day history of sore throat and fever. He says he has pain with swallowing but denies any fatigue, nasal congestion, or cough. He is the quarterback on his high school football team and is eager to recover so he can play in an upcoming game.
His blood pressure is 118/80 mm Hg, temperature is 38.5°C (101.3°F), pulse is 56, and respiratory rate is 13. A physical examination reveals creamy, white discharge on both tonsils and a bright red oropharynx. There is no cervical lymphadenopathy or splenomegaly. The lungs are clear to auscultation bilaterally.
Treatment of this infection will decrease the likelihood of development of which of the following complications?
Mitral stenosis
Rheumatic heart disease is a potential complication of S. pyogenes pharyngitis. It can cause valve leaflet thickening, commissural fusion, and mitral valve stenosis, which can be avoided with appropriate treatment.
A 78-year-old woman presents to her primary care provider with a 6-week history of headaches and blurred vision in her right eye. She first noticed blurring of her vision while reading a book at night in low light. Since then, she has noticed worsening of both symptoms while reading the daily newspaper or any fine print. The patient also reports symptoms of general fatigue and stiffness and pain in her neck and shoulders on awakening, which she has had for the past month. On physical examination, she appears fatigued and is found to have a low-grade fever. Muscle strength is 5/5 in all areas.
What is the most appropriate treatment for this patient’s condition?
Corticosteroids
Giant cell (temporal) arteritis (GCA) is a granulomatous inflammatory disease characterized by headaches and blindness secondary to inflammation of the posterior ciliary and ophthalmic arteries (branches of the internal carotid). Generally, 50% of patients presenting with GCA also have polymyalgia rheumatica. Corticosteroid treatment should be started when either condition is first suspected, especially in the case of GCA because of the high risk of blindness associated with this condition.
A 52-year-old assistant who spends much of her time typing presents to the clinic complaining of chronic and sharp pain in her right finger joints over the past year. Her finger joints are stiff for approximately 30 minutes in the morning. The stiffness generally improves with rest and worsens with activity. She denies fevers, weight loss, fatigue, and weakness. Physical examination reveals bony growth at her distal and proximal interphalangeal joints. A grating sound is heard with active and passive movements of her fingers. The rest of her physical examination is unremarkable.
Which laboratory values in the chart are most consistent with this patient’s condition?
Hb 13.4, MCV 95
Osteoarthritis is a chronic noninflammatory joint disease. Risk factors include female gender, obesity, age >50 years, and chronic mechanical trauma. Osteoarthritis presents asymmetrically with joint pain that worsens with activity and improves with rest; distal interphalangeal joint involvement is characteristic. It does not cause abnormalities in hemoglobin level or corpuscular volume.
A mother brings her 5-year-old son to his pediatrician’s office. The boy has been experiencing frequent falls and has demonstrated progressive difficulty walking, jumping, and hopping. Muscle biopsy reveals variation in fiber diameter, an increased number of internalized nuclei, and muscle fiber degeneration and regeneration. A Western blot analysis confirms the diagnosis.
Which of the following diseases demonstrates the same inheritance pattern as the condition described above?
Glucose-6-phosphate dehydrogenase deficiency
Both Duchenne muscular dystrophy (DMD) and glucose-6-phosphate dehydrogenase (G6PD) deficiency are inherited in an X-linked recessive pattern.
An 81-year-old man presents to the emergency department with acute back pain after losing his balance and falling while getting out of his car. He also reports a 2-month history of dull, constant lower back pain and difficulty maintaining a stream while urinating. The patient also notes that his clothes have been looser and that he has lost some weight over the past few months. X-ray of the spine is shown.
Which of the following is the most likely diagnosis?
Metastatic adenocarcinoma
In older men with back pain and symptoms of prostate cancer, metastasis to the bone should be considered and is far more common than primary cancers of bone.
An 8-year-old boy is brought to the pediatrician by his parents because of swelling and pain over his right femur, which has been present for the past 2–3 weeks. The child and parents deny any history of trauma to the region. The patient reports the pain often is worse at night, and his mother states he has been having low-grade fevers of 37.8°C–38.1°C (100.0°F–100.6°F) during this period. There is no erythema over the region, but examination reveals a firm and immobile mass that is tender to palpation over the proximal right lower extremity near the greater trochanter. Results of a complete blood count show:
Red blood cells (x 10^6/microL): 4.5
Hemoglobin (g/dL): 12.9
Hematocrit (%): 38.2
MCV (fL): 78
MCHC (%): 34
White blood cells (x 10^3/microL): 9.5
Neutrophils (%): 53
Lymphocytes (%): 39.5
Cytologic study of a specimen obtained on fine-needle aspiration reveals sheets of small, round, uniform cells with scant clear cytoplasm, divided into irregular lobules by fibrous strands.
Genetic evaluation of this patient is most likely to reveal which of the following?
t(11;22) chromosomal translocation
Ewing sarcoma is diagnosed histologically with blue anaplastic cells and is associated with t(11;22) translocations.
A mother brings her 3-year-old son to the pediatrician because she is concerned about his increasing weakness and clumsiness. Although he met all of his early motor milestones as a baby, the mother recalls that he was not able to walk on his own until 18 months of age. He is now having increasing difficulty keeping up physically with his peers during playtime. On examination, the child’s cognitive development is appropriate for age.
Examination of the patient’s lower extremities reveals normal patellar and Achilles reflexes, normal sensation, and 3/5 muscle strength. His calf muscles are enlarged (see image for example). Biopsy of the muscle reveals wide variation in the diameter of individual muscle fibers, with degenerative necrosis of some and interspersed regenerating fibers.
Although the mother has not experienced the symptoms seen in her son, she states that she had a “sickly” brother who died at a young age after being confined to a wheelchair for some time. Her husband does not have any history of muscle weakness in his family. The mother is now 30 weeks pregnant with a baby girl and is concerned that this child may have the same health issues as her brother.
Which of the following is the probability that the same condition causing this patient’s weakness will develop in his sister?
Negligible
Duchenne muscular dystrophy is inherited in an X-linked recessive pattern characterized by bulging, fatty calf muscles manifesting in early childhood
A 28-year-old African American woman comes to her physician for evaluation because of a 1-month history of fevers and painful joints. The patient takes no medications. Temperature is 37.8°C (100°F). Physical examination shows an erythematous rash bilaterally on her cheeks. Basic metabolic panel reveals the laboratory values shown.
Additional laboratory studies show a positive Venereal Disease Research Laboratory test and an antinuclear antibody test titer of 1:2560.
This patient is most likely to have which of the following additional physical examination findings on follow-up evaluation?
Painless erythematous oropharyngeal ulcers
Systemic lupus erythematosus (SLE) often manifests with mucosal ulcerations that are usually painless. Patients with SLE often have a false-positive VDRL.
A 52-year-old woman comes to the primary care physician because of blisters on her skin and in her mouth that have become progressively more uncomfortable during the past 3 weeks. She is most frustrated about the painful “raw spots” these blisters leave when they rupture. The patient has a 23-pack-year history of smoking, and currently smokes one pack per day. Her BMI is 21 and she does her best to follow a healthy diet. She has a history of Epstein-Barr virus mononucleosis as a 22-year-old, and recently had a minor viral upper respiratory infection.
Her vital signs include: a heart rate of 87 beats/min; blood pressure of 125/83 mmHg; respiratory rate of 17 breaths/min, and an oxygen saturation of 97%. On examination, tender erosions are found on her back and trunk. One of the lesions is biopsied with direct immunofluorescence against IgG. A light micrograph of the specimen is shown.
Which aspect of epithelial cell junctions is most likely targeted by autoantibodies in this condition?
Desmosomes
Pemphigus vulgaris is an autoimmune blistering disease of the skin and mucosa, caused by antibodies directed against desmosomes (macula adherens). Severe cases may involve life-threatening infection and thermoregulatory disruption.
A 32-year-old woman comes to the physician reporting that lately she has felt “more fatigued, especially at the end of the day.” In the office, she has difficulty rising from her chair to move to the examination table. On physical examination, the patient has asymmetric drooping of her left eyelid, a subjective feeling of “blurred vision” when reading the eye chart on the wall, and a facial droop bilaterally. A plain x-ray of her chest is shown.
Which of the following tests is most likely to confirm a diagnosis in this patient?
Electromyography
Myasthenia gravis (MG) is an autoimmune disorder characterized by the presence of acetylcholine receptor antibodies. Thymomas occur in approximately 10% of patients with MG. Electromyography can be used to confirm the diagnosis
A 68-year-old man presents to his physician’s office with diffuse pelvic pain of 2 weeks’ duration. He reports that it started gradually and that the aching quality of the pain has been worsening. The pain does not seem to be related to activity but is greater at night. The patient has no history of arthritis; he has tried taking ibuprofen and acetaminophen, but they do not relieve his pain.
On further questioning, he admits to an unintentional weight loss of 10 lb in the past 2 months and straining and a weak stream during urination; he has also noticed some blood in his urine. He denies any recent trauma or shooting radiculopathy. On physical examination, the area over the lumbar spine and several pelvic areas areas are tender to palpation. X-ray of the lumbar spine and pelvis is shown in the image.
Which of the following is the best next step to determine the source of this patient’s symptoms?
Digital rectal examination
Prostate cancer commonly produces osteoblastic lesions on metastasis. A digital rectal examination is used to detect the presence of prostate cancer.
A helpful mnemonic for remembering the cancers that commonly metastasize to bone is: lead (Pb) Kettle. Prostate; breast; Kidney, thyroid, lung.
A 42-year-old woman presents to her primary care physician reporting that she has had increasing pain and swelling of the joints in her hands and feet for several months. Her pain is worse for the first hour in the morning, which makes getting ready for work nearly impossible. However, at the end of the day, she is able to continue to type on the computer and go to the gym without the same pain and stiffness. She also states that it is becoming very difficult for her to perform common household tasks. Her vital signs are within normal limits. On physical examination, she has symmetric swelling of the joints of her hands and feet. An x-ray of both wrists obtained from a patient with a similar presentation is shown in the image.
Which of the following laboratory serologic findings would most likely be positive in this patient?
IgM antibody against Fc portion of IgG
Most cases of RA (Rheumatoid arthritis) involve accumulation of rheumatoid factor (IgM anti-IgG), which prompts an influx of inflammatory cells into the synovium.
A 35-year-old man presents to the emergency department with multiple rib fractures after a low-speed motor vehicle collision. No one else involved in the crash was injured. Laboratory findings are as follows.
Calcium: 15.3 mg/dL
Phosphate: 1.8 mg/dL
Alkaline phosphatase: 172 IU/L.
A radiograph of the patient’s femur is shown below.
Osteitis fibrosa cystica
Osteitis fibrosa cystica may be diagnosed with hypercalcemia, elevated alkaline phosphatase, hypophosphatemia, and cystic lesions on x-ray.
Patient presenting with multiple fractures from a minor accident, in the setting of high serum calcium and low phosphate, is most likely suffering from osteitis fibrosa cystica, or von Recklinghausen’s disease of the bone.
A 24-year-old man has sensorineural hearing loss, heart block, cerebellar ataxia, easy fatigability, and proximal muscle weakness. He was diagnosed with a myopathy in childhood. His mother, sister, and a maternal aunt were known to have a similar syndrome. No one on his father’s side is known to be affected. A muscle biopsy is performed (see image).
What is the most likely mode of inheritance for this man’s disorder?
Mitochondrial
The ragged red fiber myopathies (deletion of mitochondria DNA) are inherited through the mother, because all of the embryo’s mitochondria are provided via the ovum.
