A 58-year-old man presents with a lump on his neck. He says the mass gradually onset 2 months ago and has been progressively enlarging. He denies any pain, weight loss, fevers, chills, or night sweats. Past medical history is significant for HIV, diagnosed 5 years ago, managed on a new HAART regimen he just started. The patient is afebrile and vital signs are within normal limits. Physical examination shows a 3 cm mobile firm mass on the left lateral side of the neck immediately below the level of the thyroid cartilage. A biopsy of the mass is performed and reveals atypical mononuclear cells in a background of eosinophils, plasma cells, histiocytes, atypical T-lymphocytes, and binucleated Reed-Sternberg cells (shown in image). Which of the following is the most likely diagnosis in this patient?
Q102
An 82-year-old man presents with painless swelling of the neck for the past week. He reports no recent fever, night sweats, or weight loss. He has no significant medical history, and his only medication is daily aspirin. His temperature is 36.8℃ (98.2℉). On physical examination, there are several non-tender lymph nodes, each averaging 2 cm in diameter, which are palpable in the right anterior cervical triangle. No other palpable lymphadenopathy is noted. The remainder of the physical exam is unremarkable. Laboratory studies show the following:
Hemoglobin 10 g/dL
Leukocyte count 8000/mm3 with a normal differential
Platelet count 250,000/mm3
Erythrocyte sedimentation rate
30 mm/h
An excisional biopsy of a cervical lymph node reveals the presence of Reed-Sternberg (RS) cells. Computed tomography (CT) scans and positron emission tomography (PET) scans reveal no mediastinal mass or signs of additional disease. Which of the following aspects most strongly indicates a good prognosis for this patient?
Q103
A 69-year-old woman comes to the physician because of lower back pain and right-sided chest pain for the past month. The pain is aggravated by movement. Over the past 2 months, she has had increasing fatigue. Her mother died of breast cancer. She has hypertension and reflux disease. Current medications include metoprolol and omeprazole. Vital signs are within normal limits. Examination shows full muscle strength. There is tenderness to palpation over the lower spine and the right lateral chest. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 9.5 g/dL
Leukocyte count 7,300/mm3
Platelet count 230,000/mm3
Serum
Na+ 137 mEq/L
K+ 3.5 mEq/L
Creatinine 1.3 mg/dL
An ECG shows no evidence of ischemia. An x-ray of the chest shows lytic lesions in 2 ribs. Blood smear shows aggregations of erythrocytes. Protein electrophoresis of the serum with immunofixation shows an M-protein spike. This patient's condition is most likely associated with which of the following findings?
Q104
A 63-year-old male is accompanied by his wife to his primary care doctor complaining of shortness of breath. He reports a seven-month history of progressively worsening dyspnea and a dry non-productive cough. He has also lost 15 pounds over the same time despite no change in diet. Additionally, over the past week, his wife has noticed that the patient appears confused and disoriented. His past medical history is notable for stable angina, hypertension, hyperlipidemia, and diabetes mellitus. He currently takes aspirin, metoprolol, lisinopril, atorvastatin, metformin, and glyburide. He has smoked 1 pack of cigarettes per day for 30 years and previously worked as a mechanic at a shipyard. Physical examination reveals no wheezes, rales, or rhonchi with slightly decreased aeration in the left lower lung field. Mucus membranes are moist with normal skin turgor and capillary refill. Laboratory analysis reveals the following:
Na 121 mEq/L
K 3.4 mEq/L
Cl 96 mEq/L
HCO3 23 mEq/L
Cr 1.1 mg/dl
BUN 17 mg/dl
A biopsy of the responsible lesions will most likely demonstrate which of the following findings?
Q105
A 65-year-old man comes to the physician for a routine health maintenance examination. He has a strong family history of colon cancer. A screening colonoscopy shows a 4 mm polyp in the upper sigmoid colon. Which of the following findings on biopsy is associated with the lowest potential for malignant transformation into colorectal carcinoma?
Q106
A 56-year-old man presents to his physician’s office with a sudden increase in urinary frequency. During the past month, he has observed that he needs more frequent bathroom breaks. This is quite unusual as he hasn’t been consuming extra fluids. He reports feeling generally unwell over the past 2 months. He has lost over 7 kg (15.4 lb) of weight and has also been feeling progressively fatigued by the end of the day. He also has a persistent cough and on a couple of occasions, he noticed blood streaks on his napkin. In addition to all of this, he has been feeling weak with frequent muscle cramps during the day. He has never been diagnosed with any medical condition in the past. He doesn’t drink but has smoked 2 packs of cigarettes daily for the last 25 years. Prior to his appointment, he took a couple of tests. The results are given below:
Hemoglobin (Hb) 13.1 g/dL
Serum creatinine 0.8 mg/dL
Serum urea 13 mg/dL
Serum sodium 129 mEq/L
Serum potassium 3.2 mEq/L
His chest X-ray shows a central nodule with some hilar thickening. The physician recommends a biopsy of the nodule. Which of the following histological patterns is the nodule most likely to exhibit?
Q107
A 45-year-old male reports several years of asbestos exposure while working in the construction industry. He reports smoking 2 packs of cigarettes per day for over 20 years. Smoking and asbestos exposure increase the incidence of which of the following diseases?
Q108
A 51-year-old man presents to the emergency department with an episode of syncope. He was at a local farmer's market when he fainted while picking produce. He rapidly returned to his baseline mental status and did not hit his head. The patient has a past medical history of diabetes and hypertension but is not currently taking any medications. His temperature is 97.5°F (36.4°C), blood pressure is 173/101 mmHg, pulse is 82/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for clear breath sounds and a S4 heart sound. Rectal exam reveals a firm and nodular prostate that is non-tender and a fecal-occult sample that is negative for blood. Which of the following is this patient's presentation most concerning for?
Q109
A 67-year-old man comes to the physician because of urinary frequency, dysuria, and blood in his urine. He has also had a 4.5-kg (10-lb) weight loss over the past 3 months and has been feeling more fatigued than usual. He smoked one pack of cigarettes daily for 40 years but quit 2 years ago. A urinalysis shows 3+ blood. Cystoscopy shows an irregular mass on the bladder wall; a biopsy is taken. Which of the following histologic findings would indicate the worst survival prognosis?
Q110
A 74-year-old man with a history of encephalomyelitis, ataxia, and nystagmus has a new diagnosis of small cell carcinoma of the lung (T2, N1, M0) is admitted to the hospital due to painless loss of vision in his right eye. A full workup reveals optic neuritis and uveitis in the affected eye. Which of the following antibodies is most likely to be present in the serum of the patient?
Neoplasia US Medical PG Practice Questions and MCQs
Question 101: A 58-year-old man presents with a lump on his neck. He says the mass gradually onset 2 months ago and has been progressively enlarging. He denies any pain, weight loss, fevers, chills, or night sweats. Past medical history is significant for HIV, diagnosed 5 years ago, managed on a new HAART regimen he just started. The patient is afebrile and vital signs are within normal limits. Physical examination shows a 3 cm mobile firm mass on the left lateral side of the neck immediately below the level of the thyroid cartilage. A biopsy of the mass is performed and reveals atypical mononuclear cells in a background of eosinophils, plasma cells, histiocytes, atypical T-lymphocytes, and binucleated Reed-Sternberg cells (shown in image). Which of the following is the most likely diagnosis in this patient?
A. Nodular lymphocyte-predominant Hodgkin lymphoma
B. Lymphocyte depleted Hodgkin lymphoma
C. Nodular sclerosis classical Hodgkin lymphoma
D. Mixed cellularity classical Hodgkin lymphoma (Correct Answer)
E. Lymphocyte-rich classical Hodgkin lymphoma
Explanation: ***Mixed cellularity classical Hodgkin lymphoma***
- The biopsy findings of **atypical mononuclear cells** in a background of **eosinophils, plasma cells, histiocytes, atypical T-lymphocytes, and bilobed cells** (likely Reed-Sternberg cells) are characteristic of Hodgkin lymphoma.
- **Mixed cellularity Hodgkin lymphoma (MCCHL)** is particularly associated with **HIV-positive** patients and presents with systemic symptoms (though absent here) or rapidly growing **lymphadenopathy**, fitting the patient's presentation.
*Nodular lymphocyte-predominant Hodgkin lymphoma*
- This subtype is characterized by **"popcorn cells" (lymphocytic and histiocytic cells)** and a predominant **lymphocyte background**, which differs from the mixed inflammatory background described.
- It typically has a good prognosis and is less strongly associated with HIV infection compared to other subtypes.
*Lymphocyte depleted Hodgkin lymphoma*
- This is the **rarest subtype of Hodgkin lymphoma** and is often seen in older, immunocompromised individuals, including some with HIV.
- However, its histological hallmark is a **paucity of lymphocytes** relative to pleomorphic tumor cells and fibrosis, which is not consistent with the described mixed cellular background containing numerous inflammatory cells.
*Nodular sclerosis classical Hodgkin lymphoma*
- This is the **most common subtype** of Hodgkin lymphoma and is characterized by **collagen bands (sclerosis)** that divide the lymph node into nodules, and **lacunar cells**.
- While it can occur in HIV-positive individuals, the absence of sclerosis in the description and the typical presentation of the mixed cellularity subtype in this patient population make it less likely.
*Lymphocyte-rich classical Hodgkin lymphoma*
- This subtype is characterized by a high proportion of **small lymphocytes** within the tumor, distinguishing it from mixed cellularity.
- While it contains classic **Reed-Sternberg cells**, the overall cellular composition described (numerous eosinophils, plasma cells, histiocytes) points more towards a mixed cellularity picture.
Question 102: An 82-year-old man presents with painless swelling of the neck for the past week. He reports no recent fever, night sweats, or weight loss. He has no significant medical history, and his only medication is daily aspirin. His temperature is 36.8℃ (98.2℉). On physical examination, there are several non-tender lymph nodes, each averaging 2 cm in diameter, which are palpable in the right anterior cervical triangle. No other palpable lymphadenopathy is noted. The remainder of the physical exam is unremarkable. Laboratory studies show the following:
Hemoglobin 10 g/dL
Leukocyte count 8000/mm3 with a normal differential
Platelet count 250,000/mm3
Erythrocyte sedimentation rate
30 mm/h
An excisional biopsy of a cervical lymph node reveals the presence of Reed-Sternberg (RS) cells. Computed tomography (CT) scans and positron emission tomography (PET) scans reveal no mediastinal mass or signs of additional disease. Which of the following aspects most strongly indicates a good prognosis for this patient?
A. Erythrocyte sedimentation rate (ESR)
B. Leukocyte count and differential
C. Absence of B symptoms
D. Stage of the disease (Correct Answer)
E. Hemoglobin level
Explanation: ***Stage of the disease***
- The **stage of Hodgkin lymphoma** is the most significant prognostic factor, with **earlier stages (I and II)** having a much better prognosis than advanced stages (III and IV). The prompt indicates **no mediastinal mass or additional disease**, suggesting an early stage.
- Absence of widespread disease in CT and PET scans is a critical indicator of **localized disease**, which is associated with higher cure rates.
*Absence of B symptoms*
- While the **absence of B symptoms** (fever, night sweats, weight loss) is a favorable prognostic indicator, it is secondary to the overall disease stage in predicting long-term outcomes in Hodgkin lymphoma.
- The patient's lack of B symptoms is positive, but the *extent of disease spread* (stage) remains the primary determinant of prognosis.
*Erythrocyte sedimentation rate (ESR)*
- An **elevated ESR** (30 mm/h in this case) is a known adverse prognostic factor in Hodgkin lymphoma, indicating systemic inflammation.
- While important, it is a **secondary indicator** and does not outweigh the significance of disease stage in determining prognosis.
*Hemoglobin level*
- A **hemoglobin level below 10.5 g/dL** is an adverse prognostic factor in Hodgkin lymphoma according to the International Prognostic Score, and this patient's hemoglobin is 10 g/dL.
- This factor suggests a potentially **worse prognosis**, making it an incorrect answer for "good prognosis."
*Leukocyte count and differential*
- An **elevated leukocyte count** (above 15,000/mm³) and a **lymphopenia** (absolute lymphocyte count less than 600/mm³ or less than 8% of the white cell count) are adverse prognostic factors in Hodgkin lymphoma.
- This patient has a normal leukocyte count and differential (8000/mm³ with normal differential), which is **neutral to good** but less impactful than the disease stage.
Question 103: A 69-year-old woman comes to the physician because of lower back pain and right-sided chest pain for the past month. The pain is aggravated by movement. Over the past 2 months, she has had increasing fatigue. Her mother died of breast cancer. She has hypertension and reflux disease. Current medications include metoprolol and omeprazole. Vital signs are within normal limits. Examination shows full muscle strength. There is tenderness to palpation over the lower spine and the right lateral chest. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 9.5 g/dL
Leukocyte count 7,300/mm3
Platelet count 230,000/mm3
Serum
Na+ 137 mEq/L
K+ 3.5 mEq/L
Creatinine 1.3 mg/dL
An ECG shows no evidence of ischemia. An x-ray of the chest shows lytic lesions in 2 ribs. Blood smear shows aggregations of erythrocytes. Protein electrophoresis of the serum with immunofixation shows an M-protein spike. This patient's condition is most likely associated with which of the following findings?
A. Urinary tract infection (Correct Answer)
B. Leukemic hiatus
C. Splenomegaly
D. Richter's transformation
E. Autoimmune hemolytic anemia
Explanation: ***Urinary tract infection***
- Patients with **multiple myeloma** are at **increased risk of bacterial infections**, particularly **urinary tract infections** and infections with **encapsulated organisms** (e.g., *Streptococcus pneumoniae*, *Haemophilus influenzae*).
- This susceptibility results from **hypogammaglobulinemia** (decreased normal immunoglobulins despite elevated M-protein), **impaired cell-mediated immunity**, and **renal dysfunction**.
- Her symptoms of **bone pain** (back, chest), **fatigue**, **anemia** (Hgb 9.5 g/dL), **lytic bone lesions** on X-ray, **rouleaux formation** on blood smear, **elevated creatinine**, and **M-protein spike** on serum protein electrophoresis are classic features of **multiple myeloma**.
*Leukemic hiatus*
- This refers to the absence of intermediate myeloid maturation forms in peripheral blood, characteristic of **acute myeloid leukemia (AML)**, not plasma cell disorders.
- The patient's presentation with **M-protein spike** and **lytic bone lesions** points to a **plasma cell neoplasm** (multiple myeloma), not a myeloid malignancy.
*Splenomegaly*
- Splenomegaly is **uncommon** in multiple myeloma as plasma cells primarily infiltrate the bone marrow.
- It is more characteristic of **myeloproliferative neoplasms**, **chronic myeloid leukemia**, or **lymphomas**, which do not fit this clinical picture.
*Richter's transformation*
- This describes the transformation of **chronic lymphocytic leukemia (CLL)** into a more aggressive lymphoma, typically **diffuse large B-cell lymphoma**.
- This patient's findings (lytic lesions, M-protein spike, rouleaux formation) are diagnostic of **multiple myeloma**, not CLL, making Richter's transformation irrelevant.
*Autoimmune hemolytic anemia*
- This condition involves **destruction of red blood cells** by autoantibodies, typically presenting with **spherocytes** on blood smear and a **positive direct Coombs test**.
- The anemia in this patient is more likely due to **bone marrow infiltration** by plasma cells, **renal insufficiency** (causing decreased erythropoietin), and **chronic disease**.
- The blood smear shows **rouleaux formation** (stacked erythrocytes due to elevated proteins), which is characteristic of multiple myeloma, not spherocytes seen in hemolytic anemia.
Question 104: A 63-year-old male is accompanied by his wife to his primary care doctor complaining of shortness of breath. He reports a seven-month history of progressively worsening dyspnea and a dry non-productive cough. He has also lost 15 pounds over the same time despite no change in diet. Additionally, over the past week, his wife has noticed that the patient appears confused and disoriented. His past medical history is notable for stable angina, hypertension, hyperlipidemia, and diabetes mellitus. He currently takes aspirin, metoprolol, lisinopril, atorvastatin, metformin, and glyburide. He has smoked 1 pack of cigarettes per day for 30 years and previously worked as a mechanic at a shipyard. Physical examination reveals no wheezes, rales, or rhonchi with slightly decreased aeration in the left lower lung field. Mucus membranes are moist with normal skin turgor and capillary refill. Laboratory analysis reveals the following:
Na 121 mEq/L
K 3.4 mEq/L
Cl 96 mEq/L
HCO3 23 mEq/L
Cr 1.1 mg/dl
BUN 17 mg/dl
A biopsy of the responsible lesions will most likely demonstrate which of the following findings?
A. Anaplastic pleomorphic giant cells
B. Pleomorphic cells arising from the alveolar lining with disruption of the alveolar architecture
C. Sheets of large pleomorphic cells containing keratin and intercellular bridges
D. Undifferentiated small round blue cells (Correct Answer)
E. Sheets of epithelial cells with papillary fragments, necrosis, and psammoma bodies
Explanation: ***Undifferentiated small round blue cells***
- The patient's history of heavy smoking, shipyard work (exposure to **asbestos**), progressive dyspnea, weight loss, and hyponatremia point towards **small cell lung carcinoma (SCLC)** with possible paraneoplastic **SIADH** causing confusion.
- **SCLC** is characterized histologically by sheets of **small, round, blue cells** with scant cytoplasm, fine chromatin, and absent or inconspicuous nucleoli.
*Anaplastic pleomorphic giant cells*
- This description is more consistent with **large cell carcinoma**, an undifferentiated lung cancer that lacks the specific features of adenocarcinoma, squamous cell carcinoma, or small cell carcinoma.
- Large cell carcinoma does not typically present with the same paraneoplastic syndromes (like SIADH) as SCLC, nor the characteristic "small blue cell" morphology.
*Pleomorphic cells arising from the alveolar lining with disruption of the alveolar architecture*
- This description suggests **adenocarcinoma**, which typically arises from the **glandular cells** of the lung and may disrupt normal alveolar structures.
- While adenocarcinoma can cause dyspnea and weight loss, it is less strongly associated with heavy smoking than SCLC and does not commonly present with **SIADH** and confusion in this manner.
*Sheets of large pleomorphic cells containing keratin and intercellular bridges*
- This biopsy finding is characteristic of **squamous cell carcinoma**, which is often associated with a strong smoking history and can be centrally located.
- However, squamous cell carcinoma less frequently leads to paraneoplastic SIADH, and the classic description for SCLC is "small blue cells," not large pleomorphic cells with keratin.
*Sheets of epithelial cells with papillary fragments, necrosis, and psammoma bodies*
- This pathology description is included as a distractor, though **psammoma bodies are NOT characteristic of lung cancer** and are typically seen in papillary thyroid carcinoma, serous ovarian carcinoma, and meningioma.
- While the patient has asbestos exposure raising concern for **mesothelioma**, this tumor typically shows epithelioid or sarcomatoid patterns without psammoma bodies, and the clinical presentation with **SIADH** and hyponatremia strongly favors SCLC over mesothelioma.
Question 105: A 65-year-old man comes to the physician for a routine health maintenance examination. He has a strong family history of colon cancer. A screening colonoscopy shows a 4 mm polyp in the upper sigmoid colon. Which of the following findings on biopsy is associated with the lowest potential for malignant transformation into colorectal carcinoma?
A. Branching tubules embedded in lamina propria
B. Tree-like branching of muscularis mucosa
C. Regenerating epithelium with inflammatory infiltrate
D. Hyperplastic epithelium at the base of crypts (Correct Answer)
E. Finger-like projections with a fibrovascular core
Explanation: ***Hyperplastic epithelium at the base of crypts***
- This description corresponds to a **hyperplastic polyp**, which is the classic **benign colonic polyp** with **negligible malignant potential**.
- Hyperplastic polyps are characterized by a **serrated (saw-toothed) architecture** with delayed maturation of epithelial cells in the lower third of the colonic crypt.
- These polyps are **non-neoplastic** and represent the polyp type with the **lowest risk of malignant transformation** in traditional classification.
- Note: Sessile serrated adenomas/polyps (SSA/Ps) are a distinct entity with malignant potential, but traditional small hyperplastic polyps are considered benign.
*Branching tubules embedded in lamina propria*
- This morphology is characteristic of a **tubular adenoma**, which is a **neoplastic polyp** with definite malignant potential.
- Tubular adenomas have approximately **5% risk of malignancy** when small (<1 cm), but this increases with size and degree of dysplasia.
- These are **precancerous lesions** that require surveillance.
*Tree-like branching of muscularis mucosa*
- This description suggests a **villous growth pattern** characteristic of adenomas with villous architecture.
- **Villous adenomas** have a **higher risk of malignant transformation** (up to 40%) compared to pure tubular adenomas.
- The villous architecture indicates greater neoplastic potential.
*Regenerating epithelium with inflammatory infiltrate*
- This describes an **inflammatory (pseudo)polyp**, which arises from cycles of **inflammation and repair** in inflammatory bowel disease or other mucosal injury.
- **Inflammatory polyps** are **non-neoplastic** and have **no direct malignant potential** themselves.
- However, hyperplastic polyps are the traditional answer for "lowest malignant potential" polyp in screening contexts, as inflammatory polyps are typically associated with underlying inflammatory conditions rather than routine screening findings.
*Finger-like projections with a fibrovascular core*
- This is the classic histological description of a **villous adenoma**, showing finger-like projections of epithelium covering fibrovascular cores.
- **Villous adenomas** have the **highest malignant potential** among adenomatous polyps, with up to **40% risk of harboring carcinoma** depending on size.
- They often contain high-grade dysplasia and are at significant risk for progression to adenocarcinoma.
Question 106: A 56-year-old man presents to his physician’s office with a sudden increase in urinary frequency. During the past month, he has observed that he needs more frequent bathroom breaks. This is quite unusual as he hasn’t been consuming extra fluids. He reports feeling generally unwell over the past 2 months. He has lost over 7 kg (15.4 lb) of weight and has also been feeling progressively fatigued by the end of the day. He also has a persistent cough and on a couple of occasions, he noticed blood streaks on his napkin. In addition to all of this, he has been feeling weak with frequent muscle cramps during the day. He has never been diagnosed with any medical condition in the past. He doesn’t drink but has smoked 2 packs of cigarettes daily for the last 25 years. Prior to his appointment, he took a couple of tests. The results are given below:
Hemoglobin (Hb) 13.1 g/dL
Serum creatinine 0.8 mg/dL
Serum urea 13 mg/dL
Serum sodium 129 mEq/L
Serum potassium 3.2 mEq/L
His chest X-ray shows a central nodule with some hilar thickening. The physician recommends a biopsy of the nodule. Which of the following histological patterns is the nodule most likely to exhibit?
A. Glandular cells, positive for mucin
B. Squamous cells with keratin pearls
C. Kulchitsky cells with hyperchromatic nuclei (Correct Answer)
D. Papillary epithelial cells with Psammoma bodies
E. Pleomorphic giant cells
Explanation: ***Kulchitsky cells with hyperchromatic nuclei***
- This patient presents with **hyponatremia** and **hypokalemia**, indicative of **syndrome of inappropriate antidiuretic hormone (SIADH)** and **ectopic ACTH production**, respectively. These paraneoplastic syndromes are commonly associated with **small cell lung carcinoma (SCLC)**, which arises from **Kulchitsky cells** (neuroendocrine cells) and features **hyperchromatic nuclei**.
- The patient's significant **smoking history**, weight loss, fatigue, persistent cough with hemoptysis, and chest X-ray findings of a **central nodule with hilar thickening** are all highly suggestive of SCLC.
*Glandular cells, positive for mucin*
- This description is characteristic of **adenocarcinoma**, which typically presents as a **peripheral lung nodule** and is not as strongly associated with paraneoplastic syndromes like SIADH and ectopic ACTH production.
- While adenocarcinoma can cause weight loss and cough, the specific paraneoplastic endocrinopathies and central mass with hilar thickening deviate from its most common presentation.
*Squamous cells with keratin pearls*
- This defines **squamous cell carcinoma**, which is also strongly linked to smoking and often forms **central masses** with potential cavitation.
- However, squamous cell carcinoma is more commonly associated with paraneoplastic **hypercalcemia (due to PTHrP production)**, rather than the hyponatremia and hypokalemia seen in this patient.
*Papillary epithelial cells with Psammoma bodies*
- This histological pattern is characteristic of **papillary thyroid carcinoma** or **mesothelioma** (in the lungs), not typically primary lung cancer.
- It is not associated with the paraneoplastic syndromes of SIADH or ectopic ACTH production that are key to this patient's presentation.
*Pleomorphic giant cells*
- This finding is characteristic of **large cell carcinoma**, a diagnosis of exclusion in non-small cell lung cancer.
- While it can be centrally or peripherally located and linked to smoking, it is less commonly associated with the specific combination of paraneoplastic syndromes (SIADH and ectopic ACTH) seen in this case compared to SCLC.
Question 107: A 45-year-old male reports several years of asbestos exposure while working in the construction industry. He reports smoking 2 packs of cigarettes per day for over 20 years. Smoking and asbestos exposure increase the incidence of which of the following diseases?
A. Emphysema
B. Malignant pulmonary mesothelioma
C. Multiple myeloma
D. Bronchogenic carcinoma (Correct Answer)
E. Chronic bronchitis
Explanation: ***Bronchogenic carcinoma***
- **Smoking** is the leading cause of **bronchogenic carcinoma**, and **asbestos exposure** significantly *multiplies* its risk, rather than simply adding to it.
- This synergistic effect means that smokers exposed to asbestos have a **much higher incidence** of lung cancer compared to those with either exposure alone.
*Emphysema*
- Primarily linked to **smoking** and chronic exposure to irritants, but asbestos exposure does not significantly increase its incidence.
- While both smoking and asbestos can cause pulmonary issues, their primary mechanisms for emphysema are distinct.
*Malignant pulmonary mesothelioma*
- **Malignant mesothelioma** is strongly associated with **asbestos exposure**, but its incidence is *not significantly increased* by smoking.
- Smoking is a risk factor for lung cancer, but not a primary risk factor for mesothelioma itself.
*Multiple myeloma*
- This is a **hematologic malignancy** (cancer of plasma cells) and has no established link with either **smoking** or **asbestos exposure**.
- Its risk factors are largely genetic and related to other environmental factors, but not directly linked to respiratory toxins.
*Chronic bronchitis*
- **Chronic bronchitis** is primarily caused by **smoking** and exposure to environmental pollutants.
- While asbestos exposure can cause lung damage, it doesn't directly or significantly increase the incidence of chronic bronchitis.
Question 108: A 51-year-old man presents to the emergency department with an episode of syncope. He was at a local farmer's market when he fainted while picking produce. He rapidly returned to his baseline mental status and did not hit his head. The patient has a past medical history of diabetes and hypertension but is not currently taking any medications. His temperature is 97.5°F (36.4°C), blood pressure is 173/101 mmHg, pulse is 82/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for clear breath sounds and a S4 heart sound. Rectal exam reveals a firm and nodular prostate that is non-tender and a fecal-occult sample that is negative for blood. Which of the following is this patient's presentation most concerning for?
A. Prostatitis
B. Prostate abscess
C. Benign prostatic hyperplasia
D. Prostate cancer (Correct Answer)
E. Normal physical exam
Explanation: ***Prostate cancer***
- A **firm**, **nodular**, and non-tender prostate on digital rectal examination is highly suspicious for prostate cancer, particularly in a 51-year-old male.
- The patient's presentation with **syncope** could indirectly be related to a paraneoplastic syndrome in advanced prostate cancer, although this is less common.
*Prostatitis*
- Prostatitis typically presents with **perineal pain**, **dysuria**, and **fever**, none of which are noted in this patient.
- The prostate would usually be **tender** and boggy, not firm and nodular.
*Prostate abscess*
- A prostate abscess is characterized by **severe pain**, **fever**, **chills**, and urinary symptoms, which are absent in this case.
- The prostate would be exquisitely **tender** and potentially fluctuant on examination.
*Benign prostatic hyperplasia*
- While BPH can cause urinary symptoms, it typically results in a **smooth**, enlarged, and rubbery prostate, not a firm and nodular one.
- It is not associated with syncope or the specific prostate findings described.
*Normal physical exam*
- A **firm** and **nodular** prostate on rectal exam is an abnormal finding that warrants further investigation, especially given the patient's age.
- While other findings may be normal, the prostate exam is highly concerning for pathology.
Question 109: A 67-year-old man comes to the physician because of urinary frequency, dysuria, and blood in his urine. He has also had a 4.5-kg (10-lb) weight loss over the past 3 months and has been feeling more fatigued than usual. He smoked one pack of cigarettes daily for 40 years but quit 2 years ago. A urinalysis shows 3+ blood. Cystoscopy shows an irregular mass on the bladder wall; a biopsy is taken. Which of the following histologic findings would indicate the worst survival prognosis?
A. Disordered urothelium lined with papillary fronds
B. Dysplastic cells extending into the lamina propria
C. Infiltrating nests of cells with squamous differentiation
D. Nests of atypical cells in the urothelium
E. Tubular glands with mucin secretions (Correct Answer)
Explanation: ***Tubular glands with mucin secretions***
- The presence of **tubular glands with mucin secretions** indicates a diagnosis of **adenocarcinoma of the bladder**.
- Bladder adenocarcinoma is a rare and aggressive form of bladder cancer with a **significantly worse prognosis** compared to urothelial carcinoma, comprising <2% of bladder cancers and often presenting at advanced stages with limited treatment options.
*Dysplastic cells extending into the lamina propria*
- This description refers to **high-grade urothelial carcinoma** that has invaded the **lamina propria** (stage T1).
- While it's an invasive cancer with significant risk, it generally has a better prognosis than adenocarcinoma when treated appropriately.
*Disordered urothelium lined with papillary fronds*
- This suggests a **papillary urothelial neoplasm**, which could be low-grade or high-grade.
- Early-stage papillary tumors generally have a favorable prognosis, especially low-grade variants.
*Nests of atypical cells in the urothelium*
- This finding describes **carcinoma in situ (CIS)**, a high-grade, flat, non-invasive form of urothelial carcinoma.
- Although it has a high risk of progression to invasive cancer, it does not inherently indicate a worse prognosis than invasive adenocarcinoma at the time of diagnosis.
*Infiltrating nests of cells with squamous differentiation*
- This describes **squamous cell carcinoma of the bladder**, which accounts for 3-5% of bladder cancers.
- While aggressive and often associated with chronic irritation or schistosomiasis, it generally has a better prognosis than adenocarcinoma when detected and treated early.
Question 110: A 74-year-old man with a history of encephalomyelitis, ataxia, and nystagmus has a new diagnosis of small cell carcinoma of the lung (T2, N1, M0) is admitted to the hospital due to painless loss of vision in his right eye. A full workup reveals optic neuritis and uveitis in the affected eye. Which of the following antibodies is most likely to be present in the serum of the patient?
A. Anti-amphiphysin
B. Anti-Yo
C. Anti-Hu (Correct Answer)
D. Anti-CV2 (CRMP5)
E. Anti-Ri
Explanation: ***Anti-Hu***
- This antibody is strongly associated with **paraneoplastic syndromes** in **small cell lung cancer (SCLC)**, often presenting with **encephalomyelitis**, **ataxia**, and **optic neuritis/uveitis**, as described in the patient.
- Anti-Hu antibodies target neuronal proteins, leading to a wide range of neurological deficits, and the presence of SCLC makes this the most likely antibody.
*Anti-amphiphysin*
- This antibody is typically associated with **stiff-person syndrome**, which presents with muscle rigidity and spasms, and less commonly with paraneoplastic encephalomyelitis.
- While it can be associated with breast cancer or SCLC, the patient's specific presentation (encephalomyelitis, ataxia, optic neuritis) is not a classical feature.
*Anti-Yo*
- **Anti-Yo (Purkinje cell cytoplasmic antibody)** is primarily associated with **paraneoplastic cerebellar degeneration**, leading to severe ataxia, often in the context of gynecological or breast cancers.
- Although the patient has ataxia, the extensive involvement including encephalomyelitis and optic neuritis without a predominant cerebellar syndrome makes anti-Yo less likely.
*Anti-CV2 (CRMP5)*
- **Anti-CV2/CRMP5** antibodies are associated with **paraneoplastic encephalomyelitis**, **optic neuropathy**, and chorea, and are commonly seen in SCLC.
- While plausible given the symptoms, anti-Hu is historically the most frequently identified antibody in SCLC patients presenting with this breadth of neurological and visual symptoms.
*Anti-Ri*
- **Anti-Ri (ANNA-2)** antibodies are classically associated with **opsoclonus-myoclonus syndrome**, characterized by chaotic eye movements and myoclonus, often linked to SCLC or breast cancer.
- The patient's symptom of **nystagmus** could be a feature of opsoclonus-myoclonus syndrome, but the more dominant presentation of encephalomyelitis, ataxia, and optic neuritis points away from a primary opsoclonus-myoclonus syndrome.
