A 54-year-old woman comes to the physician because of an ulcer on her left ankle for 6 years. She has had multiple ulcers over her left lower extremity during this period that have subsided with wound care and dressing. She has type 2 diabetes mellitus and gastroesophageal reflux disease. Current medications include metformin, sitagliptin, and omeprazole. She appears anxious. She is 162 cm (5 ft 4 in) tall and weighs 89 kg (196 lb); BMI is 34 kg/m2. Vital signs are within normal limits. Examination shows a 7.5-cm (3-in) ulcer with elevated, indurated margins and a necrotic floor above the left medial malleolus. There are multiple dilated, tortuous veins along the left lower extremity. There is 2+ pretibial edema of the lower extremities bilaterally. The skin around the left ankle appears darker than the right and there are multiple excoriation marks. Cardiopulmonary examination shows no abnormalities. Which of the following is the most appropriate next step in management of this patient's current condition?
Q202
A 44-year-old woman presents to the outpatient infectious disease clinic. She has a known history of HIV, well-controlled on HAART for the past 8 years. She currently has no additional significant medical conditions. She feels well and a physical examination is within normal limits. She denies any current tobacco use, alcohol use, or illicit drug use, although she has a history of heroin use (injection). Her vital signs include: temperature, 36.7°C (98.0°F); blood pressure, 126/74 mm Hg; heart rate, 87/min; and respiratory rate, 17/min. She has no complaints and is up to date on all of her vaccinations and preventative care. Which of the following malignancies can be seen and is often associated with AIDS?
Q203
A 70-year-old man is at his dermatologist’s office for the treatment of a severely pruritic erythroderma with scaling on his buttocks that has been slowly progressing over the past two weeks. The patient works as a truck driver and has a history of hypertension treated with enalapril. The patient reports having tried an over-the-counter cream on the rash without improvement. The vital signs are within normal range. On physical exam, he has multiple confluent and well-demarcated pink patches on his buttocks and legs with some scaling and enlarged inguinal lymph nodes. The dermatologist orders a skin biopsy that reveals Pautrier microabscesses. What is the most likely diagnosis?
Q204
A 37-year-old woman, G1P0, visits her gynecologist's office for a routine prenatal checkup. During her quadruple screening test, her alpha-fetoprotein, β-hCG, and pregnancy-associated plasma protein were all decreased. There is also evidence of increased nuchal translucency on the scanning of the male fetus. A confirmatory test indicates signs of a genetic syndrome. The woman is counseled that her child will most likely have a severe intellectual disability. Physical features of this condition include polydactyly, cleft palate, micrognathia and clenched fists. This genetic condition also affects the formation of the brain and can lead to stillbirth. Most babies do not survive beyond the first year of life. Which of the following is responsible for this type of genetic syndrome?
Q205
A 32-year-old woman comes to the physician for a routine examination. She has no history of serious medical illness. She appears well. Physical examination shows several hundred pigmented lesions on the back and upper extremities. A photograph of the lesions is shown. The remainder of the examination shows no abnormalities. This patient is at increased risk of developing a tumor with which of the following findings?
Q206
A 35-year-old woman comes to the physician because of a 2-month history of vaginal bleeding after intercourse. Menarche occurred at the age of 13 years and menses occur at regular 28-day intervals. Gynecologic examination shows an irregular lesion at the cervical os. Histological evaluation of a cervical biopsy specimen obtained on colposcopy confirms a diagnosis of in-situ cervical cancer. This cancer is most likely derived from which of the following types of cells?
Q207
A 32-year-old man presents to the emergency room for a generalized tonic-clonic seizure. After stabilizing the patient, a full radiologic evaluation reveals multiple contrast-enhancing lesions in the brain, lungs, and liver. According to his wife, he lost several pounds in the last few months. The medical history is relevant for cryptorchidism, with abdominal testes that were surgically transferred to the scrotum just before he turned 1-year old. His lab investigation reveals:
α-fetoprotein:
9 ng/mL (normal values < 10 ng/mL)
Human chorionic gonadotropin:
1,895 IU/L (normal values < 0.5 IU/L)
Which of the following microscopic features best describes the lesions seen in this patient's imaging study?
Q208
A 65-year-old man presents with complaints of weakness and swollen gums for the past 3 weeks. He also says he cut his finger while cooking, and the bleeding took more than 10 minutes to stop. He has a family history of diabetes mellitus type 2 and prostate cancer. Current medications are multivitamin. His blood pressure is 122/67 mm Hg, the respiratory rate is 13/min, and the temperature is 36.7°C (98.0°F). On physical examination, the patient seems pale and lethargic. On cardiac exam, a pulmonary valve flow murmur is heard. There is significant hepatosplenomegaly present, and several oral mucosal petechiae in the oral cavity are noted. Gum hypertrophy is also present. A peripheral blood smear reveals myeloperoxidase-positive cells and Auer Rods. A bone marrow biopsy shows > 30% of blast cells. Which of the following chromosomal abnormalities is associated with this patient’s most likely diagnosis?
Q209
A 60-year-old man presents to your office because he noticed a "weird patch" on the floor of his mouth. He states that he noticed it a few months ago, but did not report it because it did not hurt. However, he is concerned because it has not regressed and seems to have changed in shape. On examination, you notice the patient has poor dentition and he admits to using chewing tobacco daily. The patch on the floor of his mouth is red with irregular borders. Which of the following would be an appropriate way to counsel this patient on his current condition?
Q210
A 47-year-old female comes to the emergency department because of increasing back pain for the past 2 weeks. She is unable to perform her daily chores. One month ago, she fell and hurt her back while working outside in the garden. The pain subsided with over-the-counter acetaminophen. She underwent a left mastectomy 1 year ago for breast cancer. She has type 2 diabetes mellitus. Current medications include metformin, sitagliptin, and a multivitamin. She appears uncomfortable. Her temperature is 38.9°C (102.0°F), pulse is 101/min, and blood pressure is 110/80 mm Hg. Examination of the back shows thoracic vertebral tenderness. She has mild stiffness on neck flexion. Muscle strength is decreased in the lower extremities. Deep tendon reflexes are 2+ bilaterally. Sensation to pain, fine touch, temperature, and proprioception is intact. Her hemoglobin concentration is 13.1 g/dL and leukocyte count is 19,300/mm3. Which of the following is the most appropriate next step in management?
Neoplasia US Medical PG Practice Questions and MCQs
Question 201: A 54-year-old woman comes to the physician because of an ulcer on her left ankle for 6 years. She has had multiple ulcers over her left lower extremity during this period that have subsided with wound care and dressing. She has type 2 diabetes mellitus and gastroesophageal reflux disease. Current medications include metformin, sitagliptin, and omeprazole. She appears anxious. She is 162 cm (5 ft 4 in) tall and weighs 89 kg (196 lb); BMI is 34 kg/m2. Vital signs are within normal limits. Examination shows a 7.5-cm (3-in) ulcer with elevated, indurated margins and a necrotic floor above the left medial malleolus. There are multiple dilated, tortuous veins along the left lower extremity. There is 2+ pretibial edema of the lower extremities bilaterally. The skin around the left ankle appears darker than the right and there are multiple excoriation marks. Cardiopulmonary examination shows no abnormalities. Which of the following is the most appropriate next step in management of this patient's current condition?
A. Trendelenburg test
B. Punch biopsy (Correct Answer)
C. Digital subtraction angiography
D. Perthes test
E. CT scan of the left leg
Explanation: ***Punch biopsy***
- A 6-year history of a non-healing **ulcer with elevated, indurated margins and a necrotic floor** is highly suspicious for **Marjolin's ulcer**, a type of squamous cell carcinoma arising in chronic wounds.
- A **punch biopsy** is the most appropriate next step to obtain a tissue diagnosis and confirm or rule out malignancy.
*Trendelenburg test*
- The Trendelenburg test assesses **venous valve competence** in superficial veins.
- While this patient has signs of **venous insufficiency** (dilated veins, edema, skin changes), the primary concern is the non-healing, suspicious ulcer, for which biopsy is more urgent.
*Digital subtraction angiography*
- Digital subtraction angiography is used to visualize **arterial blood flow** and diagnose peripheral artery disease.
- Although the patient has diabetes, there are no classic signs of significant arterial insufficiency (e.g., claudication, cold limb, diminished pulses), and the ulcer characteristics are more suggestive of malignancy or venous etiology.
*Perthes test*
- The Perthes test evaluates the **patency of deep veins** and the function of communicating veins by assessing changes in superficial venous distension after exercise with a tourniquet.
- Similar to the Trendelenburg test, it focuses on venous hemodynamics, which is secondary to the suspicion of malignancy in a chronic, non-healing ulcer.
*CT scan of the left leg*
- A CT scan can assess the **extent of soft tissue destruction or bone involvement** if malignancy is suspected or confirmed.
- However, it is not the initial diagnostic step for determining the nature of the ulcer itself; a **tissue biopsy** is required for definitive diagnosis.
Question 202: A 44-year-old woman presents to the outpatient infectious disease clinic. She has a known history of HIV, well-controlled on HAART for the past 8 years. She currently has no additional significant medical conditions. She feels well and a physical examination is within normal limits. She denies any current tobacco use, alcohol use, or illicit drug use, although she has a history of heroin use (injection). Her vital signs include: temperature, 36.7°C (98.0°F); blood pressure, 126/74 mm Hg; heart rate, 87/min; and respiratory rate, 17/min. She has no complaints and is up to date on all of her vaccinations and preventative care. Which of the following malignancies can be seen and is often associated with AIDS?
A. Thymomas
B. Kaposi’s sarcoma (Correct Answer)
C. Colonic adenocarcinoma
D. Malignant melanoma
E. Secondary osteosarcoma
Explanation: **Kaposi’s sarcoma**
- **Kaposi's sarcoma (KS)** is a highly characteristic malignancy associated with **AIDS**, caused by **Human Herpesvirus 8 (HHV-8)**, and often presents with skin lesions, though it can affect internal organs.
- Although the patient's HIV is well-controlled, her history of HIV infection places her at significant risk for **AIDS-defining malignancies** like KS, even with a stable immune status.
*Thymomas*
- **Thymomas** are rare tumors of the **thymus gland** and are not typically associated with HIV or AIDS.
- Their pathogenesis is distinct, often linked to autoimmune conditions like **myasthenia gravis**, not immunodeficiency.
*Colonic adenocarcinoma*
- While **colonic adenocarcinoma** can occur in individuals with HIV, it is not considered an **AIDS-defining malignancy** and its incidence is not disproportionately elevated compared to the general population in the same way as KS.
- Risk factors for colonic adenocarcinoma are generally linked to age, diet, and genetic predispositions, not directly to HIV infection.
*Malignant melanoma*
- **Malignant melanoma** is a skin cancer linked to **UV radiation exposure** and genetic factors, not directly nor significantly to HIV or AIDS.
- Although immunosuppression can potentially increase the risk of certain cancers, melanoma is not specifically an **AIDS-defining malignancy**.
*Secondary osteosarcoma*
- **Osteosarcoma** is a primary **malignancy of bone**, typically seen in adolescents and young adults, and secondary osteosarcoma refers to one that develops after radiation or in conditions like Paget's disease.
- There is no established direct link between HIV/AIDS and an increased risk of developing **osteosarcoma**.
Question 203: A 70-year-old man is at his dermatologist’s office for the treatment of a severely pruritic erythroderma with scaling on his buttocks that has been slowly progressing over the past two weeks. The patient works as a truck driver and has a history of hypertension treated with enalapril. The patient reports having tried an over-the-counter cream on the rash without improvement. The vital signs are within normal range. On physical exam, he has multiple confluent and well-demarcated pink patches on his buttocks and legs with some scaling and enlarged inguinal lymph nodes. The dermatologist orders a skin biopsy that reveals Pautrier microabscesses. What is the most likely diagnosis?
A. Atopic dermatitis
B. Kaposi sarcoma
C. Lichen planus
D. Psoriasis
E. Mycosis fungoides (Correct Answer)
Explanation: ***Mycosis fungoides***
- The presence of **severely pruritic erythroderma** with **scaling**, progressing over weeks, and **enlarged regional lymph nodes** is highly suggestive of cutaneous T-cell lymphoma, specifically mycosis fungoides.
- The definitive diagnostic finding is **Pautrier microabscesses** on skin biopsy, which are collections of atypical T lymphocytes in the epidermis, pathognomonic for mycosis fungoides.
*Atopic dermatitis*
- While it can cause **pruritic and scaly erythematous patches**, it typically presents earlier in life, often with a history of allergies or asthma, which are not mentioned.
- **Pautrier microabscesses** are not a feature of atopic dermatitis; histology would show spongiosis and inflammation.
*Kaposi sarcoma*
- This condition presents as **violaceous plaques, patches, or nodules**, often in immunocompromised individuals, and is caused by HHV-8.
- Histologically, it shows **spindle cells** and **vascular proliferation**, not Pautrier microabscesses.
*Lichen planus*
- Characterized by **pruritic, polygonal, planar, purple papules and plaques** (the 6 Ps), often with Wickham's striae.
- Biopsy would reveal a **band-like lymphocytic infiltrate** at the dermoepidermal junction, not Pautrier microabscesses.
*Psoriasis*
- Typically presents as **well-demarcated erythematous plaques with silvery scales**, often on extensor surfaces.
- While it can cause erythroderma, **Pautrier microabscesses** are not characteristic; histology shows **acanthosis**, **parakeratosis**, and **Munro microabscesses** (neutrophils in the stratum corneum).
Question 204: A 37-year-old woman, G1P0, visits her gynecologist's office for a routine prenatal checkup. During her quadruple screening test, her alpha-fetoprotein, β-hCG, and pregnancy-associated plasma protein were all decreased. There is also evidence of increased nuchal translucency on the scanning of the male fetus. A confirmatory test indicates signs of a genetic syndrome. The woman is counseled that her child will most likely have a severe intellectual disability. Physical features of this condition include polydactyly, cleft palate, micrognathia and clenched fists. This genetic condition also affects the formation of the brain and can lead to stillbirth. Most babies do not survive beyond the first year of life. Which of the following is responsible for this type of genetic syndrome?
A. Nondisjunction of chromosomes (Correct Answer)
B. Genomic imprinting
C. Error in metabolism
D. In utero infections
E. Autosomal dominant genes
Explanation: ***Nondisjunction of chromosomes***
- The combination of **decreased alpha-fetoprotein, β-hCG, and PAPP-A**, **increased nuchal translucency**, and the described physical features (polydactyly, cleft palate, micrognathia, clenched fists) strongly points to **trisomy 13 (Patau syndrome)**.
- Trisomy 13 is caused by **nondisjunction** during meiosis, where chromosomes fail to separate properly, resulting in an extra copy of chromosome 13 in the fetus.
- Classic features include holoprosencephaly, severe intellectual disability, polydactyly, and the characteristic facial abnormalities described.
*Genomic imprinting*
- **Genomic imprinting** refers to epigenetic modifications that cause genes to be expressed only from the allele inherited from a specific parent (e.g., Prader-Willi or Angelman syndromes).
- This mechanism typically involves altered gene expression, not the presence of an entire extra chromosome, and does not explain the widespread structural anomalies observed here.
*Error in metabolism*
- **Errors in metabolism** are genetic disorders that cause a deficiency or absence of specific enzymes, leading to the accumulation of toxic substances or impaired production of essential compounds (e.g., PKU, MPS).
- While metabolic disorders can cause severe intellectual disability, they typically do not present with the specific constellation of visible congenital abnormalities and abnormal screening markers seen in this case.
*In utero infections*
- **In utero infections** (e.g., TORCH infections like toxoplasmosis, rubella, CMV) can cause congenital anomalies, intellectual disability, and increased nuchal translucency.
- However, the specific pattern of quadruple screen results (all decreased markers) is highly characteristic of chromosomal abnormalities like trisomy 13, rather than infections.
*Autosomal dominant genes*
- **Autosomal dominant genes** cause disorders when a single copy of a mutated gene is sufficient to cause the disease (e.g., Huntington's disease, Marfan syndrome).
- While these can cause genetic syndromes, the severe, multiorgan structural anomalies described, coupled with the specific prenatal screening profile, are not typically characteristic of a single autosomal dominant gene mutation but rather a gross chromosomal abnormality.
Question 205: A 32-year-old woman comes to the physician for a routine examination. She has no history of serious medical illness. She appears well. Physical examination shows several hundred pigmented lesions on the back and upper extremities. A photograph of the lesions is shown. The remainder of the examination shows no abnormalities. This patient is at increased risk of developing a tumor with which of the following findings?
A. Spindle endothelial cells forming slit-like spaces
B. Atypical keratinocytes forming keratin pearls
C. S100-positive epithelioid cells with fine granules (Correct Answer)
D. Pale, round cells with palisading nuclei
E. Mucin-filled cells with peripheral nuclei
Explanation: ***S100-positive epithelioid cells with fine granules***
- The clinical presentation of a young woman with **hundreds of pigmented lesions** on her back and upper extremities, and no other significant medical history, strongly suggests the presence of **dysplastic nevi** or **atypical moles**. Such individuals are at a significantly increased risk of developing **melanoma**.
- **Melanoma** is a malignant neoplasm of **melanocytes**. Histopathologically, melanocytes in melanoma are often **S100-positive** (a common marker for neural crest-derived cells, including melanocytes), show an **epithelioid morphology** (polygonal cells with abundant eosinophilic cytoplasm), and can contain **fine pigment granules** (melanin).
*Spindle endothelial cells forming slit-like spaces*
- This description is characteristic of **Kaposi's sarcoma**, a vascular tumor.
- Kaposi's sarcoma typically presents with violaceous skin lesions and is associated with **HHV-8 infection**, particularly in immunocompromised individuals.
*Atypical keratinocytes forming keratin pearls*
- This pattern is characteristic of **squamous cell carcinoma**, a malignant tumor of keratinocytes.
- **Squamous cell carcinoma** often presents as an erosive or nodular lesion, commonly in sun-exposed areas, and is not directly linked to the large number of pigmented lesions described.
*Pale, round cells with palisading nuclei*
- This describes the typical histology of **basal cell carcinoma**, the most common skin cancer.
- **Basal cell carcinoma** presents as a pearly nodule with telangiectasias, often on the head and neck, and is not a direct risk from multiple pigmented nevi.
*Mucin-filled cells with peripheral nuclei*
- This description points to **signet ring cells**, which are characteristic of some adenocarcinomas, particularly **gastric adenocarcinoma**.
- This histological feature is unrelated to skin lesions and the development of melanoma.
Question 206: A 35-year-old woman comes to the physician because of a 2-month history of vaginal bleeding after intercourse. Menarche occurred at the age of 13 years and menses occur at regular 28-day intervals. Gynecologic examination shows an irregular lesion at the cervical os. Histological evaluation of a cervical biopsy specimen obtained on colposcopy confirms a diagnosis of in-situ cervical cancer. This cancer is most likely derived from which of the following types of cells?
A. Simple cuboidal epithelium
B. Non-keratinized stratified squamous epithelium (Correct Answer)
C. Ciliated simple columnar epithelium
D. Keratinized stratified squamous epithelium
E. Simple columnar epithelium with tubular glands
Explanation: ***Non-keratinized stratified squamous epithelium***
- The **cervical os** (ectocervix) is normally lined by **non-keratinized stratified squamous epithelium**. **Cervical cancer**, whether in situ or invasive, almost always arises from this type of epithelium.
- The **transformation zone**, where the squamous epithelium meets the columnar epithelium, is particularly vulnerable to HPV infection and subsequent dysplastic changes.
*Simple cuboidal epithelium*
- This type of epithelium is typically found in structures like the **kidney tubules** and some glands, not the cervix.
- Cervical cancer is not derived from simple cuboidal epithelium.
*Ciliated simple columnar epithelium*
- This epithelium lines the **fallopian tubes** and parts of the **endocervix**, but it is not the primary site for the development of most cervical cancers.
- Adenocarcinoma of the cervix arises from columnar cells, but squamous cell carcinoma (the most common type) originates from squamous cells.
*Keratinized stratified squamous epithelium*
- **Keratinized stratified squamous epithelium** is found on the external skin and in the vagina, providing protection against abrasion and desiccation.
- This type of epithelium is **not typically found on the cervix**, and cervical cancer does not originate from keratinized epithelium.
*Simple columnar epithelium with tubular glands*
- The **endocervix** is lined by **simple columnar epithelium** with tubular glands, which produce mucus.
- While adenocarcinoma of the cervix can arise from these cells, the most common type of cervical cancer (**squamous cell carcinoma**) originates from the squamous epithelium of the ectocervix.
Question 207: A 32-year-old man presents to the emergency room for a generalized tonic-clonic seizure. After stabilizing the patient, a full radiologic evaluation reveals multiple contrast-enhancing lesions in the brain, lungs, and liver. According to his wife, he lost several pounds in the last few months. The medical history is relevant for cryptorchidism, with abdominal testes that were surgically transferred to the scrotum just before he turned 1-year old. His lab investigation reveals:
α-fetoprotein:
9 ng/mL (normal values < 10 ng/mL)
Human chorionic gonadotropin:
1,895 IU/L (normal values < 0.5 IU/L)
Which of the following microscopic features best describes the lesions seen in this patient's imaging study?
A. Germ cells with well-defined borders, central nuclei, prominent nucleoli, and clear cytoplasm
B. Mixture of primitive neuroectoderm, loose mesenchyme, and primitive glandular structures
C. Intimate association of syncytiotrophoblast and cytotrophoblast cells (Correct Answer)
D. Glomerulus-like structure with a mesoderm core, a central capillary, and lined with germ cells
E. Cells with hyaline-like globules
Explanation: ***Intimate association of syncytiotrophoblast and cytotrophoblast cells***
- The combination of a **generalized tonic-clonic seizure** (suggesting brain metastasis), **multiple contrast-enhancing lesions** in brain, lungs, and liver, weight loss, history of **cryptorchidism**, and significantly **elevated human chorionic gonadotropin (hCG)** (1,895 IU/L, normal < 0.5 IU/L) despite normal AFP, is highly indicative of a **choriocarcinoma**.
- **Choriocarcinomas** are characterized microscopically by an intimate admixture of **syncytiotrophoblast** and **cytotrophoblast cells** lacking chorionic villi. These tumors are highly aggressive and prone to widespread metastasis, particularly to the lungs, brain, and liver.
*Germ cells with well-defined borders, central nuclei, prominent nucleoli, and clear cytoplasm*
- This description is characteristic of **seminoma**, the most common germ cell tumor.
- While seminomas can spread, the extremely high hCG levels without elevated AFP and the rapid, widespread metastasis depicted are more typical of choriocarcinoma.
*Mixture of primitive neuroectoderm, loose mesenchyme, and primitive glandular structures*
- This description refers to the microscopic features of an **immature teratoma**.
- While immature teratomas can arise from germ cells, they typically do not produce such high levels of hCG, and their metastatic pattern is often different.
*Glomerulus-like structure with a mesoderm core, a central capillary, and lined with germ cells*
- This is the classic description of a **Schiller-Duval body**, which is pathognomonic for a **yolk sac tumor** (also known as endodermal sinus tumor).
- Yolk sac tumors are associated with elevated **alpha-fetoprotein (AFP)**, which is normal in this patient.
*Cells with hyaline-like globules*
- The presence of **hyaline-like globules** (containing AFP and/or alpha-1-antitrypsin) is also a feature seen in **yolk sac tumors**.
- As mentioned, the normal AFP level in this patient makes a yolk sac tumor less likely.
Question 208: A 65-year-old man presents with complaints of weakness and swollen gums for the past 3 weeks. He also says he cut his finger while cooking, and the bleeding took more than 10 minutes to stop. He has a family history of diabetes mellitus type 2 and prostate cancer. Current medications are multivitamin. His blood pressure is 122/67 mm Hg, the respiratory rate is 13/min, and the temperature is 36.7°C (98.0°F). On physical examination, the patient seems pale and lethargic. On cardiac exam, a pulmonary valve flow murmur is heard. There is significant hepatosplenomegaly present, and several oral mucosal petechiae in the oral cavity are noted. Gum hypertrophy is also present. A peripheral blood smear reveals myeloperoxidase-positive cells and Auer Rods. A bone marrow biopsy shows > 30% of blast cells. Which of the following chromosomal abnormalities is associated with this patient’s most likely diagnosis?
A. t(9;22)
B. JAK2 mutation
C. t(11;14)
D. t(15;17) (Correct Answer)
E. t(8;14)
Explanation: ***t(15;17)***
- The presence of **myeloperoxidase-positive cells**, **Auer rods**, and **gum hypertrophy** indicates acute promyelocytic leukemia (APML), a subtype of acute myeloid leukemia (AML).
- APML is strongly associated with the **t(15;17) translocation**, which involves the **PML** and **RARα** genes.
*t(9;22)*
- The **t(9;22) translocation** (Philadelphia chromosome) is characteristic of **chronic myeloid leukemia (CML)**, which typically presents with a high white blood cell count and often with a more chronic course, not the acute features seen here.
- While CML can have splenomegaly, it's less likely to present with rapidly progressive bleeding, gum hypertrophy, and a high blast percentage in the bone marrow.
*JAK2 mutation*
- **JAK2 mutations** are commonly found in **myeloproliferative neoplasms (MPNs)** such as polycythemia vera, essential thrombocythemia, and primary myelofibrosis.
- MPNs usually present with different clinical features and laboratory findings than those indicative of acute leukemia, like the absence of a high blast count and Auer rods.
*t(11;14)*
- The **t(11;14) translocation** is characteristic of **mantle cell lymphoma**, a type of non-Hodgkin lymphoma.
- While mantle cell lymphoma can present with lymphadenopathy and splenomegaly, it does not typically manifest with Auer rods, myeloperoxidase-positive blasts, or the acute signs of bone marrow failure seen in this patient.
*t(8;14)*
- The **t(8;14) translocation** is the hallmark of **Burkitt lymphoma**, which is a highly aggressive B-cell lymphoma.
- Burkitt lymphoma typically presents with rapidly growing masses, often extranodal, and while it can involve the bone marrow, it does not show myeloperoxidase-positive blasts or Auer rods.
Question 209: A 60-year-old man presents to your office because he noticed a "weird patch" on the floor of his mouth. He states that he noticed it a few months ago, but did not report it because it did not hurt. However, he is concerned because it has not regressed and seems to have changed in shape. On examination, you notice the patient has poor dentition and he admits to using chewing tobacco daily. The patch on the floor of his mouth is red with irregular borders. Which of the following would be an appropriate way to counsel this patient on his current condition?
A. This lesion is closely associated with chronic Hepatitis C infection.
B. This lesion necessitates biopsy. (Correct Answer)
C. Tobacco use is not a risk factor.
D. This lesion carries no increased risk of cancer.
E. This lesion is due to an infection.
Explanation: ***This lesion necessitates biopsy.***
- The description of a **red patch** (erythroplakia) with **irregular borders** on the floor of the mouth, especially in a chronic **chewing tobacco user**, is highly suspicious for **dysplasia or squamous cell carcinoma**.
- **Biopsy** is essential for definitive diagnosis and to rule out malignancy, which is crucial given the high-risk features and continued tobacco use.
*This lesion is closely associated with chronic Hepatitis C infection.*
- While chronic **Hepatitis C** can be associated with certain oral lesions like **lichen planus**, it is not a direct or strong association for an isolated, evolving red patch like the one described.
- The primary risk factors here are **tobacco use** and the **morphology** of the lesion itself, not chronic viral infection.
*Tobacco use is not a risk factor.*
- This statement is incorrect; **chewing tobacco use** is a major **risk factor** for oral cancers, particularly **squamous cell carcinoma**, which can present as erythroplakia.
- The patient's history directly points to a significant behavioral risk factor for this type of lesion.
*This lesion carries no increased risk of cancer.*
- The lesion described, especially its presentation as **erythroplakia** (red patch) and its **tendency not to regress** but instead to change shape in a tobacco user, carries a **very high risk of being cancerous or precancerous**.
- **Erythroplakia** has a higher malignant transformation rate than leukoplakia.
*This lesion is due to an infection.*
- While some oral lesions can be infectious (e.g., fungal, viral), the description of a **red patch with irregular borders** that is progressive, combined with **chewing tobacco use**, is much more indicative of **dysplasia or malignancy** rather than a simple infection.
- There are no other signs of infection such as fever, pus, or acute inflammation.
Question 210: A 47-year-old female comes to the emergency department because of increasing back pain for the past 2 weeks. She is unable to perform her daily chores. One month ago, she fell and hurt her back while working outside in the garden. The pain subsided with over-the-counter acetaminophen. She underwent a left mastectomy 1 year ago for breast cancer. She has type 2 diabetes mellitus. Current medications include metformin, sitagliptin, and a multivitamin. She appears uncomfortable. Her temperature is 38.9°C (102.0°F), pulse is 101/min, and blood pressure is 110/80 mm Hg. Examination of the back shows thoracic vertebral tenderness. She has mild stiffness on neck flexion. Muscle strength is decreased in the lower extremities. Deep tendon reflexes are 2+ bilaterally. Sensation to pain, fine touch, temperature, and proprioception is intact. Her hemoglobin concentration is 13.1 g/dL and leukocyte count is 19,300/mm3. Which of the following is the most appropriate next step in management?
A. MRI of the spine (Correct Answer)
B. Vancomycin and nafcillin therapy
C. Serum protein electrophoresis
D. Methylprednisone therapy
E. X-rays of the spine
Explanation: ***MRI of the spine***
- The patient presents with **back pain, fever, leukocytosis**, and a history of **breast cancer**, which raises suspicion for **spinal metastasis** or **spinal infection (e.g., discitis, osteomyelitis)**, both requiring urgent imaging.
- Given the neurological deficits noted (decreased muscle strength in lower extremities), an **MRI is crucial** to assess for **spinal cord compression** and guide immediate surgical or medical intervention.
*Vancomycin and nafcillin therapy*
- While the patient has signs suggestive of infection (fever, leukocytosis, elevated pulse, vertebral tenderness), starting broad-spectrum antibiotics empirically **without definitive diagnosis** or imaging is not the most appropriate first step.
- An **MRI of the spine** is needed to confirm the presence of infection, identify the location, and rule out other serious etiologies like spinal metastasis before initiating targeted antimicrobial therapy.
*Serum protein electrophoresis*
- **Serum protein electrophoresis (SPEP)** is used to detect and quantify monoclonal proteins, primarily in the diagnosis and monitoring of **multiple myeloma**.
- While back pain can be a symptom of multiple myeloma, the patient's acute presentation with fever, leukocytosis, and neurological deficits makes **spinal cord compression** or **infection** more pressing concerns that require immediate anatomical imaging.
*Methylprednisone therapy*
- **Corticosteroids** like methylprednisone can reduce inflammation and swelling, potentially alleviating symptoms in cases of acute spinal cord compression due to inflammation or tumor.
- However, steroids can also **mask symptoms of infection** and are generally **contraindicated in infectious processes** unless absolutely necessary (e.g., severe spinal cord compression from epidural abscess where benefits outweigh risks), and should only be considered after an MRI and diagnosis.
*X-rays of the spine*
- **Plain X-rays** are **poor at visualizing soft tissue structures** like the spinal cord, nerve roots, or early tumor infiltration and infection (e.g., discitis, osteomyelitis).
- They have **limited sensitivity** for detecting early lesions, making them less suitable for evaluating acute neurological deficits or suspected cord compression, where an **MRI is superior**.
