Mediastinal masses evaluation and management — MCQs

During a thoracotomy procedure, a surgeon needs to access the posterior mediastinum. Which of the following structures forms the anterior boundary of the posterior mediastinum?

A 35-year-old woman comes to the physician because of blurred vision for the past 2 months. During this period, she has also had difficulty chewing and swallowing. She reports that her symptoms worsen throughout the day and improve with rest. There is no personal or family history of serious illness. The patient works as a teacher and has had a great deal of stress lately. She does not smoke and drinks a glass of wine occasionally. She takes no medications. Her temperature is 37°C (98.6°F), pulse is 68/min, and blood pressure is 130/80 mm Hg. Physical examination shows bilateral ptosis and mask-like facies. Muscle strength is decreased in both lower extremities. The anti–acetylcholine receptor (AChR) antibody test is positive. Electromyography shows a decremental response following repetitive nerve stimulation. Which of the following is the most appropriate next step in the management of this patient?

A 35-year-old man presents to his primary care provider complaining of dull pain in his scrotum and lower back pain over the last 3 months. He is a computer engineer working in a private IT company. He had an uncomplicated appendectomy at the age of 22 years, but is otherwise without a significant past medical history. He smokes 2–3 cigarettes on weekends and drinks alcohol occasionally. He is sexually active with his wife. Today his heart rate is 90/min and blood pressure is 132/76 mm Hg. Scrotal examination reveals a firm, small and painless nodule on the left testicle. Scrotal ultrasound reveals a 0.9 x 0.5 cm irregular, non-cystic mass. He undergoes a left radical orchiectomy and histopathological examination reveals uniform tumor cells with abundant clear cytoplasm and distinct cell borders, consistent with a seminoma. Subsequent PET/CT scans show supraclavicular and para-aortic lymph node involvement. Which is the next and most appropriate step in the management of this patient?

A 65-year-old man with a 40-pack-year smoking history presents with hemoptysis and a persistent cough. Chest CT shows a 3.5 cm centrally located mass in the right main bronchus. Positron emission tomography confirms a malignant nodule. Bronchoscopy with transbronchial biopsy is performed and a specimen sample of the nodule is sent for frozen section analysis. The tissue sample is most likely to show which of the following tumor types?

A 54-year-old man comes to the emergency department because of a 3-week history of intermittent swelling of his left arm and feeling of fullness in his head that is exacerbated by lying down and bending over to tie his shoes. Physical examination shows left-sided facial edema and distention of superficial veins in the neck and left chest wall. Which of the following is the most likely cause of this patient's symptoms?

A 55-year-old male smoker presents to your office with hemoptysis, central obesity, and a round face with a "moon-like" appearance. He is found to have a neoplasm near the hilum of his left lung. A biopsy of the tumor reveals small basophilic cells with finely granular nuclear chromatin (a "salt and pepper" pattern). Which of the following is the most appropriate treatment for this patient?

A 72-year-old woman is brought to the emergency department because of lethargy and weakness for the past 5 days. During this period, she has had a headache that worsens when she leans forward or lies down. Her arms and face have appeared swollen over the past 2 weeks. She has a history of hypertension and invasive ductal carcinoma of the left breast. She underwent radical amputation of the left breast followed by radiation therapy 4 years ago. She has smoked two packs of cigarettes daily for 40 years. Current medications include aspirin, hydrochlorothiazide, and tamoxifen. Her temperature is 37.2°C (99°F), pulse is 103/min, and blood pressure is 98/56 mm Hg. Examination shows jugular venous distention, a mastectomy scar over the left thorax, and engorged veins on the anterior chest wall. There is no axillary or cervical lymphadenopathy. There is 1+ pitting edema in both arms. Which of the following is the most likely cause of this patient's symptoms?

A 72-year-old man presents to his physician’s office with complaints of a cough and painful breathing for the last 2 months. He says that he has also observed a 5 kg (11 lb) weight loss during the past month. He is relatively healthy but the sudden change in his health worries him. Another problem that he has been facing is the swelling of his face and arms at unusual times of the day. He says that the swelling is more prominent when he is supine. He has also lately been experiencing difficulty with his vision. He consumes alcohol occasionally and quit smoking last year following a 25-year history of smoking. On examination, the patient is noted to have distended veins in the chest and arms. His jugular veins are distended. Physical examination shows ptosis of the right eye and miosis of the right pupil. His lungs are clear to auscultation. He is sent for an X-ray for further evaluation of his condition. Which of the following is the most likely site for the detection of the nodule on CT scan?

A 39-year-old man presents with painless swelling of the right testis and a sensation of heaviness. The physical examination revealed an intra-testicular solid mass that could not be felt separately from the testis. After a thorough evaluation, he was diagnosed with testicular seminoma. Which of the following group of lymph nodes are most likely involved?

An obese 52-year-old man is brought to the emergency department because of increasing shortness of breath for the past 8 hours. Two months ago, he noticed a mass on the right side of his neck and was diagnosed with laryngeal cancer. He has smoked two packs of cigarettes daily for 27 years. He drinks two pints of rum daily. He appears ill. He is oriented to person, place, and time. His temperature is 37°C (98.6°F), pulse is 111/min, respirations are 34/min, and blood pressure is 140/90 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 89%. Examination shows a 9-cm, tender, firm subglottic mass on the right side of the neck. Cervical lymphadenopathy is present. His breathing is labored and he has audible inspiratory stridor but is able to answer questions. The lungs are clear to auscultation. Arterial blood gas analysis on room air shows: pH 7.36 PCO2 45 mm Hg PO2 74 mm Hg HCO3- 25 mEq/L He has no advanced directive. Which of the following is the most appropriate next step in management?