1. A 55 year old man with 60 pack-years smoking history presents with cough, mild fevers bloody sputum, malaise, fatigue, and weight loss. He was well until one week ago when he developed night sweats on two occasions. The next day he began coughing up thick, yellow sputum (more than his usual morning clear sputum). Over the past two days, the sputum has become thicker, brownish in color, and blood tinged. He lost 10 pounds in the last two months, although he has been eating well. Examination is notable for a temperature of 100.3°F orally and wet crackles with egophany in the right mid lung zone, louder in the anterior chest. There is no lymphadenopathy. Mild clubbing is present. A chest radiograph shows a right middle lobe infiltrate and a questionable mass in the region of the right bronchus. The white blood cell count is 14.5K with 80% neutrophils, 8% immature band forms, 8% lymphocytes, 2% monocytes and 2% eosinophils. The sodium is 129mM, potassium 3.6mM, chloride 94mM, bicarbonate 30mM, blood urea nitrogen (BUN) 30mg/dL, creatinine 1.4mg/dL. The urine sodium is 40mM, urine creatinine is 2mg/dL. The most appropriate course of action is [1]:

   A. Immediate CT scan of the chest and antibiotic therapy
   B. Antibiotic therapy to clear the pneumonia, followed by CT scan and possible bronchoscopy
   C. Immediate Bronchoscopy with biopsy
   D. Referral to surgery for mediastinoscopy and biopsy
   E. Immediate referral for lung resection

2. The most likely type of lung neoplasm in this smoker with a proximal lung mass is [2]:

   A. Small (Oat) Cell Lung Carcinoma
   B. Carcinoid Tumor of the Lung
   C. Squamous Cell Carcinoma
   D. Adenocarcinoma of the Lung
   E. Large Cell Lung Carcinoma

3. Which of the following is the most likely cause of the low serum sodium in this patient [3] ?

   A. Anti-diuretic hormone (ADH) production by the tumor
   B. Production of ACTH by the tumor
   C. Sodium loss secondary to carcinoid syndrome
   D. Sodium loss due to renal wasting
   E. Production of parathyroid-like hormone by the tumor

4. A 32 year old man is admitted to the hospital for induction chemotherapy for acute myelogenous leukemia (AML). His white cell count is 198K/µl with 60% blasts. The hematocrit is 25% and the platelets are 40K/µl. He is given 4gm of hydroxyurea along with vigorous hydration. The potassium rises to 6.7mM and there are peaked T waves and QRS widening on an electrocardiogram (ECG). The patient becomes oliguric despite hydration. The diagnosis is [4]:

   A. Leukostasis induced renal failure
   B. Tumor lysis syndrome
   C. Prerenal azotemia secondary to dehydration
   D. Renal parenchymal hemorrhage
   E. Obstructive uropathy

5. The appropriate treatment for the patient above is [5]:

   A. Plasmapheresis
   B. Leukopheresis
   C. Furosemide in high doses, hydration, bicarbonate infusions, dextrose and insulin
   D. Sodium polystyrene sulfonate (Kayexelate®), hydration and furosemide
   E. Emergent hemodialysis

6. The patient described above eventually does well and receives induction chemotherapy with seven days of Adriamycin and three days of Arabinoside C (AraC). He receives consolidation therapy with high dose AraC (HiDAC). What is the likelihood that he will achieve an initial complete remission, and then a 5 year, relapse-free, survival [6] ?

   A. 60% complete remission, 20-30% 5 year relapse free survival
   B. 80% complete remission, 50% 5 year relapse free survival
   C. 20% complete remission, 5% 5 year relapse free survival
   D. 60% complete remission, 10% 5 year relapse free survival
   E. 80% complete remission, 50% 5 year relapse free survival

7. An advantage of allogeneic as compared with autologous bone marrow transplantation in a patient with leukemia is [7] ?

   A. Reduced incidence of graft vs. host disease
   B. Reduced incidence of engraftment failure
   C. Reduction in infections during bone marrow recovery
   D. Potential for graft vs. leukemia effect
   E. Reduced time from transplantation to marrow recovery

8. A 22 year old woman is diagnosed with Hodgkin's Disease. The most likely histological type of Hodgkin's Disease in this person is [8]:

   A. Nodular Sclerosing
   B. Lymphocyte Predominant
   C. Mixed Cellularity
   D. Lymphocyte Depleted
   E. Incorrect initial diagnosis

9. A 56 year old man undergoes an abdominal computerized tomographic (CT) scan for evaluation of abdominal pain, weight loss, and intermittant fevers. A mass is visualized in the right colon, just distal to the cecum. The liver, spleen, lymph nodes and pancreas are normal. The leading diagnosis is colon carcinoma. Which tumor marker is most likely to be abnormal if the diagnosis is correct [9] ?

   A. Alpha-fetoprotein (AFP)
   B. Carcinoembryonic Antigen (CEA)
   C. Human Chorionic Gonadotropin (HCG)
   D. CA 19-9
   E. CA 125

10. A 48 year old woman with a family history of breast cancer undergoes mamography which shows spiculated calcifications in the inner lower quadrant of the left breast. Fine needle biopsy reveals infiltrating ductal carcinoma. A lumpectomy with axillary node dissection reveals a 1.2cm mass and confirms the needle biopsy histology; 1/10 ipsilateral lymph nodes are positive for tumor. The tumor is estrogen receptor positive, progesterone receptor negative. She undergoes radiation therapy to the region. Which therapy has been shown to decrease the rate of relapse in the this patient with Stage I breast cancer [10] ?
A. Tamoxifen Therapy
B. Medroxyprogesterone Therapy
C. Cyclophosphamide - Adriamycin - Fluorouracil (CAF) Therapy
D. Bone Marrow Transplantation
E. Ifosfamide - Carboplatin - Etoposide (ICE) Therapy

Answers

1. B
2. C (Squamous cell is most common in smokers, particularly with a proximal mass.)
3. A (Small cell carcinoma is actually more likely than squamous to secrete ADH.)
4. B
5. E
6. A
7. D
8. A
9. B
10. C