A 45 year-old female comes for annual physical examination. She has no known family history of breast cancer. Which is the correct advice on breast cancer screening?
a. Suggest self-examination from time to time
b. Suggest annual clinical examination
c. Provide the opportunity to start breast MRI with or without mammography annually
d. Do screening mammography annually
D. Choices A and B are wrong as these are not recommended by USPSTF or ACS. Choice C is not the best answer as patient is unlikely to have >20% lifetime risk of breast cancer (negative family history).
Which of the following is a correct method for screening for colorectal cancer among adults age 45 years or older?
a. Sigmoidoscopy every 10 years
b. CT colonography every 5 years
c. Colonoscopy every 5 years
d. Fecal immunochemical testing every 3 years
Answer is B. Choice A is wrong because sigmoidoscopy should be done every 5 years. Choice C is wrong because colonoscopy should be done every 10 years. Choice D is wrong because FIT testing should be done every year.
A 25 year-old male came for 6-week history of aural fulness and otalgia. On physical examination, there are no palpable lymphadenopathies. On Craniocervical CT Scan, a 1.8 x 1.8 cm left nasopharyngeal mass was noted, with an enlarged 1.5 cm x 1.5 cm Level II lymph node on the left. What is the clinical stage of this patient?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
Answer is C. The nasopharyngeal mass is clinically T1, as it is less than 2 cm in dimension (another characteristic is depth of invasion <= 5 mm). However, the enlarged 1.5 cm Level II lymph node indicates N1 (<= 3 cm in greatest dimension). The presence of N1 automatically upstages the patient to Stage III.
A 35 year-old Filipino female developed a 3-month history of rapidly enlarging right breast mass. Biopsy revealed triple negative breast cancer. She then recalls that her sister also had ovarian cancer at age 40. Which drug may be beneficial for this patient?
a. Alpelisib
b. Glasdegib
c. Talazoparib
d. Trastuzumab
Answer is C. The presence of a strong family history of ovarian cancer and triple negative breast cancer (TNBC) suggest a germline BRCA1 or BRCA2 mutation. (Filipinos are also genetically predisposed to BRCA mutation.) PARP inhibitors such as olaparib and talazoparib have demonstrated benefit.
A 70 year-old female came for 9-month history of gradually enlarging right breast mass. On physical examination, 3 cm x 3 cm hard firm breast mass located on the right upper outer quadrant. There are no noted cervical lymphadenopathies nor enlarged supraclavicular lymph node, but with (+) multiple (at least 3) palpable around 1.5 cm x 1.5 cm axillary lymphadenopathies, all mobile. No noted distant metastases. Core needle biopsy showed ER (+), PR (+), HER2 (-) What is the correct management for this patient?
a. Surgery only
b. Surgery with adjuvant hormonal therapy
c. Surgery with adjuvant hormonal therapy and cytotoxic chemotherapy
d. Surgery with adjuvant hormonal therapy, cytotoxic chemotherapy, and chest wall irradiation
Answer is D. The presence of 3 cm x 3 cm breast mass suggests T2. The presence of at least 3 palpable mobile lymphadenopathies suggests N1 (as opposed to fixed lymphadenopathies - N2). This is clinical Stage IIB (T2N1M0). The presence of hormone positivity means that adjuvant hormonal therapy is of benefit. Postmastectomy chest wall and regional nodal radiation reduces locoregional recurrence and improves survival. It is indicated for patients with high risk of locoregional recurrence, such as those with tumors ≥ 5 cm, four or more positive axillary lymph nodes, or postoperative positive margins. Postmastectomy radiation is not indicated in women with cancers < 2 cm, negative lymph nodes, and negative margins. It is considered for women who fall into the areas between these (2–5 cm, one to three positive nodes, or close margins) and is usually recommended if a patient has one to three involved axillary lymph nodes. (Taking into account more recent studies, these patients would also benefit from adjuvant CDK4/6 inhibitors such as ribociclib and abemaciclib.)
HPIM Ch79 p618
What determines the staging of esophageal cancer?
a. Depth of invasion
b. Ki67 index
c. Tumor size
d. Tumor morphology
Answer is A. The depth of invasion primarily affects the tumor stage. Tis - high grade dysplasia; T1a - lamina propria, basement membrane, up to muscularis mucosae; T1b - submucosa; T2 - muscularis propria; T3 - adventitia; T4a - pleura; T4b - aorta. Ki67 is a measure of how actively cells are dividing in breast cancer.
Which of the following is/are appropriate post-operative surveillance methods for colorectal cancer patients following recovery from a complete resection?
a. CEA every 3 months
b. Completion colonoscopy within first several post-op months if not yet done pre-op
c. Annual CT scan for the first 3 post-op years
d. All of the above
Answer is D. “Following recovery from a complete resection, patients should be observed carefully for 5 years by semiannual physical examinations and blood chemistry measurements. If a complete colonoscopy was not performed preoperatively, it should be carried out within the first several postoperative months. Some authorities favor measuring plasma CEA levels at 3-month intervals because of the sensitivity of this test as a marker for otherwise undetectable tumor recurrence.” … “The value of periodic CT scans of the abdomen, assessing for an early, asymptomatic indication of tumor recurrence, while uncertain, has been recommended annually for the first 3 postoperative years.”
Which of the following is/are true about systemic chemotherapy and radiotherapy in colorectal cancer?
a. FOLFOX is more efficacious than FOLFIRI
b. Chemoradiation reduces recurrence but does not prolong survival
c. Leucovorin enhances efficacy of 5-FU
d. All of the above
Answer is C. “Radiation therapy, either administered pre- or postoperatively, further reduces the likelihood of pelvic recurrences
but does not appear to prolong survival. Combining radiation therapy with 5-fluorouracil (5-FU)-based chemotherapy, preferably prior to surgical resection, lowers local recurrence rates and improves overall survival. Radiation therapy alone is not effective as the primary treatment of colon cancer. Systemic therapy for patients with colorectal cancer has become more effective. 5-FU remains the backbone of treatment for this disease. The concomitant administration of folinic acid (leucovorin [LV]) improves the efficacy of 5-FU in patients with advanced colorectal cancer, presumably by enhancing the binding of 5-FU to its target enzyme, thymidylate synthase. FOLFIRI and FOLFOX are equal in efficacy.”
A 45 year-old male with known history of HBV infection and chronic alcoholism presented with 4-month history of jaundice, abdominal enlargement, anorexia, unintentional weight loss. On physical examination, patient is alert, oriented, not in distress, with (+) icteric sclerae, pale palpebral conjunctivae, clear breath sounds. Notable is a distended abdomen, (+) caput medusae, (+) fluid wave. Labs showed INR 2.0, biliubin 2.5 mg/dL, albumin 29. He then underwent triphasic CT scan which showed vascular uptake in arterial phase with washout in the portal venous and delayed phases. What is the treatment of choice for this patient?
a. Resection or ablation, possible transplantation
b. Trans-arterial chemoembolization (TACE)
c. Combination Atezolizumab + Bevacizumab
d. Best supportive care
Answer is D. The findings of vascular uptake in arterial phase with washout in the portal venous and delayed phases is the biologic hallmark of hepatocellular carcinoma (HCCA). Before treatment, the Barcelona Clinic Liver Cancer (BCLC) staging criteria first assesses the Child-Pugh score of the patient. Patient’s Child-Pugh Score is as follows: 2 (albumin 29) + 2 (bilirubin 2.5) + 2 (INR 2.0) + 2 (fluid wave, moderate ascites) + 1 (no encephalopathy), leading to ta total of 10 points. This is Child-Pugh Class C, which corresponds to BCLC Stage D. At this point, none of the treatments are of benefit.
HPIM Ch82 F82-2, F82-3 p646-647
What is the median overall survival of patients with resectable pancreatic cancer?
a. 6 - 10 months
b. 8.3 - 12.8 months
c. 18 - 23 months
d. More than 24 months
Answer is C. Choice A is for locally advanced disease, while choice B is for metastatic disease.
What is Stauffer’s Syndrome?
a. Superficial thrombophlebitis in patients with pancreatic cancer
b. Limb muscle weakness in patients with small cell lung cancer
c. Nonmetastatic hepatic dysfunction in patients with renal cell carcinoma
d. Sudden onset fever and painful red skin lesions in patients with breast cancer
Answer is C. Choice A refers to Trosseau Syndrome. Choice B refers to Lambert-Eaton Myasthenic Syndrome. Choice D refers to Sweet Syndrome.
HPIM Ch85 p674
A prostate cancer that has invaded the bladder wall is assigned as…
a. T3
b. T4
c. N1
d. M1
Answer is B. T3 indicates tumor beyond prostate capsule. T4 indicates spread to adjacent organs. N1 indicates spread to regional lymph nodes. M1 metastasis to distant organs
Which cytotoxic chemotherapeutic agent can cause ataxia?
a. Cyclophosphamide
b. Cytarabine
c. Doxorubicin
d. Methotrexate
Answer is B. Cyclophosphamide has an adverse effect of Hemorrhagic Cystitis, Congestive Heart Failure. Doxorubicin has an adverse effect of Congestive Heart failure, Secondary Malignancies. Methotrexate has an adverse effect of Pneumonitis.
HPIM Ch95 T95-2 p738
The correct answer is: Cytarabine
In critically ill patients to be started on PPI prophylaxis against stress-related gastric mucosal injury, which of the following scenarios would benefit due to high risk of bleeding?
a. A 65 y/o male smoker on Norepinephrine for septic shock secondary to pneumonia on day 3 of antibiotics
b. A 40 y/o obese female with Leptospirosis started on initiation dialysis and thrombocytopenia (Platelet count 40)
c. A 60 y/o male on Nitroglycerin drip for hypertensive emergency noted to be low dose aspirin for at least a year for ischemic heart disease
d. An 80 y/o female with chronic cerebrovascular infarct and prior tracheostomy admitted for sepsis due to infected sacral ulcer
B. A 40 y/o obese female with Leptospirosis started on initiation dialysis and thrombocytopenia (Platelet count 40)
The incidence of bleeding from stress-related gastric mucosal injury has decreased dramatically in recent years, most likely due to better care of critically ill patients. A guideline
suggested PPI prophylaxis in critically ill patients at high risk (≥4%) of bleeding, defined as mechanical ventilation without enteral nutrition,portal hypertension, cirrhosis, platelets <50 × 109/L, international normalized ratio >1.5,
OR two of the following: mechanical ventilation with enteral nutrition, acute kidney injury, sepsis, or shock.
HPIM 21st Ch48 p312
In a 38 y/o female with chronic NSAID use for dysmenorrhea, new-onset hematochezia which of the following steps in management is correct?
a. If presenting with hemodynamic instability with no identified source of bleeding post EGD, an abdominal CT scan is warranted
b. If with no signs of hemodynamic instability and no identified site of bleeding on colonoscopy, do CT enterography
c. If with no signs of hemodynamic instability and no identified site of bleeding on colonoscopy, do capsule endoscopy
d. If with no signs of hemodynamic instability but bleeding persists despite identifying site post colonoscopy, abdominal CT scan is warranted
C. If with no signs of hemodynamic instability and no identified site of bleeding on colonoscopy, do capsule endoscopy
In patients suspected with small intestinal bleeding, video capsule endoscopy is the next diagnostic step that may be done or repeat upper and lower endoscopy. Systematic reviews report a diagnostic yield with capsule endoscopy of ~55%. Limitations of capsule endoscopy include the inability to fully visualize the small intestinal mucosa, sample tissue, or apply therapy.
Carotenoderma is one of the differential diagnoses considered for yellowing of the skin. The following medications/conditions are associated with Carotenoderma except:
a. Sweet potatoes
b. Anorexia nervosa
c. Diabetes
d. Tobramycin
D. Tobramycin
Carotenoderma, a yellow coloring of the skin, is associated with diabetes, hypothyroidism, and anorexia nervosa, but most commonly, it is caused by the ingestion of an excessive amount of vegetables and fruits such as carrots, leafy vegetables, squash, peaches, and oranges that contain carotene.
A 31 y/o female coming in for persistent jaundice with no associated fever and abdominal pain had the following laboratory tests done: AST 88 ALT 124 ALP 525, nondilated biliary ducts on ultrasound and positive AMA. Which of the following is the next best step in management?
a. MRCP
b. Ceruloplasmin levels
c. Refer to hematology for bone marrow aspiration
d. Liver biopsy
D. Liver biopsy
Results show an obstructive type of jaundice (ALP elevation more than transaminases), and an intrahepatic cholestasis given the absence of biliary dilation.
AMA positivity may suggest primary biliary cholangitis. However, diagnosis of intrahepatic cholestasis is made with serologies AND liver biopsy.
C.C, a 35 y/o male, consulted at your clinic regarding cancer screening procedures. He is worried about the possibility of getting colorectal cancer as his father was diagnosed at age 70. He denies any constitutional symptoms as well as gastrointestinal complaints during his consultation. As an internist, you recommend:
a. Stool FIT every year with flexible sigmoidoscopy every 10 years beginning age 45
b. Flexible sigmoidoscopy every 5 years beginning age 40
c. Selective screening indicated only
d. Colonoscopy every 3-5 years beginning 10 years before the age of diagnosis
B. Flexible sigmoidoscopy every 5 years beginning age 40
Cancer screening for patients with first degree relatives diagnosed with CRC above 60 years recommend starting at age 40 with intervals similar to average risk recommendations
Choice A is part of the recommendations for average risk patients between 45-75 years of age.
Choice C is only recommended screening strategy for asymptomatic individuals >75 years of age.
Choice D is recommended for those diagnosed with Family colon cancer syndrome X
HPIM 21st Ch322 p2422 Table 322-3
A 48 year old obese male consulted at your clinic due to regurgitation and symptoms of heartburn. He also notes sleep interruption due to excessive snoring, sometimes associated as well with heartburn. He states that this was partially reduced after elevated head rest and asks regarding other interventions. You recommend weight reduction and trial of medications. Which of the following drugs have the most efficacious profile?
a. Vonoprozan
b. Esomeprazole
c. Ranitidine
d. Rebampide
A. Vonoprozan
Pharmacologically reducing the acidity of gastric juice does not prevent reflux, but it ameliorates reflux symptoms and allows esophagitis to heal. The hierarchy of effectiveness among pharmaceuticals for healing esophagitis parallels their antisecretory potency. Potassium competitive acid blockers (PCABs) are more efficacious than proton pump inhibitors (PPIs), which are more efficacious than histamine-2 receptor antagonists (H2RAs).
If antibiotic susceptibility is not available, which of the following sequences in the empiric treatment of H. pylori is correct for patients in regions with low clarithromycin resistance rates?
a. Bismuth 4 drug -> Levofloxacin 3 drug -> Rifabutin 3 drug -> Clarithromycin 3 drug
b. Bismuth 4 drug -> Levofloxacin 3 drug -> Rifabutin 3 drug
c. Clarithromycin 3 drug -> Bismuth 4 drug -> Levofloxacin 3 drug -> Rifabutin 3 drug
d. Non-bismuth 4 drug -> Levofloxacin 3 drug -> Bismuth 4 drug -> Rifabutin 3 drug
C. Clarithromycin 3 drug -> Bismuth 4 drug -> Levofloxacin 3 drug -> Rifabutin 3 drug
Choice C is a correct sequence of escalation of treatment in H. pylori eradication for low clarithromycin resistance rates
Choice A is incorrect as Rifabutin is commonly the 4th line in low resistance rates. Choice B and D is incorrect as it is proposed for those with High clarithromycin rates or unknown resistance
A 25 year old healthy male with no known comorbids consulted due to presence of blood in his stool. No associated abdominal pain, fever, diarrhea or vomiting. Upon examination, you noted protruding hemorrhoids requiring manual reduction. The following modes of treatment may be given except:
a. Short course of cortisone suppository
b. Fiber supplementation
c. Rubber band ligation
d. Infrared coagulation
D. Infrared coagulation
Table 339-6 in HPIM 22nd Ch339 summarizes the staging of hemorrhoids and their conventional treatment methods
There is benefit in smoking cessation even after diagnosis of Lung CA
What is the FDA approved first line treatment?
Second line?
First line: antidepressant (bupropion) and nicotine replacement (varenicline)
Second line: clonidine and nortriptyline
What neuroendocrine markers differentiate SCLC from NSCLC?
CD56
Neural cell adhesion molecule (NCAM)
Synaptophysin
Chromogranin
Lung CA types most commonly associated with tobacco use
Squamous and small cell CA
Smoker= Squamous & Small
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